International Journal of

Environmental Research
and Public Health

Review
Effects of an Interdisciplinary Approach in the Management of
Temporomandibular Disorders: A Scoping Review
Nicolò Brighenti 1 , Andrea Battaglino 2, * , Pierluigi Sinatti 3 , Vanesa Abuín-Porras 3 ,
Eleuterio A. Sánchez Romero 3,4,5,6,7, * , Paolo Pedersini 2 and Jorge H. Villafañe 2, *

1 Scuola di Medicina, Dipartimento di Scienze della Salute, Università degli Studi del Piemonte Orientale,
28100 Novara, Italy
2 IRCCS Fondazione don Carlo Gnocchi, 20148 Milan, Italy
3 Physiotherapy Department, Faculty of Sport Sciences, Universidad Europea de Madrid,
28670 Villaviciosa de Odón, Spain
4 Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de
Madrid, 28670 Villaviciosa de Odón, Spain
5 Physiotherapy Department, Faculty of Health Sciences, Universidad Europea de Canarias,
38300 La Orotava, Spain
6 Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea
de Canarias, 38300 Tenerife, Spain
7 Physiotherapy and Orofacial Pain Working Group, Sociedad Española de Disfunción Craneomandibular y
Dolor Orofacial (SEDCYDO), 28009 Madrid, Spain
* Correspondence: [email protected] (A.B.); [email protected] (E.A.S.R.);
[email protected] (J.H.V.)

Abstract: Temporomandibular disorders (TMD) is an umbrella term that encompasses many muscu-
loskeletal problems that include the masticatory muscles, the temporomandibular joint, and other
associated structures. TMD can be divided into two large groups: those that affect the musculature
and those that affect the joint. The treatment of TMD requires the combined skills of physiotherapists
and dentists, as well as sometimes psychologists and other medical specialists. This study aims to
Citation: Brighenti, N.; Battaglino, A.; examine the effectiveness of the interdisciplinary approach using physiotherapy and dental tech-
Sinatti, P.; Abuín-Porras, V.; niques on pain in patients with temporomandibular disorders (TMDs). This is a Scoping Review
Sánchez Romero, E.A.; Pedersini, P.;
of studies investigating the effects of combined therapy on patients with TMD. PRISMA guidelines
Villafañe, J.H. Effects of an
were followed during this review’s design, search, and reporting stages. The search was carried
Interdisciplinary Approach in the
out in the MEDLINE, CINHAL, and EMBASE databases. A total of 1031 studies were detected and
Management of Temporomandibular
analyzed by performing the proposed searches in the detailed databases. After removing duplicates
Disorders: A Scoping Review. Int. J.
Environ. Res. Public Health 2023, 20,
and analyzing the titles and abstracts of the remaining articles, six studies were ultimately selected
2777. https://doi.org/10.3390/ for this review. All the included studies showed a positive effect on pain decreasing after a combined
ijerph20042777 intervention. The interdisciplinary approach characterized by the combination of manual therapy
and splint or electrotherapy can positively influence the perceived symptoms; positively decrease
Academic Editor: Paul B. Tchounwou
pain; and reduce disability, occlusal impairments, and perception of change.
Received: 9 January 2023
Revised: 1 February 2023 Keywords: temporomandibular disorders; physical therapy modalities; dentistry; Interdisciplinary
Accepted: 1 February 2023 Health Team; musculoskeletal manipulations; exercise therapy; occlusal splint; treatment efficacy
Published: 4 February 2023

1. Introduction
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland. Temporomandibular disorders (TMDs) occur due to excessive and/or prolonged joint
This article is an open access article overload, influenced by biomechanical factors that may lead to excessive or unbalanced
distributed under the terms and joint loading as well as reduced joint adaptability [1]. Injuries can produce pathological
conditions of the Creative Commons changes in the tissue and mechanical properties of the articular disc, loss of cartilage
Attribution (CC BY) license (https:// integrity, pain caused by inflammatory mediators, displacement of the articular disc,
creativecommons.org/licenses/by/ alteration and loss of synergy of the condyle–disc–eminence complex, and, finally, can
4.0/). generate greater resistance and functional overload on the TMD [2]. A recent line of

Int. J. Environ. Res. Public Health 2023, 20, 2777. https://doi.org/10.3390/ijerph20042777 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 2777 2 of 14

research also points to a systemic contribution to the development of joint disorders [3].
TMD is an umbrella term that encompasses many musculoskeletal problems that include
the masticatory muscles, the temporomandibular joint, and other associated structures.
TMD can be divided into two large groups: those that affect the musculature and those that
affect the joint.
The treatment of TMD requires the combined skills of physiotherapists and dentists,
as well as sometimes rheumatologists and other medical specialists [4]. In certain cases, a
psychologist and additional pharmacotherapy may be necessary. Accurate assessment of
TMD is critical to define the primary driver of pain by evaluating function and morphology,
not overlooking that, in many cases, orofacial and craniofacial pain depends on muscle
issues [5,6].
The effectiveness of TMD treatments is controversial, although it is recognized that
multidisciplinary treatment with education and counseling, exercise therapy, manual and
invasive physiotherapy, and occlusal splint therapy, in addition to pharmacotherapy in
moderate to severe pain, is effective in many patients [7–9].
As with other conditions with chronic pain, such as low back pain, in TMD, the
psychological and physical factors that influence the disability of patients are of great
importance and must be considered when treating them [10]. Manual therapy in the
cervical region, for example, demonstrates effectiveness to produce local and segmental
hypoalgesic effects if the level of catastrophizing is low or medium [11]. However, if the
levels of catastrophizing are high, they may result in a poor outcome after the intervention.
While it is true that some physiotherapists and dentists may claim that an altered
occlusion may affect the spine, scientifically, there is no evidence of the beneficial effects
of orthodontic treatment on spinal deformity [12]. Furthermore, postural work through
exercise likely has a direct impact on decreasing pain that does not correlate with improved
posture [13,14].
Since in the treatment of this region, physiotherapists and dentists collaborate, the purpose
of this study is to examine the current evidence on the effectiveness of the interdisciplinary
approach using physiotherapy and dental techniques on pain in patients with TMD.

2. Materials and Methods

This is a Scoping Review of studies investigating the effects of combined therapy on
patients with TMD. PRISMA guidelines were followed during this review’s design, search,
and reporting stages.

2.1. Search Strategy

The literature search was conducted independently by two authors (N.B. and A.B.)
on MEDLINE, EMBASE, and CINAHL, for articles published before 1 September 2022,
using the keywords “temporomandibular joint disorders”, “physiotherapy”, “dentistry”,
“interdisciplinary approach”, “manual therapy”, “exercise therapy”, and “occlusal splint”,
combining with Boolean operators and MeSH terms and completing the searching operation
with manual research by a search methodology expert. The search strategy was not
language-restricted, and only human research was considered, including randomized
controlled trials (RCTs) and observational studies (cohort studies and case-control studies).

2.2. Review Inclusion Criteria

The selected studies’ participants had to be male or female adults with a diagnosis
of TMD based on the homonymous diagnostic criteria (DC/TMD) [2] or any clinical
diagnosis based on TMD signs and symptoms (myalgia, myofascial pain with referral, and
arthralgia).The interdisciplinary physiotherapy and dentistry approach was the analyzed
intervention compared with usual care. The selected outcomes were pain and functionality.
Int. J. Environ. Res. Public Health 2023, 20, 2777 3 of 14

2.3. Selection Criteria and Data Extraction

After the independent titles and abstracts screening of the identified studies by two
authors (N.B. and A.B.), full texts of the potentially relevant articles were retrieved. All
disagreements between the reviewers were settled with another author (J.H.V.). The manual
search of relevant studies’ references was applied to retrieve additional articles. Exclusion
criteria based on study design were editorials, comments, case reports/series, letters to the
editor, reviews, and meta-analyses. The studies that included subjects under 18 years of
age and subjects with a history of TMD surgery or systemic pathologies were excluded.

2.4. Methodological Quality and Risk of Bias Assessment

RCT methodological quality was evaluated using the PEDro scale. The PEDro scale is
an 11-item scale designed to rate randomized clinical trials (RCTs) methodological quality.
Each item that is satisfied on the scale contributes one point to the total possible score of
10 points [15]. The methodological index for nonrandomized studies (MINORS) has been
used to assess methodological quality and risk of bias of observational studies [16]. The tool
comprises 16 and 24 items for nonrandomized studies and comparative studies, respectively,
and each item is scored from 0 to 2 [16]. The Cochrane Risk-of-Bias for Randomized Trials
(RoB 2) and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I)
tools were used to assess the risk of bias in the RCTs and non-RCT included in the present
study. RoB 2 evaluates a set of bias domains, focusing on different aspects of trial design,
conduct, and reporting. ROBINS-I included specification of the target trial and effect of
interest, use of signaling questions to inform judgments of risk of bias, and assessments
within seven domains of bias. It was also used the NIH Quality Assessment Tool for
Observational Cohort and Cross-Sectional Studies, based on 14 items that were scored as
"cannot determine, not applicable, or not reported". Finally, the results of the NIH quality
assessment tool were obtained as " Good, Fair, or Poor”.

3. Results
3.1. Study Selection
Initially, 1031 articles were found through the databases search on MEDLINE, CIN-
HAL, and EMBASE. Once duplicates were eliminated, and the titles and abstracts of the
remaining papers were examined, nine full-text articles were explored to verify their eligi-
bility for inclusion in this review. Four of these articles were excluded, and lastly, one study
was included from related research. Six studies [17–22] were finally selected for this study.
The selection of these articles through the review procedure is reported in Figure 1 (flow
diagram based on PRISMA statement), and the details of the selected studies are gathered
in Table 1.
ron. Res. Int.
Public HealthRes.
J. Environ. 2023, 20,Health
Public x FOR PEER
2023, REVIEW
20, 2777 4
4 of 14 of 15

Figure 1. PRISMA Flow diagram.

Figure 1. PRISMA Flow diagram.
Int. J. Environ. Res. Public Health 2023, 20, 2777 5 of 14

Table 1. Characteristics of included studies.

Study Design, Participants,

Authors, Years Aim of the Study Outcomes + Follow-Up Results Conclusions Quality Score
Methods
Jaw mobility
Study design: RCT Active and passive
N: 26 patients diagnosed with maximum jaw opening Compared with the baseline, in
To evaluate the efficacy of TMD. Pain both groups, mandibular
physical therapy, in Visual Analogue Scale (VAS) movement capacity increased Physiotherapy, combined
addition to splint therapy, - 13 patients treated with significantly after treatment, with occlusal splint therapy,
occlusal splint only - Total pain intensity
Ismail et al. [22] (2007) on treatment outcomes in whereas subjective pain appears to positively affect PEDro 5/10
(group I). - Pain intensity during,
patients with TMD with decreased significantly (p < 0.05). the treatment outcome of
- 13 patients treated with without, and after
respect to objective and After therapy, the difference in patients with TMD.
occlusal splinting and mandibular
subjective parameters. active jaw opening between
physiotherapy (group II). movement
groups was significant (p < 0.05).
Follow-up: 1, 4, 8, and
12 weeks
Study design: RCT
All groups had a statistically
N: 60 participants diagnosed
Electromyographic activity significant improvement The combination of
To evaluate the effects of with TMD were randomly
Surface EMG (right and left compared to before the massage and conventional
manual therapy and distributed into 4 groups.
masseter and anterior intervention. occlusal splinting reduced
occlusal splints on the (1) massage group.
Gomes et al. [21] (2014) temporal muscles) Comparing the groups, only the the intensity of signs and PEDro 7/10
electromyographic activity (2) conventional occlusal
Follow-up: None, only pre- group that combined manual symptoms among
and signs and symptoms of splint group.
and post-treatment therapy with occlusal splinting individuals with
patients with severe TMD. (3) massage group + conventional
evaluations had a statistically significant severe TMD.
occlusal splint group.
improvement (p < 0.05).
(4) silicone occlusal splint group.

Study design: RCT Pain Regarding VAS scores, group II

N: 12 participants with anterior Visual Analogue Scale (VAS) had a greater improvement
disc displacement without for spontaneous pain (p = 0.0001) than group I (p = 0.001). The simultaneous use of an
The hypothesis tested was
reduction (TMD) were randomly Pain-free opening and path Jaw opening with and without occlusal splint and
that the simultaneous use of
assigned into 2 groups: of mouth opening pain improved significantly only physiotherapy improved
an occlusal splint and
Maximum comfortable in group II (maximum opening the range of mouth opening
Alajbeg et al. [17] (2015) physical therapy is an - 6 received an occlusal PEDro 6/10
opening (MCO) without pain p = 0.006, maximum more effectively than the
effective treatment of splint (group I). Maximum assisted opening with pain p = 0.004). The occlusal splint used alone.
anterior disc displacement - 6 received both opening (MAO) use of the occlusal splint alone Both treatment options were
without reduction (TMD). physiotherapy and Opening pattern did not lead to statistically effective in reducing pain.
occlusal splint (group II). Follow-up: 1 month, significant changes in the range
3 months, and 6 months of mouth opening (p > 0.05).
Int. J. Environ. Res. Public Health 2023, 20, 2777 6 of 14

Table 1. Cont.

Study Design, Participants,

Authors, Years Aim of the Study Outcomes + Follow-Up Results Conclusions Quality Score
Methods
Pain
Visual Analogue Scale (VAS) Manual therapy plus splint
EG showed a significant
To ascertain whether a Pain pressure threshold (PPT) therapy showed a reduction
Study design: RCT reduction in pain, higher pain
combined program of Minimal pressure which in perceived pain (3-point
N: 16 participants with TMD pressure threshold, significant
manual therapy techniques, induces pain (pressure decrease), higher pain
were assigned to either the improvement of dysfunction,
including intraoral algometry) pressure threshold (of at
Espí-López et al. [19] (2020) manual therapy plus and significantly positive PEDro 6/10
treatment, plus traditional Dysfunction Index of TMD least 1.0 kg/cm2 ), and
splint—experimental group (EG, perception of change after
splint therapy improves pain Helkimo Index improvement of disability
n = 8) or the splint therapy treatment (p < 0.05 all). The
and clinical dysfunction in Change perception caused by pain (4.4-point
alone—control group (CG, n = 8). between-group differences were
subjects with TMD. Patient Global Impression decrease), compared to
statistically significant.
of Change Scale (PGICS) splint therapy alone.
Follow-up: 1 month
The initial analysis of pain on
Study design: A retrospective palpation showed that
cohort study 151 patients (50.3%) had a high
This study aims to evaluate N: 300 patient records from the level of pain (grade III), 92 It is essential to have an
the effectiveness of ATM service file. (30.7%) had a moderate level of interdisciplinary treatment
interdisciplinary work Three factors were analyzed: Temporomandibular joint pain (grade II), 39 (13%) had a plan, where physical
NIH “Good”
Toledo Jr et al. [18] (2012) between dentistry and (1) The physiotherapy pain rates low level of pain (grade I), and 18 therapy helps pain relief
quality.
physiotherapy in techniques used. Visual Analogue Scale (VAS) (6%) had no pain. and dentistry treat the
determining the treatment (2) Guidelines or procedures for Considering the final pain on disorders related to the
plan for patients with TMD. home exercises. palpation, 13 patients (4.3%) had stomatognathic system.
(3) the temporomandibular joint grade III, 22 (7.3%) grade II, 63
(TMJ) palpation pain rates (VAS). (21%) grade I, and 202
(67.3%) were without pain.
Study design: nonrandomized
controlled trial Jaw-tracking examination After the treatment, mandibular
N: 78 participants. Computerized mandibular opening range increased by Myorelaxation therapy was
This study aimed to analyze scanner (CMS) 8 mm (19%, p < 0.05), lateral effective in the treatment of
the effectiveness of - The first group consisted Functional examination movement by 2.1 mm (36%, the patient group. A
myorelaxation therapy of 32 patients suffering Active mandibular p < 0.05), while protrusive significant improvement in
Gawriolek et al. [20] (2014) from TMD who served as MINORS 17/24
(nocturnal sublingual movements movement decreased by 0.5 mm opening range, lateral
splint + stretching the treated group. Follow-up: After 4 weeks (p > 0.05). These results were movement, and referred
exercises) in TMD. - The second group with no intervention, then supported by the decrease in pain was achieved after
consisted of 46 volunteers 3 weeks, 3 months, and reported impairment and clinical 6 months of treatment.
as a healthy group. 6 months after treatment pain occurrence (p < 0.05).
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 8 of 15
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 8 of 15
Int. J. Environ. Res. Public Health 2023, 20, 2777 7 of 14

3.2. Risk of Bias within and across the Studies

3.2. Risk
3.2. Risk of
of Bias
Bias within
within and
and across
across the
the Studies
Studies
The risk of bias analysis of the four RCTs included in this review [17,19,21,22] was
The risk
The risk of
of bias
bias analysis
analysis ofof the
the four
four RCTs
RCTs included
included in in this
this review
review [17,19,21,22]
[17,19,21,22] was was
carried out using the Cochrane risk-of-bias tool for randomized trials (RoB). All the stud-
carried out using the
carried the Cochrane
Cochranerisk-of-bias
risk-of-biastool
toolfor
forrandomized
randomized trials (RoB).
trials (RoBAll 2).the
Allstud-
the
ies analyzed results in “high risk” only in blinding items. Results from RoB are summa-
ies analyzed
studies results
analyzed in “high
results risk”risk”
in “high only only
in blinding items.items.
in blinding Results from RoB
Results fromare RoBsumma-
2 are
rized in Figure 2. The risk of bias analysis of the Gawriolek et al. study [20] was realized
rized in Figure
summarized in 2. The risk
Figure of bias
2. The risk analysis of the Gawriolek
of bias analysis et al. study
of the Gawriolek et al.[20] was[20]
study realized
was
using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) and the
realized
using theusing
Riskthe Risk In
Of Bias OfNon-randomized
Bias In Non-randomized
Studies -Studies - of Interventions
of Interventions (ROBINS-I) (ROBINS-I)
and the
result was “moderate risk” . Results from ROBINS-I are reported in Figure 3.
and thewas
result result was “moderate
“moderate risk”. Results
risk” . Results from ROBINS-I
from ROBINS-I are reported
are reported in Figure in Figure
3. 3.

.
.
Figure 2. Cochrane risk-of-bias tool for randomized trials (ROB)2)[17,19,21,22].
Figure 2. Cochrane
Figure2. Cochrane risk-of-bias
risk-of-bias tool
tool for
for randomized
randomizedtrials
trials(RoB
(ROB) [17,19,21,22].
[17,19,21,22].

Figure 3. The risk of bias in nonrandomized studies of intervention (ROBINS-I) assessment tool [20].

Figure 3. The Assessment

3.3. Quality risk of bias in nonrandomized studies of intervention (ROBINS-I) assessment tool
Figure 3. The risk of bias in nonrandomized studies of intervention (ROBINS-I) assessment tool
[20].
[20]. The PEDro scale was used to assess the quality of the four RCTs included in the review.
Three of the articles reviewed [17,19,21] were of good quality (scores 6 and 8), and one
3.3. Quality Assessment
study, the one
3.3. Quality realized by Isamil et al. in 2007 [22], was of fair quality (score 4–5). The MI-
Assessment
NORS The PEDro scale was used totheassess the ofquality of therealized
four RCTs included in the[20]
re-
The PEDro used
scale was scale to evaluate
was quality
used to assess the article
the quality of the four RCTsby Gawriolek
included et in al.
the re-
view.
that Three
resulted of the
in the articles
“good reviewed
quality”. [17,19,21]
The NIH were
quality of good
assessment quality (scores
tool for(scores 6 and
cross-sectional 8), and
view. Three of articles reviewed [17,19,21] were of good quality 6 and 8), andand
one study, the one
observational cohortrealized by was
studies Isamil et al.
used to in 2007 [22],
evaluate thewas of fairofquality
quality the (score
article 4–5). The
realized by
one study, the one realized by Isamil et al. in 2007 [22], was of fair quality (score 4–5). The
MINORS
Toledo Jr scale
et al. was
[18] used
that to evaluate
resulted in the quality
“good of theThe
quality”. article realized
results of by PEDro
the Gawriolek
scale,et the
al.
MINORS scale was used to evaluate the quality of the article realized by Gawriolek et al.
[20] that resulted
MINORS scale, and in the
“good
NIH quality”. The NIH quality
quality assessment tool canassessment
be found tool
in for cross-sectional
Table
[20] that resulted in “good quality”. The NIH quality assessment tool for 1.
cross-sectional
and observational cohort studies was used to evaluate the quality of the article realized
and observational
3.4.Toledo
StudiesJrReport cohort studies was used to evaluate the quality of the article realized
by et al. [18] that resulted in “good quality”. The results of the PEDro scale, the
by Toledo Jr et al. [18] that resulted in “good quality”. The results of the PEDro scale, the
MINORS scale, and
The study the NIH
realized quality assessment
by Espí-Lopez et al. [19] tool
wascanconducted
be found in to Table 1. whether a
ascertain
MINORS scale, and the NIH quality assessment tool can be found in Table 1.
combined program of manual therapy (MT) plus traditional splint therapy (ST) improves
3.4.
pain Studies Report in subjects with TMD. Sessions of forty-five minutes of combined MT
and function
3.4. Studies Report
techniques
The studywere realizedbyfor
realized 4 weeks,
Espí-Lopez oneet al. time
[19]a was
week, and threetoevaluations
conducted were reg-
ascertain whether a
Theatstudy
istered: realized
baseline, by Espí-Lopez
post-treatment, and etone-month
al. [19] was conducted
follow-up. to ascertain
Results of VAS whether
revealeda
combined program of manual therapy (MT) plus traditional splint therapy (ST) improves
combined
that subjectsprogram
in the EG of had
manual therapy (MT)
significantly improvedplus traditional
pain scoressplint
at T1 therapy (ST)which
(p = 0.001), improveswas
Int. J. Environ. Res. Public Health 2023, 20, 2777 8 of 14

maintained at T2 (p = 0.001), with the treatment factor explaining 33.2% (R2) of pain-score
improvement with a large effect size (f2: 0.50). About the distinctions between groups,
statistical differences were showed at T1 and T2 for VAS, with a large effect (p = 0.001,
Cohen’s d = 0.8 for both). The results of the Helkimo Index revealed a significant reduction
of 4.4 points, between T0 and T1, in the EG (p = 0.001). The CG, however, showed no
statistical differences inside the group. Regarding pain pressure threshold (PPT) there was
a significant improvement in the EG for all the TM muscles, whereas the CG remained at
similar values for the entire experimentation time. The group variances were statistically
significant for all the analyzed muscles at T1 and T2. About the effect of the intervention
over the course of time: in the EG at T1, the algometry of the three muscle groups improved
significantly, and the Helkimo and the VAS both reduced significantly. These improvements
were maintained at T2. The Patient Global Impression of Change Scale (PGICS) showed
that, at T2, the EG perceived a greater improvement after treatment (CG: 4.3, SD = 0.9;
EG: 2.4, SD = 1.4), and this difference between groups was statistically significant (mean
difference = 1.9, p = 0.005). In conclusion, this study showed that MT combined with ST
leads to a decrease in pain (3-point decrease), higher PPT (of at least 1.0 kg/cm2 ), improve-
ment of disability caused by pain (4.4-point decrease), and positive perception of change
(EG: 50% felt “much improvement”), compared to ST alone.
The aim of the study realized by Gomes et al. [21] was to analyze the effects of massage
therapy (MT), conventional occlusal splint therapy (COST), and silicone occlusal splint
therapy (SOST) on the intensity of signs and symptoms in subjects with sleep bruxism
(SB) and severe TMD and electromyographic activity in the muscles masseter and anterior
temporal. Groups were evaluated using electromyographic analysis of the masseter and
anterior temporal muscles and the Fonseca Patient History Index. The assessment was
realized before and after the intervention. In the intragroup analysis, no statistically
significant differences were found between the pre- and post-intervention assessments of
the masseter and anterior temporal muscles in the groups. In the Fonseca Patient History
Index, differences were found between the pre- and post-intervention evaluations in the MT,
COST, and SOST groups, the latter of which exhibited greater improvement in comparison
to the other groups. In conclusion, the results of this study showed that the use of SOST
and MT had no significant impact on the electromyographic activity of the masseter or
anterior temporal muscles, but the combination of interventions led to a decrease in the
signs and symptoms of subjects with severe SB and TMD.
The study realized by Toledo et al. [18] analyzed three factors: (1) therapy, which was
transcribed physical therapy modalities used; (2) if there were any procedures for home
treatment without a professional; and (3) the temporomandibular joint (TMJ) palpation
pain rates, measured with a visual analog scale (VAS). Chi-square analysis showed that an
interdisciplinary therapy between physiotherapy and dentistry is effective in TMD pain
reduction (p = 0.014). Statistical analysis of these comparisons, the Chi-square, showed that
all physiotherapy modalities contributed to TMD pain reduction. The statistical analysis
was realized by the Chi-square test, and results showed that physical therapy procedures
performed without the presence of professionals for TMD treatment are very helpful in
pain reduction (p = 0.002). In conclusion, the study realized by Toledo et al. [18] showed
that all physical therapy modalities contributed to TMJ pain reduction. Guidelines for
physiotherapy at home proved to be very helpful in reducing pain. The effectiveness
of interdisciplinary work in physiotherapy and dentistry treatments for TMD has been
adequately verified.
The work produced by Ismail et al. [22] was realized to evaluate the effects of phys-
iotherapy combined with splint therapy in subjects with temporomandibular disorders
(TMDs). Before treatment, a subjective pain level was assessed by VAS, and an electronic
recording and clinical examination of jaw movements were performed, and a second evalu-
ation was performed after 3 months. The analysis of treatment outcomes realized in this
study showed that all analyzed variables improved significantly during the intervention
in comparation with the baseline in both groups. Results showed that active jaw opening
Int. J. Environ. Res. Public Health 2023, 20, 2777 9 of 14

was significantly higher in group 2 after intervention (p < 0.05). In contrast, the were no
statistically significant difference between groups for the passive jaw opening. Analysis of
subjective pain evaluation in group 1 showed an improvement in total pain intensity, pain
intensity during mandibular movement, pain intensity without mandibular movement,
and pain intensity after mandibular loading (p < 0.05). Similarly, pain intensity in group 2
reduced after intervention (p < 0.05). No significant differences were found between the
two groups for the subjective parameters. In conclusion, the results of this study showed
that physical therapy combined with temporomandibular spin seems to have a positive
effect in patients with TMD.
The study realized by Alajbeg et al. [17] was realized to evaluate the combination of
occlusal splint (SS) and physical therapy (PT) for the treatment of anterior disc displacement
without reduction. An assessment of VAS was conducted at baseline (T0), and then after
1 month (T1), 3 months (T2), and 6 months (T3). In the treatment outcomes, there were
pain-free opening (MCO), maximum assisted opening (MAO), and path of mouth opening.
According to VAS, the mean values for the worst pain at baseline for the experimental (SS
combined with PT) and control (SS alone) groups were 74/100 and 65.3/100, respectively.
The intensity of pain was showed to decrease continuously across time; the difference was
significant between experimental (F = 28.964, p = 0.0001, effect size = 0.853) and control
(F = 8.794, p = 0.001, effect size =0.638) groups. Results showed that pain-free opening
and maximum assisted opening improved notably in the course of time only in group 1
(MCO: F = 20.971, p = 0.006; MAO: F = 24.014, p = 0.004). Using an occlusal splint alone
did not lead to statistically significant improvements in the amount of mouth opening
(p > 0.05). In conclusion, this study provided evidence that the combination of SS with PT
was more effective than the use of SS alone in decreasing deviations and improving the
range of mouth opening in a treatment period of 6 months. Moreover, both interventions
reduced pain in subjects with anterior disc displacement.
In the study realized by Gawriołek et al. [20], the jaw-tracking records (K7, Myotronics-
Noromed Inc., Washington, DC, USA) were performed, including the measurements of
opening, lateral, and protrusive ROM, and the maximal and average velocity of opening and
closing. The treatment involved daily stretching movements combined with nocturnally
applying a nonoccluding sublingual relaxation splint. After the intervention, both groups
presented patients who reported significantly reduced pain. After 6 months of therapy,
the success rate of no pain was 40% and the functional impairment of the stomatognathic
system decreased, with an average successful outcome of 86% (p < 0.05). Results showed a
significant decrease in the occurrence of muscle pain during free movement and TMJ pain
on palpation with an average successful outcome of 81%. The change in joint clicking was
nonsignificant. Results showed that the opening ROM significantly increased by 8 mm
(19%). The accompanying deviations and the constituent values of this movement also
increased. The protrusion movement showed no statistical difference from the healthy
group, but the lateral movement range improved on both sides by an average of 2.1 mm
(both sides 36%). In functional evaluations, a satisfactory result was registered by 86%
of the participants. In conclusion, the results of this study showed how myorelaxation
therapy was effective in the treatment of TMD. After six months of intervention, a significant
improvement in opening/closing velocity, opening movement range, and lateral movement
range was obtained.

4. Discussion
The main objective of this scoping review was to examine the current evidence on the
effectiveness of the interdisciplinary approach using physiotherapy and dental techniques
on pain in patients with TMDs. In terms of the effectiveness of the multidisciplinary
approach, three of the RCTs [17,19,21] included in the methodological quality analysis
showed “good quality” and “some concerns” but not “high risk” in terms of risk of bias,
Only one RCT [22] showed methodological “fair quality” and “some concerns” of risk of
Int. J. Environ. Res. Public Health 2023, 20, 2777 10 of 14

bias. In addition, an observational study included in quality assessment [18] showed “good
quality”, and another showed “good quality” and a moderate risk of bias [20].
For example, one RCT of “a fair quality” [22] found that, in a group of 13 patients with
TMD, physiotherapy in combination with Michigan occlusal splint therapy had a positive
effect in improving mandibular movement capacity and decreasing pain, compared to the
only Michigan occlusal splint therapy group. As a physiotherapy protocol, passive traction
and translation movements in all restricted directions were used, in addition to the exercise
of the levator mandibularis muscles. However, the lack of a larger sample size (although
they indeed met the appropriate sample size and dropout calculation requirements) and
adequate description of the physical therapy protocol means that the results may be biased
concerning the attribution of manual therapy as responsible for the observed effects. In
addition, it remains a pre–post study, although all patients were treated and measured
between the first, fourth, eighth, and twelfth week, there were no midterm or long-term
measurements after the end of treatment. In a recent systematic review performed to inves-
tigate the medium- and long-term efficacy of manual therapy as a management of TMD,
alone or in combination with therapeutic exercise, Herrera-Valencia et al. [23] described a
significant reduction in pain and mouth opening relative to baseline values after treatment
with manual therapy. These authors suggested manual therapy for its medium-term effects
(even though the impact seemed to decrease with time) in combination with therapeutic
exercise, as this way its effects are preserved in the long term. In another recent systematic
review, Zhang et al. [24] found no high-quality evidence to discriminate clinical efficacy
from occlusal splinting to exercise therapy for patients with TMD pain. Although the tech-
niques manual therapy may use are not determinant, therapeutic success can be attributed
to the correct diagnosis and adequate combination of multidisciplinary treatment [6]. A
recent RCT by Urbański et al. [25] evaluated the efficacy of two different physiotherapy
techniques in 70 patients affected by TMD with a dominant muscle component who were
divided into two groups: patients in group I underwent postisometric relaxation treat-
ment, and patients in group II were treated with myofascial release treatment. After ten
treatments, no significant differences were observed between the groups in terms of pain
intensity, and in both groups, there was a significant decrease in the electrical activity of
the masticatory muscles examined.
In the same way, one good quality observational study [18] evaluated the interdis-
ciplinary work between dentistry and physiotherapy in 300 patients affected by TMD,
highlighting the importance of implementing an interdisciplinary treatment program, in
which physiotherapy helps to relieve pain and dentistry treats disorders related to the
stomatognathic system. According to these observations, Al-Moraissi et al. [26] suggest
modifying the appropriate practice of exhausting conservative treatment options to the
detriment of minimally invasive procedures, such as arthrocentesis, as soon as patients do
not show a clear benefit from initial conservative treatment. In their network meta-analysis
of randomized clinical trials, these authors highlight that there is evidence (albeit at a very
low to moderate level of quality) that the use of hyaluronic acid, corticosteroid, or platelet-
enriched plasma infiltrations is significantly more efficacious than conservative treatments
in both reducing pain and improving maximum mouth opening in the short (≤5 months)
and medium term (6 months–4 years). Furthermore, those authors note that noninvasive
procedures delivered significant inferior-quality results in terms of pain and maximal oral
opening. However, in our opinion, this study is highly biased: the only physiotherapy
techniques analyzed were manual therapy and laser therapy, ignoring techniques such
as dry needling, which reaches an effectiveness level of evidence 1a in TMD of myogenic
origin [27]. In addition, these authors analyze exercise within conservative treatments,
which include flat stabilization splinting or anterior-repositioning splinting, home muscle
exercise, and self-care, which leads to a very generic and superficial analysis of exercise.
Furthermore, the type of exercise may be very important for achieving successful out-
comes, such as therapeutic exercise based on scientific evidence [28]. Bouchard et al. [28]
and Vos et al. [29] reported a lack of evidence to support arthrocentesis as a better ther-
Int. J. Environ. Res. Public Health 2023, 20, 2777 11 of 14

apeutic intervention than nonsurgical interventions. Furthermore, they underlined the

prominent role of conservative treatments such as physical therapy and oral/topical and
injected pharmacotherapies and suggested their superiority over surgery, since they are
less invasive and usually produce satisfying clinical results in mild-moderate TMD [30–44].
In the quasiexperimental study by Gawriolek et al. [20], the examination of the treated
TMD group revealed that 19 patients had muscle involvement and 31 patients were di-
agnosed with TMJ disc displacement with reduction. Interestingly, the follow-up period
conducted by the researchers, from 4 weeks post-treatment to 3 and 6 months later, de-
termined that the sublingual relaxation splint coupled with everyday active stretching
exercises were shown to be efficacious in the group of TMD patients who suffered from mus-
cle impairment and disc displacement with a reduction in the improvement of mandibular
range of motion and self-perceived pain. However, according to a recent systematic review
by Armijo-Olivo et al., there is no clear evidence of the superiority of exercises over other
conservative treatments for TMDs [31].
In terms of the effectiveness of the interdisciplinary approach, two of the three
RCTs [17,19,21] were pilot studies, consisting of only 12 [17] and 16 [19] patients in each
study, respectively. In the first study [17], the groups were six patients who were assigned
to manual therapy plus splinting (experimental group) or splint therapy alone (control
treatment), and eight patients who were assigned to similar groups in the other study [19].
Although both studies found improvements in pain and motion in patients using the
two types of treatment, the small sample size of the studies mean that the conclusions
of the studies mut be taken with some distance. However, Espí-López et al. [19] used
a more extensive manual therapy protocol comprising a combination of ten techniques
applied to the cervical, suboccipital, and temporomandibular areas, while the study by
Alajbeg et al. [17] focused on the muscles and joints of the mandibular region. We know
that better results are obtained to treat the pain and dysfunction of patients affected by TMD
if, in addition to evaluating and treating the most affected region of the jaw, we perform
treatments at a distance, such as in the region most anatomically and neurophysiologically
interconnected with it, which is the neck [45]. Furthermore, we know that patients with
TMD more frequently exhibited cervical spine pain than people without craniomandibular
pain, regardless of the classification model utilized, since the craniomandibular system and
the cervical spine are generally considered to be a functional entity [46].
Finally, the study by Gomes et al. [21] did have an adequate sample of patients to
answer their hypothesis, which was similar to that proposed by the two previous groups of
authors, reaching similar conclusions: improved range of motion and decreased pain in
patients affected by TMD if a splint + manual therapy are combined.
However, in only one [17] of the three RCTs included in this scoping review was the
positive presence of a psychiatric record considered as an exclusion criterion for participa-
tion in the study, and in none were psychological variables assessed, either as inclusion or
exclusion criteria, but as part of the variables to be analyzed. The authors of the present
review consider this to be an error since in the case of TMD, the patient’s psychological
state may have a significant influence on the onset and development of complications of
this disorder, as demonstrated by the increase in stress, anxiety, and depression in patients
with TMD [47,48].
It should be noted that, although sleep in patients was not analyzed in the included
studies, a recent systematic review found that there is insufficient evidence to suggest that
patients with temporomandibular joint osteoarthritis are associated with increased sleep
disorders or poorer sleep quality [49].
It is recognized that the sample of studies included was low. Even so, in return, it was
decided to analyze the studies that used physical therapy and dental techniques together
rather than separately to analyze the pure relationship between this type of interdisciplinary
approach. A meta-analysis could not be performed due to the considerable heterogeneity
of the studies included, which must be viewed as a limitation of the study. However, the
scoping review performed widely responds to the objectives established.
Int. J. Environ. Res. Public Health 2023, 20, 2777 12 of 14

5. Conclusions
The interdisciplinary approach characterized by the combination of manual therapy
and splint or electrotherapy can influence the perceived symptoms positively, showing
a positive effect on pain decreasing, reduction in disability, occlusal impairments, and
perception of change. Future interdisciplinary research in physiotherapy and dentistry
should include large sample sizes of experimental studies and further investigation of the
development of physiotherapy and dentistry techniques used in clinical practice to treat
patients with TMD.

Author Contributions: Conception and design, A.B. and J.H.V.; literature searching, N.B. and A.B.;
analysis and interpretation of the data, N.B. and P.S.; writing—original draft preparation, N.B., A.B.,
P.S., E.A.S.R., P.P., J.H.V.; writing—review and editing, all authors; visualization, A.B. and J.H.V.;
E.A.S.R. oversaw the review process and managed article processing charges. All authors have read
and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data presented in this study are available on request from the
corresponding authors.
Acknowledgments: This study was supported and funded by the Italian Ministry of Health—Ricerca
Corrente 2023.
Conflicts of Interest: The authors declare no conflict of interest.

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