What is the treatment for Temporomandibular Joint (TMJ) arthritis?

TMJ Arthritis Treatment

Begin with manual trigger point therapy and supervised jaw exercises immediately, as these provide the largest pain reductions (approaching twice the minimally important difference), while initiating a brief trial of scheduled NSAIDs—but be prepared to escalate rapidly to disease-modifying therapy within 3-6 weeks if response is inadequate, as TMJ is a high-risk joint with destructive potential that warrants aggressive treatment regardless of symptom severity. 1, 2, 3

Initial Conservative Management (Start Immediately)

Physical Interventions (Highest Priority)

• Manual trigger point therapy delivers nearly twice the minimally important difference in pain reduction and should be your first intervention 1, 3
• Supervised jaw exercises with stretching provide approximately 1.5 times the minimally important difference in pain relief and functional improvement 1, 3
• Therapist-assisted jaw mobilization improves joint mobility through manual techniques 1, 3
• Postural exercises correct head and neck alignment to reduce TMJ strain 1

Pharmacological First-Line

• Scheduled NSAIDs (diclofenac sodium or naproxen 500 mg twice daily) are conditionally recommended as part of initial therapy, but the trial must be brief—typically 3-6 weeks maximum 4, 2, 5
• The NSAID trial should be brief due to potential adverse effects including gastritis, bruising, and cardiovascular complications, and some experts prefer avoiding NSAIDs altogether 4, 2
• Add gastroprotective agents if the patient has risk factors for GI bleeding (age >75, history of NSAID-associated bleeding, concurrent anticoagulation) 2

Self-Management Strategies

• Patient education about avoiding aggravating activities: jaw clenching, gum chewing, hard foods 1, 3
• Soft diet to reduce joint stress 1, 3
• Heat and/or cold application to affected areas 1, 3
• Jaw rest during acute flares 1

Psychological Interventions

• Cognitive behavioral therapy (CBT), particularly augmented CBT with biofeedback or relaxation techniques, provides substantial pain reduction by addressing pain perception and psychological factors 1, 3

Critical Decision Point: When to Escalate (3-6 Weeks)

TMJ is considered a high-risk joint due to major impact on activities of daily living and potentially destructive nature—treatment is recommended regardless of clinical symptoms. 4, 3 If inactive disease is not achieved within the brief initial trial, you must escalate rapidly rather than prolonging conservative therapy alone.

Second-Line Therapy: Disease-Modifying Agents

Conventional Synthetic DMARDs (Strongly Recommended)

• Methotrexate is the preferred agent for inadequate response to or intolerance of NSAIDs and/or intra-articular glucocorticoids 4, 2, 3
• Leflunomide is conditionally recommended as an alternative if methotrexate is not tolerated 4, 3
• The limited available evidence supports methotrexate use, and early DMARD therapy is encouraged given TMJ's high-risk status 4, 3

Intra-Articular Glucocorticoid Injections (Use Sparingly)

• Conditionally recommended for refractory symptomatic TMJ dysfunction, but ONLY in skeletally mature patients 4, 3
• Unique TMJ-specific serious adverse events include heterotopic ossification and impaired growth 4
• Should be used sparingly and preferably in skeletally mature patients 4, 3
• No preferred steroid formulation has been identified 4, 3
• Oral glucocorticoids are conditionally recommended AGAINST as part of initial therapy 4, 3

Alternative Interventions for Refractory Cases

• Intra-articular lavage (arthrocentesis without steroids) may provide symptomatic relief with an improved safety profile compared to steroid injections 1, 3
• Neuromodulatory medications (amitriptyline or gabapentin) for chronic refractory TMJ pain 1, 3
• Acetaminophen may be considered, though evidence for TMJ-specific benefits is uncertain 1

Third-Line Therapy: Biologic DMARDs

• Biologic DMARDs are conditionally recommended for inadequate response to or intolerance of NSAIDs, intra-articular glucocorticoids, AND at least one conventional synthetic DMARD 4, 2, 3
• No preferred biologic DMARD has been identified, though TNF inhibitors are most commonly used 4, 3
• Current studies of TMJ arthritis with biologics have been small and observational 4

Surgical Interventions (Reserved for Specific Indications)

• Arthroscopy and arthrocentesis can help modulate pain, increase mouth opening, and relieve locking when conservative measures fail 6
• These minimally invasive procedures have few complications and can be repeated 6
• Operations to repair or remove damaged intra-articular disc or refine joint anatomy are used in select cases 6
• Total TMJ replacement is reserved for patients where joint collapse or fusion has occurred or in whom other treatments have failed 6, 7
• Skeletal surgery may be indicated in patients with dentofacial deformities and controlled TMJ arthritis 3

Critical Pitfalls to Avoid

• Do NOT rely solely on occlusal splints—evidence for effectiveness is limited and they are conditionally recommended against except in documented bruxism 1, 3
• Never perform repeated glucocorticoid injections in skeletally immature patients due to risk of growth disturbances and heterotopic ossification 4, 2, 3
• Strongly avoid combining NSAIDs with opioids due to increased risks without clear additional benefits 2, 3
• Never proceed to irreversible procedures (permanent dental alterations, discectomy) without exhausting all conservative options for at least 3-6 months 1, 3
• Do not prolong NSAID monotherapy beyond 6 weeks if response is inadequate—escalate to DMARDs 2, 3
• Avoid arthrocentesis with steroids as first-line management, particularly in skeletally immature patients 1

Monitoring Considerations

• Contrast-enhanced MRI is the best method to detect active TMJ arthritis 3
• Consider poor prognostic features (erosive disease, elevated inflammation markers, delay in diagnosis) to guide treatment intensity 4, 3
• Use validated disease activity measures to guide treatment decisions and facilitate treat-to-target approaches 4