Temporomandibular Joint Disorders: Advice for patients with face and jaw muscle pain

The TMJs are the joints that open and close your jaw. They are located on either side of the head, between the lower jaw and the skull.

Strong muscles help to move the TMJs and this allows the jaw to move, helping us to speak and chew. The TMJs and the strong muscles that help to move them, are being frequently used everyday.

“Temporomandibular Disorder” is an umbrella term which is used to describe the problem where the TMJs do not work properly. In Temporomandibular Disorder-Myofascial Pain, the condition is caused by the strong muscles that help to move the TMJs, becoming painful or going into spasm. Sometimes, the pain from the muscles can be long-lasting and persistent.

If the pain continues for 3 months or more, it is called chronic pain. Chronic pain from muscles that help to move the TMJs may not respond fully to standard medical treatment and there is no treatment which is guaranteed to cure the pain. Please see the diagram below which shows the TMJs and chewing muscles which can cause pain:

Anyone can get this condition.

The condition is common and affects 1 in 15 of the UK population. It is more common in the 20–40-year age range, however it can occur in children and older people. Women are slightly more likely to have the condition compared to men.

The most common symptom in this condition is pain in the face and jaw. The pain is usually described as a dull ache but it can be sharp and may occur suddenly. The pain can spread along the cheek bone, temples, neck and shoulders. The pain can get worse when chewing or moving the jaw. The pain can also get worse at times of stress.

Other symptoms which you may experience in this condition include:

• a feeling of tightness in your jaw
• noises from your jaw, for example clicking sounds
• difficulty opening your mouth fully
• difficulty using your jaw, for example difficulty biting into large or chewy foods
• earache, buzzing sounds or a feeling of fullness in your ear
• headaches
• other bodily pains such as neck, shoulder and back pain

Persistent pain in the face and jaw can be stressful and can affect people in different ways. The way the pain impacts you, is unique to you.

The pain may prevent you from enjoying activities that you used to and may cause you to feel frustrated. You may feel less able to manage responsibilities at home, work and with your friends and family.

The good news is that there are things you can do to help you take control of your pain, which can allow you to live a full, enjoyable life with this condition.

The condition is thought to be caused by the muscles around the face and jaw causing pain. Sometimes the muscles around the face and jaw will also tighten up due to muscle spasm.

There is no single reason to explain why this happens. However, research has shown that the condition is most likely caused by a combination of different factors.

Sometimes an exact cause cannot be found.

Research has shown that there are certain medical conditions which are commonly present with this jaw condition. These medical conditions do not cause the jaw condition.

Medical conditions which are commonly seen with this jaw condition include:

• widespread pain conditions such as fibromyalgia, chronic fatigue syndrome
• local pain conditions such as irritable bowel syndrome, endometriosis, back pain
• psychological conditions such as depression, anxiety
• headache conditions such as migraine, tension-type headaches

There is no high-quality evidence that an uneven bite or wisdom teeth cause this condition. For this reason, treatments to change the way the teeth bite together or to remove wisdom teeth are not usually recommended to treat this condition.

Stress does not cause the condition but it can increase the levels of pain. For example, the pain may increase during a stressful life event such as preparing for an exam, starting a new job or moving house. It may also affect you if you are in a job that requires you to talk a lot or use your jaw in an awkward position, for example playing a musical instrument.

Pain is a protective message which is designed to keep us safe and tell the brain if there is something wrong in the body.

In persistent pain of the muscles around the face and jaw, the muscles may be working normally and the original trigger for the pain may have stopped. However, the brain continues to tell the body that there is pain and it is not able to recognise that this protective message is not required. This means that the pain continues even when it is not required and it can lead to chronic pain from the jaw and face muscles. This type of pain can be complex and it is not always possible to cure the condition or completely stop the pain.

We understand that having this condition can be worrying. However, the condition is not usually serious and the symptoms can go away on their own. Although you may notice that the condition can fluctuate and you may have ‘flare ups’ of the condition, it does not usually get progressively worse over time. Having this condition does not mean you will get arthritis in your jaw joints.

Sometimes the pain may not go away completely. Following the advice in the leaflet can help you to manage the pain which is long term.

This condition is usually diagnosed by asking you questions about the pain you are experiencing and your general health. A physical examination is also carried out. X-rays and scans are not usually required to diagnose this condition but they might be recommended in specific situations. Your clinician will discuss with you if any additional investigations are recommended.

The aims of treatment are to reduce the painful symptoms and reduce the impact of the condition on your day-to-day life. It is not always possible to cure the condition.

Most people will find that the condition eventually resolves or becomes less frequent and more manageable by trialling a combination of simple, non-invasive treatments.

You should follow the professional advice of your clinician before attempting any treatments.

Treatments for this condition include:

• Self-care techniques: these are simple reversible treatments that you can carry out at home.
• Simple painkillers: ibuprofen or paracetamol may be recommended to help reduce discomfort. Some painkillers, such as ibuprofen, can be used as a gel applied directly to the skin on the outside of the jaw, on the painful areas.
• Other pain-relieving medications: Sometimes small doses of antidepressants can be trialled to help reduce the pain messages going to the brain. These medications are only prescribed in specific circumstances.
• Muscle relaxants: If there is severe tightening of the muscles due to spasm, a short course muscle relaxant might be recommended. These medications are only prescribed in specific circumstances.
• Mouthguard: If you grind or clench your teeth, your dentist might recommend that you try a mouthguard. This is also called an occlusal splint. This will protect your teeth against tooth wear, however it may not help your jaw and face muscle pain.
• Physiotherapy: If you have difficulties with jaw movement, physiotherapy can help to improve the mobility of your jaw and your confidence in using your jaw.
• Alternative medicine: Some people find that acupuncture to the sore muscles can provide pain relief.
• Clinical psychology: The pain you are experiencing is real and not psychological. We also know from science research that pain can affect the way we think, feel and behave. The clinical psychology team can work with you to understand how the pain is affecting you and to agree a plan with you to develop techniques to help you manage the pain. This may include techniques such as cognitive behavioural therapy and mindfulness.

There is no high-quality evidence that mouthguards, changing the bite or botulinum toxin A injections (sometimes known as ‘botox’ injections) are effective for long-term management of this condition. Surgery on the jaw is not usually recommended as it carries risks and can sometimes make the pain worse.

Self-care techniques are things that you can do at home to help reduce jaw and face pain.

Research recommends that these techniques should be used as a starting point for all forms of jaw muscle pain. This is because the evidence shows they are safe, effective and provide a good foundation to manage jaw and face pain. You should try and follow these techniques every day. It may take a few weeks until you start to notice an improvement.

Daily living and habits

• Avoid caffeine - this is a stimulant, which can increase stress and cause muscle tension
• Reserve time for relaxation techniques throughout every day
• When you are experiencing pain, adapt your diet to include softer foods. This means having foods which require minimal chewing such as pasta, omelettes, soft fish, mashed potato
• Do not chew gum, pens or nails. These habits place extra strain on the jaw muscles
• Apart from when you are eating, you should try and keep your teeth apart
• Examine your posture and try and maintain your head up and shoulders back

Facial massage

Massaging the strong chewing muscles that help to move your jaw, can help reduce muscle tension and help improve pain over time. The two major chewing muscles which can be easily reached for massage are the temporalis muscle (in your temple region) and the masseter muscle (in your cheek region, in front of your ear).

Please see the diagram below which shows these chewing muscles:

Thermal Treatment

For some people, gentle heat or cold applied to the painful jaw and face muscles can help. To find out which works best for you, apply moist heat or ice to the sore muscles on your head, face and neck for up to 10 minutes.

For heat application, a flannel wrapped around a heat pack or warm hot water bottle will provide moist heat. For cold application an ice pack wrapped in a tea towel can be used.

You can try heat for 3 days and then cold for 3 days. Apply this carefully to the affected areas, taking care not to burn yourself.

Graded exposure

If you worry that using your jaw will make things worse, you might start avoiding talking, chewing or other movements. This can lead to more stiffness, weaker muscles and even more pain. The more you avoid, the more sensitive your jaw can become, creating a cycle of pain and avoidance. Avoiding movement can make your symptoms worse over time.

Graded exposure is a technique that helps you gently and safely start using your jaw again. The idea is to slowly reintroduce jaw movements that you might be avoiding, starting with very easy activities and gradually working up to more challenging ones. This can help to reduce fear of using your jaw, improve jaw function and break the cycle of fear and avoidance which can make the pain worse.

To carry out graded exposure:

1. Start Small

   Begin with simple, comfortable movements, such as gentle mouth opening to clean your teeth and speaking. You might start eating foods you have been avoided in small amounts.

2. Increase Gradually

   As you become more confident, you can slowly try slightly harder activities, like talking for longer periods or eating foods that need a bit more chewing.

3. Build Confidence

   Each time you successfully complete a step, your confidence grows. This helps reduce fear and shows your body that movement is safe.

Stress management

Stress and worry can increase tension in your face and neck. This can make the discomfort and pain worse.

Breathing exercises, muscle relaxation, exercise and mindfulness techniques can support your overall wellbeing and help reduce pain intensity. This can help you feel more control of your condition.

A psychologist or therapist can provide more specific support to help you manage the emotional impact of chronic pain. For example, they may be able to help in managing stress, anxiety, low mood, worrying thoughts and sleep disturbance. If you feel that you could benefit from this service, please ask your doctor or dentist and they will be able to advise you further.

Some people may experience a few days or weeks where the pain is increased and mouth opening may be reduced. During this time, you can try the self-care measures below.

• Eat a soft diet. Use both sides of the mouth at the same time or alternate sides. It is important not to stay on a soft diet for a long time but to gradually return to a normal diet when the pain begins to reduce to its normal level
• Chew with your back teeth rather than with your front teeth. Return to your normal biting when the pain begins to reduce to its normal level
• Avoid activities that involve wide opening of the jaw such as yawning or prolonged dental treatments, until the pain has reduced
• Avoid habits that put a strain on jaw muscles and joints, such as chewing objects or jaw clenching
• Apply moist heat or cold (whichever feels better) on your cheek, over the jaw area.
• Keep your tongue up in the roof of your mouth and your teeth apart. This helps keep your jaw muscles in a relaxed position
• Pain medication may help, providing there is no medical reason why you cannot take these
• Carry out activities that help you to relax, for example abdominal breathing or light exercise
• Get a good nights sleep

Keeping a record of your pain can help you monitor any patterns and your progress.

This information can also help you when you talk to your clinician about your pain and to find out what is working for you and what is not working. Using a pain diary can help the clinician understand your pain better and help you to work together to make a management plan.

Pain can sometimes be difficult to describe. The following words may help you when describing your pain:

Below, there is an example pain diary which you may wish to copy. Remember to bring your completed pain diary to any future appointments you have with your clinician.

• The NHS website has a patient information page on jaw problems.
• The Royal College of Surgeons England publish evidence based guidelines on jaw problems.
• JawSpace: Your TMD Journey is an app available to download which contains information, self-management and support for patients.
• The Orofacial website provides patient information on chronic pain in the head, face and mouth.
• The Live Well with Pain website provides free information and resources to help people who are living with persistent pain.

UCLH cannot accept responsibility for information provided by other organisations.

Oral Surgery Department 
Royal National ENT & Eastman Dental Hospitals
47-49 Huntley Street
London WC1E 6DG

Email: uclh.enquiriesoralsurgery@nhs.net
Website: www.uclh.nhs.uk

If you have any concerns, PALS is a patient-focused service designed to provide a contact point to assist patients, relative and carers. PALS provide advice and information about the trust and provide support to resolve problems.

The PALS office is located in the main atrium of University College Hospital, 235 Euston Road London NW1 2BU.

Telephone: 020 3447 3042
Email: uclh.pals@nhs.net