Physical Therapy Eases
the Discomfort of TMD

by Morag Sampson, M.C.S.P., P.T.

What is Temporomandibular Dysfunction?
Temporomandibular joint pain is at best irritating and at worst debilitating for many people. The most common symptoms are pain in and around the ear, teeth or face. The jaw may lock in an open or shut position, there might be grinding or clicking in the joint and/or the inability to open the mouth sufficiently to eat, talk or brush your teeth. Patients often suffer from associated neck pain and even back pain. Head-aches are also common, often being present first thing in the morning but may occur any time of day.

What causes TMD?
TMD can be caused by prolonged stress on the joints such as by clenching, grinding or gum chewing. Trauma to the jaw such as during a car accident, blows to the jaw during physical abuse or holding the mouth open for prolonged periods of time can damage the joints and cause problems. It is not unusual for a patient to remember falling from his or her bicycle as a child and striking the chin, resulting in problems years later. Poor bite (malocclusion), stress, poor posture, thumb sucking, and habits like resting the chin on your hand and pencil chewing can aggravate or perpetuate TMD.

What is the Temporomandibular Joint?
The temporomandibular joints are hinges which connect the condyles of the mandible to the temporal bones in the skull. The joint is a complex arrangement of bone, cartilage, fascia and muscle. For the first 26 or so millimeters of opening the condyles rotate in the joint. All movement after that is made up of the condyles gliding forward during opening and backwards during closing. A soft disc (meniscus) lies between the end of the condyle and the eminence of the temporal bone to ensure smooth motion, absorb shock and keep the bones’ surfaces separated. Damage to the disc can interrupt the joint motion and cause pain.

Common Types of Dysfunctions
There are three main categories of TMJ dysfunction:

1) Internal derangement is caused by damage to the disc or poor disc position. The disc can become dislocated so that it sits too far forward in the joint. If the disc is partially dislocated there will be a clicking in the joint during opening and closing, as the condyle slips onto and off the disc. If the disc is totally dislocated, there is no reciprocal click but mouth opening is limited due to the disc preventing the normal forward gliding of the condyle. Bony damage to the condyle or dislocation of the jaw can also cause internal derangement.

2) Muscular or myofascial dysfunction of the masticatory (jaw) muscles or the neck muscles can cause pain. Spasm in the masseter muscle can prevent a person from opening his or her mouth (this is known as trismus).

3) Degenerative joint disease, such as osteoarthritis or rheumatoid arthritis in the TMJs, can cause pain and dysfunction.

Seeking Treatment
Most people seek help from their dentist or physician, depending on the symptoms. A referral to an Ear Nose and Throat specialist is often made due to the complaints of ear pain. Examination of the patient’s occlusion reveals whether general dentistry or orthodontic intervention is required and a splint may be fabricated for night and/or day use to prevent clenching and separate the joint surfaces. Sometimes surgical intervention is required. Muscle relaxers and anti-inflammatory drugs are very helpful as is the application of moist heat to the face and neck. Ice is also helpful but less well tolerated. A referral to a physical therapist can be made by the physician or dentist. In many cases people can refer themselves but their physician will be informed as a matter of courtesy.

How Can Physical Therapy Help?
The first step towards effective treatment is an evaluation, with a physical therapist who specializes in the treatment of TMD, so that a determination can be made of which category the dysfunction falls into. There may be several overlapping causes for the pain and loss of function.

A complete postural and spinal evaluation is performed to see if the root cause is actually a dysfunction lower down in the spine, even as low as the pelvis. The pelvis is the base on which the spine sits; if the base is unbalanced then the spine will also be unbalanced as it attempts to correct itself and achieve the body’s primary goal to bring the eyes level. This will adversely affect the neck and temporomandibular joints. Forward head posture – which is so prevalent with all of us – changes the delicate balance of the TMJs and can cause pain. The SSPT staff will use gentle manual therapy techniques, such as muscle energy techniques and mobilizations to correct spinal and pelvic-girdle dysfunctions. Education and postural exercises help correct poor posture.

For the muscular component – so often the cause of pain and loss of range of motion in the TMJs and neck – we use myofascial release, strain/ counter-strain, craniosacral therapy, soft tissue mobilization, trigger-point work, myofascial mobilization as well as stretches and gentle exercises. The patient will be taught to perform self massage and other applicable treatments. Many of these techniques are performed both extra- and intra-orally. Biofeedback can help patients regain control of their muscles and thus relaxation of the masticatory and cervical muscles. The modalities of ultrasound, phonophoresis, interferential therapy, electrical stimulation and iontophoresis may be used to reduce inflammation and pain and promote healing.

If the patient has lost range of motion, he or she will be instructed in specific exercises to be performed several times a day to passively stretch opening. Careful joint mobilizations and spray-and-stretch using flouri-methane spray is performed during physical therapy sessions. A passive motion device, called a therabite, is a useful home exercise tool. Other exercises are taught to strengthen jaw and neck muscles, as well as to correct posture and prevent muscular hypertonicity. Teaching the correct tongue position is one example.

Post-surgical patients are commenced on their surgeon’s protocol anywhere from one week post-op, onwards. Treatment includes education regarding post-surgical restrictions, diet and a combination of the above treatments.

To learn more about the treatment of TMD, please contact Southside Physical Therapy.

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