What percentage of patients that you have fit with an anterior mandibular positioning device return complaining of jaw and/or face pain? One study reports the incidence as high as 40% in long-term users, and up to 50% of all patients quit using the device because of dissatisfaction with side-effects.1 What if you could increase compliance by addressing undesired pain without increasing the patient’s time in your office? Referral to a qualified Physical Therapist may be the answer.
Physical Therapists (PTs) are health professionals who specialize in the evaluation and treatment of pain and dysfunction arising from the neurological, cardiopulmonary, integumentary, and musculoskeletal systems. Since 2002, all graduates of accredited Physical Therapy educational programs hold a DPT, or Doctor of Physical Therapy, degree. This requires completion of 3 years of physical therapy training after achievement of a bachelor’s degree. In addition to didactic and clinical training, there is a strong emphasis on reading, reviewing, and conducting research to fit with the American Physical Therapy’s mandate for Evidence Based Practice. Physical Therapists treat physical pain and dysfunction with modalities such as heat, cold, electricity and light, and use manual techniques of therapeutic massage and joint and soft tissue mobilizations. PTs are experts in addressing posture and body mechanics as causative or contributing factors and excel in patient education and the prescription of specific therapeutic exercises. All states require continuing education as a requirement for licensing. Some PTs voluntarily chose to gain additional certifications in their field of choice.
Over the past 10 years my patients and I have benefitted from the close working relationship established between myself and dentists that specialize in the evaluation and treatment of occlusal muscle dysfunction, oral-facial pain, and TMD. Just as I know that some of my patients will not reach their comfort and functional goals without dental intervention, I also believe that some TMD and facial pain patients benefit from Physical Therapy intervention in addition to the dental component. This is supported in the literature.1,2,3,4 The primary indication for dental referral to PT is TMD with concurrent neck pain.5,6 Due to the high prevalence of asymptomatic cervical spine dysfunctions identified in their study group of TMD patients, Fink et al recommend a thorough examination of the neck even in the absence of reported pain or problems.7 Patients that develop occlusal muscle dysfunction with use of a mandibular advancement device may present with complaints of pain at one or both TMJ in the absence of joint pathology. Pain and tenderness may also be present in the superficial and deep masseter on one or both sides. Other complaints may seem unrelated, but are actually common referred pain patterns arising from trigger points in the face and neck muscles. These include complaints of occipital or temporal headaches of new onset, pain behind the eyes, mastoid pain, a feeling of pressure, stuffiness, or ringing in the ears, pain in the vertex of the head, and teeth that hurt (upper or lower) in the absence of tooth pathology. Other indications for referral to a PT include: forward head positioning,8,9 and pain caused or influenced by static postures or movement.
Many dentists ask the patient on the intake form for the names of any ancillary health professionals that they are currently seeing. If they list a PT, a phone call to that provider can establish whether that person has the interest and ability to provide adjunctive care. The most elucidative question is simply; how would you evaluate and treat this patient with oral-facial pain or TMD? The answer would preferably include a whole-body approach. For example, I always address overall posture, not just forward head positioning or head tilt, and often make recommendations for foot orthotics if needed for optimal positioning or stability. It is mandatory to address static posturing, such as neck positioning with the use of personal hand-held devices; think smart phones, and parafunctional habits like propping their chin on their hand, stomach sleeping, or sleeping with their hand under their jaw. In addition, a thorough review of their work and leisure activities will help to identify and correct underlying problems in body mechanics that can have an adverse impact on the head and neck. Although the use of physical agents or modalities such as various types of heat energies can be helpful to reduce pain and inflammation, the use of manual techniques has been proven to be effective in the treatment of neck and oral-facial pain.11,12 Manual techniques include soft tissues mobilizations and massage, as well as mobilizations to the TM and neck joints. The dental professional should direct any mobilizations to the temporomandibular joint based on the perceived or diagnostically confirmed position of the disc and condyles, and the desired result; i.e. improved MO or excursive movements. Communication between the dentist and PT is an essential component to achieving optimal results.
Finding a qualified PT need not be a time-consuming effort. Checking with your peers may yield leads in your area. On-line resources are also available. PTs who are members of the American Physical Therapy Association (APTA) may list their name and brief biography. This can be accessed at apta.org. Click on “For the Public”, then “Find a PT”. Refine your search by choosing ‘Musculoskeletal’ as the Practice Area. Look for individuals in your area that indicate proficiency in TMJ/jaw and facial pain, or those with Orthopedic Clinical Specialist (OCS) designation. My specialty area is in Postural Restoration™. Therapists with the designation of Postural Restoration Certified (PRC) can be found at posturalrestoration.com. Click on “Find a Provider”. Physical Therapists who are members of the American 
Academy of Orofacial Pain can be found at aaop.org. Click on “Patient Resources”, then “AAOP Member Directory”. Finally, PTs that have completed a post-graduate proficiency in Cranio-Facial can be accessed via usa.edu. Click on “Continuing Education”, then “Certification Graduate Listing”. Look for the CFC (Cranio-Facial) designation. If there are no specialists in your geographic area, you can cultivate good working relationships by inviting local PTs to your office for educational networking, or including them in a study group meeting.The partnership between a dentist and a Physical Therapist can be rewarding from the professional standpoint of offering your patient another avenue for improved health and wellness, and also from a personal standpoint of advancing your own knowledge base as you reach out to another health care professional. Although a goal of 100% compliance with your MADs may be unrealistic, we owe it to our patients to optimize their comfort as they pursue sleep apnea treatment.
Clark GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and snoring: assessment of an anterior positioning device. J Am Dent Assoc 2000 Jun;131(6):766-71.
de Toledo EG Jr, Silva DP, de Toledo JA, Salgado IO. The interrelationship between dentistry and physiotherapy in the treatment of temporomandibular disorders. J Contemp Dent Pract. 2012 Sep 1;13(5):579-83.
Wright EF, North SL. Management and treatment of temporomandibular disorders: a clinical perspective. J Man Manip Ther. 2009;17(4):247-54.
Di Fabio RP. Physical therapy for patients with TMD: a descriptive study of treatment, disability, and health status. J Orofac Pain. 1998 Spring;12(2):124-35.
Weber P, Corrêa EC, Ferreira Fdos S, et al. Cervical spine dysfunction signs and symptoms in individuals with temporomandibular disorder. J Soc Bras Fonoaudiol. 2012;24(2):134-9.
Olivo SA, Fuentes J, Major PW et al. The association between neck disability and jaw disability. J Oral Rehabil. 2010 Sep;37(9):670-9.
Fink M, Tschernitschek H, Stiesch-Scholz M. Asymptomatic cervical spine dysfunction (CSD) in patients with internal derangement of the temporomandibular joint. Cranio. 2002 Jul;20(3):192-7.
Wright EF, Domenech MA, Fischer JR Jr. Usefulness of posture training for patients with temporomandibular disorders. J Am Dent Assoc. 2000 Feb;131(2):202-10.
Makofsky HW, Sexton TR, Diamond DZ, Sexton MT. The effect of head posture on muscle contact position using the T-scan system of occlusal analysis. Cranio. 1991 Oct;9(4):316-21.
Mannheimer JS, Rosenthal RM. Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am. 1991 Jan;35(1):185-208.
Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006 Oct;24(4):283-91.
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. Jul;17(3):302-8.