Tem p o ro m a n d i b u l a r J o i n t

D i s o rd e r s an d t h e E a t i n g
Experience
a,b c,
Cibele Nasri-Heir, DDS, MSD , Riva Touger-Decker, PhD, RD, CDN *

KEYWORDS
 Temporomandibular joint disorder  Diet  Orofacial pain  Nutrition

KEY POINTS
 Clinicians need to be aware of and sensitive to the impact of the TMD on patients’ eating
ability, eating experience, ERQOL and appetite.
 Careful attention to patients’ eating ability, guidance on positive adaptive eating behav-
iors, and referrals to an RDN help patients maintain a healthy diet and reduce maladaptive
eating behaviors.
 Provide positive adaptive suggestions based on patients’ diets and avoid instructing pa-
tients to follow a “soft diet.”
 Ask patients about how the condition of their mouth has altered their ability to eat, appe-
tite, eating-related quality of life, and diet quality.

INTRODUCTION AND BACKGROUND

The relationship between temporomandibular joint disorders (TMDs) and diet is multi-
directional. The Fédération Dentaire Internationale (FDI) World Dental Federation de-
fines oral health as “multifaceted and includes the ability to speak, smile, smell,
taste, touch, chew, swallow and convey a wide range of emotions through facial ex-
pressions with confidence and without pain, discomfort, and disease of the craniofa-
cial complex (FDI).”1 Individuals with TMD have compromised oral health by virtue of
the influence of the disease on masticatory function and the ability to swallow and
sometimes smile and speak without pain or discomfort. As part of the stomatognathic
system, the temporomandibular joint (TMJ) works closely with other components of

a
Department of Diagnostic Sciences, Center for Temporomandibular Disorders and Orofacial
Pain, Rutgers School of Dental Medicine, 110 Bergen Street, Newark, NJ 07101, USA;
b
Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers, The State
University, 110, Bergen Street, Room D-867, Newark, NJ 07101-1709, USA; c Department of
Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers School of Health Professions,
110 Bergen Street, Newark, NJ 07101, USA
* Corresponding author.
E-mail address: [email protected]

Dent Clin N Am 67 (2023) 367–377

https://doi.org/10.1016/j.cden.2022.11.005 dental.theclinics.com
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368 Nasri-Heir & Touger-Decker

that system, particularly the muscles and teeth, to facilitate mandibular opening,
biting, chewing, and swallowing.
TMD pathophysiology remains unknown and has created controversy over the
years; evidence suggests that biological, psychological, and social factors combine
to predispose, initiate, or perpetuate painful TMD.2 It is a complex disorder with mul-
tiple causes consistent with a biopsychosocial model of illness.3,4 The term TMD en-
compasses a group of painful and nonpainful musculoskeletal conditions that involve
the TMJs, the masticatory muscles, and all associated tissues.2,5 The most common
types of TMDs are myogenous, or muscle-generated pain and arthrogenous or joint-
generated pain.6 Myalgia affects around 80% of patients with TMD and is the most
common TMD diagnosis along with arthralgia, which frequently occurs together
with myalgia.7,8 The Diagnostic Criteria/Temporomandibular Disorder (DC/TMD)
also includes headache attributed to TMDs, which is a headache that occurs in the
temporal region secondary to painful TMD and that is aggravated by jaw movement,
jaw function, or parafunction.9 All other possible headache diagnoses should be ruled
out before attributing the headache to the TMD diagnosis. Other common types of
TMD include primary disc displacement and degenerative diseases. The 3 main signs
and symptoms of TMD are pain, limited range of mandibular movement, and TMJ
sounds that are most frequently described as “popping,” “clicking,” grating, or crep-
itus.2 Pain is often the main complaint affecting the muscles of mastication and the
periauricular area, and it is aggravated or provoked by chewing and other mandibular
activities such as yawning or talking.4
The musculoskeletal nature of the disorder, the associated pain, and treatments can
influence appetite and mechanical factors involved with eating, drinking, and swallow-
ing, thus affecting dietary intake and, potentially, nutritional status. Oral function chal-
lenges, along with the emotional and social impacts of the disease on activities of daily
living and eating-related quality of life (ERQOL), are common and can affect food
choices as well as diet quality and composition.
Management of TMD requires a patient-centered interprofessional team approach,
including orofacial pain specialists, physical therapists, registered dietitian nutritionists
(RDNs), and other health professionals.10 The interprofessional collaboration of the
orofacial pain specialist, RDN and physical therapist can help the patient improve their
ability to eat and thus positively affect their ERQOL and nutrition status. This article will
review the evidence regarding the impact of TMD on functional ability to eat comfort-
ably, ERQOL and nutrition status, and address dietary management approaches.

DISCUSSION

There is a paucity of scientifically sound research on TMD, dietary approaches to man-

agement, and nutrition status. Earlier research has explored TMD symptoms affecting
eating ability,11–14 dysphagia risk,15–18 and dietary interventions with vitamin D19 or a
gluten-free diet.20 However, there are no evidence-based dietary guidelines for pa-
tients with TMD, despite the profound impact this chronic disease can have on masti-
catory function and ERQOL.21

Therapies Used to Treat Temporomandibular Joint Disorder

Conservative therapies are the first-line treatment of TMD, including patient education,
self-care techniques, intraoral appliances, physical therapy and acupuncture, biobe-
havioral therapy, and pharmacotherapy.2,21 Pharmacologic treatments range from
simple analgesic medications to neuromodulatory agents, usually combined with
other therapy modalities.4

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 Joint Disorders and the Eating Experience 369

The most commonly used pharmacologic agents for the management of TMDs
include analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids,
benzodiazepines, muscle relaxants, and low-dose antidepressants.2,22 The analge-
sics (nonopiate preparations), corticosteroids, and benzodiazepines are indicated
for acute TMD pain; NSAIDs and muscle relaxants may be used for both acute and
chronic conditions.2 Neuromodulatory agents such as tricyclic antidepressants
(TCAs), serotonin-noradrenaline reuptake inhibitors (SSRIs), and gabapentin are
used to treat chronic TMD.4,23
The clinician should be aware of and inform patients of the potential adverse effects
and medication–medication and medication–supplement interactions that may occur.
Unintentional weight gain and xerostomia are common adverse reactions to SSRIs,
TCAs, and cyclobenzaprine that patients should be cautioned about.24 Gastrointes-
tinal side effects ranging from gastrointestinal distress to altered bowel function and
changes in taste have been reported with benzodiazepines.24 There are gastrointes-
tinal side effects of NSAIDs, including dyspepsia and gastric and duodenal ulcers.25
Although the medications may help TMD-associated pain, their impact on appetite
and eating should be considered when counseling patients.

Impact of Temporomandibular Joint Disorder on the Eating Experience, Weight,

and Symptoms of Dysphagia
As a chronic condition, the impact of TMD on eating ability and diet is long-term.
Recent research on the impact of TMD on masticatory function and swallowing has
demonstrated the breadth and depth of its effect on all aspects of eating, including
appetite, food preparation, biting, chewing and swallowing, and ERQOL.11,13,14,16 Fer-
reira and colleagues12 explored chewing difficulties in adults (aged 18–41 years) in
Italy. The investigators found that in these adults with TMD, chewing behaviors and
eating patterns were negatively affected compared with those without TMD. Edwards
and colleagues11 surveyed adults with TMD who volunteered to complete a survey
and 3-day food diary and found that participants with a limited mandibular opening
(self-reported) had more pain, had fewer foods they could eat, experienced reduced
enjoyment of food, modified their approach to food preparation, and lost weight. Par-
ticipants reported boiling, pureeing, and mashing foods to create a soft diet. Those
who modified their food preparation consumed less dietary fiber than those who did
not. There were no other significant differences in energy or nutrient intake; however,
the sample size of participants who completed the 3-day diaries was small. Gilheany
and colleagues explored masticatory and swallowing difficulties using a subjective
questionnaire in an Irish cohort of 178 adults with TMD. In this sample of adults with
TMD, 90% reported masticatory pain, 78% reported fatigue with mastication, 26% re-
ported weight loss due to difficulty with eating and drinking, and one-third reported
difficulty swallowing. Participants also experienced difficulty chewing hard and some-
times soft foods.16
Although dysphagia may not be typically associated with TMD, individuals with TMD
may experience symptoms of oral dysphagia, which involves factors affecting the first
or oral phase of swallowing.26 Oral phase symptoms include limited mandibular move-
ment, drooling, poor tongue movement, inability to form a seal with the lips, difficulty
chewing, and difficulty initiating a swallow. Prolonged eating time and fatigue with
eating are also signs of dysphagia. Although limited, there is a body of evidence
exploring the relationships between TMD and symptoms of oral dysphagia.15,16,18 Gil-
heany and colleagues found that self-reported symptoms of oral dysphagia reported
by participants were related to mastication, oromotor function (including slurred or
painful speech, bruxism), pain, hearing, and psychosocial factors.16 About 99% of

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370 Nasri-Heir & Touger-Decker

the sample had one or more problems with eating, drinking, or swallowing. Although
this was a single study in Ireland, the results are consistent with other studies
regarding masticatory difficulties and weight changes and provide insight into the
added problem of dysphagia faced by individuals with TMD. Others18 have also re-
ported weaker tongue protrusion and swallowing strength and greater chewing diffi-
culty in adults with TMD compared with controls. A systematic review on the topic15
similarly identified symptoms of oral dysphagia in adults with TMD. It also supported
prior research regarding difficult and painful mastication, prolonged eating time, and
fatigue from chewing, all of which may be symptoms of dysphagia.
These eating-related symptoms also contribute to the symptom burden experi-
enced by patients with orofacial pain and the negative impacts on ERQOL. Symptom
burden is “the subjective, quantifiable prevalence, frequency, and severity of symp-
toms placing a physiologic burden on patients and producing multiple negative, phys-
ical and emotional patient responses.”27 Given the considerable impact TMD has on
the ability to eat, and ERQOL, consideration of the symptom burden patients with this
disease experience can provide meaningful insights to the clinician when approaching
disease management with the patient. Safour and colleagues14 investigated the eating
experience of adults with TMD using a phenomenological approach with adults aged
25 to 51 years in Montreal, Canada. ERQOL was negatively impacted due to chewing
difficulties, constantly feeling bloated, and changing diets dramatically due to their
TMD. Meals took much longer to eat, and favorite foods could no longer be eaten. Par-
ticipants also reported systemic impacts of TMD, including constipation and bloating,
due to the changes they had to make in their diets. Weight changes (both gain and
loss) were common; patients with weight loss ate less because of jaw pain.

Risk of Malnutrition in Adults with Temporomandibular Joint Disorder

Risk factors for malnutrition, including micronutrient deficiencies in adults with TMD,
include difficulty eating and swallowing, weight loss, and poor diet. Unintentional
weight loss of greater than 10% in 6 months or less reflects a risk for malnutrition. Pa-
tients with TMD who experience weight loss should be probed for reasons behind the
weight loss to determine if it is due to an inadequate diet or a systemic condition. Re-
ferrals to a RDN for a comprehensive nutrition assessment and medical nutrition ther-
apy are warranted; if a systemic condition is suspected, the patient should also be
referred to their primary care provider.
Adults with TMD may risk micronutrient deficiencies due to maladaptive eating be-
haviors and nutritionally inadequate diets. The research in this area is dated,28 limited
to single institutions in a country,29,30, and heterogeneous. In a sample of patients with
TMD in Texas, USA, who had implant surgery, Mehra and Wolford28 found that one-
third or more of the patients had micronutrient deficiencies evidenced by low serum
levels of iron, beta-carotene, vitamins B1, B6, B12, C, ferritin and folate, and clinically
apparent glossitis, cheilosis, hair loss, and anemia. Almost a decade later, in Saudi
Arabia, Ahmed and colleagues examined adults with TMD for clinical and biochemical
signs of micronutrient deficiencies and also found that one-third or more had low
serum values for vitamins D and C, iron, and “B-complex” with clinical symptoms
similar to Mehra and Wolford.30 In contrast, a more recent study by Staniszewski
and colleagues29 found no evidence of micronutrient deficiencies based on biochem-
ical assays in a population of adults with TMD in Norway. The limitations of and poten-
tial for heterogeneity among studies is beyond the scope of this article; however,
because patients with TMD often take dietary supplements, it could be that while
they are missing the food sources of these nutrients in their diets, they are getting
them through supplements. Although dietary supplements may provide micronutrients

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 Joint Disorders and the Eating Experience 371

essential for health, they do not provide the other properties found in the foods such as
fruits, vegetables, and whole grains, which are also essential for health.

Diet and Nutrition Risk Evaluation and Management of Patients with

Temporomandibular Joint Disorder
Before any dietary guidance can be provided to patients, it is essential to assess each
individual in regard to the symptom burdens they are experiencing related to diet, their
ERQOL, weight and weight history, current dietary patterns, and how their TMD symp-
toms affect when, what, where, and how they eat. Responses will provide insight into
adaptive and maladaptive behaviors and the extent of the impact of the TMD on their
nutrition status. Table 131 provides a sample interview guide that any clinician can use
to assess TMD symptoms in relation to their diet and ERQOL. Asking such questions
early in the patient evaluation process can help identify patients needing referrals to
other health professionals. The medical and dental history and list of patient medica-
tions are also important to fully assess patient risks and intervention needs. The use of
dietary supplements should be carefully evaluated relative to medications the patient
is taking to determine any possible medication–nutrient interactions. Although more
than 50% of US adults use dietary supplements, there is a paucity of scientifically
sound evidence of any benefits from specific dietary supplements for TMD.
Questions about whether patients fear that eating will cause pain and how they have
modified their food and fluid consumption can provide insight into positive adaptive
and maladaptive behaviors. Responses to questions about weight change, problems
with constipation, bloating, and avoidance of major food groups or fad diets can be
used to determine if the patient needs to be referred to an RDN for medical nutrition
therapy. Some patient symptoms may be related to self-imposed diet changes. A
diet low in fiber due to avoidance of whole grains, fruits, and vegetables can contribute
to constipation and bloating and place the patient at risk for micronutrient deficiencies.
Although oral health-care professionals can provide tailored guidance on a diet for
TMD, patients with unintentional weight gain or loss, poor appetite, constipation, or
bloating related to their TMD, maladaptive dietary behaviors, or who are avoiding
many foods and food groups because of their TMD should be referred to an RDN
for a comprehensive nutrition assessment and individualized medical nutrition ther-
apy. Patients with symptoms of dysphagia or who complain of swallowing difficulties
should be referred to a speech and language pathologist for evaluation.

Diet Modifications for Temporomandibular Joint Disorder

With the lack of consensus on dietary management for TMD, patients may eliminate
whole food groups such as whole grains, fruits, and vegetables because of difficulty
or pain with biting, chewing, or swallowing. Clinicians similarly lack the resources to
guide patients on an approach to eating with TMD. Vitamin D supplements and a
gluten-free diet have been proposed as adjunctive treatment strategies.19,20 Although
it is beyond the scope of this article to discuss the theories behind the potential asso-
ciation between TMD and either a gluten-free diet or additional vitamin D, there’s a
dearth of scientifically sound evidence to support either association.
A soft diet is commonly recommended for individuals with TMD.21,32,33 The term it-
self is open to wide interpretation by clinicians and consumers. Soft breads and rolls
require a more significant masticatory effort than popcorn, broken thin pretzel sticks,
and whole grains such as brown rice, wheat berries, or couscous. Chopped tomato
and other chopped or minced vegetable salads are more appealing, contain more nu-
trients than boiled and pureed vegetables, and may actually require less masticatory
effort than a soft diet. A soft diet can lead to reductions in fruit, vegetable, and whole

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372 Nasri-Heir & Touger-Decker

Table 1
Diet and nutrition risk for temporomandibular joint disorder interview guide for clinicians

Question Recommended Actions for YES Responses

Have you altered what you eat and drink Probe by asking:
because of your TMD? Please describe what you have changed in
your food and drink choices and the
duration of these changes
This will help the provider tailor future
advice
Do you now avoid eating or drinking
anything in particular because of your
TMD? If yes, what?
Are there favorite foods or beverages you
are now avoiding because of your TMD?
Would you want to add these foods back if
there were ways to do so that would not
cause pain?
A positive response reflects a patient’s
willingness to develop adaptive
behaviors
Is it difficult or painful to open your mouth, Please tell me what is painful and what is
bite, chew, or swallow? difficult
Peeling, cutting, and chopping food can
make eating easier and less painful
Limiting sticky foods such as peanut or
almond butter can help to avoid painful
eating
Are you avoiding any specific food groups Fruits and vegetables: peel fruits and
such as fresh fruits, and vegetables, whole vegetables with skin and chop, mince, or
grain bread, nuts, and others because of mash. If needed, cooking vegetables such
TMD? as squash, carrots, broccoli, and
cauliflower until tender before cutting
may also help to reduce painful eating
Toasting and slicing whole grain bread into
thin slices may make them easier to eat
than soft white bread
Break thin pretzel sticks and other thin
crackers into small pieces to reduce the
need to open the mouth wide and
minimize biting and chewing
Chop nuts finely and add to hot cereals,
yogurt, or puddings
Make chopped fruit or vegetable salads
Use your knife and fork as your “teeth” to cut
foods into small pieces to minimize biting
and chewing needed
Make a smoothie
Are you avoiding going out for meals or If yes:
eating with others because of your TMD? What specifically do you avoid?
Try restaurants where foods may be served
cut, chopped, or pureed such as Asian,
Middle Eastern, or Indian restaurants,
those specializing in soups or places you
can ask to have your food specially
ordered

(continued on next page)

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 Joint Disorders and the Eating Experience 373

Table 1
(continued )
Question Recommended Actions for YES Responses
How has your weight changed? If unsure tell If unintentional weight loss is revealed:
me if your waistlines feel tight or loose encourage the patient to see their
(hint 10 lbs 5 1 clothing size) physician and a registered dietitian
nutritionist for medical nutrition therapy
If unintentional weight gain is revealed:
suggest that they may want to seek the
counseling of a registered dietitian
nutritionist for medical nutrition therapy
to avoid unintentional weight gain and
improve diet quality
Are you taking any vitamin, mineral, herbal, If yes, probe by asking:
or other dietary supplements? What do you take, how often, how much
and why? Probe further by asking if the
supplement does what they thought it
would do.
Decision support tools and databases such
as Lexicomp and Natural Medicines
Database can be used to evaluate risks of
interactions, side effects and potential
benefits
Are you following or have you tried any Probe to find out what diet, rationale for
special diet because of your TMD? following it and whether they think it is
working
Do you ever experience constipation? If yes:
Is this new since you were diagnosed with
TMD?
Do you think it is due to your changes in
diet?
How are you managing it?
Do you ever experience bloating before, If yes:
during, or after a meal? What do you think is causing it? (Probe to
determine if its related to their diet or
constipation)
Does it take you the same, more, or less time If yes:
to eat a meal or snack since you were Probe to understand why.
diagnosed with TMD?

Adapted from: Nasri-Heir C, Epstein JB, Touger-Decker R, Benoliel R. What should we tell patients
with painful temporomandibular disorders about what to eat? Journal of the American Dental As-
sociation. 2016;147(8):667-71.

grain intake and a resultant drop in dietary fiber and micronutrient intake. The goal of
dietary guidance for individuals with TMD should be to mechanically alter the food
forms to accommodate patients’ limited mandibular opening and minimize the amount
of biting and chewing needed.31,33 “Clinicians can advise patients to use their knives
and forks as they might their teeth, consciously cutting foods into small pieces, as well
as provide recommendations on how to modify food selections to reduce mandibular
workload and minimize jaw pain.”31 The goal of dietary guidance is to maximize diet
quality and ERQOL and avoid or limit painful eating.
Table 231 provides recommendations to share with patients to help them modify
their diet and maximize nutrient intake while reducing the mandibular workload.

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374 Nasri-Heir & Touger-Decker

Table 2
Guide to food choices and preparation hints for individuals with temporomandibular joint
disorder

Overall Principles
 Cut all foods well
 Use gravies or sauces to moisten foods to a comfortable consistency
 Peel and chop fruits and vegetables with skins (except for berries)
 Chop whole foods to consistencies that are comfortable to eat
 Take small bites of food
 Choose foods from all food groups for healthy food choices
 Leave sufficient time to eat
 Peel, chop, shred and mince foods to a consistency that is easy to eat
 Use sauces, gravies, natural vegetable and fruit juices, and broths to moisten foods and add
flavor
 At the table, use a knife and fork to cut food as needed

Food Group Food Options and Preparation Hints

Fruits Peel all fruits with hard/chewy skin: such as apples, peaches, plums,
pears
Chop: whole (peeled) fruits
Use a blender to turn fruits into smoothies or sauces
Make smoothies with any peeled fruits in a blender, adding dairy
or nondairy milks or yogurts
Vegetables Greens such as spinach, chard, kale, collards: wash, steam, or cook for
2–3 min and chop fine into ribbon-like thickness
Tomatoes: chop
Cucumbers: peel and chop fine
Root vegetables like carrots, parsnips, beets: Peel and either shred
or chop/mince fine (if chopped, cook after chopping)
Other vegetables: cook until tender, chop
Potatoes (white or sweet): cook, chop, or mash
Make smoothies or juices with vegetables in a blender
Chop vegetables and mix with water or broth and cook to make
soups
Legumes, seeds, Legumes should be cooked, and those larger than a pea should
and nuts be mashed or pureed
Chop nuts or use nut or seed butters
Animal and other Poultry/meats: Cook until tender, moisten with broth, gravies, or
protein foods other sauces and cut into bite-size pieces
Fish: cook and cut into bite-size pieces or shred, soften with sauces
as desired, or chop and mix into a fish salad
Tofu, tempeh—Chop to bite-size pieces; tempeh may need
moistening
Dairy/lactose free All milk products, yogurts, and cheeses as tolerated
dairy alternatives
Bread, cereals, Hot or cold cereals (hint: soften cereal in milk)
grains Couscous, quinoa, farro, rice, and other cooked grains
Orzo and other small pasta cooked until tender
Thinly slice whole grain bread and rolls, toast, and cut into small
pieces
Thin crackers broken into small pieces

Note: The extent to which foods may be cut, chopped, minced, or pureed varies based on what you
can do comfortably. The guidelines are intended to help you select healthful and preferred foods
and enjoy eating whether at home or out of the home.
Adapted from: Nasri-Heir C, Epstein JB, Touger-Decker R, Benoliel R. What should we tell patients
with painful temporomandibular disorders about what to eat? Journal of the American Dental As-
sociation. 2016;147(8):667-71.

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 Joint Disorders and the Eating Experience 375

Patient-centered care is essential to maximize nutritional well-being; dietary guidance

by oral health professionals should be individualized to each patient’s functional lim-
itations and challenges with the eating experience. The primary goals should be to
encourage positive adaptive behaviors, help the patient eat comfortably, and reduce
the symptom burden experienced by the patient. Working toward these goals can also
reduce the risk of unintentional weight gain or loss and micronutrient deficiencies and
address some of the systemic symptoms of TMD such as bloating and constipation.
Targeting recommendations to address each patient’s functional limitations due to
their TMD can help improve their appetite and functional ability to eat and ERQOL.
Diet quality and adequacy can also be achieved if the patient can be helped to adapt
their diet to eat comfortably. The guidelines and tips in Table 2 can be applied to pa-
tients’ socioeconomic circumstances and cultural or religious preferences.

SUMMARY

Management of adults with TMD requires an interprofessional approach. Clinicians

need to be aware of and sensitive to the impact of the TMD on patients’ eating ability,
eating experience, ERQOL, and appetite. Oral health professionals can collaborate
with RDNs and other health professionals to improve patient outcomes. Many of the
symptoms of TMD affect an individual’s mandibular opening and ability to bite,
chew, and swallow food. Careful attention to the patient’s symptoms relative to eating
ability, guidance on modifying the diet with positive adaptive behaviors, and referrals
to an RDN may help patients maintain a healthy diet and reduce weight loss and mal-
adaptive eating behaviors. Further research is required to develop evidence-based
guidelines for the diet management of patients with TMD.

CLINICS CARE POINTS

 Determine if and how TMD has affected patients’ abilities to open their mouths, bite, chew,
and swallow.
 Ask patients about how the condition of their mouth has altered their ability to eat,
appetite, ERQOL, and diet quality.
 Provide positive adaptive suggestions based on patients’ diet and avoid instructing patients
to follow a “soft diet.”
 Screen patients for weight loss and maladaptive eating behaviors.
 Provide dietary guidance individualized to the patient’s symptoms and lifestyle.
 Refer patients with weight loss, decreased appetite, or difficulty meeting their nutrient
needs to an RDN.

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

1. FDI World Dental Federation. FDI’s definition of oral health. Available at: http://
www.fdiworlddental.org/fdis-definition-oral-health. Accessed August 8th 2022.
2. American Academy of Orofacial Pain (AAOP). Differential Diagnosis and Man-
agement of TMDs. In: Leeuw Rd, Klasser GD, editors. Orofacial pain : guidelines

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

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376 Nasri-Heir & Touger-Decker

for assessment, diagnosis, and management. 6th edition. Hanover Park, IL: Quin-
tessence Publishing Co, Inc.; 2018. p. 143–60.
3. Slade GD, Fillingim RB, Sanders AE, et al. Summary of findings from the OPPERA
prospective cohort study of incidence of first-onset temporomandibular disorder:
implications and future directions. J Pain Dec 2013;14(12 Suppl):T116–24.
4. Palmer J, Durham J. Temporomandibular disorders. BJA education 2021;21(2):
44–50.
5. Greene CS. Managing the care of patients with temporomandibular disorders: a
new guideline for care. J Am Dental Assoc (1939) 2010;141(9):1086–8.
6. Nitzan D, Heir GM, Dolwick F, et al. Pain and dysfunction of the temporomandib-
ular joint. In: Sharav Y, Benoliel R, editors. Orofacial Pain and Headache. 2nd edi-
tion. Batavia, IL: Quintessence Publishing Co, Inc; 2015. p. 257–318.
7. List T, Dworkin SF. Comparing TMD diagnoses and clinical findings at Swedish
and US TMD centers using research diagnostic criteria for temporomandibular
disorders. Journal of Orofacial Pain 1996;10(3):240–53.
8. List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts.
Cephalalgia : Int J Headache Jun 2017;37(7):692–704.
9. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporoman-
dibular Disorders (DC/TMD) for Clinical and Research Applications: recommen-
dations of the International RDC/TMD Consortium Network* and Orofacial Pain
Special Interest Group. J Oral Facial Pain Headache 2014;28(1):6–27.
10. Ohrbach R, Greene C. Temporomandibular Disorders: Priorities for Research and
Care. J Dental Res Jul 2022;101(7):742–3.
11. Edwards DC, Bowes CC, Penlington C, et al. Temporomandibular disorders and
dietary changes: A cross-sectional survey. J Oral Rehabil Aug 2021;48(8):873–9.
12. Ferreira CLP, Sforza C, Rusconi FME, et al. Masticatory behaviour and chewing
difficulties in young adults with temporomandibular disorders. J Oral Rehabil
Jun 2019;46(6):533–40.
13. Ferreira MC, Porto de Toledo I, Dutra KL, et al. Association between chewing dys-
functions and temporomandibular disorders: A systematic review. J Oral Rehabil
Oct 2018;45(10):819–35.
14. Safour W, Hovey R. A phenomenologic study about the dietary habits and diges-
tive complications for people living with temporomandibular joint disorder. J Oral
Facial Pain Headache 2019;3(4):377–88.
15. Gilheaney Ó, Béchet S, Kerr P, et al. The prevalence of oral stage dysphagia in
adults presenting with temporomandibular disorders: a systematic review and
meta-analysis. Acta odontologica Scand 2018;76(6):448–58.
16. Gilheaney Ó, Stassen LF, Walshe M. Prevalence, Nature, and Management of
Oral Stage Dysphagia in Adults With Temporomandibular Joint Disorders: Find-
ings From an Irish Cohort. J Oral Maxill Surg 2018;76(8):1665–76.
17. Marim GC, Machado BCZ, Trawitzki LVV, et al. Tongue strength, masticatory and
swallowing dysfunction in patients with chronic temporomandibular disorder.
Physiol Behav Oct 15 2019;210:112616.
18. Rosa RR, Bueno M, Migliorucci RR, et al. Tongue function and swallowing in in-
dividuals with temporomandibular disorders. J Appl Oral Sci : revista FOB
2020;28:e20190355.
19. Kui A, Buduru S, Labunet A, et al. Vitamin D and Temporomandibular Disorders:
What Do We Know So Far? Nutrients 2021;13(4).
20. Araújo Oliveira Buosi J, Abreu Nogueira SM, Sousa MP, et al. Gluten-Free Diet
Reduces Pain in Women with Myofascial Pain in Masticatory Muscles: A

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

ClinicalKey.es por Elsevier en mayo 01, 2025. Para uso personal exclusivamente. No se permiten
otros usos sin autorización. Copyright ©2025. Elsevier Inc. Todos los derechos reservados.
 Joint Disorders and the Eating Experience 377

Preliminary Randomized Controlled Trial. J Oral Facial Pain Headache 2021;

35(3):199–207.
21. National academies of sciences engineering, medicine. Temporomandibular dis-
orders: priorities for research and care. Washington, DC: The National Acade-
mies Press; 2020.
22. Dionne RA. Pharmacologic treatments for temporomandibular disorders. Oral
Surgery,Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 1997;
83(1):134–42.
23. Haviv Y, Rettman A, Aframian D, et al. Myofascial pain: an open study on the
pharmacotherapeutic response to stepped treatment with tricyclic antidepres-
sants and gabapentin. J Oral Facial Pain Headache 2015;29(2):144–51.
24. Lexicomp. Available at: https://online.lexi.com/lco/action/home. Accessed
August 8, 2022 through Rutgers University Library.
25. Scheiman JM. NSAID-induced Gastrointestinal Injury: A Focused Update for Cli-
nicians. J Clin Gastroenterol 2016;50(1):5–10.
26. Wieseke A, Bantz D, Siktberg L, et al. Assessment and early diagnosis of
dysphagia. Geriatr Nurs (New York, N.Y.) 2008;29(6):376–83.
27. Gapstur RL. Symptom burden: a concept analysis and implications for oncology
nurses. Oncol Nurs Forum 2007;34(3):673–80.
28. Mehra P, Wolford LM. Serum nutrient deficiencies in the patient with complex
temporomandibular joint problems. Proceedings (Baylor University. Medical Cen-
ter) 2008;21(3):243–7.
29. Staniszewski K, Lygre H, Berge T, et al. Serum Analysis in Patients with Tempo-
romandibular Disorders: A Controlled Cross-Sectional Study in Norway. Pain
Res Manag 2019;2019:1360725.
30. Ahmed S, Tabassum N, Al Dayel O, et al. Nutritional assessment in temporoman-
dibular disease: Creating awareness on sytemic impact of temporomandibular
disorder in Saudi population. J Int Health 2016;8(11):1023–5.
31. Nasri-Heir C, Epstein JB, Touger-Decker R, et al. What should we tell patients with
painful temporomandibular disorders about what to eat? J Am Dental Assoc
(1939) 2016;147(8):667–71.
32. The TMJ Association. What and How You Eat Matters. Available at: https://tmj.org/
living-with-tmj/self-care/. Accessed August 8th, 2022.
33. Durham J, Touger-Decker R, Nixdorf DR, et al. Oro-facial pain and nutrition: a
forgotten relationship? J Oral Rehabil 2015;42(1):75–80.

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