Download The role of physical therapy in patients

The role of physical therapy in patients
with temporomandibular joint disorder
Tomislav BADEL1, Ladislav KRAPAC1, Aleksandra KRALJEVIĆ2
11Department of Removable Prosthodontics, School of Dental Medicine,
University of Zagreb, Zagreb, Croatia, 2Polyclinic for Physical Medicine and Rehabilitation,
Velika Gorica, Croatia
33Clinic of Rheumatic Diseases and Rehabilitation, Zagreb University Hospital Center,
Zagreb, Croatia
Primljeno / Received: 2012-04-02; Prihvaćeno / Accepted: 2012-05-15
Correspondence to:
Tomislav Badel, PhD
Department of Prosthodontics
School of Dental Medicine, University of Zagreb
Gundulićeva 5, HR-10000 Zagreb, Croatia
E-mail: [email protected]
Abstract
Temporomandibular disorders are musculoskeletal disorders of the stomatognathic system
related to other parts of the locomotor system: pain in the temporomandibular joint (TMJ),
craniocervical muscular fatigue, especially of the masticatory muscles, limitation of
mandibular movements, and presence of joint clicking. Since there is no gold standard in the
treatment of temporomandibular disorders, noninvasive and reversible methods are preferred.
Physical therapy, particularly exercise and mobilization of temporomandibular joints with
masticatory muscles, have a very important role in the treatment. Moreover, once the physical
therapist instructs the patient, he/she can continue doing the exercises at home according to an
individual exercise program and depending on the subjective evaluation of its effects on pain
reduction and improvement of mandibular mobility. Although causal co-dependence with
cervicocranial disorders has not been completely confirmed, it has been recommended to
include disturbances related to the cervical spine into joint physical therapy within a
framework of physiatric-rheumatologic treatment. Along with a review of the literature,
particular attention has been given to integrated diagnosis and physical therapy of functional
disorders of the temporomandibular and border cervical regions.
Key words: physical therapy, temporomandibular disorders, temporomandibular joint.
Uloga fizioterapije u bolesnika s poremećajem temporomandibularnog zgloba
Sažetak
Temporomandibularni poremećaji su muskuloskeletni poremećaji stomatognatskog sustava
srodni drugim dijelovima lokomotornog sustava: pritužbe na bol u temporomandibularnom
zglobu, umor kraniocervikalnih mišića, posebice žvačnih mišića, ograničene kretnje
mandibule i prisutnost škljocanja u zglobu. Kako ne postoji zlatni standard u liječenju
temporomandibularnih poremećaja, prednost se daje neinvanzivnim i reverzibilnim
metodama. Fizikalna terapija, posebice vježbanje i mobilizacija temporomandibularnih
zglobova sa žvačnim mišićima ima istaknutu ulogu u liječenju. Štoviše, kad ga fizioterapeut
poduči, bolesnik može nastaviti vježbati kod kuće prema individualnom programu ovisno o
subjektivnoj procjeni učinka na smanjivanje bolova i povećanju pokretljivosti mandibule.
Iako nije potpuno utvrđena uzročna međuovisnost s cervikokranijalnim poremećajima,
preporuča se u sklopu fizijatrijsko-reumatološke obrade u jedinstvenu fizikalnu terapiju
uključiti i poremećaje vezane za cervikalnu kralježnicu. Uz pregled literature dan je naglasak
na integriranu dijagnostiku i fizikalnu terapiju funkcijskih poremećaja temporomandibularnog
i graničnog cervikalnog područja.
Ključne riječi: fizikalna terapija, temporomandibularni poremećaji, temporomandibularni
zglob
Introduction
Musculoskeletal disorders of the stomatognathic system fall under the umbrella term of
temporomandibular disorders (TMDs), and they include painful conditions of the masticatory
muscles and/or temporomandibular joints (TMJ). Due to the topographic-functional position
of the mandibular elevator and depressor muscles, which are directly involved in functional
movements of the stomatognathic system, TMD-related pain also includes the
craniomandibular and cervicocranial areas (1,2). Therefore, border regions of the
stomatognathic system can encompass a broad spectrum of symptoms, from tension
headaches to disturbances of the cervical spine, and apart from the comorbidity, there is an
etiopathogenetic relationship with the cervico-facial posture (3-9).
The aim of the paper is to review TMDs treatment possibilities, with special reference to
integrated diagnosis and treatment of functional disorders of the temporomandibular and
border cervical regions based on physical therapy of muscles to increase TMJs mobility.
There is also an illustrative example of a TMD female patient with 5-year-follow-up.
Temporomandibular Disorders
Myogenic disorder includes fatigue and pain in the masticatory muscles, with or without
limited mouth opening, and it can also affect the lower segments, that is, the cervicocranial
region. Diagnosis of tendomyopathy is most commonly used as a diagnosis of myogenic
disorder. Another group of TMDs includes arthrogenic disorders, which involve pathological
forms of anterior disc displacement and osteoarthritis of TMJ (10,11). Prolapsed disc or disc
herniation of the TMJ are older terms for disc displacement, which is analogue to the wellknown pathology of spinal discopathy (12). Osteoarthritis, on the other hand, includes
degenerative changes of the articular cartilage and the subchondral bone, which is a
characteristic pathology of all joints (13). Systemic neurologic, rheumatologic and
immunologic diseases can also affect the structures of the stomatognathic system and they are
as follows: fibromyalgia, rheumatoid arthritis, psoriatic arthritis, Sjögren’s syndrome, etc.
(14).
At first, it was considered that tooth loss and disturbances of occlusal relations between teeth
played the main role in the etiopathogenesis and the resulting pressure of the articular condyle
on the auriculotemporal nerve was called Costen’s syndrome (15). The multifactorial and
biopsychosocial concept classifies TMDs into chronic musculoskeletal diseases. Due to its
nonspecific etiopathogenesis, symptomatic treatment is the most acceptable one, and it is
partially similar to the treatment of other musculoskeletal disorders in the body (16).
Diagnosis of TMJ
In order to avoid a group interpretation of different pathological occurrences, which are then
vaguely called dysfunctions, diagnostic systems have been designed that facilitate clinical
work with patients and comparison of the results of scientific studies on TMDs. With respect
to the distribution according to diagnostic subgroups (myogenic and arthrogenic), there can be
several individual diagnoses of TMDs made for one patient, even different diagnoses in the
same TMJ, that is, anterior disc displacement and osteoarthritis (2,10).
The gold standard of clinical diagnosis related to myogenic and/or arthrogenic subgroup of
TMDs is characterized by the following symptoms: pain in the masticatory muscles and/or
TMJs, limited mouth opening and pathological noise in temporomandibular joints (clicking,
crepitation). Accompanying symptoms are pain or non-specific tinnitus in the ear and tension
headaches (17,18).
Specific methods of stomatognathic system examination are used from the field of physical
and manual medicine, since the standard dental examination (primarily of the dental status)
could not completely locate and differentiate certain symptoms of functional disorders (19).
Manual functional analysis by Bumman and Groot Landeweer (20) is a group of manual
examination techniques by which the cause of disturbances is differentiated and a tissuespecific diagnosis is given. Pre-auricular pain related to mandibular movements, particularly
on mastication and wider mouth opening (regardless of whether the pathological noise was
recorded in medical history or it was recently present during examination) is examined by
dynamic compressions and translation, wherein the therapist manually pressures the lower
edge of the posterior mandibular corpus in cranial direction. The patient performs active
protrusive and mouth opening movements. Pain in the intra-articular and retrodiscal structures
is additionally examined and the therapist moves the mandible thus performing passive
compressions of the TMJs. The examination of muscle groups is performed by provoking
pain on closing or opening the mouth by isometric strain, and if the finding is positive, they
are additionally palpated with moderate strain. Pain intensity is rated on a visual analogue
scale (VAS; 0, no pain; 10 the strongest pain ever).
Physical Therapy and the Stomatognathic System
Within TMD treatment modalities, physical therapy has shown efficiency in its unique
methods as well as in those indicated for other musculoskeletal disorders. The role of physical
therapy in the treatment of musculoskeletal pain is unquestionable, and its application in the
stomatognathic system is useful and logical (21,22). Namely, the basic principle of improving
the function while removing pain is seen in mobilization exercises wherein the patient is
directly involved. Since TMDs are not an isolated musculoskeletal disorder, cervical segment
exercises are also included, which also improve head and neck statics. The basic exercises
include performing physiological and accessory movements (Maitland, Kaltenborn, modified
by Schulte) which, in cases of pronounced mandibular hypomobility, enable achieving better,
painless functioning of the joints and masticatory muscles (22-26). Self-coordination which
gives the patient an active role in the evaluation of the effects of exercising stimulates
motivation in this treatment modality.
There are numerous modifications of oral exercises regardless of whether they are performed
by the patient alone or with the manual-treatment assistance of a therapist. This segment of
physical therapy can be supplemented by other subtypes of physical therapy with the aim of
pain removal (11,27-29). This prevents nociceptive stimulation, which in the long run and
under the influence of psychological factors contributes to the chronification of
temporomandibular pain (30).
Case report
A 26-year-old female patient presented to the Department of Prosthodontics due to pain and
clicking in both TMJs. For a year she had symptoms, which were more pronounced during
dental procedures and mastication: pain in the left TMJ, which spread from the pre-auricular
region into the left ear. Clicking in the right joint was sporadic. She had pain in the left cheek
and frequent tension headaches.
Clinical examination. On the VAS, she rated the pain in the left TMJ as 8. She had treated
teeth (Angle class I), but also three teeth in the mandible which had not been
prosthodontically replaced. Mouth opening was painful and limited to 31 mm, measured on
the anterior teeth. Wear of dental planes was in accordance with the contours of the planes.
Laterotrusal movements had anterior guidance without balanced contacts. Anterior disc
displacement without repositioning was determined by manual functional analysis (upon
dynamic compression there was pain in the left TMJ and limited opening). Findings of
passive compressions supported the diagnosis because they showed inflammation of
retrodiscal tissues. Tendomyopathy of the left masseter was determined by isometric muscle
strain and palpation. During the examination, there was no painful pathology determined in
the right joint, nor clicking.
Physical therapy. The patient was examined by a physiatrist/rheumatologist and was
instructed by a physical therapist about active movement exercises. She practiced mouth
opening symmetry by using a mirror. The stretching exercise was performed by widening the
interincisal distance during mouth opening by using the thumb and index finger of the same
hand (Figure 1). By extending the tongue into the vestibulum anteriorly, she also performed
mobilization of the joints and muscles (Figure 2). The following exercise was bimanual,
simultaneous massage of the masseter and temporalis muscle as well as of the pre-auricular
region (TMJs). After that, with the mouth slightly open, the patient pressed her chin with the
fingers performing isometric contractions, which she also combined with head retractions.
Moderate at first and then forced head protractions were performed from a protracted position
(Figure 3).
Cervical spine exercises also included lateral head movements. The exercises were repeated
up to 15 times in each interval, depending on the pain threshold and the period of time in
which successive pain relief was attained. Lower pain intensity allowed longer and more
frequent exercising during the day.
Follow-up. Within a 6-month period, the patient did not have disturbances in the orofacial
region, and a significant improvement followed after only 10 days of regular physical therapy
at home. During the 5-year follow-up, she did not have any relapses, which was considered a
successful treatment by the patient.
Discussion
Numerous studies on physical therapy and exercising the joints in the body have shown its
efficiency in increasing mobility and pain removal (21). Extra-articular rheumatism (like
TMDs) as a consequence of overstrained tissue surrounding the joint and unfavorable effects
of the microclimate has been diagnosed more frequently – but it amounts to less than 1%.
These percentages of the causes of rheumatic disturbances and/or TMJ diseases can be
expected to potentially increase with age, thus multiplying physiatric treatments (8,27).
Apart from TMDs, differential diagnosis of orofacial pain should take into consideration the
neuropathic component as well, although the anatomic settings of Costen’s syndrome
etiopathogenesis have been rejected (15). However, trigeminal neuralgia as the most common
neuropathic pain of the stomatognathic system correlates the reduced distance of the
mandibular nerve with mesial disc displacement in a smaller number of selected patients
(30,31).
Immobilization of the mandible (immobilization splint) was not indicated except for cases of
jaw fractures. Proper restriction of the stomatognathic system does not treat any of the forms
of TMDs (21,23-27,32). Within the framework of personalized dentistry as a
multidisciplinary branch of various TMD treatment modalities, physical therapy and oral
exercises can be individually adjusted to each patient, and, after a physiatrist examination,
they can also be modified if indicated, which will help achieve the goal of removing
musculoskeletal disturbances from the body. Exercises which the patient performs at home
instructed by an expert – active and passive jaw movement exercises, correction of body
posture, and relaxation techniques – represent a part of the cognitive-behavioral therapy
(11,33).
Due to its nonspecific etiopathogenesis, there is still no gold standard in the treatment of
TMDs, so the modalities include irreversible, noninvasive and mostly symptomatic
procedures. The aim of treatment is to improve functioning of the stomatognathic system and
physical therapy has been advocated as a standard part of the multidisciplinary approach to
treating TMDs and the cervicocranial region (34,35). During the extended ‘Bone and Joint
Decade’, the public health issue of bone and joint diseases (such as osteoarthritis) should be
stressed as well as the development of diagnostic and treatment modalities for TMDs (36-38).
Kerschbaum et al. demonstrated the efficiency of oral gymnastics in pain reduction but it was
significantly higher in female (pain was reduced by 95%) than in male TMD patients (78%)
(39). In 8% of patients, there was no improvement during the period of physical therapy. Di
Fabio found great effects of physical therapy (mostly exercises, less than 7% of patients were
under other physiotherapeutic modalities) in the management of TMD patients (40). Physical
therapy improved both the patients’ physical and emotional dimensions of health-related
quality of life. Demling et al. found that physical therapy (mobilization of TMJ) is efficient as
adjunctive treatment to the Michigan splint, which leads to the reduction of pain and greater
mobility of the mandible (41). Nicolakis et al. assessed the influence of physical therapy
(exercise and manual therapy) on patients with osteoarthritis of TMJ (42). The initial period
without treatment served as a control period in which there was no improvement. After
physical therapy, there was a significant improvement in mandibular mobility and no pain at
rest in 80% of the patient sample. In a rigorous examination of physical therapy effectiveness
in TMD patients, Medlicott and Harris showed that active exercises and manual mobilization
may be effective (43). However, the quality of the clinical studies carried out to date did not
completely explain the efficiency of physical therapy for TMDs within evidence-based
dentistry and it is recommended to include the common physical therapy methods for cervical
spine disorders (44-46).
Based on the analysis of cervical spine and the TMJ, Matheus et al. did not find direct
connection between anterior disc displacement and the measured parameters of cervicocranial
dysfunction in TMD patients (47). However, they do not exclude the possible relation to other
forms of TMDs. La Touche et al. found a beneficial analgesic effect of joint mobilization with
exercise protocol for cervical spine in patients with myogenic TMD (48). The treated patients
had wider and painless mouth opening. Wright and North demonstrated that joint knowledge
of dentists about TMDs and of physical therapists on the application of physical therapy
methods could significantly contribute to a more efficient management of TMD patients (34).
Andrade et al. did not find differences in head and hyoid bone position between TMD patients
and controls (49). Regardless of that, TMD patients suffered on average 4.7 times higher pain
intensity in the cervical musculature than controls. A study by de Farias Neto et al. showed
that TMD patients had a tendency to present flexion of the first cervical vertebra and
hyperlordosis of the cervical spine (C2-C7) (7). However, their study cannot explain the
causal relationship, that is, the main risk factor between TMD and cervical disorder. There is
still a lack of quality studies to make a final conclusion about the relationship between
cervical disorders and the stomatognathic system (4)
Conclusion
The diagnosis and treatment of TMDs require a multidisciplinary collaboration and, due to
this, physical therapy has a prominent position when choosing treatment modalities.
Cervicocranial and orofacial pain is successfully treated by passive exercises and
mobilization, which involves TMJs and masticatory muscles. The usefulness and clinical
value of physical therapy was demonstrated in a recent review of the literature, although there
is no universal gold standard in the treatment of TMDs. It is of utmost importance for the
patient to be actively involved in a home exercise program.
Conflict of interest statement
The authors declare that there is no conflict of interest.
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