How should I approach the management of TMJ pain in patients with a history of bruxism?

Approach to managing temporomandibular joint (TMJ) pain in patients with a history of bruxism:

• Reassure and educate: Explain that temporomandibular disorders (TMDs) are usually non-progressive and symptoms often fluctuate but tend to improve. Educate about the anatomy, contributing factors including bruxism, and management goals ¹.
• Encourage self-management: Advise a soft diet and jaw rest during acute pain episodes. Recommend avoiding parafunctional activities such as teeth grinding, jaw clenching, chewing gum, nail biting, and wide yawning that may exacerbate symptoms ¹.
• Local symptomatic measures: Suggest applying covered ice or warm compresses and gentle massage of affected muscles to relieve pain and muscle spasm ¹.
• Prescribe analgesia: Use simple analgesics like paracetamol or NSAIDs for short-term pain relief ¹.
• Consider adjunctive drug therapy: For acute severe myogenous pain, a short course of low-dose benzodiazepines (e.g., diazepam 2 mg up to three times daily for max 5 days) may be considered. For chronic pain, trials of amitriptyline or gabapentin can be considered ¹.
• Refer to physiotherapy: For advice on passive jaw stretching exercises, posture training, massage, or acupuncture to relax muscle spasm and improve joint function ¹.
• Consider referral to a dentist: For assessment of dental health, malocclusion, or to consider intra-oral devices such as occlusal splints to reduce bruxism-related damage ¹.
• Address psychosocial factors: Screen for psychological distress, anxiety, depression, and sleep dysfunction, which can influence TMD prognosis. Consider referral for cognitive behavioural therapy (CBT) to help manage pain-related anxiety and chronic pain ¹.
• Specialist referral: If symptoms worsen, persist beyond 6-8 weeks despite primary care management, or if there is significant functional impairment, consider referral to oral and maxillofacial surgery, ENT, neurology, or multidisciplinary pain clinics for further investigation and management ¹.