Temporomandibular Disorders: A Pain Medicine Perspective for General Practitioners

Adj Asst Prof Singh, Prit Anand
Deputy Head & Service Chief @ CGH, SingHealth Duke-NUS Pain Centre;
Lead, Regional Anaesthesia & Pain Management Service,
Director, Chronic Pain Management Service,
Senior Consultant, Department of Anaesthesia & SICU, Changi General Hospital

Clin Asst Prof Leonardo Saigo
Head & Senior Consultant, Department of Oral & Maxillofacial Surgery, National Dental Centre Singapore and Singapore General Hospital;
Senior Consultant, SingHealth Duke-NUS Sleep Centre

Dr Amelia Chew
Consultant, Prosthodontics Unit, Department of Restorative Dentistry, National Dental Centre Singapore

Adj Asst Prof Philip Cheong
Director, Allied Health, SingHealth Duke-NUS Pain Centre;
Director, Research, SingHealth Duke-NUS Sport and Exercise Medicine Centre;
Senior Principal Physiotherapist (Clinical), Department of Physiotherapy, Singapore General Hospital

From a pain medicine perspective, temporomandibular disorders should be understood as a biopsychosocial condition rather than a purely structural disorder. This article highlights key pain mechanisms, red flags for chronicity and the role of general practitioners in early identification, initial management and timely referral to multidisciplinary pain services to reduce long-term disability and improve patient outcomes.

WHY TMD MATTERS TO GPS

Temporomandibular joint disorders (TMD) frequently present in general practice, often as jaw pain, joint clicking or chewing difficulties. While these symptoms may appear isolated or benign, a subset of patients go on to develop chronic orofacial pain that significantly affects daily functioning, sleep quality and emotional wellbeing.

Pain Management

From a pain medicine standpoint, this progression is often underpinned by central sensitisation. In this state, the nervous system becomes increasingly reactive, leading to amplified pain responses and the spread of discomfort beyond the original site. As a result, patients may report persistent and poorly localised facial pain that is difficult to attribute to any specific structural cause.

These cases are often mislabelled or cycled through multiple specialties without resolution. GPs play a pivotal role as the first line of recognition, especially when pain is persistent, disproportionately severe, or accompanied by signs of poor sleep, stress or psychological distress. Early identification and referral to multidisciplinary pain services can prevent unnecessary chronicity and improve outcomes.

AETIOLOGY AND CONTRIBUTING FACTORS

TMD is typically multifactorial, with overlapping biological, psychological and behavioural contributors.

Common contributing factors include:

• Muscle overuse and parafunction: bruxism, clenching and excessive chewing 
• Psychosocial factors: stress, anxiety and sleep disturbances
• Malocclusion or trauma: direct injury to the jaw 
• Degenerative or inflammatory joint disease: osteoarthritis, rheumatoid arthritis, psoriatic arthritis

Often, no single cause is identified — instead, symptoms arise from a combination of factors.

TMD can lead to persistent orofacial pain that may spread to other parts of the body due to ongoing central sensitisation. This pain is often influenced by psychosocial factors such as stress, anxiety and maladaptive coping strategies. TMDs are therefore best conceptualised as biopsychosocial conditions, where physical and emotional factors interact in a cycle of pain and distress.

UNDERSTANDING TMD: SIGNS AND SYMPTOMS

Patients with TMD may present with:

• Pain or tenderness over the TMJ, preauricular area or masticatory muscles 
• Clicking, popping or grating sounds during jaw movement
• Restricted or asymmetric mouth opening
• Episodes of closed-lock jaw – inability to open the mouth maximally
• Recurrent jaw dislocation (open-lock jaw) –inability to close the mouth
• Associated symptoms such as headaches, neck stiffness or referred ear pain

Symptoms are often fluctuating and aggravated by chewing, speaking, yawning or stress.

CLASSIFICATION OF TMD

Accurate classification is essential for diagnosis, communication and management — particularly when coordinating care between GPs, dentists, physiotherapists and other specialists. TMD canbe broadly categorised as myogenous (muscle) or arthrogenous (joint) disorders.

DIAGNOSIS OF TMD

A focused clinical assessment by primary care practitioners is often sufficient to identify likely TMD and rule out red flags.

Initial assessment and triage can be performed by:

• Palpation of the TMJ and masticatory muscles for tenderness
• Observation of jaw movement and range of opening (normal: 40-50 mm) 
• Auscultation or palpation for joint noises (clicking, crepitus) 
• Assessment for deviation or deflection of the mandible on opening

Imaging is not routinely required in the initial evaluation and is reserved for atypical presentations, trauma or suspected joint pathology.

INITIAL MANAGEMENT IN PRIMARY CARE

Most cases of TMD respond well to conservative, non-invasive management, which can be initiated in primary care:

1. Patient Education and Reassurance

• Reassure patients that symptoms are often self-limiting and non-progressive. Explain the role of muscle overuse and stress in perpetuating pain.

2. Lifestyle and Self-Care

• Encourage a soft diet and avoidance of wide mouth opening 
• Apply warm compresses or gentle massage to relieve muscle tension
• Recommend jaw relaxation exercises and avoidance of parafunctional habits

3. Pharmacologic Measures

• Nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term pain relief 
• Short courses of muscle relaxants in myogenous cases

4. Addressing Contributing Factors

• Stress management strategies, cognitive behavioural therapy or mindfulness 
• Review medications or habits that may contribute to clenching or bruxism

Referral to a specialist is recommended when:

• No improvement in symptoms beyond one month despite conservative measures 
• There is significant limitation in mouth opening (< 35 mm) • History of trauma, locking or recurrent dislocation 

• Presence of systemic inflammatory disease or degenerative joint changes 
• Unclear diagnosis or suspicion of pathology (e.g., neoplasm or infection) 
• Significant psychosocial issues/stressors causing flare up of symptoms and/or spread of symptoms due to central sensitisation

FURTHER MANAGEMENT OF TMD

NON-SURGICAL MANAGEMENT

The majority of TMD patients are managed non surgically
in specialist care, with individualised, multimodal treatment plans.

A. Patient Education and Behavioural Therapy

• Education remains foundational — explaining the nature of TMD, the role of muscles and stress, and realistic expectations.
• Cognitive-behavioural therapy (CBT) can be valuable adjuncts for patients with chronic or stress-related symptoms.
• Habit reversal and relaxation training reduce parafunctional activities such as clenching and bruxism.

B. Pharmacotherapy

• NSAIDs remain first-line for pain and inflammation.
• Muscle relaxants are used short-term in myogenous TMD.
• There is role for tricyclic antidepressants (TCA)/selective noradrenergic receptor inhibitor medications (SNRI). However, specialist pain management input would be needed before prescription and subsequent management.

C. Physiotherapy

Physiotherapy plays a central role in the conservative management of both myogenous and arthrogenous TMD, particularly in chronic or recurrent cases. The primary goals are to alleviate pain, restore optimal jaw function and address the postural, muscular and psychosocial factors that contribute to persistent symptoms.

Contemporary management adopts a biopsychosocial and psychologically informed approach, recognising that physical dysfunction often coexists with psychosocial stressors such as anxiety, sleep disturbances and maladaptive coping behaviours.

Education and Habit Modification

Patient education forms the foundation of effective TMD management. By helping patients understand their condition and its contributing factors, physiotherapists empower them to take an active role in self-management. Key components include advising patients to avoid behaviours that overload the temporomandibular joint—such as wide mouth opening, excessive chewing, gum use or teeth clenching—and promoting awareness of daytime parafunctional habits.

Physiotherapists also provide instruction on ergonomic optimisation and adopting supportive sleeping positions to reduce nocturnal strain. Education also extends to jaw relaxation and breathing strategies, such as maintaining a tongue-to-palate resting posture and practising diaphragmatic breathing to mitigate tension associated with stress and anxiety.

From a psychologically informed standpoint, education extends to helping patients understand how stress, anxiety and poor sleep quality can amplify muscle tension and pain sensitivity. Relaxation training, stress management strategies and sleep hygiene advice are integral in mitigating these perpetuating factors.

Manual Therapy

Manual therapy can help with restoring joint mechanics and alleviate soft tissue restriction. Temporomandibular joint mobilisation can improve joint play, correct deviations during mouth opening and relieve capsular tightness.

Soft tissue techniques help to reduce muscle hypertonicity and myofascial trigger points. Since upper cervical dysfunction often coexists with TMD, mobilisations of the C0-C3 segments can reduce referred pain and facilitate normal jaw-neck kinematics.

Therapeutic Exercises

Therapeutic exercises form the active component of TMD management, enhancing motor control, strength and functional coordination.

Incorporating psychologically informed principles, exercises are often graded and paced according to the patient’s tolerance and anxiety levels. This graded exposure approach builds confidence, reduces fear-avoidance behaviours and encourages self-efficacy in managing symptoms.

Adjunctive Modalities

Adjunctive modalities serve as supportive measures to facilitate pain relief and tissue healing within a multimodal programme. Heat and cold therapy can reduce muscle spasm and inflammation, while electrical stimulation may provide temporary analgesia. Therapeutic ultrasound can enhance local circulation, reduce inflammatory mediators and promote soft tissue repair. These modalities should be applied judiciously, complementing rather than substituting for active rehabilitation and behavioural modification.

Psychologically Informed Practice

A psychologically informed framework acknowledges that pain in TMD is not purely mechanical but shaped by complex interactions between biological, psychological and social factors. Physiotherapists play a crucial role in identifying and addressing these influences through empathic communication, reassurance and cognitive reframing.

Patients with elevated stress, anxiety or sleep disturbance often exhibit heightened muscle tension and central sensitisation, which can perpetuate pain. A psychologically informed approach involves recognising these influences and addressing them through empathetic communication, goal-setting, relaxation techniques and referral for interdisciplinary support when appropriate (e.g., psychology or pain medicine).

By integrating psychologically informed strategies with manual therapy and exercise, physiotherapy provides a holistic, patient-centred approach that targets both the physical and emotional dimensions of TMD, promoting sustainable recovery and improved quality of life.

D. Occlusal Appliances (Splints)

Custom-fitted stabilisation splints (night guards) are commonly prescribed to:

• Reduce occlusal load and protect teeth from bruxism 
• Allow muscle relaxation 
• Alleviate joint loading and improve function

Splints are typically used at night and periodically reviewed to assess fit and effect. Overuse or ill fitting devices can exacerbate symptoms, hence specialist supervision is crucial.

MINIMALLY INVASIVE PROCEDURES

If conservative measures fail, minimally invasive interventions may be indicated:

• Arthrocentesis: Lavage of the upper joint space to remove inflammatory mediators and improve mobility; often performed under local anaesthesia. 
• Arthroscopy: Direct visualisation and treatment of intra-articular pathology (e.g., adhesiolysis, lavage or disc manipulation). 
• Intra-articular injections: Corticosteroids, hyaluronic acid or platelet-rich plasma (PRP) may be used adjunctively to reduce inflammation and improve mobility. 
• Botulinum toxin injections into masticatory muscles are sometimes used in refractory myofascial pain or severe bruxism, though evidence remains mixed.

These procedures are generally low-risk, outpatient based and can provide significant relief for selected patients.

SURGICAL MANAGEMENT

Surgical intervention is reserved for patients with structural pathology or failure of all conservative modalities. Indications include:

• Severe internal derangement with persistent closed lock 
• Degenerative joint disease with functional impairment 
• Fibrous or bony ankylosis 
• Neoplasms, developmental deformities or trauma-related sequelae

Common surgical options:

• Discectomy or disc repositioning 
• Condylotomy or arthroplasty 
• Total joint replacement for advanced degenerative or ankylotic disease

Surgery aims to restore function and relieve pain but requires careful patient selection and multidisciplinary postoperative rehabilitation.

MULTIDISCIPLINARY CARE: BETTER TOGETHER

Due to the complexity of TMD, a multidisciplinary approach has become the cornerstone of modern TMD management — integrating expertise from dentistry, oral and maxillofacial surgery, pain medicine, physiotherapy and psychology to address both the physical and psychosocial dimensions of the disorder.

Within the SingHealth ecosystem:

• The National Dental Centre Singapore serves as a key entry point for patients with TMD, providing comprehensive diagnostic assessments and a full spectrum of treatment options – ranging from conservative management and minimally invasive procedures to surgical interventions. 
• The Physiotherapy Department at Singapore General Hospital plays a critical role in the nonsurgical management of TMD. Physiotherapists deliver care through a biopsychosocial framework, helping patients restore jaw mobility, alleviate pain and address contributing musculoskeletal and postural factors. They also support behavioural change by addressing stress, sleep disturbances and movement habits that often perpetuate symptoms. 
• The SGH Pain Management Centre provides a comprehensive, multidisciplinary pain management service, offering a range of interventions to support patients with complex or persistent TMD-related pain. For patients with chronic TMD, persistent orofacial pain, or central sensitisation, referral to Pain Medicine is recommended 
• The SingHealth Duke-NUS Pain Centre serves as a system-level platform to coordinate and optimise pain care services across institutions, promote interdisciplinary collaboration and support shared education and clinical pathways — ensuring equitable and streamlined access to pain management within the cluster.

Barriers such as limited awareness, unclear referral pathways and under-recognition of TMD in primary care still exist. As the first touchpoint, GPs are uniquely positioned to bridge these gaps – by early identification of potential TMD cases, initiating early intervention and facilitating timely referrals to the appropriate specialists for integrated care.

CONCLUSION

The multifactorial nature of TMD demands more than symptomatic treatment — it requires integrated, patient-centred care that addresses the biological, behavioural and social aspects of pain. A multidisciplinary approach, uniting dental specialists, oral maxillofacial surgeons, physiotherapists, psychologists, pain physicians and primary care doctors, ensures that each patient receives comprehensive evaluation and tailored therapy.

Through early recognition, coordinated management and shared decision-making across disciplines, we can significantly reduce chronicity, restore function and enhance quality of life for patients living with TMD. Ultimately, collaboration — not compartmentalisation — remains the key to achieving lasting outcomes in the management of temporomandibular disorders.

TIPS FOR GPs Screening & First-Line Management

• Ask about jaw pain, clicking or restricted opening in patients with facial or headache complaints 
• Palpate the TMJ and assess mouth opening a Rule out red flags (e.g., trauma, infection, neoplasia) 
• Initiate conservative advice: soft diet, jaw rest, stress reduction, NSAIDs or muscle relaxants 
• Refer early to dentists, physiotherapists or pain medicine when indicated