eMedicine Specialties > Emergency Medicine > Rheumatology

Temporomandibular Joint Syndrome: Treatment & Medication

Author: Joshua Parnes, MD, Staff Physician, Department of Emergency Medicine, Kings County Hospital Center
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center; Steven M Heffer, MD, Consulting Staff, Department of Emergency Medicine, Greenwich Hospital
Contributor Information and Disclosures

Updated: Aug 7, 2009

Treatment

Emergency Department Care

  • Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Muscle relaxants - Benzodiazepines
  • Moist heat and massage of masticatory muscles

Consultations

Provide outpatient follow-up care with ear, nose, and throat (ENT) specialist or oral surgeon. However, if intractable pain is present, more urgent consultation is necessary.

Medication

NSAIDs and benzodiazepines are the mainstays of treatment for TMJ syndrome within the ED. Patients eventually may require tricyclics, opioids, muscle relaxants, or steroid (intraarticular) therapy for protracted pain syndromes.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Most commonly used for relief of mild to moderate pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen usually is the DOC for initial therapy. Other options include naproxen, flurbiprofen, mefenamic acid, ketoprofen, indomethacin, and piroxicam.


Ibuprofen (Motrin, Advil, Ibuprin, Nuprin)

Usually DOC for treatment of mild to moderate pain if no contraindications exist; inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which results in inhibition of prostaglandin synthesis.

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 10-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults

Probenecid may increase concentrations and possibly toxicity of NSAIDs; ibuprofen may decrease effect of loop diuretics when coadministered; PT may increase when ibuprofen is coadministered with anticoagulants; monitor PT and bleeding closely; ibuprofen and other NSAIDs may increase serum lithium levels and risk of methotrexate toxicity

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; because of potential cross-sensitivity to other NSAIDs, do not administer to patients with documented hypersensitivity to aspirin, iodides, or other NSAIDs

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present


Naproxen (Aleve, Anaprox, Naprosyn)

Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease of prostaglandin synthesis.

Adult

250-500 mg PO bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; PT may increase with coadministration of anticoagulants; monitor PT and bleeding; coadministration with phenytoin may increase serum phenytoin levels, resulting in an increase in pharmacologic and toxic effects of phenytoin

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present


Flurbiprofen (Ansaid)

Analgesic, antipyretic, and anti-inflammatory effects; may inhibit cyclooxygenase enzyme, causing inhibition of prostaglandin biosynthesis that in turn may result in analgesic and anti-inflammatory activities.

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; coadministration with anticoagulants may prolong PT; monitor PT and bleeding; nephrotoxicity of both cyclosporine and flurbiprofen may be increased; coadministration with phenytoin may increase serum phenytoin levels, resulting in increase in pharmacologic and toxic effects of phenytoin

Documented hypersensitivity; epithelial herpes simplex keratitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present


Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderate pain and inflammation; administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease; doses >75 mg do not increase therapeutic effects; administer high doses with caution and closely observe patient for response.

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; PT may increase when ketoprofen is coadministered with anticoagulants; monitor for bleeding; coadministration with phenytoin may increase serum phenytoin levels, resulting in increase in pharmacologic and toxic effects of phenytoin

Documented hypersensitivity; GI disease; cardiovascular disease; renal or hepatic impairment; patients receiving anticoagulants

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present


Mefenamic acid (Ponstel)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

500 mg PO initially followed by 250 mg q4h prn

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May have adverse effects in fetus; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Indomethacin (Indocin, Indochron E-R)

Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Adult

25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d

Pediatric

1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; GI bleeding or renal insufficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)


Piroxicam (Feldene)

Decreases activity of cyclooxygenase, which, in turn, inhibits prostaglandin synthesis; effects decrease formation of inflammatory mediators.

Adult

10-20 mg/d PO qd

Pediatric

0.2-0.3 mg/kg/d PO qd; not to exceed 15 mg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; active GI bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)

Benzodiazepines

Used for muscle relaxant properties but relatively contraindicated in pediatric patients because of sedating properties; appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters by binding to specific receptor sites.


Diazepam (Valium)

Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA, a major inhibitory neurotransmitter.
Individualize dosage and increase cautiously to avoid adverse effects.

Adult

2-10 mg PO bid/qid

Pediatric

0.05-0.3 mg/kg/dose PO over 2-3 min q15-30min; not to exceed 10 mg; repeat in 2-4 h prn

Toxicity of benzodiazepines in CNS is increased when used concurrently with alcohols, phenothiazines, barbiturates, and MAOIs; cisapride significantly can increase diazepam levels

Documented hypersensitivity; narrow-angle glaucoma; first trimester of pregnancy

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients receiving other CNS depressants; caution in patients diagnosed with low albumin levels or hepatic failure since diazepam toxicity may increase

More on Temporomandibular Joint Syndrome

Overview: Temporomandibular Joint Syndrome
Differential Diagnoses & Workup: Temporomandibular Joint Syndrome
Treatment & Medication: Temporomandibular Joint Syndrome
Follow-up: Temporomandibular Joint Syndrome
References
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References

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Further Reading

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Keywords

temporomandibular joint dysfunction syndrome, TMJ syndrome, myofascial pain dysfunction syndrome, MPD syndrome, temporal mandibular joint, locked jaw, neck pain, movement of the jaw

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Contributor Information and Disclosures

Author

Joshua Parnes, MD, Staff Physician, Department of Emergency Medicine, Kings County Hospital Center
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Steven M Heffer, MD, Consulting Staff, Department of Emergency Medicine, Greenwich Hospital
Steven M Heffer, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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