Commonly Used Medications For Temporomandibular Disorders

1. NSAIDs

The orofacial pain conditions for which NSAIDs are prescribed include acute arthralgia (capsulitis), arthritis, and painful locked TMJ.  Although there are many options, and the clinician has to select which best suits each patient, three NSAIDs are commonly used.

1. Ibuprofen, or Motrin, has a recommended oral dose of 600 mg qid [not to exceed 3200 mg/day]
2. Nabumetone (generic) has the recommended dose being 500 mg bid P.O [up to 1500 to 2000 mg/day maximum]
3. Naproxen sodium (Aleve) has the recommended dose being 550 mg P.O. BID, [maximum does is 1600 mg/day]

All three medications must be taken with food. Side effects include serious gastritis and induced peptic ulcer if the prescription is continued for more than one month.

Diagnoses that Link with NSAIDs

1. Capsulitis
2. Osteoarthritis
3. Surgical trauma induced inflammation (e.g. biopsy)

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2. Antispasmodics

Antispasmodics are commonly used for short-term masticatory muscle spasms and pain. These include clonazepam, carisoprodol, and cyclobenzaprine.  All three medications are thought to reduce skeletal muscle tone due to their anxiolytic effects.

These medications are also used (with minor effect) for jaw tremor, assuming it is not caused by an underlying neurodegenerative disease such as Parkinson’s or CNS damage.  If the pain is stress related, anxiolytic medications or behavioral therapy is appropriate.

Diazepam, lorazepam, and Ativan are all anxiolytic medications that can be taken in small doses to reduce motor tremor.  One challenge with this approach is that it is a masking method and does not deal with the primary cause of the stress.  If the problem is only briefly reduced and returns, a behavioral treatment method is needed.

1. Clonazepam enhances the GABA-induced increase in chloride conductance. Side effects include sedation, lethargy, ataxia, and dizziness.
2. Caridisprodol is an older drug that centrally depresses polysynaptic reflexes. It has a mild addictive potential and, therefore, is not recommended for long-term use.
3. Cyclobenzaprine (10–30 mg P.O. taken at hour of sleep) is an antispasmotic drug that has less abuse potential than clonazepam or caridisprodol.

Diagnoses that Link with Antispasmodics

1. Myalgia with trismus
2. Capsulitis/arthralgia with trismus
3. Jaw muscle spasm
4. Orofacial tremor

Related Reading: Introduction to Orofacial Movement Disorders

3. Serotonin Modulators

Serotonin Modulators, including tricyclic antidepressants (amitriptyline or nortriptyline) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), such as duloxetine, are commonly used for MFP.  Both types of drugs work to suppress the re-uptake of serotonin and norepinephrine.  While the exact mechanism of how modulation of these two neurotransmitters are unclear, they suppress chronic neuropathic and myofascial pain.

1. Nortriptyline has a starting dose of 10-30 mg P.O. taken at hour of sleep. The dose is titrated upwards to a maximum therapeutic dose of 40mg and can be given BID.
2. Duloxetine has a starting dose of 30mg qd and can be titrated up to 60mg/d. The side effects include sedation, difficulty urinating, dry mouth, constipation, and weight gain over time.

Diagnoses that Link with Serotonin Modulators

1. MFP with active trigger points
2. Fibromyalgia producing pain in the jaw system
3. Neuropathic pain in the orofacial region
4. No contraindications for serotonin modulator such as obesity, cardiac disease, glaucoma, low blood pressure or being over 65 y/o

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