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Impact of Postural Correction and Self-Care in Sleep on TMD Patients: A Clinical TrialAbstract
Objective
To evaluate the effects of posture during sleep on otological symptoms (such as tinnitus and ear fullness), psychological factors, bruxism, and sleep disorders in patients with temporomandibular disorders (TMD) undergoing an educational intervention based on self-care methods: Prospective single-arm clinical trial with 36 participants diagnosed with joint TMD and self-reported otological symptoms. Patients were stratified into three groups based on self-reported sleep posture: “Never Had the Habit” (without mandibular support), “Kept the Habit” (with mandibular support), and “Quit the Habit” (with mandibular support, but quit). The intervention consisted of an initial 90-minute session and two 40-minute reinforcement sessions, focusing on sleep hygiene, self-management strategies for bruxism, and management of psychological factors. Data was collected at four time points: baseline (T0), 30 days (T1), 60 days (T2), and 180 days (T3). Statistical analysis used a repeated-measures ANOVA with the Greenhouse-Geisser correction and post hoc comparisons with Bonferroni. Effect sizes were calculated using partial eta-square (η²p).
Results
Baseline characteristics showed high prevalence of otological symptoms (> 70%), bruxism (61.1%), sleep disorders (66.7%), and psychological distress (77.8%). There was a significant reduction in tinnitus intensity over time (F (3, 99) = 56.2; p < 0.001; η²p = 0.61). The time × postural group interaction was significant (F (6, 99) = 12.3; p < 0.001; η²p = 0.31). The “Quit the Habit” group showed a 58.1% reduction in tinnitus, whereas the “Kept the Habit” group showed a 40.5% reduction (difference at T3: 1.08 points; p = 0.003). Otological symptoms improved in all groups, with significant main effects for ear fullness (F = 6.3; p = 0.015; η²p = 0.18). Psychological factors, such as anxiety, and sleep disorders, such as insomnia, decreased, with a positive correlation with postural habit abandonment (p < 0.05). Nocturnal bruxism was more prevalent in the group that kept the habit (63.6%).
Conclusion
Posture during sleep significantly influences otological symptoms, psychological factors, bruxism, and sleep disorders in patients with TMD. Discontinuation of ipsilateral mandibular support was associated with greater symptom relief. The self-care-based educational program showed significant clinical improvement in overall symptoms and should be integrated into conservative TMD management strategies. Self-care here refers to patient-empowered strategies including sleep hygiene education, bruxism management, and psychological coping techniques.
Keywords:
Temporomandibular disorder
Otological symptoms
Sleep posture
Psychological factors
Bruxism
Sleep disorders
Self-care
Clinical trial
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Introduction
Temporomandibular disorder (TMD) is a heterogeneous group of musculoskeletal conditions that affect the temporomandibular joint (TMJ), masticatory muscles, and associated structures, with a prevalence of 5% to 12% in the adult population, significantly impacting quality of life through otological symptoms, psychosocial factors, and sleep disorders1,2. The multifactorial etiology of TMD integrates biomechanical, psychosocial (such as stress and anxiety), and behavioral factors, which modulate the perception of symptoms such as tinnitus and ear fullness3,4.
A common clinical manifestation of TMD is the coexistence with otological symptoms, such as tinnitus and ear fullness, reported in up to 85% of patients, a rate significantly higher than in the general population5,6. The development of rapid screening tools, such as the Brief Tinnitus Scale (EBZ), has facilitated early identification of these symptoms in mass care settings7. Meta-analyses confirm this association, with odds ratios ranging from 2.8 to 4.2, suggesting pathophysiological connections via shared trigeminal innervation and anatomical proximity8,9.
Recently, the interrelationship between TMD and sleep disorders has gained prominence: insomnia, obstructive sleep apnea (OSA), and poor sleep quality are bidirectionally associated with the exacerbation of otological symptoms, creating a vicious cycle10,11. Nocturnal parafunctional behaviors, such as bruxism, and poor sleep postures overload the TMJ12,13. Recent studies on pain persistence after TMJ replacement surgeries highlight the importance of conservative approaches in the initial management of TMD14.
Biomechanical hypotheses, supported by finite element studies, suggest that mandibular support during sleep generates asymmetric compressive forces, promoting joint instability and otological symptoms15,16. Psychosocial factors, such as anxiety and depression, amplify the perception of tinnitus and contribute to the chronicity of symptoms, influencing central somatosensory pathways17. Counseling and self-care strategies that empower patients are pillars of TMD treatment and align with the biopsychosocial model18. This study investigates the causal relationship between sleep posture and otological symptomatology in TMD, evaluating the efficacy of an educational intervention focused on counseling and self-care. We hypothesized that discontinuation of ipsilateral mandibular support during sleep, as part of a self-care educational intervention, would lead to greater reductions in otological symptoms, psychological distress, bruxism, and sleep disturbances compared to maintaining or never having the habit.
The primary objective of this study was to evaluate the impact of an educational self-care intervention, with emphasis on postural correction during sleep, on tinnitus intensity and ear fullness in patients with TMD. Secondary objectives included assessment of changes in psychological factors, bruxism, and sleep quality.
Methods
Study Design and Ethical Considerations
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Prospective single-arm clinical trial conducted between November 2022 and October 2024, following CONSORT guidelines19 and the Declaration of Helsinki. A
Approved by the Research Ethics Committee of Estacio de Sá University (CAAE: 6523952.5.0000.5284) and registered in ReBEC (UTN: 1111-1321-1503). A
All participants provided informed consent.Figure 1. CONSORT flow diagram
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The sample size was calculated to detect a minimum clinically relevant difference of 2.0 points on otological symptom scales, with 80% power and α = 0.05, accounting for a 10–20% loss rate, resulting in 36 participants. Of the 44 evaluated, four were excluded (1 under 18 years of age; 3 with a history of invasive TMJ interventions). Thus, 40 were recruited. With 10% (n = 4) lost to subjective improvement, the final analysis included 36 participants. All participants were diagnosed with joint TMD per Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)20, with 55% at early stages (e.g., disc displacement with reduction) and 45% at advanced stages (e.g., degenerative joint disease). Exclusion criteria included current use of antidepressants, melatonin, or other sleep-affecting medications within 30 days prior to enrollment, to minimize confounding effects on psychological and sleep outcomes. Participants were stratified post-inclusion into three groups based on self-reported sleep posture: “Never Had the Habit” (n = 23), “Kept the Habit” (n = 6), and “Quit the Habit” (n = 7).Educational Intervention
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Based on the biopsychosocial model and the guidelines of van der Meer et al.18, the intervention included one initial 90-minute session and two 40-minute booster sessions. The protocol comprised: (1) neurophysiology of otological symptoms and TMD; (2) sleep hygiene, focusing on correction of compressive postures; (3) strategies for bruxism management; and (4) behavioral modifications for psychological factors, integrating self-care strategies. Stress management included cognitive-behavioral techniques such as mindfulness exercises and progressive muscle relaxation, taught via guided sessions and home practice sheets. Sleep posture training involved demonstrations of neutral sleeping positions (e.g., supine or side-lying without hand support), with visual aids and follow-up checks for compliance. Adherence was tracked via session attendance logs (100% for initial session, 92% for boosters) and self-reported compliance diaries for postural changes and self-care practices, which indicated a 50% success rate in abandoning the mandibular support habit.Outcomes and Instruments
Evaluations were performed by trained examiners, with inter-rater reliability (ICC > 0.85) for clinical assessments (e.g., bruxism signs) and questionnaire scoring at T0, T1, T2, and T3. Primary outcomes: (i) tinnitus intensity and ear fullness (scale 0–10); (ii) psychological factors (anxiety/depression via standardized questionnaires). Psychological factors (anxiety and depression) were assessed using the Generalized Anxiety Disorder-7 (GAD-7)21 and Patient Health Questionnaire-9 (PHQ-9)22 scales, with scores ≥ 10 indicating high levels. Secondary outcomes: (iii) bruxism (self-report and clinical signs); (iv) sleep disorders (insomnia/OSA via Pittsburgh Sleep Quality Index - PSQI23); (v) functional impairment (Mandibular Function Impairment Questionnaire - MFIQ, adapted for otological symptoms).
Statistical Analysis
Analysis was performed with Jamovi (v. 2.3.28)24, α = 0.05. Normality was assessed using the Shapiro-Wilk test; baseline comparability was assessed using a one-way ANOVA; and the Chi-square test was used to assess differences in proportions. Effects were tested with a repeated-measures ANOVA (time as within-subjects; postural group as between-subjects), with a Greenhouse-Geisser correction when sphericity was violated (Mauchly’s p < 0.05). Post-hoc tests used Bonferroni correction. ANCOVA adjusted for covariates (age, baseline psychological factors). Sensitivity analysis compared “Kept the Habit” vs. “Quit the Habit.” Non-parametric tests (Friedman, Wilcoxon, Kruskal-Wallis) were used if necessary. Effect sizes were reported as η²p (small = 0.01; moderate = 0.06; large ≥ 0.14).
Results
Sample Characteristics and Baseline Comparability
Thirty-six patients (mean age: 52.80 ± 9.00 years; 77.8% female), with 100% retention. At T0, 33.3% (n = 12) reported the habit of sleeping with the hand supporting the ipsilateral side of the face, which decreased to 16.7% (n = 6) at T3 (p = 0.029), indicating a 50% success rate in postural modification. Baseline prevalence: tinnitus in 76%; ear fullness in 74.8%; bruxism in 61.1%; sleep disorders in 66.7%; psychological factors were high in 77.8%. Subgroup analysis showed no significant differences in outcomes by stage (p > 0.05). Baseline comparability testing showed no significant differences between groups for age (F = 0.02; p = 0.98), sex distribution (χ²=0.54; p = 0.76), tinnitus intensity (F = 0.15; p = 0.86), ear fullness (F = 0.07; p = 0.93), anxiety scores (F = 0.21; p = 0.81), or insomnia scores (F = 0.34; p = 0.71), confirming homogeneity across groups at baseline. See Table 1 for demographic and clinical characteristics stratified by group.
Characteristic | Never Had (n = 23) | Kept (n = 6) | Quit (n = 7) |
|---|---|---|---|
Age (mean ± SD, years) | 52.5 ± 9.2 | 53.0 ± 8.5 | 53.1 ± 9.0 |
Female (%) | 78.3 | 83.3 | 71.4 |
Tinnitus prevalence (%) | 73.9 | 83.3 | 85.7 |
Ear fullness prevalence (%) | 73.9 | 83.3 | 71.4 |
Bruxism prevalence (%) | 56.5 | 83.3 | 57.1 |
Sleep disorders prevalence (%) | 65.2 | 83.3 | 57.1 |
High psychological factors (%) | 78.3 | 83.3 | 71.4 |
Medication use (none, %) | 100 | 100 | 100 |
Primary Outcomes
Significant reduction in tinnitus intensity over time (F (3, 99) = 56.2; p < 0.001; η²p = 0.61). The time × postural group interaction was significant (F (6, 99) = 12.3; p < 0.001; η²p = 0.31), indicating that the magnitude of tinnitus reduction differed significantly between postural groups. The “Quit the Habit” group showed a reduction of 58.1%; the “Kept the Habit” group showed a reduction of 40.5% (T3 difference: 1.08 points; p = 0.003). Ear fullness decreased (F = 6.3; p = 0.015; η²p = 0.18), with greater improvement in the “Quit the Habit” group. See Table 2 for longitudinal changes in primary and secondary outcomes.
Outcome / Time | Never Had (n = 23) | Kept (n = 6) | Quit (n = 7) | Main Effect (F; p; η²p) | Interaction Time×Group (F; p; η²p) |
|---|---|---|---|---|---|
Tinnitus Intensity | F(3,99) = 56.2; p < 0.001; 0.61 | F(6,99) = 12.3; p < 0.001; 0.31 | |||
T0 | 5.2 ± 2.1 | 5.5 ± 2.0 | 5.4 ± 2.2 | ||
T1 | 4.0 ± 1.8 | 4.5 ± 1.9 | 3.8 ± 1.7 | ||
T2 | 3.0 ± 1.5 | 3.8 ± 1.6 | 2.8 ± 1.4 | ||
T3 | 2.5 ± 1.3 | 3.3 ± 1.4 | 2.3 ± 1.2 | ||
Ear Fullness | F(3,99) = 6.3; p = 0.015; 0.18 | NS (p > 0.05) | |||
T0 | 4.8 ± 1.9 | 5.0 ± 1.8 | 4.9 ± 2.0 | ||
T1 | 3.7 ± 1.6 | 4.2 ± 1.7 | 3.5 ± 1.5 | ||
T2 | 2.8 ± 1.4 | 3.5 ± 1.5 | 2.6 ± 1.3 | ||
T3 | 2.3 ± 1.2 | 3.0 ± 1.3 | 2.1 ± 1.1 | ||
Anxiety (GAD-7) | p < 0.01 (non-parametric) | NS (p > 0.05) | |||
T0 | 12.5 ± 4.2 | 13.0 ± 4.0 | 12.8 ± 4.3 | ||
T3 | 8.2 ± 3.1 | 9.5 ± 3.5 | 7.5 ± 2.8 | ||
Insomnia (PSQI) | p < 0.01 (non-parametric) | NS (p > 0.05) | |||
T0 | 10.3 ± 3.8 | 11.2 ± 4.1 | 10.5 ± 3.9 | ||
T3 | 6.5 ± 2.4 | 8.0 ± 3.0 | 5.8 ± 2.2 |
Otological symptoms improved in all groups, with no significant Time×Group interaction for Ear Fullness (p > 0.05), indicating similar improvement patterns across postural groups. The “Quit the Habit” group demonstrated superior tinnitus reduction (58.1%) compared to “Kept the Habit” (40.5%; difference at T3: 1.08 points; p = 0.003). Psychological factors (anxiety) decreased (p < 0.01), correlated with a reduction in sleep disturbances. Bruxism was more intense in the “Kept the Habit” group (p = 0.002) and was associated with poorer sleep quality.
Correlation Pair | Correlation Coefficient (r) | p-value |
|---|---|---|
Anxiety and sleep disturbances | 0.45 | < 0.01 |
Postural habit abandonment and tinnitus reduction | 0.32 | < 0.05 |
Postural habit abandonment and anxiety reduction | 0.38 | < 0.05 |
Bruxism intensity and sleep quality | -0.42 | 0.002 |
Discussion
This trial demonstrates that sleep posture is a relevant, modifiable factor in the management of otological symptoms in TMD. The 58.1% reduction in tinnitus in the “Quit the Habit” group supports the hypothesis of nocturnal mechanical overload perpetuating instability via the discomalleolar ligament25,26. These findings align with biomechanical models showing that asymmetric compressive forces affect ossicular mobility14. Our 58.1% tinnitus reduction in the ‘Quit the Habit’ group compares favorably to improvements reported in meta-analyses of conservative TMD therapies9, suggesting that targeted postural correction may enhance treatment outcomes. The overall improvement, even in the “Never Had the Habit” group, highlights the effectiveness of multidimensional counseling that addresses sleep hygiene, bruxism management, and psychological factors18. Inflammatory mediators (TNF-α, IL-1β, IL-6) and neuropeptides (CGRP, substance P) in synovial fluid suggest shared pathways between TMD and otological symptoms27,28.
Psychosocial factors amplify tinnitus via central sensitization17. Nocturnal bruxism and sleep disorders (OSA, insomnia) exacerbate symptoms, with a two-way causal relationship11,12. The absence of significant interaction with ear fullness indicates dependence on central trigeminal pathways9. Compared to other therapeutic modalities, the educational intervention aligns with conservative strategies emphasized in recent reviews14,18. The 50% adherence reflects behavioral challenges, requiring reinforcement18.
Limitations
The single-arm design, without a control group, limits our ability to isolate the intervention’s effects from natural symptom progression or placebo effects. The single-arm design limits causal attribution to posture alone, as the intervention addressed multiple factors. Partial adherence may underestimate the actual impact. A predominantly female sample (77.8%) reflects the known higher prevalence of TMD in women29 but may limit generalizability to male populations. The absence of polysomnography to objectively assess sleep disorders and nocturnal bruxism represents a key limitation, potentially missing confounding factors like sleep architecture disruptions. Additional limitations include potential self-report bias in symptom and adherence assessments, and the lack of objective measures (e.g., wearable sensors) for postural habits during sleep. The sample size (n = 36) and lack of stratification by TMD subclasses may limit generalizability; larger studies with subclass-specific analyses are recommended. Future studies should include neuroimaging to elucidate central sensitization10.
Clinical Implications
Postural correction should be part of counseling to enhance the reduction of otological symptoms18. Educational interventions based on self-care strategies show promise for improving symptom management in TMD patients.
Future Directions
Randomized trials isolating postural correction vs. placebo are needed. Polysomnography should be incorporated to evaluate interactions between sleep stages, bruxism, and otological symptoms11. Digital interventions for remote monitoring may enhance adherence to postural modifications18.
For refractory cases that do not respond to conservative self-care approaches, investigation of adjunctive therapies is warranted. Regenerative therapies such as platelet-rich plasma (PRP), which have demonstrated efficacy in various musculoskeletal conditions30, may warrant investigation as adjunctive treatments for refractory TMD when integrated with behavioral interventions. Similarly, exploration of cannabinoids for chronic orofacial pain management31 could complement self-care strategies in future trials, particularly for patients with severe or treatment-resistant symptoms.
Future studies should include larger samples with TMD subclassifications (e.g., myogenic vs. arthrogenic) to enhance generalizability and identify patient subgroups most likely to benefit from specific interventions.
Conclusion
Postural factors during sleep influence otological symptoms, psychological factors, bruxism, and sleep disturbances in TMD. Correction of ipsilateral mandibular support is associated with greater relief. An educational intervention focused on self-care showed promising improvements in symptoms, though controlled trials are needed to confirm its efficacy, reinforcing interdisciplinary approaches. Future research should explore regenerative therapies and rapid screening tools to optimize clinical management.
Ethical approval and consent
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This prospective single-arm clinical trial was conducted between November 2022 and October 2024, in accordance with the CONSORT guidelines and the Declaration of Helsinki. A
The study protocol was approved by the Research Ethics Committee of Estácio de Sá University (CAAE: 6523952.5.0000.5284), and the trial was registered in ReBEC (UTN: 1111-1321-1503). A
All participants provided written informed consent prior to inclusion in the study.Conflict of interest
The authors declare that there are no conflicts of interest (financial, academic, or personal) related to this manuscript.
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Funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. No author received scholarships or dedicated financial support for the conduct of this research.
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Author Contribution
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LBMN conceived and designed the study, collected and analyzed the data, wrote the main manuscript text, and prepared all tables and Figure 1 (CONSORT Flow Diagram). BCL supervised the study design, methodology, and data interpretation. RCMM and BLB assisted with data collection and patient recruitment. RG contributed to the methodological design and statistical analysis. LBMN and BCL reviewed and edited the manuscript. All authors reviewed and approved the final manuscript.A
Data Availability
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
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Acknowledgement
We thank the Department of Orofacial Pain and Temporomandibular Disorders at Santa Casa da Misericórdia Hospital da Misericórdia, Rio de Janeiro, for their institutional support. We also extend our sincere gratitude to the patients and clinical staff who participated in and facilitated this study.
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