Editing Temporomandibular joint dysfunction (section)

==Management==
TMD can be difficult to manage, and since the disorder transcends the boundaries between several health-care disciplines – in particular, [[dentistry]] and [[neurology]], the treatment may often involve multiple approaches and be multidisciplinary.<ref name="Cuccia 2011" /> Most who are involved in treating and researching TMD now agree that any treatment carried out should not permanently alter the jaw or teeth, and should be reversible.<ref name="NIH1996">{{cite web |url=http://consensus.nih.gov/1996/1996TemporomandibularDisorders018PDF.pdf |title=Management of Temporomandibular Disorders. National Institutes of Health Technology Assessment Conference Statement |year=1996 |access-date =22 May 2013}}</ref><ref name="AADR policy statement" /> To avoid permanent change, [[over-the-counter]] or [[Prescription drug|prescription]] pain medications may be prescribed.<ref name=TMJA>{{cite web |url=http://www.tmj.org/site/pdf/TMJbrochure.pdf |title=Temporomandibular (Jaw) Joint Diseases and Disorders |author=The TMJ Association |year=2005 |access-date=2 December 2010 |archive-date=28 July 2011 |archive-url=https://web.archive.org/web/20110728111706/http://www.tmj.org/site/pdf/TMJbrochure.pdf |url-status=dead }}</ref>

===Psychosocial and behavioral interventions===
Given the important role that psychosocial factors appear to play in TMD, psychosocial interventions could be viewed to be central to management of the condition.<ref name="Orlando 2007" /> There is a suggestion that treatment of factors that modulate pain sensitivity such as [[mood disorder]]s, anxiety and [[Fatigue (medical)|fatigue]], may be important in the treatment of TMD, which often tends to attempt to address the pain directly.<ref name="Orlando 2007" />

[[Cognitive behavioral therapy]] (CBT) has been used in TMD and has been shown to be efficacious by meta analyses.<ref name="Hersen 2012">{{cite book |last1=Hersen |first1=Peter |last2=Sturmey |first2=Michel | name-list-style = vanc |title=Handbook of evidence-based practice in clinical psychology |year=2012 |publisher=Wiley |location=Hoboken, NJ |isbn=978-0-470-33546-8 |pages=594–5}}</ref>

[[Hypnosis]] is suggested by some to be appropriate for TMD. Studies have suggested that it may even be more beneficial than occlusal splint therapy, and has comparable effects to relaxation techniques.<ref name="Orlando 2007">{{cite journal | vauthors = Orlando B, Manfredini D, Salvetti G, Bosco M | s2cid = 20540193 | title = Evaluation of the effectiveness of biobehavioral therapy in the treatment of temporomandibular disorders: a literature review | journal = Behavioral Medicine | volume = 33 | issue = 3 | pages = 101–18 | year = 2007 | pmid = 18055333 | doi = 10.3200/BMED.33.3.101-118 }}</ref>

[[Relaxation techniques]] include [[progressive muscle relaxation]], [[yoga as exercise|yoga]], and [[meditation]].<ref name="Orlando 2007" /> It has been suggested that TMD involves increased sensitivity to external stimuli leading to an increased [[sympathetic nervous system|sympathetic]] ("fight or flight") response with cardiovascular and respiratory alterations.<ref name="Orlando 2007" /> Relaxation techniques cause reduced sympathetic activity, including muscle relaxation and reducing sensitivity to external stimuli, and provoke a general sense of well-being and reduced anxiety.<ref name="Orlando 2007" />

===Devices===
[[File:Knirschschiene-acht-Jahre.jpg|thumbnail|A lower, full coverage occlusal splint after 8 years in use]]
[[File:Aufbissschiene.jpg|thumbnail|An upper, full coverage occlusal splint]]
[[Occlusal splint]]s (also termed bite plates or intra-oral appliances) are often used by dentists to treat TMD. They are usually made of [[acrylate polymer|acrylic]] and can be hard or soft. They can be designed to fit onto the upper teeth or the lower teeth. They may cover all the teeth in one arch (full coverage splint) or only some (partial coverage splint). Splints are also termed according to their intended mechanism, such as the anterior positioning splint or the stabilization splint.<ref name="Wassell 2008" /> Although occlusal splints are generally considered a reversible treatment,<ref name="Hupp 2008" /> sometimes partial coverage splints lead to pathologic tooth migration (changes in the position of teeth). Normally splints are only worn during sleep, and therefore probably do nothing for people who engage in parafunctional activities during wakefulness rather than during sleep. There is slightly more evidence for the use of occlusal splints in sleep bruxism than in TMD. A splint can also have a diagnostic role if it demonstrates excessive occlusal wear after a period of wearing it each night. This may confirm the presence of sleep bruxism if it was in doubt. Soft splints are occasionally reported to worsen discomfort related to TMD.<ref name="Wassell 2008" /> Specific types of occlusal splint are discussed below.

A stabilization splint is a hard acrylic splint that forces the teeth to meet in an "ideal" relationship for the muscles of mastication and the TMJs. It is claimed that this technique reduces abnormal muscular activity and promotes "neuromuscular balance". A stabilization splint is only intended to be used for about 2–3 months.<ref name="Al-Ani 2004" /> It is more complicated to construct than other types of splint since a [[Articulator|face bow]] record is required and significantly more skill on the part of the [[dental technician]]. This kind of splint should be properly fitted to avoid exacerbating the problem and used for brief periods of time. The use of the splint should be discontinued if it is painful or increases existing pain.<ref name=TMJA/> A systematic review of all the scientific studies investigating the efficacy of stabilization splints concluded the following:

{{blockquote|"On the basis of our analysis we conclude that the literature seems to suggest that there is insufficient evidence either for or against the use of stabilization splint therapy over other active interventions for the treatment of TMD. However, there is weak evidence to suggest that the use of stabilization splints for the treatment of TMD may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment".<ref name="Al-Ani 2004" />}}

Partial coverage splints are recommended by some experts, but they have the potential to cause unwanted tooth movements, which can occasionally be severe. The mechanism of this tooth movement is that the splint effectively holds some teeth out of contact and puts all the force of the bite onto the teeth which the splint covers. This can cause the covered teeth to be intruded, and those that are not covered to over-erupted. I.e. a partial coverage splint can act as a [[Dahl appliance]]. Examples of partial coverage splints include the NTI-TSS ("nociceptive trigeminal inhibitor tension suppression system"), which covers the upper front teeth only. Due to the risks involved with long term use, some discourage the use of any type of partial coverage splint.<ref name="Wassell 2008" />

An anterior positioning splint is a splint that designed to promote an anteriorly displaced disc. It is rarely used.<ref name="Wassell 2008" /> A 2010 review of all the scientific studies carried out to investigate the use of occlusal splints in TMD concluded:

{{blockquote|"Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some [[Randomized controlled trial|RCT]] evidence of efficacy in reducing TMD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use."<ref>{{cite journal | vauthors = Fricton J, Look JO, Wright E, Alencar FG, Chen H, Lang M, Ouyang W, Velly AM | display-authors = 6 | title = Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders | journal = Journal of Orofacial Pain | volume = 24 | issue = 3 | pages = 237–54 | year = 2010 | pmid = 20664825 }}</ref> }}

Ear canal inserts are also available, but no published peer-reviewed clinical trials have shown them to be useful.

===Medication===
Medication is the main method of managing pain in TMD, mostly because there is little if any evidence of the effectiveness of surgical or dental interventions.<!-- <ref name="Mujakperuo 2010" /> --> Many drugs have been used to treat TMD pain, such as [[analgesic]]s (pain killers), [[benzodiazepine]]s (e.g. [[clonazepam]], [[prazepam]], [[diazepam]]), [[anticonvulsant]]s (e.g. [[gabapentin]]), [[muscle relaxant]]s (e.g. [[cyclobenzaprine]]), and others. Analgesics that have been studied in TMD include [[non-steroidal anti-inflammatory drug]]s (e.g. [[piroxicam]], [[diclofenac]], [[naproxen]], [[celecoxib]]).<!-- <ref name="Mujakperuo 2010" /> -->

[[Topical medication|Topical]] [[methyl salicylate]] and topical [[capsaicin]] have also been used.<!-- <ref name="Mujakperuo 2010" /> -->

Other drugs that have been described for use in TMD include [[glucosamine hydrochloride]]/[[chondroitin sulphate]] and [[propranolol]].<!-- <ref name="Mujakperuo 2010" /> --> Low-doses of [[anti-muscarinic]] [[tricyclic antidepressant]]s such as [[amitriptyline]],<ref name="Marbach 1996">{{cite journal | vauthors = Marbach JJ | title = Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment | journal = Rheumatic Disease Clinics of North America | volume = 22 | issue = 3 | pages = 477–98 | date = August 1996 | pmid = 8844909 | doi = 10.1016/S0889-857X(05)70283-0 }}</ref> or [[nortriptyline]] have also been described.<ref name="pmid9007937">{{cite journal | vauthors = Dionne RA | title = Pharmacologic treatments for temporomandibular disorders | journal = Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics | volume = 83 | issue = 1 | pages = 134–42 | date = January 1997 | pmid = 9007937 | doi = 10.1016/S1079-2104(97)90104-9 | url = https://zenodo.org/record/1260198 }}</ref>

Despite many [[randomized control trial]]s being conducted on these commonly used medications for TMD a [[systematic review]] carried out in 2010 concluded that there was insufficient evidence to support or not to support the use of these drugs in TMD.<ref name="Mujakperuo 2010" />

In a subset of people with TMD who are not helped by either noninvasive and invasive treatments, long term use of [[opiate]] analgesics has been suggested, although these drugs carry a risk of [[drug dependence]] and other side effects.<ref name="Bouloux 2011">{{cite journal | vauthors = Bouloux GF | title = Use of opioids in long-term management of temporomandibular joint dysfunction | journal = Journal of Oral and Maxillofacial Surgery | volume = 69 | issue = 7 | pages = 1885–91 | date = July 2011 | pmid = 21419546 | doi = 10.1016/j.joms.2010.12.014 }}</ref> Examples include [[morphine]], [[fentanyl]], [[oxycodone]], [[tramadol]], [[hydrocodone]], and [[methadone]].<ref name="Bouloux 2011" />

Injections of [[local anesthetic]], sometimes combined with [[steroid]]s, into the muscles (e.g. the temoralis muscle or its tendon) are also sometimes used. Local anesthetics may provide temporary pain relief, and steroids inhibit pro-inflammatory [[cytokine]]s.<ref name="Hupp 2008" /> Steroids and other medications are sometimes injected directly into the joint (See [[#Intra-articular injections|Intra-articular injections]]). Platelet-rich fibrin injection, alone or associated with arthrocentesis, can be considered a very suitable.<ref name="Treatments for painful temporomandi">{{cite journal | vauthors = Al-Moraissi, EA et al.| title = Treatments for painful temporomandibular disc displacement with reduction: a network meta-analysis of randomized clinical trials | journal = International Journal of Oral and Maxillofacial Surgery| volume = 53 | issue = 1 | pages = 45–56 | date = January 2024| pmid = 37802670 | doi = 10.1016/j.ijom.2023.09.006}}</ref>

[[Botulinum toxin]] solution ("Botox") is sometimes used to treat TMD.<ref name="Schwartz 2002">{{cite journal | vauthors = Schwartz M, Freund B | s2cid = 37480726 | title = Treatment of temporomandibular disorders with botulinum toxin | journal = The Clinical Journal of Pain | volume = 18 | issue = 6 Suppl | pages = S198-203 | date = Nov–Dec 2002 | pmid = 12569969 | doi = 10.1097/00002508-200211001-00013 }}</ref> Injection of botox into the lateral pterygoid muscle has been investigated in multiple randomized control trials, and there is evidence that it is of benefit in TMD.<ref name="Persaud 2013">{{cite journal | vauthors = Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K | title = An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions | journal = JRSM Short Reports | volume = 4 | issue = 2 | date = February 2013 | page = 10 | pmid = 23476731 | pmc = 3591685 | doi = 10.1177/2042533312472115 }}</ref> It is theorized that spasm of lateral pterygoid causes anterior disc displacement. Botulinum toxin causes temporary muscular paralysis by inhibiting [[acetylcholine]] release at the neuromuscular junction.<ref name="Glick 2003" /> The effects usually last for a period of months before they wear off. Complications include the creation of a "fixed" expression due to diffusion of the solution and subsequent involvement of the [[muscles of facial expression]],<ref name="Persaud 2013" /> which lasts until the effects of the botox wear off.

===Physiotherapy===
[[Physiotherapy]] (physical therapy) is sometimes used as an [[Adjuvant therapy|adjuvant]] to other methods of treatment in TMD.<ref name="Aggarwal 2012">{{cite journal | vauthors = Aggarwal A, Keluskar V | title = Physiotherapy as an adjuvant therapy for treatment of TMJ disorders | journal = General Dentistry | volume = 60 | issue = 2 | pages = e119-22 | date = Mar–Apr 2012 | pmid = 22414516 }}</ref> There are many different approaches described, but exercises aiming to increase the range of mandibular movements are commonly involved.<ref name="Hupp 2008">{{cite book |vauthors=Hupp JR, Ellis E, Tucker MR |title=Contemporary oral and maxillofacial surgery |url=https://archive.org/details/contemporaryoral00hupp |url-access=limited |year=2008 |publisher=Mosby Elsevier |location=St. Louis, MO |isbn=978-0-323-04903-0 |pages=[https://archive.org/details/contemporaryoral00hupp/page/n641 629]–47 |edition=5th}}</ref> Jaw exercises aim to directly oppose the negative effects of disuse that may occur in TMD, due to pain discouraging people from moving their jaw. After initial instruction, people are able to perform a physical therapy regimen at home. The most simple method is by regular stretching within pain tolerance, using the thumb and a finger in a "scissor" maneuver. Gentle force is applied until pain of resistance is felt, and then the position is held for several seconds.<!-- <ref name="Hupp 2008" /> --> Commercial devices have been developed to carry out this stretching exercise (e.g. the "Therabite" appliance). Over time, the amount of mouth opening possible without pain can be gradually increased.<!-- <ref name="Hupp 2008" /> --> A baseline record of the distance at the start of physical therapy (e.g. the number of fingers that can be placed vertically between the upper and lower incisors), can chart any improvement over time.<ref name="Hupp 2008" />

It has been suggested that massage therapy for TMD improves both the subjective and objective health status.<ref name="Miernik 2012">{{cite journal | vauthors = Miernik M, Wieckiewicz M, Paradowska A, Wieckiewicz W | title = Massage therapy in myofascial TMD pain management | journal = Advances in Clinical and Experimental Medicine | volume = 21 | issue = 5 | pages = 681–5 | date = Sep–Oct 2012 | pmid = 23356206 }}</ref> "Friction massage" uses surface pressure to cause temporary [[ischemia]] and subsequent [[hyperemia]] in the muscles, and this is hypothesized to inactivate trigger points and disrupt small fibrous adhesions within the muscle that have formed following surgery or muscular shortening due to restricted movement.<ref name="Hupp 2008" />

Occasionally physiotherapy for TMD may include the use of [[transcutaneous electrical nerve stimulation]] (TENS), which may override pain by stimulation of superficial nerve fibers and lead to pain reduction which extends after the time where the TENS is being actually being applied, possibly due to release of [[endorphin]]s.<!-- <ref name="Hupp 2008" /> --> Others recommend the use of [[ultrasound]], theorized to produce tissue heating, alter blood flow and metabolic activity at a level that is deeper than possible with surface heat applications.<ref name="Hupp 2008" /> There is tentative evidence that [[low level laser therapy]] may help with pain.<ref name="Maia 2012">{{cite journal | vauthors = Maia ML, Bonjardim LR, de Souza Siqueira Quintans J, Ribeiro MA, Maia LG, Conti PC | title = Effect of low-level laser therapy on pain levels in patients with temporomandibular disorders: a systematic review | journal = Journal of Applied Oral Science | volume = 20 | issue = 6 | pages = 594–602 | year = 2012 | pmid = 23329239 | pmc = 3881861 | doi = 10.1590/S1678-77572012000600002 }}</ref>

The goals of a PT in reference to treatment of TMD should be to decrease pain, enable muscle relaxation, reduce muscular hyperactivity, and reestablish muscle function and joint mobility. PT treatment is non-invasive and includes self-care management in an environment to create patient responsibility for their own health.<ref name=":11">{{cite journal | vauthors = Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A | title = Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis | journal = Physical Therapy | volume = 96 | issue = 1 | pages = 9–25 | date = January 2016 | pmid = 26294683 | pmc = 4706597 | doi = 10.2522/ptj.20140548 }}</ref>

Therapeutic exercise and Manual Therapy (MT) are used to improve strength, coordination and mobility and to reduce pain. Treatment may focus on poor posture, cervical muscle spasms and treatment for referred cervical origin (pain referred from upper levels of the cervical spine) or [[orofacial pain]]. MT has been used to restore normal range of motion, promoting circulation, stimulate [[proprioception]], break fibrous adhesions, stimulate synovial fluid production and reduce pain. Exercises and MT are safe and simple interventions that could potentially be beneficial for patients with TMD. No adverse events regarding exercise therapy and manual therapy have been reported.<ref name=":11" />

There have been positive results when using postural exercises and jaw exercises to treat both myogenous (muscular) and arthrogenous (articular) TMJ dysfunction. MT alone or in combination with exercises shows promising effects.<ref name=":11" />

It is necessary that trials be performed isolating the type of exercise and manual techniques to allow a better understanding of the effectiveness of this treatment. Additionally, details of exercise, dosage, and frequency as well as details on manual techniques should be reported to create reproducible results. High quality trials with larger sample sizes are needed.<ref name=":11" />

There is some evidence that some people who use nighttime [[biofeedback]] to reduce nighttime clenching experience a reduction in TMD.<ref>{{cite journal | vauthors = Crider A, Glaros AG, Gevirtz RN | s2cid = 9714081 | title = Efficacy of biofeedback-based treatments for temporomandibular disorders | journal = Applied Psychophysiology and Biofeedback | volume = 30 | issue = 4 | pages = 333–45 | date = December 2005 | pmid = 16385422 | doi = 10.1007/s10484-005-8420-5 }}</ref>

===Occlusal adjustment===
This is the adjustment or reorganizing of the existing occlusion, carried out in the belief that this will redistribute forces evenly across the dental arches or achieve a more favorable position of the condyles in the fossae, which is purported to lessen tooth wear, bruxism and TMD, but this is controversial. These techniques are sometimes termed "occlusal rehabilitation" or "occlusal equilibration".<ref name="Shetty 2010" /> At its simplest, an occlusal adjustment involves selective grinding (with a dental drill) of the enamel of the occlusal surfaces of teeth, with the aim of allowing the upper teeth to fit with the lower teeth in a more harmonious way.<ref name="Luther 2010" /> However, there is much disagreement between proponents of these techniques on most of the aspects involved, including the indications and the exact goals. Occlusal adjustment can also be very complex, involving [[orthodontic]]s, [[restorative dentistry]] or even [[orthognathic surgery]]. Some have criticized these occlusal reorganizations as having no evidence base, and irreversibly damaging the dentition on top of the damage already caused by bruxism.<ref name="Shetty 2010" /> A "middle ground" view of these techniques is that occlusal adjustment in most cases of TMD is neither desirable nor helpful as a first-line treatment, and furthermore, with few exceptions, any adjustments should be reversible.<ref name="Wassell 2008" /> However, most dentists consider this unnecessary overtreatment,<ref name="Wassell 2008" /> with no evidence of benefit.<ref name="Kerawala 2010" /> Specifically, orthodontics and orthognathic surgery are not considered by most to be appropriate treatments for TMD.<ref name="Kerawala 2010" /> A systematic review investigating all the scientific studies carried out on occlusal adjustments in TMD concluded the following: 
{{blockquote|"There is an absence of evidence of effectiveness for occlusal adjustment. Based on these data occlusal adjustment cannot be recommended for the treatment or prevention of TMD.<ref name="Koh 2004" />}}

These conclusions were based largely on the fact that, despite many different scientific studies investigating this measure as a therapy, overall no statistically significant differences can be demonstrated between treatment with occlusal adjustment and treatment with [[placebo]]. The reviewers also stated that there are ethical implications if occlusal adjustment was found to be ineffective in preventing TMD.<ref name="Koh 2004" />

Orthodontic treatment, as described earlier, is sometimes listed as a possible predisposing factor in the development of TMD. On the other hand, orthodontic treatment is also often carried out in the belief that it may treat or prevent TMD. Another systematic review investigating the relationship between orthodontics and TMD concluded the following:

{{blockquote|"There is no evidence to support or refute the use of orthodontic treatment for the treatment of TMD. In addition, there are no data which identify a link between active orthodontic intervention and the causation of TMD. Based on the lack of data, orthodontic treatment cannot be recommended for the treatment or prevention of TMD."<ref name="Luther 2010" /> }}

A common scenario where a newly placed dental restoration (e.g. a crown or a filling) is incorrectly contoured, and creates a premature contact in the bite. This may localize all the force of the bite onto one tooth, and cause inflammation of the periodontal ligament and reversible increase in tooth mobility. The tooth may become tender to bite on. Here, the "occlusal adjustment" has already taken place inadvertently, and the adjustment aims to return to the pre-existing occlusion. This should be distinguished from attempts to deliberately reorganize the native occlusion.

===Surgery===
{{Main|Surgery for temporomandibular joint dysfunction}}
Attempts in the last decade to develop [[Surgery|surgical treatment]]s based on [[MRI]] and [[Computed axial tomography|CAT]] scans now receive less attention. These techniques are reserved for the most difficult cases where other [[therapeutic modalities]] have failed. The [[American Society of Maxillofacial Surgeons]] recommends a conservative/non-surgical approach first. Only 20% of patients need to proceed to surgery.

Examples of surgical procedures that are used in TMD, some more commonly than others, include [[arthrocentesis]],<ref name="Treatments for painful temporomandi"/> [[arthroscopy]], meniscectomy, disc repositioning, condylotomy or [[joint replacement]]. Invasive surgical procedures in TMD may cause symptoms to worsen.<ref name="Guo 2009" /> Meniscectomy, also termed discectomy refers to surgical removal of the articular disc. This is rarely carried out in TMD, it may have some benefits for pain, but dysfunction may persist and overall it leads to degeneration or remodeling of the TMJ.<ref name="Hagandora 2012">{{cite journal | vauthors = Hagandora CK, Almarza AJ | s2cid = 46145202 | title = TMJ disc removal: comparison between pre-clinical studies and clinical findings | journal = Journal of Dental Research | volume = 91 | issue = 8 | pages = 745–52 | date = August 2012 | pmid = 22744995 | doi = 10.1177/0022034512453324 }}</ref>

===Alternative medicine===

====Acupuncture====
[[Acupuncture]] is sometimes used for TMD.<ref name="Cuccia 2011" /> There is limited evidence that acupuncture is an effective symptomatic treatment for TMD.<ref name="Jung 2011">{{cite journal | vauthors = Jung A, Shin BC, Lee MS, Sim H, Ernst E | title = Acupuncture for treating temporomandibular joint disorders: a systematic review and meta-analysis of randomized, sham-controlled trials | journal = Journal of Dentistry | volume = 39 | issue = 5 | pages = 341–50 | date = May 2011 | pmid = 21354460 | doi = 10.1016/j.jdent.2011.02.006 }}</ref><ref>{{cite journal | vauthors = Türp JC | title = Limited evidence that acupuncture is effective for treating temporomandibular disorders | journal = Evidence-Based Dentistry | volume = 12 | issue = 3 | pages = 89 | year = 2011 | pmid = 21979775 | doi = 10.1038/sj.ebd.6400816 | doi-access = free }}</ref><ref name="La Touche 2010" /> A short-term reduction in muscular pain of muscular origin can usually be observed after acupuncture in TMD,<ref name="La Touche 2010" /> and this is more than is seen with [[placebo]].<ref name="Cho 2010" /> There are no reported adverse events of acupuncture when used for TMD,<ref name="Cho 2010" /> and some suggest that acupuncture is best employed as an adjuvant to other treatments in TMD.<ref name="La Touche 2010">{{cite journal | vauthors = La Touche R, Goddard G, De-la-Hoz JL, Wang K, Paris-Alemany A, Angulo-Díaz-Parreño S, Mesa J, Hernández M | s2cid = 12402484 | display-authors = 6 | title = Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials | journal = The Clinical Journal of Pain | volume = 26 | issue = 6 | pages = 541–50 | year = 2010 | pmid = 20551730 | doi = 10.1097/AJP.0b013e3181e2697e }}</ref> However, some suggest that acupuncture may be no more effective than sham acupuncture,<ref>{{cite journal | vauthors = Laurence B | title = Acupuncture may be no more effective than sham acupuncture in treating temporomandibular joint disorders | journal = The Journal of Evidence-Based Dental Practice | volume = 12 | issue = 1 | pages = 2–4 | date = March 2012 | pmid = 22326146 | doi = 10.1016/j.jebdp.2011.12.001 }}</ref> that many of the studies investigating acupuncture and TMD have significant risk of bias,<ref name="La Touche 2010" /> and that the long term efficacy of acupuncture for TMD is unknown.<ref name="La Touche 2010" /><ref name="Cho 2010">{{cite journal | vauthors = Cho SH, Whang WW | title = Acupuncture for temporomandibular disorders: a systematic review | journal = Journal of Orofacial Pain | volume = 24 | issue = 2 | pages = 152–62 | year = 2010 | pmid = 20401353 }}</ref>

====Chiropractic====
[[Chiropractic adjustment]]s (also termed manipulations or mobilizations) are sometimes used in the belief that this will treat TMD.<ref name="DeVocht 2006">{{cite journal | vauthors = DeVocht JW | s2cid = 35775630 | title = History and overview of theories and methods of chiropractic: a counterpoint | journal = Clinical Orthopaedics and Related Research | volume = 444 | pages = 243–9 | date = March 2006 | pmid = 16523145 | doi = 10.1097/01.blo.0000203460.89887.8d }}</ref>  There is no credible evidence of efficacy in TMD.<ref name="Ernst 2008">{{cite book | first1 = Simon | last1 = Singh | first2 = Edzard | last2 = Ernst | name-list-style = vanc |title=Trick or treatment : the undeniable facts about alternative medicine |year=2008 |publisher=W.W. Norton |location=New York |isbn=978-0-393-06661-6 |pages=149–90 |edition=1st American}}</ref> However, there is some evidence of possible adverse effects from cervical (neck) vertebral manipulation, which sometimes may be serious.<ref name="Ernst 2008" />