<unk>  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. Most who are involved in treating and, researching<unk>  now agree that any treatment carried out should not permanently alter the jaw or teeth, and should be reversible. To avoid permanent change, over-the-counter or prescription pain medications may be prescribed. Psychosocial and behavioral interventions Given the important role that psychosocial factors appear to play in<unk> , psychosocial interventions could be viewed to be central to management of the condition. There is a suggestion that treatment of factors that modulate pain sensitivity such as mood disorders, anxiety and fatigue, may be important in the treatment of<unk> , which often tends to attempt to address the pain directly. Cognitive Behavioral Therapy (CBT) has been used in<unk>  and has been shown to be efficacious by meta analyses. Hypnosis is suggested by some to be appropriate for<unk> . Studies have suggested that it may even be more beneficial than occlusal splint therapy, and has comparable effects to relaxation techniques. Relaxation techniques include progressive muscle relaxation, yoga, and meditation. It has been suggested that<unk>  involves increased sensitivity to external stimuli leading to an increased sympathetic ("fight or flight") response with cardiovascular and respiratory alterations. 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. Devices A lower, full coverage occlusal splint after 8 years in use. An upper, full coverage occlusal splint. Occlusal splints (also termed bite plates or intra-oral appliances) are often used by dentists to treat<unk> . They are usually made of 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. Although occlusal splints are generally considered a reversible treatment, 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<unk> . 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<unk> . 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. It is more complicated to construct than other types of splint since a 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. A systematic review of all the scientific studies investigating the efficacy of stabilization splints concluded the following: "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<unk> . However, there is weak evidence to suggest that the use of stabilization splints for the treatment of<unk>  may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment". 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. An anterior positioning splint is a splint that designed to promote an anteriorly displaced disc. It is rarely used. A 2010 review of all the scientific studies carried out to investigate the use of occlusal splints in<unk>  concluded: "Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of<unk>  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 RCT evidence of efficacy in reducing<unk>  pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use." 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<unk> , mostly because there is little if any evidence of the effectiveness of surgical or dental interventions. Many drugs have been used to treat<unk>  pain, such as analgesics (pain killers), benzodiazepines (e.g. clonazepam, prazepam, diazepam), anticonvulsants (e.g. gabapentin), muscle relaxants (e.g. cyclobenzaprine), and others. Analgesics that have been studied in<unk>  include non-steroidal anti-inflammatory drugs (e.g. piroxicam, diclofenac, naproxen) and cyclo-oxygenase-2 inhibitors (e.g. celecoxib). Topical methyl salicylate and topical capsaicin have also been used. Other drugs that have been described for use in<unk>  include glucosamine hydrochloride/chondroitin sulphate and propranolol. Low-doses of anti-muscarinic tricyclic antidepressants such as amitriptyline, or nortriptyline have also been described. Despite many randomized control trials being conducted on these commonly used medications for<unk>  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<unk> . In a subset of people with<unk>  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. Examples include morphine, fentanyl, oxycodone, tramadol, hydrocodone, and methadone. Injections of local anesthetic, sometimes combined with steroids, 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 cytokines. Steroids and other medications are sometimes injected directly into the<unk>  (See Intra-articular injections). Botulinum toxin solution ("Botox") is sometimes used to treat<unk> . 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<unk> . 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. 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, which lasts until the effects of the botox wear off. Physiotherapy Physiotherapy (physical therapy) is sometimes used as an adjuvant to other methods of treatment in<unk> . There are many different approaches described, but exercises aiming to increase the range of mandibular movements are commonly involved. Jaw exercises aim to directly oppose the negative effects of disuse that may occur in<unk> , 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. 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. 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. It has been suggested that massage therapy for<unk>  improves both the subjective and objective health status. "Friction massage" uses surface pressure to causes temporary ischemia and subsequent hyperemia in the muscles, and this is
Temporomandibular joint dysfunction
Impacted wisdom teeth
Facial nerve paralysis
Eustachian tube dysfunction
Orofacial myofunctional disorders
Barodontalgia
Ear pain
Orofacial pain