What is used to treat Temporomandibular Joint (TMJ) disorder?

Treatment of Temporomandibular Joint (TMJ) Disorder

Conservative, reversible treatments should be pursued first for temporomandibular joint disorder (TMD), with a stepwise approach starting from the least invasive options before considering more invasive interventions. 1

First-Line Conservative Treatments

Non-Pharmacological Approaches

• Education and self-management strategies:

  • Jaw rest and avoiding wide mouth opening or aggravating activities
  • Soft diet implementation
  • Application of heat and/or cold to affected areas
  • Home exercises and stretching

• Physical therapies:

  • Supervised jaw exercises and stretching (with or without manual trigger point therapy) - provides important pain relief approximately 1.5× the minimally important difference 2
  • Therapist-assisted jaw mobilization - provides substantial pain reduction, approximately twice the minimally important difference 2
  • Manual trigger point therapy - provides substantial pain reduction 2
  • Supervised postural exercises - provides important pain relief 2

• Mind-body approaches:

  • Cognitive behavioral therapy (CBT) - provides important pain relief, approximately 1.5× the minimally important difference 2
  • CBT augmented with relaxation therapy or biofeedback - provides substantial pain reduction, approximately twice the minimally important difference 2

Pharmacological Approaches

• NSAIDs - conditionally recommended as part of initial therapy for active TMJ arthritis 2
  • Should be used for brief periods due to potential adverse effects (gastritis, bruising) 2
  • Provides pain relief but has limited efficacy unless inactive disease is achieved 2

Second-Line Treatments for Persistent Symptoms

Pharmacological Options

• Conventional synthetic DMARDs - strongly recommended for inadequate response to or intolerance of NSAIDs for active TMJ arthritis 2

  • Methotrexate is conditionally recommended as the preferred agent over leflunomide 2
  • Early use is encouraged due to TMJ being a high-risk joint with major impact on activities of daily living 2

• Other medications to consider:

  • Tricyclic antidepressants for persistent pain 1
  • Anticonvulsants for persistent pain 1
  • Muscle relaxants for muscle tension 1

Oral Appliances

• Bite plates or stabilization-type occlusal appliances may be used if bruxism is present 1

Third-Line Treatments

Injectable Therapies

• Intra-articular glucocorticoid injections (IAGCs) - conditionally recommended as part of initial therapy for active TMJ arthritis 2

  • Should be used sparingly, preferably in skeletally mature patients due to risk of adverse events including heterotopic ossification and impaired growth 2
  • No preferred agent has been identified 2

• Trigger/tender point injections with local anesthetics or botulinum toxin for refractory cases 1

Biologic DMARDs

• Conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least one csDMARD for active TMJ arthritis 2
• No preferred biologic DMARD has been identified 2
• TNF inhibitors are most commonly used 2

Fourth-Line/Last Resort Treatments

• Arthrocentesis, arthroscopic procedures, and open surgery should only be considered after failure of conservative therapy 1

Important Considerations

• Oral glucocorticoids are conditionally recommended against as part of initial therapy for active TMJ arthritis 2
• Routine irreversible alteration of temporomandibular joints, jaws, occlusion, or dentition is not recommended 1
• Most TMD symptoms improve without treatment, but various noninvasive therapies may reduce pain for patients who have not experienced relief from self-care 3

Treatment Algorithm

1. Start with education, self-management, and NSAIDs for brief periods
2. Add physical therapies (jaw exercises, mobilization, trigger point therapy)
3. Consider mind-body approaches (CBT with or without biofeedback)
4. For persistent symptoms, consider conventional synthetic DMARDs (methotrexate preferred)
5. For refractory cases, consider injectable therapies (with caution in skeletally immature patients)
6. For cases not responding to above treatments, consider biologic DMARDs
7. Surgical interventions only as last resort after failure of all conservative options