Intended for healthcare professionals

Rapid response to:

Practice Rapid Recommendations

Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline

BMJ 2023; 383 doi: (Published 15 December 2023) Cite this as: BMJ 2023;383:e076227 © 2023 BMJ Publishing Group Limited Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: Visual summary of recommendation Population These recommendations apply only to people with these characteristics: Summary of recommendations People with temporomandibular disorder Evidence profiles Practical issues Values and preferences Conditionalin favour Strongin favour Strongagainst Conditionalagainst Use the interactive MATCH-IT multiple comparison tool to compare the effects of treatments across outcomes, and view the certainty of effect estimates Expense may be a barrier to accessing care delivered by therapists unless patients have private coverage Adverseeffects Serious adverse events are unlikely with exercise and cognitive behavioural therapy Long-term opioids, NSAIDs, and invasive or irreversible procedures are associated with a small risk of serious, potentially catastrophic, harms Both costs and access to cognitive behavioural therapy may be facilitated by remote delivery supported by therapists, which is less costly and likely similarly effective to in-person cognitive behavioural therapy Patientengagement Patient adherence is required for active interventions such as cognitive behavioural therapy and supervised exercise. Both feasibility and patient preference should be considered when initiating a trial of active therapy Cost and access Chronic painPatients who live with chronic pain associated with temporomandibular disorder place high value on small improvements in pain relief Acceptable risks - conservative and pharmacological therapies Patients were willing to accept the typical risks associated with conservative and most pharmacological therapies for an improvement in pain relief approximating the minimally important difference of 1 cm on a 10 cm visual analogue scale Acceptable risks - surgical therapies Patients were willing to accept the typical risks associated with surgical therapies for an improvement in pain approximating 3 times the minimally important difference Contextual differencesIn making recommendations, the panel recognised that values and preferences were likely to vary between patients and between different socio-cultural and health service contexts globally Additional areas of uncertainty There may be differential effects based on subtypes of temporomandibular disorder Research is needed into the many available interventions for chronic temporomandibular disorder that are currently supported by low or very low certainty evidence Evidence is required about how the interventions affect outcomes other than pain, including adverse events, which are important to patients ? Find recommendations, evidence summaries and consultation decision aids for use in your practice Does not apply to: May not apply to: Including: <3 months duration Acute temporomandibular disorder pain Adult patients with: Moderate severity chronic pain (4-6 out of 10 on visual pain scale) ≥3 monthsduration Associated with any type of temporomandibular disorder Myofascial Degenerative joint disease Mixed Internal derangement of the joint Patients with comorbidities Mental illness Fibromyalgia Rheumatoid arthritis Those who have previously undergone surgery for temporomandibular disorder Military veterans Individuals receiving disability benefits or engaged in litigation Start with interventions that are available and supported by a strong recommendation in favour, then conditional in favour, then conditional against. Do not offer interventions for which there is a strong recommendation against Strong recommendations in favour Conditional recommendations against Strong recommendations against Shared decision making is key in ensuring patients are offered treatments in line with: their values and preferences what they have already tried accessibility of treatments in their context NSAIDs + Opioid * details on specific co-interventions that have been evaluated can be found in the MATCH-IT tool All or nearly all informed people would likely want an intervention in this category. Benefits on pain relief or function are very likely to outweigh harms or burden Most people would likely not want an intervention in this category. Benefits on pain relief and function are uncertain, and they are associated with harms or burden All or nearly all informed people would likely not want an intervention in this category. Benefits on pain relief and function are uncertain, and they are associated with important harms Conditional recommendations in favour Most, but not all, informed people would likely want an intervention in this category. Benefits on pain relief or function are likely to outweigh harms or burden Cognitive behavioural therapy + NSAIDs Jaw exercise + jaw stretching + trigger point therapy Jaw exercise + jaw mobilisation Augmented cognitive behavioural therapy Cognitive behavioural therapy Jaw mobilisation Postural exercise Jaw exercise + jaw stretching Trigger point therapy Usual care Acupuncture Manipulation Manipulation + postural exercise Acetaminophen with or without muscle relaxants or NSAIDS Arthrocentesis with or without co-interventions* Benzodiazepine Beta-blockers Biofeedback Botulinum toxin injection Capsaicin cream Cartilage supplement with or without hyaluronic acid injection Gabapentin Hyaluronic acid injection Low-level laser therapy with or without co-interventions* NSAIDs with or without steroids Relaxation therapy Removable occlusal splint with or without co-interventions* Steroid injection Transcutaneous electrical nerve stimulation Trigger point injection Ultrasound-guided arthrocentesis Discectomy Irreversible oral splint

Linked Editorial

Chronic pain associated with temporomandibular disorders

Linked Research

Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials

Rapid Response:

Re: Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline

Dear Editor

We read with interest the recent publication by Busse et al [1] concerning the management of chronic pain associated with temporomandibular disorders (TMDs). We note that among the recommendations, were conditional recommendations against arthrocentesis, botulinum toxin and steroid injections and strong recommendations against discectomy, these being included in a total of 59 interventions examined. We furthermore note that the specialty of Oral and Maxillofacial Surgery is under represented in the authorship of the article, arguably the specialty most concerned with the diagnosis and management of TMDs, some clinicians having a dedicated subspecialty interest in this regard.

We have recently been guest editors for a special edition of the British Journal of Oral and Maxillofacial Surgery [2], collating a series of papers on the growing evidence base for interventions in temporomandibular joint (TMJ) surgery including advanced arthroscopy, open arthroplasty (including discectomy) and botulinum toxin. Many of the assertions in the paper by Busse et al [1] fail to resonate with our clinical experience of such surgery (and that of our colleagues) and simultaneously do not acknowledge a growing evidence base that suggests that appropriately selected patients will yield a significant therapeutic benefit to such interventions.

The authors have based their systematic review on patients with “chronic pain associated with temporomandibular disorders”, but we would argue that not all TMDs are created equal. For instance, intra-articular pain and dysfunction from early degenerative joint disease can be attributable to demonstrable synovitis and a cascade of molecular events including the generation of free radicals and cytokines, with eventual progression to more advanced degenerative changes. In this cohort, arthroscopy or arthrocentesis may benefit up to 95% of patients with improvements in pain reduction and range of motion [3]. To assert that this can be recommended against in a published guideline is potentially short-changing patients who would significantly benefit, by creating a heterogenous group of TMDs and attempting to generate a “one size fits all” approach that is doomed to failure.

We would agree that a majority of TMD patients, including even those presenting to a tertiary referral service, can benefit from physiotherapy and/or psychological support such as cognitive behavioural therapy (CBT) due to not infrequently co-existing mental health issues and chronic pain conditions that can worsen outcomes to surgical interventions (although interestingly the authors of the current study chose to exclude patients with mental illness and fibromyalgia).

As such, we would not advocate for interventional treatment in the vast majority of patients, but would respectfully argue that surgical interventions (including those recommended against by Busse et al [1]) have an essential role to play in the management of a minority of TMD patients with a growing evidence base in the scientific literature to support their use, with an increasingly nuanced approach that should be encouraged rather than quashed in the modern era of TMJ surgery. We acknowledge that the scientific rigour of such research can be improved and welcome the advent of randomised controlled trials where possible, such as the upcoming MiTiGate [4] trial, but we would welcome a dialogue from our specialty in developing such guidelines5 to ensure that surgical candidates do not fall by the wayside.


1. Busse JW, et al. Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline. BMJ 2023;383:e076227
2. Elledge ROC, Speculand B. Current thinking in temporomandibular disorders: the science and art behind contemporary management. Br J Oral Maxillofac Surg 2024 [published online ahead of print]
3. Boloux GF, Chou J, DiFabio V, et al. The contemporary management of temporomandibular joint intra-articular pain and dysfunction. J Oral Maxillofac Surg 2024;82(6):623-631
4. National Institute for Health and Care Research (NIHR). Award ID NIHR15388. Managing chronic Myalgia Temporomandibular Disorder (M-TMD): a pragmatic randomized controlled trial of botulinum toxin type A, lidocaine, and amitriptyline/gabapentin, with internal pilot and cost-effectiveness analysis (MiTiGate trial). Available online at [last accessed 9 June 2024]
5. Beecroft E, Palmer J, Penlington C, et al. Management of painful temporomandibular disorder in adults NHS England Getting it Right First Time (GIRFT) and Royal College of Surgeons of England’s Faculty of Dental Surgery. Available online at of-painful-Temporomandibular-disorder-in-adults-March-2024.pdf [last accessed 7 June 2024]

Competing interests: No competing interests

08 July 2024
Ross O C Elledge
Consultant Oral and Maxillofacial Surgeon / Honorary Senior Clinical Lecturer
Bernie Speculand
University Hospitals Birmingham NHS Foundation Trust
c/o Sophia Dillion, Department of Oral and Maxillofacial Surgery, Nuffield House, Queen Elizabeth Medical Centre, Mindelsohn Way, Edgbaston, Birmingham B15 2GW West Midlands, United Kingdom