Bridging Smiles and Motion: The Dynamic Duo of Dentists and Physical Therapists in Treating TMD by Kaitlin Dillard

 What is Temporomandibular Disorder?

The TMJ is one of the most complicated joints in the human body, so much so that it is frequently avoided by practitioners. When the function of the TMJ is altered this dysfunction can be attributed towards surrounding muscles, ligaments, the disc within the joint or the joint itself. Headaches in the temporal region can also be caused due to jaw movement. These dysfunctions can be temporary or chronic and unlike other chronic pain disorders TMD is one of the few that mostly affect the younger generations. As of 2021, close to one third of adults have suffered from TMD. 


Common risk factors and patient populations that frequently suffer from TMD 

  • Between the ages of 20-40 years 

  • Bruxism

  • Trauma or microtrauma 

  • Psychological factors such as anxiety, depression, or PTSD

  • Occlusal abnormalities 

  • Women due to hormonal changes that increase ligament laxity 


Common symptoms of TMD seen in clinic:

  • Jaw pain

  • Difficulty opening mouth

  • Popping/clicking/catching while opening mouth

  • Lateral excursion while opening mouth

  • TMJ locking during opening

  • Headaches

  • Fatigue while chewing


Dental Treatment 

According to local dentist, Dr. Lisa Bufano, the first signs she typically sees during patient visits is the wear of the cusp tips especially on the facial aspect. The first molars are one of the first to wear down due to night time bruxism. Dr. Bufano mentioned over her years of practice TMD has grown more prevalent especially in the younger generations due to high stress and anxiety due to everyday life. A night guard is typically prescribed to preserve the integrity of the tooth as well as patient education such as a soft food diet, low dose ibuprofen as needed, decreasing/managing stressors, and reducing nail biting or ice chewing to relax facial muscles. She noticed most of her patients have flare ups of their TMJ dysfunction during higher stress times in their life. If conservative treatment is not successful or the patient has more of a severe case, Dr. Bufano typically will refer out to a local dentist with TMJ certifications, which can be rather pricey, as do the majority of the dentists she knows around the area. 



Physical Therapy Treatment

Physical therapy is researched to be one of the leading professions to treat TMD through more conservative measures rather than medications or intraoral appliances like splints or nightguards. Rather than focusing on the integrity of the teeth, PTs are more focused on restoring function of the joint and the musculature around it as well as assessing the origin of the pain. Due to the close relationship between the TMJ and the upper cervical spine, there tends to be treatment towards both regions to relieve pain or dysfunction. 

Common interventions used for physical therapy treatment are: 

  • Manual therapy (soft tissue release, joint mobilizations) 

  • Therapeutic exercises focused on strengthening/stretching 

  • Postural re-education 

  • Patient education

  • Modalities (E-stim, TENS, heat/ice)

The majority of general practice physical therapists have the ability to treat TMD but the PT profession has its own certification for TMJ treatment as well, Certified Cervical and Temporomandibular (CCTT).

 


Interprofessional Relationships

Co-treatment of TMD from both dentists and PTs has good quality evidence supporting a reduction in pain and disability. With dentists ability to diagnose, assess through imaging and provide orthotics/splints and physical therapists ability to rehabilitate the joint or muscle and manage pain, the balance between structural and functional aspects provides the best possible outcome. It is important to know when, as a dentist, to refer out to a physical therapist if your patient is not responding to conservative treatments such as lifestyle modifications or oral appliances. If a patient is suffering from chronic TMD or is experiencing limitations in daily life, such as chewing or opening their mouth, it would also be beneficial to refer to a physical therapist so they can form an individualized treatment plan for each patient. 


The interrelationships between dentists and physical therapists are crucial for these patients experiencing TMD. The majority of patients when having jaw related pain will make an appointment to see their dentist if day to day activities are being limited. This step is an important part of the process to help steer patients in the direction of physical therapy for treatment. Dr. Bufano states she wishes she had a great relationship with a local PT that she could refer her patients to but in her many years of practice no one has reached out to connect. As a physical therapist, if you are considering a speciality in treating TMD and upper cervical pain, it would be beneficial to create these interprofessional relationships early.



References 

  1. Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Phys Ther. 2016;96(1):9-25. doi:10.2522/ptj.20140548

  2. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Board on Health Sciences Policy; Committee on Temporomandibular Disorders (TMDs): From Research Discoveries to Clinical Treatment; Yost O, Liverman CT, English R, et al., editors. Temporomandibular Disorders: Priorities for Research and Care. Washington (DC): National Academies Press (US); 2020 Mar 12. 5, Caring for Individuals with a TMD. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557986/

  3. Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015;91(6):378-386.

  4. Brighenti N, Battaglino A, Sinatti P, et al. Effects of an Interdisciplinary Approach in the Management of Temporomandibular Disorders: A Scoping Review. Int J Environ Res Public Health. 2023;20(4):2777. Published 2023 Feb 4. doi:10.3390/ijerph20042777

  5. de Toledo EG Jr, Silva DP, de Toledo JA, Salgado IO. The interrelationship between dentistry and physiotherapy in the treatment of temporomandibular disorders. J Contemp Dent Pract. 2012;13(5):579-583. Published 2012 Sep 1.

  6. Ohrbach R, Dworkin SF. The Evolution of TMD Diagnosis: Past, Present, Future. J Dent Res. 2016;95(10):1093-1101. doi:10.1177/0022034516653922

  7. Valesan, L.F., Da-Cas, C.D., Réus, J.C. et al. Prevalence of temporomandibular joint disorders: a systematic review and meta-analysis. Clin Oral Invest 25, 441–453 (2021). https://doi.org/10.1007/s00784-020-03710-w

  8. Margaret L McNeely, Susan Armijo Olivo, David J Magee, A Systematic Review of the Effectiveness of Physical Therapy Interventions for Temporomandibular Disorders, Physical Therapy, Volume 86, Issue 5, 1 May 2006, Pages 710–725, https://doi.org/10.1093/ptj/86.5.710

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