Manual therapy for temporomandibular disorder in older adults: an integrative literature review

Laiza de Oliveira Lucena Camila Maria Mendes Nascimento Nadja Maria Jorge Asano Maria das Graças Wanderley de Sales Coriolano Carla Cabral dos Santos Accioly Lins About the authors

ABSTRACT

Purpose:

to describe the manual therapy techniques used to treat the temporomandibular disorder in older adults.

Methods:

an integrative literature review assessing scientific publications indexed in six databases: MEDLINE/PubMed, Web of Science, CINAHL, Scopus, LILACS, and PEDro. Only intervention studies were included, with no restriction of date or language. The articles included in the review were assessed with the Critical Appraisal Skills Programme.

Results:

after consulting the databases, 88 articles were found, six of which were considered eligible. No study was found exclusively approaching older adults. According to the analysis of the risk of bias, two articles were classified as low-risk, two as intermediate, and two as high-risk. The manual therapy techniques were intra- and extraoral massage, temporomandibular joint and cervical spine mobilization, myofascial release, trigger-point finger pressure, and deep transverse massage.

Conclusion:

the studies observed improved mandibular movements and masticatory function, eased pain, and reduced anxiety.

Keywords:
Aged; Musculoskeletal Manipulations; Temporomandibular Joint Disorders

RESUMO

Objetivo:

descrever as técnicas de terapia manual usadas no tratamento da disfunção temporomandibular em pessoas idosas.

Métodos:

trata-se de uma revisão integrativa da literatura, em que foram avaliadas publicações científicas indexadas em seis bases de dados: MEDLINE/PubMed, WEB OF SCIENCE, CINAHL, SCOPUS, LILACS e PEDro. Foram incluídos apenas estudos de intervenção, sem restrição temporal ou de idioma. Os artigos incluídos foram avaliados pelo instrumento Critical Appraisal Skill Programme.

Resultados:

após a consulta nas bases de dados, foram encontrados 88 artigos, destes, seis foram considerados elegíveis. Não foram observados estudos que abordassem exclusivamente a população idosa. Segundo a análise do risco de viés, dois artigos foram classificados como de baixo risco, dois intermediários e dois de risco alto. As técnicas de terapia manual foram: massagem intra e extraoral, mobilização da articulação temporomandibular e da coluna cervical, liberação miofascial, dígito pressão para trigger points e massagem transversa profunda.

Conclusão:

os estudos observaram melhora dos movimentos mandibulares, da função mastigatória, alívio da dor e redução da ansiedade.

Descritores:
Idoso; Manipulações Musculoesqueléticas; Transtornos da Articulação Temporomandibular

Introduction

During the aging process, the temporomandibular joint (TMJ) - the only movable joint in the head - may be overloaded11. Maydana AV. Critérios diagnósticos de pesquisa para as desordens temporomandibulares em uma população de pacientes brasileiros. São Paulo (SP): Universidade de São Paulo; 2007.. For the TMJ to function properly, it must be in perfect harmony with dental occlusion and neuromuscular balance11. Maydana AV. Critérios diagnósticos de pesquisa para as desordens temporomandibulares em uma população de pacientes brasileiros. São Paulo (SP): Universidade de São Paulo; 2007.,22. Quinto CA. Classificação e tratamento das disfunções temporomandibulares: qual o papel do fonoaudiólogo no tratamento dessas disfunções? Rev. CEFAC. 2000;2(2):15-22.. Factors present in older adults, such as parafunctional habits, deficient occlusion, and tooth loss, may result in temporomandibular disorder (TMD)33. De Almeida LHM, Farias ABL, Soares MSM, De Almeida Cruz JS, Da Cruz RES, De Lima M. Disfunção temporomandibular em idosos. Revista da Faculdade de Odontologia-UPF. 2008;(13):1. - which is a set of disorders involving functional and structural changes in the stomatognathic system that may affect joints, muscles, or both44. Moreno S, Young CY, Yanaze F, Cunali PA. Análise das características oclusais de pacientes com ruídos na articulação temporomandibular. JBA. 2002;2(6):113-9.. It is characterized by symptoms such as the reduced amplitude of mandibular movement, pain, headaches, noises, and limited mandibular mobility44. Moreno S, Young CY, Yanaze F, Cunali PA. Análise das características oclusais de pacientes com ruídos na articulação temporomandibular. JBA. 2002;2(6):113-9.. TMD signs may also manifest in the neck regions, face, and occipital, temporal, and frontal areas of the head55. Lam DK, Lawrence HP, Tenenbaum HC. Aural symptoms in temporomandibular disorder patients attending a craniofacial pain unit. J Orofac Pain. 2001;15(2):146-57. PMid:11443826.. At least 40% of the adult population is estimated to be presented with some of these disorder symptoms66. Okeson JP. American Academy of Orofacial Pain: guidelines for assessment diagnosis and management. Chicago: Quintessence; 1996. p.113-84..

The cause of TMD is multifactorial. It may result from direct or indirect trauma, psychosocial factors (depression and anxiety), systemic factors (degenerative, infectious, metabolic, neoplastic, and rheumatologic diseases), and physiopathological and genetic factors77. Carrara SV, Conti PCR, Barbosa JS. Termo do 1º consenso em disfunção temporomandibular e dor orofacial. Dental Press J Orthod. 2010;15(3):114-20. http://dx.doi.org/10.1590/S2176- 94512010000300014.
http://dx.doi.org/10.1590/S2176- 9451201...
. As for TMD prevalence in older adults, there is a disparity in the data. It is believed to be more frequent in this population than what has been reported in the literature, to which a possible explanation would be the different diagnostic methods used in research88. Okeson JP. Etiologia e identificação dos distúrbios funcionais no sistema mastigatório. In: Okeson JP, editor. Tratamento das desordens temporomandibulares e oclusão. 4 ed. São Paulo: Artes Médicas, 2000. p.117-272.

9. Österberg T, Carlsson GE. Symptoms and signs of mandibular dysfunction in 70-year-old men and women in Gothenburg, Sweden. Community Dent Oral Epidemiol. 1979;7(6):315-21.
-1010. Johansson A, Unell L, Carlsson GE, Söderfeldt B, Halling A. Gender difference in symptoms related to temporomandibular disorders in a population of 50-year-old subjects. J Orofac Pain. 2003;17(1):29-35.. TMD may have an impact on the quality of life of this age group. Miettinen et al.1111. Miettinen O, Lahti S, Sipilä K. Psychosocial aspects of temporomandibular disorders and oral health-related quality-of-life. Acta Odontol Scand. 2012;70(4):331-6. assessed the association between psychosocial aspects, TMD, and oral health quality of life and showed that the TMD group had a lower quality of life when assessed with the Oral Health Impact Profile (OHIP). They scored 90.9, three times higher than the 33.3 points of the non-TMD group.

There is a wide range of TMD treatments, which depend on good assessment to establish the most appropriate intervention1212. Greene CS, Klasser GD, Epstein JB. Revision of the American Association of Dental Rescarch's science information statement about temporomandibular disorders. J Can Dent Assoc. 2010;76:115.

13. Bontempo K, Zavanelli R. Desordem temporomandibular: prevalência e necessidade de tratamento em pacientes portadores de próteses totais duplas. Rev Gaúcha Odontol. 2011;59(1):87-94.
-1414. Reid KI, Greene CS. Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices. J Oral Rehabil. 2013;40(7):546-61.. The conservative treatment may include self-care instructions, psychological and pharmaceutical interventions, acupuncture, occlusal splints, physical therapy1414. Reid KI, Greene CS. Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices. J Oral Rehabil. 2013;40(7):546-61., and orofacial myofunctional therapy1515. Felício CM, Melchior MO, Ferreira CL, Silva MA. Otologic symptoms of temporomandibular disorder and effect of orofacial myofunctional therapy. Cranio. 2008;26(2):118-25.,1616. Felício CM, Melchior MO, Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59.. One of the most common conservative interventions to treat TMD is manual therapy1717. Calixtre LB, Grüninger BLDS, Haik MN, Albuquerque-Sendín F, Oliveira ABE. Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. J Appl Oral Sci. 2016;(24):188-97.,1818. Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Phys Ther. 2016;96(1):9-25.. Making use of mobilization, manipulation techniques, and specific exercises, it aims to increase the elasticity of the adjacent muscle fibers, stimulate proprioception and production of synovial fluid, and ease the pain1919. Grossi DB, Chaves TC. Physiotherapeutic treatment for temporomandibular disorders (TMD). Braz J Oral Sci. 2004;3(10):492-7.

20. Kalamir A, Pollard H, Vitello AL, Bonello R. Manual therapy for temporomandibular disorders: a review of literature. J Bodyw Mov Ther. 2007;11(1):84-90.
-2121. 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. J Bodyw Mov Ther. 2010;14(2):179-84.. The sample of most clinical trials using this resource to treat TMD comprised adults rather than specifically older adults2121. 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. J Bodyw Mov Ther. 2010;14(2):179-84.

22. Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24(4):283-91.

23. Grazia RC, Madruga VA, Peres CM. Efeitos da aplicação do método Mulligan e da massoterapia clássica nas disfunções da articulação temporomandibular em mulheres adultas avaliadas por meio da escala visualnumérica de dor e pelo sf-36. Sínteses: Revista Eletrônica do SIMTEC. 2006;1(3):300.

24. Gomes CAFP, Hage YE, Amaral AP, Politti F, Biasotto Gonzalez DA. Effects of massage therapy and occlusal splint therapy on electromyographic activity and the intensity of signs and symptoms in individuals with temporomandibular disorder and sleep bruxism: a randomized clinical trial. Chiropr Man Therap. 2014;22(1):43.

25. Nascimento MM, Vasconcelos BC, Porto GG, Ferdinanda G, Nogueira CM, Raimundo RC. Physical therapy and anesthetic blockage for treating temporomandibular disorders: a clinical trial. Med Oral Patol Oral Cir Bucal. 2013;18(1):e81-5.

26. Kamonseki DH, Fonseca CL, Souza TP, Zamunér AR, Peixoto BO, Yi LC. Efeito imediato da manipulação thrust aplicada na coluna cervical alta sobre a abertura ativa da boca: ensaio clínico randomizado. J Health Sci Inst. 2012;30(3):277-80.
-2727. Silveira RCCP. O cuidado de enfermagem e o cateter de Hickman: a busca de evidências . Ribeirão Preto (SP): Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto; 2005.. Hence, the objective of this review is to describe the manual therapy techniques used to treat TMD, in older adults.

Methods

This descriptive study is an integrative literature review, which synthesizes the scientific knowledge on a given topic2828. CASP O. Critical Appraisal Skills Programme. CASP checklist. 2018. Available from: https://casp-uk.net/casp-tools-checklists/.
https://casp-uk.net/casp-tools-checklist...
. Six methodological stages conducted the study: (1) establishing the research question; (2) searching the literature; (3) assessing the data; (4) categorizing the studies; (5) interpreting the results and integrating the data; and (6) presenting the integrative review. The review was conducted by the following research question: “Which manual therapy techniques have been used to treat TMD in older adults?”.

Scientific articles were searched in January 2020 in the following databases: MEDLINE/PubMed (Medical Literature Analysis and Retrieval System Online), Web of Science (bibliographic database), CINAHL (The Cumulative Index to Nursing and Allied Health Literature), Scopus (bibliographic database), LILACS (Latin American and Caribbean Health Sciences Literature), and PEDro (Physiotherapy Evidence Database).

In order to broaden the scope of the search, there was no restriction of language or year of publication. The following descriptors were used: aged, musculoskeletal manipulations, and temporomandibular joint disorders (based on MeSH - Medical Subject Headings), and their correspondent in Portuguese: idoso, manipulações musculoesqueléticas, and transtornos da articulação temporomandibular (based on DeCS - Health Sciences Descriptors); they are described in Chart 1. This review included intervention studies that approached manual therapy techniques to treat TMD in older adults, whereas it excluded review articles, case reports, and publications not available in full text or whose results had not yet been published.

Chart 1:
Database search strategy. Recife, Pernambuco, Brazil,

The studies were selected in two stages: reading of titles/abstracts and then reading preselected articles in full text. The first stage was conducted by the lead researcher, who classified the potentially eligible articles based on the inclusion and exclusion criteria, dismissing the duplicate studies. The second stage was conducted by two independent investigators, who read the selected articles in full text. Divergences during the selection process were solved by independently consulting a third reviewer to ensure the reliability and validity of the study in question. The variables selected for the study were pain, mandibular mobility, limitation of mouth opening, and psychosocial changes.

The Critical Appraisal Skills Programme (CASP)2828. CASP O. Critical Appraisal Skills Programme. CASP checklist. 2018. Available from: https://casp-uk.net/casp-tools-checklists/.
https://casp-uk.net/casp-tools-checklist...
was applied to obtain a better critical and methodological analysis of the included articles. This clinical trial checklist has 11 questions that can be answered with “yes”, “no”, or “cannot tell”. The first three are screening questions and they are quickly answered; if they are answered “yes”, it is worthwhile to proceed to the following questions and continue the review assessment.

Literature Review

After consulting the databases, 88 articles were found, of which six were excluded for being duplicates and 64 were excluded after analyzing their titles. Hence, 18 were assessed for eligibility, remaining six articles, which comprised the final sample2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). (Figure 1).

Figure 1:
Flowchart of the stages in the article selection process, according to PRISMA. Recife, Pernambuco, Brazil, 2020

The information compiled from the included articles - author/year, objectives, variable, intervention, results, and conclusions - is presented in Chart 2.

Chart 2:
Compiled description of the studies included in the review. Recife, Pernambuco, Brazil, 2020

Five (83.3%) of the articles included in this review were published in English2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.
-3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., while one (16.7%) was published in French3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.. As for the date, one article was published in the last 5 years2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32., three in the last 10 years3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.
-3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102., and two, more than 10 years ago3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).. All studies were clinical trials whose objectives were to assess a manual therapy technique protocol, either alone or in combination with other interventions in people with TMD, regarding a wide range of outcomes, such as pain, mandibular mobility, limited mouth opening, psychosocial changes, and so forth2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).. During the research, no study approaching exclusively older adults was found - the studies included in this review approached a combination of young people, adults, and older adults2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).. The sample size of the studies ranged from 20 to 51 participants of both sexes, aged 15 to 77 years2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)..

The studies included in this review used manual therapy techniques, either alone or in combination with other interventions, such as photobiomodulation2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32., home physical therapy (which involves stretching, postural correction, and active mandibular exercises)3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8., instructions3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., usual care3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50., and botulinum toxin injections3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. in participants of various ages. The participants of the botulinum toxin group were submitted to a single session with multiple injections in the masseter and temporal muscles3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102..

Although most studies2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). clearly approached the technique protocol used, one of the main biases in the articles was the blinding process2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). regarding both the sample and the study participants. However, only one article did not perform the randomization3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80., which made the sample more homogeneous, despite the variety of ages. All the articles counted the total participants in their conclusions2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., informing the losses to follow-up throughout the clinical trial. The groups were similar in approximately 67% of the studies2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.
-3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).; however, the assessment with CASP revealed that none of them had a control group that received the same treatment as the intervention group.

Three articles did not inform their treatment effect measure2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.,3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., which concerns the estimate of the relationship magnitude between the variables, the difference between the samples, and the effect of one variable on another3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).. The papers did not make clear the precision of this measure3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.

34. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).
-3535. Dworkin SF, Leresche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications critique. J. Craniomandib. Disord. Facial Oral Pain, Lombard. 1992;6(4):300-55., thus compromising the identification of their result as clinically important. In the assessment, three studies2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.,3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). demonstrated that the benefits of their therapies were greater than the risks and harms. Thus, the analysis of the risk of bias classified two articles as low-risk3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., two as intermediate2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.,3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50., and two as high-risk3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.,3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.. The CASP article assessment is fully described in Chart 3.

Chart 3:
Assessment of the articles with the Critical Appraisal Skills Programme (CASP)2828. CASP O. Critical Appraisal Skills Programme. CASP checklist. 2018. Available from: https://casp-uk.net/casp-tools-checklists/.
https://casp-uk.net/casp-tools-checklist...
for clinical trial studies

This review did not identify any research approaching manual therapy TMD treatment exclusively in older adults. Moreover, the sample size and their short follow-up were limitations in most articles, which made it difficult to identify the actual effects of their interventions2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)..

Brochado et al.2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32. used Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) in their study to diagnose TMD. The participants had to present with TMJ pain and limited mouth opening. De Laat et al.3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). likewise used Axis Ia in their research to diagnose the sample; those with dull localized pain in the face for more than 1 month and muscles sensitive to palpation were included. The RDC/TMD, besides the physical methods to diagnose TMD in Axis I, addresses pain intensity and depressive symptoms in Axis II. Hence, it is an excellent way of diagnosing this disorder3535. Dworkin SF, Leresche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications critique. J. Craniomandib. Disord. Facial Oral Pain, Lombard. 1992;6(4):300-55..

The females predominated in all papers included in this review. The most recent one, published in 20182929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32., showed an extremely high prevalence of women (95.1%) with a TMD diagnosis, whose ages ranged from 21 to 77 years. Similarly, the sample of research published in 20093333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80. comprised 93.3% of female participants. In another study, published in 20133030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8., such prevalence was 77.5%. The article that compared physical therapy treatment with usual care in people with cervicogenic headache and signs of TMD showed a little smaller prevalence of women, with 62.8%3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.. In an article published in 20123232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102., the prevalence of women in the sample was 73.3%, while another one, published in 20033434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., had 22 women out of the 26 participants, corresponding to 84.6%.

Pain, as it is the main symptom observed in TMD patients3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., was the most studied variable among the papers. The visual analog scale (VAS) was the most used to measure the pain among the participants2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.
-3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.,3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., as only one piece of research did not use it3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.. Other signs and symptoms were also observed, which made part of the everyday life of people with TMD, such as depressive symptoms, assessed with the Beck Depression Inventory2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.; maximum mouth opening without pain, measured in millimeters3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.; limited amplitude of cervical movement3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.; pressure pain threshold, assessed with algometry3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).; mandibular function, using the mandibular functional limitation questionnaire3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).; and mandibular movements (mouth opening, right and left laterotrusion, and protrusion)3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102..

Various manual therapy techniques were used to treat TMD. The protocol in the study by Tuncer3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8. included intra- and extraoral massage of the masticatory muscles, TMJ and cervical spine mobilization, TMJ stabilization, and stretching. Barriere et al.3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80. investigated the use of deep transverse massage applied transversally with continuous and deep pressure on the tissues to restore mobility, ease the pain, and prevent scar adherence3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.. Another protocol3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. performed circular massages, sliding and compressing proximal and distal face areas, on the masseter, temporal, and medial pterygoid muscles, bilaterally. Yet another protocol approached the cervical spine, including cervical mobilization, high-speed techniques, trigger points approach, and neck muscle stretching and strengthening3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50..

Only one article3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80. performed a protocol with manual therapy techniques alone; the other papers compared the effectiveness of these techniques with that of various interventions. One study3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8. compared home physical therapy alone with home physical therapy in combination with manual therapy techniques concerning pain intensity and maximum mouth opening without pain. Another one3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. compared myofascial manipulation with a single bilateral application of botulinum toxin injections in the masseter muscle. Manual therapy was also compared with photobiomodulation2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32. to treat the pain, limited movements, psychosocial disorders, and anxiety symptoms. Orofacial care3131. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50. and instructions3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1). on how to relax the mandibular muscles were also investigated in other pieces of research.

The manual therapy treatment lasted 4 weeks on average, with three sessions a week. One protocol performed three 21-minute sessions a week, totaling 4 weeks2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.. The protocol used by Tuncer et al.3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8. likewise had three sessions a week for 4 weeks, although each intervention was longer, lasting 30 minutes. One of the studies did not inform the number of sessions or the total time of therapy; it only indicated the maneuver application time in each muscle, which was 30 seconds3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.. The protocol that used myofascial manipulation as a manual therapy technique had the longest intervention of all studies included in the review, with 50 minutes of therapy performed three times a week for 2 to 4 weeks3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102..

Regarding the results, the study that compared manual therapy, photobiomodulation, and combined therapy (manual therapy + photobiomodulation) to treat TMD stands out. It showed an improvement in the amplitude of mandibular movements, masticatory functions, nonspecific physical symptoms, as well as a decrease in anxiety symptoms, though without a statistically significant difference between the groups2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.. Another paper3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8. showed that the maximum mouth opening without pain was decreased in both groups, although it was more evident in the group of manual therapy combined with home physical therapy, achieving a minimum clinical difference of 10 millimeters, compared with 4.4 millimeters in the home physical therapy group.

The study3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. that compared the application of botulinum toxin injections with myofascial manipulation showed that both groups had their pain eased. The group that received botulinum toxin had their pain eased to 5.2 in the post-injection assessment, while the group submitted to myofascial manipulation had it eased to 2.1 in the VAS, though with no statistical difference between the groups. The authors point out as a limitation that the VAS was not matched in the baseline - the participants of the group that received botulinum toxin had a higher level of pain. Moreover, this group had the injections applied only once, which may have compromised their results.

Barriere et al.3333. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80. treated their patients with transverse massage and demonstrated that joint clicking decreased in 13% of the patients, the amplitude of mouth opening increased by 12.8%, and the pain disappeared in 51% of the cases after the massage. However, the study did not have a control group for comparison, the 15-participant sample was small, and it did not show the effect measure of their results; instead, they presented the variables only in relative frequency, making it impossible to identify their clinical significance.

Lastly, few articles assessed a protocol exclusively with manual therapy to treat TMD. Most of them used other combined interventions that also had significant effects, which made it difficult to interpret the effectiveness results of manual therapy alone. The main results were eased pain2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., improved mandibular mobility2929. Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.

30. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8.

31. Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.

32. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.

33. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
-3434. De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1)., and increased pressure pain threshold3232. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102. and maximum mouth opening without pain3030. 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. Journal of bodywork and movement therapies. 2013;17(3):302-8..

The limitations of this study are the absence of a reverse search among the included articles, absence of analysis of the grey literature, and the important biases present in the methodology of the studies, such as the limited number of participants, rather heterogeneous samples regarding age groups, and the need for longer follow-up to verify the long-term effects.

Conclusion

The manual therapy techniques described by the literature to treat TMD in older adults were intra- and extraoral massage, TMJ and cervical spine mobilization, myofascial release, trigger-point finger pressure, and deep transverse massage. The studies observed clinical improvements in the amplitude of mandibular movements, masticatory function, and eased pain, reduced anxiety and joint noises, and increased amplitude of mouth opening without pain.

REFERENCES

  • 1
    Maydana AV. Critérios diagnósticos de pesquisa para as desordens temporomandibulares em uma população de pacientes brasileiros. São Paulo (SP): Universidade de São Paulo; 2007.
  • 2
    Quinto CA. Classificação e tratamento das disfunções temporomandibulares: qual o papel do fonoaudiólogo no tratamento dessas disfunções? Rev. CEFAC. 2000;2(2):15-22.
  • 3
    De Almeida LHM, Farias ABL, Soares MSM, De Almeida Cruz JS, Da Cruz RES, De Lima M. Disfunção temporomandibular em idosos. Revista da Faculdade de Odontologia-UPF. 2008;(13):1.
  • 4
    Moreno S, Young CY, Yanaze F, Cunali PA. Análise das características oclusais de pacientes com ruídos na articulação temporomandibular. JBA. 2002;2(6):113-9.
  • 5
    Lam DK, Lawrence HP, Tenenbaum HC. Aural symptoms in temporomandibular disorder patients attending a craniofacial pain unit. J Orofac Pain. 2001;15(2):146-57. PMid:11443826.
  • 6
    Okeson JP. American Academy of Orofacial Pain: guidelines for assessment diagnosis and management. Chicago: Quintessence; 1996. p.113-84.
  • 7
    Carrara SV, Conti PCR, Barbosa JS. Termo do 1º consenso em disfunção temporomandibular e dor orofacial. Dental Press J Orthod. 2010;15(3):114-20. http://dx.doi.org/10.1590/S2176- 94512010000300014
    » http://dx.doi.org/10.1590/S2176- 94512010000300014
  • 8
    Okeson JP. Etiologia e identificação dos distúrbios funcionais no sistema mastigatório. In: Okeson JP, editor. Tratamento das desordens temporomandibulares e oclusão. 4 ed. São Paulo: Artes Médicas, 2000. p.117-272.
  • 9
    Österberg T, Carlsson GE. Symptoms and signs of mandibular dysfunction in 70-year-old men and women in Gothenburg, Sweden. Community Dent Oral Epidemiol. 1979;7(6):315-21.
  • 10
    Johansson A, Unell L, Carlsson GE, Söderfeldt B, Halling A. Gender difference in symptoms related to temporomandibular disorders in a population of 50-year-old subjects. J Orofac Pain. 2003;17(1):29-35.
  • 11
    Miettinen O, Lahti S, Sipilä K. Psychosocial aspects of temporomandibular disorders and oral health-related quality-of-life. Acta Odontol Scand. 2012;70(4):331-6.
  • 12
    Greene CS, Klasser GD, Epstein JB. Revision of the American Association of Dental Rescarch's science information statement about temporomandibular disorders. J Can Dent Assoc. 2010;76:115.
  • 13
    Bontempo K, Zavanelli R. Desordem temporomandibular: prevalência e necessidade de tratamento em pacientes portadores de próteses totais duplas. Rev Gaúcha Odontol. 2011;59(1):87-94.
  • 14
    Reid KI, Greene CS. Diagnosis and treatment of temporomandibular disorders: an ethical analysis of current practices. J Oral Rehabil. 2013;40(7):546-61.
  • 15
    Felício CM, Melchior MO, Ferreira CL, Silva MA. Otologic symptoms of temporomandibular disorder and effect of orofacial myofunctional therapy. Cranio. 2008;26(2):118-25.
  • 16
    Felício CM, Melchior MO, Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59.
  • 17
    Calixtre LB, Grüninger BLDS, Haik MN, Albuquerque-Sendín F, Oliveira ABE. Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. J Appl Oral Sci. 2016;(24):188-97.
  • 18
    Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis. Phys Ther. 2016;96(1):9-25.
  • 19
    Grossi DB, Chaves TC. Physiotherapeutic treatment for temporomandibular disorders (TMD). Braz J Oral Sci. 2004;3(10):492-7.
  • 20
    Kalamir A, Pollard H, Vitello AL, Bonello R. Manual therapy for temporomandibular disorders: a review of literature. J Bodyw Mov Ther. 2007;11(1):84-90.
  • 21
    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. J Bodyw Mov Ther. 2010;14(2):179-84.
  • 22
    Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio. 2006;24(4):283-91.
  • 23
    Grazia RC, Madruga VA, Peres CM. Efeitos da aplicação do método Mulligan e da massoterapia clássica nas disfunções da articulação temporomandibular em mulheres adultas avaliadas por meio da escala visualnumérica de dor e pelo sf-36. Sínteses: Revista Eletrônica do SIMTEC. 2006;1(3):300.
  • 24
    Gomes CAFP, Hage YE, Amaral AP, Politti F, Biasotto Gonzalez DA. Effects of massage therapy and occlusal splint therapy on electromyographic activity and the intensity of signs and symptoms in individuals with temporomandibular disorder and sleep bruxism: a randomized clinical trial. Chiropr Man Therap. 2014;22(1):43.
  • 25
    Nascimento MM, Vasconcelos BC, Porto GG, Ferdinanda G, Nogueira CM, Raimundo RC. Physical therapy and anesthetic blockage for treating temporomandibular disorders: a clinical trial. Med Oral Patol Oral Cir Bucal. 2013;18(1):e81-5.
  • 26
    Kamonseki DH, Fonseca CL, Souza TP, Zamunér AR, Peixoto BO, Yi LC. Efeito imediato da manipulação thrust aplicada na coluna cervical alta sobre a abertura ativa da boca: ensaio clínico randomizado. J Health Sci Inst. 2012;30(3):277-80.
  • 27
    Silveira RCCP. O cuidado de enfermagem e o cateter de Hickman: a busca de evidências . Ribeirão Preto (SP): Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto; 2005.
  • 28
    CASP O. Critical Appraisal Skills Programme. CASP checklist. 2018. Available from: https://casp-uk.net/casp-tools-checklists/
    » https://casp-uk.net/casp-tools-checklists/
  • 29
    Brochado FT, Jesus LHD, Carrard VC, Freddo AL, Chaves KD, Martins MD. Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial. Brazilian oral research. 2018;32.
  • 30
    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. Journal of bodywork and movement therapies. 2013;17(3):302-8.
  • 31
    Von Piekartz H, Hall T. Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: a randomized controlled trial. Manual therapy. 2013;18(4):345-50.
  • 32
    Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique. Cranio. 2012;30(2):95-102.
  • 33
    Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A. Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome. Revue de stomatologie et de chirurgie maxillo-faciale. 2009;110(2):77-80.
  • 34
    De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. Journal of orofacial pain. 2003;17(1).
  • 35
    Dworkin SF, Leresche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications critique. J. Craniomandib. Disord. Facial Oral Pain, Lombard. 1992;6(4):300-55.

Publication Dates

  • Publication in this collection
    04 Apr 2022
  • Date of issue
    2022

History

  • Received
    18 Oct 2021
  • Accepted
    29 Nov 2021
ABRAMO Associação Brasileira de Motricidade Orofacial Rua Uruguaiana, 516, Cep 13026-001 Campinas SP Brasil, Tel.: +55 19 3254-0342 - São Paulo - SP - Brazil
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