• Dr. Brian Abelson

Temporomandibular Disorders (TMD)

Updated: Nov 1


Temporomandibular Disorders (TMD) are a group of common disorders that affect millions of people each year. Although commonly occurring, TMD is 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 evaluate properly, 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 comprises two osseous structures the temporal bone and the mandible.


Here are some of the critical 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 the opening of the mouth there is rotation and anterior translation of the TMJ condyles.

  • On lateral deviation of the jaw, a complex process occurs in the TMJ, ipsilateral rotation, and contra-lateral anterior translation with medial rotation

  • The TMJ contains a biconcave Intra-articular disc. This disc is divided into an upper joint capsule (discotemperal region) and a lower joint capsule region (discomandibular region)

  • The TMJ disc is attached to the medial and lateral aspects of the mandibular condyle. In addition, the disc is attached to surrounding ligamentous and muscular tissues. The surfaces of the TMJ are lined with fibrocartilage (not hyaline cartilage).

Clinically


If the patient's jaw pain is joint-related (arthrogenous), there is usually joint line pain. There will be pain directly over the TMJ with motion or palpation. In addition, there is often a grinding sound or sensation of joint motion (crepitus).


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, and 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 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 addition, it is the second most common MSK disorder (chronic low back pain is number one). (1)

Temporomandibular disorders are divided into intra and extra‐articular disorders.

  • Intra‐articular disorders are often related to inflammation within the joint, degeneration (osteoarthritic processes), or internal structural change.

  • Extra‐articular disorders are often due to over-activity or muscle imbalances within the muscles of mastication and often have contributing factors from the cervical spine. (3)

 

TMD SYMPTOMS

TMD symptoms include: (11)

  • Jaw discomfort or soreness

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

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

  • Abnormal joint sounds (clicking, popping, snapping, 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 autonomic nervous system dysfunction, especially in increased stress or anxiety cases. Abnormal breathing patterns are commonly seen 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 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 region of your body.

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

  • Tinnitus, Vertigo, or hearing issue – (Vestibular impulses)

  • Noticed changes in sensation head, neck, and shoulders – (peripheral neuropathy).

  • Bruxism or grinding.

  • Comorbidities.

  • Observation - Check for:

  • Local swelling, apparent asymmetry, scars.

  • Observed deviation of the mandible when opening the jaw.

  • Resisted deviation of the mandible

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

  • Abnormalities of both oral and extra-oralwear structures.

  • Abnormal Wear of teeth.

  • Crepitus (continuous grating)

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

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

  • Pain-free – unassisted mouth opening (Normal is 35 to 40 mm).

  • Maximum unassisted mouth opening.

  • Maximum assisted mouth opening.

  • Lateral deviation (normal 7 mm).

  • Jaw protrusion (6 mm).

  • Resisted mouth opening

  • Resisted closing of the mouth

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

  • Crepitus - Record any sounds of crepitus or grinding sounds (DJD/OA)

  • Compression Test for TMJD – Create an overpressure during jaw movements, and evaluate the results. Compression Test article.

  • Palpation of the muscles of mastication. Typical results are: (8,9)

  • A localized pain in 57% to 97% of patients with TMD.

  • A localized pain in 10% to 29% of patients without TMD.

  • Check for myofascial pain with referral in jaw muscles (trigger points).

  • Assess both the cervical and thoracic spine in all TMD cases.

  • Include a postural assessment for all TMD patients.




 

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 on to 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 particular pain-referral pattern (refer pain to the TMJ and the ear). Here are some of the major features of the masseter muscle: (11)

  • Masseter Muscle Origin: The superficial and deep portions 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).

  • Masseter Muscle Innervation: Masseteric nerve arises from the anterior branch of the mandibular division of the trigeminal nerve (CN V). (34)

  • Masseter Muscle Palpation:

  • First, do the three knuckle test. If the patient passes the three knuckle test, they are unlikely to have trigger points in the masseter or temporalis muscles.

  • The superficial section of the masseter muscle is most commonly involved with trigger point formation.

  • The entire masseter muscle should be palpated for trigger points. The belly of the masseter can be palpated using cross friction pincer palpation. One digit of the practitioner's hand is inside the cheek, and one is on the outside.

  • It is easier to feel trigger points inside the mouth, because the parotid gland is on the outside.

  • The masseter near the angle of the mandible can be palpated externally using a cross fibre palpation method. Have the patient bite bite down to feel the muscle.

  • Masseter Muscle Trigger Points:

  • Trigger points in the deeper sections of the masseter muscle often refer pain to the TMJ and the ear, which can cause tinnitus symptoms. (38) In some cases applying pressure to masseter muscle can alter the tinnitus symptoms. Tinnitus of neurological origin must be distinguished from myofascial origin.

  • The superficial sections of the masseter muscle often refer pain to the maxilla, mandible, and eyebrow. (35)

  • Restrictions or trigger points in the masseter muscle can make it difficult for the patient to open their mouth. A restriction on only one side of the masseter muscle will deviate the jaw inward on the affected side. (10,11)

  • Trigger points in the masseter muscle often contribute to tension headaches and mechanical neck pain. (36,37)

The Temporalis Muscle

The temporalis is another muscle commonly involved in TMD (and tension headaches). (41) Here are some of the significant 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. Interestingly, the temporalis muscle has demonstrated an antagonistic contraction during mouth opening in patients with masseter muscle contracture. (40)

  • Temporalis Muscle Innervation: Anterior and posterior deep temporal nerves arise from the anterior branch of the mandibular division of the trigeminal nerve (CN V).

  • Temporalis Muscle Palpation:

  • Practitioners should be careful when palpating the temporalis muscle. Even when being gentle, trigger points in this muscle can be very painful.

  • Trigger points are often found in the anterior portion of the muscle, though they can be located anywhere in the muscle.

  • The patient can be supine or sitting. The jawfibre should be slightly open in a relaxed position (increases muscle fibre stretch).

  • Use cross-fibre flat palpation externally, looking for tight bands.

  • For the section near coronoid process, use a gloved internal exam on the inner surface of the coronoid process. Apply pressure outward against the coronoid process.

  • Temporalis Muscle Trigger Points:

  • Trigger points in the temporalis muscle are often related to headaches, deep head pain throughout the entire temple region, eyebrow pain, upper teeth pain, and pain behind the eyes. In some cases, pain refers to the Maxilla the TMJ.(10)

  • Direct trauma from a fall, MVA, or any type of hit can cause trigger points to form in the temporalis muscle.

  • The pain-referral pattern for the temporalis muscles often reproduces the same pain pattern as a tension headache.

  • Any action that keeps the temporalis muscle in a shortened or lengthened position can aggravate trigger points in the temporalis muscle. For example, gum chewing, grinding teeth, jaw clenching, or even keeping the mouth open for an extended period (dental appointments).

  • Forward head posture (anterior posture) increases tension on the temporalis muscle. This is caused by increasing pressure being placed on both the suprahyoid muscles and the infrahyoid muscles.


Clinically: Patients who grind their teeth (bruxism) often exacerbate problems involving the temporalis muscle. (10) One of the differentials that should be ruled out in treating the temporalis is temporal arthritis.

The Medial Pterygoid Muscle

The medial pterygoid is deep to the mandible and comprises two heads (superficial and deep).


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


Though there has not been as much research on the medial pterygoid muscle compared to the other muscles of mastication, the medial pterygoid muscle can still be involved in TMD. Some of the significant features of the medial pterygoid muscle: (11)

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

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

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

  • Medial Pterygoid Muscle Innervation: Medial pterygoid branch of the mandibular division of the trigeminal nerve (CN V).

  • Medial Pterygoid Muscle Palpation:

  • Patient supine, intraorally examined (use glove). Cross over molars to the anterior edge of ramus of mandible (posterior and lateral to first molar). The belly of the muscle is immediately posterior to the border edge of the ramus.

  • A very thin layer of mucosa covers the belly of the medial pterygoid muscle. Note: Palpation of the medial pterygoid muscle is often extremely painful when a trigger point is present.

  • Medial Pterygoid Muscle Trigger points:

  • Pain-referral patterns for the medial pterygoid muscle are usually more dispersed (rather than localized), with pain referring to the mandible, maxilla, teeth, and ear. (12,42)

  • Patients with trigger points in the medial pterygoid will have increased pain with jaw opening, in addition to an actual physical jaw restriction.

  • Patients with a trigger point in the medial pterygoid often have associated trigger points in the masseter, temporalis, lateral pterygoid and SCM muscles.


The Lateral Pterygoid Muscle


The lateral pterygoid muscle plays a significant role in 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 can play a significant role in cases of TMD. It can also be involved in headaches, nerve entrapment syndromes, oromandibular dystonia, otolarynic symptoms (ears, nose, throat, head and neck), and even myositis ossificans.


The lateral pterygoid muscle has an upper and lower head. Some of the significant 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 parts of the inferior division are innervated by a branch of the buccal nerve. The medial aspect of the lower head is innervated by a branch that comes from the anterior trunk of the mandibular nerve.

  • Lateral Pterygoid Muscle Action:

  • There is some controversy in the literature about lateral pterygoid actions. Most authors agree that the lateral pterygoid muscle opens the mouth (causes mandibular depression), and contra-lateral excursion. Especially while chewing food. (46)

  • Another function noted in the literature for the lateral pterygoid is decreasing tension on the TMJ disc, by keeping it positioned beneath the condyle. Lateral pterygoid contraction creates forward pressure on the disc and the neck of the mandible. (47)

  • Lateral Pterygoid Muscle Palpation:

  • Patient supine, index finger presses posterior along the vestibule that forms the cheek pouch. Move your finger past the maxillary tuberosity and squeeze between the maxilla and the coronoid process. Lateral deviation of the jaw to the ipsilateral side will increase this space, making it easier to palpate. (50)

  • Lateral Pterygoid Muscle Trigger Points:

  • Patients with trigger points in the lateral pterygoid muscle often report sinus pain (or recurrent sinusitis). In addition, they may have throat or neck discomfort (including congestion, sore throat, nasal congestion or pressure). (48) Research has also shown a possible link to trigger points in the lateral pterygoid muscle and tinnitus. (48)

  • Pain from the trigger point in the lateral pterygoid muscles can refer deep into the Temporomandibular joint (TMJ) and the Maxillary Sinus region.

  • Trigger points can even contribute to increased secretion of mucus in the maxillary sinus, tinnitus symptoms, and limitations in the range of motion of the TMJ. (48)

  • It should be noted that trigger points in the cervical region can refer directly to the lateral pterygoid muscle. Because of this, the lateral pterygoid muscle trigger points may not resolve until cervical issues are addressed. (48)



Anatomy and Palpation

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


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




 

TREATMENT OF TMD

Good evidence supports the effectiveness of manual therapies and exercise in treating TMD. Good evidence supports the efficacy of (16). In addition to using soft-tissue techniques, mobilization of the cervical spine has been shown to decrease overall pain intensity and increase mandibular movement. (16)


Adjusting The Jaw?


I am all for doing manual therapy on both the osseous and soft tissue surrounding the jaw. That being said, I am not a fan of HVLA jaw adjustments (High Velocity Low Amplitude adjustments). There is very little research (good search) to support these procedures.


From my clinical experience (over the last 30 years), HVLA adjustments toto the jaw can be counterproductive (Neck yes, jaw NO). I have had numerous patients who were previously treated by practitioners making osseous adjustments of the TMJ. Many of these patients did not see any improvement or had a substantial increase in symptoms. Especially when the joint being adjusted was already hyper-mobile.


I have found mobilization techniques to be very effective in increasing mobility of restricted TMJ. There is evidence to support these procedures. I am referring to anterior medial or lateral gliding or distraction procedures. (27)

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. 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 behavioural 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


Good evidence supports using a multi-modal approach combining soft tissue procedures and 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 the 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) need 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, he demonstrates 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.

  • Some cases of TMD require a localized approach (18), while others require a more systemic approach (18).

  • In all cases of TMD, the practitioner must consider kinetic chain connections, tissue remodelling of previous injuries, muscle imbalances, postural stresses, and even the neurological effects of long‐term stress (central sensitization mechanisms).

  • Joint restrictions of the cervical and thoracic spine must also be addressed.

  • We have found that the key to effectively treating TMD is to formulate a treatment specific to the individual's needs.


 

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 from the fascial community. In comparison, Dry Needling (medical acupuncture) is primarily directed at releasing trigger points (tender points within the muscle and connective tissue).


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


An in-depth discussion on acupuncture and dry needling is far beyond the scope of this article. That being said, a lot of research supports the use of acupuncture/dry needling in treating TMD. (51,52,53) Even using a limited amount of acupuncture points can reduce pain, and speed the healing process.


Specific Points


The following are some common acupuncture points we use in treating TMD. We would also use dry needling procedures on related anatomical structures (muscles of mastication). Which points or regions we would address would depend on the specific TMD case. There is good evidence to support the use of acupuncture in treating stress and anxiety, a major component of TMD. (54,55,56,57,58)


ST 6 Acupuncture Point – Jiache. Location - One finger width anterior and superior to the angle of the mandible at the belly of the masseter muscle with teeth clenched.

ST 7 Acupuncture Point – Xiaguan. Location - On the face, anterior to the ear, in a depression between the zygomatic arch and the mandibular notch, with the mouth closed.


SI 8 Acupuncture Point – Xiao Hai. Location - Between the ulna's olecranon process and the humerus's medial epicondyle, found with the elbow flexed.




LI 4 Acupuncture Point - He Gu. Location - The middle of the 2nd metacarpal bone on the radial side.






GB 20 Acupuncture Point - Feng Chi. Location - In a depression between the upper portion of the sternocleidomastoid muscle at the trapezius.


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





 


FASCIAL EXPANSIONS


In the world of musculoskeletal medicine, fascia is the new golden child. Practitioners who integrate fascial procedures into their excellent treatment modalities can often obtain outstanding results.


Fascia forms a seamless web of connective tissue, which connects, holds, and infuses the tendons, organs, muscles, tissues, and skeletal structures. Fascia plays a critical role in communication, in maintaining a memory of our body’s history and acting as both a tensional network and as a living matrix.


Restrictions in these facial planes can be addressed with various procedures, including acupuncture. In my opinion, at least three fascial planes in the case of TMD should be considered. (9) These are:


Epicranial Fascia (Green Circles)

The epicranial fascia forms a union between the occipitalis and frontalis muscles, and it is continuous with the temporal fascia, which covers the temporalis muscle. Anteriorly the epicranial fascia becomes Tenon’s Fascia.


Acupuncture Point ST-8 (Touwei) Indications: tinnitus, facial paralysis, facial pain, and motor impairment of the jaw


Tenon’s Fascia (Red Circles)


Tenon’s fascia forms a sheath for the elevator muscle of the upper eyelid. The posterior third of Tenon’s fascia connects with the orbital fat which,h becomes continuous with the sheath of the optic nerve.

Acupuncture Points B1 (Jingming) Indications: blurred vision, myopia, eye pain, and lacrimation.


Acupuncture Point B2 (Zanzhu) Indications: headache, blurred vision, supraorbital pain, twitching of the eyelids, and glaucoma.




Pterygoid Fascia (Light Brown Circles)

The pterygoid fascia covers the medial and lateral pterygoid muscles and connects with the capsule of the temporomandibular joint (TMJ). A portion of the upper head of the lateral pterygoid muscle inserts directly into the anteromedial part of the articular disc. Therefore, the lateral pterygoid muscle and its fascia can directly influence the position of the articular disc during TMJ movement.


Acupuncture Point SI-19 (Tinggong) Indications: tinnitus and motor impairment of the temporomandibular joint.




Acupuncture Point S-7 (Xiaguan) Indications: tinnitus, facial paralysis, facial pain, and motor impairment of the jaw

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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 cause 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 patient including contraindications and the 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 an excellent 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.

I think it is essential 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, which we teach in our Motion Specific Release courses.






















Note: Research demonstrates that upper cervical adjusting decreases facial pain (direct 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!


RECOMMENDED REFERENCE BOOKS

Netter Atlas of Human Anatomy https://amzn.to/3SQYWgx

Functional Atlas of the Human Fascial System - Carla Stecco https://amzn.to/3TE1EqP Functional Anatomy: Anatomy, Kinesiology, and Palpation https://amzn.to/3f49Xgn

The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns and Stretching Joseph E. Muscolino – https://amzn.to/3SAh5Pl

Anatomy Trains: Myofascial Meridians for Manual Therapists https://amzn.to/3SCkhtZ

Neuro Anatomy Publications https://amzn.to/3fj1RRe

Joint mobilization/manipulation extremity and spinal techniques https://amzn.to/3DxqCCs

The Trigger Point Manual - https://amzn.to/3gFDDRu

Chinese Acupuncture and Moxibustion (4th Edition) - https://amzn.to/3TRDs3M

Temporomandibular Disorder Publications/Books - https://amzn.to/3WjZX3w

 

EXERCISE & PATIENT EDUCATION

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


Exercises


Below is an example of some exercises 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 we prescribe to our patients after performing Motion Specific Release - MSR TMJ procedures.







Neck Stretching - PNF: PNF (Proprioceptive Neuromuscular Facilitation) is a type of stretching designed to increase flexibility/mobility and overall range of motion. PNF is a progressive stretch technique involving muscle contraction and relaxation. Neck stretching is crucial in 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 the best results. These exercises can make a huge difference in your posture, especially if you have been sitting for an extended period.






Jaw Clenching: For patients who clench their jaw throughout the day, we recommend jaw opening against resistance exercises. This is used to increase reciprocal inhibition of the masseter and medial pterygoid muscles, which will reduce excessive muscle activation.


Breathing Exercises: Research has shown that flexibility, strengthening, and naso-diaphragmatic breathing exercises can significantly improve posture. Which in turn can have a positive effect on treating TMD.


 

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 in treating severe cases of TMD. Considering this, prescription medications are not within the scope of most manual practitioners. When your patient's TMD is so painful 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 that hurts their jaw, such as yelling, singing or nail biting.


Hot & Cold Therapy: Practitioners should recommend using heat or ice based on sound logic. In my clinical experience, the 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 exacerbate your patient's problems when they are suffering from 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, and anything that is not soft.

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

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

Postural Recommendations

In clinical experience, postural recommendations can have a significant effect 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 a position where shoulders are relaxed), monitor position, use headset (do not cradle phone with shoulder). Take frequent brakes while working.

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

  • Use an orthopedic pillow during sleeping.

  • Forward head posture can contribute to the development of trigger points in the masseter and temporalis muscles. Research has shown that mouth breathing, compared to nose breathing, can significantly negatively impact posture. (44, 45)


Stress Management

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


Note: Forward head posture is often associated with mouth breathing, a contributing factor in the development of trigger points related to TMD. In Tai Chi and Yoga, the tongue is often placed on the roof of the mouth behind the incisor teeth. This is an effective strategy that can be used throughout 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 evaluate properly, 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 education must cover pain management, dietary, postural, 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). EBPs 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 Motion Specific Release (MSR) Treatment Systems developer. His clinical practice is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication, which will be available later this year.


 


Make Your Appointment Today!

Make an appointment with our incredible team at Kinetic Health in NW Calgary, Alberta. Call Kinetic Health at 403-241-3772 to make an appointment today, or just click the MSR logo to the right. We look forward to seeing you!






 

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


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


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










 

REFERENCES

  1. National Institute of Dental and Craniofacial Research [7/28/2013];Facial Pain. http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/FacialPain/

  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.

  7. Eur J Oral Sci,
Okeson JP. (1998). Management of temporomandibular disorders and occlusion. St Louis: CV Mosby.

  8. Orbach R, Fillingim RB, Mulkey F et al. Clinical finding and pain symptoms as potential r