The first medications in my TMD toolbox

Temporomandibular disorders (TMDs) are a highly prevalent group of interrelated conditions affecting the temporomandibular joints, muscles of mastication, and intra-articular structures [1]. Understanding the pathophysiology of TMD and the nuances between subtypes is paramount in management, particularly when incorporating medications into care. Dentists expertly employ local anesthetics, analgesics, sedatives, and antibiotics in daily practice, but many feel less confident prescribing medications when treating TMD. This editorial will highlight medications I have found to be particularly useful, with an eye on optimal medication selection. In contrast to many musculoskeletal pain conditions, the great majority of individuals with TMD improve over time without invasive therapy [2–5]. While the effectiveness of conservative therapy is encouraging, this also suggests the potential role that medications may play to improve quality of life when symptoms are present. Unfortunately, pharmacotherapy in TMD has not been rigorously studied in large randomized trials [6,7]. When scientific literature is less than ideal, we are left to make the best choices for our patients with the data available. I encourage each of you to explore the data and compare my experiences with those in your practice to determine if judicious use of medication could be beneficial as part of a comprehensive care protocol. In my practice, I have found three classes to be particularly useful: non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and tricyclic antidepressants. Understanding the indications for each, and the characteristics of drugs in each class, allows for application in a variety of circumstances. The first consideration when prescribing is also the simplest: Why prescribe at all? Before “reaching for the prescription pad,” one must be able to clearly articulate the precise goals of therapy. What am I trying to accomplish with this drug? Are alternative therapies available? Would pharmacotherapy help to improve function or quality of life in a condition that cannot be cured? Answers vary in each individual circumstance. Non-steroidal anti-inflammatory drugs are useful in treating many dental and orofacial conditions, due to their analgesic and anti-inflammatory properties. In TMD, they are the drugs of choice in treating acute (e.g., capsulitis) and chronic (e.g., degenerative joint disease) inflammatory conditions within the joint [6,8,9]. NSAIDs can provide acute pain relief in myalgia but are less effective in treating chronic myofascial pain, likely because most muscular pain is not caused by inflammation [10]. All NSAIDs inhibit cyclooxygenase 2 (COX-2), resulting in decreased synthesis of prostaglandin E2, a key mediator in inflammation and pain sensitization [11]. Unfortunately, most also block structurally similar COX-1, which negatively affects platelet aggregation, kidney function, and protection of gastrointestinal mucosa [12,13]. NSAIDs are cautioned in patients taking antiplatelet and anticoagulant drugs, due to increased bleeding risk, especially in the GI tract. Risk factors for GI bleeding include past history of GI bleeding, gastric and duodenal ulcers, H. pylori infection, alcohol and tobacco use, and age over 65 [13]. Short-term use is unlikely to produce GI symptoms de novo, with meta-analysis reporting 2–3 months of continuous therapy to induce symptoms when non-indomethacin NSAIDs are taken at recommended doses [14]. Ibuprofen is considered first-line therapy in temporomandibular joint (TMJ) arthralgia [15]. It is effective, inexpensive, and widely available [8,15,16]. The analgesic effect compares favorably to other NSAIDs [17]; however, higher doses (600 mg QID) are required to produce anti-inflammatory effects comparable to more potent NSAIDs [18,19]. The anti-inflammatory effect is important to consider, given the observation that pain relief in TMJ arthralgia may be due to decreased inflammation rather than direct pain relief [20,21]. Many patients struggle to be compliant with fourtimes-daily dosing. Use of a once-daily medication can help alleviate this issue. In healthy individuals, I often begin with piroxicam 10 mg daily for 10–14 days. While it is an excellent anti-inflammatory, piroxicam has greater potential for GI side effects than many NSAIDs [16]. CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 2020, VOL. 38, NO. 1, 1–4 https://doi.org/10.1080/08869634.2020.1691707