Reviewed by: Zachary Stango, SPT; Bridget Collier, PT, DPT

Temporomandibular disorders (TMD) are characterized by dysfunctions within the temporomandibular joint and/or surrounding masticatory musculature and tissue of the head and neck. The incidence of temporomandibular disorders can plague the affected individuals at random, with treatment consisting of analyzing the insidious onset of those aggravating factors. This has led to research suggesting the use of home exercise protocols for mitigation measures of TMD, with evidence also favoring the use of manual therapy as an effective treatment strategy. The randomized controlled trial conducted by Tuncer et al. (2013) aimed to analyze the effects of manual therapy, along with a home exercise program, for the treatment of temporomandibular related pain and mouth opening dysfunction.

The inclusion criteria for this study consisted of individuals diagnosed with myogenous TMD or anterior disc displacement with reduction, which is characterized by tenderness to palpation of the temporalis and masseter, and painful clicking or crepitus upon opening and closing of the mouth, respectively. Individuals who did not meet those TMD diagnoses were still included if their TMJ pain was occurring for at least 3 months. A total of 40 participants completed this trial, of which were randomly assigned to a group solely completing a home exercise program, or a group completing a home exercise program with an additional manual therapy component. The home exercise program provided to both groups consisted of a multitude of educational components on ergonomics, pain, breathing, posture, and repetitive mandibular exercises focusing on opening and closing of the mouth, as well as medial and lateral gliding of the jaw. The manual therapy group completed the same home exercise program, with the addition of manual-based interventions focused on soft tissue mobilization of the masticatory muscles, gentle jaw isometrics, TMJ and cervical traction, and stretching of the surrounding musculature. The interventions in each group were assigned three times a week for four weeks, with pain and maximal mouth opening serving as the primary outcomes measured.

Pain was measured using the visual analogue scale and analyzed with the participant at rest (defined as pain during the mandible’s resting position), and with stress (defined as pain when chewing gum for one minute, designed to mimic daily chewing habits). Maximal mouth opening was measured in millimeters by asking the participants to open their mouths as wide as possible in a pain-free range. All parameters significantly decreased within each group, but the reductions in visual analogue pain scores and improvements in mouth opening were significantly higher within the group completing both a home exercise program and manual therapy. On average, the group undergoing the manual therapy and home exercises had point reductions of 22.5 for visual analogue scores at rest and 55.5 for visual analogue scores with stress, compared to a 13.0 and 23.0 point reduction, respectively, for the group completing only home exercises. Smaller, but significant, numeric differences were observed in the millimeters of maximal mouth opening, as the manual therapy group displayed an average of a 5.8mm improvement compared to 2.4mm improvement with the home exercise group.

Clinical Bottom Line:

The results of this study serve as evidence that treatment interventions for TMD should consist of a manual therapy component in conjunction with home exercise protocols in reducing pain and restoring mandibular kinematics. These interventions suggest the clinical benefit of skilled therapy services when compared to a biomedical alternative or self-management model, as large variations in the etiology of temporomandibular pain and dysfunction can be assessed and addressed by trained physical therapists.


Tuncer AB, Ergun N, Tuncer AH, Karahan S. Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: A randomized controlled trial. J Bodyw Mov Ther. 2013;17(3):302-308. doi:10.1016/j.jbmt.2012.10.006