Temporomandibular disorders (TMD) are the most common pain condition of the face and jaw, and they affect up to 15% of adults (List 2017). The pain sits in the jaw muscles, in the joint just in front of the ear, or both, and it can make chewing, talking and yawning hurt. At Modal Pain Management NYC, 369 Lexington Avenue, Floor 25 in Midtown East, near Turtle Bay, Murray Hill and Grand Central, Dr. Alex Movshis evaluates jaw pain and offers non-surgical injection treatments alongside the dental and physical therapy care that most patients need first.
Understanding TMJ Disorders
The temporomandibular joint connects the lower jaw (mandible) to the temporal bone of the skull. It both hinges and glides, and a small disc of cartilage cushions it. TMD is an umbrella term for pain and dysfunction in the chewing muscles, the joint, or both (List 2017). The validated Diagnostic Criteria for TMD (DC/TMD) sort it into pain disorders, such as muscle pain (myalgia), joint pain (arthralgia) and headache caused by TMD, and joint disorders, mainly disc displacement and degenerative change (Schiffman 2014). When the pain persists, sensitization of the nervous system often plays a part alongside the muscles and the joint (List 2017).
Common Causes of Jaw Pain
Usually several causes act at once. Biological, environmental, emotional and social factors all contribute (Gauer 2015). Clenching and grinding (bruxism), during sleep or while awake, load the masseter and temporalis muscles. Arthritis of the joint, including osteoarthritis and rheumatoid arthritis, can damage the joint surfaces. Disc displacement can cause clicking and, when the disc does not slide back into place, a jaw that catches or will not open fully. A blow to the jaw can start it. Stress, poor sleep, depression and other pain conditions make TMD more likely to persist (List 2017). Tender, sometimes enlarged masseter muscles are a common finding in people who clench.
Diagnosis and Assessment
The diagnosis rests mostly on the history and the examination (Gauer 2015). Dr. Movshis asks when the pain started, what makes it worse, and whether the jaw clicks, catches or locks. He then measures jaw opening, presses on the chewing muscles and the joint, and looks for tender spots in the muscles that reproduce your pain (Fernández-de-las-Peñas 2018). Imaging is not routine. X-rays, MRI or ultrasound are ordered when a joint problem such as disc displacement or arthritis is suspected, or when the bite has changed (Gauer 2015). Pain from a tooth, the ear, a sinus or a facial nerve can feel like jaw pain, and the nerve causes are covered on the facial and cranial nerve pain page.
Treatment Options
Most people with TMD improve with non-invasive care: education and self-care, a night guard from a dentist, physical therapy, cognitive behavioral therapy, and medicines such as anti-inflammatories or a muscle relaxant for a short time (Gauer 2015, List 2017). Injections are for pain that has not settled with those steps, and they work alongside them.
Trigger point injections. When a tight, tender spot in the masseter or temporalis reproduces your pain, a small amount of local anesthetic can be injected into it, by feel or with ultrasound depending on the muscle. Relief is often quick, but the long-term evidence for trigger point injections is limited, so they are paired with jaw exercises. The trigger point injections page covers that evidence.
Botox, Dysport and Daxxify, off-label. No botulinum toxin product is FDA-approved for TMD, jaw clenching or bruxism, so this is an off-label use, and insurance often does not cover it. Injected into the masseter, and sometimes the temporalis, the toxin weakens the clenching muscles until its effect wears off. The measured benefit for pain is modest. In a 2024 meta-analysis of 15 randomized trials with 504 participants, pain on a 0 to 10 scale was about 2 points lower than with placebo at 1 and 6 months (Li 2024). An earlier meta-analysis rated the evidence as low quality and found a benefit over placebo only at 1 month (Machado 2020), and a double-blind trial in persistent jaw-muscle pain found no clinically relevant effect (Ernberg 2011). An umbrella review of 18 systematic reviews found it better than placebo but not better than standard treatments, and because of possible effects on muscle and bone it recommended toxin as the last treatment option (De la Torre Canales 2024). Chewing can feel weaker while it works. The animation of Botox for TMJ shows how it acts on the muscle, and the neuromodulator injections page covers the products.
Nerve blocks. For pain centered in the joint, a block of the nerves that supply it, with a small volume of local anesthetic, with or without a steroid, is sometimes used, both to ease the pain and to help show where it is coming from.
Physical therapy and jaw exercises are part of almost every plan, and we coordinate with your dentist when a night guard or bite work is needed.
What to Expect
Most injection visits take 15 to 30 minutes. Mild soreness at the injection sites for a day or two is common, and most people go back to their usual day straight away. Trigger point injections can ease pain the same day. Botox takes days to start working and is judged over weeks. Follow-up visits check your progress and adjust the plan.
Long-Term Management
TMD often comes and goes. Habits that load the jaw, such as daytime clenching, chewing gum and resting the teeth together, are worth working on, along with sleep, stress and posture. Home exercises help keep the gains from physical therapy. Most people improve with this kind of non-invasive care (Gauer 2015). Some need occasional repeat treatment, and the small number whose joint problem does not respond are referred to an oral and maxillofacial surgeon (Gauer 2015).
References
- Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache. 2014;28(1):6–27. doi:10.11607/jop.1151 · PubMed
- List T, Jensen RH. Temporomandibular disorders: Old ideas and new concepts. Cephalalgia. 2017;37(7):692–704. doi:10.1177/0333102416686302 · PubMed
- Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015;91(6):378–86. PubMed
- Ernberg M, Hedenberg-Magnusson B, List T, Svensson P. Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study. Pain. 2011;152(9):1988–1996. doi:10.1016/j.pain.2011.03.036 · PubMed
- Fernández-de-Las-Peñas C, Dommerholt J. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med. 2018;19(1):142–150. doi:10.1093/pm/pnx207 · PubMed
- Li K, Tan K, Yacovelli A, Bi WG. Effect of botulinum toxin type A on muscular temporomandibular disorder: a systematic review and meta-analysis of randomized controlled trials. J Oral Rehabil. 2024;51(5):886–897. doi:10.1111/joor.13648 · PubMed
- Machado D, Martimbianco ALC, Bussadori SK, Pacheco RL, Riera R, Santos EM. Botulinum toxin type A for painful temporomandibular disorders: systematic review and meta-analysis. J Pain. 2020;21(3–4):281–293. doi:10.1016/j.jpain.2019.08.011 · PubMed
- De la Torre Canales G, Câmara-Souza MB, Ernberg M, et al. Botulinum toxin-A for the treatment of myogenous temporomandibular disorders: an umbrella review of systematic reviews. Drugs. 2024;84(7):779–809. doi:10.1007/s40265-024-02048-x · PubMed