From the Guidelines
For TMJ disorder pain in the Emergency Department, the most effective first-line treatment is NSAIDs, such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg initially followed by 250mg every 6-8 hours, as recommended by recent guidelines 1. The goal of treatment is to reduce inflammation, relieve pain, and improve function, thereby minimizing morbidity, mortality, and enhancing quality of life. Key interventions include:
- NSAIDs to reduce inflammation and pain
- Muscle relaxants like cyclobenzaprine 5-10mg every 8 hours for muscle spasm
- Applying moist heat or ice packs to the affected area for 10-20 minutes several times daily
- Advising patients to eat soft foods, avoid wide mouth opening, and discontinue habits like gum chewing or nail biting
- Considering a short course of oral corticosteroids like prednisone 40mg daily for 3-5 days for severe inflammation, as suggested by the Royal College of Dental Surgeons of Ontario guideline 1 It is crucial to avoid opioids due to the risk of dependence and limited evidence for efficacy in treating TMJ disorder pain, as emphasized by various guidelines 1. These interventions are aimed at reducing inflammation in the joint space, relaxing the masticatory muscles, and decreasing overall strain on the temporomandibular joint, ultimately improving patient outcomes. Patients should be referred for outpatient follow-up with a dentist or oral surgeon for comprehensive management, including potential consideration of other therapies such as physiotherapy, acupuncture, or splint therapy, as recommended by the Korea Standard CPG Development Agency and American Association of Oral and Maxillofacial Surgeons guidelines 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals [see WARNINGS] After observing the response to initial therapy with ibuprofen tablets, the dose and frequency should be adjusted to suit an individual patient's needs. Do not exceed 3200 mg total daily dose. If gastrointestinal complaints occur, administer ibuprofen tablets with meals or milk Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.
For temporomandibular joint (TMJ) disorder pain in the Emergency Department (ED), ibuprofen (PO) can be given at a dose of 400 mg every 4 to 6 hours as necessary for relief of mild to moderate pain 2. It is essential to use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.
From the Research
Temporomandibular Joint Disorder Pain Management in the Emergency Department
Temporomandibular joint disorder is defined by pain and/or loss of function of the temporomandibular joint and its associated muscles and structures. The following options can be considered for managing TMJ disorder pain in the Emergency Department:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) 3, 4, 5, 6
- Muscle relaxants 3, 4, 5
- Benzodiazepines 3, 4, 5
- Antidepressants 3, 4, 5
- Anticonvulsants 3, 5
- Corticosteroids 3, 5
- Botulinum toxin, platelet-rich plasma, hyaluronic acid, and prolotherapy with hypertonic glucose may also be considered as minimally invasive injections 3
Key Considerations
When managing TMJ disorder pain, it is essential to consider the potential adverse drug reactions and interactions associated with the use of these agents 5. The decision to select any of these agents depends on a full understanding of the drug's risks and benefits. It is also recommended to use the lowest effective dose of NSAIDs for the shortest possible time and to prescribe supplementary gastroprotective agents in patients with increased risk of gastrointestinal complications 6.
Diagnosis and Treatment
Diagnosis of TMJ disorders is most often based on history and physical examination, and diagnostic imaging may be beneficial when malocclusion or intra-articular abnormalities are suspected 4. Treatment is directed toward reducing pain and improving function, and many non-invasive therapies, such as self-care, physical therapy, and appliance therapy, are commonly used for the treatment of TMD 5.