Treatment Options for Temporomandibular Joint (TMJ) Synovitis

Initial Treatment Options

The American College of Rheumatology recommends a stepwise approach for the treatment of TMJ synovitis, starting with NSAIDs and potentially progressing to DMARDs and biologics for refractory cases, with careful consideration of the patient's skeletal maturity when considering intra-articular injections 1, 2, 3
NSAIDs are conditionally recommended as part of initial therapy for active TMJ synovitis, with a brief trial due to potential adverse effects and limited efficacy 1, 2
Intra-articular Glucocorticoid Injections (IAGCs) may be indicated for active TMJ arthritis with orofacial symptoms in skeletally mature patients, but are not recommended as first-line management for skeletally immature patients due to unique TMJ-specific adverse events 4, 5
Oral Glucocorticoids are conditionally recommended against as part of initial therapy for active TMJ arthritis 2, 6

Conventional Synthetic DMARDs are strongly recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs, with methotrexate conditionally recommended as the preferred agent and leflunomide recommended as an alternative 1, 2, 3
Biologic DMARDs are conditionally recommended for inadequate response to or intolerance of NSAIDs and/or IAGCs and at least one conventional synthetic DMARD, with TNF inhibitors most commonly used 1, 2, 3

Occlusal Splints/Mouthguards may be beneficial in patients with orofacial symptoms and/or TMJ dysfunction, as a reversible, safe, and relatively low-cost intervention 4, 5, 7
Physical Therapy may be beneficial for TMJ dysfunction, though evidence is limited and based primarily on extrapolation from related conditions 4, 5, 7
Intra-articular Lavage (without steroids) may be beneficial for TMJ arthritis-related symptoms and dysfunction in both growing and skeletally mature patients 7

Dentofacial Orthopedics and Orthodontics may improve facial development, occlusion, and function in skeletally immature patients with TMJ arthritis-related dentofacial deformities 4, 5
Skeletal Surgery may be indicated in both skeletally immature and mature patients with dentofacial deformities and controlled TMJ arthritis 4, 5

Contrast-enhanced MRI is currently the best method to detect active TMJ arthritis 4, 5
Clinical Examination should be used to diagnose TMJ arthritis-related dysfunction, with a standardized approach recommended to monitor changes over time 4, 5

TMJ is considered a high-risk joint due to its major impact on activities of daily living, thus early and aggressive treatment is often warranted 1, 2
Treatment of TMJ arthritis is recommended regardless of the presence of clinical symptoms due to its potentially destructive nature and impact on oral health-related quality of life 1, 2, 4