How to manage repetitive jaw cracking?

Management of Repetitive Jaw Cracking

For repetitive jaw cracking, strongly recommended first-line treatments include supervised jaw exercises and stretching, manual trigger point therapy, therapist-assisted mobilization, and cognitive behavioral therapy, as these provide the greatest pain reduction and functional improvement with minimal risk of harm. 1

First-Line Conservative Approaches

• Supervised jaw exercises and stretching (with or without manual trigger point therapy) are strongly recommended as they provide significant pain relief and functional improvement, approximately 1.5 times the minimally important difference in pain reduction 1
• Manual trigger point therapy is strongly recommended as it provides one of the largest reductions in pain severity, approaching twice the minimally important difference 1
• Therapist-assisted jaw mobilization is strongly recommended as it significantly improves joint mobility and reduces pain 2
• Cognitive behavioral therapy (CBT), with or without biofeedback or relaxation therapy, is strongly recommended as it provides substantial pain reduction 1, 2
• Supervised postural exercises are strongly recommended as they improve head and neck alignment and reduce TMJ strain 1, 2
• Patient education, home exercises, stretching, self-massage, and reassurance (usual care) are strongly recommended as they provide important pain relief 1

Second-Line Approaches

• Manipulation techniques for joint realignment are conditionally recommended and may be beneficial for some patients 1, 2
• Supervised jaw exercise combined with mobilization shows improved outcomes compared to either intervention alone 1, 2
• Manipulation with postural exercise provides better functional results than manipulation alone 2
• Acupuncture is conditionally recommended and may provide relief for some patients 1
• CBT with NSAIDs may be considered if medications are still partially effective 2

Interventions to Consider Cautiously or Avoid

• Reversible occlusal splints (alone or in combination with other interventions) are conditionally recommended against despite their common use 1
• Arthrocentesis (joint lavage) is conditionally recommended against as a primary treatment 1
• Low-level laser therapy shows limited evidence for effectiveness and is conditionally recommended against 1, 2
• Biofeedback alone (without CBT) is conditionally recommended against 1
• Botulinum toxin injections may provide temporary relief in refractory cases but are conditionally recommended against as a primary treatment 1, 2
• Strong recommendations against irreversible oral splints, discectomy, and NSAIDs with opioids due to risk of serious harm 1

Special Considerations

• When jaw cracking is associated with bruxism (teeth grinding/clenching), addressing this underlying condition is important 3
• Patient education about avoiding aggravating activities is recommended 3
• Massage of masticatory muscles can provide relief of associated muscle tension 3
• Heat and/or cold application to affected areas may help manage symptoms 3
• Regular reassessment of symptoms and function is essential to monitor treatment effectiveness 2

Treatment Algorithm

1. Begin with strongly recommended conservative approaches:

   • Supervised jaw exercises and stretching
   • Manual trigger point therapy
   • Therapist-assisted mobilization
   • Patient education and home care instructions

2. If inadequate improvement after 4-6 weeks, add:

   • Cognitive behavioral therapy
   • Supervised postural exercises

3. If still inadequate improvement after an additional 4-6 weeks, consider conditionally recommended approaches:

   • Manipulation techniques
   • Combined approaches (jaw exercise with mobilization)
   • Acupuncture

4. Avoid rushing to invasive procedures or irreversible treatments, as conservative approaches provide the best balance of benefits and harms 2

Common Pitfalls to Avoid

• Relying on occlusal splints as the only treatment despite limited evidence for their effectiveness 1, 3
• Proceeding to invasive procedures before exhausting conservative options 2
• Using NSAIDs with opioids, which carries significant risk without clear additional benefit 1
• Neglecting patient education about the condition and self-management strategies 2
• Performing irreversible procedures like permanent alterations to dentition or discectomy 1, 2