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Telerehabilitation in Temporomandibular Disorders

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Original Editor - İbrahim Seker
Top Contributors - İbrahim Seker and Alexandra Stead

Introduction

Temporomandibular disorders (TMDs) are commonly characterised by jaw pain, difficulty in opening and closing the mouth, lateral deviation, and clicking or popping sounds during jaw movement[1][2][3]. Impairment of joint function can affect activities such as eating, breathing, swallowing, and both verbal and nonverbal communication[3][2]. The temporomandibular joint has a complex structure that encompasses the neck and the masticatory muscles, nerves, ligaments, joint capsules, and arteries[1]. Due to this anatomical complexity, the development of TMDs involve a multifactorial aetiology[1]. The aetiology is related to various parameters such as trauma, emotional stress, parafunctional habits, muscle impairment, disc or bone morphology changes, inflammatory conditions, and congenital causes[4].

The traditional model of TMD care relies on in-person assessment; however, the COVID-19 pandemic accelerated the adoption of telemedicine, prompting its integration into both diagnosis and management of TMDs[1]. Additionally, TMDs need a multimodal treatment approach, and common treatment options include occlusal appliances, physiotherapy, pharmacologic treatment, and a behavioural approach[4][1]. The rationale for adopting telerehabilitation includes reduced travelling time, lower treatment costs, and shorter waiting lists, while earlier access to diagnosis by different professionals can streamline the overall care pathway[5].

The Integration of Digital Assessment in TMD

Teleconsultation and Its Role in Reducing Clinical Burden

Teleconsultation aids in decreasing the number of non-urgent patient consultations from primary health centres to higher centres around 45%[6]. Additionally, the burden on healthcare industries is reduced[6] [4]. Ignatius and Perälä[7] performed a 13-month study to evaluate the reliability and feasibility of videoconferencing and concluded that videoconferencing is reliable and feasible for diagnosis and treatment planning for patients who need prosthetic or temporomandibular joint rehabilitation. Another study by Fernando G Exposto[8] and colleagues compared the video communication examination to the standard examination in 16 individuals. There was a high to perfect agreement between both standard and online assessments for the diagnoses of both myalgia and arthralgia.

Standardised Protocols for Remote Orofacial Pain Assessment

In the first line of the online assessment, regarding orofacial pain conditions, the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) were followed for temporomandibular disorders[9], and the International Classification of Orofacial Pain (ICOP) was followed for other orofacial pain diagnoses[10]. Patients applied pressure of approximately 1 kilogram-force (≈10 Newtons) -equivalent to the pressure required to blanch the fingernail - and held it for 5 seconds per site, as per DC/TMD standards[9]. A study by Exposto et al. examined the accuracy of patient self-palpation by comparing force application and anatomical location against clinician-performed palpation, finding substantial agreement between the two methods, suggesting that guided self-palpation may be a viable alternative for remote assessment of TMDs[8]. Temporomandibular joint movement was assessed by a ruler for inter-incisal distance and for Maximum mouth opening (MMO)[3].

Kinematic Technologies for Remote Jaw Movement Analysis

The shift towards telerehabilitation has required the development of alternative kinematic methodologies capable of capturing these parameters reliably via a camera interface. Recent Studies in biomechanics have facilitated the application of two- and three-dimensional capture technologies (such as artificial intelligence-based computer vision, optical tracking systems, and digital goniometry) to jaw function[7][11]. Monje-Gil et al.[11] demonstrated the utility of an artificial intelligence-based two-dimensional motion analysis platform in a TMD case series, employing it to quantify maximum mouth opening and lateral excursion whilst classifying mandibular deviation into five distinct kinematic subtypes - a framework with direct implications for remotely prescribed, individualised exercise programmes.

Validated Outcome Measures in Remote TMD Assessment

Secondly, patients' conditions within various parameters were comprehensively assessed across multiple clinical parameters using a battery of validated questionnaires, which include:

  • Pain: Graded Chronic Pain Scale (GCPS)[9]
  • Psychological: GAD-7[12], Patient Health Questionnaire-4 (PHQ-4)[9]
  • Sleep: Pittsburgh Sleep Quality Index (PSQI)[13]
  • Functional: Oral Behaviour Checklist (OBC)[14], Neck Disability Index (NDI)[15], Fonseca Anamnestic Index[16] Jaw Functional Limitation Scale - short form (JFLS-8)[9]

Technical and Clinical Setup Requirements for Telerehabilitation

The setup requirements for implementing telerehabilitation in TMD management from both the clinician and patient perspectives are outlined below:

On the clinician side, the setup requires a high-definition (HD) camera and optimal, direct lighting to accurately evaluate facial asymmetries, jaw deviation patterns, and cervical movements without shadows[17][8]. Furthermore, secure, synchronous video platforms complying with data privacy regulations are mandatory to protect patient data while enabling real-time clinical interaction[18]. Clinicians must also possess strong digital communication skills to effectively translate hands-on manual techniques into precise verbal instructions, guiding patients safely through self-palpation of the masseter and temporalis muscles[19].

On the patient side, a stable, high-speed internet connection is vital to eliminate video lag, ensuring the clinician can detect subtle jaw clicks, catching, or restricted movement in real time[17]. The physical environment must be a quiet, well-lit room with a fixed camera placement (such as a laptop or tablet at eye level) to provide an unobstructed frontal view of the face and jaw during the assessment[8]. Ultimately, successful remote management depends on the patient's behavioural readiness, requiring sufficient eHealth literacy and self-management capabilities to accurately locate anatomical landmarks and adhere to home-based therapeutic instructions[20].

Technological Framework and Modalities

Telerehabilitation can take one of the three forms: asynchronous (store and forward approach), synchronous (real-time interaction), and mobile health care services (manage and track general health with educational videos, blogs, and general planned exercise programmes)[21]. Asynchronous form can be performed via applications for instant messaging (WhatsApp, Telegram, Instagram, SMS, and Messenger) or synchronous -video calling- (Google Meet, Skype, FaceTime, and WhatsApp)[4].

The study by Ezgi Hatice Abaci et al.[3] compared two groups: synchronous 30-minute weekly sessions 8 weeks long and asynchronous home exercise group 8 weeks long, and concluded that the supervised-synchronous group's results were better than the home exercise group. Another study by Kerstin Wahlund et al.[22] is assessing the results of a jaw exercise (JE) intervention programme combined with an information/counselling programme (IC) vs. information/counselling alone. To conclude, both treatment programmes had positive effects on symptom alleviation during the treatment period. Overall, the structured JE training programme, combined with IC, had significantly stronger effects on adolescent-reported severity of TMJ symptoms compared to treatment with IC alone[22].

Petruzzi and De Benedittis[23] concluded that 82% of the remote-consulted cases agreed with the clinicopathological diagnosis by the use of WhatsApp in the process of oral diagnosis, and recommended the reliability of this method.

Patient Selection for Telerehabilitation in TMD: Indications and Contraindications

Not all patients with TMD are equally suited to telerehabilitation, and appropriate patient selection is essential to ensure both clinical safety and treatment effectiveness.

Suitable Candidates: Indications for Telerehabilitation

Patients likely to benefit from telerehabilitation include those presenting with mild to moderate pain-related TMDs, such as myalgia or arthralgia, where management centres on exercise prescription, pain neuroscience education, and behavioural advice rather than hands-on intervention[3][5][24]. Telerehabilitation is also appropriate for follow-up and monitoring sessions following an initial in-person assessment, and for patients in geographically remote areas or those with mobility limitations that restrict clinic attendance[1][4]. Internet-based multimodal programmes incorporating jaw exercise, counselling, and self-management strategies have demonstrated positive outcomes in adults and adolescents with chronic TMD pain[5][22].

Unsuitable Cases: Contraindications and Clinical Limitations

Patients for whom telerehabilitation is less appropriate or insufficient include those with complex structural pathology such as significant disc displacement, osteoarthritis, or conditions requiring advanced imaging for accurate diagnosis, as these cannot be fully evaluated via a video interface[1]. Similarly, cases requiring hands-on clinical techniques - including intraoral palpation, bite registration, occlusal assessment, or manual therapy - are not adequately managed remotely, given that current telehealth physical examination protocols are limited in their capacity to replicate these procedures[8][17].

Practical and Technological Barriers to Patient Participation

Practical barriers to patient participation must also be considered. Successful telerehabilitation depends on access to a stable, high-speed internet connection, appropriate hardware, and a suitable physical environment[3][4]. Patients with insufficient eHealth literacy or limited self-management capability may struggle to accurately locate anatomical landmarks, perform self-palpation, or adhere to home-based therapeutic instructions without in-person guidance[20]. Data security and compliance with applicable data protection regulations add a further layer of complexity, particularly when using third-party platforms or consumer messaging applications[18].

In practice, the most appropriate model may combine initial in-person assessment with ongoing telerehabilitation for monitoring, exercise progression, and psychosocial support - allowing the strengths of both approaches to be preserved[24][25][26].

Comparison of Traditional and Digital TMD Management

The management of TMDs with both methods has strong sides and is beneficial. Traditional methods offer several benefits, including direct physical examination and the ability to maintain a strong clinician–patient relationship[25]; however, in the case of dynamic assessment by AI, the lack of usage of healthy behaviour information and exercise demonstration, telerehabilitation can be integrated into the clinical settings[25].

A recent review comparing traditional and AI-assisted TMJ disorder management suggests that digital technologies can complement conventional clinical care by improving diagnostic precision and supporting more efficient treatment planning[11]. While traditional approaches remain important for direct examination and clinical judgment, AI-assisted methods may add value in cases where objective analysis and faster decision-making are needed. Therefore, the most effective model for TMD management may be an integrated approach that combines the strengths of both traditional and digital systems rather than relying on only one method[11].

Conclusion

Telerehabilitation technologies and research show promise as an efficient modality in the management of TMD[4][1]. This is particularly relevant for patients in rural areas who face barriers to consistent follow-up care[26][4]. Telerehabilitation has shown effectiveness in reducing TMD symptoms, offering a promising alternative to unsupervised exercise[4]. However, key challenges including reimbursement concerns, licensing regulations, cost implications, limitations in physical examination, optimal treatment protocol, must be addressed before teledentistry and telerehabilitation can be fully integrated into routine clinical practice[4]. As telemedicine continues to evolve, it is essential that healthcare professionals ensure the quality of care, patient safety, and confidentiality are maintained throughout its implementation[4]. As digital technologies continue to rapidly evolve and the global burden of these disorders increases, the integration of telerehabilitation becomes increasingly essential to optimise outcomes for both patients and clinicians.[27][24] [26].

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Abdul NS, Kumari M, Shenoy M, Shivakumar GC, Herford AS, Cicciù M, et al. Telemedicine in the diagnosis and management of temporomandibular disorders: A systematic review conducted according to PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. J Oral Rehabil. 2023;50(11):1346-1356.
  2. ↑ 2.0 2.1 Dworkin SF. The OPPERA Study: Act One. J Pain. 2011 Nov;12(11 Suppl):T1-T3.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Abaci EH, Tuncer A, Tuncer AH. Effectiveness of telerehabilitation-supported exercises in patients with temporomandibular disorders with probable sleep bruxism during the COVID-19 pandemic: A randomized controlled trial. Cranio. 2026 Mar;44(2):287-298.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Minervini G, Russo D, Herford AS, Gorassini F, Meto A, D'Amico C, et al. Teledentistry in the Management of Patients with Dental and Temporomandibular Disorders. Biomed Res Int. 2022;2022:7091153.
  5. ↑ 5.0 5.1 5.2 Lam J, Svensson P, Alstergren P. Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial. J Med Internet Res. 2020 Oct 13;22(10):e22326.
  6. ↑ 6.0 6.1 Bavaresco CS, Hauser L, Haddad AE, Harzheim E. Impact of teleconsultations on the conduct of oral health teams in the Telehealth Brazil Networks Programme. Braz Oral Res. 2020 Feb 27;34:e011.
  7. ↑ 7.0 7.1 Ignatius E, Perälä SMK, Mäkelä K. Use of videoconferencing for consultation in dental prosthetics and oral rehabilitation. J Telemed Telecare. 2010;16(8):467-470.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Exposto FG, Castrillon EE, Exposto CR, Costa DMF, Gøkhan MA, Svensson P, et al. Remote physical examination for temporomandibular disorders. Pain. 2022 May 1;163(5):936-942. doi: 10.1097/j.pain.0000000000002455.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1):6-27.
  10. ↑ International Classification of Orofacial Pain, 1st edition (ICOP). Cephalalgia. 2020 Feb;40(2):129-221.
  11. ↑ 11.0 11.1 11.2 11.3 Woo J, Jeon J, Hong J. Kinematic Analysis-Guided Individualized Exercise for Temporomandibular Disorders: A Case Series. J Clin Med. 2026;15(2):655.
  12. ↑ Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097.
  13. ↑ Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.
  14. ↑ Ohrbach R, Markiewicz MR, McCall WD Jr. Waking-state oral parafunctional behaviours: specificity and validity as assessed by electromyography. Eur J Oral Sci. 2008;116(5):438–444.
  15. ↑ Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther. 1991;14(7):409–415.
  16. ↑ Sánchez-Torrelo CM, Zagalaz-Anula N, Alonso-Royo R, et al. Transcultural adaptation and validation of the Fonseca Anamnestic Index in a Spanish population with temporomandibular disorders. J Clin Med. 2020;9(10):3250. doi: 10.3390/jcm9103250.
  17. ↑ 17.0 17.1 17.2 Hartono J, Cottrell M, Window P, Russell T. Performance of key physical tests for temporomandibular disorder via telehealth: Establishing validity and reliability. J Oral Rehabil. 2024 Apr;51(4):648-656.
  18. ↑ 18.0 18.1 ICO UK GDPR Guidance (regulatory standard) Information Commissioner's Office. UK GDPR Guidance and Resources [Internet]. ICO; 2024 [cited 2025].
  19. ↑ Kringle EA, Trammell M, Donoso Brown E; American Congress of Rehabilitation Medicine Stroke International Special Interest Group. Telerehabilitation strategies and resources for rehabilitation professionals. Arch Phys Med Rehabil. 2023 Dec;104(12):2191-2197.
  20. ↑ 20.0 20.1 Georgas K, Bromis K, Vagenas TP, Giannakopoulou O, Vasileiou N, Kouris I, et al. eHealth literacy assessment as a promoter of user adherence in using digital health systems and services. A case study for balance physiotherapy in the TeleRehaB DSS project. Front Digit Health. 2025 Feb 18;7:1535582.
  21. ↑ Minervini G, Russo D, Herford AS, Gorassini F, Meto A, D'Amico C, et al. Teledentistry in the management of patients with dental and temporomandibular disorders. Biomed Res Int. 2022;2022:7091153. doi: 10.1155/2022/7091153.
  22. ↑ 22.0 22.1 22.2 Wahlund K, Nilsson IM, Carlsson AD, Larsson B, Wänman A. Internet-based treatment for adolescents with symptomatic temporomandibular joint disc displacement with reduction. A randomized controlled clinical trial. Acta Odontol Scand. 2021 Aug;79(6):473-481.
  23. ↑ Petruzzi M, De Benedittis M. WhatsApp: a telemedicine platform for facilitating remote oral medicine consultation and improving clinical examinations. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016 Mar;121(3):248–254. Available from: https://doi.org/10.1016/j.oooo.2015.11.005 Scopus ID: 2-s2.0-84958977372. PMID: 26868466.
  24. ↑ 24.0 24.1 24.2 Park SY, On SW, Yi S, Che SA, Kim B, Byun SH, Yang BE. Evaluating the Efficacy of a Digital Therapeutic Intervention for Temporomandibular Disorders: Multicenter, Randomized, Sham-Controlled Trial. J Med Internet Res. 2025;27:e83545.
  25. ↑ 25.0 25.1 25.2 Mehta V, Vathani A, Kamma PKG, Chaturvedi S, Mathur A, Noor T. Comparing Traditional Versus AI-Assisted TMJ Disorder Management Approaches: A Systematic Review and Meta-Analysis. Clin Exp Dent Res. 2026 Apr;12(2):e70370.
  26. ↑ 26.0 26.1 26.2 Molina-García P, Mora-Traverso M, Prieto-Moreno R, et al. Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: a systematic review and meta-analysis. Ann Phys Rehabil Med. 2024;67(1):101791.
  27. ↑ łaszewski M, Bettany-Saltikov J. Editorial: Insights in rehabilitation for musculoskeletal conditions 2023/2024. Frontiers in rehabilitation sciences. 2025;6:1729389.
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