Version May 2024
INTRODUCTION — Temporomandibular disorders (TMD) are commonly encountered by primary care providers. Although they have been classified in a number of different ways [1], they are most reasonably classified as a subtype of secondary headache disorder [2]. In 2020, a collaborative group (including the American Academy of Orofacial Pain [AAOP], the International Headache Society [IHS], the Orofacial and Head Pain Special Interest Group [OFHP SIG] of the International Association for the Study of Pain [IASP], and the International Network for Orofacial Pain and Related Disorders Methodology [INFORM]) produced the first International Classification of Orofacial Pain [3], the first comprehensive classification system dealing exclusively with orofacial pain conditions, which is modelled on the International Classification of Headache Disorders.
The goals of TMD management are to alleviate pain and to improve jaw function and quality of life.
This topic will review the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of TMD. The evaluation and management of temporomandibular joint (TMJ) dislocation is reviewed separately. (See "Temporomandibular joint (TMJ) dislocation".)
EPIDEMIOLOGY — Temporomandibular disorders (TMD) are common, with a systematic review suggesting a prevalence as high as 31 percent in adults and 11 percent in children [4]. TMD is associated with substantial morbidity, affecting quality of life and work productivity. As an example, it is estimated that for every 100 million working adults in the United States, TMD contributes to 17.8 million lost workdays annually [5]. TMD patients have also been shown to use health care services at a higher rate, with a mean health care expenditure that is 1.6 times higher when compared with non-TMD individuals [6].
In observational studies:
●The prevalence of TMD is about 1.5 times higher in females than males [7,8].
●The greatest risk of onset of TMD is between the ages of 18 and 44 [7].
●Non-Hispanic White persons have a higher risk for TMD [9]. There does not seem to be an association with socioeconomic status.
●There is an association between chronic TMD and mood disorders as well as other psychiatric comorbidities [10-17].
●There is an increased prevalence of TMD among patients with rheumatoid arthritis, ranging from 50 to 94 percent [18-20].
●TMD may be associated with teeth grinding (bruxism) [21].
●TMD is more common among people with medical comorbidities, other pain conditions, poor sleep quality, and cigarette smoking [22].
●Although there is a lack of high-quality evidence, repetitive jaw motions (eg, clenching, grinding, or gritting of teeth; gum chewing and pencil biting) and jaw positions (eg, scuba divers, violinists/violists, singers, woodwind players) are believed to be associated with TMD pain [23].
ANATOMY OF THE TMJ AND RELATED STRUCTURES — The temporomandibular joint (TMJ), a hinged joint, is the articulation between the mandibular condyle and the glenoid fossa of the temporal bone (figure 1). The TMJ is a fibrocartilaginous joint, with a capsule, an articular disc, and synovial membranes.
The muscles of mastication which primarily affect TMJ function include the masseter, temporalis, and medial and lateral pterygoid muscles (figure 2). Innervation of these muscles is provided by branches of the motor division (V3) of the trigeminal nerve, which also innervate the muscles of the middle ear. In addition, the tensor tympani (the muscle within the ear responsible for dampening loud sounds) and the tensor palati (the muscle involved in soft palate elevation and eustachian tube function) wrap around the hamular notch of the posterior maxilla.
PATHOGENESIS — Temporomandibular disorders (TMD) were previously attributed solely to alterations in dental occlusion (the alignment of the upper and lower teeth) that affected maxillomandibular position and function. However, although there is a structural component to TMD, there are also multiple contributing and comorbid factors, including biological, behavioral, environmental, and cognitive, which can all contribute to the development of symptoms [22,24-27]. Decades of research have determined that TMD is not simply a manifestation of biomechanical issues but rather a complex disease involving an interplay of multiple genetic, psychological, and environmental domains [22]. Most experts consider chronic TMD a biopsychosocial pain condition with many features similar to other chronic pain disorders [28,29]. (See "Evaluation of chronic non-cancer pain in adults", section on 'Chronic pain in context'.)
Several factors can contribute to the development of TMD symptoms including:
●Joint trauma – Trauma to the temporomandibular joint (TMJ) can result from cervical sprain injuries [30], bruxism, or injuries to the jaw [31]. Damage to the affected TMJ ligaments, articular cartilage, disc, and bone results in oxidative stress and generates free radicals within the intraarticular space. Subsequent synovial fluid inflammation produces cytokines that causes degenerative TMJ disease [32-36].
●Cervicogenic etiology – Poor head and cervical posture may contribute to TMD and pain because of the muscular attachments connecting the mandible, head, and neck [37]. Although in one systematic review, the poor methodology of included studies limited the ability to determine an association [38], in a subsequent small series, deep cervical plexus blocks were beneficial in relieving pain in some patients with orofacial and TMD pain [39].
●Pain threshold and processing – There is a subjective component to the perception of pain in TMD; differences in pain modulation have been reported in individuals with TMD compared with healthy controls. As an example, in a small case-control study, females with TMD demonstrated lower pain tolerance than control subjects [40].
Central pain processing may have a role in pain perception in patients with TMD. Among people with TMD, functional brain imaging studies demonstrated increased activation in cortical regions (eg, somatosensory, anterior cingulate, and prefrontal) and decreased thalamic activation [41]. This pattern of neural activation is similar to that seen in patients with other chronic pain disorders and may be related to abnormal pain processing in the trigeminal system. Myofascial pain disorders, in particular, may reflect a central sensitization or pain producing process [42]. (See "Evaluation of chronic non-cancer pain in adults", section on 'Chronic pain in context' and "Evaluation of chronic non-cancer pain in adults", section on 'Definition of pain'.)
Furthermore, genetic studies suggest that in TMD patients, certain gene polymorphisms (eg, the catechol-O-methyl transferase [COMT] gene) might be associated with differences in pain response and processing [43-45].
Among patients with TMD, there may be an association between increased sympathetic tone and the chronicity of symptoms [46,47].
●Psychological factors – Some studies support an association between chronic TMD and psychological conditions, including anxiety, depression, posttraumatic stress disorder, or a history of abuse [10-15]. In a small observational study, depression, compared with euthymia, was associated with an increased risk of TMJ pain (table 1) [48].
CLINICAL MANIFESTATIONS — Symptoms of temporomandibular disorder (TMD) are characterized by acute or chronic pain and may include pain and dysfunction of the temporomandibular joint (TMJ), headache, and earache. The anatomic source of pain can originate from the joint itself or from the muscles of mastication (figure 2).
In a retrospective study including over 4500 patients with TMD, the most common presenting signs and symptoms were [49]:
●Pain (96 percent)
●Ear discomfort or dysfunction (82 percent)
●Headache (80 percent)
●TMJ discomfort or dysfunction (75 percent)
Facial pain — The pain of TMD is classically described as a dull, unilateral facial ache that is constant but waxes and wanes in intensity. The pain may radiate to the ear, temporal and periorbital regions, the angle of the mandible, and frequently to the posterior neck. It may be present intermittently, with many patients having pain-free periods, alternating with episodes of sharper, more intense pain. When present, it is aggravated by jaw motion. Patients may describe a "sinus" pain in the zygomatic or orbital area [50].
Nocturnal or daytime jaw clenching, tooth grinding, or other jaw habits may cause muscle discomfort or fatigue. Patients may notice this after meals and report a "heavy" and "tired" feeling in the jaw muscles chewing.
Ear pain, fullness, and tinnitus — TMD may also present with otologic symptoms, including otalgia, aural fullness, and tinnitus due to the close anatomic relationship with nerves that innervate the muscles of the ear [51-54]. (See 'Anatomy of the TMJ and related structures' above.)
Patients with internal derangement of the TMJ frequently report unilateral sharp, jabbing ear pain with jaw movement. Otalgia and other ear symptoms in the presence of a normal otologic examination are among the most common reasons to evaluate for TMD as the etiology of these symptoms.
Tinnitus can also have a peripheral musculoskeletal etiology (ie, somatic tinnitus) [54]. Specifically, cervical and mandibular postural factors (eg, repetitive movements and postures) that may affect musculoskeletal mechanics have been noted in some individuals with tinnitus. In some patients, tinnitus may be improved by altering maxillomandibular relationships and through manual physical therapy treatment focusing on the cervical paraspinal musculature. (See "Etiology and diagnosis of tinnitus".)
Headache — The typical headache associated with TMD is described as pain that radiates to the jaw, temple, or forehead. It can be unilateral or bilateral and is typically dull, aching, continuous, moderate in intensity, and worse in the morning [55-57]. Morning TMD headaches may be related to nocturnal bruxism or sleep disorders [58], while discomfort that increases over the day may be due to masticatory muscle over-use or head and neck posture [59].
Some individuals present with headache without being aware of a TMD problem [60-62]. In addition to the typical headache, other types of TMD-related headache include:
●Frontal headache – Patients may complain of a "sinus headache" with accompanying pressure along the upper front teeth, bridge of the nose, and behind the eyes. Contractions or tension of the posterior neck muscles or frontalis muscle may also cause band-like pains in the front of the head.
●Temporal headache – Temporal headaches related to TMD are primarily caused by muscle contraction and spasm of the temporalis muscles (figure 2). The anterior temporalis muscle fibers bring the lower jaw up and forward; the middle and posterior temporalis fibers swing the jaw closed and retract the mandible.
Generally, the temporalis muscle is affected by any dysfunction of the lower jaw [63]. Headaches in the temporal area may be induced by recurrent pencil or pen biting or gum chewing. Teeth clenching, grinding, or biting on objects while the jaw is in an anteriorly displaced position causes pain in the anterior temporalis group (figure 2). In particular, individuals who work at computers where the head is kept forward and down may develop postural problems that can affect the TMJ and muscles of mastication.
Bruxism during sleep fatigues the middle and posterior group of temporalis fibers, causing pain in a more posterior temporal location. Among patients with TMD and bruxism, the temporalis tendon attachment to the coronoid process of the mandible is frequently tender to palpation (figure 1); this is often overlooked during the evaluation of facial pain.
●Occipital headache – Deep, dull, constant pain in the back of the head is usually caused by spasms of the trapezius and sternocleidomastoid muscles. When tensed or strained, these muscles pull on their bony attachments to the skull in the occiput and mastoid areas, leading to soreness in the bone and pain radiating to the back of the head and neck.
Jaw and TMJ dysfunction — Jaw and TMJ dysfunction manifest as decreased mandibular range of motion, clicking or popping noises with jaw movement, or jaw deviation to the affected side. Intermittent jaw locking may be present and is experienced as the temporary inability to open the mouth. Symptoms are usually worse in the morning with improvement and resolution over the day. The symptoms can, however, progress to permanent jaw locking in the closed position.
Other symptoms — Other symptoms which also may be associated with TMD include:
●Neck pain – Cervical pain and stiffness are commonly associated with TMD symptoms [64-67]. Trauma, poor posture, and musculoskeletal tension in the cervical area may contribute to pain, stiffness, and trigger points in the muscles of the head and neck.
●Orbital pain – Orbital and periorbital pain symptoms may be seen in patients with TMD and are typically unilateral and described as "boring" and constant [50,68-70]. (See 'Headache' above.)
●Dizziness – Individuals with TMD may experience dizziness or vertigo that is associated with aural fullness or otalgia. In such cases, other causes of dizziness should be considered. (See "Approach to the patient with dizziness".)
EVALUATION
Diagnosis typically established by history and physical examination — The diagnosis of temporomandibular disorders (TMD) is based primarily upon the history, including the patient's constellation of symptoms, and compatible physical examination findings.
●History – For all patients with suspected TMD, we perform a focused history with specific attention to [71]:
•Facial pain, including the nature and location of the discomfort, and any aggravating and relieving factors.
•Jaw symptoms, including pain with jaw function, limitation of jaw movement, cracking or popping noise with jaw function, and jaw muscle fatigue after eating.
•Ear symptoms, including pain, aural fullness, tinnitus, vertigo, hearing loss.
•Pain in the head, neck, shoulder, and upper back [72].
•Headaches, including "sinus headache" and temporal or occipital pain.
•A history of previous TMJ surgery or trauma.
•A history of arthritis (including osteoarthritis or inflammatory arthritis).
•"Habits" such as pencil biting, gum chewing, or clenching, gritting or grinding of teeth.
•Hobbies or occupational factors (eg, scuba diving, violin or woodwind instrument playing, singing).
•Bruxism, either night (sleep-related) or daytime (awake).
•Evaluation for depression and anxiety as well as the presence of other chronic pain symptoms [73].
•Sleep quality [27].
●Physical examination- We perform a focused physical examination with attention to the TMJ as well as the surrounding structures of the head and neck:
•Abnormal mandibular movements – We ask the patient to open and close their mouth, observing for any jaw deviation or protrusion with these movements [74]. We check for normal alignment of upper teeth and lower teeth (picture 1).
•Decreased TMJ range of motion – We evaluate the range of motion of the TMJ by measuring the distance between the incisal edges of the upper and lower teeth when asking the patient to open their mouth as wide as possible. The normal functional opening is 35 to 55 mm [23,74]; in patients with TMD, it is typically less than 25 mm and is often associated with pain.
•Palpation for tenderness and crepitus – We palpate the muscles of mastication (including the masseter, temporalis, and medial and lateral pterygoids), assessing for muscle tenderness [75]. We also palpate the lateral pole of the mandibular condyle (figure 1) for tenderness and feel for joint crepitus (clicking or crunching during opening and closing movements).
•Pain with dynamic loading – We have the patient bite down with a cotton roll or tongue blade between the upper and lower canine teeth on each side; this compresses the contralateral TMJ and will cause pain if inflammation is present in the joint Alternatively, this can be evaluated by grasping the mandible on both sides, pressing down and back, compressing the TMJ bilaterally [74].
•Evaluate for bruxism – We examine the dentition, looking for signs of tooth wear (teeth that are fractured, chipped, or with areas of worn enamel on the chewing surfaces). The patient can also be referred to a dental professional for evaluation of bruxism.
•Postural asymmetry – We assess upper body and neck posture, inspecting for slouching or a preference to lean to one side.
•Neuromuscular examination of the head, neck, and face – We inspect and palpate the muscles of the neck (anterior and posterior) and shoulders, assessing for muscle tension, generalized tenderness, or focal trigger points. In addition, we perform a general cranial nerve examination with a focused examination specifically checking for decreased sensation in the trigeminal nerve (CN V) distribution and facial nerve (CN VII) function.
Imaging for patients with severe or persistent symptoms — For the majority of patients in whom TMD is suspected, the diagnosis can be made based upon the history and physical examination alone. However, for patients with more severe symptoms and those with persistent symptoms that fail to respond to education and self-care, we obtain imaging to rule out local pathology in the teeth and jaw bones; a screening panoramic radiograph or cone beam computed tomography (CBCT) are both reasonable choices. We advise against the routine use of a standard radiograph of the TMJ, as this study does not provide valuable information regarding dentition and mandibular alignment and symmetry.
In addition, for those patients in whom the diagnosis remains uncertain (eg, for those without typical historical features or findings on physical examination), or for those in whom another diagnosis is suspected (eg, a mandibular or soft tissue tumor, sinus infection), further imaging may be necessary:
●If sinusitis is a concern, CT of the sinuses without contrast can be done; if CT scan is not available, sinus radiographs can be obtained.
●The mandible and surrounding soft tissues, including the neck, parotid glands, and the muscles of mastication, can be evaluated with CT. In addition, the structure of the TMJ can be imaged in greater detail with magnetic resonance imaging (MRI).
DIFFERENTIAL DIAGNOSIS — Although a careful history and physical examination will typically distinguish between the numerous causes of orofacial pain, some potentially serious disorders may present with similar symptoms [76]. (See "Overview of craniofacial pain".)
Such disorders include:
●Dental disorders, including malocclusion, dental abscess, caries, and periodontal disease. (See "Epidemiology, pathogenesis, and clinical manifestations of odontogenic infections" and "Overview of gingivitis and periodontitis in adults".)
●Benign disorders of the parotid glands. (See "Suppurative parotitis in adults" and "Salivary gland swelling: Evaluation and diagnostic approach" and "Salivary gland stones", section on 'Clinical features'.)
●Acute and chronic rhinosinusitis. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)
●Otologic disorders, including acute otitis media, otitis media with effusion, Eustachian tube dysfunction, middle ear trauma, barotrauma, and causes of tinnitus. (See 'Ear pain, fullness, and tinnitus' above and "Acute otitis media in adults", section on 'Clinical manifestations' and "Acute otitis media in adults", section on 'Otitis media with effusion' and "Evaluation and management of middle ear trauma", section on 'Evaluation' and "Ear barotrauma" and "Etiology and diagnosis of tinnitus", section on 'Introduction'.)
●Head and neck cancer, including tumors of the oropharynx, mandible, muscles, and salivary glands. (See "Overview of the diagnosis and staging of head and neck cancer" and "Salivary gland tumors: Epidemiology, diagnosis, evaluation, and staging" and "Osteosarcoma: Epidemiology, pathology, clinical presentation, and diagnosis".)
●Trigeminal neuralgia, which is classically described as recurrent brief episodes of sharp, superficial, lancinating pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve (figure 3). (See "Trigeminal neuralgia".)
●Glossopharyngeal neuralgia, which is less common than trigeminal neuralgia and is characterized by brief, paroxysmal episodes of severe, stabbing pain involving the ear, tonsillar fossa, base of the tongue, or under the angle of the jaw.
If these symptoms occur, evaluation by an otorhinolaryngologist is mandatory as symptoms can be caused by a nasopharyngeal tumor or other malignancy of the upper aerodigestive tract. (See "Overview of craniofacial pain", section on 'Glossopharyngeal neuralgia'.)
●Postherpetic neuralgia, which is typically described as a burning discomfort, with many patients experiencing areas of anesthesia accompanied by thermal, tactile, pinprick, and vibratory deficits within the affected dermatomes. A history of skin rash is consistent with the diagnosis. (See "Postherpetic neuralgia".)
●Carotidynia, which encompasses pain syndromes caused by non-inflammatory conditions of the carotid or vertebral arteries. (See "Overview of craniofacial pain", section on 'Secondary causes'.)
●Headache syndromes, including temporal arteritis (giant cell arteritis [GCA]), migraines, cluster, and tension headaches. (See "Evaluation of headache in adults".)
•In GCA, the headache is typically unilateral. In addition, nearly one-half of GCA patients experience jaw claudication, characterized by mandibular pain or fatigue brought on by mastication and relieved by stopping. However, unlike temporomandibular disorders (TMD), there is classically a palpable, tender, pulseless temporal artery on examination in GCA. (See "Clinical manifestations of giant cell arteritis".)
•Migraine headaches are typically unilateral, but unlike TMD are often accompanied by nausea, vomiting, and phono- or photophobia. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)
•Cluster headaches are characterized by unilateral orbital, supraorbital, or temporal pain. However, unlike TMD-related headaches, cluster headaches are accompanied by autonomic symptoms ipsilateral to the pain, such as ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. Occasionally, symptoms may involve the upper jaw and can be mistaken for dental pain. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".)
•Tension-type headaches and TMD can present with similar symptoms: They may be distinct but overlapping conditions, or they may exist as part of a continuum of headache disorders [77]. When seen together, they need to be addressed concurrently [78]. (See "Tension-type headache in adults: Etiology, clinical features, and diagnosis" and "Tension-type headache in adults: Preventive treatment".)
●Temporomandibular joint (TMJ) dislocation is an acute, painful event which typically follows extreme jaw opening (eg, yawning, shouting). On examination, the patient is unable to close their mouth, and a depression may be noted in the preauricular area where the mandibular condyle has come out of the fossa. (See "Temporomandibular joint (TMJ) dislocation" and "Initial evaluation and management of facial trauma in adults".)
TREATMENT — Our management approach is based upon clinical experience, as there are few high-quality data informing the treatment of temporomandibular disorders (TMD) [79-90].
Our approach is similar to that used in other pain conditions, with a combined, multi-modal treatment strategy. We begin with patient education and self-care for all patients, and we use adjunctive pharmacotherapy when necessary. For those patients with a prominent muscular component to their pain, an occlusal splint (worn at night and/or during the day) along with physical therapy can be helpful; for patients with psychological comorbidities that increase the risk for developing chronic pain or disabling symptoms, we refer for biobehavioral management. In addition, trigger point, botulinum toxin, and intraarticular temporomandibular joint (TMJ) injections may also have a role.
In a 2023 network meta-analysis of 153 trials comparing therapies for chronic pain due to TMD, the three most effective therapies (determined by decrease in pain reported on a visual analog scale) were cognitive behavioral therapy with biofeedback or relaxation therapy, therapist-assisted jaw mobilization, and manual trigger point therapy [91].
In another 2023 network meta-analysis, evidence supported a different treatment approach for patients with symptoms related to the masticatory muscles (TMD-M) compared with the temporomandibular joint (TMD-J) [92]. For TMD-M, wet needling techniques were most effective, while other treatment approaches, including NSAIDs, were best for patients with symptoms of the temporomandibular joint.
For patients who have persistent functional limitations despite three to six months of nonsurgical management, and who have structural anatomic pathology or intraarticular disorders, surgical intervention may be a treatment option.
Initial management for all patients
Patient education and self-care — For all patients with TMD, we suggest education and self-care measures. We provide education regarding the natural history of the condition and the rationale behind our treatment approach [93]. In addition, individuals are counseled on self-care measures including optimal head posture, jaw exercises (picture 2 and picture 3), proper sleep hygiene, as well as avoidance of triggers (eg, oral behaviors such as nail biting, pen chewing) if these factors contribute to symptoms. Patients typically improve with these conservative interventions.
There are limited high-quality data supporting the use of self-care and education in the treatment of TMD [93-96]; however, given the lack of harm and the potential benefit, these interventions are appropriate for all patients.
Evaluate and treat contributory factors
Physical therapy for musculoskeletal causes — For patients with TMD, particularly those with a prominent musculoskeletal component or cervical or shoulder symptoms, we refer for physical therapy evaluation and treatment. Components of physical therapy may include TMJ mobilization and stability exercises, massage (to jaw, facial, and/or neck muscles), and postural evaluation and instruction.
There is, however, a lack of high-quality data evaluating the overall efficacy of physical therapy in the management of TMD, with methodologic issues limiting comparison between treatments [97-99]. However, for patients with identifiable contributors, we find that physical therapy directed at the underlying cause of the TMD is often helpful. The efficacy of physical therapy interventions may vary depending upon the skill and experience of the physical therapy provider in treating TMD.
Occlusal (bite) splints for musculoskeletal symptoms or bruxism — For some patients with TMD, particularly those with prominent musculoskeletal symptoms or evidence of bruxism, occlusal splints fitted by a dental clinician can be used as an adjunctive therapy along with other TMD treatments.
For TMD patients with musculoskeletal symptoms, occlusal splints (worn at night and/or during the day) can be helpful when used with a physical therapy program [100].
In addition, for some patients with TMD clearly attributable to bruxism, the use of occlusal splints fitted by a dental clinician can provide some relief of symptoms. However, evidence supporting the efficacy of occlusal splints among all patients with TMD is mixed with some systematic reviews demonstrating a benefit and others demonstrating no improvement [101,102].
The evaluation and diagnosis of bruxism (sleep-related and awake) are reviewed elsewhere. (See "Sleep-related bruxism (tooth grinding)" and "Polysomnography in the evaluation of abnormal movements during sleep", section on 'Sleep-related bruxism'.)
Biobehavioral management for psychological contributors — For patients with comorbid depression, anxiety, and stress disorders, biobehavioral management is used as adjunctive therapy in TMD treatment. Risk factors for chronic TMD may be similar to those for other chronic pain syndromes [37,47], and addressing psychological contributors to pain is an essential component of pain management consistent with a biopsychosocial pain model. (See "Evaluation of chronic non-cancer pain in adults", section on 'Chronic pain in context'.)
In some trials, the addition of biobehavioral management, including biofeedback and cognitive behavioral therapy [CBT]) to usual care resulted in short-term improvement in TMD symptoms [103] and reduced overall medical utilization [104]. In a meta-analysis including 15 trials of patients with TMD, CBT, either alone or in combination with biofeedback, resulted in long-term improvement in activity interference and pain level [105]. However, the meta-analysis was limited by the small number of high-quality trials and the risk of bias.
Adjunctive pharmacologic therapy — For patients with persistent symptoms despite education and self-care, we use adjunctive pharmacotherapy concurrently with other treatments. Although nonpharmacologic therapy is generally preferred over pharmacologic therapy, they are commonly used together in clinical practice [106,107].
We use nonsteroidal antiinflammatory drugs (NSAIDs), tricyclic antidepressants (TCAs), and muscle relaxants in the treatment of TMD [82-85,87,108]. Although these agents are used in the treatment of many acute and chronic pain disorders, particularly myofascial pain disorders, there is a lack of high-quality evidence supporting their efficacy in treating chronic TMD [109].
NSAIDS for acute management — For patients with persistent TMD pain, we suggest using an NSAID as first-line pharmacologic therapy. We generally treat patients with a 10- to 14-day course of a long-acting NSAID (eg, naproxen 250 to 500 mg orally twice daily) [109]. We encourage patients to take the lowest effective dose of an NSAID for the shortest period of time.
For patients unable to take oral NSAIDs, topical diclofenac massaged into the skin over the painful muscle or joint (1% gel, 2 to 4 g applied two to three times daily; or 2% solution, one to two pump actions applied two times daily) can be helpful. As with oral NSAIDS, we treat for the shortest possible period, generally no longer than 14 days.
NSAIDs are associated with well-known gastrointestinal and renal side effects. In addition, exposure to NSAIDS is associated with an increased risk of myocardial infarction, which may be related to the degree of cyclooxygenase 2 (COX-2) inhibition [110]. Cardiovascular and gastrointestinal risk factors should be assessed before prescribing NSAIDs. (See "NSAIDs: Adverse cardiovascular effects" and "Nonselective NSAIDs: Overview of adverse effects".)
Acetaminophen can also be helpful to relieve pain but has no antiinflammatory properties and may be less effective for many patients. When used, we advise acetaminophen 650 mg orally every six hours as needed (maximum 3 g per 24 hours) for most adults, although we would use a lower total daily dose for older adult patients and those with any hepatic impairment.
Skeletal muscle relaxant for muscle tenderness — For patients with tenderness of the muscles of mastication, we suggest treatment with a skeletal muscle relaxant in addition to an NSAID. Examples include:
●Cyclobenzaprine 5 to 10 mg orally once daily at bedtime
●Metaxalone 400 to 800 mg orally every eight hours
For TMD, we generally prescribe the skeletal muscle relaxant to be taken as a scheduled dose rather than "as needed"; in our clinical experience, it is more effective for this indication when taken regularly.
Due to its sedating properties, we advise that cyclobenzaprine be taken only at bedtime; metaxalone is prescribed if daytime use is preferred. In addition, patients who may be more sensitive to the sedating effects of muscle relaxants may better tolerate a reduced starting dose, less frequent administration, and more gradual titration.
For most patients, we prescribe the muscle relaxant for 10 to 14 days only. However, some patients with persistent muscular pain may benefit from an additional week of treatment. In a trial of 41 patients with TMD, treatment with cyclobenzaprine (10 mg at night) was compared with clonazepam and placebo; cyclobenzaprine improved jaw pain upon awakening compared with the other groups [83].
Tricyclic antidepressants for persistent pain — For patients with persistent TMD symptoms that warrant continued adjunctive pharmacotherapy after two weeks of NSAID treatment (or three weeks for those patients taking additional skeletal muscle relaxants), we suggest treatment with a TCA.
We typically use nortriptyline, starting at 10 mg orally once daily at bedtime, increasing the dose at weekly intervals in 10 mg increments (based on response and tolerability) to a maximum dose of 25 to 50 mg once daily at bedtime. Higher doses may not be tolerated due to side effects (eg, dry mouth, somnolence, weight gain) and are rarely used for TMD patients. In our dental practice, we typically prescribe a maximum of 25 mg; if a higher dose is required, we prescribe it in consultation with the patient's primary care clinician or other appropriate consulting physician. It can take up to 6 to 12 weeks, including two weeks at the highest dose tolerated, for an adequate treatment trial.
For patients whose symptoms respond adequately to treatment with a TCA, we reduce the dose slowly using the same increments we used for up-titration, and we continue the patient on the lowest effective dose for approximately four more months. If pain management remains adequate, the medication is tapered off over a period of four to six weeks. If pain recurs as the TCA is tapered off, the medication taper is discontinued and the lowest effective TCA dose is resumed.
Treatment for TMD with tricyclic antidepressants has been found to be of benefit in some patients, especially if TMD is part of generalized chronic muscular pain [23]. As an example, in a small trial of 12 TMD patients, those treated with amitriptyline (25 mg daily for 14 days) had a decrease in pain compared with placebo (75 versus 28 percent, respectively) [108].
In older adults, starting doses of tricyclics should be reduced by one-half, and dose escalation should be done more slowly. We avoid the use of TCAs with greater anticholinergic effects (ie, amitriptyline) in this population. In addition, TCAs should be avoided in patients with cardiac conduction system abnormalities. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Tricyclic antidepressants'.)
Interventional management for some patients — For certain patients, such as those with severe arthritis of the TMJ and patients with persistent symptoms due to internal derangement and joint pathology, interventional treatments may be offered.
Arthritis of the TMJ — Patients with arthritis of the TMJ (documented on imaging) are generally managed in the same way as other TMD patients (eg, self-care and education, physical therapy, occlusal splints, behavioral therapy, adjunctive pharmacotherapy). However, some may have persistent symptoms and may benefit from interventional management.
In a systematic review including randomized trials evaluating different intraarticular injections (eg, hyaluronic acid, corticosteroids, and blood products such as platelet-rich plasma), all studied injectables (in conjunction with arthrocentesis) were effective in alleviating pain and improving mandibular function in TMJ osteoarthritis [111]. In a meta-analysis of randomized clinical trials including patients with arthritis of the TMJ, there was moderate-quality evidence that minimally invasive TMJ procedures, including intraarticular injections, improved pain and function compared with noninterventional treatments in the short and intermediate term [112].
●Osteoarthritis – Patients with TMJ osteoarthritis (documented on imaging) and acute pain may benefit from intraarticular injection of a long-acting glucocorticoid (eg, beclomethasone) or hyaluronic acid into the joint [78,113-117].
We prefer glucocorticoid injection rather than hyaluronic acid, and we typically use 10 mg methylprednisolone injected into the upper joint space (0.5 mL of a 20 mg/mL solution) following a local auriculotemporal nerve block using bupivacaine 0.5% with epinephrine. There are few high-quality data demonstrating the efficacy of this approach, but in our clinical experience an injection can provide symptomatic relief of pain for up to six months in selected patients [115].
In general, we limit injections to two to three injections separated by at least four to six weeks. If there is no clinical response to the first injection, a second injection may be given; if there is no response to the second injection, no further injections are offered. Injections are reserved for patients with significant arthritic change. Those patients whose symptoms are refractory to injections may be candidates for surgical intervention. (See 'Refractory temporomandibular disorders' below.)
●Rheumatoid arthritis – For patients with TMD and rheumatoid arthritis affecting the TMJ, in addition to the standard initial management for TMD, patients are referred for appropriate medical management of rheumatoid arthritis. (See "General principles and overview of management of rheumatoid arthritis in adults".)
If medical management of rheumatoid arthritis is inadequate in controlling symptoms, surgical treatment may be appropriate. (See 'Refractory temporomandibular disorders' below.)
Refractory temporomandibular disorders — For patients with TMD symptoms refractory to noninvasive management, including self-care and education, physical therapy, occlusal splints, behavioral therapy, and adjunctive pharmacotherapy, referral to an oral and maxillofacial surgeon with experience in managing TMD is warranted. Treatment options for these patients include trigger point muscle injections [118], botulinum toxin injections, intraarticular injections, or, in some patients, surgery, such as arthrocentesis, arthroscopy, arthroplasty, or TMJ reconstruction [119,120].
For TMD patients with predominantly musculoskeletal symptoms, trigger point injections and botulinum injections might be beneficial. Botulinum toxin can be injected into the masseter and temporalis muscles; this can also be combined with trigger point injections of long-acting local anesthesia (eg, bupivacaine) into the temporalis tendon and other muscles [121].
For some patients, such as those who have structural anatomic pathology on imaging (eg, internal derangement of the TMJ including displacement of the disc meniscus) and persistent jaw locking severe enough to interfere with activities of daily living despite three to six months of nonsurgical management, we suggest surgical intervention. The specific surgical intervention indicated will depend upon the specific intraarticular disorder [120,122-126]. As examples, severe condylar destruction due to osteoarthritis, rheumatoid arthritis, or progressive condylar resorption may cause pain, limitation of motion, and bite change; in such cases, joint reconstruction with costochondral grafts or total joint prostheses may be necessary. In these patients, jaw motion and occlusion can often be restored and quality of life improved with surgery [127,128]. However, pain relief from surgical intervention is more variable as there is often a myofascial pain component and chronic pain that requires multimodal management.
TREATMENTS OF LIMITED VALUE — Benzodiazepines and opioids are infrequently used in the management of temporomandibular disorders (TMD). Rarely, we may prescribe them for a patient with acute, severe pain (eg, as a result of trauma); however, symptoms are rarely severe enough to justify their use. Further, there is no evidence to support the long-term use of benzodiazepines or opioids in the management of TMD [83,109,129]. Further, there are risks of substance use disorder and overdose, particularly if taken in combination, and the risk and benefits should be carefully evaluated before prescribing them [130].
Prolotherapy, the injection of a 12 to 15% dextrose solution into the temporomandibular joint (TMJ), is being used as an option in some patients with persistent TMD symptoms, although there is limited high-quality evidence to support its use [131-133].
There are no high-quality data supporting the efficacy of alternative and complementary therapies in the management of TMD [134,135].
PROGNOSIS — In the general population, temporomandibular disorder (TMD) symptoms are self-limiting and majority of individuals respond well to treatment, although a small minority of patients will go on to develop chronic TMD. Almost 90 percent of patients with TMD respond to noninvasive treatments [136].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Temporomandibular joint (TMJ) disorders (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Pathogenesis – Several factors can contribute to the development of temporomandibular disorder (TMD) symptoms, including temporomandibular joint (TMJ) trauma, poor head and cervical posture, differences in pain threshold and processing, and psychological factors such as depression and anxiety. (See 'Pathogenesis' above.)
●Clinical manifestations – Symptoms of TMD most commonly include facial pain: a dull, unilateral facial ache that is constant but waxes and wanes in intensity and is typically aggravated by jaw motion. Other common symptoms include earache, headache (typically frontal or temporal and often radiating to the jaw), and jaw and TMJ dysfunction (eg, decreased mandibular range of motion, clicking with jaw movement, intermittent jaw locking). (See 'Clinical manifestations' above.)
●Evaluation and diagnosis – The diagnosis of TMD is based primarily upon the history, including the patient's constellation of symptoms, and compatible physical examination findings. For patients with more severe symptoms and those with persistent symptoms, we obtain imaging to rule out local pathology in the teeth and jaw bones; a panoramic radiograph or cone beam computed tomography (CBCT) are both reasonable choices. We advise against the routine use of a standard radiograph of the TMJ, as this study does not provide valuable information regarding dentition and mandibular alignment and symmetry. (See 'Evaluation' above.)
●Initial management with patient education and self-care measures – For all patients with TMD, we suggest initial management with education and self-care measures (Grade 2C). This includes education regarding the natural history of TMD and counseling on optimal head posture, jaw exercises (picture 2 and picture 3), and proper sleep hygiene, as well as avoidance of triggers (eg, oral behaviors such as nail biting, pen chewing) if these factors contribute to symptoms. There are limited high-quality data supporting the use of self-care and education in the treatment of TMD; however, given the lack of harm and the potential benefit, these interventions are appropriate for all patients. (See 'Initial management for all patients' above.)
•Physical therapy for musculoskeletal causes – For patients with a prominent musculoskeletal component or cervical or shoulder symptoms, we refer for physical therapy evaluation and treatment. (See 'Physical therapy for musculoskeletal causes' above.)
•Oclusal (bite) splints as adjunctive therapy – For some patients with TMD, particularly those with prominent musculoskeletal symptoms or evidence of bruxism, occlusal splints fitted by a dental clinician can be used as an adjunctive therapy along with other TMD treatments such as physical therapy. (See 'Occlusal (bite) splints for musculoskeletal symptoms or bruxism' above.)
•Biobehavioral management for comorbid psychological conditions – For patients with comorbid depression, anxiety, and stress disorders, biobehavioral management is used as adjunctive therapy in TMD treatment. (See 'Biobehavioral management for psychological contributors' above.)
●Adjunctive pharmacotherapy for persistent symptoms – For patients with persistent symptoms despite education and self-care, we use adjunctive pharmacotherapy concurrently with other treatments. (See 'Adjunctive pharmacologic therapy' above.)
•For such patients, we suggest using a nonsteroidal antiinflammatory drug (NSAID) as first-line pharmacologic therapy rather than other medications (Grade 2C). We generally treat patients with a 10- to 14-day course of a long-acting NSAID (eg, naproxen 250 to 500 mg orally twice daily). (See 'NSAIDS for acute management' above.)
•For patients with tenderness of the muscles of mastication, we suggest treatment with a skeletal muscle relaxant in addition to the NSAID (Grade 2C). For most patients, we prescribe the muscle relaxant for 10 to 14 days only. However, some patients with persistent muscular pain may benefit from an additional week of treatment. (See 'Skeletal muscle relaxant for muscle tenderness' above.)
•For patients with persistent TMD symptoms that warrant continued adjunctive pharmacotherapy after two weeks of NSAID treatment (or three weeks for those patients taking additional skeletal muscle relaxants), we suggest treatment with a tricyclic antidepressant (TCA) rather than other therapies (Grade 2C). (See 'Tricyclic antidepressants for persistent pain' above.)
●Interventional management for severe or refractory symptoms – For patients with TMD symptoms refractory to noninvasive management, referral to an oral and maxillofacial surgeon with experience in managing TMD is warranted. Treatment options for these patients include trigger point muscle injections, botulinum toxin injections, and intraarticular injections. (See 'Interventional management for some patients' above.)
●Surgical referral for refractory symptoms despite nonsurgical interventions – For some patients, such as those who have structural anatomic pathology on imaging and persistent jaw locking severe enough to interfere with activities of daily living despite three to six months of nonsurgical management, we suggest surgical intervention rather than no surgery (Grade 2C). Although the specific surgery offered will depend upon the intraarticular disorder, such patients are unlikely to achieve adequate symptom control without surgical intervention. (See 'Refractory temporomandibular disorders' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Steven Scrivani, DMD, DMedSc, who contributed to an earlier version of this topic review.
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