Muscle Relaxers Are Not Recommended for TMJ Pain
Based on the most recent and highest quality evidence, muscle relaxers should not be used for TMJ pain. The 2023 BMJ clinical practice guideline explicitly places acetaminophen with or without muscle relaxants in the "conditional recommendations against" category, meaning the benefits are uncertain and they are associated with harms or burden 1.
Why Muscle Relaxers Don't Work for TMJ
The evidence shows that muscle relaxants have uncertain benefits for TMJ pain relief and function 1. The 2023 international guideline panel, which included dentists, oral surgeons, pain specialists, and patients with TMD, systematically reviewed all available treatments and found insufficient evidence to support muscle relaxant use 1.
Benzodiazepines (a class of muscle relaxants) are also specifically conditionally recommended against due to their potential harms, including dependency risk, cognitive impairment, and lack of proven benefit for TMJ disorders 1.
What Actually Works: Evidence-Based Treatment Algorithm
First-Line Treatments (Start Here - Strong Recommendations)
These interventions have no serious harms and provide pain relief approximately 1.5-2 times the minimally important difference compared to placebo 2:
- Manual trigger point therapy - Provides one of the largest pain reductions, approaching twice the minimally important difference 2, 3
- Supervised jaw exercises and stretching - Delivers significant pain relief and functional improvement 1, 2, 3
- Therapist-assisted jaw mobilization - Provides substantial pain reduction with moderate certainty evidence 2, 3
- Supervised postural exercises - Corrects head and neck alignment to reduce TMJ strain 1, 2, 3
- Cognitive behavioral therapy (CBT) with or without biofeedback/relaxation - Delivers the greatest pain relief and addresses psychological factors 1, 2, 3
- Usual care - Home exercises, stretching, reassurance, education, soft diet, heat/cold application 1, 2, 3
Second-Line Options (If First-Line Insufficient After 4-12 Weeks)
These have conditional recommendations in favor 1:
- Manipulation techniques for joint realignment 1, 3
- Acupuncture - Shows moderate evidence of effectiveness 1, 3
- CBT combined with NSAIDs - If medications remain partially effective 1, 3
- Jaw exercise plus jaw mobilization 1, 3
Pharmacological Management
- NSAIDs alone are appropriate for pain and inflammation 3
- Avoid acetaminophen with or without muscle relaxants - Uncertain benefits 1, 3
- Never combine NSAIDs with opioids - Strong recommendation against due to increased risk of GI bleeding, addiction, and overdose without additional benefit 1, 3
Critical Pitfalls to Avoid
Do not prescribe muscle relaxants or benzodiazepines - They carry dependency risks and lack evidence for TMJ pain 1, 3
Do not proceed to invasive procedures (arthrocentesis, injections, surgery) before exhausting 3-6 months of conservative treatment 3
Do not rely solely on occlusal splints - Despite widespread use, they are conditionally recommended against due to limited effectiveness evidence 1, 3
Never perform irreversible procedures (permanent dental alterations, discectomy) - These are strongly recommended against 1, 3
Why Conservative Treatments Succeed
Up to 30% of acute TMD becomes chronic, making early intervention with effective conservative treatments critical 1, 2. The strongly recommended interventions work because they:
- Address the underlying myofascial pain (the most common TMD subtype) 1
- Improve self-efficacy through education, which leads to fewer symptoms 2
- Have no serious harms, creating a favorable benefit-harm profile 2
- Address psychological comorbidities (depression, catastrophizing) that reduce treatment success 2
When to Refer
Refer to a multidisciplinary team (oral surgeons, orofacial pain specialists, physical therapists, psychologists) if symptoms persist after 3-6 months of appropriate conservative treatment 3. However, do not delay physical therapy referral - manual trigger point therapy and jaw exercises should be initiated early as they are among the most effective treatments 3.