Strategies to train mastication and swallowing in individuals with temporomandibular disorder and orofacial pain: a scoping review

Amaral, Mariana Souza; Furlan, Renata Maria Moreira Moraes; Almeida-Leite, Camila Megale; Motta, Andréa Rodrigues

doi:10.1590/2317-6431-2022-2669en

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Audiology - Communication Research

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Sumário

Literature Review • Audiol., Commun. Res. 27 • 2022 • https://doi.org/10.1590/2317-6431-2022-2669en copy

Strategies to train mastication and swallowing in individuals with temporomandibular disorder and orofacial pain: a scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To identify and synthesize evidence on strategies used to train chewing and swallowing in individuals with temporomandibular disorder and orofacial pain.

Research strategy

Scoping review conducted by search in MEDLINE, LILACS, BBO, IBECS, BINACIS, CUMED, SOF, DeCS, Index Psi, LIPECS, and ColecionaSUS (via VHL), Scopus, CINAHL, Embase, Web of Science, Cochrane, and the grey literature: Brazilian Digital Theses and Dissertations Library (BDTD), OpenGrey, and Google Scholar.

Selection criteria

Quantitative or qualitative studies, with no restriction on time or language of publication, with the following descriptors or keywords: Temporomandibular Joint; Temporomandibular Joint Dysfunction Syndrome; Temporomandibular Joint Disorders; Facial Pain; chewing (Mastication); swallowing (Deglutition); Therapeutics; Myofunctional Therapy; Speech, Language and Hearing Sciences. In the first stage, two reviewers independently screened the studies by title and abstract reading. In the second stage, the reviewers independently read the preselected documents in full text. In case of divergences, a third researcher was consulted.

Results

The 11 documents included in the review were published between 2000 and 2018. The mostly used training strategies were simultaneous bilateral mastication/chewing, followed by alternating bilateral mastication. In swallowing, increased mastication time was proposed to break food into smaller bits and better lubricate the bolus; training with upper tongue support was also indicated.

Conclusion

Functional training proved to be effective in rehabilitation, although it was not standardized or performed alone. The studies had low levels of evidence. It is essential to conduct more encompassing and standardized studies, such as randomized clinical trials.

Keywords:
Mastication, Deglutition; Temporomandibular Joint Dysfunction Syndrome; Myofunctional Therapy; Speech, Language and Hearing Sciences

VHL	PubMed and other international databases	Grey literature
(“Articulação Temporomandibular” OR “Temporomandibular Joint” OR “Articulación Temporomandibular” OR “Articulation temporomandibulaire” OR “Síndrome da Disfunção da Articulação Temporomandibular” OR “Temporomandibular Joint Dysfunction Syndrome” OR “Síndrome de la Disfunción de Articulación Temporomandibular” OR “Syndrome de l'articulation temporomandibulaire” OR “Síndrome Miofascial de Disfunção Dolorosa Temporomandibular” OR “Síndrome da ATM” OR “Síndrome da Articulação Temporomandibular” OR “Transtornos da Articulação Temporomandibular” OR “Temporomandibular Joint Disorders” OR “Trastornos de la Articulación Temporomandibular” OR “Troubles de l'articulation temporomandibulaire” OR “Transtornos da ATM” OR “Dor Facial” OR “Facial Pain” OR “Dolor Facial” OR “Algie faciale” OR “Dor Craniofacial” OR “Dor Miofacial” OR “Dor Orofacial” OR “Disfunção Temporomandibular” OR “Temporomandibular Joint Dysfunction” OR “Temporomandibular Joint Dysfunctions” OR “Temporomandibular Dysfunction” OR “Temporomandibular Dysfunctions” OR “TMJ” OR “TMJ Syndrome” OR “Temporomandibular Joint Syndrome” OR “TMJ Disease” OR “TMJ Diseases” OR “TMJ Disorder” OR “TMJ Disorders” OR “Temporomandibular Disorder” OR “Temporomandibular Disorders” OR “Temporomandibular Joint Disease” OR “Temporomandibular Joint Diseases” OR “Temporomandibular Joint Disorder” OR “Face Pain” OR “Myofacial Pain”) AND (Mastigação OR Mastication OR Masticación OR Mastication OR Deglutição OR Deglutition OR Deglución OR Déglutition OR Swallowing) AND (Terapêutica OR Therapeutics OR Terapéutica OR Thérapeutique OR Terapia OR Terapias OR Tratamento OR Tratamentos OR “Terapia Miofuncional” OR “Myofunctional Therapy” OR “Terapia Miofuncional” OR “Thérapie myofonctionnelle” OR “Miologia Orofacial” OR Fonoaudiologia OR “Speech, Language and Hearing Sciences” OR Fonoaudiología OR Phonoaudiologie OR “Terapia Fonoaudiológica” OR “Tratamento Fonoaudiológico” OR “Terapêutica Fonoaudiológica” OR “Speech Therapy” OR “Speech-language Therapy” OR “Orofacial Myotherapy”).	(“Temporomandibular Joint” OR “Temporomandibular Joint Dysfunction Syndrome” OR “Temporomandibular Joint Disorders” OR “Facial Pain” OR “Temporomandibular Joint Dysfunction” OR “Temporomandibular Joint Dysfunctions” OR “Temporomandibular Dysfunction” OR “Temporomandibular Dysfunctions” OR “TMJ” OR “TMJ Syndrome” OR “Temporomandibular Joint Syndrome” OR “TMJ Disease” OR “TMJ Diseases” OR “TMJ Disorder” OR “TMJ Disorders” OR “Temporomandibular Disorder” OR “Temporomandibular Disorders” OR “Temporomandibular Joint Disease” OR “Temporomandibular Joint Diseases” OR “Temporomandibular Joint Disorder” OR “Face Pain” OR “Myofacial Pain”) AND (Mastication OR Deglutition OR Swallowing) AND (Therapeutics OR “Myofunctional Therapy” OR “Speech, Language and Hearing Sciences” OR “Speech Therapy” OR “Speech-language Therapy” OR “Orofacial Myotherapy”).	“Temporomandibular AND Mastication”, “Temporomandibular AND Deglutition”, “Temporomandibular AND Mastigação” e “Temporomandibular AND Deglutição”.

LEVEL OF EVIDENCE	DEGREE OF RECOMMENDATION
Level 1: Experimental designs	1.a – Systematic review of randomized controlled clinical trials
	1.b – Systematic review of randomized controlled clinical trials and other study designs
	1.c – Randomized controlled clinical trial
	1.d – Pseudo randomized controlled clinical trial
Level 2: Quasi-experimental designs	2.a – Systematic review of quasi-experimental studies
	2.b – Systematic review of quasi-experimental studies and other lower study designs
	2.c – Quasi-experimental prospectively controlled study
	2.d – Pre-test – post-test or historic/retrospective control group study
Level 3: Observational-analytic designs	3.a – Systematic review of comparable cohort studies
	3.b – Systematic review of comparable cohort and other lower study designs
	3.c – Cohort study with control group
	3.d – Case-controlled study
	3.e – Observational study without a control group
Level 4: Observational-descriptive designs	4.a – Systematic review of descriptive studies
	4.b – Cross-sectional study
	4.c – Case series
	4.d – Case study
Level 5: Expert opinion and bench research	5.a – Systematic review of expert opinion
	5.b – Expert consensus
	5.c – Bench research/single expert opinion

Author(s)	Year	Type	Objective	Design	Place	Level of evidence
Bacha and Ríspoli⁽¹⁷17 Bacha SM, Ríspoli CF. Mastication in the oral myofunctional disorders. Int J Orofacial Myology. 2000;26:57-64. http://dx.doi.org/10.52010/ijom.2000.26.1.7. PMid:11307351. http://dx.doi.org/10.52010/ijom.2000.26.... ⁾	2000	Article	To present two clinical approaches to mastication in orofacial myofunctional disorders.	Expert consensus/ Qualitative	Brazil	5.b
Nogueira⁽¹⁸18 Nogueira MF. Disfunção da articulação temporomandibular (DTM) e mastigação: uma relação de causa e efeito. Recife [monografia]. Recife: Centro de Especialização em Fonoaudiologia Clínica- CEFAC; 2001.⁾	2001	Postgraduate writing project	To explore, in speech-language-hearing therapy, the existing relationship between temporomandibular disorders (TMD) and stomatognathic functions, particularly mastication.	Qualitative	Recife, Brazil	-
Gavish et al.⁽¹⁹19 Gavish A, Winocur E, Astandzelov-Nachmias T, Gazit E. Effect of controlled masticatory exercise on pain and muscle performance in myofascial pain patients: a pilot study. Cranio. 2006;24(3):184-90. http://dx.doi.org/10.1179/crn.2006.030. PMid:16933459. http://dx.doi.org/10.1179/crn.2006.030... ⁾	2006	Article	To test the hypothesis that, by strengthening masticatory muscles with a controlled mastication exercise protocol, muscle function is improved, pain is eased, both at rest and in the function.	Quasi-experimental prospectively controlled study/ Quantitative	Tel Aviv, Israel	2.c
De Felício et al.⁽¹¹11 de Felicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: case study. Int J Orofacial Myology. 2007;33(1):21-9. http://dx.doi.org/10.52010/ijom.2007.33.1.2. PMid:18942478. http://dx.doi.org/10.52010/ijom.2007.33.... ⁾	2007	Article	To describe a case of TMD with clinical signs of hypermobility treated with orofacial myofunctional therapy and occlusal splint.	Case study/ Qualitative	São Paulo, Brazil	4.d
De Felício et al.⁽²2 de Felício CM, Melchior MO, da Silva MAMR. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59. http://dx.doi.org/10.1179/crn.2010.033. PMid:21032979. http://dx.doi.org/10.1179/crn.2010.033... ⁾	2010	Article	To analyze the effects of orofacial myofunctional therapy on individuals with combined muscular and joint TMD.	Quasi-experimental prospectively controlled study/ Quantitative	Ribeirão Preto (SP), Brazil	2.c
Nasri-Heir et al.⁽²⁰20 Nasri-Heir C, Epstein JB, Touger-Decker R, Benoliel R. What should we tell patients with painful temporomandibular disorders about what to eat? J Am Dent Assoc. 2016;147(8):667-71. http://dx.doi.org/10.1016/j.adaj.2016.04.016. PMid:27301850. http://dx.doi.org/10.1016/j.adaj.2016.04... ⁾	2016	Article	To present guidance recommendations to physicians to help patients with painful TMD improve the quality of their diets and avoid or minimize the pain related to eating.	Expert consensus/ Qualitative	United States	5.b
Melchior et al.⁽¹⁰10 Melchior MO, Machado BCZ, Magri LV, Mazzetto MO. Effect of speech-language therapy after low-level laser therapy in patients with TMD: a descriptive study. CoDAS. 2016 Dez;28(6):818-22. http://dx.doi.org/10.1590/2317-1782/20162015099. PMid:28001273. http://dx.doi.org/10.1590/2317-1782/2016... ⁾	2016	Article	To analyze the effect of orofacial myofunctional therapy on the treatment of patients with TMD after analgesia with low-level laser therapy.	Case series/ Qualitative	Ribeirão Preto (SP), Brazil	4.c

Author(s)	Year	Type	Objective	Design	Place	Level of evidence
Marzotto and Bianchini⁽²¹21 Marzotto SR, Bianchini EMG. Anquilose temporomandibular bilateral: aspectos fonoaudiológicos e procedimentos clínicos. Rev CEFAC. 2007;9(3):358-66. http://dx.doi.org/10.1590/S1516-18462007000300009. http://dx.doi.org/10.1590/S1516-18462007... ⁾	2007	Article	To present an orofacial myofunctional therapy approach, its procedures, and results in a case of bilateral temporomandibular ankylosis.	Case study/ Qualitative	São Paulo, Brazil	4.d
Bautzer et al.⁽²²22 Bautzer APD, Alonso N, Agostino L. Terapia miofuncional no tratamento de aquilose temporomandibular: análise de 7 pacientes. Rev Soc Bras Cir Craniomaxilofac. 2008;11(4):151-5.⁾	2008	Article	To assess the role of speech-language-hearing therapists in the treatment of seven patients with temporomandibular ankylosis, after surgical procedure.	Case series/ Qualitative	São Paulo, Brazil	4.c
Bianchini et al.⁽²³23 Bianchini EMG, Moraes RB, Nazario D, Luz JGC. Terapêutica interdisciplinar para fratura cominutiva de côndilo por projétil de arma de fogo: enfoque miofuncional. Rev CEFAC. 2010;12(5):881-8. http://dx.doi.org/10.1590/S1516-18462010000500020. http://dx.doi.org/10.1590/S1516-18462010... ⁾	2010	Article	To present the procedures and results of nonsurgical treatment associated with orofacial myofunctional therapy in a clinical case of comminuted condylar fracture caused by a firearm bullet.	Case study/ Qualitative	São Paulo, Brazil	4.d

Author(s)	Population	TMD diagnosis	Strategies
Bacha and Ríspoli⁽¹⁷17 Bacha SM, Ríspoli CF. Mastication in the oral myofunctional disorders. Int J Orofacial Myology. 2000;26:57-64. http://dx.doi.org/10.52010/ijom.2000.26.1.7. PMid:11307351. http://dx.doi.org/10.52010/ijom.2000.26.... ⁾	All age groups	-	It was proposed not to use direct mastication and swallowing therapy in individuals with TMD. Instead, therapy should guide and control consistency, quality, volume, masticatory rhythm, and lip closure when eating. Patients are given such information in writing, along with charts to record their daily diet. The information is discussed with the therapists in the session.
Nogueira⁽¹⁸18 Nogueira MF. Disfunção da articulação temporomandibular (DTM) e mastigação: uma relação de causa e efeito. Recife [monografia]. Recife: Centro de Especialização em Fonoaudiologia Clínica- CEFAC; 2001.⁾	-	-	Mastication must be initially alternating unilateral and then bilateral, with cyclic movements and adequate and symmetric muscle strength. The diet is initially changed to soft food, avoiding the overload of orofacial structures; pureed to minced food is maintained, gradually returning to more solid food. Masticatory training should use only foods.
Gavish et al.⁽¹⁹19 Gavish A, Winocur E, Astandzelov-Nachmias T, Gazit E. Effect of controlled masticatory exercise on pain and muscle performance in myofascial pain patients: a pilot study. Cranio. 2006;24(3):184-90. http://dx.doi.org/10.1179/crn.2006.030. PMid:16933459. http://dx.doi.org/10.1179/crn.2006.030... ⁾	Women 20 to 45 years old	Muscular TMD	It proposed a controlled exercise protocol for chewing gums for 8 weeks.
Marzotto and Bianchini⁽²¹21 Marzotto SR, Bianchini EMG. Anquilose temporomandibular bilateral: aspectos fonoaudiológicos e procedimentos clínicos. Rev CEFAC. 2007;9(3):358-66. http://dx.doi.org/10.1590/S1516-18462007000300009. http://dx.doi.org/10.1590/S1516-18462007... ⁾	Man 28 years old	Temporomandibular ankylosis	Alternating unilateral mastication training, directing unilaterally the buccinator contraction and tongue lateralization mechanisms. Masticatory training with consistent foods of various textures, taking small or medium portions of food. Occasional training with rubber tubes in the final phase of the treatment (because it is ankylosis).
De Felício et al.⁽¹¹11 de Felicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: case study. Int J Orofacial Myology. 2007;33(1):21-9. http://dx.doi.org/10.52010/ijom.2007.33.1.2. PMid:18942478. http://dx.doi.org/10.52010/ijom.2007.33.... ⁾	Man 49 years old	Joint TMD	The patient was instructed to masticate simultaneously on both sides. Alternating bilateral mastication training began after the patient had better developed the muscle conditions. As for swallowing, the patient was instructed to increase the mastication time to break food into smaller parts and better lubricate the bolus.
Bautzer et al.⁽²²22 Bautzer APD, Alonso N, Agostino L. Terapia miofuncional no tratamento de aquilose temporomandibular: análise de 7 pacientes. Rev Soc Bras Cir Craniomaxilofac. 2008;11(4):151-5.⁾	Both sexes; median age of 15 years	Temporomandibular ankylosis	Unilateral e bilateral mastication exercises.
De Felício et al.⁽²2 de Felício CM, Melchior MO, da Silva MAMR. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59. http://dx.doi.org/10.1179/crn.2010.033. PMid:21032979. http://dx.doi.org/10.1179/crn.2010.033... ⁾	40 women aged 13 to 68 years	Muscular and joint TMD	Patients with unilateral mastication were first instructed to masticate simultaneously on both sides. Alternating bilateral mastication training must begin after the patient improved muscle function and dental occlusion does not cause functional overload. As for swallowing, patients were instructed to increase the mastication time to break food into smaller parts and better lubricate the bolus. Tongue, lip, and cheek contraction, mobility, and coordination exercises also help perform this function.
Bianchini et al.⁽²³23 Bianchini EMG, Moraes RB, Nazario D, Luz JGC. Terapêutica interdisciplinar para fratura cominutiva de côndilo por projétil de arma de fogo: enfoque miofuncional. Rev CEFAC. 2010;12(5):881-8. http://dx.doi.org/10.1590/S1516-18462010000500020. http://dx.doi.org/10.1590/S1516-18462010... ⁾	Man 20 years old	Condylar fracture	Systematic unilateral mastication training contralateral to the fracture, directing unilaterally the buccinator contraction and tongue lateralization mechanisms, inducing rotatory mandibular movement. Masticatory training used soft foods, initially passing to varied textures to gradually organize and restore eating. Directed swallowing training with upper tongue support and wave movement, without pressure on perioral musculature, and perception of soft laryngeal elevation movement.
Nasri-Heir et al.⁽²⁰20 Nasri-Heir C, Epstein JB, Touger-Decker R, Benoliel R. What should we tell patients with painful temporomandibular disorders about what to eat? J Am Dent Assoc. 2016;147(8):667-71. http://dx.doi.org/10.1016/j.adaj.2016.04.016. PMid:27301850. http://dx.doi.org/10.1016/j.adaj.2016.04... ⁾	-	-	The authors suggest mincing well all foods, choosing moist foods or moistening them with sauces until finding a comfortable consistency, peeling fruits and vegetables; chopping food into consistencies that can be comfortably taken when opening the mandible, taking small bites, and masticating slowly.
Melchior et al.⁽¹⁰10 Melchior MO, Machado BCZ, Magri LV, Mazzetto MO. Effect of speech-language therapy after low-level laser therapy in patients with TMD: a descriptive study. CoDAS. 2016 Dez;28(6):818-22. http://dx.doi.org/10.1590/2317-1782/20162015099. PMid:28001273. http://dx.doi.org/10.1590/2317-1782/2016... ⁾	Women 50 to 61 years old	Muscular and joint TMD	The procedures for each stage, based on the article by De Felício et al.⁽²2 de Felício CM, Melchior MO, da Silva MAMR. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59. http://dx.doi.org/10.1179/crn.2010.033. PMid:21032979. http://dx.doi.org/10.1179/crn.2010.033... ⁾, vary according to the patient and rehabilitation needs. Food was used in mastication training to coordinate the masticatory cycle pattern, ease the pain, and minimize joint noises (respectively in cases of arthralgia and disk displacement with reduction); swallowing was trained likewise so that it would be effortless and painless.
Melchior et al.⁽²⁴24 Melchior MO, Magri LV, Mazzetto MO. Orofacial myofunctional disorder, a possible complicating factor in the management of painful temporomandibular disorder. Case report. BrJP. 2018;1(1):80-6. http://dx.doi.org/10.5935/2595-0118.20180017. http://dx.doi.org/10.5935/2595-0118.2018... ⁾	Woman 35 years old	Muscular and joint TMD	Usual conscious mastication training with different foods, broadening the perception of sensations such as pain, easiness, difficulties, differences between the sides, and physical and taste characteristics of foods. Simultaneous bilateral mastication training – i.e., masticating a portion of food on each side of the mouth at the same time. Training to swallow water and foods, instructing to place the tip of the tongue against the anterior region of the hard palate, with wave movements in the body of the tongue in the anteroposterior direction, to drive the bolus to the pharynx.

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[1] Conflict of interest: No.