From the Guidelines
Refractory temporomandibular joint (TMJ) disorder should be treated with cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, as it has been shown to be effective in managing chronic pain associated with TMD. This approach is supported by the most recent and highest quality study, which issued strong recommendations in favour of CBT with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care 1.
When considering treatment options, it is essential to prioritize conservative measures, including reassurance and education, avoidance of wide mouth opening or aggravating activities, soft diet, jaw exercises, massage, non-steroidal anti-inflammatory drugs (NSAIDs), heat and/or cold, and physiotherapy 1. Some key points to consider when treating refractory TMJ disorder include:
- Avoiding irreversible oral splints, discectomy, and NSAIDS with opioids, as they have been strongly recommended against 1
- Considering conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture 1
- Ruling out other treatment options that have been conditionally recommended against, such as reversible occlusal splints, arthrocentesis, cartilage supplement with or without hyaluronic acid injection, low level laser therapy, transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen, topical capsaicin, biofeedback, corticosteroid injection, benzodiazepines, and β blockers 1
By prioritizing the most effective and conservative treatment options, patients with refractory TMJ disorder can experience improved outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Treatment Options for Refractory TMJ
- Conservative therapies include nonsteroidal anti-inflammatory drugs, muscle relaxants, benzodiazepines, antidepressants, and anticonvulsants 2
- Minimally invasive injections include botulinum toxin, corticosteroids, platelet-rich plasma, hyaluronic acid, and prolotherapy with hypertonic glucose 2
- Surgical treatment options are available for patients with severe and/or refractory TMJ disease who have failed conservative treatment 3, 4, 5
- Arthrocentesis and arthroscopy can help modulate pain, increase mouth opening, and relieve locking in patients with inflammatory arthritis 4
- Alloplastic reconstruction of the temporomandibular joint is considered as the treatment of choice in most severe TMJ disorders due to its many advantages 5
- Initial treatment with arthrocentesis reduced TMJ arthralgia more efficaciously than non-surgical intervention in the long term, while maintaining similar mandibular function 6
Management of Refractory TMJ
- A multidisciplinary team approach to management is essential in the fundamental care of all TMD patients so that treatment can be specifically tailored to individual patient needs 3
- Jaw rest, a soft diet, a bite splint, and medical therapy, including disease-modifying antirheumatic drugs (DMARDs) and simple analgesia, are the bedrock of initial treatment and will improve most symptoms in most patients 4
- Total TMJ replacement is reserved for patients where joint collapse or fusion has occurred or in whom other treatments have failed to provide adequate symptomatic control 4