What is the treatment (Tx) for Temporomandibular Joint (TMJ) dysfunction?

Treatment for TMJ Dysfunction

Start with cognitive behavioral therapy (CBT), supervised jaw exercises with stretching, and manual trigger point therapy—these are the most effective first-line treatments with strong evidence for reducing chronic TMJ pain. 1

First-Line Treatments (Start Here)

The following interventions have strong recommendations and should be initiated immediately for chronic TMJ dysfunction:

• Supervised jaw exercises and stretching provide approximately 1.5 times the minimally important difference in pain reduction and are among the most effective treatments 1, 2
• Manual trigger point therapy delivers one of the largest reductions in pain severity, approaching twice the minimally important difference 1, 2
• Cognitive behavioral therapy (CBT) with or without biofeedback provides substantial pain reduction by addressing pain perception and psychological factors 1, 2
• Therapist-assisted mobilization improves joint mobility and reduces pain through manual techniques 1, 2
• Supervised postural exercises correct head and neck alignment to reduce TMJ strain 1, 2
• Usual care including patient education about avoiding aggravating activities, maintaining a soft diet, applying heat/cold therapy, and home exercises forms the foundation of management 1, 2

Pharmacological Management

• NSAIDs are first-line medications for pain relief and inflammation reduction 1, 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 TMJ pain 2, 3
• Acetaminophen with or without muscle relaxants is conditionally recommended against due to uncertain benefits 2
• Never combine NSAIDs with opioids—this is strongly recommended against due to increased risks without clear additional benefits 1, 2, 3
• Benzodiazepines and beta-blockers are conditionally recommended against due to potential harms 2

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

These interventions have conditional recommendations and may be considered if first-line treatments are insufficient:

• Manipulation techniques for joint realignment may benefit some patients 1, 2
• Acupuncture shows moderate evidence for TMJ pain relief 1, 2
• Combined jaw exercise with mobilization may be considered 1, 2
• CBT combined with NSAIDs if medications remain partially effective 1, 2
• Combined manipulation with postural exercise for patients not responding to first-line interventions 2

Interventions to Avoid or Use with Extreme Caution

The 2023 BMJ guideline provides clear guidance on what NOT to do:

• Reversible occlusal splints are conditionally recommended against despite widespread use—evidence for effectiveness is limited, though may be considered specifically for documented bruxism 1, 2, 4
• Arthrocentesis (joint lavage) with or without co-interventions is conditionally recommended against due to uncertain benefits 1, 2
• Low-level laser therapy is conditionally recommended against 1, 2, 4
• Botulinum toxin injections are conditionally recommended against 1, 2
• Hyaluronic acid injections are conditionally recommended against 1, 2
• Biofeedback alone (without CBT) is conditionally recommended against 1, 2, 4
• Relaxation therapy alone is conditionally recommended against 1, 2
• Trigger point injections are conditionally recommended against 1
• Topical capsaicin is conditionally recommended against 1
• Corticosteroid injections are conditionally recommended against 1
• Cartilage supplements are conditionally recommended against 1, 2
• TENS (transcutaneous electrical nerve stimulation) is conditionally recommended against 1

Strongly Contraindicated Interventions

Never perform these procedures:

• Irreversible oral splints (permanent dental alterations) are strongly recommended against 1, 2, 3
• Discectomy (surgical disc removal) is strongly recommended against 1, 2, 3
• NSAIDs combined with opioids are strongly recommended against 1, 2, 3

Special Considerations for TMJ Arthritis

If TMJ arthritis is present (distinct from typical TMJ dysfunction):

• Scheduled NSAIDs are conditionally recommended as initial therapy 1, 3
• Intra-articular glucocorticoid injections may be indicated for refractory and symptomatic TMJ dysfunction but are NOT first-line, especially in skeletally immature patients 1, 3
• Intra-articular lavage without steroids may provide symptomatic relief in refractory cases and has an improved safety profile compared to steroid injections 1, 2
• Conventional synthetic DMARDs are strongly recommended for inadequate response to NSAIDs and/or intra-articular glucocorticoids 3
• Biologic DMARDs are conditionally recommended for inadequate response to NSAIDs, intra-articular glucocorticoids, and at least one conventional synthetic DMARD 3

Treatment Algorithm

Weeks 0-4 (Initial Management):

• Patient education and self-management strategies 2, 5
• NSAIDs for pain and inflammation 1, 2
• Jaw rest and soft diet 2, 6
• Heat/cold application 2, 5

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

• Supervised jaw exercises and stretching 1, 2
• Manual trigger point therapy 1, 2
• Therapist-assisted mobilization 1, 2
• Supervised postural exercises 1, 2
• CBT if psychological factors are present 1, 2

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

• Manipulation techniques 1, 2
• Acupuncture 1, 2
• Occlusal splints ONLY for patients with documented bruxism 1, 2

After 6 Months (Refractory Cases):

• Referral to multidisciplinary team including oral and maxillofacial surgeons, orofacial pain specialists, physical therapists, and psychologists 2
• Consider arthrocentesis (lavage without steroids) 1, 2
• Intra-articular glucocorticoid injections only in skeletally mature patients with refractory symptoms 1, 3
• Surgical consultation only for severe structural abnormalities after all conservative options exhausted 2

Critical Pitfalls to Avoid

• Never proceed to invasive procedures before exhausting 3-6 months of conservative options 2, 3
• Do not rely solely on occlusal splints—they have limited evidence and are conditionally recommended against by the BMJ guideline 1, 2, 3
• Avoid irreversible procedures like permanent dental alterations or discectomy—these are strongly contraindicated 1, 2, 3
• Never combine NSAIDs with opioids—this significantly increases harm without additional benefit 1, 2, 3
• Do not perform repeated glucocorticoid injections in skeletally immature patients 1, 3
• Do not neglect patient education and self-management strategies—these are foundational to successful treatment 2, 5
• Avoid jumping to arthrocentesis or other invasive procedures—these are conditionally recommended against 1, 2