One of the beauties of chiropractic is that, in some cases, it provides a drug-free, surgery-free health care option. However, usually when we think of this, we think of back and neck pain. A new case report published in the Journal of Contemporary Chiropractic has brought a new option to the fore – chiropractic co-management of an acute jaw injury. It is a single case report, which carries certain limitations, but it is a noteworthy paper as it cast light on the potential of chiropractic care for issues with the temporomandibular joint near the ear at the top of the jaw. In this case, surgery could not be avoided, but chiropractic care in the lead up to surgery and post-surgery appears to have offered much in terms of pain and swelling management, and recovery from surgery. As there is a paucity of literature about severe acute temporomandibular injuries and chiropractic, it is a significant case indeed.
Temporomandibular displacement (TMD) is a group of symptoms that may include pain or tenderness in the temporomandibular joint (TMJ) or surrounding muscles. It can include headaches, earaches, neck, back, or shoulder pain, limited jaw movement, and clicking or popping of jaw that is caused by either dysfunction of the TMJ or another problem such as muscle spasms or tension. There is a lot to be desired in terms of general research pertaining to the prevalence or burden of disorders like TMD, but studies do suggest that TMD is second only to low back pain in terms of musculoskeletal disorders resulting in pain and disability.
TMD is thought to be relatively common in the paediatric population. There are many traditional treatment options for TMD including medication, intraoral appliances, injections, surgery, and physical therapy. But there is no single accepted treatment method, and management is usually a combination of these options tailored to the patient’s needs, ability and developmental stage.
TMD can be further categorised into three types. The recent case report involved the most common of these categories: displacement of the disc. This can also be further refined into the direction of disc displacement, the relevant one for this case report being anterior disc displacement (ADD). And yeah, you guessed it, we can further refine that to two possibilities: ADD with reduction – meaning that the disc was repositioned to its normal position on mouth opening, (often associated with clicking) and ADD without reduction without repositioning of the disc (often associated with restricted movement at the TMJ).
Pain is significantly more likely in those with ADD without reduction than those with reduction. TMD with disc displacement can be caused by many things, either repeated microtrauma or acute trauma as in the case report you are about to read of.
The main issue is this: these conditions are very painful and can really disrupt people’s lives, so literature supporting non-invasive and/or effective management options is important to lay out the full range of options in terms of treatment and pain management.
The Case Report:
In the recent case report, a 12-year-old female presented for chiropractic care following a referral from her oral surgeon. When she first presented, she was 1 week post injury sustained during a volleyball match where she had sustained a strike to the right of her jaw. Immediately following the injury, the patient experienced pain over the area of impact and in the region of the left TMJ. Due to the significant pain and difficulty opening her mouth, she went to the dentist and a panoramic dental x-ray was completed.
A fracture in the mandibular could not be completely ruled out so further oral surgical consultation was sought, after which a CT scan was performed and showed no fracture had been sustained. The course of treatment following this clarification included ibuprofen and physical therapy for TMD (temporomandibular joint disorder) by her oral surgeon. However, pain in the left TMJ persisted while the right-sided pain resolved. In fact, the left-sided pain worsened whenever she opened her mouth. She had been unable to eat solid foods since the injury and noted a bump over her left jaw.
The patient had a history of frequent headaches which had no change in intensity or frequency since the injury. Her pain was self-reported as 8/10 a week post injury, and she rated the pain a 10/10 immediately following the injury. When asked she said there was no change to facial sensation or salivation .
When assessed by a chiropractor it was noted that there was no bruising or abnormalities in cranial nerves V and VI. There was a bulge over the TMJ suggestive of joint swelling, and the left side was tender to the touch. She was able to clench her teeth, but active opening of the mouth was significantly restricted and painful iin that she was barely able to fit the width of her index finger in between her teeth.
The thorough chiropractic examination included many of the common tests (and is described in great detail in the original case report referenced below ). Postural examination showed anterior head carriage, right head tilt, and a high left shoulder. Static palpation elicited pain throughout the cervical and upper thoracic spine, and the muscles of the paravertebral was noted to be tight and tender. The examination also revealed potential upper-crossed syndrome which occurs when the muscles of the shoulder, neck and chest are out of balance and do not work together as they should. Restriction of the upper cervical vertebrae and thoracic vertebrae was also found, and the patient commenced a course of chiropractic care initially provided for 12 visits over a 4-week period. During this course of care, chiropractic adjustments were performed using diversified technique (contact specific High-Velocity Low Amplitude adjustments). She also received treatment with instrument-assisted soft-tissue mobilization .
The patient reported slow but consistent improvement in pain throughout the initial phase of treatment. She patient was re-evaluated on the 7th visit after two weeks of care. During this re-evaluation, it was noted that her TMJ pain had significantly reduced and was rated a 4/10 at rest and a 7/10 when attempting to open her mouth. Her diet had remained restricted to liquids and soft foods. Mouth opening remained restricted but with a small amount of improvement.
She was evaluated again on the 12th visit. During this visit, her left-sided TMJ pain was now rated a 2/10 at rest and a 7/10 when opening her mouth. Further tests were done which indicated a further decrease in the indicators for vertebral subluxation.
At this point, the patient followed up with her oral surgeon again and an MRI revealed anterior temporomandibular disc displacement on both sides. Bilateral TMJ arthrocentesis and manipulation of the mandible under anaesthesia was recommended and later performed without complication by an oral-maxillofacial surgeon. Following this procedure, the patient was provided with an oral appliance, and its use combined with a course of chiropractic care was the recommended/decided post-operative management. Chiropractic care at this point included therapeutic exercises, myofascial release techniques and chiropractic adjustments.
Re-examination was done by both the chiro and oral surgeon two weeks post operation. The patient used the oral appliance minimally, as she felt her range of motion was now normal. She had no pain or swelling and was engaging with her normal activities pre-injury. Examination revealed no tenderness over the TMJ on either side, and the cranial nerves were intact.
This case report is an example of successful co-management of an acute injury. It is clear from the case report that, while surgery did facilitate major improvement, chiropractic care either side of that was positive, and may have helped pre-surgery with pain and swelling management.
It does post chiropractic not only as an effective therapy to use under co-management with other care, but as an effective alternative to more invasive surgical procedures for the treatment of acute persistent closed lock of the TMJ. It may also be a good option for TMD patients early on, in an attempt to prevent unnecessary chronic sequelae.
- Hughes F. Chiropractic and oral surgical co-management of acute anterior temporomandibular disc displacement without reduction due to sports-related trauma in a pediatric patient – a case study and review of the literature. Journal of Contemporary Chiropractic. 2021. 4(1):26–34.