Physical Therapy Guide to Temporomandibular Joint Disorder
Temporomandibular joint disorder, or dysfunction, (TMD) is a common condition that limits the natural functions of the jaw, such as opening the mouth and chewing. It currently affects more than 10 million people in the United States. It is sometimes incorrectly referred to as simply “TMJ,” which represents the name of the joint itself. TMD affects more women than men and is most often diagnosed in individuals aged 20 to 40 years. Its causes range from poor posture, chronic jaw clenching, and poor teeth alignment, to fracture or conditions such as lockjaw, where the muscles around the jaw spasm and reduce the opening of the mouth. Physical therapists help people with TMD ease pain, regain normal jaw movement, and lessen daily stress on the jaw.
What Is Temporomandibular Joint Disorder?
Temporomandibular joint disorder (TMD) is a common condition that limits the natural function of the jaw, such as opening the mouth and chewing, and can cause pain. The temporomandibular joint (TMJ) is a hinge joint that connects your jaw to your skull in front of your ear. The TMJ guides jaw movement and allows you to open and close your mouth and move it from side to side to talk, yawn, or chew. TMD can be caused by:
- Bad posture habits. One of the reasons TMD is so common is because many of us spend a great deal of time sitting at a desk, where we often hold our heads too far forward as we work. But there are many other kinds of bad posture. Sitting in the car for a long commute, working at a checkout station, always carrying your child on the same hip—all can place the head in an awkward position and cause jaw problems. The "forward head position" puts a strain on the muscles, disk, and ligaments of the TMJ. The jaw is forced to "rest" in an opened position, and the chewing muscles become overused.
- Chronic jaw clenching ("bruxism"). Many people clench their jaws at night while they sleep, usually because of stress. Some clench their teeth throughout the day as well, especially when dealing with stressful situations. This puts a strain on the TMJ and its surrounding muscles.
- Problems with teeth alignment ("malocclusion"). If your teeth are positioned in an unusual way, greater stress is placed on the TMJ when performing everyday jaw motions, such as chewing.
- Fracture. In a traumatic accident involving the face or head, a fracture to the lower jaw may result and cause TMD. Even when the fracture is fully healed, TMJ stiffness and pain may remain.
- Surgery. Individuals may experience a loss of TMJ mobility and function following certain kinds of surgery to the face and jaw.
- Trismus ("lockjaw"). This condition—where the jaw muscles spasm and the jaw cannot be fully opened—can be both a cause and a symptom of TMD. Other causes of trismus include trauma to the jaw, tetanus, and radiation therapy to the face and neck.
- Displacement of the disc or soft-tissue cushion located between the ball and socket of the TMJ, which causes popping or clicking of the jaw and, frequently, pain.
- Arthritis in the TMJ.
How Does It Feel?
The symptoms of TMD can be temporary or last for years. Jaw pain is the most common symptom.
CAUTION: Jaw pain also can be a symptom of heart attack. Seek medical care immediately if jaw pain is accompanied by:
- Chest pain
- Shortness of breath
- Left arm pain
- Numbness in the left arm
TMD can cause the jaw to lock or get stuck in a certain position. You may experience headaches, feel pain when chewing certain foods, or have difficulty fully opening your mouth.
TMD symptoms include:
- Jaw pain
- Jaw fatigue
- Difficulty opening your mouth to eat or talk
- Ringing in your ears
- Popping sounds in your jaw
- Neck pain
- Locking jaw
How Is It Diagnosed?
To identify the cause of your symptoms, your physical therapist may:
- Review your medical history, and discuss any previous surgery, fractures, or other injuries to your head, neck, or jaw.
- Ask you to describe your pain, including headaches, and observe any pain patterns in the neck and TMJ.
- Conduct a physical examination of your jaw and neck, including the soft tissue and muscles in the area.
Your physical therapist will evaluate your posture and observe how your cervical spine—the upper portion of your spine, situated in your neck—moves. Your physical therapist will examine your TMJ to find out how well it functions and whether there are any abnormalities in your jaw motion.
If, after the examination, your physical therapist suspects that your pain is a result of the position ("alignment") of your teeth, the therapist will refer you to your dentist for further examination.
How Can a Physical Therapist Help?
Your physical therapist can help you restore the natural movement of your jaw and decrease your pain. Based on your condition, your therapist will select treatments that will work best for you. Your treatments may include:
Posture Education. If you sit with your head in an increased forward position, you are placing greater strain on the muscles beneath your chin, causing the lower jaw to pull back and the mouth to be in an open position even when resting, increasing stress on the TMJ. You also might be overworking the jaw muscles to force the jaw closed so your mouth isn't open all the time. Your physical therapist will teach you to be aware of your posture so that you can improve the resting position of your jaw, head, neck, breastbone, and shoulder blades when you're sitting and walking.
Improving Jaw Movement. Physical therapists use skilled hands-on techniques (manual therapy) to gently increase movement and relieve pain in tissues and joints. Your physical therapist may use manual therapy to stretch the jaw in order to restore normal joint and muscle flexibility or break up scar tissues ("adhesions") that sometimes develop when there is constant injury.
Your physical therapist will teach you special "low-load" exercises that don't exert a lot of pressure on your TMJ, but can strengthen the muscles of the jaw and restore a more natural, pain-free motion.
Special Pain Treatments. If your pain is severe, your physical therapist may provide treatments, such as electrical stimulation or ultrasound to reduce it.
Referral to a Dentist. If your TMD is caused by teeth alignment problems, your physical therapist can refer you to a dentist who specializes in TMD, who can correct the alignment with special appliances, such as "bite guards" that create a natural resting position to relax the TMJ, relieve pain, and improve jaw function.
Can This Injury or Condition Be Prevented?
Maintaining good sitting posture is key to preventing TMJ problems. Your physical therapist will show you how to maintain better posture to prevent future episodes of TMD.
- Place any work you are focusing on (written documents, computer screens) directly in front of you and not off to the side where you are forced to look in one direction for long periods of time.
- Place your computer monitor at eye level so you don’t have to look up, down, or to the side throughout your day.
- If you are on the phone at work for long periods of time, use a headset that allows the neck and jaw to remain in a restful ("neutral") position.
- Avoid repetitive chewing, such as chewing gum.
- Avoid smoking.
- Avoid opening the jaw too wide.
- Avoid eating hard or chewy foods.
- Maintain good oral hygiene and tooth health.
- Avoid sleeping on your stomach, which forces the neck to rotate to one direction in order to maintain an open airway, increasing stress on the TMJ.
Real Life Experiences
Eleanor is a paralegal with a busy workload. She spends long hours at her desk, reviewing documents and filing lengthy reports to meet multiple deadlines. She clenches her teeth when feeling stressed, and often complains to her coworkers about her stiff neck.
Eleanor is extremely proud of her daughter Rebecca, who is a star athlete. Last night, Eleanor attended Rebecca's state championship volleyball match. All season long, Eleanor has been cheering when Rebecca's team was winning, and grinding her teeth when the score was close. She's also been sitting on bleachers without any back support. Last night, Rebecca's team was ahead by 1 point; Rebecca set up for the winning point, and scored.
The next morning, Eleanor noticed her jaw was really sore, and it hurt to chew. Over the next week, the pain got worse. She called her physical therapist.
Eleanor's physical therapist conducted a thorough examination of her jaw and neck, and listened carefully as she described her recent experiences at her daughter's games and her high-stress job. He diagnosed TMD, and determined that her pain was related to postural habits and stress, not to the alignment of her teeth.
Eleanor's physical therapist began her treatment by teaching her how to maintain proper posture at work. He helped her achieve a proper resting position of the jaw to minimize pressure on the muscles around the jaw, and explained that this was the position she needed to maintain throughout her day. He asked her to focus on returning her jaw to this position whenever she began to feel tense.
He then applied specialized manual therapy techniques to her TMJ and surrounding muscles, and guided her through a few neck and middle-back strengthening exercises. He designed an individualized home-exercise program for Eleanor that included postural exercises, gentle stretches, and strengthening exercises for the neck and middle back. Finally, he taught her some gentle relaxation techniques to help her manage her stress.
After a month of receiving physical therapy treatments and sticking to her home-exercise program, Eleanor felt much less pain in the TMJ, and was able to fully open and close her mouth and chew normally.
This week, Eleanor attended Rebecca's first tennis match of the season. She brought her own stadium chair with back support. And, as she had promised her daughter and her physical therapist, she cheered less and was careful to not grind her teeth at the big points.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with a craniofacial focus, meaning that they focus on movement disorders related to the skull and facial structures.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with TMD.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide the best scientific evidence for how to treat TMD. The articles report recent research and give an overview of the standards of practice for the treatment of TMD both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or free full text so that you can read it or print out a copy to bring with you to your health care provider.
Calixtre LB, Moreira RF, Franchini GH, et al. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomized controlled trials. J Oral Rehabil. 2015;42:847-861. Article Summary.
Furlan RM, Giovanardi RS, Britto AT, Oliveira e Britto DB. The use of superficial heat for treatment of temporomandibular disorders: an integrative review [article in English, Portuguese]. Codas. 2015;27:207-212. Article Summary.
Gauer RL, Semidev MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015;91:378-386. Article Summary.
Sault JD, Emerson Kavchak AJ, Courtney CA, Tow N. Regional effects of orthopedic manual physical therapy in the successful management of chronic jaw pain. Cranio. 2014 December 30 [Epub ahead of print]. Article Summary.
Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24:283–291. Article Summary.
Michelotti A, de Wijer A, Steenks M, Farella M. Home exercise regimes for the management of non-specific temporomandibular disorders. J Oral Rehabil. 2005;32:779–785. Article Summary.
Cleland J, Palmer J. Effectiveness of manual physical therapy, therapeutic exercise, and patient education on bilateral disc displacement without reduction of the temporomandibular joint: a single-case design. J Orthop Sports Phys Ther. 2004;34:535–548. Article Summary.
Carmeli E, Sheklow S, Bloomenfeld I. Comparative study of repositioning splint therapy and passive manual range of motion techniques for anterior displaced temporomandibular discs with unstable excursive reduction. Physiotherapy. 2001;87:26–36. Article summary not available.
Nicolakis P, Burak EC, Kollmitzer J, et al. An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. Cranio. 2001;19:26–32. Article Summary.
Komiyama O, Kawara M, Arai M, et al. Posture correction as part of behavioral therapy in the treatment of myofascial pain with limited opening. J Oral Rehabil. 1999;26:428–435. Article Summary.
Wilk BR, Stenback JT, McCain JP. Postarthroscopy physical therapy management of a patient with temporomandibular joint dysfunction. J Orthop Sports Phys Ther. 1993;18:473–478. Article Summary.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Eric S. Furto, PT, DPT, MTC, FAAOMPT. Reviewed by Julie A. Mulcahy, PT, MPT. Reviewed by the editorial board.