What are the treatment options for Temporomandibular Joint (TMJ) disorders?

Treatment for Temporomandibular Joint (TMJ) Disorders

Start with Conservative Therapies—They Work Best

Begin treatment with cognitive behavioral therapy (with or without biofeedback), therapist-assisted jaw mobilization, manual trigger point therapy, supervised jaw exercises and stretching, and supervised postural exercises, as these provide the most substantial pain relief (approximately 1.5-2 times the minimally important difference) with minimal risk of harm. 1, 2

First-Line Strongly Recommended Interventions

The 2023 BMJ guideline provides the strongest evidence base for TMJ disorder management, prioritizing interventions with moderate to high certainty evidence:

Physical Therapy Approaches

• Cognitive behavioral therapy augmented with relaxation therapy or biofeedback provides the largest reduction in chronic pain severity, approximating twice the minimally important difference 1, 2
• Therapist-assisted jaw mobilization (manual techniques to improve joint mobility) ranks among the most effective interventions 1, 2
• Manual trigger point therapy delivers substantial pain reduction approaching twice the minimally important difference 1, 2
• Supervised postural exercises correct head and neck alignment to reduce TMJ strain 1, 2
• Supervised jaw exercises and stretching (with or without manual trigger point therapy) provide approximately 1.5 times the minimally important difference in pain reduction 1, 2

Self-Care and Education

• Usual care including patient education, home exercises and stretching, self-massage, avoiding aggravating activities, maintaining a soft diet, and applying heat/cold therapy forms the foundation of management 1, 2

Pharmacological Management

• NSAIDs alone are recommended for pain relief and inflammation reduction 2, 3
• Avoid combining NSAIDs with opioids—this combination is strongly recommended against due to increased risk of gastrointestinal bleeding, addiction, and overdose without clear additional benefit 1, 2, 3

Second-Line Approaches (If First-Line Fails After 12 Weeks)

• Manipulation techniques for joint realignment may benefit select patients 2, 4
• Acupuncture shows moderate certainty evidence for effectiveness 2, 4
• Combined jaw exercise with jaw mobilization may provide synergistic benefits 4
• CBT combined with NSAIDs if medications remain partially effective 2, 4

Interventions to Use Cautiously or Avoid

Conditionally Recommended Against (Uncertain Benefits)

• Occlusal splints (bite plates) have limited evidence despite widespread use; may be considered specifically for documented bruxism only 1, 2, 3
• Arthrocentesis (joint lavage) has uncertain benefits and potential for moderate harm including local infection 1, 2, 4
• Low-level laser therapy has limited effectiveness evidence 2, 4
• Botulinum toxin injections carry potential harms with limited effectiveness evidence 2, 4
• Biofeedback alone (without CBT) has limited effectiveness evidence 4

Strongly Recommended Against (Risk of Serious Harm)

• Irreversible oral splints (permanent dental alterations) may cause permanent changes in range of motion 1, 2, 3
• Discectomy (surgical disc removal) may result in serious harms including facial nerve weakness 1, 2, 3

Surgical Options (Only After 3-6 Months of Failed Conservative Treatment)

Exhaust all conservative options for at least 3-6 months before considering invasive procedures. 2, 4

When conservative management fails:

• Arthroscopy provides the best diagnostic aid and enables appropriate surgical planning, with 80% of patients improving after arthroscopic investigation and arthrocentesis 5
• Open joint surgery should be based on specific pathology encountered during arthroscopy rather than a "one size fits all" approach, achieving 80% success rates when tailored to individual pathology 5
• Joint replacement may be considered in selected patients with joint destruction or ankylosis 2

Special Considerations for TMJ Arthritis

If inflammatory arthritis is present:

• Scheduled NSAIDs as initial therapy 3
• Intra-articular glucocorticoid injections used sparingly and preferably in skeletally mature patients (avoid repeated injections in skeletally immature patients) 2, 3
• Conventional synthetic DMARDs for inadequate response to NSAIDs and/or intra-articular glucocorticoids 3
• Biologic DMARDs for inadequate response to NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 3

Chronic Refractory Pain Management

For patients with persistent pain despite conservative measures:

• Neuromodulatory medications (amitriptyline, gabapentin) can be considered 2, 3
• Muscle relaxants may help overcome muscle spasm when other approaches fail 2, 3
• Avoid acetaminophen with or without muscle relaxants as first-line due to uncertain benefits 4
• Avoid benzodiazepines and beta-blockers due to potential harms 4

Critical Pitfalls to Avoid

• Never proceed to invasive procedures before exhausting conservative options for at least 3-6 months 2, 4
• Do not rely solely on occlusal splints—evidence for effectiveness is limited except in documented bruxism 1, 2, 3
• Avoid irreversible procedures (permanent dental alterations, discectomy) without clear structural indication 1, 2, 3
• Never combine NSAIDs with opioids—increased harm without additional benefit 1, 2, 3
• Do not perform repeated glucocorticoid injections in skeletally immature patients 2, 3
• Do not neglect patient education about the condition and self-management strategies 2, 3

Multidisciplinary Referral

Refer to a multidisciplinary team (oral and maxillofacial surgeons, orofacial pain specialists, physical therapists with TMJ expertise, psychologists for CBT) when conservative treatments fail after 3-6 months 2