Nonsurgical Management

of Pediatric
Tem p o ro m a n d i b u l a r J o i n t
Dysfunction
Steven John Scrivani, DDS, DMedSca,*,
Shehryar Nasir Khawaja, BDS, MSca,b,
Paula Furlan Bavia, DDS, PhDa

KEYWORDS

Temporomandibular disorder
Temporomandibular joint
Management
Pediatric
Children

Therapy

KEY POINTS

Patients with temporomandibular joint dysfunction most commonly present with pain, restricted or
asymmetric mandibular motion, and temporomandibular joint sounds during mandibular
movements.

The prevalence of temporomandibular disorders in infants, children, and adolescents tends to in-
crease with age. However, the prevalence varies extensively in the literature.

Nonsurgical management of temporomandibular joint dysfunction consists of a combination of pa-
tient education, home-care plan, biobehavioral therapy, physical therapy, pharmacotherapy, and
orthotic jaw appliance therapy.

INTRODUCTION headache disorders, and associated structures

Temporomandibular disorders (TMD) are defined
as a subgroup of craniofacial pain problems that
involve the temporomandibular joint (TMJ), masti-
catory muscles, and associated head and neck
musculoskeletal structures.1,2 Patients with TMD
most commonly present with pain, restricted or
asymmetric mandibular motion, and TMJ sounds
during mandibular movements.2 TMD can become
chronic, produce significant dysfunction,
suffering, disability, and alteration of function and
activities of daily living. The American Academy
of Orofacial Pain (AAOP) has suggested that
TMD can be divided in 4 broad categories: TMJ
(Boxes 1–3).3
The prevalence of TMD in infants, children, and
adolescents tends to increase with age.4 However,
the prevalence varies extensively in the literature.
This variation may be attributed to multiple meth-
odological differences, such as disparity in exami-
nation and assessment methodology, difference in
diagnostic criteria, dissimilar cohort samples, and
inter-rater and/or intrarater variations among ex-
aminers.5 Most articles have reported the preva-
lence of TMD-associated signs and symptoms to
be rare in infants with primary dentition. However,
others have reported that up to 34% of children
with primary dentition may have at least 1 sign or
oralmaxsurgery.theclinics.com

articular disorders, masticatory muscle disorders, symptom associated with TMD.5–8 Similar disparity

Disclosure: The authors have no disclosures or conflicts of interest.

a
Division of Oral and Maxillofacial Pain, Orofacial Pain Residency Program, Department of Oral and Maxillo-
facial Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; b Orofacial Pain
Consultant, Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Cen-
ter, Lahore, Pakistan
* Corresponding author. 55 Fruit Street, Suite Warren 1201, Boston, MA 02114.
E-mail address: sscrivani1@partners.org

Oral Maxillofacial Surg Clin N Am 30 (2018) 35–45

http://dx.doi.org/10.1016/j.coms.2017.08.001
1042-3699/18/Ó 2017 Elsevier Inc. All rights reserved.
36 Scrivani et al
Box 1
Taxonomic classification for
temporomandibular disorder
1. Temporomandibular joint articular disorder
2. Masticatory muscle disorders
3. Headache disorders
4. Associated structures
Box 2
Taxonomic classification for
temporomandibular joint articular disorders
1. Joint pain
A. Arthralgia
B. Arthritis
2. Joint disorders
A. Disk: condyle complex disorders
i. Disk displacement with reduction
ii. Disk displacement with reduction
with intermittent locking
iii. Disk displacement without reduction
with limited mouth opening
iv. Disk displacement without reduction
without limited mouth opening
B. Other hypomobility disorders
i. Adhesions/adherence
ii. Ankylosis (fibrous, osseous)
C. Hypermobility disorders
i. Subluxation
ii. Luxation
3. Joint diseases
A. Degenerative joint disease (osteoarthro-
sis, osteoarthritis)
B. Condylysis
C. Osteochondritis dissecans
D. Osteonecrosis
E. Systemic arthritides
F. Neoplasms
G. Synovial chondromatosis
4. Fractures
5. Congenital/developmental disorders
A. Aplasia
B. Hypoplasia
C. Hyperplasia
Box 3
Taxonomic classification for masticatory muscle
disorders
1. Muscle pain limited to the orofacial region
A. Myalgia
i. Local myalgia
ii. Myofascial pain with spreading
iii. Myofascial pain with referral
B. Tendonitis
C. Myositis
i. Noninfective
ii. Infective
D. Spasm
2. Contracture
A. Muscle
B. Tendon
3. Hypertrophy
4. Neoplasms
A. Jaw
B. Soft tissues of head, face, and neck
5. Movement disorders
A. Orofacial dyskinesia
B. Oromandibular dystonia
6. Masticatory muscle pain attributed to sys-
temic/central disorders
is observed in children with mixed dentition. The
prevalence varies from as low as 5% to nearly
10%.5,9 Likewise, in adolescents with permanent
dentition, prevalence of symptoms and signs asso-
ciated with TMD ranges from 5% to 32.5%.5,10
Among adolescents from 16 to 19 years of age,
32.5% of girls and 9.7% of boys have reported
school absences and analgesic consumption
caused by pain associated with TMD.10
Irrespective of the subtype of TMD, the
pathophysiology is poorly understood. However,
it is considered to be multifactorial. The most
commonly identified causal factors include female
gender,11,12 pain provoked during jaw function
and/or palpation, oral parafunctional behaviors,
trauma, presence of other chronic pain conditions,
pain sensitivity,13 and psychosocial characteris-
tics.4,13,14 This article focuses on TMJ articular dis-
orders (TMJADs), which seem to be more
prevalent in the pediatric population.
Management of TMJADs consists of a combina-
tion of patient education, home-care plan,
 Pediatric Temporomandibular Joint Dysfunction
biobehavioral therapy, physiotherapy, pharmaco-
therapy, orthotic jaw appliance therapy, and/or
surgery. The goal is to increase function, reduce
pain, and improve quality of life. Surgery is per-
formed only to treat structural anatomic disorder
that is producing pain and dysfunction. Surgical
procedures consist of arthrocentesis, arthros-
copy, open arthrotomy and arthroplasty, TMJ
replacement, and/or combined joint and recon-
structive jaw procedures. Most patients with
TMJADs can be treated with noninvasive, non-
surgical, and reversible interventions.15,16 For pa-
tients with TMJADs that do not respond to a
course of nonsurgical interventions (up to 6 months
in length), and if the structural anatomic disorder is
a source of substantial pain and limitations to ac-
tivities of daily living, surgical intervention may be
considered.
PATIENT EDUCATION, HOME-CARE PLAN,
AND BIOBEHAVIORAL THERAPY
Patient education includes educating patients and
parents in simple and clear language about multi-
ple areas: (1) the nature of the disorder; (2) initi-
ating, predisposing, and perpetuating factors; (3)
anatomy of the TMJ; (4) management modalities;
and (5) goals of therapy. A tailored home-care
plan should be fabricated, consisting of (1) dietary
and habit modification (eg, avoidance of mastica-
tion of foods with a hard or chewy consistency,
small bites, bilateral chewing), (2) application of
cold and/or warm compresses, (3) avoidance of
habits that overload the masticatory muscles and
TMJ (eg, chewing gum, clenching, jaw or tongue
thrusting, and other oral parafunctional behaviors),
and (4) maintenance of the jaw in a comfortable
position with teeth apart and masticatory muscles
relaxed.1,15,17,18 In this context, biobehavioral
therapy is recommended and plays a fundamental
role for an effective treatment.19
Biobehavioral therapy is a noninvasive and
reversible modality that helps in the management
of pain and associated functional and emotional
disability. It comprises a variety of methods and
techniques, the most commonly studied being
progressive relaxation, abdominal breathing,
hypnosis, coping skills training, biofeedback, and
cognitive behavior therapy.19 Current literature
suggests that there is sufficient evidence for effec-
tiveness of these modalities for management of
TMJAD.20–23 These techniques have not been
comprehensively studied in a pediatric population
with TMJAD.
Relaxation training focuses on acquiring control
over physiologic response to stressful events. It
generally decreases sympathetic activity and
37
(possibly) arousal.19,24 Methods for relaxation
training include autogenic training, meditation,
and progressive muscle relaxation. These tech-
niques are intended to result in calming the mind
and reducing muscle tone. There are different
techniques through which this can be achieved;
for example, self-control muscle relaxation, paced
respiration, and deep breathing during episodes of
body stress and pain.19,24 Based on the limited
literature, it seems that behavioral therapy in the
form of relaxation training is less effective than
occlusal orthotic appliance therapy25,26 but may
provide relief for patients who fail to respond to
other treatments.26
Cognitive behavior therapy concentrates on
monitoring maladaptive and adaptive cognitions
and behaviors through application of coping skills
(eg, trying not to think about pain, thinking about
something else, continuing usual activities, and
trying to forget the pain).19,27,28 Cognitive behavior
therapy and hypnosis have been suggested to
block pain from entering consciousness by
activating the frontal limbic attention system to
inhibit pain impulse transmission in tertiary neu-
rons (thalamus to cortical structures). Similarly,
functional imaging studies show that central ner-
vous system (CNS) activity alters in response to
changes in thought patterns.24 Such techniques
have been shown to be helpful in management of
pain associated with TMJAD.29,30 Furthermore,
behavioral modalities seem to be important tools
for self-management of pain, modification of
cognitive perception, and the maintenance of an
acceptable psychosocial function even in the
presence of pain.19
Biofeedback is another type of biobehavioral
therapy that provides continuous feedback to the
patient using either visual or auditory signals.
This technique monitors either electrical activity
of the muscles with surface electrodes or periph-
eral temperature, and provides patients with
physiologic information that is intended to alter
physiologic functions to produce a response
similar to relaxation therapy.19,24,28,31,32 Literature
on the use of biofeedback in the pediatric popula-
tion for management of TMJAD is limited. None-
theless, biofeedback has been shown to be
beneficial in the management of pain associated
with TMJAD in the adult population and in
management of pain and dysfunction associated
with other pain disorders in the pediatric
population.24,28,31,33,34
PHYSICAL THERAPY
Physical therapy is a noninvasive, conservative
therapy that helps to relieve musculoskeletal pain
38 Scrivani et al
and restore function by altering sensory input,
reducing inflammation, increasing mandibular
range of motion, promoting repair and regene-
ration of tissue, and helping in reestablishment of
oral motor function.35 Types of physical therapy
include manual manipulation, massage, TMJ
distraction and mobilization, therapeutic exer-
cises, coolant therapy (spray and stretch tech-
nique), photobiomodulation, ultrasound therapy,
ionophoresis, and transcutaneous electrical nerve
stimulation (TENS).15,35,36
Manual manipulation and massage therapy
consist of controlled soft tissue and TMJ mobi-
lization, and stretching. Similarly, if performed in
concomitance with vapocoolant spray, it is
referred to as coolant therapy or spray-and-
stretch therapy. It is usually merged with therapeu-
tic exercises, such as isometric tension exercises,
and opening and closing jaw movements with
guidance.36 Manual therapies have been effective
in increasing mandibular range of motion and
decreasing pain intensity in adult patients with
TMJAD.37–39 Although scarce evidence exists for
pediatric population with TMJAD,40 this modality
has promising effects and is associated with no
adverse events.41
Photobiomodulation therapy or low-level laser
therapy (LLLT) is a therapeutic modality that gen-
erates light of a single wavelength. Exposure to
LLLT results in photochemical reactions within
the cells, which is referred to as photobiomodula-
tion or photobiostimulation. LLLT involves the use
of visible red or near-infrared light. Light energy is
absorbed within the cells by cellular photorecep-
tors called cytochromophores.42 There are various
types of LLLT devices available. They are primarily
characterized based on the element used for
generating the light. Photobiomodulation therapy
has been suggested to be effective in manage-
ment of TMJ arthralgia, inflammatory joint dis-
eases, and/or degenerative joint disease.43–45
However, the literature on the efficacy is equiv-
ocal,43–49 possibly because of multiple methodo-
logical limitations, such as inappropriate control
groups, short-term follow-up, inadequate evalua-
tion techniques, and heterogeneity of the stan-
dardization regarding the parameters of
photobiomodulation therapy.44,45,49
Ultrasound therapy is a frequently used physical
treatment modality for musculoskeletal disorders
such as cervical pain disorder, back pain, and
TMD. The high-frequency oscillations produce ul-
trasound waves that result in stimulation of cellular
pathways. It is proposed to result in reduced pain
and inflammation, and to induce repair and
growth. Evidence for its efficacy is low. However,
compared with occlusal stabilization appliances,
it was found to be equally efficacious in reducing
pain and improving range of mandibular motion.50
Ionophoresis is a technique that is used to carry
drug ions across a tissue barrier. A weak current is
used to enhance transport of the medication
through the skin to deeper tissues. It has been pro-
posed to be beneficial in management of inflam-
matory TMJ disease disorders such as juvenile
idiopathic arthritis.51,52 However, literature is
limited by a lack of randomized controlled trials,
control groups, and short-term follow-up.15,52
TENS therapy uses a low-voltage, low-
amperage biphasic current of varying frequency.
As an adjunctive therapy, it has been shown to
be effective in improving TMJ function by reducing
pain and improving range of motion in patients
with TMJ arthralgia and disc displacement disor-
ders.1,15,37,50,53 However, similar to other physical
therapy modalities, literature is limited by the pres-
ence of multiple methodological limitations.
Overall, physical therapy is a noninvasive treat-
ment modality that may provide relief in pain asso-
ciated with TMJAD, and improvement in mouth
opening and TMJ function.
ORTHOTIC JAW APPLIANCE THERAPY
Orthotic jaw appliance therapy refers to custom-
ized acrylic devices that fit onto maxillary teeth,
mandibular teeth, or both. They are available in a
variety of materials and designs. The most com-
mon types are (1) stabilization appliances of
hard, soft, or dual acrylic; (2) anterior positioning
appliances; and (3) anterior bite appliances.54
The purpose of orthotic jaw appliance therapy is
to reduce TMJ-related pain, increase range of mo-
tion, and improve joint function. The exact mecha-
nism of action of these devices is unknown. It is
suggested that orthotic occlusal device therapy
may alter the TMJ mechanics and increase joint
mobility, enhance patient awareness of oral paraf-
unctional behaviors, disrupt neuromuscular
engram that determines TMJ-fossa relationships,
and protect teeth and restorations from jaw
clenching, causing potential fracture or attrition
of dentition.54,55 There is no evidence that such
devices unload the TMJ by distracting condyle or
by pivoting on molar contacts, retrain muscles to
be less active after therapy, relieve headaches
that are primarily vascular or neurovascular in
origin, produce ideal neuromuscular/occlusal rela-
tionship, establish a correct vertical dimension of
occlusion, or eliminate oral parafunctional
behaviors.54
The most commonly used design is called a
stabilization appliance (Fig. 1). It has been shown
to be effective in management of symptoms
 Pediatric Temporomandibular Joint Dysfunction
Fig. 1. Full-coverage hard stabilization orthotic jaw
appliance. It has a flat occlusal surface to allow uni-
form posterior and anterior contacts with the
opposing teeth on closure.
associated with TMJ arthralgia, disc displacement
disorders, and degenerative joint disease.54–58
The occluding surfaces of these devices are usu-
ally made flat and adjusted to provide a stable
physiologic mandibular posture by creating bilat-
eral, even, posterior and anterior contacts for the
opposing teeth on closure. Because of this,
when adequately fabricated, these devices have
the least potential for adverse effects to the oral
structures.8,15,55 Few investigators have sug-
gested modification of the occluding surfaces by
adding canine or molar guidance. However, there
seems to be no difference in efficacy between
flat splints and splints designed to provide canine
guidance on lateral excursions of the mandible.56
Similarly, stabilization appliances can be fabri-
cated using soft, resilient material or hard acrylic.
There are now materials available that have a
soft inner lining with a hard outer shell. They
have been suggested to be more comfortable. In
terms of effectiveness, soft devices seem to be
similar in efficacy to hard devices.57 However,
they are more difficult to adjust and repair.15,54
The anterior repositioning appliance, or mandib-
ular orthopedic repositioning appliance (MORA), is
a full-coverage appliance with a reverse anterior
ramp that guides the mandible into the protrusive
position (Fig. 2). In addition, there is minimal con-
tact between the posterior teeth of the opposite
arch and the appliance. This device is associated
with significant adverse tooth movement, such
as posterior open bite.54,55 As a result, only
short-term use is advised. It is indicated for
the management of acute pain associated
with TMJ arthralgia and disc displacement
disorders.15,50,54,55
Anterior bite appliances are usually partial-
coverage devices that cover the anterior teeth
only, or in certain designs they are full coverage
with an anterior ramp for occlusal contact
39
Fig. 2. Anterior repositioning appliance, or MORA.
Note the reverse anterior ramp (arrows) on the palatal
section of the anterior segment of the device. It func-
tions as a guide to place the mandible into a protru-
sive position.
(Fig. 3). They are indicated in the management of
symptoms associated with TMJ arthralgia and
disc displacement disorders.54,59 Anterior bite ap-
pliances have been shown to be similar in efficacy
to stabilization appliances in improving pain and
range of motion.59 However, they have been asso-
ciated with significantly more incidences of
adverse tooth movements, such as supraeruption
of posterior teeth and anterior open bite.17,54,55
Unlike the adult population, only a few studies
have assessed the effectiveness of the orthotic
jaw appliance modality in the pediatric population
for the management of TMJAD. The quality of ev-
idence is limited. Investigators have found stabili-
zation appliances and anterior repositioning
appliances to be efficacious in reducing pain and
improving TMJ function.25,26,40,60 However, these
devices should be used with caution. Hard mate-
rial devices may interfere with the craniofacial
and odontogenic development and growth in
children with primary and mixed dentition. Current
evidence suggests short-term use of soft material
devices, such as soft stabilization appliances, with
even bilateral stable contacts with the opposite
dentition to minimize adverse tooth movements
in children with primary and mixed dentition.15,61
Fig. 3. Full-coverage anterior bite appliance. This de-
vice allows only anterior teeth of the opposing arch
to contact on closure.
40 Scrivani et al

PHARMACOTHERAPY COX-I and COX-II inhibitors seem to be more effec-

Pharmacologic therapy is intended to reduce pain
and promote improvement in function and quality
of life. The data on pediatric management of TMJ
disorders with medications are limited. However,
data from the adult population and from joints
other than the TMJ can be extrapolated. The
pharmacologic agents used in the management
of TMJ disorders include nonsteroidal antiinflam-
matory drugs (NSAIDs) and acetaminophen; corti-
costeroids; opioid therapy; hyaluronic acid; and
adjunctive agents, such as muscle relaxants, anti-
depressants, and benzodiazepines.
NSAIDs block the enzymatic effects of cyclo-
oxygenase (COX), which inhibits the production of
prostaglandins associated with nociception (prosta-
glandin E2). Nonsteroidal medications can be subdi-
vided based on the specificity of these medications
to inhibit COX enzymes.62,63 Topical and systemic
NSAIDs are effective in reducing pain and inflamma-
tion, and in improving joint function and stiff-
ness.64–67 However, use of NSAIDs is associated
with an increased risk for gastrointestinal, renal,
and cardiovascular side effects.62 Nonspecific
tive than specific COX-II inhibitors in the manage-
ment of pain associated with TMJAD.66 Commonly
used NSAIDs include ibuprofen, naproxen, diclofe-
nac, meloxicam, and celecoxib. Pediatric doses of
these drugs are summarized in Table 1.
Acetaminophen is a weak inhibitor of the synthesis
of prostaglandin. It seems to decrease the nocicep-
tive activity evoked in thalamic neurons by electrical
stimulation of nociceptive afferents, and is sug-
gested to have a central analgesic effect indepen-
dent of endogenous opioids.63,68 It has been shown
to be effective in the management of pain and inflam-
mation associated with degenerative joint disease.69
Compared with NSAIDs, acetaminophen is relatively
safe and has minimal side effects.63,68 Pediatric
doses of acetaminophen are listed in Table 1.
Corticosteroids are potent antiinflammatory
agents that exert their action by blocking the
breakdown of arachidonic acid, thus inhibiting
the production of leukotrienes and prostaglandins.
Systemic corticosteroids are not routinely recom-
mended for use in management of pediatric
TMJAD because of associated side effects.
Systemic corticosteroid use is associated with

Table 1
List of medications used in management of temporomandibular joint dysfunction in pediatric
population

Medicine Indication Dosage

Ibuprofen TMJ pain, TMJ Infants and children (6 mo to 12 y old): 5–10 mg/kg orally
degenerative joint every 6–8 h as needed. Maximum of 4 doses/d
disease Adolescents (12 y) 200–400 mg orally every 4–6 h as needed.
Maximum of 1200 mg/d
Naproxen TMJ pain, TMJ Infants (<2 y old): safety and efficacy of naproxen has not
degenerative joint been established
disease Children (25 kg or greater) 10 mg/kg/d orally in 2 divided
doses
Adolescents (12 y of age): 220 mg every 8–12 h as needed
with maximum dose of 660 mg in 24 h
Duration of therapy should not be longer than 10 d
Diclofenac TMJ pain, TMJ Infants: safety and efficacy have not been established
degenerative joint Children and adolescents <18 y old: 2–3 mg/kg/d in 2–4
disease divided doses. Maximum of 200 mg/d
Available as topical preparation
Meloxicam TMJ pain, TMJ Infants: safety and efficacy not been established
degenerative joint Children and adolescents: 0.125 mg/kg orally once daily with
disease maximum of 7.5 mg
Celecoxib TMJ pain, TMJ Infants: safety and efficacy have not been established
degenerative joint Children (2 y and older, 10–25 kg): 50 mg orally twice daily
disease Children and adolescents (25 kg or more): 100 mg orally twice
daily
Acetaminophen TMJ pain, TMJ Infants and children (<60 kg) 10–15 mg/kg/dose orally every
degenerative joint 4–6 h, with maximum of 1625 mg/d
disease Adolescents (60 kg or greater) 650 mg orally every 4–6 h, as
needed. Maximum dose of 3250 mg/d
 Pediatric Temporomandibular Joint Dysfunction 41

gastrointestinal, orthopedic, renal, and cardio-
vascular effects.15,63,70 However, they may be
useful for management of acute painful exacerba-
tion of TMJAD, or TMJ inflammation associated
with polyarthritides.15,71 Intrajoint injection of corti-
costeroids has been shown to be effective in the
management of TMJ pain refractory to conserva-
tive therapy, and inflammatory temporomandib-
ular disorders, such as juvenile idiopathic arthritis
(JIA).72 It has been shown to provide symptomatic
relief in pain, improve range of motion, and reduce
stiffness in children and adolescents with JIA.
These effects have been shown to persist after
8 to 12 years following the injections.73–75 Simi-
larly, localized use of corticosteroids is associated
with few or no systemic effects. However, intrajoint
injections may result in localized osteoarthritic
remodeling, infection, and progression of the
underlying degenerative joint disease. Therefore,
it is recommended to limit the use of corticosteroid
injection to a maximum of 3 injections per joint,
and to have an interval of at least 4 weeks between
each injection.73,75
Opioids are analgesic medications that act on
opiate receptor sites in the peripheral nervous sys-
tem and CNS. They are suggested for short-term
use in the management of moderate to severe
pain associated with TMJ disorders.15 However,
caution is advised with use of opioids. Opioid
use is associated with gastrointestinal (dry mouth,
nausea, and constipation), neurologic (hallucina-
tion, CNS depression), and cardiovascular side
effects, and have the potential for addiction.63,76
Patients with comorbid masticatory muscle dis-
orders (eg, masticatory myofascial pain, myalgia,
myofascial spasm) benefit from adjunctive medica-
tions such as muscle relaxants, antidepressants,
and benzodiazepines. Muscle relaxants depress
spinal polysynaptic reflexes preferentially more
than monosynaptic reflexes. Most commonly
used muscle relaxants consist of cyclobenzaprine,
methocarbamol, tizanidine, and metaxalone. Simi-
larly, antidepressants such as amitriptyline, venla-
faxine, and duloxetine have been used in the
management of chronic pain disorders. The anal-
gesic effect of these medications is not associated
with the antidepressant effect of such drugs and is
thought to be caused by alterations in levels of neu-
rotransmitters and alterations in certain receptor
mechanisms.77 Some benzodiazepines are also
considered neuropathic medications and are
thought to be effective by a similar

Table 2
List of adjunctive medications used in management of temporomandibular joint dysfunction in
pediatric population

Medicine Indication Dosage

Cyclobenzaprine Comorbid masticatory
muscle pain disorders
Tizanidine Comorbid masticatory
muscle pain disorders
Metaxalone Comorbid masticatory
muscle pain disorders
Methocarbamol Comorbid masticatory
muscle pain disorders
Amitriptyline Comorbid masticatory
muscle pain disorders,
chronic pain disorder
Clonazepam Comorbid masticatory
muscle spasm
Duloxetine Comorbid masticatory
muscle pain disorders,
chronic pain disorder
Adolescent (15 y): 5 mg orally 3 times/d. Can be
increased to 10 mg orally 3 times/d based on
response. Longer than 2–3 wk use not recommended
Safety and efficacy of tizanidine have not been
evaluated in pediatric population
Safety and effectiveness in children 12 y of age have
not been established
Adolescents (13 y): 800 mg orally 3–4 times/d
Children and adolescents: 15 mg/kg; may repeat every
6 h as required
Adolescents (12 y): 1 mg/kg/d orally in 3 divided
doses, increased after 3 d to 1.5 mg/kg/d
Infants and children (up to 10 y of age or 30 kg of body
weight) should be 0.01–0.03 mg/kg/d, not to exceed
0.05 mg/kg/d, given in 2 or 3 divided doses
Older than 10 years or > 30 kg: 0.25 mg orally at night.
Dosage can be increased to 0.5 mg up to three times
a day based on response. Dosage should be increased
by 0.25 mg/day after every 3-6 days. Longer than 2-3
week use not recommended.
Children (7 y of age) and adolescents: 30 mg/d
42 Scrivani et al
mechanism.1,15,63,78 The pediatric doses of these
medications are summarized in Table 2. Sodium
hyaluronate is a glycosaminoglycan. It is synthe-
sized and released by synovial cells in the TMJ
cartilage and synovial fluid. It has antiinflammatory
and analgesic properties. In addition, it plays
an important role in the maintenance of intra-
articular hemostasis. Hyaluronic acid is a lubricant
and helps synovial fluid to act as a shock absorber
in the joint. Similarly, it supports the tissue repair
processes in the intra-articular region. Intra-
articular administration of sodium hyaluronate has
been shown to aid in the management of TMJ
pain that is refractory to conservative therapy,
and in traumatic and degenerative TMJ diseases.
It helps to alleviate pain during rest and function,
improve TMJ mobility, and reduce joint noises.
The efficacy of sodium hyaluronate therapy is
similar to that of intra-articular use of corticosteroid
injections. However, the use of sodium hyaluronate
is associated with a lower side effect profile.79
SUMMARY
TMD is defined as a subgroup of craniofacial pain
problems that involve the TMJ, masticatory mus-
cles, and associated head and neck musculoskel-
etal structures. The prevalence of TMD in infants,
children, and adolescents tends to increase with
age. The most common signs and symptoms
associated with TMD consist of pain, restricted
or asymmetric mandibular motion, and TMJ
sounds during mandibular movements. The path-
ophysiology of these disorders is poorly under-
stood. Management of TMJAD consists of a
combination of patient education, home self-
care, biobehavioral medicine, physiotherapy,
pharmacotherapy, orthotic jaw appliance therapy,
and surgery. The goal is to increase function,
reduce pain, and improve quality of life. Surgery
is performed only to treat a structural anatomic
disorder that is producing pain and dysfunction.
Only a few studies have assessed the effective-
ness of noninvasive treatment modalities on the
management of TMJAD in the pediatric popula-
tion. However, extrapolating data from the adult
population, and from joints other than TMJ, it
seems that there is sufficient evidence to support
the use of patient education, home self-care, bio-
behavioral medicine, physiotherapy, pharmaco-
therapy, and orthotic jaw appliance therapy.
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