Treatment of Temporomandibular Joint (TMJ) Disorders
Initial Conservative Management (First 12 Weeks)
Start with cognitive behavioral therapy combined with manual trigger point therapy and supervised jaw exercises, as these provide the largest pain reduction—approximately twice the minimally important difference—and are strongly recommended based on moderate to high certainty evidence. 1, 2, 3
Strongly Recommended First-Line Interventions
Cognitive behavioral therapy (CBT) with or without biofeedback or relaxation therapy reduces pain severity by addressing both physical and psychological components of TMD, achieving approximately twice the minimally important difference in pain reduction 1, 2, 3
Manual trigger point therapy releases tension in specific muscle points and provides one of the largest reductions in chronic TMD pain 1, 2, 3
Therapist-assisted jaw mobilization improves joint mobility and reduces pain through manual techniques applied by trained therapists 1, 2
Supervised jaw exercises and stretching (with or without manual trigger point therapy) provide significant pain relief and functional improvement, approximately 1.5 times the minimally important difference 1, 2, 3
Supervised postural exercises correct head and neck alignment to reduce TMJ strain and improve symptoms 1, 2
Usual care including patient education about avoiding aggravating activities (wide mouth opening, hard foods), maintaining a soft diet, applying heat/cold therapy, and using over-the-counter NSAIDs forms the foundation of management 1, 2, 3
Pharmacological Management
NSAIDs are first-line medications for pain relief and inflammation reduction 2, 3
Muscle relaxants may help overcome muscle spasm when other approaches fail, but should not be first-line 2, 3
Neuromodulatory medications (amitriptyline, gabapentin) can be considered for chronic refractory TMJ pain after conservative measures 2, 3
Never combine NSAIDs with opioids—this combination is strongly recommended against due to increased risks (gastrointestinal bleeding, addiction, overdose) without clear additional benefits 1, 2, 3
Second-Line Approaches (After 12 Weeks Without Adequate Response)
Acupuncture shows moderate evidence of effectiveness for TMJ pain relief and may be considered 2, 3
Manipulation techniques for joint realignment may benefit select patients who have not responded to first-line interventions 2, 3
Combined jaw exercise with mobilization may be considered for patients not responding to individual interventions 2
Interventions to Use Cautiously or Avoid
Conditionally Recommended Against (Uncertain Benefits)
Occlusal splints (bite plates) are conditionally recommended against despite widespread use, as evidence for effectiveness is limited; consider only for patients with documented bruxism 1, 2, 3
Arthrocentesis (joint lavage) with or without co-interventions is conditionally recommended against due to uncertain benefits and potential moderate harms including local infection 1, 2
Low-level laser therapy is conditionally recommended against due to limited evidence 2
Botulinum toxin injections are conditionally recommended against due to potential harms and limited evidence 2
Hyaluronic acid injections are conditionally recommended against due to limited evidence 2
Biofeedback alone is conditionally recommended against due to limited evidence 2
Relaxation therapy alone is conditionally recommended against due to limited evidence 2
Acetaminophen with or without muscle relaxants is conditionally recommended against due to uncertain benefits 2
Benzodiazepines and beta-blockers are conditionally recommended against due to potential harms 2
Strongly Recommended Against (Potential for Serious Harm)
Irreversible oral splints (permanent dental alterations) are strongly recommended against due to potential for permanent change in range of motion and serious harms 1, 2, 3
Discectomy (surgical disc removal) is strongly recommended against due to potential serious harms including facial nerve weakness and permanent functional changes 1, 2, 3
Special Considerations for TMJ Arthritis
When TMJ symptoms are due to inflammatory arthritis rather than primary TMD:
Scheduled NSAIDs are conditionally recommended as part of initial therapy for TMJ arthritis 2, 3
Intra-articular glucocorticoid injections may be considered for refractory TMJ arthritis but should be used sparingly and preferably only in skeletally mature patients; repeated injections in skeletally immature patients are contraindicated 2, 3
Conventional synthetic DMARDs are strongly recommended for inadequate response to or intolerance of NSAIDs and/or intra-articular glucocorticoids in active TMJ arthritis 2, 3
Biologic DMARDs are conditionally recommended for inadequate response to NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 2, 3
Surgical Considerations for Severe Refractory Cases
Surgical interventions should only be considered after at least 3-6 months of failed conservative therapies 2:
Arthroscopy may be considered for internal joint assessment and treatment when conservative measures fail 2
Joint replacement may be considered in selected patients with severe joint destruction or ankylosis 2
Prophylactic antibiotics (1st- or 2nd-generation cephalosporins) should be administered one hour prior to surgery, with a 7-10 day course of oral antibiotics postoperatively due to proximity to contamination sources 1
Most common organisms in prosthetic joint infections are Staphylococcus aureus (53%) and Propionibacterium acnes (33%), requiring targeted antibiotic coverage 1
Critical Pitfalls to Avoid
Never proceed to invasive procedures before exhausting conservative options for at least 3-6 months 2, 3
Do not rely solely on occlusal splints despite their popularity—evidence for effectiveness is limited except in documented bruxism 1, 2, 3
Avoid irreversible procedures (permanent dental alterations, discectomy) without clear structural indication, as these carry risk of serious permanent harm 1, 2, 3
Never combine NSAIDs with opioids due to increased harm (gastrointestinal bleeding, addiction, overdose) without additional benefit 1, 2, 3
Do not perform repeated glucocorticoid injections in skeletally immature patients due to potential growth plate damage 2, 3
Do not neglect patient education about the condition and self-management strategies, as this forms the foundation of successful treatment 2, 3