Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives

Journal of Complementary Therapies in Health ISSN 2975-9323 |eISSN 2975-9552 Journal of Complementary Therapies in Health 2025:3(3). doi:10.5281/zenodo.17390501 institutoptc.com/journal-complementary-therapies Review Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives. Paula Silva1*, Luísa Almeida1, José Ferreira de Oliveira2, Tony Bastos de Oliveira2, Alexandre Penelas Constantino1. 1 Independent researcher; 2 ABS – Health Level, Atlântico Business School, Vila Nova de Gaia, Porto, Portugal. * Correspondence: [email protected] Abstract Background: Temporomandibular Disorder (TMD) is a multifactorial condition affecting the temporomandibular joint (TMJ), masticatory muscles, and associated structures, resulting in pain, limited movement, and joint sounds. Its prevalence is high worldwide, with considerable variability across regions, genders, and age groups. TMD imposes significant economic and quality-of-life burdens, and its aetiology involves complex interactions of physical, psychosocial, and behavioural factors. Objectives: This study aims to examine TMD from both Western and Traditional Chinese Medicine (TCM) perspectives, highlighting anatomical, biomechanical, diagnostic, and therapeutic aspects, and providing a foundation for evidence-based integrative management. Methods: A comprehensive review of the literature was conducted, covering TMJ anatomy and biomechanics, TMD classification, causes, conventional diagnosis and treatment, and TCM approaches including acupuncture, herbal medicine, Taijiquan, Qigong, and Tui Na. The study emphasizes both structural-functional considerations in Western medicine and systemic, holistic concepts in TCM. Results: Western medicine focuses on clinical history, physical examination, imaging, and conventional therapies, including pharmacological, physiotherapeutic, and surgical interventions. TCM identifies syndromes related to Qi, Blood, Liver, Kidney, and pathogenic factors, offering holistic strategies to address systemic imbalances contributing to TMD. Both approaches provide complementary insights, with TCM emphasizing prevention, individualized treatment, and integration of mind-body practices. Conclusions: TMD is a complex disorder with multifactorial origins. Understanding its pathophysiology through both Western and TCM lenses provides a comprehensive framework for integrative management. This foundation supports the subsequent evidence-based analysis presented in Part 2, which explores the efficacy of TCM interventions in TMD treatment. Keywords: Temporomandibular Disorder; Temporomandibular Joint; Traditional Chinese Medicine; Integrative Medicine; Masticatory Muscles; Anatomy. 1. Introduction TMD is a multifactorial condition that affects the TMJ, the masticatory muscles, and the associated structures 1. Alterations in these structures result in pain, limited movements, and joint sounds 2. The global prevalence of TMDs is around 30% 3,4, varying according to region 3, gender 5, and age 6-8. The aetiology is complex, involving physical, psychosocial, and behavioural factors 2,5. Citation: Silva P., Almeida L., de Oliveira J.F., de Oliveira T.B., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives. Journal of Complementary Therapies in Health. 2025;3(3) 10.5281/zenodo.17390501 Academic Editor: Jorge Rodrigues Received: 10 August 2025 Reviewed: 29 August 2025 Revised: 15 September 2025 Accepted: 16 September 2025 Published: 18 September 2025 Publisher’s Note: IPTC stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: ©2025 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Journal of Complementary Therapies in Health 2025: 3(3). 2 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 Thus, due to their complex aetiology and high prevalence, TMDs represent a significant economic burden for both healthcare systems and patients 9-11. The treatment of TMDs requires a multidisciplinary approach, including conservative methods and, in more severe cases, invasive interventions 12,13. Core therapeutic strategies include occlusal splints, physiotherapy, and relaxation techniques aimed at reducing muscle tension. Pharmacotherapy is often used as a complement, including non-steroidal anti-inflammatory drugs, analgesics, and sometimes botulinum toxin to reduce the activity of the masticatory muscles 12-14. In chronic cases that are resistant to conservative treatment, surgical procedures may be considered 15,16. To complement existing treatments and enhance their effectiveness, it is important that new therapeutic procedures are explored. TCM offers a holistic approach to health, focused on the harmonious balance of internal biological functions, and emerges as a promising therapeutic option 17. Recent scientific literature shows a considerable increase in research on this traditional medical system 18-30, in parallel with a growing effort to build a knowledge bridge with Western medicine 31-39. Several TCM therapeutic approaches have shown promising results in the management of pain syndromes 40-42, with some studies conducted specifically on TMD 43-45. Therefore, this study aims to examine TMD from both Western and Traditional Chinese Medicine perspectives, providing a foundation for the evidence-based analysis presented in Part 2 of this paper. 2. The Temporomandibular Joint and Temporomandibular Disorder The TMJ, essential for chewing and speech, is a topic of great interest for dentists, orthodontists, and radiologists. Its study encompasses structure, function, adaptability, symptomatology, pathology, and how it is visualized in imaging examinations 46. The TMJ is classified as a ginglymoarthrodial joint, a term that combines the concepts of ginglymus (hinge), which allows back-and-forth movements in a single plane, and arthrodia (sliding), which enables the gliding movement of surfaces 47. The right and left TMJs form a bicondylar synovial joint, similar to the knee joint 48. Although the TMJ shares the common features of synovial joints (disc, bone, fibrous capsule, synovial fluid, synovial membrane, and ligaments), what makes it unique is its articular surface, which is covered by fibrocartilage instead of hyaline cartilage. Furthermore, TMJ movement is not guided solely by the shape of bones, muscles, and ligaments but also by dental occlusion. Because they are connected by the same mandible, the two joints cannot move independently 46. 2.1. Anatomy and Biomechanics of the Temporomandibular Joint Mandibular Surface The mandibular component consists of an oval-shaped condylar process, which rests on a narrow mandibular neck. Measuring 15–20 mm laterally and 8–10 mm anteroposteriorly, the long axes of the two condyles meet medially at the basion, on the anterior border of the foramen magnum, forming an angle of 145° to 160° opening anteriorly 46, as shown in Figure 1. The lateral pole of the condyle is rough and slightly pointed, projecting moderately from the plane of the mandibular ramus. In contrast, the medial pole extends markedly inward. The articular surface, located on the anterosuperior aspect, is oriented toward the posterior slope of the articular eminence of the temporal bone. Medially, this surface continues downward to envelop the medial pole of the condyle, directing toward the entoglenoid process of the temporal bone, where the mandible is positioned in occlusion 46,49. Regarding the morphology of the mandibular condyle, it varies considerably across different age groups and individuals. Morphological changes may occur due to normal developmental variations, as well as condylar remodeling to adapt to developmental differences, malocclusion, trauma, and other anomalies 50. Journal of Complementary Therapies in Health 2025: 3(3). 3 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 Figure 1. Mandible and the angle formed by the condyle positions. Cranial Surface The cranial component of the TMJ is located beneath the squamous portion of the temporal bone and anterior to the tympanic plate. The articular fossa is entirely formed by the squamous portion of the temporal bone. The posterior part of the fossa is elevated, forming the posterior articular crest. In most individuals, this crest becomes thicker laterally, resulting in a cone-shaped projection known as the postglenoid process 51. The tympano-squamous fissure is located posteriorly and laterally in the glenoid fossa, between the squamous and tympanic portions of the petrous bone, separating the articular from the non-articular surface of the glenoid fossa. Along the medial part of the glenoid fossa are the petrotympanic fissure anteriorly and the petro-squamous fissure posteriorly 46,51. The articular eminence forms the anterior boundary of the glenoid fossa. It is a transverse bony bar, anterior to the glenoid fossa and medial to the posterior margin of the zygomatic process. Its anterior slope, known as the pre-glenoid plane, rises gently from the infratemporal surface of the squamous bone. During maximum mouth opening, the mandibular condyle and articular disc move anteriorly to the top of the articular eminence and the pre-glenoid plane 49. The gentle slope of this surface facilitates the smooth return of the condyle and disc to their neutral position. The articular tubercle is a small bony protuberance on the lateral aspect of the articular eminence, serving as an attachment point for the lateral collateral ligament. The lateral edge of the glenoid fossa is slightly elevated, connecting the anterior tubercle to the postglenoid process 46,51. Figure 2 shows these structures. Articular Disc The articular disc is a key anatomical structure of the TMJ 52. It is a biconcave fibrocartilaginous structure situated between the mandibular condyle and the temporal bone. Its functions include allowing both hinge and sliding movements between the articular surfaces of the temporal bone and the mandible 46,49. 145° a 160° Mandible Left condyle Right condyle Journal of Complementary Therapies in Health 2025: 3(3). 4 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 Figure 2. Cranial component of the TMJ The disc is a firm, fibrous, oval-shaped plate, with its long axis oriented transversely. Its shape, resembling a peaked cap, divides the joint into two compartments: a larger superior compartment and a smaller inferior compartment. Hinge movements occur in the inferior compartment, while sliding movements occur in the superior compartment. The superior surface of the disc is saddle-shaped to fit the cranial contour, and the inferior surface is concave to accommodate the mandibular condyle 52. The disc is thick and rounded to oval at its borders. It is divided into an anterior band 2 mm thick, a posterior band 3 mm thick, and a thin intermediate zone at the centre, 1 mm thick. Posteriorly, there is a bilaminar or retrodiscal region. The disc is attached to the entire articular capsule, except for the strong bands that directly anchor it to the medial and lateral poles of the condyle. These attachments ensure that the disc and condyle move together during protraction and retraction 46,48. The anterior extension of the disc is connected to the fibrous capsule both superiorly and inferiorly. Between these connections lies the insertion of the lateral pterygoid muscle, where the fibrous capsule is absent and the synovial membrane is supported only by loose areolar tissue 46,51. The anterior and posterior bands are predominantly composed of transversely oriented fibres, while the thin intermediate zone has fibres oriented anteroposteriorly. In the Articular eminence Glenoid fossa Pre-glenoid plane Postglenoid process Journal of Complementary Therapies in Health 2025: 3(3). 5 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 posterior part, the bilaminar region consists of two fibre layers separated by loose connective tissue. The superior layer, or temporal lamina, is composed of elastin and attaches to the postglenoid process, an extended medial crest that forms the true posterior boundary of the joint. It prevents the disc from slipping during yawning. The inferior fibre layer, or inferior lamina, curves behind the condyle to merge with the capsule and the posterior part of the condylar neck at the lower limit of the articular space. Its function is to prevent excessive rotation of the disc over the condyle 53. Between these two layers lies a soft, expandable pad of blood vessels and nerves, surrounded by elastic fibres that assist in vessel contraction and disc retraction during jaw closing movements. When the mandible is in the closed-mouth position, the thick posterior band lies immediately above the condyle, near the 12 o’clock position. To be considered normal (95th percentile), the junction of the posterior band with the bilaminar zone should deviate up to 10 degrees from the vertical. If the displacement angle exceeds 10 degrees, it is considered pathological 53. Some studies indicate that disc displacement is observed in a large number of asymptomatic volunteers (33%) 54, whereas other authors use the intermediate zone as a reference point, an approach that does not consider the displacement angle of the posterior band 55. The retrodiscal attachment tissues constitute the intra-articular part of the joint located posterior to the condyle and disc. Functionally, the condyle and disc are positioned more anteriorly, being strictly defined when in centric relation. The volume of the retrodiscal tissue must increase instantly when the condyle translates forward. This tissue is folded and compressed within the articular space when the mandible is closed. Upon mouth opening, the condyle moves downward and forward (translates) 46,49. The superior part of the retrodiscal attachment contains a prominent vascular shunt, a network of vessels contained within adipose tissue, collagen, and elastin arranged loosely. Perhaps because the disc tends to rotate against the condyle (rather than translate as it does against the superior articular surface), the inferior lamina or inferior retrodiscal tissue stretches and serves to stabilize the disc over the condyle. It is composed of relatively inelastic, densely packed collagen 46,53. Fibrous Capsule, Ligament Complex, and Musculature The fibrous capsule is a thin layer of tissue that completely surrounds the joint. It extends from the circumference of the cranial articular surface to the mandibular neck 46. The contour of the capsular attachment at the base of the skull follows this course: • Anterolaterally: to the articular tubercle; • Laterally: to the lateral border of the mandibular fossa; • Posterolaterally: to the postglenoid process; • Posteriorly: to the posterior articular crest; • Medially: to the medial margin of the temporal bone at its suture with the greater wing of the sphenoid; • Anteriorly: it attaches to the pre-glenoid plane, ensuring it is included in the articular cavity56. Regarding the TMJ ligament complex, it plays a crucial role in joint stability and movement limitation. It consists of collateral and accessory ligaments, which work together to guide and restrict mandibular motion 46. The collateral ligaments, present in each joint, are divided into two layers. The outer or superficial layer is broad, fan-shaped, and originates from the external surface of the articular tubercle and most of the posterior zygomatic arch. Its fibres run obliquely downward and backward, inserting posteriorly, behind and below the mandibular neck. Medial to this, a narrower inner or deep ligamentous band originates from the crest of the articular tubercle. This internal band runs horizontally backward, attaching to the lateral Journal of Complementary Therapies in Health 2025: 3(3). 6 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 pole of the condyle. A superior portion of this band continues to merge with the posterior part of the disc, lateral to the condylar pole 57. Medial condylar sliding is prevented by the entoglenoid process, while lateral sliding is restrained by the temporomandibular ligament. The oblique external band becomes tense during condylar protrusion, accompanying jaw opening, limiting inferior distraction in sliding and forward rotation movements. Conversely, the internal horizontal band is tensioned during mandibular head retraction, limiting posterior condylar motion 58. The sphenomandibular ligament originates from the angular spine of the sphenoid and the petrotympanic fissure, running downward and outward to insert at the mandibular lingula. It is a passive ligament, maintaining constant tension during jaw opening and closing 57. The stylomandibular ligament is a dense concentration of deep cervical fascia extending from the apex and adjacent anterior portion of the styloid process and the stylohyoid ligament to the angle and posterior border of the mandible. This ligament is loose when the jaw is closed and relaxes markedly upon mouth opening. It only becomes tense during extreme protrusive movements and is therefore considered an accessory ligament of uncertain function 46. Since many TMJ disorders involve the muscles, understanding their function is extremely useful. The masticatory muscles surrounding the joint work in harmony to ensure proper mandibular function. When relaxed and unstressed, they act synergistically with the rest of the TMJ complex. The masticatory muscles are responsible for all mandibular movements and can be divided into abductors and adductors 59. The temporalis, masseter, and medial pterygoid muscles are adductors, while the lateral pterygoid is the primary abductor. Muscles producing forward movement (protrusion) are also alternately used to move the mandible side to side (laterally) 60,61. • Masseter: The main and strongest masticatory muscle, originating from the temporal bone and extending along the external surface of the mandible to its lower angle, with broad insertion along the lateral edge of the condyle 62,63. • Medial Pterygoid: Parallel to the masseter but on the internal side of the mandible, originating from a wing-shaped protrusion on the skull. This muscle, together with the masseter, forms a “loop” around the posterior part of the mandible, working synergistically to close it 51,64,65. • Temporalis: A fan-shaped muscle on the lateral side of the head, with its broad portion originating from the temporal fossa and temporal fascia. The narrow portion inserts on the coronoid process of the mandible 63. Protrusive and lateral movements are mainly produced by the pair of lateral pterygoid muscles, which originate from the same cranial regions as the medial pterygoids, extending backward and outward toward the condyles. The lateral pterygoid consists of two parts: the superior belly and the inferior belly. The inferior bellies are primarily responsible for moving the mandible forward, opening the mouth, and pulling the jaw to one side. When contracted, they pull the condyles forward and downward from the fossae to the lowest points of the eminences. Alternating contraction allows lateral mandibular movement 46,49. The fibres of the superior belly pass through the articular capsule and connect to the anterior part of the articular disc. The superior belly ensures proper disc movement in coordination with the mandible, especially during mouth closure, acting in opposition to the inferior belly. It applies forward pressure on both the condyle and disc, stabilizing their relationship and ensuring the most effective position when strong masticatory forces move the condyle back and forth 46 . Journal of Complementary Therapies in Health 2025: 3(3). 7 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 2.2. Temporomandibular Disorder Based on quantitative and qualitative data, the pathway for a patient to obtain an accurate diagnosis and appropriate treatment for TMD is often long and costly 66. This has a significant impact on personal finances and individual quality of life, comparable to more widely recognized conditions such as arthritis and depression. Healthcare costs remain consistently high, largely driven by multiple consultations with different specialists or care providers. Despite the level of intervention received, the probability of improvement in high-impact pain appears to be low (with only a 48% chance of transitioning from a high-pain state to a low-pain state within six months) 67. Individuals with TMD differ from other chronic pain patients due to their extremely low rates of absenteeism. However, they experience a reduction in both the quality and quantity of work they are able to perform (approximately 12% reduction in each). This results in a considerable “hidden” cost for employers, ranging between €685 and €1439 in lost productivity every six months. Compared with migraine data from the United States and the European Union 68,69, TMD patients missed less than half the number of workdays. However, on average, they spent 35 days at work in pain over a six-month period, compared with approximately 7.5 days for migraine patients in the United States69. Classes and Causes TMDs comprise a group of more than 30 conditions that cause pain and dysfunction in the temporomandibular joint and the muscles responsible for its movement 70. There are three main classes of TMDs: • Joint disorders: including problems affecting the articular disc; • Masticatory muscle disorders: involving the muscles used for chewing; • Headaches associated with TMD 71. Each of these classes includes several specific disorders, as outlined in Table 1 Table 1. Classification of temporomandibular disorders, adapted from the National Institute of Dental and Craniofacial Research 70. Temporomandibular Disorder Examples Joint disorders Joint pain (arthralgia) Disc disorder (disc in abnormal position) Bone degeneration. Masticatory muscle disorders Localized pain exacerbated by pressure (myalgia) Pain that radiates or is perceived at a distance from its origin (referred/non-referred myofascial pain) Headache associated with TMD Any type of headache occurring concurrently with painful TMD As shown in the table, TMD symptoms are not always limited to the TMJ. For this reason, according to Sharma et al. 72 some authors consider the term “TMD” too restrictive and advocate for a broader nomenclature, such as “craniomandibular disorders”. This term is often used synonymously with TMD and is regarded as one of the main causes of non-dental orofacial pain. Additionally, the use of such varied terminology has contributed to the persistent confusion in this already complex field. To address this, the American Dental Association officially adopted the term “temporomandibular disorders (TMDs),” as originally suggested by Okeson et al. 73. Other terms, such as fascial arthromyalgia, mandibular dysfunction, myofascial pain, masticatory myalgia syndrome, and primary myalgia of the masticatory muscles, are also used as synonyms. However, TMD is the most widely accepted and standardized term within the scientific community 72. Journal of Complementary Therapies in Health 2025: 3(3). 8 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 The causes of TMDs are complex and multifactorial, with numerous contributing factors 72,74: • Predisposing factors are those that increase the risk of developing TMDs; • Initiating factors are those that trigger the onset; • Perpetuating factors interfere with recovery or accelerate disease progression. In some cases, a single factor may play one or all of these roles. Successful treatment of TMDs depends on identifying and controlling the contributing factors, which may include occlusal anomalies, orthodontic treatment, bruxism and orthopaedic instability, macroand microtrauma, poor health and nutrition, joint laxity, and exogenous oestrogen exposure 75. Psychosocial factors such as stress, tension, anxiety, and depression may also contribute to temporomandibular joint dysfunction 76. A study conducted at a dental school used clinical and neurophysiological assessments to investigate the role of sleep dysfunction and depression, either alone or in combination with TMDs. The analysis demonstrated that depression was significantly more prevalent in the TMD group compared to controls 77. For a more comprehensive discussion of the aetiology and contributing factors, the review by Chisnoiu et al. 2 serves as a useful reference. Diagnosis and Conventional Treatments The diagnosis of TMDs is primarily based on clinical history and physical examination. Symptoms are often associated with mandibular movements (such as opening and closing the mouth) and manifest as pain in the preauricular, masseteric, or temporal regions. If orofacial pain is not influenced by mandibular movement, alternative causes should be suspected. Joint sounds such as clicking, popping, or crepitus may occur, but they are also common in up to 50% of asymptomatic patients 78. A retrospective study 79, involving 4,528 participants found that the most common signs and symptoms were facial pain (96%), ear discomfort (82%), headache (79%), and mandibular discomfort or dysfunction (75%). Other reported symptoms may include dizziness, pain in the neck, eyes, arms, or back. Physical examination may reveal several signs supporting the diagnosis of TMD 13, such as: • Abnormal mandibular movement or reduced range of motion; • Tenderness to palpation of the masticatory muscles; • Pain upon loading the mandible; • Signs of bruxism (clenching or grinding of teeth); • Tenderness in the neck or shoulder muscles. Clinicians should also assess occlusal abnormalities (such as missing teeth or facial asymmetries) that may contribute to the manifestation of TMD. However, cranial nerve abnormalities should not be attributed to TMD 80. Joint dysfunction may be accompanied by clicking, crepitus, or locking. A single click during mouth opening may indicate anterior disc displacement. When a second click occurs during mouth closure, the disc returns to its position—a condition called disc displacement with reduction. Conversely, a closed lock occurs when the patient cannot fully open the mouth because the disc prevents condylar translation. Crepitus is associated with articular surface disruption, commonly observed in osteoarthritis 81. Reproducible tenderness upon palpation of the TMJ suggests an intra-articular problem. Conversely, tenderness in the masseter, temporalis, or adjacent cervical muscles may indicate myalgia, myofascial trigger points, or referred pain. Deviation of the mandible toward the affected side during mouth opening may be a sign of anterior disc displacement 82. Journal of Complementary Therapies in Health 2025: 3(3). 9 of 17 Silva P., Almeida L., de Oliveira J.F., Oliveira T., Constantino A.P. Temporomandibular Disorders and Traditional Chinese Medicine: Part I – Conceptual Perspectives doi:10.5281/zenodo.17390501 Imaging studies may assist in diagnosing TMD when clinical history and physical examination findings are inconclusive 83. Although not routinely employed, several modalities are available to provide additional information regarding possible underlying causes 84,85. The initial imaging exam should be a plain radiograph (transcranial and transmaxillary views) or a panoramic radiograph, which can detect acute fractures, dislocations, and severe degenerative joint disease 13. Computed tomography (CT) is superior to radiography for evaluating subtle bony morphology. However, magnetic resonance imaging (MRI) is the ideal modality for comprehensive evaluation of the joint in symptomatic patients, as it allows assessment of soft tissues. While MRI demonstrates a correlation of 78% to 95% with joint morphology in symptomatic patients 82,86,87, false positives occur in 20% to 34% of asymptomatic individuals 88. For this reason, MRI is generally reserved for patients with persistent symptoms who do not respond to conservative management or when internal joint pathology is suspected 13. Finally, ultrasonography is a non-invasive, dynamic, and low-cost technique that can be used to diagnose internal joint problems when MRI is unavailable 89. Regarding treatment, only 5% to 10% of patients require therapy for TMD, while 40% experience spontaneous resolution of symptoms 90. According to Gauer et al. 13, registry data showed that patients received various types of medication, including: • Anti-inflammatories (73%); • Over-the-counter analgesics (56%); • Antidepressants (50%); • Opioids (48%); • Anxiolytics (41%); • Muscle relaxants (40%). Surgical interventions are reserved for patients whose symptoms do not improve after a period of conservative therapy 13. A Cochrane review 91, assessed nonsteroidal anti-inflammatory drugs (NSAIDs, including salicylates and cyclooxygenase inhibitors), benzodiazepines, antiepileptics, and muscle relaxants. The authors concluded that there is insufficient evidence to support or refute the effectiveness of any of these drugs in treating TMD. Some medications have demonstrated limited or no effectiveness for TMD treatment, including Tramadol (Ultram), topical agents such as capsaicin (Zostrix), lidocaine, and diclofenac 92, as well as newer antidepressants like selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs) 91. With respect to nonpharmacological therapy, initial treatment for TMD typically involves patient education and support. Measures include jaw rest, a soft diet, warm moist compresses, and passive stretching exercises. TMJ immobilization has no benefit and may worsen symptoms 1,93,94. There is evidence, though contradictory, regarding the effectiveness of physiotherapy for improving TMD symptoms 95,96. Techniques may be active or passive, aiming to enhance muscle strength, coordination, relaxation, and range of motion 96. Specialized therapies such as ultrasound or low-level laser therapy are also used, despite the lack of supporting evidence for their efficacy 97. Additionally, another Cochrane review supports the use of cognitive behavioural therapy (CBT) and biofeedback for pain control in symptomatic TMD patients, although the evidence is considered weak due to the limited number and quality of available studies 98. 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