1. Evaluation & Treatment of TMD
Presented by:
Christy Dauner, OTR
Laurie Applebee, PT
Susan Vaughn, MS, OTR

2. Learning Objectives Identify TMD risk factors and related diagnoses
Differentiate joint and muscle disorders
Understand goals of Occupational Therapy for TMD
Understand OT treatments for TMD and muscle disorders
Perform assessment and treatment approaches for TMD

3. Disorders of the TMJ Myofascial Dysfunction Internal Derangement
Capsulitis
Subluxation
Arthritis

4. Risk Factors for TMD
Trauma such as blow to the jaw, whiplash injuries, MVA, dental work, opening the mouth too wide or for too long, prolonged chewing
Oral parafunctional habits such as clenching and bruxism that place continued strain on the masticatory system
Malocclusion causes bite instability or functional interference during chewing that places postural strain on the masticatory system
Stressful life events can trigger parafunctional habits and muscle guarding/tension
Emotional factors such as depression or anxiety decreases the ability to cope with pain and can increase parafunctional habits.

5. TMJ Evaluation History & Symptoms (referred pain)
Functional Limitations
Tests, Measures & Palpation
AROM (active/passive incisal opening, lateral excursion, and protrusion)
PROM – scissor stretch
TMJ Noise
Muscle Palpation

6. Differential Diagnosis
Scissor stretch test: if opens further - muscular, if not - internal derangement
Clench test: bite down on tongue depressor for 10 – 15 seconds. Pain on same side – muscle, opposite side – joint
“S” vs. “C” curve with opening

7. Occupational Therapy Goals for TMD
Increase ROM to >40mm
Decrease pain
Teach joint protection (decrease parafunctional habits, limited opening)
Improve function (eating, yawning, DDS visit tolerance, oral hygiene, talking, sleep, work)
HEP independence
Neutral posture (head on neck, jaw, scapular position, TUTA)

8. Myofascial Pain Dysfunction
Most common disorder
Referred muscle pain
Muscle pain aggravated by jaw function or parafunction
HA’s
Tenderness of muscles w/o mechanical symptoms
Loss of motion or painful motion

9. Myofascial Pain Dysfunction
Caused by an underlying related disorder – malocclusion, arthritis, internal
derangement, poor posture
Education is key! – posture, parafunction, stress management
Often chronic and cyclical
Often a myofascial component with all diagnoses

10. Myofascial Dysfunction
Myofascial contributors may include:
* Lateral pterygoid
* Medial pterygoid
* Temporalis
* Masseter
* Digastrics
* Muscles of the cervical spine

11. Lateral Pterygoid Origin: Lateral Pterygoid Plate of Sphenoid Insertion: Condylar Neck, Ramus of Mandible and Disc

12. TMJ Muscles – Lateral Pterygoid
#1 myofascial source of pain
Due to attachment to disc it can cause disc and jaw to be unable to return to normal resting position and cause clicking or popping.
Malocclusion of teeth/missing teeth

13. Referral pattern – zygomatic arch, TMJ

14. Medial Pterygoid Origin: Inner Surface of Lateral Pterygoid Plate Insertion: Ramus of Mandible by the Angle

15. TMJ Muscles – Medial Pterygoid
Stuffiness in ear
Swallowing difficulty as restriction in protrusion of jaw

16. Referral pattern – posterior mandible, mouth, below and behind TMJ including internal ear – not teeth

17. Temporalis Origin: Temporal Fascia, Superior to Zygomatic Arch Insertion: Coronoid Process of Mandible

18. TMJ Muscles - Temporalis
Significant postural muscle (the only time it isn’t working is when you’re lying supine)
Perpetual clenching

19. Referral pattern – lower jaw, molar teeth and gum, maxilla, lower portion of mandible, temple eyebrow and external ear

20. Masseter Origin: Zygomatic Arch Insertion: Mandibular Angle and Ramus

21. TMJ Muscles - Masseter
“Sinusitis”

22. Referral pattern - temple, along eyebrow, behind eye or upper teeth

23. Digastrics Origin: Mastoid Notch (posterior), Symphysis of Mandible (anterior) Insertion: Join by a Common Tendon to the Hyoid Bone

24. TMJ Muscles - Digastrics
Rarely in spasm due to forward head posture (stretch weakness)

25. Referral pattern – behind mandible toward back of ear, lower incisors

26. Cervical Spine Muscles
Form stable base for TMJ on which to work
Poor posture – condyle rotates backward – change of biomechanics
Referral pattern from the cervical spine-Temporal Headaches, SCM
Assess for tension in upper traps, scalenes, and SCM

27. Parafunctional Behaviors
Gum/candy chewing (chewing limited to 15 – 20 minutes/day!) – including chewing on one side
Clenching/bruxing/grinding
Leaning on chin/jaw
Biting nails, pencils, cheeks
Sleep position
Caffeine use
Musical instruments
Mouth breathing
Phone cradling

28. Treatment – Myofascial Pain Dysfunction
Modalities: US – 1.2 w/cm2, 3 MHz, x5 minutes to joint or muscle, heat, electrical stimulation
Manual Therapy – joint mobs/distraction, MFR – including upper cervical region
HEP/Lifestyle changes
Tongue positioning (TUTA)
Self-joint distraction &/or MFR
Eliminating parafunctional behaviors
Postural instruction
Conjunction with splint therapy &/or counseling (Referral to psychology for CBT as needed for stress and anxiety management)

29. Resting Joint Position Capsule – anterior/posterior only

30. Normal Joint Motion

31. Internal Derangement

32. Disc Disorder Internal Derangement
Disc held in place by collateral ligaments and posterior ligament, w/ movement dictated by lateral pterygoid
Click, pop, lock
Pain at joint
“S” shaped opening/closing to reposition jaw
Eye pain
History of trauma

33. Treatment – Internal Derangement
Modalities: Iontophoresis, electrical stimulation, cold – ice massage
Manual therapy – Joint distraction
Joint protection techniques: Limit motion to no noise, soft food diet or chewing behaviors
Home exercise instruction
Change parafunctional behaviors
Self joint distraction techniques
Tongue positioning for relaxation (TUTA)
Postural instruction and controlled opening/neuromuscular re-education

34. Treatment - Other Capsulitis Subluxation
Usually a result of another disorder unless post surgery
Modalities, MT and HEP
Subluxation
Excess opening (>40 mm)
Usually a component of myofascial pain dysfunction, and treated as this, with addition of stab exercises and controlled opening

35. Treatment - Other Arthritis phono/iontophoresis, E-stim)
Generalized joint pain and inflammation
Usually seen in conjunction w/ other Dx
Joint protection, rest
Stretching, therapeutic exercise
Modalities (cold vs. heat, pulsed US,
phono/iontophoresis, E-stim)

36. Intervention: Dentist
Assess occlusion
Parafunctions of clenching/bruxing
Malocclusions
Pressure on back teeth activate temporalis an superior head of lateral pterygoid, anterior teeth activate masseters

37. Lab - Evaluation AROM (Therabite)
Active Incisal Opening (Normal mm)
Passive Incisal Opening (Normal mm)
Lateral Excursion (Normal >7 mm)
Protrusion (Normal > 7 mm)

38. Lab - Evaluation TMJ Palpation/Observation
Quality of Motion: Smooth/Rigid/Jerky/Guarded/Fasciculation/ Thrusting
TMJ Noise: Opening Click, Closing Click, Reproducible
Visually Assess Opening (S or C Shaped Curve)

39. Lab
Muscle Palpation
Medial Pterygoid (elevation, protrusion, and lateral deviation to opposite side)
Place index finer on muscle at inside of bottom teeth in mouth. Place opposite thumb under jaw line below ear. Apply pressure to muscle as if to touch finger and thumb. Move along gum line until reach incisors in front. Hold until relaxes 1-2X/day
Lateral Pterygoid (elevation, protrusion, and lateral deviation to opposite side)
Place index finger inside mouth, under cheek bone. Point finger up and towards opposite eye. Apply pressure to muscle until it relaxes. To check positioning of finger, actively move jaw in opposite direction and muscle will contract under finger. Hold until relaxes 1-2X/day

40. Lab Manual Therapy Trigger point release Joint distraction
Place thumb on back, bottom molar and wrap fingers under jaw
Press down as you lift on jaw in scooping motion
Do NOT pull jaw forward

41. Thank You
Feel free to contact Christy at or at with questions.
PDR Clinic Locations: Edina, Burnsville, Maplewood, Burnsville, Chanhassen
Specializing in the treatment of chronic neck, back and TMJ pain.