DOI: 10.

1051/odfen/2011205 J Dentofacial Anom Orthod 2011;14:206

 RODF / EDP Sciences

Managing temporomandibular
disorders (TMD) by integrating
exercise therapy into therapeutic
patient educational programs:
why, when, how?
Philippe AMAT

ABSTRACT
Current evidence based data found in the scientific literature recommend that
the therapeutic management of patients suffering from temporomandibular
disorders (TMD) should be based initially on simple, conservative and reversible
procedures including exercise therapy. The integration of this message into oral
health instructions for patients makes it easy for them to keep informed about
TMD and aware of the steps they can take to deal with their symptoms.
The integration of exercise therapy into structured patient education programs
provides patients with information about TMD and suggests methods to deal
with it. This medical approach is similar to those used to treat other joints in the
musculoskeletal system.
Easy to set up, this exercise therapy helps patients suffering from
temporomandibular disorders to become partners in the conduct of their
treatment plan of reducing pain and restoring functional comfort.

KEYWORDS
Temporomandibular disorders,
Exercise therapy,
Therapeutic patient education,
Received: 03-2011
Compliance. Accepted: 05-2011

Address for correspondence:

P. AMAT,
19, place des Comtes du Maine,
72000 Le Mans
amatph@noos.fr 1
Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011205
 PHILIPPE AMAT

1 – INTRODUCTION
Early in 2010, the American Asso- simple, and reversible, including max-
ciation of Dental Research published a illo-facial re-education that will be
revised version35 of its scientific re- augmented with a home care pro-
commendations first issued in 1996 gram, in which patients are taught
on the diagnosis and treatment of about their disorder and how to
temporomandibular disorders (TMD). manage their symptoms9.
This document stated that ‘‘tempor- Evidence based data suggest that
omandibular disorders (TMDs) encom- occlusal factors do not play an im-
pass a group of musculoskeletal and portant role in the etiology of
neuromuscular conditions that involve TMD36,41. However, these results
the temporomandibular joints (TMJs), must be interpreted with prudence.
the masticatory muscles, and all asso- The authors of systematic reviews
ciated tissues.’’ and meta-analyses are unanimous in
Because TMD is frequently accom- deploring their limitations, because of
panied by acute or chronic pain and the lack of homogeneity in the meth-
interference with smooth operation of odologies employed by various stu-
orofacial functioning, it persistently dies on TMD and of the imprecise
provokes patients to consult dentists definition of the diagnostic criteria
in general and orthodontists espe- applied to discerning temporomandib-
cially. ular disorders32.
A number of factors combine to The current absence of proof that
make the management of therapy for occlusal factors cause TMD doesn’t
patients suffering from TMD a com- mean that, in addition to optimizing
plex procedure: facial equilibrium and the beauty of the
smile (Fig. 1 a and b) orthodontists
• The diversity of its clinical forms;
should lessen their zeal in achieving
• The multi-factorial nature of the
the objective of a functional occlusion
mechanisms of its etiology that
with excellent inter-digitation, center-
are, essentially genetic, environ-
ing, and guidance31. Simple common
mental, and psychological;
sense suggests this is still a worthy
• The difficulty of establishing a pre-
goal.
cise diagnosis;
• The usually favorable response to The use of elasto-positioning as a
the diverse therapies that are per- finishing tool helps in attaining the
formed no matter what they may objective of a functional occlusion that
be. is individualized and takes biological
The consensus that emerges from a variability into account14. We use the
study of the current evidence based appliance Elasto-finisher made on a
data available in the scientific litera- totally individualized set-up mounted
ture35 reaffirms the principle of pri- on a SAM articulator with the Axio
mum non nocere8 and indicates that Split system (Fig. 2).
the management of patients suffering The objective of this article is to
from TMD must, fundamentally, con- present the indications for maxillo-
sist of therapies that are conservative, facial re-education as an element of

2 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

Figures 1 a and b
Optimization of facial equilibrium and of the smile.

Figure 2
A totally individualized therapeutic set-up made on the SAM articulator, with the Axio Split system. (Elastodontie
Laboratory France Elastodontie @).

J Dentofacial Anom Orthod 2011;14:206 3

 PHILIPPE AMAT

therapeutic TMD management, and The therapeutic modalities of max-

how to integrate it in a planned illo-facial re-education include exer-
approach of therapeutic patient educa- cises and informative pamphlets.
tion, all supported by evidence based
data from the literature.

2 – WHEN TO BEGIN MAXILLO-FACIAL RE-EDUCATION?

Pain, together with articular noises of therapy indicated by that diagno-
and dyskinesia, is just one of the sis44.
symptoms of malfunctioning of the The essential bases for diagnosis
masticatory system6, we agree with are the intake interviews, clinical ex-
J.D. Orthlieb, that French professionals ams, and, when indicated radiographic
should abandon old terminology and images of the TMJ12,35.
adopt the Anglo-Saxon term TMD, (or
TMD symptoms are not specific but
DAM), Temporomandibular Disorder
J. -D. Orthlieb, et al 30 have proposed
and shall use it through this paper.
a diagnostic algorithm. Its use helps
Basing its conclusions on an ex- practitioners to make a differential
haustive analysis of the literature, the diagnosis that will rule out grave
American Association of Dental Re- etiological factors including tumors,
search (AADR) recently re-affirmed neurological and rhumatological disor-
the necessity for practitioners to treat ders, and trauma, etc that would make
TMD with therapies that are non- the prognosis more delicate.
invasive, simple, and reversible35.
In this light, it is clear that dentists
should employ maxillo-facial re-educa- 2 – 2 – After having reassured
tion as the primary treatment of and informed the
choice for TMD. patient fully
They should propose it to patients
after having completed these essen- The first step for practitioners is to
tial initial steps: reassure anxious patients20 and re-
– formed a diagnosis; store their confidence in an effort to
– Informed and reassured the patient reduce their emotional distress that
about the situation; might be causing harmful parafunc-
– relieved pain and reduced inflam- tional habits, reducing their capacity to
mation. adapt, and lowering their pain thresh-
olds3.
The fundamental task is to inform
2 – 1 – After the establishment patients of the facts about TMD2 as
of a diagnosis spelled out by published data showing
that it is not a serious affliction and
Practitioners cannot properly treat a that health care professionals can deal
patient before they have established a with it in a non-invasive way. For
diagnosis and elucidated precise goals example:

4 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

– there is a high prevalence of the Practitioners usually rely on anti-

signs and symptoms of TMD in the inflammatory and analgesic medica-
general population that fluctuates tion to manage pain and inflammation
with age23; initially, following these up with relax-
– the signs and symptoms of non- ants and tranquilizers.
reducible luxation disappear with The next step is to eliminate ex-
time and in the absence of any acerbating factors. Orthodontists
treatment19,40. might, for example, ask patients suf-
fering from pain to temporarily sus-
pend wearing intermaxillary elastics or
2 – 3 – After relieving pain and place miniature bite blocks of glass
treating the inflammation ionomer cement on molar occlusal
surfaces to provide quick relief for
All patients suffer from anxiety the TMJ (Fig. 3).
about the rapid onset of TMD and
they expect their practitioners to
relieve their pain promptly10.

3 – WHY USE MAXILLO-FACIAL RE-EDUCATION?

There is a broad consensus in the of individual patients in a planned
literature that a medically constant approach of therapeutic patient educa-
maxillo-facial re-education plan based tion (TPE).
on data presented in the literature and
similar to programs used by physi-
cians for other joints in the human 3 – 1 – General principles
musculo-skeletal system should be of maxillofacial
the basis for all TMD treatment9,35.
re-education
It is a conservative, simple, and
reversible therapeutic modality whose Treatment of TMD with maxillary-
effectiveness is reinforced by adapt- facial re-education has several objec-
ing it to the specific needs and wishes tives:

Figure 3
Miniature bite blocks for articular decompression.

J Dentofacial Anom Orthod 2011;14:206 5

 PHILIPPE AMAT

– reduce pain; – recorded in an exercise calendar so

– correct malfunctioning; that the regularity of their perfor-
– restore correct articular and muscu- mance can be demonstrably as-
lar functions; sured;
– optimize posture and oro-facial – eventually completed when a kine-
functions. siologist takes over their manage-
Exercises used in maxillo-facial re- ment.
education are:
– classified in four families grouped in 3 – 2 – The major groups
relation to their objectives38; of maxillary-facial
– prescribed in the form of individua- re-education exercises
lized programs;
– repeated 3 to 6 times daily by Authors agree that maxillary-facial
patients in accordance with indivi- re-education exercises can be classi-
dual needs; fied in four major groups1,33,39:
– organized in sequence, beginning – Stretching ;
with the incorporation of a specific – Against resistance;
work posture and supported by the – re-coordination ;
application of heat to reduce neuro- – Neck excercises.
muscular excitability;
– composed of movements that
3 – 2 – 1 – Stretching exercises
must be gentle, progressive, regu-
lar, and stopped promptly at the These exercises are designed to
first indication that they are becom- improve the mandible’s mobility.
ing painful; To perform them patients open and
– easy enough to perform so that close their mouths, (Fig. 4 a and 4 b),
patients will integrate them into move the mandible to the right and
their daily lives; left (Fig. 5 a to 5 c), and thrust the jaw

Figures 4 a and b
Stretching movements. a: opening; b: closing.

6 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

Figures 5 a to c
Stretching movements a: right lateral; b: starting position; c: left lateral.

Figures 6 a and b
Stretching movements a: propulsive; b: retropulsive.

forward and then retrude it (Fig. 6 a Patients perform these exercises as

and 6 b). continuous opening, closing, propulsive
(Fig. 7 a to 7 c), and right and left lateral
movements (Fig. 8 a and 8 b) with
3 – 2 – 2 – Exercises against increasing force against resistance.
resistance
These exercises are designed to:
3 – 2 – 3 – Re-coordinating
– reinforce muscular strength;
exercises
– inhibit the action of antagonistic
muscles responding to contracting These exercises are designed to
muscles stimulated by movement help patients reprogram the functional
in a Sherrington reflex. cycles of the mandible, by becoming

J Dentofacial Anom Orthod 2011;14:206 7

 PHILIPPE AMAT

Figures 7 a to c
Movements against resistance a: opening; b: closing; c: propulsive.

Figures 8 a and b
Movements against resistance a: right lateral; b: left lateral.

aware of them and correcting any 3 – 2 – 4 – Neck exercises

faulty movements that may have These exercises are designed to
become ingrained. relieve tension in cervical and neck
Patients perform the opening and muscles.
closing movements in front of a mirror To perform them patients flex and
upon which they have traced a vertical extend the neck (Fig. 10 a to 10 c)
line (Fig. 9) that allows them to observe rotate it from side to side and incline it
any deviations they may be making. to the right and left.

8 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

3 – 3 – Effectiveness of maxillo- – other systematic reviews;

facial re-education – original studies.
In a search of French National Author-
Here is the evidence-based data we ity of Health (HAS[1]) and the National
consulted in descending order of the Guideline Clearinghouse (NGC [2]) we
level of their methodological quality: found no evidence based clinical guides
– evidence based clinical guides; for maxillo-facial re-education.
– systematic reviews published by Nor did a search of the Cochrane
the Cochrane Collaboration; Collaboration [3] uncover any systematic

Figure 9
Working posture for re-coordination
exercises.

Figure 10 a to c
Neck exercises: flexing and extension movements.

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 PHILIPPE AMAT

Cochrane reviews devoted to the effec- dently because of a number of

tiveness of the use of maxillo-facial re- methodological problems that viti-
education for patients suffering from ate their reliability;
TMD. – maxillo-facial re-education, advice
On the other hand protocols of on behavior, passive mobilization,
three systematic reviews in progress and relaxation techniques seem to
seem promising11,17,34. be effective in ameliorating TMD
symptoms;
In a search of Medline [4] we found
– the integration of behavioral advice
several systematic reviews dealing
into TMD treatment is desirable,
with maxillo-facial re-education in
even though no proof of its long-
which the conclusions of the most
term effectiveness has as yet been
recent were similar22,25-29,43:
demonstrated.
– the results of the systematic re-
views should be interpreted pru-

4 – HOW SHOULD MAXILLO-FACIAL RE-EDUCATION BE USED?

The American Association for Dental – education about patient’s global
Research recommends that maxillo- health;
facial re-education should be ‘‘augmen- – education about patient’s specific
ted with a home care program, in which malady;
patients are taught about their disorder Practitioners should become skillful
and how to manage their symp- in dealing with each level but because
toms’’35, which is a forcible way of of the limited space available in this
integrating TMD self help in an overall article we shall discuss only therapeu-
program of instruction in healthy living. tic patient education whose name
explicitly shows that it’s an integral
component of treatment.
4 – 1 – The concept of patient
education
Patient education is an important 4 – 2 – Therapeutic education
component of the concept of patients of patients (TPE)
abandoning their traditional role of
being inactive recipients of care pro- The goal of therapeutic patient
vided by authoritative practitioners education is to make patients and
and becoming fully informed of their their families aware of and competent
situation and participating as equal to assume optimum daily manage-
partners in their own treatment3,4. ment of life with a malady as a
This encompasses three levels of permanent and integral component
participation, often interwoven with of treatment13.
active care 13: The inclusion of therapeutic educa-
tion for patients in the HPST, a
[1] www.has-sante.fr hospital, patients, and health law
[2] www.guideline.gov
[3] www.cochrane.org promulgated in 2009 (Article 84),
[4] www.ncbi.nlm.nih.gov made this new relationship of patients

10 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

as partners in their own care an official • TPE is not the exclusive preserve of
part of French policy. patients suffering from chronic dis-
It views the concept as one that is: eases; it is equally applicable to
individuals who have certain risk
– continuous and integrated into the
factors in their health profiles such
delivery of care;
as arterial hypertension and is also
– personalized and focused on indivi-
indicated for life situations like
dual patients;
pregnancy;
– adapted to the age of patients, their
• TPE can help orthodontists strength-
psychosocial milieu, and the sever-
en the therapeutic relationships they
ity of the malady;
establish with patients and their
– strongly influenced by the quality of
families that often begin when they
the therapeutic relationship7 be-
see 6 to 9 year-old children for initial
tween patients, their families, and
consultations and continue until they
their care givers.
Therapeutic patient education com- take final post-retention records on 20
bines information essential for both to 21 year-old.
preventive and curative treatment. • It is important to observe that patient
education is a procedure similar to
the awareness training, functional
cognitive education21, functional
4 – 3 – The role of TPE in education37, and oro-functional re-
dentofacial orthopedics education3,4 (Fig. 11) etc. methods
and orthodontics that dentists use in their daily prac-
tices to enhance patients’ dental
Does therapeutic patient education awareness and optimize their orofa-
(TPE have a place in dentofacial cial functioning in important areas
orthopedics where a critical or life- like ventilation5,42;
threatening prognosis is rarely, if ever, • It also seems clear that TPE can
an issue? Yes. A number of considera- solidify and maintain what is perhaps
tions make the integration of thera- the most crucial element contributing
peutic patient education into our to the success of orthodontic therapy,
therapies necessary, even vital. their compliance.

Figure 11
Therapeutic patient education in dentofacial orthopedics4.
(RMF: Maxillo-facial re-education).

J Dentofacial Anom Orthod 2011;14:206 11

 PHILIPPE AMAT

4 – 4 – Integrating maxillo-facial 4 – 4 – 2 – 1 – The educational

re-education into a TPE diagnosis
program This procedure delimits and describes
the patient’s needs and expectations.
4 – 4 – 1 – The objectives During the course of the intake
interview clinicians pose questions
of therapeutic patient
that will stimulate patients to provide
education of a patient information about their health beha-
suffering from TMD viors that might affect the malady15:
Clinicians can use therapeutic pa- • What is the nature of the ailment?
tient education to establish goals for
assisting patients suffering from TMD, The clinician explains what TMD is,
and their families: the severity of the patient’s disorder,
the possibility of its eventually exerting
• stay informed about current data
a negative impact on the patient’s
published in the literature on the
quality of live, what treatments have
etiology of TMD;
been already used , and identifies other
• to participate actively in the man-
possible eventual health problems.
agement of the malady;
• to make effective and durable life • What does the patient know?
changes by adhering to principles
The clinician evaluates the patient’s
learned in maxillo-facial re-educa-
knowledge of and beliefs about TMD
tion, by relaxation, by reducing or
and the treatments available for it.
eliminating noxious oral habits, and
by improving the quality of their • How will patients manage their
physical activity all of which are ailment?
indispensable to the global manage- Clinicians assess the capacity that
ment of their disorder; their patients possess for adapting to
• to maintain or even improve their TMD and to its repercussions in their
quality of life. daily lives.
• Patients: who are they, what do
4 – 4 – 2 – The stages they do?
of therapeutic Clinicians explore the ramifications
education of patients of the behavior of patients in the
suffering from TMD context of their family, social, and
professional environments and the
This educational process is accom-
constraints to which they are sub-
plished in four stages15:
jected. They also identify possible
1. educational diagnosis; projects and other sources of motiva-
2. definition of objectives and pre- tion suitable for individual patients.
paration of an educational con-
• What do patients want?
tract;
Clinicians should ask patients what
3. educational program; results they expect from their TMD
4. evaluation of the results. treatment.

12 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

After having information about pa- – placed in a priority order based on

tients, much of which was already their importance to the individual
recorded in their medical histories, clin- health needs of patients and the
icians can define, in cooperation with probability of patients’ complying
their patients, what objectives can be with them;
anticipated from the course of treatment. – non-specific, that is applicable to
the majority of patients or specifi-
cally designed to meet the needs
4 – 4 – 2 – 2 – Definition of of individual patients such as sing-
objectives and ers whose professional activities
preparation of the require wide mouth opening;
education contract – negotiated with patients to re-
• The definition of objectives spond to their desires. This coop-
There are three types of objectives: erative effort will enhance future
– Health objectives cooperation;
Their goal is to improve physical – revised regularly to adapt to data
well by improving, for example, the recovered during treatment ses-
extent of mandibular movements sions.
• Preparing an education contract
– Behavioral objectives
This written document, persona-
Their goal is to improve activities
lized and prepared in collaboration
conducive to improved health (for ex-
with the patient, formalizes the treat-
ample, getting physical exercise and
ment plan in a way that is adapted to
following a maxillo-facial re-education
the needs of patients and the con-
program) and to encourage patients to
straints they confront. It transcribes:
change or lessen unfavorable habits
like gum chewing or nail biting and to – the final version of the negotiated
reduce consumption of stimulants like objective in terms of the health,
coffee, black tea, and alcohol. behavioral, and psychosocial as-
pects of the patient’s therapeutic
– Psycho-social objectives
education;
Their goal is to adjust factors that
– the description of the content and
influence the behavior of patients by
the programming of the PTE.
analyzing unhealthy sociocultural, en-
vironmental, and financial influences In this way patients provide a fully
so as to effectively and permanently informed consent to the treatment plan,
improve their orofacial functioning; which is accordingly reinforced by a
These objectives should be: projected joint effort with the responsi-
bilities of each partner clearly defined
– precise, measureable and time
and the limitations of the clinician’s
limited such as cutting down gum
responsibilities especially clarified.
chewing by 50% in a three week
period or increasing extent of jaw
opening by 5 mm in 4 weeks; 4 – 4 – 2 – 3 – The Education
– goals that patients can realistically Program
accomplish and be designed to • Educating isn’t informing
meet the actual needs of the An education program prepared for
individual patient; patients suffering from TMD is not

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 PHILIPPE AMAT

designed solely to improve their un- tion, and continuing modules of

derstanding of the disorder that afflicts specified instruction and duration
them but, more important, to improve designed for the patient’s specific
their health and their quality of life. needs and preferences;
The information in the program is – the central element of the program
necessary but not sufficient. The should be the doctor-patient relation-
program must stimulate patients to ship beginning with the introductory
participate actively in their treatment oral presentation, supplemented with
and to make lasting changes in their written and audio-visual material, on
health behavior. the educational procedures. The prac-
titioner then demonstrates the exer-
• Contents of an education program
cises, asks patients to repeat them,
A variety of tools, logbooks, log
giving encouragement and correction
sheets, workbooks, CD-ROMs, action
where needed;
plans, and videos, and pedagogical
– after the dentist’s initial presenta-
techniques, problem resolution training,
tion, dental assistants can serve as
project solving, and Socratic and intuitive
mentors of patients learning how to
methods, useful for a practical patient
accomplish exercises under the
education program. But frequently the
dentist’s supervision to assure the
simplest techniques, reinforced by the
procedure is neither shortened nor
clinician’s empathy and common sense,
distorted.
are the most effective.
It is important to emphasize certain Among the tools at a dentist’s dis-
key elements: posal, the plan of action is especially well
designed for management of TMD.
– clinicians’ attentive listening, empa-
Dentists give this personalized docu-
thy, and approval of the patient’s
ment to all patients and after they have
efforts without being judgmental,
read it, review its contents, explaining
strengthens the therapeutic alliance;
any obscure points, and being sure they
– clinicians must deliver positive,
comprehend and accept it.
understandable, explicit and fully
synthesized messages; In it patients find:
– patients must view the first steps – the exercises that must be per-
of the program as realistic and formed in their education programs;
manageable; – what to do if they experience pain;
– patients’ families must be able to – suggestions on how to manage
observe the movements accom- environmental factors like, for ex-
plished in the education program ample, the situations encountered
so that they can provide positive at work and how to optimize their
reinforcement; health behavior;
– audiovisual and written components – advice on eliminating or decreasing
of the education program complete their consumption of stimulants like
but do not replace the oral information alcohol, black tea and coffee etc.;
that the therapist presents; – recommendation on how to relax
– the education program is persona- and deal with conflicts;
lized, centered on the patient, and – how to reduce sedentary preoccu-
organized in priority units of initia- pations like TV watching or playing

14 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

video games and how to commit to showing them how to perform re-
outdoor activities. coordination exercises.
It is worth noting that orthodontists
– Hypermobility of the mandible
are experienced in ortho-functional re-
– explanation and behavioral counsel-
education4,5 elements of which they
ing including how to reduce extent
routinely present to patients who are
of mandibular opening during yawn-
mouth breathers or tongue thrusters.
ing (Fig. 12) and how to strengthen
• Examples of maxillo-facial elevator muscles and flaccid liga-
re-education programs ments by performing exercises
In the limited space available for this against resistance;
article, we can only suggest the – showing patients how to perform
general outlines of exercises offered exercises against resistance to
in a re-education program9, depending strengthen the mandibular elevator
on the DTM’ type. It is worth noting muscles.
that TPE should be implemented as – TMJ subluxation
soon pain and inflammation have been – explanations and behavioral counsel-
adequately managed. ing on how to reduce mandibular
– Protective muscle splinting opening during yawning (Fig. 12),
of elevator muscles how to limit jaw opening by reducing
– explanation and counseling about the size of food particles, and how to
health behavior, for example reduc- perform against resistance exercises
tion of gum chewing, elimination of to strengthen the elevator muscles.
noxious habits; – Bruxism
– stretching exercises; – explanations and behavioral coun-
– excercises against resistance (Sher- seling;
rington reflex or reciprocal inhibi- – re-education of the habitual rest
tion: inhibition of the antagonistic position of the mandible.
muscles in response to the con-
traction of the muscles during the – Disc dislocation with reduction
exercise). – explanation and behavioral counsel-
ing;
– Contraction of the mandible’s – re-coordination exercises;
elevator muscles – then, after several appointments,
– explanation and behavioral counsel- showing patients how to strength-
ing about abating gum chewing, en the elevator muscles and the
reducing noxious habits such as flaccid ligaments with against resis-
day time tooth clenching, and learn- tance exercises.
ing how to relax muscles;
– stretching exercises; – Disc dislocation without reduction
– exercises against resistance. – explanations and behavioral coun-
seling;
– An avoidance reflex may persist – stretching and re-coordination exer-
after the interference that provoked cises.
it has been eliminated. Therapist
helps patients to deal with this by – Tense muscles in the neck and
explaining what is happening and cervical area

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 PHILIPPE AMAT

working posture and report their own

evaluation of their progress in reducing
TMD distress and improving their
quality of life.
With this information in hand the
doctor-patient team can re-schedule
future appointments to conform to the
patient’s current TMD status and de-
termine whether auxiliary treatment
with occlusodontists, physical thera-
pists, or psychotherapists are indi-
cated.
If a patients adherence to the
program decreases it is important for
therapists not to be judgmental and to
express sympathy and understanding7
using each appointment to offer pa-
tients positive reinforcement. Thera-
Figure 12 pists should re-emphasize the
Limiting jaw opening during yawning with
educational messages of the program
finger pressure.
and assure patients that they are
respected and understood. These
confidence-boosting strategies of ac-
– explanations and behavioral coun- tive and empathic listening can often
seling; bolster cooperation and help patients
– neck exercises. eventually make lasting beneficial
changes in their health behavior.
4 – 4 – 2 – 4 – Evaluating results
Either the orthodontist or an assis- 4 – 5 – Benefits of using written
tant evaluates results considering im- material in maxillo-facial
provements made in the three areas of re-education for TMD
objectives, health, behavior, and psy-
chosocial adjustment that were deli- Written educational material is par-
neated in the education contract after ticularly well suited for maxillo-facial
each appointment and in a final assess- re-education for patients suffering
ment. This evaluation records how well from TMD. Pamphlets given to pa-
patients have digested information tients after they have heard oral
about TMD, how well they have per- explanations of the disorder serve to
formed the maxillo-facial re-education reinforce what they have learned and
exercises, and how well they have help them conduct assigned exer-
dealt with exacerbating factors like cises. They can reassure patients they
stress, bruxism, nail biting, and habits are performing these exercises cor-
like gum chewing. Patients demon- rectly and help them inform family
strate how well they have acquired a members what the nature of the

16 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

Figure 13

J Dentofacial Anom Orthod 2011;14:206 17

 PHILIPPE AMAT

Figure 14

18 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

Figure 15

J Dentofacial Anom Orthod 2011;14:206 19

 PHILIPPE AMAT

Figure 16

20 Amat P. Managing temporomandibular disorders (TMD) by integrating exercise therapy into therapeutic patient
educational programs: why, when, how?
 MANAGING TEMPOROMANDIBULAR DISORDERS TMD BY INTEGRATING EXERCISE THERAPY INTO THERAPEUTIC PATIENT EDUCATIONAL PROGRAMS: WHY, WHEN, HOW

disorder is and how it is being treated. loaded from the site of the Collège
And they formalize the details of the National d’Occlusodontologie [5]).
roles played by each partner in the In our daily practice we use bro-
doctor-patient team. chures on maxillo-facial reeducation
from the University Department of
Occlusodontia Paris V16 (Fig 13 to 16)
4 – 6 – Examples of brochures that are recommendations taken from
used in maxillo-facial brochures of C. Pianello to which we
reeducation for TMD. have appended didactic illustrations.
But we are now developing new, more
Among the many pamphlets available multi-facetted brochures that specifi-
in French are documents written by D cally adapted to orthodontic practice.
and G Rozencweig38, J. D. Orthlieb; and
C. Pianello33 (one that can be down- [5] http:/www.occluso.com/excercise.pdf

5 – CONCLUSION
The management of TMD treat- This medical approach, similar to
ment by means of maxillo-facial re- those employed by physicians for
education is a simple, conservative, treating other joints of the human
and reversible therapeutic modality musculo-skeletal system, is readily
whose evidence based utilization is available to all practitioners and en-
amply justified by a large consensus in ables them to respond simply and
the scientific literature35. effectively to all clinical situations9.
Clinicians can reinforce the effec- With it clinicians can help patients
tiveness of maxillofacial re-education with temporo-mandibular disorders to
by adapting it to the needs and desires make adjustments that will relieve
of individual patients by planning steps their pain and regain functional com-
of their therapeutic education espe- fort.
cially suited to their requirements.

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