TMJ Pain Relief Using Self Treatment Protocol

These home care instructions should only be used after professional consultation with an Orofacial Pain Specialist. However, a health care professional who is trained in TMJ disorders should demonstrate the exercises explained in this article for correct use. Not all of the recommendations mentioned in this article apply for every TMJ patient, your TMJ disorders specialist should tell you which of the recommendations are best for your condition.

1. Avoidance Therapy for TMJ Pain Relief

These are things that you should avoid as they contribute to TMJ disorders or make your TMJ pain worse.

Clicking Avoidance

Once a disc is out of place it can not be put back. Therefore, first and most important is avoidance of theclicking by limiting the opening of the jaw. However, avoidance will allow the disc to adapt to its new position and reduce the chances of getting arthritis in the joint in the future. Fortunately, the jaw joint can hinge open two fingers width (25 mm) without sliding forward. It is critical that you must not slide forward or side to-side.

• Hinge of motion without protrusion (limited jaw opening): Put both hands over your jaw joints and feel whether your joints are sliding forward while opening part way. Your mouth opening should be limited to the amount before the forward position.
• Avoid clicking while talking or singing.
• Avoid clicking while eating:
• Have soft foods and cut food into small pieces.
• If you have a one sided click, it may be possible to chew median to hard food in one area of the mouth (often on the same side as the click) without inducing a jaw click.
• Monitor how successful you are: Keep track in a diary of how many times per day your joint clicks.

Clenching Avoidance

Many patients are not aware that they put their teeth together during the day. This is not good, since it
allows you to generate additional contraction in the jaw muscles. When you do this you compromise or
reduce blood flow in the jaw muscles. You should consciously avoid all tooth contact (unless eating)
during the day.
_ No tooth contact except when eating:
> Use a timer to remind you every 30 minutes to keep you teeth apart.
> Place stickers in different locations that you pass during the day (walls, desk, phone, car, refrigerator, etc). Every time you see the stickers remember that your teeth should be apart.

Reduced Jaw Function

As mentioned in click avoidance, you need to avoid all hard food(e.g. tough breads, hard meat)!
and any chewy food(e.g. gum, salad). Hard foods delay the healing process. A soft diet will allow your!
chewing muscles to rest. Chewy foods produce a repetitive rubbing of the joint surfaces together. If they
are damage they never have a chance to heal and repair. It similar to typing several hour with a sore wrist; it might not hurt while you are doing it, but it will hurt later. The injured joint has a better chance!
of healing with a strict program of reduced function.

• Avoid hard/chewy food: Limit foods to those that do not aggravate the pain, this does not!
  mean eat foods with low nutritional value (high in sugar and fat and low in protein). 
• Cut food into small pieces: One way of achieving a good soft diet program can be by simply cutting your food into small pieces.
• Avoid talking, singing, laughing: Limited talking and use of the jaw during the initial treatment.period (usually 3-4 weeks).

Habit Avoidance

• Do NOT bite your nails.
• Do NOT chew your checks or lips.
• Avoid chewing ice cubes.
• Avoid biting on pens or pencils.

Opening Wide Avoidance

• Hold your chin up when yawning and tip your head forward.
• Cut food into small pieces.

Prolonged dental Appointment Avoidance

When you go to the dental office, make sure you tell the dentist or hygienist about your jaw problem and ask if they have a bite block, they can give you to help support your jaw when it is open. (The best bite blocks are made of soft Styrofoam). Next it is critical to ask that they only work for short! periods and give you the opportunity to close your mouth regularly during the appointment.

• Use a bite block.
• Ask for short dental appointments.
• Reset your jaw regularly during the dental work.

2. TMJ Pain Relief using Thermal Therapy / Heat or Cold Pads

Heat Pack (muscle pain)

Apply a heat pack to the painful site for 20 minutes up to 3 times a day: The heat will increase circulation and remove pain-inducing metabolites from the muscles and fascia sites.
You can have your moist heat prepared in one of the following ways:

• Electric heating pad: An electric heating pad is convenient for this purpose but care must be taken not to leave it unattended as surface bums can result. If you buy an electric heating pad, make sure it is a “moist heat” electric heating pad, since ft is more effective than dry heat and less likely to produce a skin bum.
• Hydrocollator heating unit and canvas bag: One way to have a heat pack ready whenever you want it is to get a large coffee maker at a discount store. Use it to heat the water for the hydrocollator bags you keep inside. The hydrocollator bags are canvas bags filled with very small heat retaining rocks. This bag will hold heat for at least 15 to 20 minutes. The canvas bag is removed from the hot water and wrapped in cloth and applied to the pain site. The hydrocollator bags can be purchased at a medical supply store or pharmacy (special order).
• Microwave heat pack: Roll a small towel lengthwise, wet it, fold and place in a plastic bag.
  Put in a microwave and heat on high for 5 minutes. Carefully remove towel from plastic bag with tongs, cover with an additional dry towel to prevent burning yourself, and put around back of neck and sides of face.

Ice Pack (muscle pain or nerve pain)

Apply an iced gel pack to the painful site for 20 minutes un to 3 times a day: There are many
gel packs that can be purchased at a pharmacy. These packs are kept in a freezer and then
wrapped in a towel before applying to the painful area.

Admittedly, some patients do better with heat and some with ice. This is determined by trial and error and to some degree patient’s preference. Like heat, ice packs applied to a local area of the body will also increase regional circulation. This occurs since, while you obviously cool the skin under the ice, the tissues beneath the cooled areas have a reactive vasodilatation to attempt to warm the site back to body temperature. In either case, increased circulation results. One distinct advantage of ice is that it will decrease nerve activity in the area being cooled, so if the pain is more of a nerve irritation and on the surface, ice packs are preferred.

Ice Cube (TMJ pain or nerve pain)

Apply ice to the painful site for 10 minutes up to 6 times a day. If you feel your skin burning, remove the ice for a couple of seconds and reapply.
You can have your ice prepared in one of the following ways:

• Ice cube: Done with a squared ice cube covered with a thin cloth.
• Ice in a paper cup: Put water in a small paper cup, freeze it and use the cup to apply the ice.
• Can of cold soda: If you are not home, buy a cold soda and hold the can on the painful area.

3. Jaw Exercises

4. Neck Exercises For Jaw and TMJ Pain Relief

Head Flexion (chin to the chest)

1. Stand or sit in correct postural position.
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your chest.
5. Hold for 6 seconds.

Repeat this exercise 6 times. This should be done 6 times per day (approximately every 2 hours). (6 seconds X 6 repetitions X 6 times per day)

Head Lateral Flexion (ear to the shoulder)

1. Stand or sit in correct postural position. .
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your shoulder.
5. Make sure you do NOT rotate your head.
6. Hold for 6 seconds.

Repeat this exercise 6 times to one side followed by 6 times to the other side. This should be done 6 times per day (approximately every 2 hours). (6 seconds X 6 repetitions X 6 times per day)

Head y4 Flexsion (chin to the arm pit)

Stretch With Load For TMJ Pain Relief

Head Flexion (chin to the chest)

1. Stand or sit in correct postural position.
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your chest.
5. Place both hands behind your head.
6. Let the weight of your hands and arm pull your head gently forward.
7. Hold for 6 seconds.

Repeat this exercise 6 times. This should be done 6 times per day (approximately every 2 hours). (6 seconds X 6 repetitions X 6 times per day)

Head Lateral Flexion (ear to the shoulder)

1. Stand or sit in correct postural position.
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your RIGHT shoulder.
5. Make sure you do NOT rotate your head.
6. Place your RIGHT hand on side of your head.
7. Let the weight of your RIGHT hand/arm pull your head gently to the RIGHT side.
8. Make sure you do NOT elevate your LEFT shoulder.
9. Hold for 6 seconds.

Repeat this exercise 6 times to the right side followed by 6 times to the left. This should be done 6 times per day (approximately every 2 hours). (6 seconds X 6 repetitions X 6 times per day)

Head 3/4 Flexion (chin to the arm pit)

1. Stand or sit in correct postural position.
2. Slowly rotate your head 45 degrees (halfway) to the RIGHT side.
3. Slowly tilt your head down in direction to your RIGHT arm pit.
4. Place your RIGHT hand on top of your head with your elbow directly in front of your face.
5. Let the weight of your RIGHT hand/and pull your head gently forward.
6. Hold for 6 seconds.
   Repeat this exercise 6 times to the right side followed by 6 times to the left. This should be done 6 times
   per day (approximately every 2 hours). (6 seconds X 6 repetitions X 6 times per day

Stretch With  Spray / Ice

As a way of assisting the stretch process we recommend the use of a counter-irritant before or during muscle stretching. The counter-irritant can be a direct icing by rubbing a large ice cube or spraying the muscle area to be stretched with Fluori-Methane spray or Ethyl-Chloride spray. The counter-irritant acts to reduce pain during the stretch making it easier to achieve a better stretch. You may use ice before jaw exercises too.

GOALS:

Aid in performing therapeutic exercises. Aid in a feeling of self-control.

METHOD:

1. Hold the bottle with fluid in neck (upside down).
2. Press hard on lever to ensure steady flow.
   3. Hold bottle 12-18 inches from the skin at 45 degree angle.
   4. Spray slowly (4 inches per second) in direction of arrows in diagram.
3. Perform muscle stretch during or after application.
   6. Increase stretch for a count of 6 seconds after application.
   7. Warm skin between applications with your hands.
   8. Massage muscles with your hands doing small circles movements.
   9. Repeat 2 times each day (in 2 series of 6 stretching exercises).

NOTE: SPRAY IS THE DISTRACTION, STRETCH IS THE ACTION.

N-Stretch Jaw Exercises (masseter and temporalis muscles – side of face)

1. Cover eye and mouth with hand.
2. Place tip of tongue up against roof of mouth (in the N-position).
3. Stretch the jaw open in a straight line without dropping the tongue (about 2 inches).
4. Hold for 6 seconds.
5. Do not touch teeth when closing.

Head Flexion (upper/middle trapezius – back of neck)

1. Stand up or sit down in correct postural position.
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your chest.
5. Hold for 6 seconds.

Head Lateral Flexion (upper trapezius – side of neck)

1. Stand up or sit down in correct postural position.
2. Look straight forward.
3. Perform axial extension (chin tuck).
4. Slowly tilt your head to your shoulder.
5. Make sure you do NOT rotate your head.
6. Hold for 6 seconds.

Head 3/4 Flexion (upper trapezius – side of neck)

1. Stand up or sit down in correct postural position.
2. Slowly rotate your head 45 degrees (half way) to one side.
3. Slowly tilt your head down in direction of your arm pit.
4. Hold for 6 seconds.

Head Lateral Extension & Rotation (sternocleidomastoid -front of neck)

turn 45 degrees then tip head back.

Part A: (clavicular division)

1. Stand up or sit down in correct postural position.
2. Slowly rotate your head 45 degrees (half way) to one side.
3. Slowly tilt your head backwards.
4. Hold for 6 seconds.

Part B: (sternal division)

1. Return to upright position.
2. Rotate your head completely to the opposite side.
3. Tip your chin downward.
4. Hold for 6 seconds.

Restfull Jaw Posture For Jaw Pain Relief

• N-position rest: To find a comfortable jaw posture, first rest the tip of your tongue against the roof of your mouth, behind, but not touching, the front teeth. This is where the tongue touches when saying “N”. Keep teeth slightly apart at all times except when talking or chewing. The lips should also be apart slightly and relaxed. Breathe through your nose. The diagram at the left shows the tongue is up and the teeth and lips are apart.
• Do NOT lean your chin or your face on your hands.

Head and Neck Posture For TMJ Pain Relief

1. Place two fingers on the top lip and press the head back and up until a slight stretch is felt in the back of the neck.
2. Keep your head level during this movement.
3. Allow the head to return to neutral.
4. Repeat two or three times each day.

Sleep Posture For TMJ Pain Relief

• Sleep on your side or on your back using the appropriate size of pillow.
• Do NOT sleep on your stomach.
• Do NOT sleep with your head tilted to one side (as this twists and strains the spine).

Work Posture For Jaw Pain Relief

• Consult a desk ergonomics expert when setting up your desk, selecting a chair and positioning your computer keyboard and mouse.
• Poor workstation design can cause eyestrain, headache, strain and inflammation of muscles, joints and tendons in the wrists, hands, neck, back, arms and legs.
• Key elements of an ergonomic workstation include:

Key elements of an ergonomic workstation:

1. A well designed chair that provides good mid and lower back support and has a backrest and seat that are independently adjustable. However, a reclining seat back and seat pan, which can be adjusted to varying angles, will allow you to control the degree of pressure on your thighs and back.
2. An adjustable bi-bevel terminal table that allows the keyboard and screen height to be independently adjusted. To reduced neck strain, screen height should be adjusted so that the top of screen is at approximately eye level. Additionally, keyboard height should be adjusted so that the forearms and wrist can be roughly parallel to the floor.
3. A padded and detachable wrist rest to assist in maintaining your wrists and hands in a straight, or “neutral”, position while keying.
4. A copy holder adjustable in angle and height, and placed near the screen, to reduce awkward movements of the head and minimize the need for the eyes to adjust to different distances.
5. A thin detachable keyboard that can be moved close to or away from the screen. The top surface of the “home row” of keys should be no higher than 2.5 inches above the work surface to avoid hand and wrist difficulties.
6. Adequate knee clearance under the desk to allow free movement; thin table tops are best.
7. A foot rest to relieve seat pressure on the thighs of shorter operators.
8. Rest breaks to allow the opportunity for movement. Above all, sitting still, in any position, for long periods of times is stressful on the body.

The following picture illustrates the main aspects of a work station design.

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This protocol adopted from the USC Orofacial Pain Program.