AN EVIDENCE-BASED GUIDELINE FOR PHYSICAL

THERAPY MANAGEMENT OF TEMPOROMANDIBULAR

JOINT DYSFUNCTION (TMD)
Physical therapists have an important role on the interpersonal team to provide care for people with temporomandibular
disorders (TMDs). The purpose of this guideline is to provide the clinician with a variety of evidence based methods to
effectively evaluate and manage TMD.

Patient reported outcome measures

• The recommended patient reported outcome measure is the TMD Disability Index
• The TMD Disability Index (also referred to as the Steigerwald Maher TMD Disability Index) was created in 1997
and involves 10 functionally related questions associated with TMD. The scale is a self-report, disease-specific
instrument with five possible selections for each question, each with increasing severity. (6)
• A study in 2015 at European School of Osteopathy, University of Greenwich suggests that the TMD Disability
Index offers sufficient external validity and could be integrated into practice life as a quick, accessible, and easy
tool to monitor patients’ progress and assess levels of inflammation, without the need for repetitive imaging. (6)

Dietary considerations

• Dietary considerations include soft foods to minimize over stretching of the mastication muscles such as beans,
steamed vegetables or fruits, cheese or cottage cheese, fish, fruit smoothies, oatmeal or other soft, hot breakfast
cereals, mashed potatoes, scrambled eggs, soup, or yogurt (3)
• Refrain from eating any foods that require one to open too wide, sticky or chewy items such as caramel apples or
candy bars, hard or crunchy foods, apples, pretzels, or raw carrots, crunchy cereals, or tough steak
• One can progress to foods that initially were painful or difficult to consume
• Once symptoms have decreased to a manageable level, harder foods can be periodically tested for provocation
and reintroduced when appropriate (3)

Considerations for manual therapy

• Consider implementation of joint mobilization (grade I or II) for pain including distraction, anterior glide, anterior
glide with pre-positioned mouth opening (5)
• medial/lateral glides, caudal-anterior-medial (CAM) glide and CAM with pre-positioned mouth opening (5)
• Joint mobilization should be applied when a movement restriction is evident but should be avoided if joint
hypermobility is suspected or verified unless a low-grade technique is utilized (5)
• Joint mobilization dosage should be guided by an informed decision that takes into account the patient’s irritability
level and can include cervical manual techniques
• Consider implementation of intraoral and extraoral soft tissue mobilization
• At a minimum, the temporalis, masseter, medial pterygoid, and lateral pterygoid muscles must be considered (8)
• Accessory muscles of mastication and cervical spine musculature may also require management through soft
tissue mobilization (8)
• Utilizing one digit or one reinforced digit to contact a myofascial trigger point or the general muscle belly can be
helpful
• Friction massage can be applied in a variety of directions and are easily applied to the masseter and temporalis
muscle bellies
• Intra-oral techniques directed at the medial and lateral pterygoid muscles are useful as well (consideration of
patient gag reflex is recommended) (9)

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 • Trigger Point Dry Needling could be considered when TMD associated muscle pain is related to trigger points
(must be sufficiently trained to implement) (5)

Considerations for therapeutic exercise

• Perhaps the most widely known exercise routine for TMD is the Rocabado 6 x 6 program which utilizes six
exercises six time per day (see table 1)
• The program has only been studied once for effectiveness and suggests the program adds no extra benefit to the
rehabilitation process
• Kraus’ temporomandibular joint exercises include those to inhibit excessive masticatory muscle activity, target
both neuro-muscular control of mandibular movement, and address joint clicking, muscle asymmetry, deviations
in active ROM patterns, and spasms that limit opening via isometrics (see table 2)

Patient education

• Patient education is a central component of TMD management and should include reducing parafunctional habits,
addressing psychosocial factors, and providing pain science education
• Functional habits are generally limited to caloric intake, breathing, and yawning
• Parafunctional habits can include bruxism and lip biting
• The clinician should educate the patient with regard to food consistency, laterality of chewing (ie chewing on both
sides if able to promote symmetry or unilaterally initially if chewing is too uncomfortable), symptom behavior, and
pain variables
• Harder, drier foods require an increased number of chewing cycles and longer times in the mouth before
swallowing
• Those with hypermobility may require education to avoid end range positions such as with yawning
• To avoid overstretching and irritating joint structures with yawning, the patient should be taught not to depress
their mandible farther than the position that permits the tip of the tongue to maintain contact with the hard palate
just posterior to the upper incisors
• Refrain from weight bearing through the joint (ie: resting the hand on the mandible if sitting at a desk)

Modalities

• Electrical stimulation has been recommended for the management of TMD

• Both interferential current and transcutaneous electrical nerve stimulation (TENS) have been show to produce an
analgesic effect in pain-free volunteers provoked by ischemic conditions
• In this study, stimulation was applied for 30 minutes, which may exceed dosage times commonly utilized in
clinical settings
• The utilization of biofeedback has also been recommended for the management of TMD during which surface
electrodes are typically placed over the masseter or anterior temporalis
• Iontophoresis with dexamethasone has been recommended for use in the management of TMD; however,
evidence supporting this approach is mixed
• Studies have shown that iontophoresis can deliver dexamethasone between eight and 17 mm deep and that long
duration (3 hours) application via low current is more effective than more traditional delivery by higher currents
over 10-30 minutes
• There an abundance of evidence suggesting little benefit from therapeutic ultrasound in managing TMD, and is
not recommended by the authors who conducted the studies (10)

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Multimodal approaches

• A series of studies demonstrated that over a minimum of five 30-minute sessions, multimodal management of
TMD including soft tissue mobilization, muscle stretching, gentle isometric tension exercises against resistance,
guided opening and closing, manual joint distraction, disc/condyle mobilization, postural corrections, and
relaxation techniques are helpful in reducing symptoms associated with TMD (4)

Cervical spine management

• The clinician should take care to address any cervical spine range deficits, accessory movement restrictions, and
altered muscle recruitment patterns

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Author:

Erik Phillips, PT, DPT, MBA, OCS

Reviewers:

Paul Tadak, PT, DPT, OCS

Damian Jankowski, PT, DPT, MBA

Completion date: 11/19/18

References:

1.) Wilk B, Stenback J, McCain J. Post arthroscopy Physical Therapy Management with Temporomandibular Joint
Dysfunction. JOSPT, Vol 18 September 1993
2.) Placzek J, Boyce B. Orthopaedic Physical Therapy Secrets 2nd ed. pp 496. Elsevier Inc, 2006.
3.) Shaffer S, Brismee J, Sizer P, Courtney C. Temporomandibular disorders. Part 1: Anatomy and
Examination/Diagnosis. Journal of Manual and Manipulative Therapy 2014 Vol 22.
4.) Shaffer S, Brismee J, Sizer P, Courtney C. Temporomandibular disorders. Part 2: Conservative Management- A
Systematic Review. Journal of Manual and Manipulative Therapy 2014 Vol 22.
5.) Effectiveness of Manual Therapy and Home Physical Therapy in Patients with Temporomandibular Disorders: A
Randomized Control Trial. Journal of Bodywork and Movement Therapies 2013.
6.) Johnston K, Bird L, Bright, P. Temporomandibular Joint Effusion and its Relationship with Perceived Disability
Assessed Using musculoskeletal Ultrasound and a Patient-reported Disability Index. Ultrasound 2015 May; 2
7.) Harrison A, Thorp J, Ritzline P. A Proposed Diagnostic Classification of Patients with Temporomandibular
Disorders: Implications for Physical Therapists. Journal of Orthopedic and Sports Physical Therapy March 2014
Vol 44
8.) Cook C. Orthopedic Manual Therapy: An Evidence-Based Approach. 2007 Pearson Education, Inc. pp 151-176.
9.) Cleland J. Orthopedic Clinical Examination: An Evidence-Based Approach for Physical Therapist. 2005 Icon
Learning Systems pp 141-199.
10.) Vander Windt, DA, vander Heijen GJ, Vanden Berg SG, Bouter LM. Ultrasound therapy for musculoskeletal
disorders: A Systematic Review. Pain. 1999; 81: 257-71.

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Appendix

Figure 1 Distraction of the temporomandibular joint (TMJ); large arrow: distraction force placed through the
ipsilateral lower molars and premolars with the first digit while the second and third digits provide a counterforce
on the inferior aspect of the ipsilateral and contralateral mandibular bodies, respectively; medium arrow:
posteriorly directed stabilization force applied through the ipsilateral aspect of the patient’s forehead; small
arrow: the examiner palpates the joint line to assess for movement of the mandibular condyle.

Figure 2 Anterior glide of the temporomandibular joint (TMJ); large arrow: anterior glide force with mild
caudal bias placed through the mandible via gripping the ipsilateral lower molars and premolars with the
first digit while the second and third digits provide a counterforce on the inferior aspect of the ipsilateral
and contralateral mandibular bodies, respectively; medium arrow: posteriorly directed stabilization
force applied through the ipsilateral aspect of the patient’s forehead; small arrow: the examiner
palpates the joint line to assess for movement of the mandibular condyle.

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Figure 3 Medial/lateral glide of the temporomandibular joint (TMJ); large arrow: medial glide force placed through the
mandibular condyle and/or mandibular ramus; small arrow: the contralateral hand provides a stabilizing force either
through the contralateral zygomatic arch of the temporal bone and/or the contralateral mandibular condyle, depending
on the patient’s experience.

Figure 4 Caudal-anterior-medial (CAM) glide of the temporo- mandibular joint (TMJ); large arrow: combined
caudal, anterior, and medial glide force placed through the mandibular condyle and/or mandibular ramus;
small arrow: the contralateral hand provides a stabilizing force either through the contralateral zygomatic arch
of the temporal bone and/or the contralateral mandibular condyle, depending on the patient’s experience.

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Figure 5 Caudal-anterior-medial (CAM) glide of the temporomandibular joint (TMJ) with pre-positioned mouth opening;
large arrow: medial glide force placed through the mandibular condyle and/or mandibular ramus; small arrow: the
contralateral hand provides a stabilizing force either through the contralateral zygomatic arch of the temporal bone and/or
the contralateral mandibular condyle, depending on the patient’s experience.

Figure 6 Self-mobilization of the temporomandibular joint (TMJ); large arrow: medial glide force placed through the
mandibular condyle and/or mandibular ramus; small arrow: the contralateral hand provides a stabilizing force either
through the contralateral zygomatic arch of the temporal bone and/or the contralateral mandibular condyle,
depending on the patient’s experience.

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Figure 7 Self-mobilization of the temporomandibular joint (TMJ) with pre-positioned mouth opening; large
arrow: medial glide force placed through the mandibular condyle and/or mandibular ramus; small arrow: the
contralateral hand provides a stabilizing force either through the contralateral zygomatic arch of the temporal
bone and/or the contralateral mandibular condyle, depending on the patient’s experience

Figure 8 Soft tissue mobilization of the temporalis muscle utilizing one digit for contact and one hand for
contralateral stabilization. Palpation of an MTrP or the general muscle belly by the tip of one digit (second digit
shown) to apply soft tissue mobilization to the temporalis muscle. Switching between different digits can be
helpful in prolonging technique application time before the onset of fatigue. Note that a contralateral hand provides
a counterforce to stabilize the head and prevent inadvertent head motion. In this instance, the therapist begins
at the anterior margin of the muscle and moves posteriorly while focusing on areas of the muscle that require
treatment.

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Figure 9 Bilateral soft tissue mobilization of the temporalis muscle utilizing reinforced digits for contact. Palpation
of an MTrP or the general muscle belly by the tips of the second digits with reinforcement by the third digits to
apply soft tissue mobilization to the temporalis muscles. Note that both hands provide simultaneous treatment
and therefore serve as both the treating and stabilizing forces. In this instance, the therapist begins at the
anterior margin of the muscles and moves posteriorly.

Figure 10 Soft tissue mobilization of the medial pterygoid muscle. Palpation of the muscle belly by the tip of the
second digit to apply soft tissue mobilization to the medial pterygoid muscle. For treatment purposes, having the
patient relax so that the mouth is not opened widely can be advantageous. The open mouth position is utilized
here for visualization purposes.

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Table 1 Rocabado’s 6x6 exercise program

Name Exercise description/purpose

Rest position of the tongue The anterior 1/3 of the tongue is placed at the palate with mild pressure, which
rests the tongue and jaw musculature and promotes diaphragmatic breathing

Control of TMJ rotation The jaw is repeatedly opened and closed with the
anterior 1/3 of the tongue on the palate, which
decreases initiating jaw movements (e.g. protrusive
movement in opening, talking, or chewing)
Rhythmic stabilization technique Gentle isometrics in the resting position are performed for jaw opening, closing,
and lateral deviation to promote muscular relaxation via reciprocal inhibition,
which promotes an improved resting position of the jaw through proprioceptive
input
Axial extension of the neck Combined upper cervical flexion with lower cervical extension, allowing reduction
of tension in the cervical musculature
Shoulder posture Shoulder girdle retraction and depression to
facilitate postural corrections

Stabilized head flexion Upper cervical spine distraction via chin tuck (without
additional cervical flexion), during which it is
recommended that the fingers be laced behind the neck
to stabilize C2-7 while the head nods

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Table 2 Kraus’ temporomandibular joint exercises

Name Exercise description/purpose

Tongue position at rest The patient is instructed to maintain a resting tongue position except during
function, which involves the tip of the tongue sitting on the palate with the tip
resting just posterior to the upper incisors

Teeth apart The patient is educated that maintaining the teeth apart
can be therapeutic, which facilitates the resting tongue
position
Nasal-diaphragmatic breathing The patient is instructed in nasal breathing to facilitate function of the diaphragm,
which reinforces positioning of both the tongue and teeth
Tongue up and wiggle Patients who brace but whose teeth do not touch or grind while doing so are
instructed to routinely assume the resting position and gently oscillate the mandible
side-to-side to interrupt the bracing contractions. If clicking or popping occurs,
intensity is decreased
Strengthening Resisted closing via self-manual resistance of lower
incisors: 5–10-second contractions, 10 repetitions,
3–56/day

Touch and bite Proprioceptive re-education: Lateral deviation – the patient

touches the contralateral maxillary canine with the fingertip
(with affected right lateral deviation touch left canine) and
then bites the finger, which requires lateral deviation toward
the finger. Protrusion – repeat with finger touching the outer
surface of maxillary incisors.
Neuro-muscular control When excessive anterior movement of the mandibular condyle is noted, instruct
the patient to define end range opening by placing the tip of the tongue on the
anterior palate while the fingers gently palpate the chin and mandibular condyle.
Repeatedly open and close to that range.
Progression: incrementally remove feedback.
Isometric exercises Reciprocal click: isometrics are performed immediately before
the closing click. Weakness or AROM deviations not believed to
be from a structural anomaly: isometrics are performed in any
position. Muscle inhibition to improve ROM: agonists or
antagonists can be contracted gently.

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