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The Somatic Connection  |   April 2012
Intraoral Manipulation and Jaw Exercises Shown to Be of Benefit in Temporomandibular Joint Disorder
Article Information
The Somatic Connection   |   April 2012
Intraoral Manipulation and Jaw Exercises Shown to Be of Benefit in Temporomandibular Joint Disorder
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 156-157. doi:10.7556/jaoa.2012.112.4.156
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 156-157. doi:10.7556/jaoa.2012.112.4.156
Kalamir A, Bonello R, Graham P, Vitiello AL, Pollard H. Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: a randomized controlled trial. J Manipulative Physiol Ther. 2012;35(1):26-37.  
Readers of JAOA—The Journal of the American Osteopathic Association who treat patients with temporomandibular disorder (TMD) may have collected a number of useful articles appearing in these pages on the topic of such treatment.1-3 Accessing the complete texts of these JAOA articles, together with the article by Kalamir et al published in the chiropractic Journal of Manipulative and Physiological Therapeutics, will provide an excellent bibliography of research apropos to the clinical management of TMD. 
In the study by Kalamir et al, which was recognized with an award by the World Federation of Chiropractic, chiropractic researchers associated with Macquarie University in Sydney, Australia, evaluated 2 treatment approaches for patients with TMD. Using intraoral manipulative techniques similar to those described in cranial osteopathic manipulative medicine training manuals and texts,4,5 the authors compared results in the following 3 groups of patients with TMD: (1) those receiving intraoral myofascial therapy (IMT), (2) those receiving IMT plus education and “self-care” exercises (IMTESC), and (3) those serving as wait-list control patients. 
Patients were recruited from the primary author's private practice. Inclusion criteria were age between 18 and 50 years, daily history of periauricular pain, and availability for 1-year follow-up. Exclusion criteria were previous treatment at this private practice, history of malignancy in the previous 5 years, edentulousness, fracture, dislocation, inflammatory arthritide, connective tissue disease, rheumatic disorder, and hematologic disorder. To be included as a study participant, the patient also had to report a minimum baseline graded pain score of 3 (on an 11-point scale) on each of the following primary outcome measures: jaw pain at rest, jaw pain on maximal active opening, and jaw pain on clenching. A secondary measure was interincisal range of opening, in millimeters. 
The IMT group (n=31) received 2 treatment sessions per week for 5 weeks. Interventions were as follows: (1) intraoral temporalis release; (2) intraoral medial and lateral pterygoid technique; and (3) intraoral sphenopalatine ganglion technique. As an educator who has taught in cranial osteopathic manipulative medicine courses, I can report that the techniques described in this article appear to be similar to techniques used in the practice of osteopathic medicine. The IMTESC group (n=31) received the same 5 weeks of IMT, in addition to educational reading material concerning temporomandibular joint anatomy and instructions in applying self-administered mandibular exercises (which are thoroughly described and pictured in the article). As with the 2 intervention groups, the wait-list control group (n=31) had outcome measures at 6 weeks, 6 months, and 1 year. 
Study results showed that both the IMT and IMTESC groups had statistically significant lower pain scores compared with the control group at the 6-week, 6-month, and 1-year assessments (P<.05). No statistically significant differences were observed between the IMT and IMTESC groups until the 1-year assessment, when the IMT group regressed with slightly increased pain scores. This finding surprised the investigators, who had expected the IMTESC group to show more pain reduction at every assessment point. 
The study results were limited by the facts that all patients were from the same practice and only 1 provider administered the interventions. Another possible design flaw of the study is that nowhere in the article did the authors mention whether the patients in the IMTESC group were instructed to discontinue the self-administered exercises after the initial 5 weeks of treatment—nor whether the patients in this group were encouraged to report having done so over the 1-year duration of the study. If some patients in the IMTESC group did continue the self-administered exercises beyond the initial 5-week treatment period, this continuation could account for the sustained benefit in pain reduction at the 1-year assessment. 
From a clinical perspective, it would seem prudent to encourage a patient with TMD to continue self-administered mandibular exercises indefinitely—if only intermittently—based on the results reported by Kalamir et al. To the interested reader, the procedures and exercises used in this study make up a good, current rendition of a useful approach to the treatment of patients with TMD. 
Despite the limitations, the results of the study by Kalamir et al are consistent with my clinical experience in the treatment of patients with TMD. Thus, I believe that the study may be considered as further support for the clinical application of cranial osteopathic manipulative medicine.—H.H.K. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the   renewed interest in manual medicine internationally, especially in Europe.
 
   To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (mseffinger@westernu.edu), or Editorial Board Member Hollis H. King, DO, PhD (hollis.king@fammedwisc.edu).
 
References
Hruby RJ. The total body approach to the osteopathic management of temporomandibular joint dysfunction. J Am Osteopath Assoc. 1985;85(8):502-510. [PubMed]
Cuccia AM, Caradonna C, Caradonna D. Manual therapy of the mandibular accessory ligaments for the management of temporomandibular joint disorders. J Am Osteopath Assoc. 2011;111(2):102-112. [PubMed]
Cuccia AM, Caradonna C, Annunziata V, Caradonna D. Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial [published online ahead of print September 20, 2009]. J Bodyw Mov Ther. 2010;14(2):179-184. [CrossRef] [PubMed]
Frymann VM. Cranial osteopathy and its role in disorders of the temporomandibular joint. Dent Clin North Am. 1983;27(3):595-611. [PubMed]
Larsen NJ. Osteopathic manipulative contribution to treatment of TMJ syndrome. Int J Osteopath Med. 1976;3:15-27.