The Role of Physical Therapy in Treating TMD by W. Hunter Lohorn
Conservative treatments for musculoskeletal disorders, specifically temporomandibular disorders (TMD), should always be considered as the first treatment option. Physical therapy (PT) is a well-known conservative treatment option for many musculoskeletal disorders. Unfortunately, many dental professionals are unaware of the role and treatment options that PT provides for effectively treating TMD. The purpose of this commentary is to highlight the issue of dentist being unaware of PT as a conservative option for TMD, to discuss the importance of a multidisciplinary approach for treating TMD, to briefly inform the readers of the role of PT in treating TMD, and to provide helpful resources for dentist including where to refer patients with TMD for PT.
In a cross-sectional descriptive study by Gadotti et al., 256 dentists that practice in the state of Florida completed a survey to “determine the awareness of dentists in Florida about the importance of PT for TMD pain”.(1) Almost half (41%) of the dentist that complete the survey were not aware that Physical Therapist can treat patients with TMD and 58% reported not referring patients to PT because they did not know about the benefits of PT in treating TMD.(1) While this study was limited to a relatively small region, it is reasonable to infer that a lack of understanding/awareness of PT as a beneficial treatment option is similar across the dental profession. Many reasons for not referring patients to PT for TMD have been reported throughout the literature. Some of these include lack of knowledge of the referral process, the belief that TMD requires too specific of treatment for PT to be beneficial, PT being only a temporary fix, or being unaware of where to refer the patient.
Temporomandibular disorders are termed as a musculoskeletal disorder that may originate from multiple areas associated with the orofacial region. These include the temporomandibular joint (TMJ), masticatory musculature, dental occlusion, and the cervical spine.(1) TMD is commonly associated with pain around the TMJ/masticatory musculature, decreased mouth range of motion (ROM), unusual sounds (e.g., popping, clicking, grinding, etc.), and headaches.
As the most common chronic orofacial pain condition(1), TMD can greatly affect an individual's work/social participation and subsequently decrease their quality of life. One topic that will be further discussed later is the importance of a multidisciplinary approach for treating TMD. This is largely due to the complexity of TMD and possible patient presentations including myalgia, arthralgia, myofascial pain, disc displacement disorders, degenerative joint disease, and headache attributed to TMD.(2)
The American Physical Therapy Association defines physical therapy as “treatment provided by a physical therapist or physical therapist assistant that helps people improve their movement and physical function, manage pain and other chronic conditions, and recover from and prevent injury and chronic disease.” (3) Physical Therapist are licensed doctors that are trained to examine and treat movement dysfunctions to improve the patient’s quality of life. For patients with TMD in particular, PT’s are able to identify the musculoskeletal components that contribute to the symptoms associated with TMD. Once identified they are then qualified to administer multiple modalities to treat TMD pain resulting from masticatory muscle pain, disc displacement, inflammation, TMJ hypo/hypermobility, fibrous adhesion, and/or bruxism.
Some common methods of treating patients with TMD by dentist are bite splints, prescription medication, followed by occlusion correction. (1) These have proven to be beneficial in improving pain associated with TMD. In a prospective randomized study comparing physical therapy to splint therapy in treating arthrogenous TMD, Ismail et al. reported that a combination of dental splint therapy PT resulted in “greater gains in mouth range of motion than splint therapy alone”. (4) In the same study, Ismail et al. determined that further improvement in passive jaw opening, maximum protrusive mandibular movement and total pain intensity was noted following PT. (4)
Physical Therapists should work in conjunction with dentist to rule in/out the cause of the patients complaints. For example, if a patient presents to a PT clinic with TMJ and neck pain the PT may need to refer the patient to their dentist after ruling in/out all musculoskeletal components. In line with that, if the same patient presents to a dentist first then the dentist may need to refer the patient to PT for a thorough examination of musculoskeletal concerns (e.g., cervical spine).
Collaboration between Dentist and Physical Therapists will only provide additional treatment options to improve the patient’s prognosis. As for the role of the PT, they are equipped with the knowledge and expertise to first educate the patient on proper posture and body mechanics, self-management, stress management, exercise, and much more. Secondly, as movement experts, they will prescribe postural and jaw exercises that have exhibited positive results when treating myogenous and arthrogenous TMD disorders. (5) Exercises that address posture and mobility of the head, neck, and orofacial region can be effective in reducing musculoskeletal pain and improving oromotor function. (5)
A common misconception of PT is that they only prescribe exercises and are similarly grouped with personal trainers. Manual therapy techniques independently or in combination with specific exercises has demonstrated positive results in musculoskeletal disorders. Benefits of manual therapy include restoration of normal ROM, reducing local ischemia, provoking proprioception, breaking-up fibrous adhesions, stimulating synovial fluid production, and reducing pain. (5) For example, when treating fibrous adhesion of the TMJ, an intraoral mobilization that is termed ‘lateral glide’ may be performed to target the restrictions in the lateral aspect of the capsular ligament complex. (6) In some cases, mobilizations of the cervical spine may elicit positive outcomes on orofacial pain and TMJ mobility. Other modalities provided by PT include but are not limited to soft-tissue release, ultrasound, electrical stimulation, dry-needling, iontophoresis, and phonophoresis. (5)(7)
For more information on modalities and the role of Physical Therapist in treating TMD please visit the link provided here.
While all Physical Therapist are qualified and capable of treating patients with TMD, as with any profession, some by more skilled than others. At this time, Physical Therapist that are certified and obtain the full depth of knowledge to treat TMD is somewhat limited. To assist with locating a certified Physical Therapist use the links provided below:
References
Gadotti IC, Hulse C, Vlassov J, Sanders D, Biasotto-Gonzalez DA. Dentists' Awareness of Physical Therapy in the Treatment of Temporomandibular Disorders: A Preliminary Study. Pain Res Manag. 2018;2018:1563716. Published 2018 Feb 28. doi:10.1155/2018/1563716
Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache. 2014;28(1):6-27. doi:10.11607/jop.1151
APTA. Resource: About physical therapists and physical therapist assistants. Choose PT. 2023. Accessed November 15, 2023. https://www.choosept.com/why-physical-therapy/about-physical-therapists-and-physical-therapist-assistants.
Ismail F, Demling A, Hessling K, Fink M, Stiesch-Scholz M. Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD. J Oral Rehabil. 2007;34(11):807-813. doi:10.1111/j.1365-2842.2007.01748.x
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
Kraus S. Temporomandibular disorders, head and orofacial pain: cervical spine considerations. Dent Clin North Am. 2007;51(1):161-vii. doi:10.1016/j.cden.2006.10.001
APTA. GUIDE: Physical therapy guide to temporomandibular joint disorder. Choose PT. July 29, 2022. Accessed November 15, 2023. https://www.choosept.com/guide/physical-therapy-guide-temporomandibular-joint-disorder.
