Initial management should include resting the joint and muscles. Try to give comparison to the knee or shoulder which are the joints that may become painful. Explain and make the patient aware of the things that they would do if these joints were tender, painful, or swollen. First and foremost, resting the joint is required. For knee, shoulder, or any other joint, resting the joint is easy: just sit down or lie down. These joints can be unused or minimally used for days or weeks if needed. But it is difcult to stop using TMJ and chewing muscles. These structures move while talking, eating, laughing, singing, etc. Resting is the most difcult task regarding TMJ-related dis­orders. Make the patient aware of this difculty, and advise them to eat soft food and to eat slowly. Also advise them not to open their mouth wide. If you explain the difculty by comparing a similar situation with other joints, patients are most

Avoid oral NSAIDs for elderly patients, preg­nant patients, and patients with gastric issues and kidney problems. Use Tylenol instead even though it is a weak anti-inammatory medica­tion. Alternatives include topical medications. There are several over-the-counter topical pain relievers like Voltaren (TM) gel, Aspercreme (TM), and Biofreeze (TM). You can also discuss with a pharmacist for compounded topical pain options.

There are several injection techniques indicated for TMD.For acute closed lock, meaning the disc dislocation is preventing translation of the con­dyle, a joint injection with anesthetic with or without steroid can help manually (self or practi­tioner assisted) reduce the disc from the locked position allowing translation of the condyle. TMJ steroid injection can also be used for acute joint inammation caused by trauma and are-up of arthritis [37, 38].

Sometimes, a patient with TMD presents with

are easy to identify and palpate (Fig. 7). Pterygoids are not easy to isolate for injection, but these muscles can also be injected with the help of an electromyography (EMG) machine by a trained specialist [40, 41].

Next, examine TMJ region, which is the pre­auricular area in front of the ear, and external muscles of mastication (masseter and temporalis) and cervical muscles, mainly the sternocleido­mastoid and trapezius muscles. Also take mea­surements of maximum mouth (interincisal) opening without pain and with pain separately. You need to record any joint sounds while open­ing the mouth during exams and their mouth opening pathway which can be straight, deviated (transiently deviates from the midline), or deected (off to an angle). The next step is to examine intraorally for any dental or periodon­tally related diseases, soft and hard tissue dis­eases, and malocclusion. A mylar strip (shim stock) would be benecial to check occlusion between each tooth.

Initial observation should be to determine whether it is primary TMD or secondary TMD disorder related to other causes like dental or periodontal pain. Once TMD is suspected, the next step is to determine whether the symptoms are from the TMJ or muscles by palpating these areas and observingthe patient’s response.

If it is determined that the primary cause of pain is within the joint, and any emergency cause like fracture has been ruled out, the next step is to control the pain.

As we discussed earlier, the initial measure to control pain is achieved by resting the joint (soft diet, slower chewing, smaller bites) and not open­ing mouth wider. Instruct patients to take an anti­inammatory medication, like ibuprofen or naproxen. In patients who cannot tolerate NSAIDs, Tylenol or a topical NSAID can be given. Patients should also be advised to use cold compresses sev­eral times a day to reduce inammation. A cus­tom-made or a short-term OTC night guard should be considered to reduce joint loading.