Self-care, education, and awareness of the patient with temporomandibular disorder: a systematic review

JUSTIFICATIVA E OBJETIVOS: Disfunção temporomandibu lar consiste em uma variedade de condições associadas com dor e disfunção da articulação temporomandibular, músculos da masti gação e estruturas associadas. Os protocolos clínicos de autocuidado são comumente usados como terapia inicial do paciente com disfun ção temporomandibular, após o diagnóstico, como uma abordagem conservadora e não invasiva. O objetivo deste estudo foi estudar as técnicas de autocuidado presentes na literatura e sua eficácia.

CONTEÚDO: Foi realizada uma revisão sistemática da litera tura, com um levantamento nas bases de dados Science Direct e Pubmed, além da literatura cinzenta, Google Acadêmico. Os seguintes descritores foram utilizados: “autocuidado”, “disfunção temporomandibular” e “aconselhamento”. Artigos em inglês e português, publicados entre 2010 e 2018, foram incluídos. Vin te e um artigos foram selecionados com base em uma série de critérios de inclusão e exclusão.

CONCLUSÃO: Há dois objetivos principais no tratamento do paciente com disfunção temporomandibular, sendo a redução da dor e a melhora da função. Concluiu-se que terapias de au tocuidado são efetivas em atingir estes objetivos, além de não -invasivas e de baixo custo tecnológico. Pacientes que participam ativamente no próprio processo de cura apresentam melhorias mais rapidamente, alterando sua percepção geral da dor.

Descritores:
Protocolos; Transtornos da articulação temporo mandibular; Tratamento conservador

Therapy	Authors	Conclusion
Education	Durham et al.¹	Diagnosis and "optimistic counseling" (reassurance that TMD is typically benign and self-limiting in the clear majority of cases). Education should also include TMD's biopsychosocial etiology; cautions against invasive and irreversible treatments; sleep practices; sensible and time-limited use of analgesia; avoidance of OTC splints bought without consultation with the dentist; caffeine usage; anatomy and usual function of TMJ complex and associated musculature.
	Michelotti et al.¹⁵	Patients that receive extensive information and considerable patient-doctor interaction present faster improvement. Therefore, the psychophysiological mechanisms associated with education and reassurance reveal positive effects. The improvement is mediated, however, by each patient's coping skills, mood and emotional state.
	Conti et al.¹⁶	Education is slightly more effective than only an occlusal appliance in treating spontaneous muscle pain.
	Freitas et al.²⁰	Treatment modalities should include counseling and education for self-care and self-regulation, such as an explanation concerning the role of pain, possible etiological factors of the patient's TMD, the relationship between chronic pain and psychosocial distress, and its benign character. A list of recommendations can be given to patients: - Encouragement of patients to rest their masticatory muscles; - Observation and reduction in parafunctional habits; - Avoidance of excessive mandibular movements; - Maintenance of soft diet and recommendation to chew carefully; - Performance of simultaneous bilateral mastication; - Improvement of posture and sleep onset. However, education should be associated with posture training and physical therapy programmes, since counseling and self-management-based therapies provide better results when they are not used alone. Also, although it represents a conservative low-cost and beneficial treatment for the relief of signs and symptoms by improving psychological domains and potentially reducing harmful behaviors, the evidence remains unclear due to the reduced number of controlled and randomized well-designed clinical trials.
	Miernik and Więckiewicz²¹	As the natural course of the closed lock is self-limiting, some authors recommend just education and counseling. It is important to explain the mechanism of disc displacement and the negative effects of parafunctions on the stomatognathic system, especially the TMJ.
	Vernooij, Willson and Gagliardi²²	Single or multifaceted educational interventions may reinforce general information about the condition and lifestyle advice and contribute to positive outcomes. Information and evidence about the condition, prognosis, what to expect, and its management. Information and advice on how to undertake generic activities such as hygiene, dressing, preparing meals, transportation. Information and guidance on lifestyle behaviors that support disease management.
	Craane et al.¹⁷	The study showed that improvement was purely based on the education of the patients, which includes informing and explaining the presumed etiology, the good prognosis of this benign disorder and reassuring the patient regarding this problem.
Self-exercise	Durham et al.¹	Jaw (muscle) exercises, relaxation and posture training. Can be implemented by the clinician or by referral to other health care professions, such as physical or occupational therapists.
	Craane et al.¹⁷	Exhibits significant improvement over time for pain and impairment. However, there is no evidence of the clinically important benefit of a single physical therapeutic modality, while combinations of physical therapeutic modalities seem to be more effective than a single one.
	Bouchard et al.¹⁸	For the treatment of non-reducing discs, institute a home exercise program performed for jaw muscle and range of motion.
	Campi et al.¹⁹	Stretching, stabilization, coordination and mobilization exercises. Although these treatments are effective to decrease pain and improve dysfunction associated with TMD, there is still a lack of studies defining effectiveness parameters.
Thermal modalities	Durham et al.¹	Use of heat and /or ice to areas of pain.
	Conti, Corrêa and Lauris¹⁰	For painful temporomandibular joint clicking, hot thermotherapy.
	de Freitas et al.²⁰	Apply heat or cold to the most painful masticatory areas.
	Miernik and Więckiewicz²¹	For the closed lock, the recommended self-care protocol might include thermotherapy (cold or warm packs) in the initial period of locking.
	Giro et al.¹³	Thermotherapy to promote pain relief, improve muscle tone, and relax mandibular muscles. Patients should be advised to place moist heat pads on the painful muscle for 15 minutes, 3 times per day.
Diet and nutrition	Durham et al.¹	Clinicians should implement a "pain-free diet", as opposed to a "soft diet", for a two-week period. After that, a new review determines whether the individual advances as tolerated to firmer and chewier consistency foods.
	Schiffman et al.⁸	To the patient minimally inconvenienced by diet, should be recommended a regular diet that, at worst, avoids tough or hard foods.
	Ommerborn et al.¹⁴	Diet counseling for the patient with bruxism.
	Mukherjee, Sen and Sinha¹²	For the management of orofacial pain, a successful home care program should emphasize a soft diet. Some patients find eating mild food helpful.
	Miernik and Więckiewicz²¹	For the closed lock, the recommended self-care protocol might include soft food diet in the initial period of locking.
	Martins et al.⁴	Avoid foods of thick consistency.
	de Freitas et al.²⁰	Maintenance of soft diet and recommendation to chew carefully.
	Craane et al.¹⁷	In their study, patients were advised to use a soft diet and chew bilaterally
Self-massage	Durham et al.¹	Massage is limited to the anatomic location of the painful or tense affected masticatory muscles. The most easily accessible to palpation are masseter and temporalis.
	Giro et al.¹³	Self-massage promotes the improvement of local blood circulation and relieves pain and muscle tension. Patients can be instructed to bilaterally massage the masseter and temporal muscles 3 times per day with circular movements performed using the index, middle, and ring fingers. It was concluded that the improvement of blood flow in the masticatory muscles and decreased muscle tension provided by massages followed by exercises and hot pads can reduce pain, which also contributes to improvement in mandibular function.
	Conti et al.¹⁶	Instruct the patients to massage painful areas.
	Brantingham et al.²³	Considered soft tissue procedures, such as trigger point therapy, transverse friction massage and therapeutic massage. A typical relaxing massage is focused on reducing muscular tension and improving circulation.
Parafunctional behavior monitoring and avoidance	Durham et al.¹	Orient the patient to identify, monitor, and avoid any parafunctional behavior that exacerbate their pain.
	Mukherjee, Sen and Sinha¹²	A reduction in stress/tension-related parafunctional activity can lead to immediate less pain reported by patients. A successful home care program includes parafunctional habit modification.
	Miernik and Więckiewicz²¹	It is important to explain the mechanism of disc displacement and the negative effects of parafunctions on the stomatognathic system, especially the TMJ.
	Martins et al.⁴	Their study revealed an improvement in the symptomology, which included modifications in parafunctional activities, greater awareness of the patient and the cognitive placebo effect. Counseling should include guidance on reducing parafunctional mandibular activities.
	Giro et al.¹³	Parafunctional habits are involved in the development and maintenance of the signs and symptoms of TMD. Behavioral therapies may help relieve musculoskeletal pain and restore mandibular function by reducing inflammation, relieving muscle tension, and improving psychological health. Counseling and self-care approaches include guidance in reducing parafunctional jaw activities.
	de Freitas et al.²⁰	A TMD self-management program should orient the patient towards becoming aware of parafunctional habits, such as teeth clenching. Patient must be able to monitor and reduce muscle parafunction in the head and neck region.
	Conti et al.¹⁶	In their study, the improvement in pain reported after a 3-month period reflected the importance of behavioral alterations and the avoidance of deleterious and parafunctional habits in the facial pain of masticatory origin.
	Campi et al.¹⁹	A self-care program should include habit reversion techniques and correct jaw use.

Self-management clinical protocol
TMD definition and etiology	Temporomandibular disorder (TMD) refers to a group of masticatory system changes characterized by pain in the temporomandibular joint (TMJ) and/or masticatory muscles, joint sounds, joint movement shifts or limitations. The etiology of TMDs can be quite varied, and known causes include developmental conditions, trauma, infection, and autoimmune conditions. However, the etiology most frequently seen in the clinic is at best speculative, and factors that are frequently held as responsible for pain and dysfunction comprise grinding, clenching and stress.
"Optimistic counseling"	TMD is typically benign and self-limiting in the vast majority of cases. It is important to emphasize the good prognosis of this benign disorder. Patients that receive extensive information and considerable patient-doctor interaction present faster improvement.
Rest of masticatory muscles	Avoid excessive mandibular movements, such as chewing gums. When your jaw is at rest, your teeth should never touch - the teeth only touch during chewing and swallowing. The jaw should be kept in the postural position, with the teeth separated, avoiding an involuntary muscular contraction. To learn the position, repeatedly pronounce the letter "N" and hold the tongue in this position behind the upper incisor teeth, with the lips in slight contact. Avoid leaning on your jaw at rest. Limit your maximum buccal opening, especially when yawning or singing.
Soft diet/Bilateral mastication	Avoid tough, hard and thick consistency food. Try to eat soft food slowly, in small pieces. Some patients find eating mild food helpful. Chew carefully and bilaterally, in order not to overload the TMJ.
Observation and reduction in parafunctional habits	Parafunctional habits exacerbate pain. They are involved in the development and maintenance of the signs and symptoms of TMD. Therefore, it is important to identify, monitor and avoid this type of habits. Avoid clenching and/or grinding your teeth. Avoid pen (objects in general) and nails biting. Use some type of reminder to notice any parafunctions and try to turn them into a non-jaw-related habit. Patient must be able to monitor and reduce muscle parafunction in the head and neck region.
Improvement of posture	This is part of a specific physical self-regulation strategy which helps in the management of pain complaints. It involves posture training with a physical therapist, awareness training to improve symmetric head and neck postures and training in diaphragmatic breathing.
Improvement of sleep	This is also part of a specific physical self-regulation strategy which helps in the management of pain complaints. It involves instructions for improving sleep onset, position-oriented relaxation training and positioning the pillow supporting the head and neck during sleep.
Use of heat	Apply hot packs to areas of pain, for 15 minutes 3 times per day. Thermotherapy promotes pain relief, improves muscle tone and relaxes mandibular muscles.
Self-massage	Bilaterally massage the masseter and temporal muscles 3 times per day with circular movements performed using the index, middle, and ring fingers. Self-massage promotes the improvement of local blood circulation and relieves pain and muscle tension, which also contributes to the improvement in mandibular function.
Jaw muscles exercises, relaxation and posture training	The therapeutic self-exercise consists in the prescription of muscular contractions and body movements in order to improve general function and help satisfy the demands of daily life. · Relaxation exercises: Movements of opening, laterality, protrusion and closing resistance (with the fist as support, for example). · Relaxation exercises with diaphragmatic breathing: Exhale completely with one hand resting on the chest and the other on the abdomen, training to become aware of the mechanism of breathing only by the position and hand movement. Diaphragmatic breathing should be performed for 5 minutes every day, every 2 hours. However, use this coordinated breathing the most frequent possible throughout the day. · Stretching exercises: Open your mouth slowly until you experience an initial sensation of pain. Open a little more with slight pressure, positioning the thumb in the upper arch, approximately in the region of premolars, and the index finger in the lower arch, also in the region of the premolars. The technique should be performed every day, every 2 hours, keeping the elongated jaw in position for one minute, six times in a row. · Coordination exercises: Consist of repeated opening, laterality, protrusion and mandibular retrusion movements. They must be performed slowly and coordinated, in front of the mirror, 3 times per day. · Mobilization exercises: Perform mandibular laterality movements to recapture the disc, if possible. Then perform gentle protrusion and retrusion movements by holding some small object between the teeth.

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