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

Treatment for Temporomandibular Joint (TMJ) Disorders

Start with jaw exercises and stretching, manual trigger point therapy, and cognitive behavioral therapy as first-line treatments, as these provide the strongest evidence for pain reduction and functional improvement in chronic TMJ disorders. 1, 2, 3

First-Line Strongly Recommended Treatments

The following interventions have strong evidence supporting their use and should be initiated together as the foundation of TMJ disorder management:

• Supervised jaw exercises with stretching provide approximately 1.5 times the minimally important difference in pain reduction and are among the most effective treatments 2, 3
• Manual trigger point therapy delivers one of the largest reductions in pain severity, approaching twice the minimally important difference, making it a cornerstone of treatment 2, 3
• Cognitive behavioral therapy (CBT) with or without biofeedback provides substantial pain reduction by addressing pain perception and psychological factors that commonly accompany TMJ disorders 2, 3
• Therapist-assisted jaw mobilization improves joint mobility and reduces pain through manual techniques 2, 3
• Supervised postural exercises correct head and neck alignment to reduce TMJ strain 2, 3

Essential Supportive Measures

These should be implemented immediately alongside first-line treatments:

• Patient education about avoiding aggravating activities (gum chewing, wide yawning, nail biting) 2, 3
• Soft diet to reduce joint stress 2, 3
• Heat and cold application to affected areas for pain and inflammation control 2, 3
• NSAIDs for pain relief and inflammation reduction 2, 3

Second-Line Treatments (If Inadequate Response After 12 Weeks)

Consider these interventions only after exhausting first-line options:

• Manipulation techniques for joint realignment may benefit select patients 2, 3
• Acupuncture shows moderate evidence for TMJ pain relief 2, 3
• Occlusal splints may be beneficial specifically for patients with documented bruxism, though evidence for general use is limited and they are conditionally recommended against as standalone treatment 1, 2, 3

Pharmacological Management

• NSAIDs alone are first-line medications for pain and inflammation 2, 3
• Muscle relaxants may help when muscle spasm persists despite other approaches 2, 3
• Neuromodulatory medications (amitriptyline, gabapentin) can be considered for chronic refractory pain 2, 3
• Strongly avoid combining NSAIDs with opioids due to increased risks without clear additional benefits 1, 2, 3

Special Considerations for TMJ Arthritis

If inflammatory arthritis is the underlying cause, the treatment algorithm differs:

• Scheduled NSAIDs as part of initial therapy 2, 3
• Intra-articular glucocorticoid injections may be considered for refractory cases in skeletally mature patients only, used sparingly 2, 3
• Conventional synthetic DMARDs are strongly recommended for inadequate response to NSAIDs and/or intra-articular glucocorticoids 2, 3
• Biologic DMARDs are conditionally recommended after failure of NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 2, 3

Interventions to Avoid or Use with Extreme Caution

The 2023 BMJ guideline provides clear recommendations against several commonly used interventions:

• Arthrocentesis is conditionally recommended against due to uncertain benefits 1, 3
• Low-level laser therapy is conditionally recommended against 1, 3
• Botulinum toxin injections are conditionally recommended against 1, 3
• Irreversible oral splints (permanent dental alterations) are strongly recommended against 1, 2, 3
• Discectomy (surgical disc removal) is strongly recommended against 1, 2, 3

Treatment Algorithm

Weeks 0-4 (Initial Management):

• Patient education and self-management strategies 2, 3
• NSAIDs for pain and inflammation 2, 3
• Jaw rest and soft diet 2, 3
• Heat/cold application 2, 3

Weeks 4-12 (First-Line Active Treatment):

• Initiate supervised jaw exercises and stretching 2, 3
• Begin manual trigger point therapy 2, 3
• Start cognitive behavioral therapy if psychological factors are present 2, 3
• Continue supportive measures 2, 3

After 12 Weeks (Second-Line if Inadequate Response):

• Consider occlusal splints only for patients with documented bruxism 2, 3
• Trial acupuncture 2, 3
• Add manipulation techniques 2, 3

After 6 Months (Refractory Cases):

• Refer to multidisciplinary team including oral and maxillofacial surgeons, orofacial pain specialists, physical therapists, and psychologists 3
• Consider arthrocentesis only in highly selected cases 3
• Intra-articular glucocorticoid injections in skeletally mature patients only 2, 3
• Surgical consultation only for severe structural abnormalities 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; they have limited evidence and are conditionally recommended against 1, 2, 3
• Avoid irreversible procedures such as permanent dental alterations or discectomy without clear structural indication 1, 2, 3
• Never combine NSAIDs with opioids as this increases harm without additional benefit 1, 2, 3
• Do not perform repeated glucocorticoid injections in skeletally immature patients 2, 3
• Do not delay physical therapy referral as manual trigger point therapy and jaw exercises are among the most effective treatments 3