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PATHOLOGY PERSPECTIVES And at the jaw itself, we have some choices. The masseter and temporalis muscles are obvious and easy to work with, and they have a lot of influence on the health of the joint. The pterygoid muscles require more specialized skill, but they are also palpable (at the back of the inside of the cheek) without the thick layers of skin, fat, and fascia that cover most muscles. Work inside the mouth carries some serious responsibilities. Hygienically, of course, we use clean, hypoallergenic gloves to work in this location. But it is important to mention a few other points about intraoral massage: • It's not for beginners, and it's not for dabbling. When things go wrong in this joint, problems can reverberate through the whole body. Let's not accidentally contribute to dysfunction by being careless and undereducated. Are you interested in intraoral work? Get advanced training. • Local laws about massage therapy and intraoral work vary. Some states don't address it at all. Others require a doctor's prescription. Others require signed client consent. And some don't allow massage therapists to do intraoral work without documentation of a minimum standard of advanced training. Find out what your local laws allow, and be compliant. • Intraoral massage may trigger unintended responses. A gag reflex is common and annoying, but emotional release in response to work in and around the mouth is also a strong possibility. It is critical that massage therapists be mindful of their scope of practice and respectful of their clients' processes if this happens. Massage therapists must be prepared to be present, nonjudgmental, and appropriately supportive for this kind of event. Once again, it's not for dabblers. If you want to do this work, get appropriate training. • Intraoral work is the only place where we work inside the body. The rules here are different. The quality of the epithelium is different. The amount of tissue between our fingers and the targeted structures is different. And innervation is different: sensory supply inside the mouth is greater than in other parts of the body. A little touch here goes a long way, and a short session is likely to be more effective than a longer one. This article barely scratches the surface of what we can understand about the TMJ, the way its status affects the whole body, and how massage therapy might be used in this context. You could say that in taking on this topic, I bit off more than I could chew (ha ha). Interested readers can find some more specific suggestions for bodywork in two fine Massage & Bodywork articles: "Working with the Masseter" by Til Luchau (September/October 2013, page 114) and "Clicking Jaw Syndrome" by Erik Dalton ( January/February 2015, page 99). Resources Chisnoiu, A. et al. "Factors Involved in the Etiology of Temporomandibular Disorders—A Literature Review." Clujul Medical 88, no. 4 (2015): 473–78. cjmed-485. Grootel, Robert J. van et al. "Towards an Optimal Therapy Strategy for Myogenous TMD, Physiotherapy Compared with Occlusal Splint Therapy in an RCT with Therapy-and-Patient- Specific Treatment Durations." BMC Musculoskeletal Disorders 18 (February 10, 2017). "Maximal Bite Force and Its Association with Temporomandibular Disorders." Accessed November 2018. 64402007000100014&lng=en&nrm=iso&tlng=en. Morell, Gaston Coutsiers. "Manual Therapy Improved Signs and Symptoms of Temporomandibular Disorders." Evidence-Based Dentistry 17, no. 1 (March 2016): 25–6. National Institute of Dental and Craniofacial Research. "Prevalence of TMJD and Its Signs and Symptoms." Accessed November 2018. pain/prevalence. Scrivani, Steven. "Temporomandibular Disorders in Adults." UpToDate. Accessed November 2018. Scientific American. "The Power of the Human Jaw." Accessed November 2018. Wroe, Stephen et al. "The Craniomandibular Mechanics of Being Human." Proceedings of the Royal Society of London B: Biological Sciences 277, no. 1700 (December 7, 2010): 3,579–86. We have important skills to offer our clients with TMJ disorders, if we are skillful, professional, well trained, and mindful of the power of our work. What are you waiting for? Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, (available at, now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner. com or Yo u r M & B i s w o r t h 2 C E s ! G o t o w w w. a b m p . c o m / c e t o l e a r n m o r e . 39

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