Pain Management for Central Sensitization in Temporomandibular Disorders

May 31, 2024

Pain Management for Central Sensitization in Temporomandibular Disorders

Central sensitization (CSS) and referred pain can be characteristics of temporomandibular disorder (TMD), which can make diagnosis more challenging.

Therapeutic approaches that positively impact the central sensitization of TMD pain include non-surgical TMJ treatments. Conservative approaches may include occlusal splints, physical therapy, and mayofacial pain release.

But let’s back up and start with some basics.

What is Central Sensitization?

Central sensitization can be defined as an amplified response of your central nervous system to sensory stimuli and peripheral nociceptive. It may lead to increased pain sensation from noxious stimuli, known as hypersensitivity (allodynia). Chronic temporomandibular disorders are associated with a higher propensity to develop central sensitization. [1]

Central sensitization is like your brain’s alarm system becoming overly sensitive. Normally, when you get hurt, your nerves send a pain signal to your brain. With central sensitization, this system gets overactive. It’s like a blaring alarm even when there’s no imminent danger.

What does Central Sensitization have to do with TMD?

Central sensitization is a central nervous system (CNS) process that can trigger pain hypersensitivity. It can be a factor in chronic pain associated with temporomandibular disorders (TMD), a group of conditions that affect the temporomandibular joint (TMJ), masticatory muscles, and trigeminal nerve.

Chronic TMDs are largely characterized by chronic pain, which is also a characteristic of CSS.

Central sensitization relationship to TMD explained

When persistent and intense nociceptive sensitized central nervous system pain signals are emitted, the patient becomes more reactive. They often experience more pain with less provocation. Pain management practitioners who know pain signals can best determine the origins of orofacial pain. A deep understanding of the trigeminal system and mechanisms differentiating pain types and causes helps clinicians treat the underlying cause rather than just reported symptoms.

Central sensitization can cause the following symptoms:

  1. Hypersensitivity: Normal pain feels much worse than it should.
  2. Allodynia: Something that normally wouldn’t hurt at all, like a light touch to your jaw, starts causing pain.
  3. Altered Pain Patterns: Your pain might last longer, spread to neighboring areas, spike, or feel worse over time.
  4. Referred pain. [2]
  5. Pressure hyperalgesia: An extreme response to pain. Hyperalgesia may happen if there is damage to your nerves or chemical changes to the nerve pathways involved in sensing pain. This may be caused by jaw tissue injury or inflammation or by taking certain drugs, such as SSRIs and opioids for chronic pain.
  6. Increased temporal pain: Pressure may be felt around the temples and can feel like a dull, throbbing headache, stabbing, or burning sensation. [3]
  7. Masseter muscle pain: Your masseter muscle is located on your face from the cheekbone to the mandible on both sides of the face. Its function is to help elevate and protrude the lower jaw. It also plays a role in stabilizing your temporomandibular joint (TMJ) when you clench your teeth.

Think of it like a sunburn. Having one makes your skin extra sensitive. With central sensitization, it’s like your nervous system feels “sunburnt.” Your brain’s pain system may be stuck on high alert, making even minor triggers feel much worse. It’s important to talk to your pain specialist if you think this might be occurring in your jaw, head, and neck area; there are pain treatments that can help calm down an overactive pain alarm system.

Professional Jaw Pain Treatment for Central Sensitization in Temporomandibular Disorders

TMD Disorders can Become Chronic if Treatment is Delayed

Untreated chronic pain may become associated with significant emotional distress and/or significant functional disability. These stresses can cause pain in your jaw joint and the muscles controlling jaw movement.

When a head or jaw injury is promptly treated in the acute state, potential progression to “central sensitization” and, therefore, chronic pain is easier to avoid.

Stage one of TMJ is disc displacement with reduction. It occurs when the disc is displaced in the closed-mouth position and becomes more normal in the open-mouth position. A chronic condition can be avoided if diagnosis and treatment began at this stage.

What is the Diagnosis Process for Central Sensitization in Temporomandibular Disorders?

Its diagnosis is mainly clinical; diagnostic criteria may include the following:

  • Ruling out other conditions and reviewing the patient’s medical history.
  • An investigation of central and peripheral factors affecting pressure pain thresholds of the person’s jaw muscles.
  • Evaluate if there was a peripheral injury and/or dysfunction.
  • Assess if the chronic pain has extended beyond a normal healing time.
  • Assess how your stomatognathic muscles work while at rest and while functioning.
  • Consideration of a psychological component. Emotional distress should be considered during the diagnosis process. Anxiety, frustration, and depression may contribute to the development, persistence, and exacerbation of pain.

If any medical terms in this article or during your clinic visit are new to you, be sure to ask for an explanation.

What is a person’s stomatognathic system?

Your stomatognathic system is a complex anatomical system that includes your jaws, teeth, and associated soft tissues. It is responsible for many sensory functions, such as your ability to chew, swallow, breathe, speak, yawn, smile, and sing. A strong link exists between chewing functional limitations and the progression of TMD.

Therefore, your central sensitization could represent the basis of chronic pain if you are affected by TMD.

Scientific literature demonstrates that central sensitization may have a role not only in the pathophysiology of TMD but also in several chronic pain conditions, including: fibromyalgia, migraine, tension-type headache, and chronic fatigue syndrome.

What is nociplastic pain?

Nociplastic pain is one type of chronic pain that may happen when pain-related sensory pathways in the central nervous system (CNS) and periphery are altered, causing increased sensitivity. Trigeminal neuralgia, peripheral nerve injury, and painful temporomandibular disorders (TMDs) are chronic orofacial pain conditions that can be considered chronic peripheral neuropathic pain.

This is very similar to central sensitivity or peripheral pain. TMD-related chronic pain has been primarily caused by peripheral factors, such as chronic inflammation of the TMJ. Eight disorders have been identified as relating to central sensitization. Among them are chronic fatigue syndrome, fibromyalgia, temporomandibular disorder, migraine or tension headache, and non-specific emotional disorders that include anxiety or panic attacks and depression. [4]

Neuroplasticity refers to brain structures and sensory pathways in your central nervous system that can adapt and be altered in response to sensory input, sensations, and traumatic events. This may include a blow to the jaw, sports injury to the head, or whiplash that may trigger TMJ-related neck pain.

“Nociplastic pain is a type of pain that can describe chronic temporomandibular pain disorders (TMDs). Nociplastic pain is a broad term that can include conditions that cause increased processing of pain signals or decreased pain inhibition. TMDs are a type of temporomandibular joint (TMJ) disorder that can cause pain in the jaw joint and muscles that control jaw movement. In some TMD patients, nociplastic pain can be a better description of the clinical appearance of altered nociception.” – NIH: Current understanding of nociplastic pain [4]

Evidence for Central Sensitization in TMD

Studies suggest that therapeutic strategies for managing central sensitization in TMD pain can be divided into two groups.[2]

  1. Bottom-up (Example: tissue-based impairment treatments).
  2. Top-down interventions (Example: strategies targeting the central nervous system).

A bottom-up strategy could include of joint, soft tissue-, and nerve-targeting interventions, such as trigger point injections. A top-down strategy will more likely include physical therapy and pain education. Providers at the Minnesota Head & Neck Pain Clinics often use a multimodal approach that can be effective in patients with TMD.

Pain management for patients with TMD is complex; no one treatment works for all patients. It is best if each patient is appropriately diagnosed for a specific subtype of TMD and treated once an individually tailored care pathway is created. Integrated self-care with professional TMD guidance may alleviate the frequency and the level of TMD pain severity.

The March 22, 2024, Is painful temporomandibular disorder a real headache for many patients? article discusses how central sensitization may contribute to headaches and the development of myofascial trigger points.

“One of the possible links between migraine and TMD is peripheral and central sensitisation.34 When peripheral injury triggers pain signals in the trigeminal nerve, local tissue inflammation releases cytokines and pro-inflammatory mediators that stimulate and amplify the pain response. Peripheral sensitisation decreases the depolarisation threshold so that normal stimuli are perceived as painful. The persistence of peripheral pain input can lead to central sensitisation, resulting in increased excitability of central pain pathways. Central sensitisation is the physiological hallmark of persistent pain syndromes and is responsible for the clinical symptoms of hyperalgesia and allodynia. Therefore, normal or sub-threshold stimulators from TMJ and associated structures may become migraine-inducing factors or vice versa.”

SUMMARY: When TMD Pain Sensitivity Links to Central Sensitization

Orofacial pain specialists understand how to establish treatment and pain management for central sensitization in TMD patients. So, you don’t need to worry if you struggle to understand how TMD and CSS are associated. We can establish your pain management and evidence-based treatment for TMD-related central sensitization so you can enjoy life with less pain.

Schedule your Assessment Strategy for Chronic Pain and Central Sensitization with our Minnesota orofacial pain specialists.

Reach out to us at a location near you.

CALL Plymouth: (763) 577-2484St. Paul: (651) 332-7474Burnsville: (952) 892-6222St. Cloud: 763-233-7252



[1] Cayrol, Timothée, et al., “Chronic temporomandibular disorders are associated with higher propensity to develop central sensitization: a case–control study,” May 2023,

[2] Martina Ferrillo, et al., “Pain Management and Rehabilitation for Central Sensitization in Temporomandibular Disorders: A Comprehensive Review,” Oct 2022,

[3] Annalisa Monaco, et al., “Central Sensitization-Based Classification for Temporomandibular Disorders: A Pathogenetic Hypothesis,” Aug 2017,

[4] Yeong-Min Yoo and Kyung-Hoon Kim, “Current understanding of nociplastic pain,” April 2024,


Our mission is to provide high-quality, effective patient care for head and neck disorders through a multispecialty, interdisciplinary approach designed to reduce pain and improve function for all our patients.

3475 Plymouth Blvd # 200, Minneapolis, MN 55447


Plymouth: (763) 577-2484
Fax: (763) 577-1375

St. Paul: (651) 332-7474
Fax: (651) 332-7475

Burnsville: (952) 892-6222
Fax: (952) 892-6477

St. Cloud: (763) 233-7252
Fax: (952) 892-6477

Copyright by Minnesota Neck and Pain Clinic 2024. All rights reserved.