What are the treatment options for Temporomandibular Joint (TMJ) disorders?

Treatment Options for Temporomandibular Joint (TMJ) Disorders

For patients with temporomandibular joint disorders, cognitive behavioral therapy (CBT), therapist-assisted mobilization, manual trigger point therapy, supervised postural exercise, and supervised jaw exercise with stretching are strongly recommended as first-line treatments due to their effectiveness in reducing pain and improving function. 1

First-Line Conservative Treatments

Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT):

  • Strongly recommended with or without biofeedback or relaxation therapy 1
  • Addresses stress, anxiety, and emotional factors contributing to jaw tension 2
  • Helps identify and modify parafunctional habits

• Physical Therapy Interventions:

  • Therapist-assisted mobilization: Strongly recommended 1
  • Manual trigger point therapy: Strongly recommended; involves applying gentle pressure to tender points in masseter and temporalis muscles for 30-60 seconds 1, 2
  • Supervised postural exercise: Strongly recommended 1
  • Supervised jaw exercises and stretching: Strongly recommended with or without manual trigger point therapy 1
    • Examples: Opening/closing mouth slowly 10 times, moving jaw side to side 10 times in each direction, 3-4 times daily 2
    • Jaw stretching: Placing thumb under upper front teeth and index finger on lower front teeth, gently pulling down to stretch jaw muscles, holding for 30 seconds, repeated 3 times 2

• Education and Self-Management:

  • Jaw rest and behavioral modifications (avoiding wide mouth opening, adopting soft diet) 2
  • Application of heat and/or cold 2

Conditionally Recommended Approaches

• Manipulation: Conditionally recommended, especially when combined with postural exercise 1, 2
• Supervised jaw exercise with mobilization: Conditionally recommended 1
• Acupuncture: Conditionally recommended 1, 2
• CBT with NSAIDs: Conditionally recommended for additional pain management 1, 2

Pharmacological Options

• NSAIDs: Conditionally recommended as part of initial therapy for pain management 2
• Conventional synthetic DMARDs: Strongly recommended for TMJ arthritis that doesn't respond to initial therapy 2
• Biologic DMARDs: Conditionally recommended after failure of NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 2

Intra-articular Injections

• Intra-articular glucocorticoid injections: Conditionally recommended as part of initial therapy for TMJ arthritis 2
  • Caution: Should be used carefully in skeletally immature patients 1, 2
  • Not recommended as first-line management in skeletally immature patients 1
  • May be indicated in skeletally mature patients with active TMJ arthritis and orofacial symptoms 1

Treatments to Avoid

• Occlusal splints: Conditionally recommended against (alone or in combination with other interventions) 1

  • Cochrane review found insufficient evidence for their effectiveness 3

• Strongly recommended against:

  • Irreversible oral splints 1, 2
  • Discectomy 1
  • NSAIDs with opioids 1, 2

• Conditionally recommended against:

  • Arthrocentesis 1
  • Low-level laser therapy 1
  • Botulinum toxin injection 1, 4 (associated with risks including dysphagia and breathing difficulties)
  • Hyaluronic acid injection 1
  • Relaxation therapy alone 1
  • Trigger point injection 1
  • Benzodiazepines 1
  • Corticosteroid injection with NSAIDs 1

Special Considerations

• For TMJ arthritis in juvenile idiopathic arthritis:

  • Goals include timely diagnosis, reducing inflammation and symptoms, normalizing dentofacial development, and addressing deformities 1
  • Contrast-enhanced MRI is currently the best method to detect active TMJ arthritis 1
  • Standardized approaches for assessment are recommended 1

• Treatment algorithm:

  1. Start with education, self-management strategies, and conservative therapies
  2. If insufficient relief, add CBT, physical therapy interventions
  3. Consider pharmacological options for persistent pain
  4. For refractory cases with specific indications, consider intra-articular injections (with caution in skeletally immature patients)
  5. Surgical interventions should only be considered after failure of conservative therapy 2

Monitoring and Follow-up

• Use validated disease activity measures to guide treatment decisions 2
• Regular reassessment of joint function, pain levels, and range of motion 2
• Consider patient factors such as age when selecting treatments 2
• For juvenile patients, longitudinal evaluation into adulthood is recommended regardless of current TMJ disease activity 1

Remember that most TMJ symptoms improve without treatment 5, but these evidence-based approaches can provide significant relief for those requiring intervention.