What are the treatment options for jaw pain?

Treatment of Jaw Pain

For chronic jaw pain related to temporomandibular disorders (TMD), start with jaw exercises, jaw stretching, manual trigger point therapy, and cognitive behavioral therapy—these are strongly recommended first-line treatments with proven benefits that far outweigh any harms. 1

Initial Assessment: Rule Out Life-Threatening Causes First

Before treating as TMD, you must exclude dangerous conditions:

• Giant cell arteritis if patient is >50 years old with jaw claudication (pain with chewing), temporal headache, scalp tenderness, visual changes, fever, or malaise—check ESR and CRP immediately and start high-dose corticosteroids (minimum 40 mg prednisone daily) without delay to prevent permanent vision loss 1, 2
• Trigeminal neuralgia presents with brief (seconds to minutes), electric shock-like pain triggered by light touch, eating, or washing—requires MRI and anticonvulsant therapy 1, 2
• Glossopharyngeal neuralgia causes deep ear/throat pain triggered by swallowing and can provoke syncope—needs MRI and specialist referral 1, 2

Treatment Algorithm for TMD-Related Jaw Pain

Phase 1: First-Line Strongly Recommended Treatments (Start Here)

These interventions have benefits that very likely outweigh harms:

• Jaw exercises and stretching: Supervised programs provide approximately 1.5 times the minimally important difference in pain reduction 1, 3
• Manual trigger point therapy: Provides one of the largest reductions in pain severity among conservative treatments 1, 3
• Jaw mobilization: Therapist-assisted techniques to improve joint mobility 1, 3
• Postural exercises: Address head and neck alignment contributing to TMD pain 1, 3
• Augmented cognitive behavioral therapy (CBT with biofeedback or relaxation): Provides substantial pain reduction, particularly when psychological factors are present 1, 3
• Combination therapy: Jaw exercise + jaw stretching + trigger point therapy together 1

Implementation: These should be delivered by trained therapists; remote delivery of CBT is less costly and likely similarly effective to in-person therapy 1

Phase 2: Pharmacological Management for Acute Pain

For immediate pain relief while initiating physical therapy:

• Ibuprofen 400 mg is the preferred analgesic—it is superior to acetaminophen 1000 mg for dental/jaw pain with a risk ratio of 1.47 for achieving at least 50% pain relief 4, 5, 6, 7
• NSAIDs alone are more effective than acetaminophen with or without muscle relaxants for TMD pain 1
• Avoid acetaminophen with muscle relaxants (including cyclobenzaprine)—this combination is conditionally recommended against due to uncertain benefits and potential harms 1, 3

Critical pitfall: Do NOT combine NSAIDs with opioids—this is strongly recommended against due to important harms without clear benefits 1, 3

Phase 3: Second-Line Options (If First-Line Insufficient After 4-12 Weeks)

Consider these when most, but not all, informed patients would want them:

• Manipulation techniques: May benefit some patients by realigning the joint 1, 3
• Acupuncture: Shows moderate evidence of effectiveness 1, 3
• Jaw exercise combined with mobilization 1
• Manipulation with postural exercise 1
• CBT combined with NSAIDs 1

Phase 4: Treatments to Generally Avoid

These are conditionally recommended against because benefits are uncertain and they carry harms or burden:

• Occlusal splints (removable or with co-interventions): Limited evidence except specifically for bruxism 1, 3
• Botulinum toxin injections: Uncertain benefits for pain relief and function 1, 3
• Benzodiazepines, gabapentin, beta-blockers: Uncertain efficacy with potential for harm 1
• Low-level laser therapy, TENS, biofeedback: Insufficient evidence of benefit 1
• Arthrocentesis, hyaluronic acid injections, steroid injections: Reserved only for refractory cases after 6+ months of conservative treatment failure 1, 3

Phase 5: Strongly Contraindicated Treatments

Never offer these—they have uncertain benefits with important harms:

• Irreversible oral splints: Permanent alterations without proven benefit 1
• Discectomy: Surgical intervention with significant risks 1
• NSAIDs combined with opioids: Increased harm without additional benefit 1, 3

Special Considerations for Non-TMD Jaw Pain

Neuropathic Pain Syndromes

• Post-herpetic neuralgia or post-traumatic trigeminal neuropathic pain: Treat with neuropathic pain medications (anticonvulsants, tricyclic antidepressants) 1
• Atypical odontalgia (persistent tooth pain without dental cause): Manage as neuropathic pain; cognitive behavioral therapy may help 1
• Burning mouth syndrome: Reassurance that it won't worsen is crucial; exclude secondary causes (candidiasis, hematological disorders); consider CBT and neuropathic pain medications 1

Acute Dental Pain

For post-extraction or acute dental pain:

• Ibuprofen 400 mg provides superior pain relief compared to acetaminophen 600 mg/codeine 60 mg combination, with a standardized mean difference of 3.009 for total pain relief over 6 hours 6
• Combination paracetamol 1000 mg + ibuprofen 400 mg shows promising results with risk ratio of 1.77 for achieving 50% pain relief 7

Common Pitfalls to Avoid

• Do not proceed to invasive procedures (Botox, arthrocentesis, injections) before exhausting 3-6 months of conservative options 3
• Do not rely solely on occlusal splints despite their popularity—evidence is limited except for documented bruxism 3
• Do not prescribe muscle relaxants for chronic TMD pain—they lack efficacy evidence and carry adverse effect risks 3
• Do not perform irreversible procedures (permanent splints, surgery) without clear indication and failure of all conservative measures 1, 3
• Do not neglect patient education about self-management strategies, jaw rest, soft diet, and heat/cold application 3
• Do not delay ESR/CRP testing in patients >50 with jaw claudication—missing giant cell arteritis can result in permanent blindness 1, 2

Practical Implementation Timeline

Weeks 0-4: Patient education, NSAIDs for pain, jaw rest, soft diet, heat/cold application 3

Weeks 4-12: Initiate jaw exercises/stretching, trigger point therapy, CBT if psychological factors present 1, 3

After 12 weeks if inadequate response: Add manipulation, acupuncture, or occlusal splint (if bruxism documented) 1, 3

After 6 months if refractory: Consider arthrocentesis or intra-articular glucocorticoid injections in skeletally mature patients only 1, 3