Friday 5! 5 Tips to Use with TMD Patients | Modern Manual Therapy Blog

Friday 5! 5 Tips to Use with TMD Patients

Thanks to a reader who found me through Craig Libenson for asking a question that lead me to write this blog post. Here are 5 things I make sure to focus on for TMD patients.

The question specifically was other than light tissue work around the TMJ, how do you lock in the improvements?

1) Education
  • locking the improvements with any manual technique has to be done with education
  • letting the patient know the effects of your treatments are transient
  • avoiding hard, crunchy, chewy foods for a few weeks similar to avoidance of hard ADLs after spraining an ankle
  • education of the head/neck posture influencing mandible position, and possibly contributing to neck pain/headaches which leads to point...
2) Every TMD patient is a cervical patient
  • I look at every TMD patient as 90% cervical, 10% TMJ and only tweaks in the educational pieces are needed
  • get a symptom baseline, start with postural correction and see if there are any changes
  • ask them if different head positions change their bite or occlusion
  • here is a vid I made explaining how I go about this with a patient interaction

3) STM to the mandible elevators

  • the pattern of greatest resistance that seems to offer the best relief and decrease tone is light and slow stroking of the mandible elevators (temporalis and masseter) in a proximal to distal direction
  • start very lightly and stroke slowly to reduce tone
  • use reciprocal inhibition of the mandible depressors to assist with this
  • teach the same reciprocal inhibition techniques to keep the tone reduced throughout the day - make sure to keep them in neutral, it's easy to protract the head and retract the mandible doing this!

4) Light TMJ mobilizations
  • patients who have dysfunctional clenching, capsular or movement dysfunction or small subluxations often benefit from light TMJ distractions along with lateral greater than medial glides
  • too often providers just focus on restoring mandible depression, but you cannot forget about lateral excursion
  • mastication is a circular motion, we do not eat like pac man, so we need to restore medial and lateral glides to improve mandible lateral excursion, which assists with eating
  • this is a small joint so you can get grade 3 or 4 oscillations very easily, Rocabado says "Finesse" - sounds a lot better with a Chilean accent!

5) Lock it in!
  • cervical retractions to restore craniomandibular position
  • education on bringing the food to you while sitting mostly upright as opposed to bringing your head to the food often helps
  • lingual re-education, tongue at the rest position (like saying "nnnnnn" or clucking), clucking - snapping the tongue off of the palate just behind the two upper middle incisors and leave it there
    • tongue in rest position should reflexively decrease mandible elevator tone
  • scapular retractions (90% down, 10% back to inhibit upper traps by firing lower traps
  • diaphragmatic breathing should be looked at as well if the above are not locking in improvements
  • occasionally a patient may also need to be cued on repeated mandible protrusion, but not to end range, just a few millimeters to counter the inferior posterior pull of a forward head
Those are some of my top tips for TMD in an nutshell. I hope everyone has a wonderful weekend! You stay classy!


  1. Excellent Erson - I had never even thought about the protraction while eating thing, will implement. Surprising given daily tongue/mouth and head position is the hugest thing I drone on about to my jaws.

  2. It's just something that occurred to me on patients while problem solving and listening to what makes them better and worse. As McKenzie says, if you listen to the patient, they often have the answer.