Pharmacotherapy can play an important role in the management of TMD symptoms. It is important to emphasize again, however, that the objective of treatment should not be simply symptom management but rather the identification and management of the underlying problem that is contributing to the symptoms. In that respect, pharmacotherapy should play a limited, and hopefully a short term role in the overall management of TMDs. Other therapies will be the means of addressing the actual problem that is causing the symptoms and the emphasis of treatment should be on those therapies, once the actual condition is identified (diagnosis) and reasonable treatment objectives determined and undertaken.

The medications that are most likely to be abused are narcotics and tranquilizers. To the degree that is reasonable in the individual case, the use of narcotic analgesics and tranquilizers should be very limited. In most cases of TMD management, these stronger medications should not be required at all. If there is indication for their use, they should not be prescribed on a “prn” basis. It is recommended that these drugs, when required, be prescribed to be taken at regular intervals for a prescribed period of time, and only in conjunction with other therapies. If the patient is unable or unwilling to undertake therapies that are likely to address the actual underlying problem, prescribing narcotic analgesics and tranquilizers is usually contraindicated to avoid the patient becoming reliant on medications in lieu of more appropriate treatment.

The medications most commonly used in TMD management include analgesics, anti-inflammatory drugs, corticosteroids, anxiolytic agents, muscle relaxants, antidepressants, and local anesthetics.

ANALGESICS

Analgesics are either opiate or non-opiate medications. The opiate analgesics are appropriate for moderate to severe pain management. The non-opiate analgesics are appropriate for mild to moderate pain.

Acetaminophen is a good choice to control mild to moderate pain because it is well tolerated and has minimal side effects. It is available over the counter and is inexpensive. It should be remembered that acetaminophen is effective as an analgesic but has no anti-inflammatory or antipyretic properties.

Aspirin is the traditional analgesic of choice for mild to moderate pain and incorporates antipyretic, analgesic, and anti-inflammatory properties. For patients who are sensitive to aspirin, other similar drugs, the non-acetylated version of aspirin (Tilisate and Disalcid) can be considered.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

Another category of non-opiate analgesics are the nonsteoidal antiinflammatory drugs (NSAIDs) and these are quite useful in the management of TMD-related mild to moderate pain and for acute postoperative pain. They have the same therapeutic effects as aspirin. The most common are ibuprofen compounds (Motrin, Advil, Nuprin) and these are available over the counter and as a generic. They may not be tolerated by some patients. As with aspirin, stomach irritation or even ulceration can be a problem and they should be taken with meals to lessen the likelihood of these complications. There are a whole range of other NSAIDs requiring a prescription. These are more expensive than the ibuprophen compunds. How much more effective they are is subject to debate.

OPIOID ANALGESICS

OpioId analgesics have central nervous system depressive qualities as well as the potential for addiction. When there is a need to manage moderate to severe acute pain, these should be considered for only short-term use. Choices include codeine or hydrocodone combined with either a salicylate or acetaminophen.

CORTICOSTEROIDS

Corticosteroids have a limited use in TMD pain management. Oral corticosteroids can be prescribed in a “dose pak”, beginning with a loading dose that is gradually decreased over a period of a few days. This approach might be considered in the case of an acute onset of TMD pain, such as following trauma.

Injectable corticosteroids, to be used directly into the TM joint, are usually considered appropriate on a one-time basis. Harmful effects to intracapsular structures have been reported with multiple injections of corticosteroids.

ANXIOLYTIC MEDICATIONS

Anxiolytic medications might be appropriate in the management of a TMD if high levels of stress appear to be a contributing factor. They do not eliminate stress but simply alter the perception or reaction to stress. The benzodiazepines are the most commonly used anxiolytic medications. They have a potential for dependency and should be used for no more than one week. Diazapam (Valium) has been the most commonly used and can be useful as a single dose at bedtime to relax muscles and aid in sleep. It may also help in decreasing nocturnal parafunctional behaviors. However, a single dose at bedtime should be limited to no more than 2 weeks. Two other drugs, clonazepam (Klonopin) and alprazolam (Xanax) have also been used but they carry the same potential for dependency.

MUSCLE RELAXANTS

Muscle Relaxants are actually sedatives. Several of the more common ones are members of a family called propanediols and include carisoprodol (Soma), methocarbamol (Robaxin) and chloraxazome (Parafon). All of these have significant central effects. One that has fewer central effects is metaxalone (Skelaxin) and may be more appropriate for a patient who needs to be able to work while taking the drug.

Perhaps the most commonly use muscle relaxant is cyclobenzaprine (Flexeril). It is chemically related to the tricyclic antidepressants and may work in a similar way. A single dose prior to bedtime can be effective in reducing muscle pain and improving sleep. When taken during the day, patients often experience drowsiness and this is not advisable when driving or operating any kind of dangerous machinery.

ANTIDEPRESSANTS

The most commonly used antidepressants today are of the SSRI family and there is now significant evidence, much of it anecdotal, that a number of these compounds appear to exacerbate bruxism. This presents challenges when the patient is experiencing endogenous or exogenous depression and also has a TMD. Other medications, such as clonazepam (Klonopin), can be prescribed to be taken with the SSRIs and have been shown to reduce bruxism. When indicated, it is best that these drug regimens be directed by the patient's primary care doctor or psychiatrist.

The tricyclic antidepressants, which are no longer much used to treat depression, have shown benefits in the management of musculoskeletal pain. The typical dose of 10 to 25 mg can be given prior to bedtime and have been shown to be effective in certain types of sleep disorders and in the management of fibromyalgia. Dosages typically used for anti-depressant management are much higher and, when indicated for that purpose, should be prescribed by the patient’s physician.

LOCAL ANESTHETICS

Local anesthetics can be used for diagnostic purposes to differentiate the true source of pain from the perceived site of the pain (see Okeson, Chapter 10). It has also been used for trigger point injections (see Okeson, Chapter 12) and to break the pain cycle from a source of deep pain input.