• Dr. Brian Abelson

Jaw Pain 101 - Temporomandibular Disorders (TMD

Updated: May 12


Temporomandibular Disorders (TMD) are a group of common disorders that affect millions of people each year. Although commonly occurring, TMD is actually a very complex problem.

Individuals suffering from TMD may experience similar symptoms, but the affected anatomical structures and causes of this condition may vary from person to person.

The good news is that this complex problem can often be treated effectively, especially if one is willing to take the time to properly evaluate, and then customize each treatment to address that individual’s specific needs.


TMJ ANATOMY


The TMJ (Temporomandibular Joint) is one of the most complex joints in the human body. The TMJ is made up of two osseus structures the temporal bone and the mandible.


Here are some of the key anatomical aspects of the TMJ: (28,29,30)

  • The TMJ is a hinge or sliding synovial joint.

  • Besides being a sliding joint, it also involves spinning and compression movements.

  • Both sides of the TMJ act synergistically. On opening of the mouth there is rotation and anterior translation of the TMJ condyles.


Clinically



Restrictions or imbalances of one (or both) joints (and their related soft-tissues) can lead to headaches, tinnitus type symptoms, facial pain, vision problems, eye pain, tooth pain, balance issues, swallowing difficulties (dysphagia), neck pain, and dizziness.

WHAT IS TMD?

Temporomandibular Disorders (TMD) are a group of conditions that affect both the joints and the soft-tissue structures of the orofacial region. Orofacial pain is a general term covering any pain which is felt in the mouth, jaw and the face.

TMD affects millions of people each year. The prevalence of TMD is between 5% to 12% of the general population. It is also twice as common in women as men. (1, 2) In addiiton it is the second most common MSK disorder (chronic low back pain is number one).(1)

TMD SYMPTOMS

TMD symptoms include: (11)

  • Jaw discomfort or soreness

  • Pain directly over the Temporomandibular Joint (jaw line pain or pain in front of the ear).

  • Pain that radiated behind the eyes, facial pain, neck pain, shoulder pain, upper back pain.

  • Abnormal joint sounds (clicking, popping, snapping sound or grating sensation (crepitus) when eating food or opening or closing the mouth.

  • Clenching or Grinding of the teeth (Bruxism).

  • Limited motion or even locking of the Jaw

  • Difficulty chewing.

  • Difficulty opening or closing the jaw (limited mobility).

  • Pain in, and around, the ear.

  • Dizziness.

  • Teeth Sensitivity (without the presence of oral health issues).


CONCURRENT CONDITIONS

It is common for patients with TMD to suffer from other concurrent conditions. Some of these conditions are:(4,5)


Some of these conditions could be related to the autonomic nervous system dysfunction. Especially in cases of increased stress or anxiety. Abnormal breathing patterns, is commonly seem in cases of increased stress or anxiety.(4, 5)



DIAGNOSIS OF TMD

The diagnosis of TMD should be based on a review of the patient’s clinical history and a comprehensive physical examination.


When ruling out the presence of Red Flags check for:

The following are some of the factors that should be evaluated during the physical examination of TMD patients. This is in addition to any imaging that is required.

  • History - Check for

  • Pain intensity (Graded pain scale).

  • Pain Location (Pain drawing).

  • Jaw function (Graded scale) - how is pain made better or worse by jaw function and movement.

  • Arthritis in any other regions of your body.

  • Slow Progressive of Jaw Limitations – (Arthrosis of the TMJ.)

  • Observation - Check for:

  • Local swelling, obvious asymmetry, scars.

  • Observed deviation of mandible when opening jaw.

  • Resisted deviation of the mandible

  • Lowering of ipsilateral side of the mouth – (Bells Palsy)

  • Abnormalities of both oral and extra oral structures.

  • Abnormal Wear of teeth.

  • Crepitus (continuous grating)

  • Mandibular Range of Motion. (6,7) Record deviations to either side during mouth opening.

  • Number of knuckles in open mouth: (Normal 40-55 mm. ☐ 3-Normal, ☐ 2-reduction ☐ 1-decreased function.

  • Pain free – unassisted mouth opening

  • Maximum unassisted mouth opening.

  • Maximum assisted mouth opening.

  • Lateral deviation

  • Jaw protrusion

  • Resisted mouth opening

  • Resisted closing of the mouth

  • Clicking/Poping – Record any clicking sounds and identify which motions caused the clicking. (possible anterior subluxated meniscus)


MUSCLES OF MASTICATION

The muscles of mastication are often involved in TMD.

The pain a patient experiences may be directly related to the muscles of mastication or it can be caused by referred pain from other areas to these muscles.

The muscles of mastication involved in TMD cases are:

  • Masseter muscle.

  • Temporalis muscle.

  • Lateral Pterygoid muscle.

  • Medial Pterygoid muscle.


Note: This section is technical. It is designed for students, anatomy nerds and clinicians like myself. Feel free to move onto the next section "TREATMENT OF TMD".

The Masseter Muscle

The masseter muscle is one of the most common muscles involved in TMD pain. (35) When this muscle is involved, palpation often elicits a very specific pain-referral pattern. Here are some of the major features of the masseter muscle: (11)

  • Masseter Muscle Origin: Both the superficial and the deep portion attach to the Zygomatic Arch.

  • Masseter Muscle Insertion: Attaches to the Coronoid Process, to the superior half of the Ramus, and the angle of the Mandible.

  • Masseter Muscle Action: Elevates the Mandible and clenches the teeth (closes the jaw).


The Temporalis Muscle

The temporalis is another muscle commonly involved in TMD (and tension headaches). (41) Here are some of the major features of the temporalis muscle: (11)

  • Temporalis Muscle Origin: The Temporal Fossa and the Temporal Fascia, superior to the Zygomatic Arch.

  • Temporalis Muscle Insertion: The Coronoid process and the anterior border of the Ramus of the Mandible.

  • Temporalis Muscle Action: Elevates and closes the mouth, and is involved in retrusion and protrusion of the Mandible. What is interesting is that the temporalis muscle has demonstrated an antagonistic contraction during mouth opening in patients with masseter muscle contracture. (40)

The Medial Pterygoid Muscle

The medial pterygoid is deep to the mandible, and is comprised of two heads (superficial and deep).


Think of the medial pterygoid as serving a parallel function to the masseter muscle. Both these muscles are able to suspend the mandible. The masseter and temporalis muscles both help to close the jaw.


Some of the major features of the medial pterygoid muscle: (11)

  • Medial Pterygoid Muscle Origin: Superficial section: Tuberosity of maxilla, pyramidal process of palatine bone; Deep section: Medial surface of lateral pterygoid plate of sphenoid bone, just deep to the lateral pterygoid muscle. .

  • Medial Pterygoid Muscle Insertion: Medial surface of ramus and angle of mandible.

  • Medial Pterygoid Muscle Action: Bilateral contraction - Elevates and protrudes mandible Unilateral contraction - Medial movement (rotation) of mandible, deviates the mandible toward the contra-lateral side.

The Lateral Pterygoid Muscle


The lateral pterygoid muscle plays a significant role in both jaw movement and control. One of the things that makes the lateral pterygoid so interesting is that the superior head of this muscle is attached to the articular disc. (12) Tension in the lateral pterygoid could cause a progressive anterior displacement of the disc.


The lateral pterygoid muscle has an upper and lower head. Some of the major features of the medial pterygoid muscle: (11)



  • Lateral Pterygoid Muscle Origin: The Lateral Pterygoid has two heads. The upper head attaches to the greater wing of the Sphenoid bone and the lower head originates from the surface of the lateral Plate of the Sphenoid bone.

  • Lateral Pterygoid Muscle Insertion: The two heads converge to insert into the pterygoid fovea, on the front of the neck of the mandible (mandibular condyle).

  • Lateral Pterygoid Muscle Innervation: Superior and lateral part of the inferior division are innervated by a branch of the buccal nerve. The medial pat of the lower head is innervated by a branch that comes from the anterior trunk of the mandibular nerve.




Anatomy and Palpation

Want to learn more about the anatomical structures of the jaw and head, and how to palpate them? This is great information for students, practitioners, and patients.


Click to play this video - " 9 Muscles of the Head & Jaw" .





TREATMENT OF TMD

There is good evidence supporting the effectiveness of using manual therapies and exercise in the treatment of TMD. (16) In addition to the use of soft-tissue techniques, mobilization of the cervical spine has been shown to decrease overall pain intensity, and increase mandibular movement. (16)


Working With Your Dentist (Interdisciplinary Care)

I have found that taking a multidisciplinary approach often achieves excellent results.

We often treat our patients with TMD in conjunction with the advice of their dentist. In fact the Canadian Dental Association talks about this on their website in a section called "How Your Dentist Can Help". (19)

"After a thorough examination and, if needed, appropriate x-rays, your dentist may suggest a plan to treat your TMD. This treatment plan may include relaxation techniques, a referral to a physiotherapist, a chiropractor, or a behavioral therapist to help you ease muscle pain."

"Your dentist may suggest wearing a night guard, also called an occlusal splint. It is made of clear plastic and fits over the biting surfaces of the teeth of one jaw so that you bite against the splint rather than your teeth. This often helps your jaw joints and muscles to relax."

MANUAL THERAPY


There is good evidence to support using a multi-modal approach combining soft tissue procedures, osseous mobilization, with exercise. (31,32,33)


Addressing Soft Tissue Restrictions


The specific soft tissue procedures used to address trigger points, or soft tissue restrictions can vary greatly depending on patient and practitioner. Some of the procedures we have clinically effective are:

  • Motion Specific Release (MSR) Protocols

  • Cross friction massage

  • Instrument assisted modalities

  • Acupuncture and Dry Needling

  • Myofascial Release

Clinically we have found that both inter-oral and extra-oral structures need to be addressed for optimum results. In addition to the muscles of mastication, muscular in the cervical spine, and related restrictions in the shoulders (often involving posture) needs to be addressed.


Motion Specific Release - TMD Protocol


Motion Specific Release (MSR) is a “Treatment System”, combining the benefits of various and diverse therapeutic perspectives. MSR is NOT a technique, it is a treatment system! The following protocol is designed for integration into other treatment modalities.


The following two videos demonstrate the basic MSR-10 Point TMJ Protocol. In Part One Dr. Abelson demonstrates the external TMJ procedures, and in Part Two, the internal TMJ procedures.


Caution: MSR protocols should only be performed by certified MSR practitioners, and are not for practice by the general public. The videos we provide are strictly used for demonstration purposes only!

MSR 10‐Point TMJ Protocol (Part 1 and Part 2)























Practitioners often combine this protocol with cervical and shoulder/thoracic protocols - depending on the specific needs of the individual.



ACUPUNCTURE

DRY NEEDLING


The purpose of traditional acupuncture is to balance the flow of energy (Chi) and circulation in the body, and to reduce pain. Traditional acupuncture often produces a wide range of effects in areas of the body other than where the acupuncture needles are inserted. This is now supported by the incredible research coming out of the fascial community. In comparison, Dry Needling (medical acupuncture) is primarily directed at releasing trigger points (tender points within the muscle and connective tissue).


Personally I often combine Acupuncture/Dry Needling with our hands-on treatment modalities to release restrictions in the myofascial network (the body’ kinetic web/chain).


Note: Though acupressure can be used on these locations, we have found that needling (especially with electrical stimulation) is most effective.





NECK ADJUSTMENT VS. NECK MOBILIZATION


Restrictions in the cervical region are a common problem affecting the kinetic chain of patients who suffer from TMD (20). While Restrictions in the cervical spine may not be the cause of TMD, limited range of motion (lack of mobility) can be a significant perpetuating factor.


What procedure you use for addressing those restrictions should be based on the specific needs of the patients needs including contraindications and patient's treatment choices. Two of the common categories we use for addressing cervical spine restrictions are neck adjustments and neck mobilization

  • Neck Manipulation is a great tool for removing restrictions. That being said, cervical manipulation is not appropriate for everyone!

  • Neck Mobilization is a safe and effective alternative for releasing restrictions in the neck area.

In my opinion its is important to inform patients about the alternatives to just neck adjustments.

  • In the first video Dr. Mylonas reviews the differences between "Neck Adjustments Vs. Neck Mobilization".

  • In the second video Dr. Abelson demonstrates some of the neck mobilization procedures we use at Kinetic Health, and which we teach in our Motion Specific Release courses.






















Note: There is research demonstrating that upper cervical adjusting does decreased facial pain (immediate nociceptive modulation in the trigeminocervical complex). (23) There is also research evidence that cervical manipulation, especially when combined with craniomandibular manipulative therapy, decreases pain intensity and increases function. (22,24,26)


Caution: MSR protocols should only be performed by certified MSR practitioners, and are not for practice by the general public. The videos we provide are strictly used for demonstration purposes only!


EXERCISE & PATIENT EDUCATION

Supporting exercises, and patient edition are a critical components of any TMD treatment. The type of exercises that should be prescribed should always be dependent on the patient’s needs, and the current phase of treatment.


Exercises


Below is an example of some of the exercises that we could prescribe to our patients. Please note this is not a prescription for individual cases, our recommendations will vary depending on the specific case.


6 Effective - TMJ Exercises: These are examples of exercises that we prescribe to our patients after performing Motion Specific Release - MSR TMJ procedures. Caution:







Neck Stretching - PNF: PNF (Proprioceptive Neuromuscular Facilitation) is a type of stretching designed to increase flexibility/mobility and increase overall range of motion. PNF is a progressive stretch technique involving muscle contraction and relaxation. Neck stretching is a key aspect of inactivating any trigger points in the neck that could be perpetuating trigger points in the masseter, and temporalis muscles. (42)





5 Daily Shoulder Mobilization Exercises: You can perform these exercises throughout your day for best results. These exercises can make a huge difference in your posture, especially if you have been sitting for a long period of time.






Patient Education


Some of the most common recommendations we give are related to pain management, diet recommendations, and anxiety and stress reduction techniques.


Pain Management


Medications: Taking a multidisciplinary approach can give your patients a considerable advantage, especially treating severe cases of TMD. Consider this, prescription medications are not within the scope of most manual practitioners. When your patients TMD is so severe they cannot sleep, perform recommended exercise, or even tolerate treatment, then prescription medications may be needed.


Jaw Support: Make sure patients support their jaw when yawning, by putting a fist under their jaw then apply gentle pressure. Have them avoid any activity the hurts their jaw, such as yelling, singing or nail biting.


Hot & Cold Therapy: Practitioners should make recommendations for using heat or ice based on good logic. In my clinical experience heat seems to work better for most cases of TMD. Want to learn more. Click the following link and read Dr. Abelson's blog "Ice or Heat - Make an Educated Choice!"




Dietary Recommendations

Chewing the wrong foods can really exacerbate your patients problems when they are suffering form TMD. Some of the most common dietary recommendations we make are:

  • Choose soft foods to eat. These include scrambled eggs, oatmeal, yogurt, quiche, tofu, soup, smoothies, pasta, fish, mashed potatoes, milkshakes, bananas, applesauce, gelatin, or ice cream.

  • Don’t bite into hard foods. These include whole apples, carrots, corn on the cob, anything that is not soft.

  • Generally avoid any type of hard or chewy food: caramel, chips, dried meats, gum, gummy candies, hard breads, hard vegetables, nuts, popcorn, pretzels.

  • Cut your foods into bite-sized pieces before attempting to chew it. Try grinding or finely chop meats or other hard foods.

Postural Recommendations

In clinical experience, postural recommendations can have a significant effects on on treating TMD. The following are some of the common postural recommendations we make in cases of TMD

  • Work station ergonomics: Spinal supported ergonomic chair (armrests in position where shoulders are relaxed), monitor position, use headset (do not cradle phone with shoulder). Take frequent brake while working.

  • Keep your head in neutral position, avoid anterior head position. Try to keep your ears in line with your shoulders.

  • Use a orthopedic pillow during sleeping.

  • Forward head posture can be contributing factor in the the development of trigger points in the masseter and temporalis muscles. Research has shown that mouth breathing as compared to nose breathing can have a significant negative impact on posture. (44, 45)



Stress Management

In cases where a patient is experiencing severe stress it would be best to make a referral to professional. That being said, making recommendations of relaxation techniques such as breathing exercises can be of great benefit. Wan to learn more read Dr. Abelson article "Mindful Meditation - The Power of Breath".


Note: Forward head posture is often associated with mouth breathing, a contributing factor in the development of trigger points associated with TMD. In Tai Chi and Yoga the tongue is often places on the roof of the mouth behind the incisor teeth. This is an effective strategy that can be used through out the day, to minimize mouth breathing.






CONCLUSION

Temporomandibular Disorders (TMD) affects millions of people each year. Individuals suffering from TMD may experience similar symptoms, but the affected anatomical structures and causes of injury can be quite different.

The good news is that this complex problem can be treated effectively, in most cases, if one is willing to take the time to properly evaluate, and then build customized treatments that address that individual’s specific needs. Research supports the combination of addressing both osseous and soft tissue dysfunction. (21,22,25,26)


In addition exercise and patient education is extremely important. Patient educations must cover pain management, dietary recommendations, postural recommendations, and stress reduction.


Bottom-line, research supports treating TMD with a multi-modal approach. This perspective has provided our patients with faster, more effective lasting results.



DR. BRIAN ABELSON DC.

Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.

Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.



Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!







Discover more in Dr. Abelson’s book “Exercises for the Jaw to Shoulder”.


This book provides carefully selected exercises that help you to progress through the various phases of addressing TMD and problems of the cervical spine.


Exercises range in intensity, and help you to progress systematically through Beginners, Intermediate, and Advanced exercises for the Jaw, Neck, and shoulders. (18)










REFERENCES

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  2. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV. Oro‐facial pain in the community: prevalence and associated impact. Community Dent Oral Epidemiol 2002; 30: 52–60.

  3. Balasubramanium, R; Delcanho, R, Temporomandibular disorders and related headache; Headache, Orofacial Pain and Bruxism, Diagnosis and multidisciplinary approaches to management, Chapt 7, pg 76‐77, Churchill Livingston Elsevier, 2009.

  4. Lee WY1, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. J Orofac Pain. 1995 Spring; 9(2):161‐7.

  5. Edward F. Wright, D.D.S., M.S., Sandra L. Bifano, Ph.D. The Relationship between Tinnitus and Temporomandibular Disorder (TMD) Therapy ; International Tinnitus Journal, Vol 3, No. I, 55‐61 (1997).

  6. Dimitroulis G, Dolwick MF, and Gremillion HA. (1995). Temporomandibular disorders: clinical evaluation: Aust Dent J, 40(5), pp. 301‐305. In: Gould JA, ed, . St Louis: C.V.

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Okeson JP. (1998). Management of temporomandibular disorders and occlusion. St Louis: CV Mosby.

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  9. Stecco C. (2015). Functional Atlas of the Human Fascial System. Kindle Edition. Canada: Elsevier Health Sciences. Kindle Edition. Canada

  10. Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. 2nd ed. Baltimore: Lippincott William & Wilkins; 1999.

  11. Donnelly, Joseph. Travell, Simons & Simons' Myofascial Pain and Dysfunction Wolters Kluwer Health. Third edition, Copyright © 2019 Wolters Kluwer.

  12. Schmolke C. (1994). The relationship between the temporomandibular joint capsule, articular disc and jaw muscles. 184(2), J Anat, pp. 335‐345.

  13. Fujita S, Iizuka T, Dauber W. Variation of heads of lateral pterygoid muscle and morphology of articular disc of human temporomandibular joint: anatomical and histological analysis. J Oral Rehabil 2001; 28: 560–571.

  14. Tanaka E, Hirose M, Inubushi T et al. Effect of hyperactivity of the lateral pterygoid muscle on the temporomandibular joint disk. J Biomech Eng 2007; 129: 890–897.

  15. Stelzenmueller W, Umstadt H, Weber D, Goenner‐Oezkan V, Kopp S, Lisson J. The intraoral palpability of the lateral pterygoid muscle: A prospective study. Ann Anat 2016; 206: 89–95.

  16. Armijo‐Olivo S, Gadotti, I. Temporomandibular disorders. In Magee DJ, Zachazeski JE, Quillen WS, Manske RC, Pathology and Intervention in Musculoskeletal Rehabilitation. 2nd ed, pp. 119‐156.

  17. Enix DE, Scali F, DC, and Pontell ME. (2014). The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc, 58(2), pp. 
184‐192.

  18. Brian James Abelson, Kamali T. Abelson. Exercises for the Jaw to Shoulder ‐ Volume 1 of Release Your Kinetic Chain. Published by Rowan Tree Books Ltd. 2009.

  19. TMD (Temporomandibular Joint Disorder) https://www.cda-adc.ca/en/oral_health/talk/complications/temporomandibular_disorder/

  20. Calixtre LB, Oliveira AB, de Sena Rosa LR et al. Effectiveness of mobilisation of the upper cervical region and craniocervical flexor training on orofacial pain, mandibular function and headache in women with TMD. A randomised, controlled trial. J Oral Rehabil 2019; 46(2): 109–19.

  21. Corum M, Basoglu C, Topaloglu M et al. Spinal high-velocity low-amplitude manipulation with exercise in women with chronic temporomandibular disorders. Man Medizin 2018; 56(3): 230–8.

  22. Garrigos-Pedron M, La Touche R, Navarro-Desentre P et al. Effects of a physical therapy protocol in patients with chronic migraine and temporomandibular disorders: A randomized, single-blinded, clinical trial. J Oral Facial Pain Headache 2018; 32(2): 137–50.

  23. La Touche R, Paris-Alemany A, Mannheimer JS et al. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervo