1112513 PRD Primary Dental Journal

Key words Learning Objectives Authors

Oral surgery, temporomandibular •• To understand the aetiology and Aneesha Shah BDS, MJDF (RCS Eng),
disorders, guide for commissioning oral presentation of temporomandibular MSurgDent (RCS Eng)
surgery, Level 1 treatment disorders (TMDs) Consultant Oral Surgeon, Department of Oral Surgery,
King’s College Hospital NHS Foundation Trust, London, UK
•• To recognise the role played by dental
practitioners in the recognition and Ambareen Naqvi BDS(Hons), MJDF
referral of patients presenting with TMDs (RCS Eng)
•• To gain knowledge of the tools used for Specialty dentist in Oral Surgery, Department of Oral
examination and diagnosis of TMDs Surgery, King’s College Hospital NHS Foundation
•• To gain an insight into the current Trust, London, UK

modes of management of TMDs

Aneesha Shah,
Ambareen Naqvi
Prim Dent J. 2022;11(3):118-125

Temporomandibular Disorder:
A Guide for General Dental
Practitioners
Abstract
The presentation of patients with symptoms associated with
temporomandibular disorders (TMDs) is a common finding in general dental
practice. The management of patients with TMDs is often complicated by its
multifactorial aetiology. This paper aims to provide a guide for dental
practitioners to the clinical examination, diagnosis, and recognition of red
flags in relation to TMDs and inform the busy practitioner when to refer
patients presenting with TMDs for specialist/secondary care management.

Introduction other causes of pain. Additionally, TMD is

First described by Costen in 1934, the recognised to also have a psychosocial
definition and terminology of contributing aetiology and, commonly,
temporomandibular disorders (TMDs) has significant impact on quality of life. The
evolved to surmise a collection of nature of regular dental visits provide
disorders affecting the temporomandibular dental practitioners with the opportunity to
joint (TMJ), masticatory muscles and adopt a holistic approach, necessary for
associated structures, which all function the management of this condition.
together.1 As such, variation in any one
component will inherently lead to changes The guide document for commissioning
in the others either due to disease, trauma oral surgery and oral medicine,
or interventions. Up to 15% of the global published by NHS England (2015),
adult population is thought to be affected recognises a need to facilitate efficient
with presentation of TMDs and they are and effective primary care services
assumed to be more common in female which act as the gateway for secondary
patients than males, although this may be care services.3 According to this
as a consequence of female patients document, management of TMD
seeking medical help more often than classified as Level 1 care is the minimum
males.2 The multifactorial aetiology of that NHS England Dental Commissioners
temporomandibular disorder (TMD) can would expect to be delivered under an
complicate the diagnosis, thus knowing NHS primary care contract. The guide
the signs and symptoms, together with specifically lists “Recognition of disorders
being able to carry out a thorough history in patients with craniofacial pain
and examination is paramount to ensure including initial management of
that a diagnosis of TMD is correctly made, temporomandibular disorders and
differentiating it from dentoalveolar or identification of those patients who

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118 Pr i ma r y De n ta l J ou r n a l journals.sagepub.com/home/PRD
require specialised management” as a implications.6 Some generalised The management should be patient
Level 1 procedure which puts the initial conclusions from the project include the focused, not condition focused.
diagnosis and management of TMD recognition that TMDs disproportionately Sometimes it is possible to cure the
under the remit of dental practitioners in affect patients with poor general health, symptoms of TMD, but the patient can
primary care.3 Therefore, recognition which may be influenced by one or more still be left with signs such as
and initial management of TMD allows of the following: co-morbidities, poor asymptomatic joint noises, which may be
for both early and effective management sleep conditions, smoking or other acceptable to the patient.
in primary care, thus freeing up existing pain conditions.7 The dental
secondary care pathways for those most practitioner is therefore ideally Pain
in need. This paper discusses the positioned for early recognition of Pain due to TMD can present either as
aetiology of TMD, summarises the tools “at-risk” patients and to provide an acute problem or, if it persists, as a
available for examination of the TMJ, prevention advice, as patients attending chronic issue. Acute TMD can commonly
aids in the diagnosis of TMDs, and general dental practice are usually seen occur after protracted dental treatment
provides an outline of primary care regularly for routine dental care such as lengthy root canal treatment or
management and guidance on when to providing an opportunity for regular surgical extractions. The most commonly
refer to specialist/secondary care. reinforcement of general health presenting complaint is pain, followed
messages. by restricted jaw movement and joint
Aetiology noises.
The biopsychosocial model of healthcare Other known causes of TMD include
and illness is now widely accepted in trauma, prolonged mouth opening (either Pain dysfunction syndrome may present
medicine and dentistry in understanding, from protracted dental treatment or as a combination of pain on palpation
diagnosing and ultimately managing general anaesthetic), and parafunctional of the TMJ or associated muscles,
chronic pain, such as in TMDs.4 This habits (e.g. grinding and/or clenching limitation or deviation of mandibular
model proposes that the general of teeth). movements, joint noises, and headache.
wellbeing of a patient is affected equally Headache or joint noises alone are not
by three domains: biological factors, Multiple classifications for TMDs have diagnostic.
psychological factors (e.g. stress, been proposed based upon aetiology,
anxiety, depression), and social factors presentation, or anatomical factors. The For about 10% of patients pain
(e.g. access to medical care, support, Research diagnostic criteria for becomes persistent, usually lasting
stigma).4 A disorder in any one domain temporomandibular disorders (RDC longer than three months.10 Patients
affects the other two domains and, in /TMD) was published in 1992 and has report increased pain compared to
the case of TMD, may predispose since been validated in 2014 within the acute TMD and biopsychosocial
patients to parafunctional habits. The Diagnostic criteria for TMD (DC consequences can impact on the
significance of the biopsychosocial /TMD).4,8 In 2020 the International patient’s life, both personal and work.
model is further validated if the patient Headache Society published the first Twelve per cent of patients report single
acknowledges the importance of all edition of the International Classification episodes but 19% have persistent
three elements early in their diagnosis of of Orofacial Pain (ICOP).9 The DC/TMD pain.10 Reduced jaw movement,
TMD enabling more successful have been included in ICOP with a stiffness and difficulty in mastication can
management of the condition.4 hierarchical style of classification seen be presenting features. A number of
within the International Classification of patients initially present to ear, nose
Changes in general health can also be Headache Disorders, 3rd edition and throat (ENT) departments due to
an aetiological factor, such as chronic (ICHD-3) to allow for ease of use and presenting symptoms such as ear
fatigue syndrome and fibromyalgia. consistency.10 TMJ pain is divided into fullness or tinnitus.
Migraines can sometimes muddy the primary and secondary pain conditions.
diagnosis of TMD, and it is therefore Primary TMJ pain is subdivided into Joint noises
important to differentiate a diagnosis of acute and chronic conditions and coded During normal opening and closing there
TMD to allow for correct management. by frequency of episodes. Secondary are no audible sounds from the joints.
Dental practitioners should obtain a TMJ pain refers to pain that is secondary Pathological displacement of the disc
thorough history which is better aided to or caused by another known medical occurs due to injury either to the disc, its
with the use of a bespoke TMD condition or cause.9 Although the attachments or to the bilaminar zone of
questionnaire that can be carried out in classification was developed for the articular disc of the TMJ.
advance of the consultation appointment, research purposes, the subdivision helps Hypertonicity of the superior head of the
further informing the clinician and clinicians to diagnose TMD and aims to lateral pterygoid muscle displaces the
allowing a targeted discussion at the ensure clear communication between disc antero-medially causing tension in
consultation.5 healthcare professionals with clear the bilaminar zone, which eventually
terminology. exceeds the pressure provided by the
The OPPERA study which set out to condyle on the disc causing the disc to
identify key risk factors for the Presentation be displaced backwards suddenly into a
development of symptomatic TMD The presentation of TMD varies with normal position.11 The sudden movement
concluded a complex multifactorial progression of the disorder. Not all produces the joint noise which is audible
aetiology that has multiple clinical presentations of TMD require treatment. as a “click”.

Vol. 1 1 No . 3 autumn 2022 119

 Temporomandibular Disorder: A Guide for
General Dental Practitioners

Joint noises are heard during both the when a patient’s mouth is open during aspects of the examination are carried
opening and closing phases, when a the traumatic event. Fractures of the out to aid decision making. Range of
patient is said to have “reciprocal mandible are diagnosed jaw movement and mouth opening are
clicking”. The disc is compressed radiographically, supported by a the only objective and measurable
posteriorly during the closing phase thorough history of the event. All trauma parameters that can be reproduced at
providing a sound when it is suddenly requires referral to a specialist for further subsequent visits to assess progress or
displaced forwards into a normal investigation and management. deterioration. All other parameters rely
position.11 on the patient’s account and are
Rheumatoid arthritis within the TMJ is subjective.
The timing of the joint noise can also uncommon. Patients with a diagnosis of
indicate the severity of the problem.12 rheumatoid arthritis rarely complain of While taking the history and carrying
Early joint noises usually indicate mild pain within the temporomandibular joints out the examination, it is important to
displacement. The later the joint noise (TMJs).11 Psoriatic arthritis can affect the look out for red flags which can mimic
occurs, the more severe the TMJ but presentation usually follows TMD. These are highlighted in Table 2
displacement, and the joint noise itself is systemic exacerbations of the condition. while further reference can be found in
usually louder. Multiple joint noises Exacerbation of either disease process the 2013 RCS England guidelines for
within a single excursion can indicate an tends to resolve once the patient is in TMDs15 and from the NICE Clinical
unstable disc or one with perforations remission.11 Dental practitioners can Knowledge Summaries on TMDs.17
and tends to be associated with symptomatically manage these patients, Additional red flags might include:
symptoms of pain.11 but the underlying cause will require
simultaneous management with their •• general symptoms of unexplained
Internal derangement does not usually medical specialist. Rare conditions fever or weight loss which may
present with pain in the early stages, and affecting the TMJs include ankylosis of indicate malignancy or an
is characterised by joint noises such as the joint, neoplasia, infection, and undiagnosed infective cause
clicking, popping or crepitus. These can developmental defects such as •• recurrent nosebleeds, purulent nasal
be painless and are likely to result from hyperplasia, hypoplasia, and aplasia. discharge, loss of smell or reduced
disc displacement with reduction. Pain hearing on the affected side, which
becomes a feature in the later stages History may indicate nasopharyngeal
when derangement becomes a chronic A thorough medical history, identifying carcinoma17
problem due to associated muscle spasm. any potential widespread pain •• unexplained jaw pain in patients at
Restricted movement can be associated diagnoses, other facial pain diagnoses risk of osteonecrosis
with disc displacement without reduction or areas of increased stress or anxiety, •• unexplained headache symptoms
together with patients who have repeated can help identify associated risk factors suggesting secondary headache16
dislocations. Joint noises such as a single or chronic pain conditions that may be (reference can be made to the
“click” occur in about 50% of contributing. A well-designed and American Headache Society for
asymptomatic patients and do not require comprehensive medical history SNOOP4 or expanded SNNOOP10
treatment unless symptoms develop.13 questionnaire can often highlight many mnemonic)18
of these conditions and narrow the •• persistent worsening symptoms
Osteoarthrosis is typically characterised differential diagnoses. following initial treatment
by crepitus and indicates degeneration
within the articulating surfaces of the The use of a simple tool such as the It is important that patients who have
joint or disc. Jaw movement is limited, mnemonic SOCRATES can aid in potential red flags are urgently referred
and patients note restriction due to narrowing the questions to ask towards to appropriate specialists in primary
function. Pain is usually limited to the a particular diagnosis.14 The Faculty of care or secondary care hospital
area immediately over the TMJ in the Dental Surgery of the Royal College of departments.
preauricular region with no radiation to Surgeons of England provides a useful
the musculature.11 tool for asking the relevant questions Once the history, examination and
when obtaining a pain history in patients relevant special tests are completed and
Restriction in movement with suspected TMD.15 Table 1 provides the differential diagnoses have been
External trauma to the face or jaws can a summary of the typical signs and ruled out, a diagnosis of TMD can be
result in traumatic arthritis due to the symptoms seen and relevant questions proposed.
sudden impact on the condyle within the that could be asked when a diagnosis of
glenoid fossa resulting in acute TMD is suspected. Management of TMD
inflammation, sudden pain, and Current evidence supports conservative
trismus.11 Pain and trismus usually Examination: practical management in primary care including
resolve within seven days with the use of considerations self-management, awareness, and
non-steroidal anti-inflammatory drugs A thorough examination is imperative self-education, supplemented with
(NSAIDs) for symptomatic relief. and simple to carry out routinely in physiotherapy and pharmacotherapy
dental practice. Table 2 provides a where appropriate. Multidisciplinary
Dislocation is rare without anatomical reference tool that can be used to adopt care is advocated for TMD that is
defects or trauma, and usually occurs a systematic approach and ensures all attributed to other causes or which does

120 Pr i ma r y De n ta l J ou r n a l
 Tabl e 1

Tmd Signs And Symptoms And Pertinent Questions To Ask

TMD signs and symptoms Specific findings Pertinent questions to ask

Pain - in the pre-auricular region - Recent history of lengthy dental

- along the line of the jaw treatment or trauma?
- in the masseter and temporalis muscles - Number of episodes – single or
- in the upper cervical spine (anteriorly near recurrent?
the origin of sternocleidomastoid muscle and - Duration of symptoms – >3 months?
posteriorly around the suboccipital region)

Joint noises - “clicking” – painful/asymptomatic, - Record the type and number of joint
single/multiple, early/late noises during a single excursion
- crepitus – painful/asymptomatic

Limitation of movement - Trismus - Measure and record mouth opening

- TMJ Locking – open/closed - Locking – does it occur after a joint
noise?
- How often does it occur?
- How long does it take to ease and what
eases it?
- Can the jaw be manipulated
open/closed?

Headache – a symptom of various - Site – usually temporal Secondary headache will require referral
different disorders. Headache alone - Duration – usually lasts 6–8 hours for specialist management. Refer to
without other signs of TMD should be - Severity – usually mild (e.g. on a scale of SNOOP4/SSNOOP1016 (systemic
investigated by a neurologist. 1–10) symptoms/signs and disease, secondary
TMD-related headache will usually - Onset – usually on waking headache risk factors, neurologic
exhibit signs of a chronic tension- - Associated symptoms – usually no associated symptoms or signs, onset sudden or onset
type headache. symptoms such as nausea, aura, light after the age of 40 years, and change of
sensitivity, etc. headache pattern)

Previous TMJ history Identify associated causes: Record any previous TMD diagnoses
- Trauma to the head and neck
- Surgery to the head and neck
- Previous facial pain treatment

Parafunction habits - Evidence of tooth wear Ask about any habits such as chewing
- Awareness of habits gum, chewing pens, nail biting

Any other symptoms reported - Ear symptoms – fullness in the ear, pulsating Ear symptoms could indicate inner ear
by the patient in the ear, ringing/tinnitus pathology, peripheral vestibular
dysfunction (Meniere’s disease) or carotid
artery dysfunction that require referral to
ENT services

not respond to first line conservative 75% of patients are thought to improve • identification of underlying stress
measures in primary care. within 3–6 months.19 Typical first line or anxiety triggers
conservative management includes the • avoidance of any causative or
Most patients presenting with symptoms following: worsening habits (e.g. chewing
of TMD will improve with little or no gum/pens, nail biting, use of the
treatment. First line conservative • reassurance that TMD is not teeth to open bottles)
measures are usually adequate to progressive and does not worsen • avoidance of wide opening of
manage a diagnosis of TMD in primary but can fluctuate the mouth, especially yawning.
care, where there are no other • explanation of TMD with the use Advice to aid this includes the
complicating factors, and should be of appropriate resources or use of hand/fist support during
reviewed to ensure compliance and patient information leaflet (PIL) wide opening to prevent over
response to treatment. Approximately (see Table 3) extension of the joint

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 Temporomandibular Disorder: A Guide for
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Tabl e 2

Examination And Red Flags

Area Examination Signs Red flags

Facial Examine the patient Record size of swelling, consistency, overlying - Swellings risking airway
asymmetry front-on and from behind erythema of skin compromise
the dental chair looking - Unexplained facial asymmetry
down on the patient - New onset unilateral headache
or scalp tenderness
TMJ Feel for tenderness of both Tenderness indicates the presence of inflammation - Signs and symptoms of temporal
joints on palpation in front which can be due to trauma arteritis (jaw claudication,
of the ear and within the general malaise, >50 years old)
ear - Unexplained preauricular or
neck mass/lump
- Unexplained cervical
lymphadenopathy
- Previous history of malignancy
- Cranial nerve dysfunction
Range of jaw movement Deviations can be marked pictorially when viewed
from the front11
Could indicate adhesions within
the joint

Could indicate anterior disc

displacement without reduction
when there is overall reduction
in range of opening

Could indicate disc

displacement with reduction

Measure mouth opening Restriction in mouth opening can be due to pain Trismus preventing any intra-oral
(muscular issue) or physical obstruction (likely due examination
to disc displacement)
Can the mandible be Record pain or complete restrictions to further
manipulated to open further opening
Listen and feel for joint Record crepitus or clicking. Refer any crepitus for specialist
noises A “click” can be heard: investigation and management
- early – indicating mild displacement
- late and/or loud – indicating a greater degree
of displacement
Muscles of Palpate insertion into bone - Masseter – tenderness can indicate bruxism
mastication - Temporalis – tenderness usually indicates bruxism
- Lateral pterygoid – difficult to examine however
pre-auricular pain can be due to tenderness
within this muscle
Intra-oral Soft tissues Record cheek biting/ridging in buccal mucosae Undiagnosed red/white patch or
examination (unilateral or bilateral, adjacent to occlusal plane), ulceration
scalloping of tongue along external border
Hard tissues - Examine any dental pathology to exclude this as Unexplained occlusal changes
a cause
- Wear facets/attrition – usually accompanied by
tooth sensitivity indicates active bruxism

122 Pr i ma r y De n ta l J ou r n a l
 • a
 doption of a soft diet with It is recommended that general dental any parafunction habits that may be
avoidance of hard and chewy foods practitioners (GDPs) adopt a flexible contributing. Better understanding of
• utilising posterior teeth for approach to review intervals dependent triggers can help patients prepare for the
mastication and avoiding eating upon the severity of symptoms and onset of acute symptoms and combat
on one side only clinical findings. If there has been no these early.
• simple jaw exercises reinforced improvement of symptoms or a worsening
with the aid of an explanatory PIL of symptoms within approximately six Alternative therapies could also be
(Table 3) months, prompt onward referral is considered and are often effective
• during a flare of TMD: required for specialist management.19 strategies in some patients who respond
○ massaging the painful muscles Often, the review process triggers patient to the suggestion of these interventions.
and, if appropriate, the use of compliance and provides the GDP an Although there is no robust evidence for
a NSAID gel externally on opportunity to assess for resolution of the the use of some of these interventions,
these muscles initial symptoms. the reduction of stress is thought to have
○ the use of heat and/or cold a positive effect in the management of
application externally (e.g. a It is important to adopt a holistic TMD.21 Directing patients to applications
hot flannel, a covered hot water approach to diagnose and manage such as mindfulness, meditation, yoga or
bottle, a covered icepack) TMD. Stress and anxiety have been acupuncture, has also been shown to
○ the use of systemic NSAIDs for shown to contribute, as well as other help patients – together with the use of
a short but regular duration15 pain diagnoses, and delays in access sleep hygiene in those patients who
• if bruxism has been identified, during COVID-19 will mean patients admit to poor sleep as a factor in their
provision of a simple may present with worsened symptoms or diagnosis.22,23
full-coverage soft bite raising with heightened anxiety of multifactorial
appliance for nocturnal wear. aetiology. Education of patients is For patients who have asymptomatic
Written instructions for use and considered one of the main conservative joint noises with no other signs or
maintenance should be management techniques for empowering symptoms and no impact of this on their
provided, and patients should be patients to participate in treatment. The lifestyle, reassurance that this is normal
warned that improvement in use of PILs have been shown to improve and not an indication of pathology, can
symptoms typically takes 3–6 patient outcomes and increase patient be all that is required.
months of continuous nightly use understanding.20 Simply spending time
as directed to explain the mechanism of TMD and Splint therapy
• referral for a course of the psychosocial aspect can give For patients with acute pain and
physiotherapy for TMD if this patients a better understanding of their identifiable habits such as nocturnal
service is locally available diagnosis and bring to their attention bruxing, an economical soft bite raising

Tabl e 3

Patient Information Resources

Resource name Source Weblink (short link in brackets)

Temporomandibular disorder (TMD) NHS https://www.nhs.uk/conditions/temporomandibular-

disorder-tmd/ (https://bit.ly/3vfqLG0)

Temporomandibular dysfunction King’s College Hospital patient https://www.kch.nhs.uk/Doc/pl%20-%20869.1%20-%20

(TMD) leaflet temporomandibular%20dysfunction%20(tmd).pdf (https://
bit.ly/3S4UFXi)

Temporomandibular disorders NICE https://cks.nice.org.uk/topics/temporomandibular-disorders-

(TMDs) tmds/ (https://bit.ly/3oty9Kn)

Temporomandibular joint disorders Orofacialpain.org.uk https://orofacialpain.org.uk/education/temporomandibular-

joint-disorders/ (https://bit.ly/3owhBBi)

Temporomandibular (jaw) disorders Patient.info https://patient.info/bones-joints-muscles/

temporomandibular-joint-disorders (https://bit.ly/3viLOHP)

Temporomandibular disorders European Pain Federation https://www.orofacialpain.org.uk/downloads/

(EFIC) Orofacial%20pain%20patient%20leaflets/EYAP2013%20
Patient%20Leaflet%20TMD.pdf (https://bit.ly/3be2QzY)

Temporomandibular (jaw) joint British Association of Oral https://www.baos.org.uk/resources/Temporo

problems Surgeons (BAOS) mandibular(Jaw)JointProblems.pdf (https://bit.ly/3PzORn6)

Vol. 1 1 No . 3 autumn 2022 123

 Temporomandibular Disorder: A Guide for
General Dental Practitioners

Physiotherapy
Tabl e 4 Physiotherapy is beneficial for patients
with a muscular component in their TMD
Information To Be Included In A Referral Letter To diagnosis.28 Availability of
Specialist/Secondary Care physiotherapy services varies in different
regions in the UK and referral to a
1. Working diagnosis service is often common practice in
areas where this provision exists.
2. Full medical history
Treatment aims to achieve muscle
3. Duration of symptoms relaxation and, in turn, relieve pain or
muscle spasm, re-establish joint
4. Location of pain/discomfort movement and enable normal function.28
5. Relieving and exacerbating factors
Pharmacotherapy
6. Has the patient seen any specialists/hospitals for this condition At the time of presentation patients have
often tried a combination of analgesics
7. Restriction in mouth opening: and may have a preferred regime or
a. mouth opening in cm analgesic to treat their acute symptoms.
Advice should include the use of a short
8. If the patient has identified bruxism, do they use a bite raising appliance/splint
course of NSAIDs, if the patient’s
9. Has the following advice been given?: medical history allows, as single doses
a. soft diet, no biting into apples, chewy or hard foods of this drug only provide mild relief.15
b. avoid chewing gum and nail biting Regular timed doses provide an
c. avoid over-opening and try to limit wide stretch of yawning anti-inflammatory effect together with a
d. analgesics as necessary (oral and topical) profound analgesic effect and is more
e. hot water bottle on affected side beneficial to treat an acute
exacerbation.29 Paracetamol may be
recommended in addition or as an
appliance can be constructed in primary specialist with experience in treating alternative for those unable to take
care using a polyvinyl material of uniform TMD who may identify the need for full NSAIDs, and provides symptomatic
thickness simply with an alginate or partial coverage splint therapy. short-term relief while the cause is
impression. The appliance can be Stabilisation splints, including the treated.15 Secondary care settings may
constructed for either the upper or lower Michigan splint (used in the maxillary prescribe neuromodulatory medications
teeth ensuring full coverage without the arch) and the Tanner appliance (used in (e.g. amitriptyline or gabapentin) which
need for occlusal registration or the mandibular arch), provide an ideal are used off licence at differing doses to
adjustments. These appliances are removable occlusion which is thought to their primary use for the purpose of
thought to provide symptomatic relief aid in identifying the occlusion as a providing pain relief.15 Evidence for this
through potential absorption of occlusal cause for TMD.26 Construction requires use is extrapolated from positive
forces during bruxing due to the soft the use of articulated models of the jaw responses to other pain conditions.
nature of the material, breaking off the with repeated adjustments until a stable Education of patients and explanation of
habit due to the introduction of an and reproducible centric relation position the side effects is imperative to ensure
additional occlusal component or due to is achieved at review. Wear of the compliance.
a placebo effect.24 The appliance should appliance is then gradually reduced until
be fitted in primary care and written the patient is symptom-free. Surgical management
instructions for nocturnal wear alongside For most patients suffering from
appliance maintenance instructions Psychology myofascial pain, surgical management is
should be provided to the patient. Most For many patients the process of having not an option that needs to be discussed.
patients report improvement in symptoms their symptoms diagnosed and explained Simple reassurance that surgery is not
following nocturnal use for a period of to them in simple terms provides great indicated can help alleviate any fear
three to six months.25 Patients can then relief even if only reassurance is surrounding their diagnosis.
be advised to reduce usage until it is only provided.23 Patients who demonstrate
utilised as needed for symptomatic relief. high anxiety, depression or who do not Surgery is usually only an option where
take the self-management advice, may patients fail to respond to all non-surgical
Where a full coverage soft bite raising benefit from referral for psychological interventions, radiographic imaging
appliance made in primary care has not support or cognitive behavioural indicates pathology or quality of life is
provided adequate pain relief, an therapy.27 It is important that an affected to an unacceptable degree.30
acrylic based stabilisation splint may be explanation for the benefit of Surgery requires referral to a specialist
considered.26 When occlusion is thought psychological support is given to ensure unit in secondary care and can include
to contribute to the diagnosis, compliance and overall success in their arthrocentesis, arthroscopy or open
management is best provided by a management. surgery of the TMJ.29 Post-operative care

124 Pr i ma r y De n ta l J ou r n a l
is usually extensive and long-term, with and any interventions already carried outlined in the guide document for
limited success and the potential for high out. Providing complete information commissioning oral surgery and oral
risk iatrogenic damage, such as damage within the referral will ensure that the medicine.3 Arguably, TMDs are one of
to the facial nerve.29 patient does not experience any delays the most difficult conditions for dental
and can be directed to the appropriate practitioners to manage in primary care.
Referral to secondary care service for management in a timely Current research trails behind other
For patients who have not responded to fashion (see Table 4). conditions, with a lack of patient centred
conservative first line management or studies due to the complex aetiology of
those who have chronic TMD, red flags Conclusion TMD. Future research is required to add
or trauma to the face or jaws, a prompt Management of TMD is commonplace in to the current evidence base and
referral should be made to secondary primary care and a requirement within therefore improve patient care for this
care outlining the justification for referral the primary care NHS contract as condition.

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disturbed function of the temporomandibular disorders (DC/ guidelines/ [Accessed May 2022]. 23 Penlington C, Otemade AA, Bowes
temporomandibular joint. Ann Otol TMD) for clinical and research 16 Do TP, Remmers A, Schytz HW, C, et al. Psychological therapies
Rhinol Laryngol. 1934;43:1-15. applications: Recommendations of et al. Red and orange flags for for temporomandibular disorders
2 National Institute of Dental and the international RDC/TMD secondary headaches in clinical (TMD). Cochrane Database Syst
Craniofacial Research (NIDCR). consortium network and orofacial practice: SNNOOP10 list. Rev. 2019. Issue 12. Art. No.:
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