A Comprehensive Guide to Jaw Pain

If you’re experiencing jaw pain, stiffness and clicking, physiotherapy may be the answer. Jaw pain, stiffness and clicking fall under the category of temporomandibular joint disorders (TMD). The jaw (or temporomandibular joint) is a biarticular sliding hinge joint that connects the skull to the lower jaw. When people think about physiotherapy, most will think about sports injuries or rehabilitation after surgery. Not many will consider seeing a physiotherapist for a sore jaw. In this blog post, we’ll discuss common jaw conditions that physiotherapists treat, how physiotherapists can help and self-management strategies. We’ll also give you our top exercises to try at home!

What is the temporomandibular joint?

The temporomandibular joint (TMJ) is a bi-articular hinge joint that connects the skull to the lower jaw. The TMJ allows us to open our mouths wide enough for food intake and speech production as well as close it tightly in order to chew foods with strong textures. It is a relatively complex structure and is one of the most important joints in our body.

The TMJ comprises two main components, namely the mandibular condyle and the articular disc that form a gliding surface for jaw movement. Outside of these two structures, the TMJ also includes the supporting ligaments, retrodiscal tissue and the muscles that produce opening, closing, protrusion/retrusion and deviation movements of the jaw.

Common temporomandibular joint conditions

Many conditions can cause dysfunction and pain in the jaw. These include:

• myofascial (muscular) pain
• articular disc displacement
• retrodiscal tissue inflammation
• arthritis of the TMJ
• trigeminal neuralgia

A physiotherapist trained to assess and treat temporomandibular disorders will be able to examine your jaw and determine the cause of your symptoms.

In the next section of this post, we’ll discuss each of the conditions listed above including the common symptoms of each and treatment strategies.

Myofascial pain

Myofascial pain is pain that is felt in the jaw muscles, usually on one side of the face. This pain can be caused by a variety of factors including overuse of the muscles on one side of the face, clenching of the jaw or grinding of the teeth overnight.

Symptoms of myofascial pain

• pain on one side of the face
• a sensation of tightness in the jaw
• pain and stiffness triggered by use of the jaw (i.e. chewing or yawning)
• tenderness in the affected muscles

Treatment of myofascial pain

A specially trained physiotherapist will be able to assess and treat myofascial pain in the jaw. Physiotherapists may prescribe a personalised exercise program, teach you self-massage techniques or make adjustments to your diet – all of which are effective treatments for myofascial pain.

Exercises for myofascial pain

Exercises for myofascial pain focus on reducing overactivity of the muscles involved in chewing. This can include self-massage, jaw stretches and jaw posture correction.

Self-massage of the jaw muscles helps to relax tight muscles such as the masseter and temporalis. These muscles are involved in producing the powerful closing action of the jaw and can become tight if a person clenches their jaw in stressful situations or grinds their teeth overnight. To massage these muscles, we recommend placing your index and middle finger on the muscle bulk on the painful jaw and massaging gently in a circular motion. Do this three times for 30 seconds and repeat three times per day.

Jaw stretches can also help relieve jaw stiffness. To stretch your jaw, gently open your mouth and place your thumb on the back teeth on the lower jaw. Press down through the teeth as you open your mouth wider to increase the stretch. Be careful so you don’t overdo the stretch, as pushing too far can irritate your jaw. Your physiotherapist will teach you how to perform the stretch safely and comfortably in the clinic so that you can do this at home. We recommend performing the stretch for 30 seconds, three times per session and three sessions per day.

Lastly, jaw posture correction helps to reduce tension in the jaw muscles when you are resting. The recommended position is called the ‘Upright Posture Position of the Mandible’ or UPPM for short. Here are the steps to get into this posture:

1. Sit up tall in your chair
2. Place your tongue on the roof of your mouth behind your front teeth as if you were about to pronounce the letter ‘N’
3. Separate your teeth very slightly (i.e. 1-2mm apart)
4. Close your lips gently

If you feel your jaw muscles in this position, you will find that the muscles are more relaxed than if your teeth were touching. You can even give it a try by gently closing and separating your teeth while feeling the jaw muscles.

To build the habit of relaxing your jaw into this posture, we recommend that you set a reminder to correct your jaw posture every 20-30 minutes during the day.

Articular Disc Displacement

The articular disc of the temporomandibular joint is a thick, circular disc of fibrocartilage that helps to create a seal between the ball and socket joint.

The articular disc may be displaced when there is repetitive stress or trauma to the jaw. The most common direction for articular disc displacement is forwards. This is called anterior disc displacement. In anterior disc displacement, the articular disc sits in front of its usual position inside the temporomandibular joint in a closed mouth position. When the mouth is opened, the movement of the jaw can cause the disc to slip back into its normal position with a clicking sound. This is called anterior disc displacement with reduction. If the disc does not return to its normal position and, instead, restricts opening range of motion of the jaw, then this is called anterior disc displacement without reduction.

Your physiotherapist will thoroughly assess your jaw to determine whether the your articular disc has been displaced and whether it returns to its normal position during movement of the jaw.

Symptoms of anterior disc displacement with reduction

• jaw clicking with opening and closing
• pain on one side of the face, usually the side that clicks
• usually no loss of range of motion

Treatment of anterior disc displacement with reduction

Anterior disc displacement in the TMJ can be effectively treated by a physiotherapist. Most treatment programs for anterior disc displacement with reduction take between 6 and 12 weeks. The main goals are to reduce the pain associated with inflammation resulting from the disc displacement as well as to minimise the click.

Conservative treatment of anterior disc displacement with reduction involves reducing the overactivity of the muscles that produce forwards translation of the disc (the lateral pterygoid muscle), stretches for the joint capsule of the temporomandibular joint and an exercise to assist in the relocation of the articular disc.

Exercises for anterior disc displacement with reduction

There are two main exercises that physiotherapists prescribe for anterior disc displacement with reduction. These are the disc recapture drills and stretching of the jaw joint capsule.

To perform the disc recapture exercise:

1. Open your mouth fully so that the jaw clicks. This click typically indicates that the disc is relocated in its normal position
2. With your mouth open, push your bottom jaw forwards
3. While maintaining this forward positioning of the jaw, slowly close your mouth. Ensure that the jaw does not click as you close your jaw. A click during closing movements typically indicates displacement of the disc in front of the joint. Avoiding this click means that the disc has been relocated and maintained in the correct position during the closing movement
4. Once your mouth is closed, slowly slide your bottom jaw backwards. Do not allow your jaw to click during this movement
5. Repeat the entire sequence 10-15 times, ensuring that the jaw does not click during the closing movement

The disc recapture exercise should be performed 3 times per day. Stop this exercise if it causes any pain or discomfort in the jaw.

To stretch the jaw joint capsule:

1. Open your mouth wide so that the jaw clicks
2. With a clean hand, place the pad of your thumb on the back molar on the side of the jaw that clicks
3. Gently apply a downwards pressure, encouraging the jaw to stretch into an open position
4. Hold this stretch for 30 seconds and repeat for 3 sets

You should perform this capsular stretch 3 times per day. When starting this stretch, ensure that you do not push too hard. Increase the stretch over time as your jaw mobility improves.

Symptoms of anterior disc displacement without reduction

• significant restriction to opening range of motion
• restricted lateral deviation movement of the jaw (away from the side of disc displacement)
• pain on one side of the face
• no clicking because the disc does not return to its normal position

Treatment of anterior disc displacement without reduction

Treatment of anterior disc displacement without reduction involves physiotherapy to manage pain and improve joint mobility. Your doctor may also prescribe pain relief or muscle relaxants to assist in reducing pain and discomfort.

Physiotherapy for anterior disc displacement without reduction is focused on manual therapy to the affected joint and massage of the muscles around the TMJ. The goal is to stretch the jaw joint to improve the range of motion into opening.

In some cases, the stiffness caused by anterior disc displacement without reduction does not improve with conservative treatment. If this is the case, your physiotherapist will refer you to a maxillofacial surgeon for opinion on surgical management.

Exercises for anterior disc displacement without reduction

Your physiotherapist will prescribe exercises for you to do at home to stretch your jaw. The most common exercise is the TMJ capsule stretch. To perform this stretch:

1. Open your mouth as wide as you comfortably can
2. With clean hands, place the pads of your thumbs on the back molars of the bottom jaw. Cross your hands over so that your right thumb is on the left molars and the left thumb is on the right molars
3. Gently apply a downwards pressure with both hands, encouraging the jaw to stretch into an open position
4. Hold this stretch for 30 seconds and repeat for 3 sets

Perform this stretch at least 3 times per day. Do not push your jaw as this may increase the pain associated with the disc displacement.

Retrodiscal tissue inflammation

The retrodiscal tissue is located behind the articular disc in the TMJ. It is richly supplied with blood vessels and nerve endings. It is susceptible to inflammation and can be a source of aching or throbbing pain in the jaw. It can even refer pain into the ear, causing confusion for people with retrodiscal tissue inflammation who have seen their doctors but do not have any signs of ear infection.

The retrodiscal tissue can become inflamed due to a single excessive loading event (i.e. chewing tough meat) or due to repetitive irritation associated with anterior disc displacement. Because the retrodiscal tissue is located behind the articular disc, the forwards translation of the disc in anterior disc displacement pulls the retrodiscal tissue into the jaw joint space. This places significant pressure on the retrodiscal tissue and can lead to inflammation of the tissue.

Symptoms of retrodiscal tissue inflammation

• aching or throbbing pain in the jaw or ear
• earache
• pain with chewing and opening
• tenderness behind the jaw
• potentially associated with anterior disc displacement, so may also present with some clicking

Treatment of retrodiscal tissue inflammation

Retrodiscal tissue inflammation can be effectively managed through conservative means. These include heat or ice, rest for the jaw, anti-inflammatory medications and physiotherapy.

Often, resting from excessive chewing or clenching can make a big difference to pain caused by inflammation of the retrodiscal tissue. This rest gives the tissue a break from the irritating activities and allows the tissue time to heal.

Your physiotherapist will teach you the best posture to rest your jaw to reduce pressure on the retrodiscal tissue. This posture is called the upright posture position of the mandible (UPPM). Here are the steps to get into this posture:

1. Sit up tall in your chair
2. Place your tongue on the roof of your mouth behind your front teeth as if you were about to pronounce the letter ‘N’
3. Separate your teeth very slightly (i.e. 1-2mm apart)
4. Close your lips gently

To build the habit of relaxing your jaw into this posture, we recommend that you set a reminder to correct your jaw posture every 20-30 minutes during the day.

Arthritis of the temporomandibular joint

Arthritis of the temporomandibular joint can be associated with previous injury, infection, autoimmune diseases like rheumatoid arthritis or simple wear-and-tear over time.

The symptoms of temporomandibular joint arthritis

• pain in the affected jaw
• stiffness of the jaw
• difficulty chewing
• tenderness to touch
• light clicking or grating noise with movement of the jaw

Treatment of temporomandibular joint arthritis

Physiotherapy for temporomandibular joint arthritis focuses on maintaining range of motion of the jaw, strength of the jaw muscles for chewing and minimising pain in the jaw joint. Your physiotherapist will use techniques such as joint mobilisations, soft tissue massage, heat and exercise to achieve these treatment outcomes.

Exercise for temporomandibular joint arthritis

The most common exercises for temporomandibular joint arthritis are stretches of the jaw joint and postural correction.

Because arthritis causes stiffness in multiple directions of movement, gentle stretching should be performed in all affected directions. You can stretch your jaw by moving your jaw through the full available range of motion, pausing for 2 seconds before moving back the other way. Repeat this gentle movement for 10 repetitions and 3 sets. You can do this stretch 3 times per day.

Postural correction for the jaw follows the same steps as above for UPPM:

1. Sit up tall in your chair
2. Place your tongue on the roof of your mouth behind your front teeth as if you were about to pronounce the letter ‘N’
3. Separate your teeth very slightly (i.e. 1-2mm apart)
4. Close your lips gently

Trigeminal neuralgia

Trigeminal neuralgia is a rare condition that is often characterized by stabbing sharp facial pain or electric shock-like sensations on just one side of the face (mostly affecting areas around the mouth and teeth). The pain can last for seconds to minutes at a time, leaving sufferers with sudden spasms of pain.

Trigeminal neuralgia is caused by compression or irritation of the trigeminal nerve. The trigeminal nerve is the fifth cranial nerve. It is made up of three brances; the Ophthalmic nerve (V1) 1st branch (sensory), the Maxillary nerve (V2) 2nd branch (sensory), and the Mandibular nerve (V3) 3rd branch (sensory and motor, controlling the muscles of mastication – the temporalis and masseter).

Symptoms of trigeminal neuralgia

The most common symptoms are:

• Painful sensations on one side of the face that come and go at intervals ranging from a few seconds to minutes
• Burning pain
• Muscle spasms
• Constant aching in one side of the face
• Increased sensitivity on one side of the face
• Cold sensitivity

Treatment of trigeminal neuralgia

Physiotherapy for trigeminal neuralgia typically involves a combination of electrical stimulation (TENS), acupuncture or dry needling for pain management and neck exercises.

Your physiotherapist may also advise you to see your doctor for appropriate medical management for trigeminal neuralgia. There are a range of medications that have demonstrated efficacy in the management of trigeminal nerualgia.

Summary

In this blog post, we provided a comprehensive guide to jaw pain treatment. We discussed the normal function of the jaw, some common jaw disorders that physiotherapists treat and also provided self-management strategies and our top exercises for managing temporomandibular joint disorders.