Management of Temporomandibular Disorders with Orofacial Myofunctional Therapy

Dr. Zareth Jana Hernández talks about the debilitating pain of TMJ disorders, and how oral myofunctional therapy may help.

Myofunctional therapyby Zareth Jana Hernández, DMD

Temporomandibular disorders (TMDs) are debilitating conditions that may cause pain, dysfunction, and impaired quality of life.1 TMD patients may present with dysfunctional breathing, chewing, and speech patterns. They may compensate by recruiting orofacial muscles that should not be activated to perform these essential stomatognathic functions, which turns this into a vicious cycle that potentiates pain and dysfunction.2-4 Non-invasive therapies reported in the literature to alleviate pain are self-care guidelines, orthotics, and laser therapy.5-7 In addition to reducing pain, healthcare providers should aim to improve dysfunction.

Myofunctional therapy (OMT) involves neurologic reeducation through daily exercises that assist in breathing, chewing, speech,8 and even facial expressions in a social context.9 Modifying dysfunctional muscle patterns associated with TMDs may be achieved due to the principle of neuroplasticity.

Myofunctional therapy has three main goals:

  1. The tongue should rest on the palate
  2. Lips together, teeth apart
  3. Primarily nasal breathe10

Collaboration with dentists, ENTs, and osteopaths, among other specialties, is often required for comprehensive diagnosis and treatment planning.

Myofunctional therapy
Figure 1 (left): Rubber band to “the spot” is a passive exercise in which a rubber band is placed at the tip of the tongue and pressed against the “spot” as the patient multitasks. They should have lips sealed and freeway space as they maintain this posture.10 Figure 2 (right): Lip rest with a chopstick between the lips and a rubber band to “the spot” is a passive exercise that promotes lip seal and proper tongue posture.10

Figures 1-3 show examples of myofunctional exercises. During the first phase, myofunctional therapists may provide these and other exercises in weekly treatment sheets after thoroughly assessing orofacial functions.10

Myofunctional therapy
Figure 3: Caves or Tongue Suction Hold, a classic OMT exercise that promotes tongue to palate contact.10

The role of OMT in improving health and quality of life cannot be emphasized enough. A recent international consensus statement reported that OMT should be considered an integral part of the interdisciplinary management of obstructive sleep apnea.11 Studies have found that OMT reduces the AHI by 50% in adults and 62% in children.12 Interestingly, the clinical and radiographic findings of TMD patients are often indistinguishable from those of airway patients.13

Myofunctional therapy
Figure 4: First page of the OMES protocol17

A systematic review that evaluated the evidence of OMT to manage TMD found a reduction in pain and dysfunction from baseline in symptomatic subjects that performed OMT. Results should be interpreted cautiously since the overall risk of bias was “High” and the certainty of the evidence for both outcomes was “Very low.”14 In this review, the primary outcome was pain which was measured subjectively via validated instruments,15 and the secondary outcome was dysfunction, measured with the validated Orofacial Myofunctional Evaluation with Scores (OMES) protocol.16

Most subjects were female (F= 92, M= 7) in all studies17-20 included in the review.14 The TMD diagnoses were made using the Research Diagnostic Criteria.21-22 Three-dimensional imaging was not reported in any of the studies for TMD diagnosis, which can be considered a limitation.23

Claudia María de Felício, a speech pathologist and myofunctional therapist from Brazil, developed an OMT protocol for TMD patients. The clinical trials included in the Jana et al. systematic review14 applied de Felício’s original or adapted protocol. Although this protocol is available, having the appropriate training is critical to individualizing the treatment exercises depending on the needs of each patient.8,17-20

The role of OMT in improving health and quality of life cannot be emphasized enough.

de Felício’s protocol is completed in 120 days. Patients receive a treatment sheet with exercises that change weekly during the first month and every two weeks afterward. Patients should be sitting with their backs straight while completing the exercises. They should also use a mirror for immediate feedback. The myofunctional therapist assesses compliance and reviews the exercises at each appointment.

In the first stage of de Felício’s protocol, mobility exercises are done in which oral structures are trained individually. Patients should slowly move the tongue and oral structures to maintain the target position for at least three seconds. The therapist decides on the number of repetitions based on the tonicity and fatigue limit of the orofacial muscles. After the mobility stage, strength and resistance exercises are implemented. Finally, coordination exercises are prescribed; in this phase, multiple orofacial muscles synchronize to assist stomatognathic functions.8

Take-home Message:

  1. OMT is a tool for healthcare providers to improve TMD patients’ pain and dysfunction.
  2. An OMT practitioner familiar with de Felício’s protocol would be a valuable member of the treatment team.

Karese Laguerre, RDH, delves into the benefits and challenges of incorporating myofunctional therapy into the dental practice in this CE. Subscribers can take the quiz and receive 2 CE credits!

Myofunctional therapyZareth Jana Hernández, DMD, is a graduate of the University of Puerto Rico School of Dental Medicine and completed a 12-month Advanced Education in General Dentistry Postdoctoral Program with NYU Langone Hospitals’ affiliated institution in Puerto Rico. Dr. Jana trained in Orofacial Myofunctional Therapy with the Academy of Orofacial Myofunctional Therapy in 2020. She is in her senior year of Prosthodontics Residency at Puerto Rico’s Medical Sciences Campus. After residency, Dr. Jana will pursue further education in craniofacial development, airway, sleep, and TMD. She enjoys research, running, and spending time with her partner, Armando.

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