TEMPOROMANDIBULAR DISORDERS AND PRINCIPLES OF REHABILITATION

tmjkapak

PHARMACOLOGIC MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS

Emine Dündar Ahi

Private Physician, Physical Medicine and Rehabilitation, İstanbul, Türkiye

Dündar Ahi E. Pharmacologic Management of Temporomandibular Disorders. In: Coşar SN, Afşar Sİ editors. Temporomandibular Disorders and Principles of Rehabilitation. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.127-140.

ABSTRACT

Temporomandibular disorders (TMD) are disorders that cause pain in the face and mouth areas and may occur due to intra-articular or extra-articular causes. Medications are generally preferred in the treatment of TMJ-related pain, and are often supplemented with other non-surgical methods. Various medications such as non-steroidal anti-inflammatory drugs, corticosteroids, muscle relaxants, anticonvulsants, and anxiolytics are widely used in the management of TMD. However, since there are no sufficient systematic studies comparing the effectiveness of these drugs, treatment planning should be patient-centered and individualized. Although the mechanism of TMJ pain has not been fully elucidated, it is thought that both central and peripheral factors play a role. Furthermore, both the psychological and emotional dimensions of the pain must be evaluated. NSAIDs are the first choice and have an important place in the treatment by reducing inflammation and providing an analgesic effect. Muscle relaxants may also be added if there are muscle-related problems. In cases where pharmacological treatment alone is not sufficient, different approaches should be preferred according to the patient’s needs and with the mutual decision of the patient and the physician. The side effects and drug interactions of the drugs to be prescribed must be taken into consideration and the treatment process must be planned specifically for the individual.

Keywords: Temporomandibular joint; Temporomandibular joint dysfunction syndrome; Drug therapy

Referanslar

  1. Ferrillo M, Giudice A, Marotta N, Fortunato F, Di Venere D, Ammendolia A, et al. Pain Management and Rehabilitation for Central Sensitization in Temporomandibular Disorders: A Comprehensive Review. International Journal of Molecular Sciences. MDPI; 2022. [Crossref]  [PubMed]  [PMC]
  2. Militi A, Bonanno M, Calabrò RS. It Is Time for a Multidisciplinary Rehabilitation Approach: A Scoping Review on Stomatognathic Diseases in Neurological Disorders. J Clin Med. 2023;12(10):3528. [Crossref]  [PubMed]  [PMC]
  3. Liu F, Steinkeler A. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dent Clin North Am. 2013 Jul;57(3):465–79. [Crossref]  [PubMed]
  4. Matheson EM, Fermo JD, Blackwelder RS. Temporomandibular Disorders: Rapid Evidence Review. Am Fam Physician. American Academy of Family Physicians; 2023 Jan 1;107(1):52–58. [PubMed]
  5. National Institute of Dental and Craniofacial Research. Facial pain. Updated July 2018. Accessed August 6, 2022.
  6. Li W, Cheng Y, Wei L, Li B, Zheng H. Gender and Age Differences of Temporomandibular Joint Disc Perforation: A Cross-Sectional Study in a Population of Patients With Temporomandibular Disorders. J Craniofac Surg. 2019;30(5):1497-1498. [Crossref]  [PubMed]
  7. Ohrbach R, Gonzalez Y, Michelotti A, Schiffman E. Diagnostic Criteria for Temporomandibular Disorders (DC/ TMD) Clinical Examination Protocol. [cited 2025 Feb 1]; www.rdc-tmdinternational.org.
  8. Busse JW, Casassus R, Carrasco-Labra A, Durham J, Mock D, Zakrzewska JM, et al. Management of chronic pain associated with temporomandibular disorders: A clinical practice guideline. BMJ. BMJ Publishing Group; 2023; . [Crossref]  [PubMed]
  9. Simoen L, Van den Berghe L, Jacquet W, Marks L. Depression and anxiety levels in patients with temporomandibular disorders: comparison with the general population. Clin Oral Investig. 2020;24(11):3939–3945. [Crossref]  [PubMed]
  10. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008;359(25):2693-705. [Crossref]  [PubMed]
  11. Garstka AA, Kozowska L, Kijak K, Brzózka M, Gronwald H, Skomro P, et al. Accurate Diagnosis and Treatment of Painful Temporomandibular Disorders: A Literature Review Supplemented by Own Clinical Experience. Pain Res Manag. 2023;2023:1002235. [Crossref]  [PubMed]  [PMC]
  12. Orlando B, Manfredini D, Salvetti G, Bosco M. Evaluation of the effectiveness of biobehavioral therapy in the treatment of temporomandibular disorders: a literature review. Behav Med. 2007;33(3):101-18.118. [Crossref]  [PubMed]
  13. Dionne RA. Pharmacologic treatments for temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;83(1):134-42. [Crossref]  [PubMed]
  14. Alam MK, Rashid ME, Akhter K, Abdelghani A, Babkair HA, Sghaireen MG. Surgical vs. Non-Surgical Management of Temporomandibular Joint Disorders: Clinical Outcomes. J Pharm Bioallied Sci. 2024;16(Suppl 1):S678-S680. [Crossref]  [PubMed]  [PMC]
  15. Buer JK. Origins and impact of the term ‘NSAID’. Inflammopharmacology. 2014;22(5):263-7. [Crossref]  [PubMed]
  16. Patrignani P, Tacconelli S, Bruno A, Sostres C, Lanas A. Managing the adverse effects of nonsteroidal anti-inflammatory drugs. Expert Rev Clin Pharmacol. 2011;4(5):605-21. [Crossref]  [PubMed]
  17. Harirforoosh S, Asghar W, Jamali F. Adverse effects of nonsteroidal antiinflammatory drugs: an update of gastrointestinal, cardiovascular and renal complications. J Pharm Pharm Sci. 2013;16(5):821-47. [Crossref]  [PubMed]
  18. Ta LE, Dionne RA. Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: a randomized placebo-controlled comparison of celecoxib to naproxen. Pain. 2004;111(1-2):13-21. [Crossref]  [PubMed]
  19. Marini I, Lavinia Bartolucci M, Bortolotti F, Rosaria Gatto M, Alessandri Bonetti G. Palmitoylethanolamide versus a nonsteroidal anti-inflammatory drug in the treatment of temporomandibular joint inflammatory pain. J Orofac Pain [Internet]. 2012;26:99-104. [Crossref]  [PubMed]
  20. de Carli ML, Guerra MB, Nunes TB, di Matteo RC, de Luca CE, Aranha AC, et al. Piroxicam and laser phototherapy in the treatment of TMJ arthralgia: a double-blind randomised controlled trial. J Oral Rehabil. 2013;40(3):171-8. [Crossref]  [PubMed]
  21. Di Rienzo Businco L, Di Rienzo Businco A, D’Emilia M, Lauriello M, Coen Tirelli G. Topical versus systemic diclofenac in the treatment of temporo-mandibular joint dysfunction symptoms. Acta Otorhinolaryngol Ital. 2004;24(5):279-83. [PubMed]
  22. Dong XD, Svensson P, Cairns BE. The analgesic action of topical diclofenac may be mediated through peripheral NMDA receptor antagonism. Pain. 2009 Dec 15;147(13):36-45. [Crossref]  [PubMed]
  23. Kulkarni S, Thambar S, Arora H. Evaluating the effectiveness of nonsteroidal anti-inflammatory drug(s) for relief of pain associated with temporomandibular joint disorders: A systematic review. Clin Exp Dent Res; 2020;6(1):134-146. gov/32067407 [PubMed]
  24. Montinaro F, Nucci L, d’Apuzzo F, Perillo L, Chiarenza MC, Grassia V. Oral nonsteroidal anti-inflammatory drugs as treatment of joint and muscle pain in temporomandibular disorders: A systematic review. Cranio. 2024;42(6):641650. [Crossref]  [PubMed]
  25. Hayashi K, Sugisaiki M, Ota S, Tanabe H. mu-Opioid receptor mRNA expression and immunohistochemical localization in the rat temporomandibular joint. Peptides. 2002;23(5):889-93. [Crossref]  [PubMed]
  26. List T, Tegelberg Å, Haraldson T, Isacsson G. Intra-articular morphine as analgesic in temporomandibular joint arthralgia/ osteoarthritis. Pain; 2001;94(3):275-282. [PubMed]
  27. Hersh EV, Balasubramaniam R, Pinto A. Pharmacologic management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am. 2008;20(2):197-210, vi. [Crossref]  [PubMed]
  28. Dym H, Bowler D, Zeidan J. Pharmacologic Treatment for Temporomandibular Disorders. Dent Clin North Am. 2016 Apr;60(2):367-79. [Crossref]  [PubMed]
  29. Ouanounou A, Goldberg M, Haas DA. Pharmacotherapy in Temporomandibular Disorders: A Review. J Can Dent Assoc. 2017;83:h7. [PubMed]
  30. Bouloux GF. Use of opioids in long-term management of temporomandibular joint dysfunction. J Oral Maxillofac Surg; 2011;69(7):1885-1891. https:// pubmed.ncbi.nlm.nih.gov/21419546 [PubMed]
  31. List T, Axelsson S, Leijon G. Pharmacologic interventions in the treatment of temporomandibular disorders, atypical facial pain, and burning mouth syndrome. A qualitative systematic review. J Orofac Pain. 2003;17(4):301-10. [PubMed]
  32. Minervini G, Franco R, Crimi S, Di Blasio M, D’Amico C, Ronsivalle V, et al. Pharmacological therapy in the management of temporomandibular disorders and orofacial pain: a systematic review and meta-analysis. BMC Oral Health. 2024;24(1):78. [Crossref]  [PubMed]  [PMC]
  33. Hersh EV, Balasubramaniam R, Pinto A. Pharmacologic management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am. 2008;20(2):197-210, vi. [Crossref]  [PubMed]
  34. Derwich M, Mitus-Kenig M, Pawlowska E. Mechanisms of Action and Efficacy of Hyaluronic Acid, Corticosteroids and Platelet-Rich Plasma in the Treatment of Temporomandibular Joint Osteoarthritis-A Systematic Review. Int J Mol Sci. 2021;22(14):7405. [Crossref]  [PubMed]  [PMC]
  35. Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol. 2010;29(4):347- [Crossref] [PubMed]
  36. Habib GS. Systemic effects of intra-articular corticosteroids. Clin Rheumatol; 2009 [cited 2025;28(7):749-756. [PubMed]
  37. Alstergren P, Appelgren A, Appelgren B, Kopp S, Lundeberg T, Theodorsson E. The effect on joint fluid concentration of neuropeptide Y by intra-articular injection of glucocorticoid in temporomandibular joint arthritis. Acta Odontol Scand. 1996;54(1):1-7. nih.gov/8669234 [PubMed]
  38. Arabshahi B, Dewitt EM, Cahill AM, Kaye RD, Baskin KM, Towbin RB, Cron RQ. Utility of corticosteroid injection for temporomandibular arthritis in children with juvenile idiopathic arthritis. Arthritis Rheum. 2005;3563-3569. [PubMed]
  39. Torres D, Zaror C, Iturriaga V, Tobias A, Brignardello-Petersen R. Corticosteroids for the Treatment of Internal Temporomandibular Joint Disorders: A Systematic Review and Network Meta-Analysis. J Clin Med; 2024;13(15). [Crossref]  [PubMed]  [PMC]
  40. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;2003(2):CD004252. [Crossref]  [PubMed]  [PMC]
  41. Pratzel HG, Alken RG, Ramm S. Efficacy and tolerance of repeated oral doses of tolperisone hydrochloride in the treatment of painful reflex muscle spasm: results of a prospective placebo-controlled double-blind trial. Pain. 1996;67(2– 3):417-425. gov/8951937 [PubMed]
  42. Häggman-Henrikson B, Alstergren P, Davidson T, Högestätt ED, Östlund P, Tranæus S, et al. Pharmacological treatment of oro-facial pain health technology assessment including a systematic review with network meta-analysis. J Oral Rehabil. 2017;44(10):800-826. [Crossref]
  43. Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J Orofac Pain. 2002;16(1):64-70. [PubMed]
  44. Moldofsky H, Harris HW, Archambault WT, Kwong T, Lederman S. Effects of bedtime very low dose cyclobenzaprine on symptoms and sleep physiology in patients with fibromyalgia syndrome: a double-blind randomized placebo-controlled study. J Rheumatol. 2011;38(12):2653-63. [Crossref]  [PubMed]
  45. Indresano AT, Park CM. 39-Nonsurgical Management of Temporomandibular Joint Disorders. Third Edit. Oral and Maxillofacial Surgery. Elsevier Inc 2020: 865-82. [Crossref]  [PubMed]
  46. Micó JA, Ardid D, Berrocoso E, Eschalier A. Antidepressants and pain. Trends Pharmacol Sci. 2006;27(7):348-54. [Crossref]  [PubMed]
  47. Rizzatti-Barbosa CM, Nogueira MT, de Andrade ED, Ambrosano GM, de Barbosa JR. Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders. Cranio. 2003;21(3):221-5. [Crossref]  [PubMed]
  48. Cascos-Romero J, Vázquez-Delgado E, Vázquez-Rodríguez E, Gay-Escoda C. The use of tricyclic antidepressants in the treatment of temporomandibular joint disorders: systematic review of the literature of the last 20 years. Med Oral Patol Oral Cir Bucal. 2009;14(1):E3-7. [PubMed]
  49. Goyal P, Singh RK, Gangwar S, Mohammad S, Pal US, Singh G. Effect of duloxetine in temporomandibular joint disorders: A comparison with arthrocentesis. Natl J Maxillofac Surg. 2020;11(2):219-223. [Crossref]  [PubMed]  [PMC]
  50. Plesh O, Curtis D, Levine J, McCall WD Jr. Amitriptyline treatment of chronic pain in patients with temporomandibular disorders. J Oral Rehabil. 2000;27(10):834-41. [Crossref]  [PubMed]
  51. Haas DA. Pharmacologic considerations in the management of temporomandibular disorders. J Can Dent Assoc. 1995;61(2):105-9,112-4. [PubMed]
  52. de Sousa BM, López-Valverde A, Caramelo F, Rodrigues MJ, López-Valverde N. Use of antidepressants in the treatment of chronic orofacial pain caused by temporomandibular disorders: A randomized controlled clinical trial. Med Clin (Barc). 2024;163(2):74-77. English, Spanish. [Crossref]  [PubMed]
  53. Wallem A, Felipe-Spada N, Tomàs-Aliberas J. Influence of selective serotonin reuptake inhibitors (SSRIs) in the development of bruxism. Cranio. 2025;43(2):236-242. [Crossref]  [PubMed]
  54. Garrett AR, Hawley JS. SSRI-associated bruxism: A systematic review of published case reports. Neurol Clin Pract. 2018;8(2):135-141. [Crossref]  [PubMed]  [PMC]
  55. Haviv Y, Rettman A, Aframian D, Sharav Y, Benoliel R. Myofascial pain: an open study on the pharmacotherapeutic response to stepped treatment with tricyclic antidepressants and gabapentin. J Oral Facial Pain Headache. 2015;29(2):144-51. [Crossref]  [PubMed]
  56. Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56(4):1336-44. [Crossref]  [PubMed]
  57. Kimos P, Biggs C, Mah J, Heo G, Rashiq S, Thie NM, et al. Analgesic action of gabapentin on chronic pain in the masticatory muscles: a randomized controlled trial. Pain. 2007;127(1-2):151-60. [Crossref]  [PubMed]
  58. Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep. 2007;30(2):213-8. [Crossref]  [PubMed]
  59. Moore, P. A. “Sedative hypnotics, antianxiety drugs, and centrally acting muscle relaxants.” Pharmacology and Therapeutics in Dentistry, 5th edn. Oxford: Elsevier Mosby 2004: 193-218. [Crossref]  [PubMed]
  60. Singer E, Dionne R. A controlled evaluation of ibuprofen and diazepam for chronic orofacial muscle pain. J Orofac Pain. 1997;11(2):139-46. [PubMed]
  61. Harkins S, Linford J, Cohen J, Kramer T, Cueva L. Administration of clonazepam in the treatment of TMD and associated myofascial pain: a double-blind pilot study. J Craniomandib Disord. 1991;5(3):179-86. [PubMed]
  62. DeNucci DJ, Sobiski C, Dionne RA. Triazolam improves sleep but fails to alter pain in TMD patients. J Orofac Pain. 1998;12(2):116-23. [PubMed]
  63. Laroche ML, Charmes JP, Nouaille Y, Picard N, Merle L. Is inappropriate medication use a major cause of adverse drug reactions in the elderly? Br J Clin Pharmacol. 2007;63(2):177-86. [Crossref]  [PubMed]  [PMC]