Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions

Figures & data

Figure 1 The four dimensions of the biobehavioral model of pain perception and motor behavior.

Notes: The four circle segments are variables for assessment and treatment according to each dimension. Outside boxes are transverse or aspecific variables that are dependent on interactions among the different dimensions.

Table 1 Evidence on treatment options for pain related to TMD

Treatment/intervention	Evidence-based	Type of TMD	Magnitude of effects
Oral and topical pharmacotherapy	One meta-analysis,^Citation61 two RCTs^Citation62,Citation67	Arthrogenic Myogenic	Joint-pain reduction achieved with oral sodium diclofenac, naproxen sodium, and topical diclofenac
	One meta-analysis,^Citation61 one RCT,^Citation73 one CT^Citation75		Muscle-pain reduction obtained with diazepam; cyclobenzaprine for local spasm and acute muscle pain; sodium diclofenac with coadjuvants (acetaminophen, carisoprodol, caffeine) for muscle pain; amitriptyline and nortriptyline used for masticatory myofascial chronic pain
Infiltrated pharmacotherapy	One meta-analysis^Citation61	Arthrogenic	Injection with corticosteroid β-metasone and hyaluronate for joint pain
Dental management: occlusal splints	One systematic review^Citation98	Myogenic	Stabilization splints can be used to prevent dental damage in patients with bruxism
Physical therapy
• Manual therapy	One meta-analysis,^Citation52 one systematic review^Citation100	Myogenic	Intra- and extraoral myofascial techniques are effective in reducing pain and increasing mouth opening
	One meta-analysis^Citation52	Myogenic and mixed	Manual therapy (joint and myofascial approach) on the jaw and cervical regions produces similar effects to other usual conservative treatments (splints, exercise, and/or toxins) to improve pain and mandibular function
	One meta-analysis,^Citation52 one systematic review^Citation100	Myogenic	Upper cervical joint mobilizations are effective in reducing pain intensity
• Therapeutic exercise	One meta-analysis,^Citation52 two systematic reviews^Citation45,Citation46	Myogenic	Postural exercise combined with self-management care and/or cognitive-behavior treatment is more effective than self-management alone in decreasing pain symptomatology and increasing mouth opening
	One meta-analysis^Citation52	Myogenic, articular, mixed	A general exercise program focused on the jaw and/or cervical region is effective for reducing pain intensity and improving mandibular function, but not more effective than other interventions
	One meta-analysis^Citation52	Myogenic	A general exercise program is more effective than splint devices to increase ROM in mouth opening
• Manual therapy and therapeutic exercise	One meta-analysis,^Citation52 two systematic reviews^Citation45,Citation46	Articular and mixed	Manual therapy plus therapeutic exercise is more effective than other active interventions for improving pain and jaw ROM
	One meta-analysis^Citation52	Mixed	Manual therapy plus therapeutic exercise applied to the orofacial and cervical region could be more effective than application on cervical region alone for improving mouth opening
• Dry needling and acupuncture	Three meta-analyses,^Citation132,Citation133,Citation142 one systematic review^Citation141	Myogenic	Acupuncture is effective in decreasing pain intensity, but not to increase mouth-opening ROM
	One meta-analysis,^Citation142 one systematic review^Citation141	Myogenic	Acupuncture could be more effective when applied to the orofacial region than remote regions, and not necessarily at standard acupuncture points
	Two meta-analyses^Citation132,Citation133	Myogenic	Acupuncture produces greater pain decrease than sham nonpenetrating acupuncture, but not sham penetrating acupuncture
	Three RCTs^Citation126,Citation128,Citation145	Myogenic	Dry needling may be effective for pain-intensity reduction and increasing mouth opening
• Electrotherapy	One meta-analysis^Citation146	Articular and mixed	Low-level laser therapy is effective in improving jaw ROM
Surgical interventions	Three meta-analyses^Citation81^–^Citation83	Arthrogenic	Internal derangements are better managed with nonsurgical interventions
Cognitive-behavioral therapy	One meta-analysis^Citation151	Myogenic and mixed	Good complement for disability and pain reduction in patients with specific psychological characteristics
Education and self-management	Two meta-analyses^Citation151,Citation218	Myogenic and mixed	Good complements to combine with other techniques, since they are low-cost interventions and potentially control signs and symptoms
Relaxation techniques	One meta-analysis^Citation155	Myogenic	May be beneficial in reducing maximal pain and active mouth opening

Abbreviations: RCT, randomized controlled trial; ROM, range of motion.

Figure 2 Mechanisms involved in the biobehavioral model of pain perception and motor behavior.

Notes: Generation of pain perception from somatosensory or emotional stimuli or the combination of both according to different contexts can influence increased or decreased pain perception. The black boxes show the cognitive processes involved in the maintenance and “chronification” of symptoms from behavioral changes, emphasizing those related to motor behavior that in turn can influence feedback and learning for the maintenance of pain perception and increase perceived disability.

Figure 3 Representation of the therapeutic approach according to the biobehavioral model of pain perception and motor behavior.

Notes: An essential objective within the model is the reduction of the disability. It is proposed that this objective can be approached from the achievement of two secondary objectives: reduction in perception of pain, and improvement in motor behavior. It is a biobehavioral therapeutic structure based on diverse treatment methods that influence the four dimensions raised in the model.

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