For an adult with acute inflammatory temporomandibular joint pain unresponsive to NSAIDs, heat/ice, soft diet, jaw‑relaxation exercises, and a stabilization splint, can a short course of oral prednisone or a single intra‑articular steroid injection be used, and what are the contraindications?

Steroid Use for TMJ: Recommendations and Contraindications

For adults with acute inflammatory TMJ pain unresponsive to conservative measures, intra-articular corticosteroid injection may provide temporary relief (approximately 3 weeks) but is NOT recommended as first-line therapy; oral prednisone is not supported by guidelines for TMJ treatment. 1, 2

Intra-Articular Corticosteroid Injections

When They May Be Considered

• Intra-articular glucocorticoid injections may be indicated in skeletally mature patients with active TMJ arthritis confirmed on contrast-enhanced MRI and persistent orofacial symptoms after failing conservative therapy. 3

• Methylprednisolone injections temporarily alleviate pain and improve mouth opening capacity for approximately 3 weeks, allowing patients to perform jaw exercises during this window of relief. 4

• After arthrocentesis, corticosteroid injections are superior to placebo for long-term pain relief but inferior for improving maximal mouth opening. 5

Critical Contraindications and Warnings

• Intra-articular glucocorticoid injection is NOT recommended as first-line treatment, especially in skeletally immature patients, due to risks of mandibular growth suppression and intra-articular calcifications that may outweigh anti-inflammatory benefits. 3, 1

• Repeated glucocorticoid injections are NOT recommended due to temporary, non-curative effects and cumulative risks. 3

• Injection into an infected joint must be avoided; appropriate examination of joint fluid is necessary to exclude septic arthritis before any intra-articular injection. 6

• Severe joint destruction has been documented after intra-articular triamcinolone injection, including condylar necrosis, disk destruction, and ankylosis requiring surgical intervention. 7

• Corticosteroid injection into unstable joints is generally not recommended, and injection may result in damage to joint tissues. 6

Dosing When Used

• For TMJ intra-articular injection: 5-15 mg triamcinolone acetonide for larger joints, with single injections up to 40 mg for larger areas. 6

• Strict aseptic technique is mandatory; the suspension must be shaken before use and injected without delay to prevent settling. 6

Oral Corticosteroids

• Oral prednisone is not mentioned in any TMJ treatment guidelines and lacks evidence for efficacy in TMJ disorder. 1, 2

• Systemic corticosteroids carry significant risks including adrenal suppression, osteoporosis (particularly in postmenopausal women), psychiatric derangements, elevated intraocular pressure, and gastrointestinal complications. 6

Recommended Treatment Algorithm Instead

Phase 1: Mandatory Conservative Management (0-12 weeks)

• Physical therapy with supervised jaw exercises provides 1.5 times the minimally important difference in pain reduction and should be the cornerstone of treatment. 1, 2

• Manual trigger point therapy delivers the largest pain reductions, approaching twice the minimally important difference. 1, 2

• Cognitive behavioral therapy with or without biofeedback is strongly recommended for pain reduction and addressing pain perception. 1

• NSAIDs may be used as part of initial therapy, though the trial should be brief. 1

• Occlusal splints and physical therapy may be beneficial for orofacial symptoms and TMJ dysfunction. 3, 1

Phase 2: Second-Line Options (12-24 weeks if inadequate response)

• Intra-articular lavage without steroid may be beneficial for TMJ arthritis-related symptoms and dysfunction in both growing and skeletally mature patients, with no additional effect reported from adding steroid to lavage. 3, 2

• Conventional synthetic DMARDs (methotrexate preferred) are strongly recommended for inadequate response to NSAIDs in patients with true inflammatory TMJ arthritis. 1

Phase 3: Refractory Cases Only (after 6 months)

• Intra-articular glucocorticoid injections may be considered for true inflammatory TMJ arthritis confirmed on MRI in skeletally mature patients only. 3, 2

• Arthrocentesis may be performed before considering steroid injection. 2, 5

Key Pitfalls to Avoid

• Never perform irreversible procedures like permanent dental alterations or discectomy. 1

• Do not combine NSAIDs with opioids due to increased risks without clear additional benefits. 1

• Hyaluronate injections have a significantly higher success rate than corticosteroid injections in the short term and may be the better alternative. 5, 8

• If systemic inflammatory arthritis is suspected (especially in patients under 30 or with other joint involvement), refer to rheumatology for evaluation before considering local steroid injection. 1