The temporomandibular joint is the jaw joint in front of the external auditory canal. It is active when you speak, eat or swallow. It moves smoothly when you open and close your mouth.
How to recognize this temporomandibular disorder
Pain in the chewing muscles felt in the cheeks and/or temples,
Joint pain in front of the ear, which can extend into the external auditory canal. Pinching-type pain.
Presence of dysfunctions affecting jaw activities:
- Lack of opening amplitude,
- Difficulty and pain when chewing.
Physiotherapy will have a positive effect if your jaw is painful and there is the presence of dysfunctions i.e. lack of opening and/or difficulties when chewing. The first thing to try is a physiotherapeutic treatment combining manual therapy and prescribed exercises, to teach you how to loosen your jaw and strengthen the superficial and deep muscles of your neck. The fitting of an occlusal splint is recommended in the case of bilateral morning and awakening pain and stiffness, which diminishes as the day progresses.
This disorder is very often associated with parafunctions meaning that you clench your teeth all the time or almost all the time, bite your nails,… Parafunctions are linked to overuse of the jaw or a period of increased stress/fatigue. The body responds by causing teeth to clench.
Is joint noise serious? No, it’s not serious! It’s linked to a subluxation of the disc, a small structure within your joint which may be more or less mobile within it, creating this noise. This noise is not predictive of pain or dysfunction! Aging, physical activity or changes in the shape of the structure may be contributing factors.
For a joint noise alone, physiotherapy won’t help. On the other hand, if a noise is associated with the above-mentioned complaints, physiotherapy can provide relief.
This noise can appear and disappear at different times of life. The mechanism of onset is not always clear. How does a joint sound appear? In the case of the jaw, it’s a bone that fits into the arch in which the disc is located. Eventually, the disc becomes deformed and off-center, resulting in joint noise. This deformation is part of the normal aging process of the human body.
Is TMJ clicking a real danger?
Temporomandibular joint disorders (TMD) are a complex set of conditions that affect the joint connecting the jaw to the skull, as well as the surrounding muscles. These disorders manifest themselves through a variety of symptoms, ranging from pain, limitations of movement and joint noise to more profound dysfunction. Approximately 10-12% of the population suffers from it, but only 1-2% seek professional treatment, often from a dentist or physiotherapist. This low level of treatment-seeking may be due to a lack of understanding of care options, or confusion about whom to consult.
Patient profiles and types of TMD
Patient profiles vary according to age and gender. Women are more frequently affected, often with pain and functional limitations. On the other hand, men in their forties tend to suffer from subluxations or joint noise without major pain. Older people, meanwhile, are more prone to degenerative TMJ disorders, which can lead to pain, chewing difficulties and swallowing disorders. This spectrum of profiles underlines the diversity of clinical manifestations, making each case unique in its presentation and treatment.
Risk factors: why do we develop TMJ disorders?
There are many causes of TMJ disorders, based on a complex interplay of biopsychosocial factors. To put it simply, there are three main types of factor:
- Behavioural: parafunctions, such as clenching teeth or excessive chewing of gum, are common behaviours conducive to TMD.
- Psychosocial: Anxiety, depression, somatization and catastrophization are strongly associated with symptom aggravation.
- Genetic: Certain genotypes may predispose to chronic pain, although this is still an emerging field of research.
- Sleep disorders: Sleep deprivation or disorders such as apnea may also contribute to the development of TMD.
Warning signs: Red Flags and Yellow Flags
Although red flags for TMD disorders are not always easy to identify, certain symptoms should arouse vigilance. Orofacial pain, particularly if it worsens during joint function, requires careful evaluation. It is also important to take into account any history of cancer or untreated dental infections, such as caries or pulpitis, which may require specialist medical advice before considering physiotherapeutic rehabilitation.
Yellow flags concern psychosocial factors such as depression or severe anxiety. In these cases, the use of validated questionnaires such as GAD-7 (Generalized Anxiety Disorder) or PHQ-9 (Patient Health Questionnaire) is recommended to assess the need for further intervention.
Treatment in a physiotherapy practice
Initial assessment
The assessment begins with an evaluation of active and passive movements of the jaw and neck, followed by careful palpation of the muscles involved, particularly the masseter and temporalis muscles. Locating the pain and assessing its intensity are essential to determine whether the cause is muscular or articular.
It may be useful to complement this assessment with the Jaw Functional Limitation Scale 20, a questionnaire that helps target specific actions to work on with the patient. This tool also helps to clarify the functional impact of disorders and to better adapt the exercises to be prescribed.
Intra-oral palpation: a nuanced approach
Although intra-oral palpation is often used to assess TMJ, its usefulness remains limited. It is difficult to distinguish real pain from mere tenderness, especially in control subjects who often present with similar pain. However, this technique can be beneficial as part of the treatment to desensitize the painful area. It is important to remain collaborative with the patient, as this approach may be perceived as intrusive.
Treatments: manuals, exercises and parafunction management
Manual treatments, when performed correctly, are effective for TMD. However, specific exercises and parafunction management (such as teeth clenching) are crucial elements in rehabilitation. As for dry needling, its use depends on the patient and the therapist. It can be proposed on a case-by-case basis, according to the patient’s tolerance and preferences.
TMD and comorbidities: frequent associations
TMDs are frequently associated with other disorders, notably headaches. Studies show a higher prevalence of migraines and tension headaches in TMD patients. Bruxism (teeth clenching or grinding) is also linked to these disorders and can aggravate TMJ pain.
With regard to posture, it has long been accepted that forward head posture is a major risk factor for TMJ disorders. However, recent research shows that this link is weaker than assumed. That said, addressing posture as part of treatment can have beneficial effects by modulating the patient’s bodily perceptions.
Future prospects: research and new directions
Future research will probably focus on the link between TMD and other conditions such as tinnitus and sleep apnea. These areas offer interesting prospects for better understanding the interactions between TMJ musculoskeletal disorders and other systemic conditions.
Disc displacement: a factor in joint noise, but not pain
Displacement of the TMJ articular disc is often highlighted in discussions of TMD. However, several studies have shown that there is no direct link between disc position and pain or functional disturbance. In other words, the presence of a joint noise associated with disc displacement does not necessarily mean that the patient will experience pain or impaired function. This noise is often benign, and treatment should aim to reassure the patient and encourage normal use of the joint.
