Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

temporomandibular joint pain: at initial presentation

1st line – joint rest

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INITIAL
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temporomandibular joint pain: at initial presentation
1st line – 

joint rest

Upon diagnosis, patients should be advised to begin joint rest immediately to allow the muscles of mastication to relax and reduce mandibular condyle movement.

Patients should be instructed to avoid chewing gum, biting nails, or excessive talking. Patients should be placed on a soft diet.[49]

Plus – patient education and self-management

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INITIAL
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temporomandibular joint pain: at initial presentation
Plus – 

patient education and self-management

Treatment recommended for ALL patients in selected patient group

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

Consider – physical therapy

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INITIAL
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temporomandibular joint pain: at initial presentation
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

Physical therapy may be useful if provided by a specialist TMD physical therapist. Interventions such as manual therapy, exercise, electrophysiologic modalities (such as ultrasound, transcutaneous electrical nerve stimulation, or laser), and neuromuscular re-education have been found to be helpful.[74]​ Significant improvement in maximum mouth opening and reduction in pain were reported in patients with TMDs who underwent physical therapy.[54][74]

Consider – splints and/or bite guards

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INITIAL
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temporomandibular joint pain: at initial presentation
Consider – 

splints and/or bite guards

Treatment recommended for SOME patients in selected patient group

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 stabilization appliances may be more effective in reducing temporomandibular joint pain than soft stabilization 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]

Consider – stress management

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INITIAL
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temporomandibular joint pain: at initial presentation
Consider – 

stress management

Treatment recommended for SOME patients in selected patient group

Patients should be counseled to reduce stress.[49]

Stress may lead to parafunctional 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.

Consider – cognitive behavioral therapy (CBT)

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INITIAL
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temporomandibular joint pain: at initial presentation
Consider – 

cognitive behavioral therapy (CBT)

Treatment recommended for SOME patients in selected patient group

CBT aims to teach patients how to cope up with their pain. In one randomized 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]

Consider – muscle relaxant

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INITIAL
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temporomandibular joint pain: at initial presentation
Consider – 

muscle relaxant

Treatment recommended for SOME patients in selected patient group

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]​ These drugs may be used in patients in whom nonpharmacologic interventions do not provide relief. 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]

Primary options

diazepam: 2-10 mg orally three to four times daily

OR

cyclobenzaprine: 5-10 mg orally (immediate-release) once daily at bedtime

ACUTE

persistent pain after 2 weeks of joint rest and <3 months of duration

1st line – nonsteroidal anti-inflammatory drug (NSAID)

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ACUTE
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persistent pain after 2 weeks of joint rest and <3 months of duration
1st line – 

nonsteroidal anti-inflammatory drug (NSAID)

NSAIDs are most frequently used for acute TMD.​[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]

NSAIDs inhibit platelet aggregation and cause gastric irritation when used orally. There is also a risk of hepatotoxicity and nephrotoxicity. Use caution when prescribing to patients with bleeding disorders, or to those with kidney or liver disorders.

Use the lowest effective dose for the shortest treatment duration (e.g., up to 14 days treatment may be required for this indication).

Primary options

diclofenac topical: (1% gel) apply 2 g to the affected area(s) four times daily when required, maximum 8 g/joint/day (upper extremity joints) or 32 g/day total

Secondary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

ONGOING

chronic pain ≥3 months

1st line – nonpharmacologic therapies

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ONGOING
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chronic pain ≥3 months
1st line – 

nonpharmacologic therapies

Effective nonpharmacologic interventions to manage chronic pain (≥3 months) include: cognitive behavioral therapy (CBT) augmented with biofeedback or relaxation therapy, therapist-assisted jaw mobilization, and manual trigger point therapy. One systematic review and network meta-analysis found that CBT with or without biofeedback or relaxation therapy, therapist-assisted jaw mobilization, and manual trigger point therapy are the most effective interventions to manage chronic TMD pain.[51]

Other interventions that are less effective but still can be used include: supervised postural exercises, supervised jaw exercises and stretching, supervised jaw exercises and stretching with manual trigger point therapy, and usual care (such as education, support, home exercises, and stretching).[51]

CBT aims to teach patients how to cope up with their pain. With or without biofeedback or relaxation therapy, CBT is the ideal psychologic treatment for managing chronic pain.[4][50]​​[51]

The tight and sensitive muscles around the jaw, known as trigger points, are the primary reason for TMD pain. Pain associated with trigger points can be relieved by manual therapy, wherein a physical therapist applies targeted pressure with hands to promote circulation in affected areas. This helps release muscle knots and provides relief from pain.[4][51]

Consider – low-dose antidepressant or anticonvulsant or opioid

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ONGOING
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chronic pain ≥3 months
Consider – 

low-dose antidepressant or anticonvulsant or opioid

Treatment recommended for SOME patients in selected patient group

Pharmacologic therapy may be prescribed if nonpharmacologic interventions alone do not provide relief.

Low-dose tricyclic antidepressants (e.g., amitriptyline) may aid in the management of chronic TMD pain (>3 months duration).[61][64][66]​​ One randomized controlled clinical 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.

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]

Opioids are drugs of last choice and should be avoided unless under the guidance of a pain physician. 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 nonopioid 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]​ 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]

Primary options

amitriptyline: 10-25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 150 mg/day

OR

gabapentin: 300 mg orally once daily for 1 day, followed by 300 mg twice daily for 1 day, then 300 mg three times daily, increase gradually according to response, maximum 3600 mg/day

OR

pregabalin: 50 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 600 mg/day

Secondary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

OR

hydromorphone: 2-4 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

OR

fentanyl transdermal: dose depends on current opioid intake; consult specialist for guidance on dose

refractory pain or disability: osteoarthritis or internal derangement subtype

1st line – consider surgery

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ONGOING
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refractory pain or disability: osteoarthritis or internal derangement subtype
1st line – 

consider surgery

Refer to an appropriately trained maxillofacial surgeon following a period of failed conservative management with persistent joint pain, limited mouth opening (<35 mm), or frequent locking.

Surgical procedures include a stepwise ladder approach from arthrocentesis and arthroscopy, open surgery, and even total alloplastic temporomandibular joint replacement, which have good long-term outcomes.​[58][71][72]​ Recurrent dislocation should be referred to an appropriately trained maxillofacial surgeon.

Surgery is reserved for patients with moderate to severe pain, notable pathology, or recurrent dislocation and those who are disabled by their condition.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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