Approach

This is generally a self-limiting disorder.[12] The pain and clicking of TMDs rarely become more serious.[18] Joint noises in the absence of pain do not require treatment. Most symptoms of TMDs improve without medical treatment or within 3-6 months of non-surgical treatment.[45] Patients should be referred to a specialist if:

  1. Patient has a medical history of inflammatory joint disease

  2. Symptoms do not improve after 6 weeks

  3. There is progressive difficulty in opening the mouth

  4. There is an inability to eat a normal diet

  5. ​Acute severe restriction of opening <26 mm in a young adult

  6. There is recurrent dislocation of the temporomandibular joint - two or more episodes requiring manual reduction.[45]

Anchored disc phenomenon warrants urgent referral, as leaving the situation without intervention can lead to permanent restriction of mouth opening.

Non-pharmacological therapy

Patient education and self-management

Educating and reassuring the patients that the condition is benign and non-progressive can be helpful.[49]​ Patient information and anatomical diagrams explaining the condition and therapeutic approaches can be provided.[2][49] ​BMJ Best Practice: patient information - temporomandibular disorders Opens in new window

Upon diagnosis, patients should be advised to begin joint rest immediately to allow the muscles of mastication to relax and reduce mandibular condyle movement. Instructions include avoiding chewing gum, biting nails, or talking excessively. Patients should follow a soft diet and should be counselled to reduce stress.[49]​ Stress may lead to para-functional habits like bruxism or clenching. Relaxation techniques such as diaphragmatic breathing may be beneficial.[2]​ Advise patients to massage the areas of spasm for 1 minute, four times per day.

Cognitive behavioural therapy (CBT)

CBT aims to teach patients how to cope up with their pain. CBT with or without biofeedback or relaxation therapy is the ideal psychological treatment for managing chronic pain.[4][50]​​​[51]​​​ In one randomised controlled trial, CBT reduced pain and disability to the same extent as occlusal splint therapy, but it was more effective at improving patient pain-coping skills.[52]​ One systematic review found that CBT was slightly better than alternative treatments in reducing pain intensity or psychological distress. However, the evidence was of low or very low certainty.[53]​ If CBT is unavailable, offer an alternative treatment.

Physiotherapy

​Physiotherapy may be useful if provided by a specialist TMD physiotherapist. ​One systematic review and meta-analysis found that therapy and exercise interventions reduced pain and improved maximum mouth opening in patients with TMDs.[54]​ In ​​patients with chronic pain associated with trigger points, manual trigger point therapy can be employed wherein a physiotherapist applies targeted pressure with hands to promote circulation in affected areas. This helps release muscle knots and provides relief from pain.[4][51]

Intra-oral devices, splints, night guards, and bite guards

​If symptoms do not improve after 2 weeks’ joint rest, patients may be referred to their dental practitioner to construct an oral splint. These should cover the whole of the occlusal surface of one arch. Some studies indicate that hard stabilisation appliances may be more effective in reducing temporomandibular joint pain than soft stabilisation appliances.[55] Splints may help in relieving muscle spasm, offloading the joints, and changing the oral habits of patients that may contribute to TMDs.

Evidence for the efficacy of splints is mixed and of low certainty. One systematic review indicated that splints are useful in reducing pain, but not in improving masticatory function.[56]

Another systematic review concluded that occlusive splint therapy, alone or in combination with other treatment modalities, effectively reduced pain.[57]​ However, one rapid review concluded that occlusal splint therapy was not recommended for the management of TMDs owing to lack of conclusive evidence.[58]​ Another systematic review found that evidence supporting the effectiveness of oral splints for the management of patients with TMDs and bruxism was of low certainty.[59]​ Irreversible oral splints are not recommended.[4][51]

In patients with chronic TMD pain (≥3 months), considerable reduction in pain can be achieved with CBT with or without biofeedback or relaxation therapy, therapist-assisted jaw mobilisation, and manual trigger point therapy.[4][51]

Supervised postural and jaw exercises under the guidance of a consultant TMD physiotherapist, stretching with or without manual trigger point therapy, and patient education and self-management, although less effective than other treatments, can also aid in the management of chronic TMD pain.​[4][51]

Pharmacological therapy

Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose antidepressants, or anticonvulsants can be used in patients with acute or persistent TMD pain in whom non-pharmacological interventions do not provide relief. Opioids are drugs of last choice and should be avoided unless under the guidance of a pain physician. The choice of treatment should be based on patients’ overall assessment and the presence of comorbidities.[60]

NSAIDs are most frequently used for acute TMD (after 2 weeks of joint rest and <3 months of duration).​[60][61]​​​ Oral NSAIDs may be helpful to relieve pain, and can relieve pain and inflammation in patients with osteoarthritis or internal derangement.[62][63]​​​​​ Topical NSAIDs (e.g., diclofenac) can be applied over the temporomandibular joint to alleviate joint pain. One systematic review reported reduction in pain and improved range of motion with NSAIDs, but a consensus could not be reached because of heterogeneity.[62]​ Topical NSAIDs may be preferred because limited evidence suggests they are as effective as oral NSAIDs, but do not cause gastrointestinal side effects.[62]

Muscle relaxants act by reducing muscle hyperactivity and relieving muscle-related symptoms, and are typically used at initial presentation for up to 2 weeks.[60]​ Benzodiazepines (e.g., diazepam), if used, must be limited to the initial treatment phase only (up to 2 weeks).[64]​ Benzodiazepines are associated with misuse, abuse, and addiction, and should only be prescribed under the guidance of a pain management clinician. If TMD symptoms are muscle-related, cyclobenzaprine may be prescribed.[61][64]​​[65]​​​​​​ Cyclobenzaprine is structurally related to benzodiazepines. It is contraindicated in patients with hyperthyroidism, congestive heart failure, arrhythmias, and recent heart attacks.[60]​

Low-dose tricyclic antidepressants (e.g., amitriptyline) may aid in the management of chronic TMD pain (>3 months duration).[61][64][66]​​​​​ One randomised controlled trial found that low doses of amitriptyline reduced orofacial pain due to TMD.[67][68]​​​ Adverse effects of tricyclic antidepressants include sedation, dizziness, blurred vision, constipation, cardiac complications, and xerostomia.[61][65]​​ Caution should be exercised when using these drugs in older patients and in those with cardiac conditions. Selective serotonin-reuptake inhibitors (SSRIs), one of the commonly used antidepressants, may cause jaw pain and/or bruxism, which can further exacerbate TMDs.[41][42][43]​​ Thus, they are not recommended for patients with TMDs.[69]

Anticonvulsants (e.g., gabapentin, pregabalin) may be prescribed to patients in whom temporomandibular joint surgery has failed or to those with persistent/chronic pain (>3 months duration).[61][64][70]​​

Opioid analgesics can effectively reduce pain and have been used in dentistry to manage moderate to severe pain. Opioids are generally not recommended in TMDs, and their use should be restricted for patients with chronic pain (>3 months duration) in whom non-opioid therapies are ineffective.[64]​ Opioids (e.g., codeine, oxycodone) may be prescribed for short-term management of severe TMD pain.[60]​ Hydromorphone may be used for severe intractable pain.[61][65]​ Judicious use under physician supervision is warranted. Long-term use for chronic pain management is discouraged as it can result in addiction and/or overdose.[4][51][61][65]​ Fentanyl transdermal patches can be used as an alternative to the oral route.[60]

Surgery

Referral to a maxillofacial surgeon should be considered urgently for patients with acute severe restriction of opening. Failure of improvement of symptoms of pain, restriction of opening, or locking after at least 6 weeks of management with splint, rest, and muscle massage warrants surgical intervention.

Surgery can be considered in patients with persistent significant joint pain, dysfunction that is disabling, and/or evidence of pathological conditions. Surgical procedures include arthrocentesis, arthroscopy, condylotomy, arthroplasty. disc surgery, and total TMJ replacement and normally follow a stepwise approach.[58][71]​​[72][73]

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