What are the treatment options for Temporomandibular (TM) joint pain?

Treatment of Temporomandibular Joint Pain

Start with jaw exercises, manual trigger point therapy, and patient education as first-line treatment, as these provide the most substantial pain relief (approximately 1.5-2 times the minimally important difference) with strong evidence from the American College of Physicians. 1

Initial Management (First 0-4 Weeks)

Begin immediately with these foundational interventions:

• Patient education about avoiding jaw clenching, chewing gum, and hard foods while maintaining a soft diet 1, 2
• NSAIDs for pain relief and inflammation reduction as first-line pharmacotherapy 1, 2
• Heat or cold application to the affected area for symptomatic relief 1
• Jaw rest during the acute phase to prevent further aggravation 1

First-Line Active Treatment (Weeks 4-12)

These interventions have the strongest evidence and should be initiated early, not delayed:

• Jaw exercises and stretching provide approximately 1.5 times the minimally important difference in pain reduction 1, 2
• Manual trigger point therapy delivers one of the largest reductions in pain severity, approaching twice the minimally important difference 1, 2
• Therapist-assisted jaw mobilization improves joint mobility and reduces pain through manual techniques 1, 3
• Supervised postural exercises correct head and neck alignment to reduce TMJ strain 1, 3
• Cognitive behavioral therapy (CBT) addresses pain perception and psychological factors, providing substantial pain reduction 1, 2, 3

Do not delay referral to physical therapy with TMJ expertise, as manual trigger point therapy and jaw exercises are among the most effective treatments and should be initiated early. 1

Pharmacological Management

Follow this hierarchy:

• NSAIDs alone are the first-line medication 1, 2
• Muscle relaxants may be added if muscle spasm persists despite other approaches 1, 2
• Neuromodulatory medications (amitriptyline or gabapentin) for chronic refractory pain beyond 3 months 1, 2
• Never combine NSAIDs with opioids - this is strongly recommended against due to increased risks without additional benefits 1, 2, 3

Second-Line Treatment (After 12 Weeks Without Adequate Response)

Consider these interventions if first-line approaches are insufficient:

• Acupuncture has moderate certainty evidence for effectiveness 1, 3
• Manipulation techniques for joint realignment may benefit select patients 1, 3
• Combined jaw exercise with mobilization for synergistic effects 1, 3
• CBT combined with NSAIDs if medications remain partially effective 1, 3
• Occlusal splints specifically for patients with documented bruxism, though evidence for general use is limited and they are conditionally recommended against 1, 2, 3

Refractory Cases (After 6 Months of Conservative Treatment)

Only after exhausting conservative options for at least 3-6 months:

• Arthrocentesis (joint lavage without steroid) may provide symptomatic relief 1, 3
• Intra-articular glucocorticoid injections only in skeletally mature patients with refractory symptoms, not as first-line 1, 2
• Arthroscopy for internal joint assessment when conservative measures fail 1, 3
• Referral to multidisciplinary team including oral and maxillofacial surgeons, orofacial pain specialists, physical therapists, and psychologists 1

Special Consideration: TMJ Arthritis

If inflammatory arthritis is suspected or confirmed:

• Scheduled NSAIDs as initial therapy 2
• Conventional synthetic DMARDs are strongly recommended for inadequate response to NSAIDs and/or intra-articular glucocorticoids 2
• Biologic DMARDs for inadequate response to NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 2
• Avoid repeated glucocorticoid injections in skeletally immature patients 1, 2

Interventions to Avoid

These have strong recommendations against their use:

• Irreversible oral splints (permanent dental alterations) - strongly recommended against 1, 2, 3
• Discectomy (surgical disc removal) - strongly recommended against 1, 3
• NSAIDs combined with opioids - strongly recommended against 1, 2, 3
• Low-level laser therapy - conditionally recommended against due to limited evidence 1, 3
• Botulinum toxin injections - conditionally recommended against 1, 3

Critical Pitfalls to Avoid

• Never proceed to invasive procedures before exhausting conservative options for at least 3-6 months 1, 2, 3
• Do not rely solely on occlusal splints despite their widespread use; evidence for effectiveness is limited 1, 2
• Avoid irreversible procedures without clear structural indication on imaging 1, 2
• Do not neglect patient education about self-management strategies, as this forms the foundation of treatment 1, 2