SOME PHYSIOTHERAPY PROTOCOLS FOR THE MANAGEMENT OF TEMPOROMANDIBULAR JOINT DISORDERS

 

SOME PHYSIOTHERAPY PROTOCOLS FOR THE MANAGEMENT OF TEMPOROMANDIBULAR JOINT DISORDERS

Dr Amna Khalid(king Edward Medical University Lahore), Dr Saima Jabbar(University of Lahore), Saba Irfan(Government College University Faisalabad).

ABSTRACT

Physiotherapy plays an important role in the management of muscular, musculoskeletal, neuromuscular and neuro-musculoskeletal disorders. Physical therapy treatments can be used to relieve pain and for restoration of movements and normal functioning of the Temporomandibular joint. The main purpose of this study was to know about different physiotherapy protocols for the management of Temporomandibular joint dysfunctions/ disorders. It is a literature review and different search engines were used to review this article.

KEYWORDS

Temporomandibular joint(TMJ), temporomandibular joint disorders, non-surgical treatments for TMJ dysfunctions, manual therapy for TMJ, LASER therapy for TMJ.

TMJ= temporomandibular joint.

INTRODUCTION

The temporomandibular joint is categorised as a hinge joint present between the mandibular fossa of the temporal bone and the condylar head of the mandible. It is also known as the jaw joint.

The articular disc between the condyle and the temporal bone serves to separate the structures into two separate joint cavities. In the inferior joint between the head of the mandibular condyle and the articular disc, the movement is almost totally of a rotary or hinge type whereas in the superior joint between the temporal bone and the articular disc the movement is gliding or translatory. The movement of the mandible needs coordination between them to maximize function and minimize the damage to surrounding structures (Sharma et al., 2011).

PREVALENCE OF TMJ DISORDERS

Temporomandibular pain and jaw dysfunctions have negative effects on daily life. The temporomandibular joint disorder can affect 5 to 12% of the population. Some studies have even reported higher incidences up to 25% and 33%  to 40%  in the general population (kmeid et al.,2020). Women are affected more often than men, with 9 women to every 1 man experiencing severe pain and restricted jaw movement (Porten, 2017).

CLINICAL FEATURES

The American Dental Association in 1983 suggested that temporomandibular joint disorders are characterized by the following sign and symptoms;

·         pain in temporomandibular joint, periarticular area and muscles of mastication.

·         Sounds in TMJ ( clicking, popping, crepitus).

·         Joint locking (Munir et al., 2015).

Additional signs and symptoms include headache, neck pain, tenderness of the jaw, difficulty in chewing, dizziness. It is also linked with conditions like sleep apnea, autoimmune disorders, psychiatric illness i.e. depression (Mishra, 2019).

RISK FACTORS

·         Joint or muscle trauma

·         Arthritis ( rheumatoid, osteoarthritis )

·         Chronic grinding and clenching of teeth

·         Connective tissue diseases (Mayo clinic, 2018).

PHYSIOTHERAPY TREATMENTS FOR TEMPOROMANDIBULAR JOINT DISORDERS

The American Academy of Craniomandibular Disorders and the Minnesota Dental Association have cited physical therapy as an important treatment  to relieve musculoskeletal pain, reduce inflammation, and restore oral motor function. Numerous physical therapy interventions are potentially effective in managing TMD, including electrophysical modalities, exercise, and manual therapy techniques (McLeeny et al., 2006).

ELECTROTHERAPY MODALITIES

·         TENS(Transcutaneous electric nerve stimulation)

TENS is a mild electrical current applied to the skin over the temporomandibular joint to interfere with the pain signals, to relax the muscles and improve the circulation (Health wise staff, 2019).

·         ULTRASOUND

Ultrasound uses the high frequency sound waves directed to the temporomandibular joint to reduce the pain and swelling and improve circulation (Health wise staff, 2019).

·         LASER THERAPY / LLLT(LOW-LEVEL LASER THERAPY)

 LLLT has been considered effective in reducing pain and muscular tension; thus improving the quality of patients' lives having temporomandibular joint disorders (Dostalova et al., 2012).

·         IONTOPHORESIS AND PHONOPHORESIS

Iontophoresis is the transcutaneous delivery of ions into the body for the therapeutic purpose by using DC electric current. Phonophoresis is a physical therapy technique that combines ultrasound and topical drugs(NSAIDs) such as dexamethasone, diclofenac(Jewell, 2018). Diclofenac gel phonophoresis is an effective physical therapy for the management of TMD, evaluated by pain improvement and function recovery (Caudors et al., 2020).

EXERCISE THERAPY

·         Stretching and Relaxation:

Stretching and relaxation exercises are used to decrease the tension of muscle fibers. These exercises are recommended when motion range is limited and pain is present. The elevator jaw muscles are stretched when the jaw moves downwards (opening the mouth).This is considered an isotonic exercise because it presents dynamic muscle work, with rhythmic alternation between contraction and relaxation. One of the exercises frequently used to promote relaxation and stretching of the elevator jaw muscles involves opening and closing the mouth slowly. The apex of the tongue is positioned on the lingual surface of the maxillary incisors (pronunciation of the letter "N"). Pronouncing the letter "N" several times a day and keeping the tongue in this position, with lips closed, also promotes muscular relaxation (MORAES et al., 2013).

·         Coordination exercises:

Many times, besides causing limited range of motion and pain, temporomandibular joint disorders also cause incoordination of jaw movements, thus causing joint sounds like clicking ,popping and crepitus. Coordinated exercise includes exercises of opening and closing the mouth slowly in front of a mirror with a  straight vertical line is drawn, with the patient trying to keep the midline of the lower dental arch parallel to the mirror during the execution of movements (MORAES et al., 2013).

·         Strengthening and endurance exercises:

 muscular strength can be achieved by isometric, isotonic and isokinetic exercises. These can be performed by applying counter-resistance force (MORAES et al., 2013).According to dental press journal of orthodontics Exercises for stretching and relaxation are prescribed as a first-choice therapy when painful symptomatology is present.  Coordination exercises improve joint muscle function, mobility and biomechanics, reestablishing synchronism of jaw movements. strengthening and endurance exercises hinder relapse of TMD and are performed through isometric exercises along with the application of a light counter-resistant force (MORAES et al., 2013).

MANUAL THERAPY

·         Manual Reduction

 If the patient is unable to reduce the displacement by laterally moving the mandible and opening the mouth wide, manual reduction should be attempted. Manual reduction of the disk can usually be achieved by inserting the thumb into the patient’s mouth, grasping under the chin, and simultaneously pushing down on the posterior teeth and pulling up on the chin. The mandibular condyle will be distracted downward, allowing the disk to move posteriorly into place (Buescher, 2007).

·         Mobilization and manipulation

A number of studies have proved that Mobilization and manipulation techniques  can also be used for management of  temporomandibular joint disorders (Brantingham et al., 2013).  In mobilization, therapist moves the joint slowly within the range and in manipulation, short and sharp movement of joint beyond its normal range takes place.

The aim is to passively restore joint motion(ROM) and improve joint function (Mishra et al., 2020).

·         ACUPUNCTURE TECHNIQUE

Multiple research articles have shown that acupuncture helps in pain management, muscle relaxation, and minimising muscular spasm. Acupuncture technique can also help minimize the TMJ clicking by relaxing the lateral pterygoid muscle and reducing the anterior displacing force on the meniscus of temporomandibular joint (Goldstein et al., 2016). It can be done by inserting the sterilized thin hair like needle in area of jaw or around the ear. According to practical pain management  Acupuncture therapy may not eliminate the cause of temporomandibular joint disorder due to degenerative changes and disc displacement. It is an effective therapeutic intervention for head and facial pain due to muscular reasons (Goldstein et al., 2016).

In addition heat therapy uses to improve the blood circulation and ice therapy uses to reduce swelling and relieve pain.

A  national survey in the United Kingdom showed that, despite limited evidence, 72% of respondents considered physical therapy to be an effective treatment option for TMD, with jaw exercise (79%), ultrasound (52%), manual therapy (MT) (48%), acupuncture (41%), and laser therapy (15%) as the most effective modalities for managing TMD(Olivo et al., 2015).

CONCLUSION

Temporomandibular joint dysfunctions are becoming common among the population now a days. Physical therapy techniques seem to be more effective in PAIN management due to orofacial muscles impairments. Exercise therapy is more efficient as compared to other therapies. No doubt, physical therapy treatment is a slow working process but, Multiple studies have shown that physiotherapy is playing a positive role in management of multiple diseases.

 

ACKNOWLEDGEMENT

Special thanks to

 Sir M. Ahsan ul. Haqq  (M. Phill scholar, researcher in molecular and medical genetics, scout leader at Pakistan boy scout association).

Dr. Amna khalid ( research officer at GCUF).

Concepts of science academy .

AUTHOR’S DETAIL

Saba Irfan ( DPT)

Collage of Physical Therapy GCUF

 

 

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