To analyse the effectiveness of exercise therapy in improving pain and active or passive maximum mouth opening in patients with temporomandibular disorders.
Data sources
PubMed Medline, Web of Science, Scopus, CINAHL Complete and Physiotherapy Evidence Database, until April 2022, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Review methods
We included randomized controlled trials evaluating the effect of exercise therapy on pain and on active and passive maximum mouth opening in patients with temporomandibular disorders. Effect size was calculated using Cohen's standardized mean difference (SMD) and their 95% confidence interval (95% CI) in a random-effects model.
Results
A total of 16 studies with 812 participants were included. Exercise therapy is effective in reducing pain (SMD: −0.58; 95% CI: −1.01 to −0.12) and increasing the pain pressure threshold (SMD: 0.45; 95% CI: 0.14–0.76), active and passive maximum mouth opening (SMD: 0.43; 95% CI: 0.14–0.71 and SMD: 0.4; 95% CI: 0.06–0.75, respectively). Subgroup analyses showed more effect of exercise therapy more splints versus splints on pain (SMD: −0.5; 95% CI: −0.73 to −0.26), active and passive maximum mouth opening (SMD: 1.14; 95% CI: 0.22–2.07 and SMD: 0.56; 95% CI: 0.06–1.06, respectively). On pain pressure threshold, exercise therapy was better than physiotherapy approach (manual therapy and electrotherapy) (SMD: 0.48; 95% CI: 0.09–0.87).
Conclusions
Therapeutic exercise is an effective therapy to reduce pain and increase pain pressure threshold and active and passive maximum mouth opening in patients with temporomandibular disorders.
GauerRLSemideyMJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician2015; 91: 378–386.
2.
OkesonJPde LeeuwR. Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dent Clin North Am2011; 55: 105–120.
3.
ValesanLFDa-CasCDRéusJC, et al.Prevalence of temporomandibular joint disorders: a systematic review and meta-analysis. Clin Oral Investig2021; 25: 441–453.
4.
BuenoCHPereiraDDPattussiMP, et al.Gender differences in temporomandibular disorders in adult populational studies: a systematic review and meta-analysis. J Oral Rehabil2018; 45: 720–729.
5.
Sánchez-TorreloCMZagalaz-AnulaNAlonso-RoyoR, et al.Transcultural adaptation and validation of the fonseca anamnestic Index in a spanish population with temporomandibular disorders. J Clin Med2020; 9: 1–11.
6.
CruzDMonteiroFPaçoM, et al.Genetic overlap between temporomandibular disorders and primary headaches: a systematic review. Jpn Dent Sci Rev2022; 58: 69–88.
7.
KaposFPExpostoFGOyarzoJF, et al.Temporomandibular disorders: a review of current concepts in aetiology, diagnosis and management. Oral Surg2020; 13: 321–334.
8.
ProgiantePPattussiMLawrenceH, et al.Prevalence of temporomandibular disorders in an adult Brazilian community population using the research diagnostic criteria (axes I and II) for temporomandibular disorders (The Maringá Study). Int J Prosthodont2015; 28: 600–609.
9.
HarperDESayreKSchrepfA, et al.Impact of fibromyalgia phenotype in temporomandibular disorders. Pain Med2021; 22: 2050–2056.
10.
Al-KhotaniAMeishaDEAl SayeghS, et al. The association between psychological symptoms and self-reported temporomandibular disorders pain symptoms in children and adolescents. Front Oral Heal2021; 2:675709.
11.
SaghafiETuomiLKjellerG. The prevalence and symptoms of temporomandibular disorders in head and neck cancer patients. Acta Odontol Scand2022; 80: 252–257.
12.
LobbezooFNaeijeM. Bruxism is mainly regulated centrally, not peripherally. J Oral Rehabil2001; 28: 1085–1091.
ListTJensenRH. Temporomandibular disorders: old ideas and new concepts. Cephalalgia2017; 37: 692–704.
15.
WieckiewiczMBoeningKWilandP, et al.Reported concepts for the treatment modalities and pain management of temporomandibular disorders. J Headache Pain2015; 16: 106.
16.
MagalhãesBGFreitasJdMBarbosaAdS, et al.Temporomandibular disorder: otologic implications and its relationship to sleep bruxism. Braz J Otorhinolaryngol2018; 84: 614–619.
17.
Ibáñez-VeraAJAlonso-RoyoRSánchez-TorreloCM, et al.Psychometric evaluation of the Krogh-Poulsen test for the diagnosis of the temporomandibular disorders. Diagnostics2021; 11: 1876.
18.
YekkalamNWänmanA. Association between signs of hyperalgesia and reported frequent pain in jaw-face and head. Acta Odontol Scand2021; 79: 188–193.
19.
LiuFSteinkelerA. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dent Clin North Am2013; 57: 465–479.
20.
KulkarniSThambarSAroraH. Evaluating the effectiveness of nonsteroidal anti–inflammatory drug(s) for relief of pain associated with temporomandibular joint disorders: a systematic review. Clin Exp Dent Res2020; 6: 134–146.
21.
AndreAKangJDymH. Pharmacologic treatment for temporomandibular and temporomandibular joint disorders. Oral Maxillofac Surg Clin North Am2022; 34: 49–59.
22.
HershEVBalasubramaniamRPintoA. Pharmacologic management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am2008; 20: 197–210.
23.
SabhlokAGuptaSGirishM, et al.Practice of occlusal splint therapy for treating temporomandibular disorders by general dentists of Jabalpur – A cross-sectional survey. J Pharm Bioallied Sci2021; 13: S1079.
24.
HardyRSBonsorSJ. The efficacy of occlusal splints in the treatment of bruxism: a systematic review. J Dent2021; 108: 103621.
25.
Kuzmanovic PficerJDodicSLazicV, et al.Occlusal stabilization splint for patients with temporomandibular disorders: meta-analysis of short and long term effects. PLoS One2017; 12: e0171296.
26.
Al-MoraissiEAFareaRQasemKA, et al.Effectiveness of occlusal splint therapy in the management of temporomandibular disorders: network meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg2020; 49: 1042–1056.
27.
Armijo-OlivoSPitanceLSinghV, et al.Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Phys Ther2016; 96: 9–25.
28.
La ToucheRBoo-MalloTZarzosa-RodríguezJ, et al.Manual therapy and exercise in temporomandibular joint disc displacement without reduction. A systematic review. CRANIO2022; 40: 440–450.
29.
DickersonSMWeaverJMBoysonAN, et al.The effectiveness of exercise therapy for temporomandibular dysfunction: a systematic review and meta-analysis. Clin Rehabil2017; 31: 1039–1043.
30.
ZhangLXuLWuD, et al.Effectiveness of exercise therapy versus occlusal splint therapy for the treatment of painful temporomandibular disorders: a systematic review and meta-analysis. Ann Palliat Med2021; 10: 6122–6132.
31.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J2021; 372: n71.
32.
HigginsJThomasJ. Cochrane handbook for systematic reviews of interventions, 2nd edition | Wiley. 2nd ed.Hoboken, NJ: Wiley Blackwell & Sons, 2020.
33.
AtkinsDBestDBrissPA, et al.Grading quality of evidence and strength of recommendations. Br Med J2004; 328: 1490.
34.
MeaderNKingKLlewellynA, et al.A checklist designed to aid consistency and reproducibility of GRADE assessments: development and pilot validation. Syst Rev2014; 3: 82.
35.
MoseleyAMHerbertRDSherringtonC, et al.Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother2002; 48: 43–49.
36.
DerSimonianRLairdN. Meta-analysis in clinical trials. Control Clin Trials1986; 7: 177–188.
37.
CohenJ. Statistical power analysis for the behavioral sciences. New York, New York: Academic Press, 1977.
38.
FaraoneSV. Interpreting estimates of treatment effects: implications for managed care. P T2008; 33: 700–711.
39.
RückerGSchwarzerG. Beyond the forest plot: The drapery plot. Res Synth Methods2021; 12: 13–19.
40.
SterneJACEggerM. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol2001; 54: 1046–1055.
41.
DuvalSTweedieR. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics2000; 56: 455–463.
42.
HigginsJThompsonSDeeksJ, et al.Measuring inconsistency in meta-analyses. Br Med J2003; 327: 557–560.
43.
HigginsJThompsonSDeeksJ, et al.Statistical heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practice. J Heal Serv Res Policy2002; 7: 51–61.
44.
CooperHHedgesLVValentineJC. The handbook of research synthesis and meta-analysis. New York, New Your, United States: Russell Sage Foundation, 2009.
45.
AlajbegIGikićMValentić PeruzovićM. Mandibular range of movement and pain intensity in patients with anterior disc displacement without reduction. Acta Stomatol Croat2015; 49: 119–127.
46.
BaeYParkY. The effect of relaxation exercises for the masticator muscles on temporomandibular joint dysfunction (TMD). J Phys Ther Sci2013; 25: 583–586.
47.
PatilSRAileniKR. Effect of transcutaneous electrical nerve stimulation versus home exercise programme in management of temporomandibular joint disorder. J Clin DIAGNOSTIC Res2017; 11: 19–22.
48.
ShoushaTMSolimanESBehiryMA. The effect of a short term conservative physiotherapy versus occlusive splinting on pain and range of motion in cases of myogenic temporomandibular joint dysfunction: a randomized controlled trial. J Phys Ther Sci2018; 30: 1156–1160.
49.
TanhanAOzerAYPolatMG. Efficacy of different combinations of physiotherapy techniques compared to exercise and patient education in temporomandibular disorders: a randomized controlled study. CRANIO2021: 1–13.
50.
WahlundKNilssonI-MCarlssonAD, et al.Internet-based treatment for adolescents with symptomatic temporomandibular joint disc displacement with reduction. A randomized controlled clinical trial. Acta Odontol Scand2021; 79: 473–481.
51.
WänmanAMarklundS. Treatment outcome of supervised exercise, home exercise and bite splint therapy, respectively, in patients with symptomatic disc displacement with reduction: a randomised clinical trial. J Oral Rehabil2020; 47: 143–149.
52.
YuasaHKuritaKOgiN, et al.Randomized clinical trial of primary treatment for temporomandibular joint disk displacement without reduction and without osseous changes: a combination of NSAIDs and mouth-opening exercise versus no treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2001; 91: 671–675.
53.
BarbosaMATaharaAKFerreiraIC, et al.Effects of 8 weeks of masticatory muscles focused endurance exercises on women with oro–facial pain and temporomandibular disorders: a placebo randomised controlled trial. J Oral Rehabil2019; 46: 885–894.
54.
BasBKazanDKutukN, et al.The effect of exercise on range of movement and pain after temporomandibular joint arthrocentesis. J Oral Maxillofac Surg2018; 76: 1181–1186.
55.
CraaneBDijkstraPUStappaertsK, et al.Randomized controlled trial on physical therapy for TMJ closed lock. J Dent Res2012; 91: 364–369.
56.
HaketaTKinoKSugisakiM, et al.Randomized clinical trial of treatment for TMJ disc displacement. J Dent Res2010; 89: 1259–1263.
57.
IsmailFDemlingAHeßlingK, et al.Short-term efficacy of physical therapy compared to splint therapy in treatment of arthrogenous TMD. J Oral Rehabil2007; 34: 807–813.
58.
KalamirAGrahamPLVitielloAL, et al. Intra-oral myofascial therapy versus education and self-care in the treatment of chronic, myogenous temporomandibular disorder: a randomised, clinical trial. Chiropr Man Therap2013; 21:17.
59.
MagestyRASilvaMAMSimõesCASC, et al.Oral health–related quality of life in patients with disc displacement with reduction after counselling treatment versus counselling associated with jaw exercises. J Oral Rehabil2021; 48: 369–374.
60.
MuletMDeckerKLLookJO, et al.A randomized clinical trial assessing the efficacy of adding 6 × 6 exercises to self-care for the treatment of masticatory myofascial pain. J Orofac Pain2007; 21: 318–328.
61.
CalixtreLBOliveiraABAlburquerque-SendínF, et al.What is the minimal important difference of pain intensity, mandibular function, and headache impact in patients with temporomandibular disorders? Clinical significance analysis of a randomized controlled trial. Musculoskelet Sci Pract2020; 46: 102108.
62.
MachadoBCZMazzettoMODa SilvaMAMR, et al.Effects of oral motor exercises and laser therapy on chronic temporomandibular disorders: a randomized study with follow-up. Lasers Med Sci2016; 31: 945–954.
63.
FougerontNFleiterB. Temporomandibular disorder and comorbid neck pain: facts and hypotheses regarding pain-induced and rehabilitation-induced motor activity changes. Can J Physiol Pharmacol2018; 96: 1051–1059.
64.
DominMGrimmNKKlepzigK, et al.Gray matter brain alterations in temporomandibular disorder tested in a population cohort and three clinical samples. J Pain2021; 22: 739–747.
65.
YinYYLiFHeSS, et al.Abnormal static and dynamic brain function in patients with temporomandibular disorders: a resting-state functional magnetic resonance imaging study. Hua Xi Kou Qiang Yi Xue Za Zhi2021; 39: 682–689.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
