Management of temporomandibular disorders

The aim of temporomandibular disorder management is to control the patient’s symptoms rather than achieve a cure. Treatment goals should be tailored to the specific diagnosis, and may include reducing pain and adverse loading, restoring mandibular function and resuming normal daily activities.

Management strategies are conservative and can include:

• patient education and reassurance
• jaw rest, using strategies such as dietary modification to minimise chewing (eg eating only soft foods)
• avoidance of extreme jaw movements (eg yawning, chewing gum, singing)
• massage and application of warm packs to the temporomandibular joints and cheeks several times per day. Cold packs can be useful in the presence of redness and swelling
• behavioural modification (eg identifying and managing sources of stress, which may be facilitated by individual or group counselling)
• regular treatment (gentle muscle stretching and massaging) by a physiotherapist familiar in the management of temporomandibular disorders
• use of custom-made full-coverage intraoral occlusal splints¹ to reduce joint loading, muscle activity and pain—splints are generally worn at night and protect teeth from the effects of bruxism. They should constitute only one part of a broader management approach
• short-term use of drugs—discourage patients from relying on drugs alone (particularly drugs of dependence) to treat the symptoms of temporomandibular disorders because of their chronic nature. Analgesics, muscle relaxants, anxiolytics, anticonvulsants, corticosteroids and antidepressants have been used with variable success.

An acute exacerbation of chronic temporomandibular disorder can be treated with ibuprofen and/or paracetamol (see Choice of analgesic for acute dental pain).

If conservative measures are inadequate and pain and dysfunction become severe or chronic, refer the patient to an oral medicine specialist or oral and maxillofacial surgeon.

There is some evidence for the use of botulinum toxin to manage the symptoms of temporomandibular disorders when conservative measures are inadequate. Ensure patients understand that botulinum toxin is not a cure for temporomandibular disorders, but may be used as part of the overall management strategy. The use of botulinum toxin for temporomandibular disorders is off-label. Dentists require additional training to administer botulinum toxin². If the recommended doses and protocols are adhered to, the incidence of adverse effects is low. Local complications include stinging during injections, bruising at the site of injection and excessive muscle weakness. Adverse effects associated with inadvertent injection of botulinum toxin into nontarget tissues are rare, but can include alteration in smile and temporary dry mouth. Systemic adverse effects include an influenza-like syndrome that is transient and hypersensitivity reactions.

Surgery for temporomandibular disorders is rarely required. Only consider referring the patient for a surgical assessment if symptoms have not responded to conservative management and there is definitive evidence of internal joint derangement or other joint pathology on imaging.