Pharmacological and non-pharmacological approaches to temporomandibular disorder chronic pain: a narrative review

ABSTRACT

Temporomandibular disorders (TMD) involve the temporomandibular joint and related structures, causing chronic pain, impaired jaw function, and reduced quality of life. TMD has multifactorial origins, including mechanical, neuromuscular, and inflammatory factors. Chronic TMD pain is difficult to manage due to its complex pathophysiology and the limited long-term effectiveness of existing treatments. A combination of pharmacological and non-pharmacological strategies is essential for optimal pain management. This narrative review provides an integrative overview of current treatments for TMD-associated chronic pain. Pharmacological options discussed include analgesics, muscle relaxants, antidepressants, anticonvulsants, and botulinum toxin injections. Non-pharmacological strategies include physical therapy, cognitive-behavioral therapy, acupuncture, and lifestyle modifications. A comprehensive literature search was conducted using PubMed, Embase.com, Cochrane, and Evidence Alerts databases through October 2024. We focused on original research articles, randomized controlled trials, narrative and systematic reviews, and meta-analyses. Effective management of chronic TMD pain requires a multidisciplinary approach tailored to individual needs. Evidence supports the integration of physical and psychological therapies into treatment plans. Future research should aim to develop targeted interventions that address underlying mechanisms of TMD pain and evaluate the long-term outcomes of noninvasive therapies.

TREATING JAW PAIN BY COMBINING MEDICINES AND THERAPIES – PLAIN LANGUAGE SUMMARY

TMD is a condition that causes pain and problems in the jaw joint and the muscles that control jaw movement. This can lead to long-term pain, trouble moving the jaw, and a lower quality of life. TMD has many causes, like stress on the joint, muscle problems, and swelling, which makes it hard to treat. Current treatments don’t always work well over time, so using a mix of different treatments is important for better pain relief. This review looked at both medicine-based and non-medicine treatments for TMD pain. Medicine treatments include painkillers, muscle relaxers, antidepressants, seizure medications, and Botox injections. Non-medicine treatments include physical therapy, therapy for mental health, acupuncture, and lifestyle changes. The authors searched medical research studies without date limits, focusing on high-quality studies. They found that the best way to treat chronic TMD pain is to combine medicine and non-medicine treatments, designed to meet each person’s physical and emotional needs.

1. Introduction

1.1. Temporomandibular disorders: definitions and prevalence

TMD refer to a group of conditions affecting the temporomandibular joint (TMJ), muscles of mastication, and associated structures. These disorders are characterized by pain in the jaw, face, and head and difficulties in jaw movement, including clicking, popping, or locking of the jaw [1]. TMD can result from various causes, including trauma, arthritis, bruxism, and stress-related clenching. It is classified into three main categories: myofascial pain, internal derangement of the TMJ, and arthritis. The prevalence of TMD varies, but it is estimated that between 5% and 12% of the population experience TMD symptoms, with a higher incidence among women, particularly in the reproductive age group [2]. The condition can range from mild discomfort to severe, chronic pain, significantly impacting quality of life. While TMD can occur at any age, it is most diagnosed in individuals between the ages of 20 and 40 [3]. Managing TMD involves a multidisciplinary approach, including dental care, physical therapy, and behavioral interventions.

1.2. Pathophysiology and common symptoms

The pathophysiology of TMD involves a complex interplay between mechanical, neuromuscular, and inflammatory factors. The TMJ connects the jawbone to the skull, allowing for movements essential for chewing, speaking, and yawning. In TMD, abnormalities in the joint structure, such as disc displacement or degeneration, can lead to mechanical dysfunction. Additionally, overuse or tension in the muscles of mastication may cause muscle fatigue and spasms, contributing to pain. Inflammation from conditions like arthritis can further exacerbate joint damage and discomfort. Neuroplastic changes in the brain’s pain pathways are also thought to play a role in the chronic nature of TMD-related pain [4]. Common symptoms include jaw pain or tenderness, difficulty or discomfort while chewing, locking of the jaw, restricted range of motion, and audible sounds such as clicking or popping when opening or closing the mouth. Headaches, earaches, and facial pain are also frequently reported. These symptoms may be intermittent or chronic, significantly affecting daily activities and quality of life [5].

1.3. Challenges in managing chronic TMD

Managing chronic TMD presents several challenges due to the complexity and multifactorial nature of the condition. One significant challenge is the difficulty in pinpointing the exact cause of TMD, as it can stem from a combination of mechanical issues, muscle dysfunction, and psychological factors such as stress or anxiety [6]. This variability makes it difficult to establish a standardized treatment protocol, and as a result, patients often undergo trial-and-error with therapies that may or may not provide relief. Chronic TMD often leads to persistent pain, which can be difficult to manage, especially in cases where conservative treatments fail [7]. The standard of care involves a multidisciplinary approach combining self-care practices, physical and manual therapies, combined with short-term pharmacological treatments if needed [8]. Additionally, many patients experience overlapping conditions, such as fibromyalgia or migraines, complicating treatment further [9]. Another key challenge is the lack of effective, long-term solutions to address the underlying pathology, as many current treatments focus primarily on symptom management rather than targeting the root cause [10]. This creates an unmet medical need for more research into the pathophysiology of TMD and the development of novel therapies that can provide sustained relief and potentially prevent disease progression. Moreover, the absence of comprehensive, multidisciplinary care and access to specialized TMD clinicians further hinders effective management for many patients.

2. Objectives of the review

The goal of the review is to provide a broad and integrative overview of both pharmacological and non-pharmacological treatments for TMD-associated chronic pain. We aim to summarize and critically analyze both pharmacological and non-pharmacological treatments for chronic TMD to provide a comprehensive overview of the management possibilities. We also emphasize identifying gaps in the literature and proposing future research directions.

3. Methodology

A comprehensive literature search was conducted across multiple databases without publication date restrictions (from their inception to October 2024) to ensure broad and inclusive coverage of relevant studies. The databases searched included PubMed (1946–2024), Embase.com (1971–2024), Cochrane Library (1996–2024), and Evidence Alerts (2003–2024). The search strategy incorporated keywords related to temporomandibular disorders, pharmacological treatments, non-pharmacological therapies, and chronic pain management to capture diverse perspectives and findings.

The review focused on original research articles, randomized controlled trials (RCTs), narrative and systematic reviews, and meta-analyses to provide a balanced overview of current evidence. Studies exclusively addressing acute TMD conditions or focusing solely on pathophysiology were excluded to maintain the review’s focus on chronic pain management strategies. Additionally, relevant references within selected articles were manually screened to identify further studies of interest.

Given the narrative nature of this review, no formal quality assessment or risk of bias analysis was performed; however, preference was given to high-quality, peer-reviewed studies. This approach allowed for a comprehensive synthesis of both pharmacological and non-pharmacological interventions for TMD-associated chronic pain, integrating diverse study designs and outcomes to provide a broad and informative overview.

3.1. Pharmacological interventions

3.1.1. Analgesics

Analgesics, particularly non-opioid options such as acetaminophen, are commonly recommended as first-line treatment for managing pain in temporomandibular disorders [10]. Their central analgesic properties provide significant relief but do not impact inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, are more commonly prescribed due to their dual role in reducing pain and inflammation by inhibiting cyclooxygenase enzymes and reducing the formation of prostaglandins [11]. This mechanism can be efficient in cases involving joint-related TMD pain [12–14]. However, long-term use of NSAIDs raises concerns about gastrointestinal issues such as ulcers and gastro-intestinal bleeding, particularly in older patients [12,13,15]. Therefore, this approach is reserved for short-term treatment [16]. Non-systemic approaches with topical NSAIDs (e.g., diclofenac gel) [15] or intra-articular injections [17] may offer localized relief with fewer systemic effects. However, the benefits seem modest, and the evidence is currently insufficient to support the use of topical NSAIDs [18]. Overall, analgesics are recommended for short-term treatment only, and should be used in combination with physical therapy or behavioral interventions.

3.1.2. Muscle relaxants

Muscle relaxants, particularly cyclobenzaprine, are commonly used to alleviate muscle tension and spasms associated with TMD [14]. Cyclobenzaprine is effective in decreasing muscle hyperactivity, which can significantly relieve discomfort [5,12,15]. However, its sedative side effects, including drowsiness and dizziness, limit its use to short-term management [14]. The centrally-acting skeletal muscle relaxant methocarbamol and benzodiazepines, which bear muscle-relaxing properties, are other options used in more resistant cases of muscle tension [12]. These medications should also be used with physical therapy or behavioral interventions to enhance patient outcomes [14,19].

3.1.3. Antidepressants

Antidepressants, especially tricyclic antidepressants (TCAs) such as amitriptyline, can be used to treat chronic TMD pain, particularly when depression or anxiety exacerbates the condition [12]. TCAs effectively modulate pain by altering serotonin and norepinephrine levels in the brain, which play a critical role in pain perception [15]. Selective serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine have also been explored for their dual effects on pain relief and mood [12,13,15]. The use of these medications can lead to side effects, including dry mouth, weight gain, and potentially harmful cardiovascular issues, such as reduced heart rate variability and QT interval prolongation [20]. Therefore, monitoring patients closely is crucial [12,15]. Combining antidepressants with non-pharmacological treatments, such as cognitive behavioral therapy (CBT), can enhance outcomes [14]. Further research is necessary to understand the long-term benefits and optimal dosing strategies for antidepressants in TMD management [12].

3.1.4. Anticonvulsants

The anticonvulsants gabapentinoids, gabapentin, and pregabalin modulate nociceptive signal transmission and are commonly prescribed for neuropathic pain; their application is increasingly recognized in managing TMD pain [12,15]. Gabapentin has shown significant efficacy in reducing chronic myofascial pain and improving sleep and overall function [15]. Pregabalin has also proven beneficial in reducing pain intensity and associated sleep disturbances [12,15,16]. However, common side effects like dizziness, somnolence, and weight gain may limit the use of anticonvulsants in some patients [21]. For optimal outcomes, anticonvulsants should be used in conjunction with physical therapy or other non-pharmacological treatments [15].

3.1.5. Botulinum toxin injections

Botulinum toxin (BTX), a neurotoxin produced by Clostridium botulinum, blocks the release of acetylcholine at the neuromuscular junction. By suppressing muscle contractions, BTX can alleviate pain and improve jaw function in TMD [16]. Its analgesic effects may also be mediated by inhibiting pain-related neurotransmitters such as substance P and glutamate [19]. Research suggests that BTX can provide an alternative option when other therapies fail [15]; however, its overall impact remains debated. While certain studies suggest that BTX can alleviate pain and enhance quality of life, others show minimal benefits, and a recent meta-analysis revealed no conclusive evidence [22]. The effects of BTX typically last around three months, requiring repeated injections, which may be costly and inconvenient [23]. Additionally, further research is needed to evaluate the long-term safety and cost-effectiveness of BTX for TMD [15]. It is essential to note that the specific dosage and injection sites are crucial factors affecting treatment outcomes. Improper administration can lead to suboptimal results or adverse effects, such as muscle weakness and atrophy, underscoring the importance of treatment by experienced practitioners [14]. In summary, while BTX is not a first-line treatment, it may offer relief for patients with persistent, muscle-related TMD pain unresponsive to other therapies. Further large-scale studies are necessary to determine the long-term efficacy and cost-effectiveness of BTX for TMD [16,19].

3.1.6. Other oral pharmacological agents

Other pharmacological agents are listed in the management of TMD, which are mainly opioids, corticosteroids, benzodiazepines, betablockers, cannabis, and glucosamine/chondroitin sulfate combination.

Opioids are sometimes employed in managing severe and refractory TMD [15]. Opioids, such as codeine, morphine, and oxycodone, are generally reserved for short-term use due to their risk of dependency, tolerance, and other adverse effects, and are therefore regarded as a last-resort treatment for severe refractory cases [12,16,17]. As with other analgesics, its association with physical therapy and behavioral interventions is crucial.

Systemic corticosteroids, such as prednisone or triamcinolone, provide strong anti-inflammatory effects and are especially effective in joint inflammation or TM arthritis [13,15]. While providing effective short-term relief, their systemic long-term use is contra-indicated by major side effects, such as immunosuppression and osteoporosis [13,15,17].

Studies comparing benzodiazepines with a placebo for TMD pain indicate no significant difference in pain relief; they also emphasize the potential side effects associated with long-term use of benzodiazepines and recommend against their use for TMD management [24,25].

Beta-blockers may alleviate pain by inhibiting adrenergic neurotransmission [26]. Although the modulation of the sympathetic response does not bear a direct analgesic effect, it can impact stress responses, indirectly alleviating pain in patients with TMD [12,26]. However, two recent meta-analyses on TMJ pain management recommended against their use in clinical practice, with potentially more harm than benefits [16,27]. Therefore, the use of beta-blockers should be limited to patients with TMD and comorbidities that warrant their prescription [13,15,28].

Recent research on medical cannabis and cannabinoids for chronic pain has gained significant attention, and there is growing evidence supporting its use in various conditions [29]. However, no studies have yet examined the efficacy of these compounds for TMD to our knowledge.

Finally, glucosamine and chondroitin sulfate, the primary components of the articular cartilage, are widely used for alleviating arthritic pain. The proposed mechanism of action appears to involve the modulation of inflammatory pathways [30–32]. Although this treatment is relatively inexpensive and well-tolerated, evidence supporting its effectiveness for TMD pain is limited. A few recent articles indicate a potential reduction in pain and improvement in symptoms, such as mouth opening [33,34].

3.1.7. Ozone therapy

Ozone therapy has emerged as a novel approach to managing TMD pain, administered by injection into the joint space. Ozone (O3) has strong oxidizing properties and is believed to exert anti-inflammatory properties by reducing pro-inflammatory cytokines, modulating oxidative stress, and promoting tissue oxygenation [35]. Therefore, it may reduce pain and improve joint function [36]. As a potential alternative for patients resistant to conventional treatments, further research is needed to establish standardized protocols and to fully understand its long-term effects and safety in the treatment of TMJ disorders.

3.1.8. Other topical therapies

Lidocaine patches and other substances, such as capsaicin and methyl salicylate, are being investigated as noninvasive alternatives for localized pain management. Lidocaine transdermal patches are sometimes mentioned in the literature [37], but almost no evidence exists regarding their efficacy in TMD management. Capsaicin, the main pungent component in hot chili peppers, is an agonist of the Transient Receptor Potential Vanilloid 1 (TRPV1) channel [38]. This channel is found in sensitive neurons, including those of the nerves supplying the TMJ [39], and functions as a transducer for noxious stimuli. High concentrations of topical capsaicin can lead to defunctionalization of the TRPV1, resulting in long-lasting analgesia [40]. While this therapy is relatively inexpensive, noninvasive, and devoid of major side effects (limited to erythema, skin irritation, and local burning sensation), studies have failed to prove a statistically significantly difference between placebo and topical capsaicin group on TDM pain reduction [41], and a recent meta-analysis recommends against use of capsaicin for chronic TMJ pain [16,27]. Methyl salicylate is an organic compound found naturally in various plant species, particularly wintergreens. Chemically related to acetylsalicylic acid, this substance exhibits properties like NSAIDs [42]. Due to its low molecular weight, it is suitable for topical applications (often in association with menthol or camphor) in conditions such as musculoskeletal pain, arthritis, and localized inflammation, though it can also produce systemic effects [43,44]. There is a lack of studies concentrating on its use in TMD joints, but a small study suggests that this product can significantly alleviate pain in the TMJ. However, the composition of these mixtures can vary widely, potentially leading to side effects [45]. For this reason, chronic use of these agents is not advisable.

3.2. Non-pharmacological interventions

3.2.1. Therapeutic exercises and manual therapy

Manual therapies encompass mobilization techniques, therapeutic exercises, and postural adjustments, which are critical in managing TMD. These therapies target the TMJ and its associated structures, including the cervical spine, to alleviate pain, improve joint function, and restore overall mobility. In a systematic review and network meta-analysis of randomized controlled trials involving over 8000 patients, exercise therapy, combined with manual interventions such as jaw mobilization and postural exercises, significantly improved pain intensity, enhanced the pain pressure threshold, and increased both active and passive mouth opening in patients with TMD [27]. Similarly, in a meta-analysis, this approach provided significant benefits compared to interventions using splints alone [47]. Recent studies emphasize the interconnectedness of cervical issues in managing TMD, highlighting the importance of addressing cervical dysfunction as part of a holistic treatment plan [48]. Another meta-analysis explored the impact of simultaneously targeting the cervical and craniomandibular regions, demonstrating that this comprehensive approach improved short-term outcomes in pain relief and functional enhancement [49]. In parallel, in patients experiencing TMD-associated tinnitus, it is beneficial to incorporate cervico-mandibular manual therapy alongside an exercise and education program, with findings revealing significantly reduced TMD-related disability [48]. All studies underscore the value of integrating manual therapies into a multidisciplinary approach. While further long-term studies are necessary to confirm their lasting effects, the evidence from recent systematic reviews and clinical trials strongly supports using manual therapy and therapeutic exercises to manage TMD. This underscores their relevance not only for symptom management but also for addressing biomechanical contributors to TMD. This makes a compelling case for more comprehensive treatment protocols in clinical practice, especially for physiotherapists, osteopaths, and trained doctors.

3.2.2. Cognitive-behavioral therapy

CBT have emerged as effective psychological approaches for managing pain associated with TMD. By targeting maladaptive thoughts and behaviors, CBT enhances coping strategies and improves the overall quality of life for affected individuals. This multifaceted approach addresses pain perception and plays a crucial role in modifying emotional responses to discomfort, particularly in patients with coexisting anxiety, depression, or stress-related exacerbations [50].

Recent research underscores the efficacy of CBT and its variations, such as biofeedback-based cognitive-behavioral therapy (BFB-CBT), in treating chronic TMD pain. Exploring both short- and long-term effects of brief CBT on chronic TMD patients, significant enhancements in pain-related beliefs, jaw function, activity interference, and depression were observed over one year [51]. Participants in the CBT group demonstrated reductions in catastrophizing and an increased sense of control over pain, reinforcing the enduring benefits of psychological interventions. Another study compared BFB-CBT to occlusal splints in patients with chronic TMD. Findings indicated that while both treatments effectively reduced pain intensity and disability, patients undergoing BFB-CBT experienced greater improvements in pain coping skills and overall satisfaction [52]. Supporting these findings, a systematic review of randomized controlled trials highlighted that CBT is comparable to traditional treatments like oral splints and medications in alleviating pain intensity [53]. Importantly, this review also emphasized the superior ability of CBT to address psychological dimensions of chronic pain, such as anxiety and depression, which are often underrecognized in TMD care. Moreover, they noted that CBT may offer superior long-term outcomes in reducing psychological distress, suggesting that the benefits of psychological interventions extend beyond immediate relief. This continuity of positive outcomes across studies emphasizes the potential of CBT to transform how individuals perceive and manage their pain. Further reinforcing this evidence, another large meta-analysis confirmed that psychological therapies, including CBT, effectively manage pain and improve function when compared to other treatment modalities [27]. Incorporating CBT into interdisciplinary care models allows clinicians to treat not just physical symptoms, but also the emotional and cognitive drivers of pain, offering a more holistic approach.

These studies highlight the viability of psychological therapies and their essential role in improving pain management, psychological well-being, and functional outcomes. The collective evidence advocates for incorporating CBT as a crucial component of TMD management strategies, while also calling for further research to solidify these findings in clinical practice.

3.2.3. Integrative therapies: acupuncture and yoga

Acupuncture and yoga are increasingly recognized as complementary treatments for managing TMD, offering unique benefits that address the multifaceted nature of this condition. A systematic review evaluated randomized controlled trials on acupuncture for TMD, concluding that acupuncture can deliver a short-term analgesic effect, reducing pain and improving jaw function [49]. However, they raised concerns about potential bias. Supporting this, in a recent study, acupuncture was found to significantly improve TMD symptoms in patients undergoing treatment for tension-type headaches [54]. Compared to therapeutic exercises, those receiving acupuncture experienced greater reductions in TMD scores at three- and six-months post-treatment. This suggests that acupuncture not only alleviates TMD symptoms but may also provide sustained relief, particularly for individuals with coexisting headaches, demonstrating its broader therapeutic scope. It could indicate that acupuncture not only alleviates TMD symptoms but may also provide sustained relief, particularly for individuals with coexisting headaches. Despite these limitations, acupuncture is suggested as a reasonable adjunctive treatment for TMD, with calls for further research to confirm its efficacy. Similarly, yoga is recognized for its potential benefits in managing TMD, primarily through stress reduction and relaxation, although high-quality evidence specifically linking yoga to TMD relief is limited. A recent study demonstrated that a yoga-based exercise program significantly reduced pain and improved jaw function and quality of life in female patients with myofascial pain related to TMD [55]. This highlights yoga’s potential role in addressing the stress-related components of TMD, further enhancing its therapeutic value. Both acupuncture and yoga illustrate the potential of complementary medicine approaches in TMD management, emphasizing their roles in enhancing overall well-being. Further research is essential to solidify their efficacy and integrate these complementary therapies into comprehensive pain management strategies for TMD.

3.2.4. Mind-body approaches: hypnosis, mindfulness, and biofeedback

Mindfulness-based interventions are effective in managing chronic pain by encouraging individuals to observe pain nonjudgmentally, which can reduce emotional and physical distress and ultimately lower pain intensity and improve quality of life [56]. However, data on mindfulness was limited and insufficient to draw reliable conclusions about its effectiveness. Given its focus on emotional regulation and pain awareness, mindfulness could potentially address both the sensory and emotional components of TMD. More high-quality research on mindfulness is needed to evaluate its effects on pain intensity, pain-related disability, and psychological distress in patients with TMD [53].

There is increasing evidence supporting the use of hypnosis in various areas of medicine [57,58], particularly in the management of both acute and chronic pain [59]. Studies have shown that hypnosis can influence the functional activity and connectivity of brain regions involved in the pain experience (the pain neuromatrix), leading to a reduction in both the intensity and unpleasantness of pain [60–62]. Recent systematic reviews reveal critical methodological flaws in hypnosis research within this unique field. While hypnosis holds promise as a treatment worldwide, the overall quality of the evidence remains low. This highlights the need for better-controlled trials and consistency in hypnosis protocols, and underlines the need for careful interpretation of the findings, which, unfortunately, have yet to yield compelling results. To unlock the true potential of hypnosis, there is an urgent requirement for stricter and more standardized methodologies in future studies [63,64].

Clinical biofeedback is a technique that has been proven effective for various diseases and conditions, including rehabilitation to promote normal movement patterns following injuries [65]. This therapeutic approach provides patients with real-time biological data through monitoring devices (e.g., electromyography), which helps them gain control over physiological processes (self-regulation) [66]. A recent systematic review found that biofeedback has the potential to reduce muscle activity and possibly alleviate TMD pain, but the quality of evidence is limited [67]. Further research is required to explore its long-term effects and determine optimal protocols for TMD pain management.

3.2.5. Occlusal appliances

Occlusal appliances, or splints or bite guards, are dental devices worn over the teeth to protect the TMJ and alleviate symptoms associated with TMD. These appliances create a cushioning effect that prevents the upper and lower teeth from grinding against each other, thereby reducing strain on the TMJ and surrounding muscles [68]. Additionally, they may help redistribute occlusal forces and mitigate muscle hyperactivity, offering benefits beyond simple tooth separation. Typically made from hard or soft acrylic, they are custom-fitted by dental professionals to ensure both comfort and efficacy [68]. Emerging 3D‑printed designs promise enhanced precision and faster production times, potentially improving patient compliance. To date, occlusal appliances are a popular choice among clinicians and patients and the literature has discussed the effectiveness of occlusal appliances in managing TMD symptoms [68]. A review by Cochrane written in 2012 indicated that the clinical effectiveness of these appliances can vary and emphasized the need for more robust studies to establish their long-term benefits [69]. A more recent review highlighted weak evidence supporting their efficacy [27]. A recent trial suggest that combining splints with physical therapy or behavioral interventions may yield better outcomes than splints alone [70]. In conclusion, occlusal appliances should be cautiously advised, particularly when used independently of other therapies.

3.2.6. Transcutaneous electrical nerve stimulation and low-level laser therapy or photobiomodulation therapy

Transcutaneous Electrical Nerve Stimulation (TENS) is a well-established, noninvasive method that uses low-voltage electrical currents to alleviate pain. It is easy to administer, portable, and risk-free, although some patients may experience discomfort from the electrical impulses delivered to the skin [71]. TENS works by stimulating nerve pathways (descending inhibitory pathways, segmental inhibition in the spinal cord), attenuating the nociceptive stimulation (gate control theory), and activating the endogenous opioid system [72]. It is widely used for musculoskeletal issues, including TMD, which often involves muscle tension and pain in the jaw area. TENS has demonstrated advantages for TMD in small clinical studies, such as reducing muscle tension, improving mouth opening amplitude, and short-term pain relief in certain cases [73,74]. However, a systematic review showed no difference between TENS and other similar modalities such as laser or ultrasound [75].

Low-Level Laser Therapy (LLLT), or Photobiomodulation Therapy (PBMT), employs low-intensity laser light to promote tissue regeneration and reduce inflammation. It is used in managing musculoskeletal disorders [76], including TMD, as it can reduce muscle pain, improve mouth-opening capacity, and decrease inflammation around the joint. A recent systematic review favored this therapy for pain management but with variable effects on functional outcomes [77].

A systematic review comparing LLLT with TENS indicated that LLLT was more effective than TENS for short-term pain relief and provided more consistent and lasting relief [78]. Recent research, including a systematic review indicates that PBMT shows promising results for pain relief and functional improvement in TMD [79]. The review concluded that applying PBMT with energy densities below 100 J/cm² and power outputs up to 500 mW over at least six sessions can improve maximum mouth opening and reduce pain [79]. However, it is important to note that variations in PBMT treatment protocols across different studies have made it challenging to establish a standardized approach. Moreover, clear guidelines for its use in clinical practice are lacking. Altogether, clinicians should consider patient preferences, treatment goals, and individual responses to therapy when determining whether to use TENS or LLLT or possibly even combine both for an integrated approach to managing TMD symptoms.

3.2.7. Extremely low frequency magnetic field (ELF-MF) and LED light therapy

ELF-MF therapy uses low-frequency electromagnetic waves to reduce inflammation and promote tissue repair, showing promise in alleviating TMD pain by improving blood flow and reducing TMJ inflammation [80]. However, evidence remains moderate, with studies lacking standardization and long-term follow-up [81].

LED therapy uses specific light wavelengths to reduce TMD pain and improve jaw mobility. Its safety and accessibility make it a viable alternative to low-level laser therapy. Preliminary findings suggest its potential for inflammation reduction and tissue repair, but inconsistencies in protocols and limited data require further research [82].

These therapies offer noninvasive, low-risk options for TMD management but require larger, high-quality trials with standardized protocols and long-term follow-up to confirm efficacy and refine clinical use. Moreover, combining ELF‑MF or LED with manual therapies or exercise programs may yield synergistic benefits, though this has yet to be formally tested.

3.2.8. Kinesiotaping

Kinesio taping (KT) is a noninvasive, supportive therapy used in managing TMD, though current evidence on its effectiveness remains limited. Its potential benefits are supposedly linked to increased blood flow, lymphatic circulation, and the tape’s skin-lifting effect, which reduces pressure on pain receptors and inflammation [83]. KT may also aid in muscle relaxation and proprioception, supporting jaw alignment over time [84]. While not effective as a standalone treatment, KT combined with physical therapy and medication may offer pain relief for patients seeking a noninvasive approach to TMD management. However, the lack of standardized application techniques, tension parameters, and long‑term follow‑up highlights the need for rigorous randomized controlled trials to determine optimal protocols and confirm clinical efficacy.

3.2.9. Trigger point therapy

Three main types of trigger point therapy are commonly used: trigger point dry needling, trigger point manual manipulation, and trigger point injections [85]. These therapies are employed to relieve various chronic musculoskeletal conditions that involve trigger points, such as chronic neck or lower back pain, tension headaches, tinnitus, TMJ pain, and reduced range of motion in the legs [86]. Mechanistically, these interventions may disrupt dysfunctional motor endplates and modulate nociceptive input at the spinal cord level, contributing to pain reduction. However, due to heterogeneous application protocols, variable injection substances, and small sample sizes, there is a lack of robust evidence regarding the effectiveness of these therapies specifically for TMJ disorders. High‑quality randomized trials with standardized outcome measures and longer follow‑up are needed to determine their true clinical utility in TMD management.

3.2.10. Lifestyle and dietary modifications

While studies suggest that TMD can significantly affect patients’ quality of life, dietary habits, and sleep, research on the impact of lifestyle and dietary modifications on TMD is limited. Lifestyle interventions may influence TMD through mechanisms such as reducing systemic inflammation and improving muscle tension regulation. A promising randomized trial published in 2024 showed that lifestyle modifications (including physical exercise and listening to music) improved pain severity, periauricular pain, and maximum mouth opening in patients with TMD [87]. Future studies should explore specific dietary patterns and their long‑term effects on TMD symptoms and overall quality of life.

3.2.11. Surgical approaches

The surgical management of patients with TMD may be considered for those who continue to experience symptoms despite conservative management. Less invasive surgical options include intra-articular hyaluronic acid injections, corticosteroids, platelet-rich plasma, or growth factors [88]. Hyaluronic acid injections restore the viscoelastic properties of synovial fluid in the temporomandibular joint, reducing pain and inflammation [89]. In TMD, some clinical trials showed some benefits but were not superior to other injection treatments [90]. A recent systematic review failed to draw solid conclusions about its effectiveness [91]. Corticosteroids can provide significant, though often temporary, relief from pain and improvement in joint function [64]. However, repeated use may lead to potential side effects, such as joint degeneration or cartilage damage. PRP injections have gained attention as a promising therapy due to their potential regenerative properties and ability to reduce inflammation. Clinical trials have shown mixed but generally positive results, with PRP reported to decrease pain and improve function in patients with TMD [92]. The efficacy can depend on the preparation method and the concentration of platelets. Finally, using growth factor injections, such as transforming growth factor-beta (TGF-β) and bone morphogenetic proteins (BMPs), is still relatively experimental for TMD. Some small studies have suggested that they may promote cartilage regeneration and reduce inflammation in the temporomandibular joint, but the clinical evidence is limited, and further high-quality trials are necessary to establish efficacy and safety [93]. Combining these agents can also be a strategy, as outlined in a recent meta-analysis where combining hyaluronic acid and plasma-rich platelets was superior to other arthrocentesis agents [94].

Arthrocentesis, which may be performed with or without an intra-articular injection, is another minimally invasive option. This technique involves removing inflammatory tissue and rinsing the articular capsule, which can enhance jaw mobility and alleviate pain, particularly in the early stages of TMD or when there is a clear arthrogenic cause [95,96]. Although minimally invasive, arthrocentesis carries the risk of injury to the facial nerve. If these treatments prove ineffective, either through arthroscopy or open surgery, discectomy or arthroplasty may be performed. However, there are limitations due to higher complication rates, including vascular or nerve injuries [64,97]. Overall, a careful approach that escalates from noninvasive techniques to more invasive treatments appears to be the most effective strategy, with open surgery reserved for the most severe and refractory cases.

4. Discussion

Managing TMD is a complex challenge due to its multifactorial nature, involving mechanical dysfunction, neuromuscular issues, and psychological factors. These diverse underlying causes contribute to persistent pain and functional impairment, making effective treatment difficult. For chronic TMD pain, it is essential to shift from a purely curative, symptom-focused model to a patient-centered approach tailored to individual needs [46]. This strategy must address the bio-psycho-social aspects of the disorder and consider the significant impact of chronic pain on patients’ quality of life. Therefore, a multimodal approach that integrates both pharmacological and non-pharmacological therapies is crucial for achieving long-term, sustainable pain relief and functional recovery [98].

Pharmacological treatments, including NSAIDs, muscle relaxants, antidepressants, and anticonvulsants, offer valuable symptom relief, particularly for managing acute pain and inflammation. However, their long-term use is often limited by adverse effects such as gastrointestinal discomfort, sedation, and dependency risks. More importantly, these treatments primarily address symptoms without targeting the underlying mechanisms of TMD, often resulting in incomplete or temporary relief [15]. This limitation highlights the need for complementary therapies that can provide more comprehensive and lasting outcomes.

Non-pharmacological therapies are gaining increasing attention for their potential to manage TMD more effectively over the long term with fewer side effects. Physical therapies, such as jaw exercises, manual therapy, and ultrasound treatments, help alleviate muscle tension, enhance joint mobility, and reduce mechanical stress on the temporomandibular joint. These interventions can improve overall jaw function and reduce pain severity. Behavioral therapies, particularly CBT, further support pain management by addressing psychological factors like stress, anxiety, and maladaptive coping behaviors, which are closely linked to the persistence of chronic TMD pain.

Research consistently demonstrates that a combined, individualized treatment approach is more effective than isolated therapies, as it holistically addresses the complex and multifactorial nature of chronic pain. However, despite the promising potential of non-pharmacological therapies, significant gaps in the literature remain. Many studies suffer from methodological weaknesses, including small sample sizes and short follow-up periods, limiting the ability to draw strong conclusions about long-term efficacy and safety. Moreover, the long-term outcomes of emerging treatments like LLLT, botulinum toxin injections, and ozone therapy are not yet well established. Overall, the most effective supportive treatment for managing TMD is still unclear due to limited scientific evidence [99]. The methodological limitations in researching complementary therapies stem partly from their inherent nature, which challenges conventional research frameworks, as the traditional evidence hierarchy often fails to accommodate approaches that cannot always be tested through mainstream methods.

Given these challenges, adopting a comprehensive, multimodal strategy that integrates pharmacological treatments with physical and behavioral therapies is increasingly recommended for optimal TMD management. This patient-centered approach not only provides symptom relief but also promotes long-term improvements in jaw function and overall quality of life. Future research should prioritize large-scale, high-quality clinical trials to establish standardized protocols and explore innovative therapies, ultimately guiding more effective and personalized treatment strategies for TMD, especially in multidisciplinary integrative medicine centers.

5. Conclusion

This review emphasizes the importance of both pharmacological and non-pharmacological approaches in managing TMD. While pharmacological treatments like NSAIDs and muscle relaxants offer short-term symptom relief, they do not address the underlying causes of TMD. In contrast, non-pharmacological therapies such as physical therapy, CBT and LLLT demonstrate greater potential for long-term improvement. This review gives an updated overview on complementary options and emphasizes that a multidisciplinary, personalized treatment plan that combines these approaches is crucial for effective pain relief and functional recovery. However, the persistence of symptoms in many patients highlights the urgent need for more research into the underlying mechanisms of TMD and the development of targeted, long-term therapies. Clinicians should prioritize individualized, multimodal care strategies to optimize outcomes and enhance the quality of life for TMD patients.

6. Future perspectives

Future studies on TMD should address several unresolved issues, particularly the need for more targeted, long-term therapies. Research into the underlying pathophysiology of TMD, including the roles of neuroplasticity and chronic pain mechanisms, could pave the way for disease-modifying treatments. Additionally, large-scale clinical trials are needed to establish standardized protocols for non-pharmacological therapies, such as LLLT and botulinum toxin injections, to determine their efficacy and safety over extended periods. Exploring personalized medicine approaches and incorporating genetic, psychological, and biomechanical factors may also improve treatment outcomes, although there are methodological difficulties in applying the methods valued by conventional medicine to complementary and integrative approaches. Overall, a more holistic understanding of the condition will enable the development of innovative, patient-centered strategies beyond symptomatic relief.

In the next 5–10 years, the field is likely to shift toward precision medicine, integrating genetic profiling and biomarkers to tailor treatments for individual patients. Advancements in neuroimaging and pain modulation research could lead to novel therapies targeting central pain pathways. Non-pharmacological treatments, such as LLLT and botulinum toxin, may become more standardized and widely accepted as evidence of their long-term safety and effectiveness grows. Additionally, digital health tools, including wearable devices and telemedicine, could play a larger role in monitoring symptoms and delivering personalized care. This multidisciplinary, technology-driven approach holds promise for improving outcomes and enhancing the quality of life for individuals with chronic TMD.

Funding Statement

This paper was not funded.

Author contributions

FJ, AG, QRM reviewed the literature, drafted the manuscript and tables. AF and MC supervised the work, reviewed the literature, edited the manuscript and tables, and synthesized the findings. AG, JDG and FS read and commented the manuscript.

Disclosure statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Article highlights

Introduction

• TMD is a common condition affecting a significant portion of the population, with higher prevalence in individuals with chronic pain conditions.

• TMD has a multifactorial origin, including mechanical stress, muscle dysfunction, inflammation, and psychological factors. Common symptoms include jaw pain, limited or painful jaw movement, clicking or popping sounds, headaches, and facial discomfort.

• Treatment is difficult due to the complex and varied causes of TMD and the limited long-term effectiveness of current therapies.

• A combination of pharmacological and non-pharmacological treatments is often required for effective management. Personalized, multidisciplinary approaches are essential to address both physical and psychological aspects of the disorder.

Methodology

• Databases searched: PubMed, Embase.com, Cochrane Library, and Evidence Alerts (from inception to Oct 2024).

• Search strategy: Included terms related to temporomandibular disorders, chronic pain, pharmacological and non-pharmacological treatments.

• Study types included: Original research, RCTs, narrative/systematic reviews, and meta-analyses.

• Exclusion criteria: Studies focused only on acute TMD or pathophysiology.

• Reference screening: Additional relevant studies identified through manual reference checks.

• Quality assessment: No formal risk of bias analysis, but emphasis on high-quality, peer-reviewed studies.

• Review type: Narrative synthesis integrating diverse evidence on chronic TMD pain management.

Pharmacological Interventions

• Analgesics have a limited use in TMD-related pain management because of their side effects and lack of long-term efficacy.

• NSAIDs and acetaminophen provide short-term pain relief but do not address underlying causes.

• Muscle relaxants can be used to reduce muscle tension and spasms, offering moderate pain relief.

• Antidepressants such as low-dose tricyclic antidepressants may help manage chronic pain and improve sleep.

• Gabapentin and pregabalin may reduce nerve-related pain in TMD patients.

• Botulinum Toxin (Botox) injections may reduce muscle overactivity and pain, though long-term safety is still under study.

• Some experimental treatment using ozone therapy show potential anti-inflammatory and pain-relieving effects.

• Capsaicin and lidocaine patches may provide localized pain relief with minimal side effects, but their efficacy is questioned.

Non-Pharmacological Interventions

• In managing chronic pain, a combined approach tailored to individual patient needs is more effective than isolated treatments [47,48].

• In TMD, non-pharmacological approaches are increasingly emphasized for their potential for long-term efficacy and fewer side effects (Figure 1).

• Incorporating physical therapies, manual therapy, and ultrasound, can enhance functional outcomes by addressing muscle tension, improving mobility, and reducing joint stress.

• Behavioral therapies, such as cognitive-behavioral therapy (CBT), further complement these approaches by addressing stress, maladaptive behaviors, and pain-coping mechanisms.

• For optimal management of temporomandibular disorders (TMD), a multimodal approach that combines pharmacological treatments with physical and behavioral therapies is therefore increasingly recommended.

Figure 1.

Number of PubMed occurrences per year and per treatment for the last 10 years, focusing on non-pharmacological and non-surgical approaches.

Conclusion

• A dual approach combining pharmacological and non-pharmacological treatments is required for effective TMD management.

• Pharmacological approaches with NSAIDs and muscle relaxants offer short-term relief but do not target root causes.

• Non-pharmacological therapies such as physical therapy, CBT, and LLLT show promise for long-term improvement.

• Personalized, integrative treatment plans are essential for pain relief and functional recovery.

• There is a need for further studies on TMD mechanisms and targeted therapies.

• The current clinical recommendation is to emphasize an individualized, multimodal care to improve outcomes and quality of life.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17581869.2025.2502311