Management of painful Temporomandibular disorder in adults

NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’
Faculty of Dental Surgery.
Contents

1. Sponsoring body
2. Associate Bodies
3. Contributors and Acknowledgments
4. Glossary of terms
5. Introduction
6. Intended audience
7. Statement of conflict of interest
8. Aims and objective
9. Development, evidence base and summary of evidence table
10. Background
11. History
12. Examination
13. Further investigations
14. Diagnosis
15. Early secondary care referral / Adjunctive medical referral
16. Management
17. Development of service
18. Suggested TMD care pathway
19. Conclusion
20. Appendices
21. References
1. Sponsoring Body

Faculty of Dental Surgery Royal College of Surgeons England

2. Associate bodies
• Association of British Academic Oral and Maxillofacial Surgeons (ABAOMS)
• Association of Chartered Physiotherapists in Temporomandibular Disorders (ACPTMD)
• Association of Consultants and Specialists in Restorative Dentistry (RD-UK)
• British Association of Oral and Maxillofacial Surgeons (BAOMS)
• British Association of Oral Surgeons (BAOS)
• British and Irish Society for Oral Medicine (BISOM)
• British Society of Prosthodontists (BSSPD)
• British Society of Special Care Dentistry (BSSCD)
• College of General Dentistry UK
• NHS England Getting It Right First Time (GIRFT) for hospital dentistry
3. Contributors

Mrs. Emma Beecroft1: Clinical Fellow and honorary Oral Surgery Specialty trainee. Newcastle University

Dr. Julia Palmer1: Academic Clinical Fellow and Specialist Oral Surgeon. Newcastle University

Dr. Chris Penlington2: Clinical Psychologist. Newcastle University

Senior author and chair: Professor Justin Durham, Professor of Orofacial pain and Honorary Consultant Oral
Surgeon. Newcastle University

Guideline Development Group (Name: Specialism, institution).

All relevant stakeholders represented.

Professor. Leah Avery: Patient representative and Professor of Applied Health Psychology, Teesside University.

Dr. Vishal R. Aggarwal: Clinical Associate Professor in Acute Dental Care and Chronic Pain, University of Leeds.

Matthew Chase: Advanced Physiotherapy Practitioner, Tyneside Integrated Musculoskeletal Service.

Mr. Stephen Davies: Specialist in Restorative Dentistry and lecturer in Occlusal and Temporomandibular Studies,
University of Manchester.

Ms. Barbara Gerber: Consultant Oral and Maxillofacial Surgeon, Oxford University Hospitals.

Dr. Robert Jagger: Retired senior lecturer/ Consultant in Restorative Dentistry, University of Bristol.

Dr. Sheelah Harrison: Senior clinical lecturer and Honorary Consultant Oral Surgeon, Queen Mary’s University,
London.

Dr. Mick Horton: Primary care dental practitioner, Chair of Trustees College of General Dentistry UK.

Dr. Liz Jones: National Clinical Lead for the Getting It Right First-Time programme, NHS England.

Mr. Athanasios Kalantzis: Consultant Oral and Maxillofacial Surgeon, Manchester University Hospitals.

Dr. Sophia Lie: General Medical Practitioner. North Tyneside Integrated Care Board.

Professor. Gerry McKenna: Professor of Oral Health Services Research and Gerodontology and Consultant in
Restorative Dentistry, Centre for Public Health, Queen's University Belfast.

Dr. Roddy McMillan: Consultant and Honorary Clinical Teaching Fellow in Oral Medicine and Facial Pain, University
College London Hospitals NHS Foundation Trust / University College London.
Miss. Maire Morton: Consultant Oral and Maxillofacial Surgeon, East Lancashire NHS trust. OMFS GIRFT clinical lead
and Chair of Oral Surgery MCN national forum.

Dr. Eamonn Murphy: Orofacial Pain Practitioner, Cork, Ireland.

Professor. Tara Renton: Professor in Oral Surgery, Honorary Consultant Oral Surgeon and Clinical Lead for Kings
Health Partners Orofacial Pain Service. Kings' college London.

Mr. Tom Thayer: Consultant and Honorary Lecturer in Oral Surgery, Royal Liverpool Dental Hospital, Liverpool.

Mr. Alexander Weden: Clinical Specialist Physiotherapist in Craniomandibular Disorders, Queens Medical

Centre, Nottingham.

Acknowledgements

Professor Donald Nixdorf: Division of TMD and Orofacial pain, University of Minnesota. Imaging expertise.

Dr. Agata Witkowska: Patient experience video

Mr. James Allison: Wellcome Trust Clinical Research Fellow, Newcastle University. Clinical image generation.

This guideline should be cited as:

Beecroft E, Palmer J, Penlington C, Avery L, Aggarwal V, Chase M, Davies S, Gerber B, Jagger R, Harrison S, Horton M,
Jones L, Kalantzis A, Lie S, McKenna G, McMillan R, Morton M, Murphy E, Renton T, Thayer T, Weden A, Durham J
(2023). Management of painful Temporomandibular disorder in adults. NHS England Getting It Right First Time
(GIRFT) and Royal College of Surgeons’ Faculty of Dental Surgery. Available from: https://www.rcseng.ac.uk/dental-
faculties/fds/publications-guidelines/clinical-guidelines/.
4. Glossary of terms

3Q/TMD 3 question TMD screener

A-TMD Arthrogenous TMD
CBCT Cone-beam computed tomography
CBD Cannabidiol
CT Computed tomography
COMT Catechol-O-methyltransferase
CPI Characteristic Pain Intensity
DC/TMD Diagnostic Criteria for Temporomandibular Disorders
DDwoR Disc displacement without reduction
DJD Degenerative joint disease
ENT Ear, nose and throat
FDS Faculty of Dental Surgery
GDG Guideline development group
GDP General dental practitioner
GI Gastrointestinal
GIRFT Getting It Right First Time
GP General medical practitioner
LLLT Low level laser therapy
LSS Lower soft splint
M-TMD Myogenous TMD
MMO Maximal mouth opening
MRI Magnetic resonance imaging
NICE National Institute for Health and Care Excellence
NSAIDs Non-steroidal anti-inflammatory drugs
OD Once daily
OMFS Oral and maxillofacial surgery
OSA Obstructive sleep apnoea
PHQ-4 Patient Health Questionnaire 4
QDS Four times daily
RCS Royal College of Surgeons
SSM Supported self-management
TDS Three times daily
TMD Temporomandibular disorders
TMJ Temporomandibular joint
UK United Kingdom
US Ultrasound scan
5. Introduction

Temporomandibular disorders (TMD) are the second most common cause of orofacial pain after “toothache”
(odontogenic pain).[1] They affect up to 1 in 15 of the UK population and predominantly arise in the 20-40 age
range. [1, 2] Females are marginally more likely to develop TMD than males and there are US data suggesting that
TMD incidence is higher in black ethnic groups and lower in Asian ethnic groups when compared to white ethnic
groups, however much more worldwide research is required to understand all aspects of TMD in different ethnic
groups.[1-3] TMD are a group of musculoskeletal conditions that affect the muscles of mastication, the
temporomandibular joint (TMJ) and associated structures.[4] There are twelve common types (Table 1) which
confirmatory examination findings can attribute to being either myogenous (muscular in origin) or arthrogenous
(joint or joint structure in origin).[5] Those of arthrogenous nature have a good prognosis and generally remain
stable rather than progress with only around 1 in 7 cases demonstrating any progression[6] (Table 1 footnote).

Table 1: Twelve common types of TMD [5]

Type of TMD Origin

1. Myalgia Myogenous
2. Local myalgia
3. Myofascial pain
4. Myofascial pain with referral
5. Headache attributed to TMD
6. Disc displacement with reductiona Arthrogenous
7. Disc displacement with reduction with intermittent
locking
8. Disc displacement without reduction with limited
opening
9. Disc displacement without reduction without limited
opening
10. Osteoarthrosis/ osteoarthritis (Degenerative joint
disease) b
11. Subluxation
12. Arthralgia
a Data demonstrated over two-thirds of people (76%) with disc displacement have no progression of over 8 years, 10% show reversal with 14%
demonstrating any progression towards any form of disc displacement without reduction.[6] Only a small number of disc displacements require
intervention, these are outlined in table 7 and figure 3.

b Degenerative joint disease (previously known as osteoarthritis and osteoarthrosis) tends to be a stable condition, with 71% of cases showing
no progression towards more deterioration over an eight year-period.[6] Over the same period 14% of cases demonstrated reversal leaving a
small minority (15%) which progress in any way. [6]
TMD frequently present with moderate-intensity pain that can radiate and refer across the mouth and face causing a
wide range of biopsychosocial impacts including impacts on health-related quality of life commensurate with other
types of persistent pain.[1, 2] Other symptoms include joint noises (clicking, popping, crepitus [rustling or grinding]);
ear pain (otalgia); changes in the range of movement of the TMJ; headaches.[2] Only a small percentage of those
presenting with TMD-like symptoms have occult, mimicking neoplastic pathology (<1% are intracranial or
oro/nasopharyngeal tumours [7, 8]). There are, however, well-defined and accepted red flags (Table 2) that should
raise the index of suspicion of a mimicking pathology [9-11].

If TMD are treated early in their presentation with simple reversible management techniques, the majority (75-90%)
improve to the satisfaction of the patient and are successfully managed either through resolution or by becoming
intermittent and manageable [12]. Some TMD, particularly myogenous ones, have a propensity to become persistent
(chronic), lasting greater than 3 months. Due to the impact of the persistent pain, they cause a reduction in generic,
health-related quality of life commensurate with that caused by chronic illnesses such as arthritis and depression
and exert a substantial health economic impact on the patient, the health service and the economy [1, 13]. This
impact is particularly pronounced due to the expressed uncertainty of medical and dental practitioners on
management and the lack of structured care pathways which often result in circular or protracted journeys to obtain
care [14-18]. This guideline, therefore, seeks to provide evidence-based approaches to the provision of care along a
structured and clear pathway to improve care provision, reduce the impact of painful TMD and hopefully its
likelihood to become persistent.
Table 2: Red flag signs of potential mimicking condition (Adapted from [10] supplemented with information
from[19])

Sign Possible cause or origin

History of previous malignant tumour with facial pain or headache Potential for new primary,
recurrence or metastases
Lymphadenopathy, face or neck mass/swelling Neoplastic, infective or
autoimmune
Jaw claudication (Cramp like pain in tongue or jaw). Commonly presents with: Giant cell arteritis
Unilateral headache, flu-like symptoms, vision disturbances, inflammation of
temporal artery, trismus
Unplanned weight loss Neoplastic, systemic illness
Pyrexia (+/-) swelling and trismus Infective
Neurological signs/symptoms Neoplastic, infective or
• Acute onset loss of smell or hearing autoimmune cause
• Acute onset visual problems
• Neurosensory change
• Motor function changes
Pain with exertion, coughing or sneezing. Neoplastic or infective cause.
(Suggests raised intracranial pressure)
Nasal symptoms (persistent and profuse bleeding or (purulent) discharge) Neoplastic (nasopharyngeal) or
infective
Acute onset of profound, or worsening, trismus Neoplastic, infective, severe
arthrogenous or traumatic cause
Persistent hoarseness of the voice (≥3 weeks) Neoplastic
Persistent mouth ulcer(s) (≥3 weeks) Neoplastic, autoimmune
Occlusal changes Neoplastic, traumatic, growth
disturbance
New onset jaw pain in those taking bisphosphonates or related medication Medication related
osteonecrosis of the jaws
6. Intended Audience

This guideline provides information for all clinical dental professionals (dentists, dental hygienists, dental therapists,
clinical dental technicians), general medical practitioners (GPs) and other healthcare professionals (e.g., pharmacists,
physiotherapists, chiropractors, osteopaths) to whom individuals living with TMD may present. The guideline
supports the recognition of adults living with painful TMD and facilitates evidence-based management. It presents
the most appropriate care pathway for an individual who presents with any of the 12 most common painful TMD
subtypes (Table 1) in any health care setting. For the purpose of this document the term “adult” includes all
individuals ≥18 years old.

These guidelines are applicable for all dental specialties and adult services in primary and secondary care, across
general dental, community and hospital-based settings. The guidelines support informed, evidence-based
discussions and shared decisions between clinical dental and medical professionals and individuals living with TMD.
This guidance can be used by those living with TMD to help inform them about the management of their condition.
Additionally, this guidance can be used by medical professionals and other healthcare professionals (e.g.,
pharmacists, physiotherapists, chiropractor’s and osteopaths) to inform about the care requirements for patients
with TMD.

7. Statement of conflict of interest

The Faculty of Dental Surgery is funded by its fellows and members, and no contributors or reviewers were paid for
their work on this guidance, and nor is any payment provided in kind.

8. Aims and Objectives

This guideline aims to consolidate the recent literature and help inform and support dental, medical and other
healthcare professionals in their ability to:

1. Appropriately identify patients at risk of painful TMD

2. Accurately diagnose an individual with at least a broad TMD grouping: Myogenous, arthrogenous, or
combination.
3. Clarify requirements for initial management of painful TMD including supported self-management.
4. Propose appropriate hierarchical steps for adjunctive management strategies of painful persistent TMD that
can be discussed in shared decision making with patients.
5. Reinforce appropriate points for onward referral.
6. Clarify best route(s) of onward referral, if deemed appropriate.
9. Development and evidence base

This guideline supersedes the 2013 Royal College of Surgeons (RCS), Faculty of Dental Surgery document
“Temporomandibular disorders (TMDs): an update and management guidance for primary care from the UK
Specialist Interest Group in Orofacial Pain and TMDs”.[20] Development took into consideration existing national UK
guidance and recently published national and international evidence for appropriate management pathways and
strategies for painful TMD and other persistent pain conditions. [11, 19, 21-27]

A modified Delphi methodology was employed by the guideline development group (GDG)[28]:

1) Evidence synthesis: All published systematic reviews on TMD available from PubMed, Scopus, EMBASE,
MEDLINE and Health Management Information Consortium by 30/03/2022.
2) Evidence reviewed
3) Evidence statements created from review of evidence and appraised by GDG.
4) GRADE rating for certainty of evidence and strength of recommendations confirmed and agreed with GDG
and presented in Table 3.
5) Guideline draft constructed from evidence statements and circulated to GDG, feedback collated, changes
made, updated draft re-circulated to GDG for appraisal.

At least 75% of GDG were required to provide approval at each stage of the process: evidence statement, review and
guideline drafting.

A final draft of the guideline was produced once RCS England’s consultation had closed, all the associate bodies
commentary collated, the GDG core team examined all consultation responses. No consultee’s response highlighted
substantiated, fundamental, problems with the proposed guidance and the majority were either positive
endorsement of (the need for) the guidance, constructive critique of circumscribed areas of the guidance, or matters
of phraseology/clarity. The GDG core team responded to each piece of feedback in each consultation submitted as
well as acting on each by either re-examining the evidence base and/or adjusting text/guidance as appropriate. Any
fundamental changes to the guideline were proposed to the full GDG prior to adjustment and adoption. The
guideline and all supporting material were critically examined by the RCS clinical standards committee prior to
publication and their comments responded to and acted upon.
Table 3: Summary of evidence table

Articles Summary findings GRADE

Prevalence
Pantoja LLQ et al, 2019; Valesan LF et al, 2021; Silva MAG et al, 2020; No new information
Campos LGN et al, 2021; Chaves TC et al, 2014; De La Torre Canales G et al,
2018; Gilheaney O et al, 2020; Herranz-Gomez A et al, 2020; Xie C et al, 2019;
Yakkaphan P et al, 2022.
Pathogenesis
Yin Y et al, 2020; Brancher JA et al, 2021; Carvalho Soares FF et al, 2020; da Polymorphisms in COMT were significantly associated with TMD. NOT A RECOMMENDATION JUST A FINDING
Costa GFA et al, 2017; Dutra Dias H et al, 2021; Pitance L et al, 2016; Yin Y et al.
2020; Afroz S et al, 2018; La Touche R et al, 2018. Evidence for extra segmental hyperresponsiveness and generalized hyper-excitability MODERATE QUALITY EVIDENCE
in the central nervous system in patients with TMD.
Other: Aaron LA et al, 2000
Aetiology/presentation/epidemiology
Al-Moraissi EA et al, 2017; Oghli I et al, 2020; Dinsdale A et al, 2021; Dinsdale A Consultation for any individual presenting with TMD should include exploration of STRONG RECOMMENDATION MODERATE EVIDENCE
et al, 2020; Haggman-Henrikson B et al, 2013; Ferreira MC et al, 2018; Alqhtani headache symptoms.
N et al, 2021; Réus JC et al, 2021; Fan XC et al, 2020; Jiménez-Silva A et al,
2017; Rocha CP et al, 2013; Aranha RLB et al, 2021; Gilheaney Ó et al, 2018;
Gilheaney Ó et al, 2017; Pigozzi LB et al, 2021; Al-Moraissi EA et al, 2017;
Bueno CH et al, 2018; Bizzarri, P. et al, 2021; Farronato G et al, 2016; Jimenez-
Silva A et al, 2017; Manfredini D et al, 2017; Marques FBC et al, 2021; Robinson
LJ et al, 2016; Sabsoob O et al, 2021; Shu C et al, 2021; Visscher CM et al, 2015;
Wilkowicz W et al, 2021.

Other: Yanagi Y et al, 2003; Liu, YT et al 2018; NICE Suspected

cancer:recognition and referral 2021; Beecroft E V, et al 2019; Greene C S,
2001; Beecroft E V et al, 2013; Breckons M et al, 2017; Magnusson T and
Carlsson G E, Swed Dent J 1978; Magnusson T and Carlsson G E, Acta Odontol
Scand 1978; Carlson C R et al, 1998; Aggarwal V et al, 2006; Elliott E et al, 2022;
Ohrbach R et al, 2011; Ohrbach R et al, 2013
Bruxism
Lobbezoo F et al, 2018; Chattrattrai T et al, 2023; Manfredini D et al, 2021; Remove bruxism from parafunction section as no longer considered parafunctional STRONG RECOMMENDATIONS, HIGH QUALITY
Baad-Hansen L et al, 2019; Luiz de Barreto Aranha R et al, 2018; Lobbezoo F et activity. EVIDENCE.
al, 2014[29]; Lobbezoo F et al, 2023; Manfredini D et al, 2022; Manfredini D et Include new motor bruxism descriptions and distinction between awake and sleep
al, 2020; Lobbezoo F et al, 2013; Jiménez-Silva A et al, 2017; Camparis CM et al, bruxism.
2006; Manfredini D et al, 2023.
The association between bruxism and TMD remains unclear. Evidence is equivocal. MODERATE RECOMMENDATION, MODERATE
QUALITY EVIDENCE.

Masticatory muscle activity in terms of bruxism is most likely not enough to cause the MODERATE RECOMMENDATION, LOW QUALITY
onset or persistence of musculoskeletal pain in the absence of other risk factors. EVIDENCE.
 STAB and the Bruxism Screener (BruxScreen) may be available in the near future to
support identification of bruxism as part of TMD assessment in appropriate
individuals.

Otological
Omidvar S et al, 2019; Skog C et al, 2018; Bousema EJ et al, 2018; Porto De Exploring otological signs in those who complain from temporomandibular disorders STRONG RECOMMENDATION MODERATE QUALITY
Toledo I et al, 2017; Jose MR et al, 2014; Jose MR et al 2015; Mottaghi A et al, should be encouraged. Referral to ENT for assessment of positive findings should be EVIDENCE
2019; Stechman-Neto J et al, 2016; Stepan L et al, 2017; Hernandez-Nuno de la considered on an individual basis.
Rosa MF et al, 2021.
TMD and Sleep
Dreweck FDS et al, 2020; Jiménez-Silva A et al, 2017; Da Silva CAG et al, 2020; Sleep quality and painful TMD have a reciprocal relationship, sleep quality and MODERATE RECOMMENDATION, MODERATE
Al-Jewair T et al, 2021; Shibeika D et al, 2019; Roithmann CC et al, 2021; Burr quantity should be appraised at assessment and sleep hygiene advice provided for EVIDENCE
MR et al, 2021; Alessandri-Bonetti A et al, 2019; Alessandri-Bonetti A et al, those who need additional support.
2020; Sommer I et al, 2015; Veiga DM et al, 2013.

Obstructive sleep apnoea

Lobbezoo F et al, 2020; Manfredini D et al, 2023; Pala Mendes AT et al, 2022; There is an increased incidence of TMD in those with obstructive sleep apnoea STRONG RECOMMENDATIONS, MODERATE QUALITY
Kang JH et al, 2022; Alessandri-Bonetti A et al, 2019; Sanders AE et al, 2013; EVIDENCE
Alessandri-Bonetti A et al, 2021; Pivetta B et al, 2021; Chung F et al, 2016; Dental teams should be aware of signs, symptoms and risk factors for obstructive
Solecka et al, 2022; Miller et al, 2018; Prasad et al, 2017; Silva et at, 2011; sleep apnoea given its potentially life-threatening nature and facilitate formal medical
Bernhardt et al, 2020. assessment and appropriate management of this condition as required noting its
importance and risk of morbidity and mortality.
Other: Langaliya A et al, 2023[30]; Alessandri-Bonetti A et al, 2023; NICE, 2021;
Ramar et al, 2015[31] STOP-BANG questionnaire can support screening for obstructive sleep apnoea in the
dental setting and in TMD patients.

Obesity
Wang et al, 2023; Chin et al, 2019; Green et al, 2015; Narouze and The prevalence of pain has been shown to be higher in obese populations. MODERATE RECOMMENDATIONS MODERATE
Souzdalnitski, 2015; Minervini et al, 2023; QUALITY EVIDENCE
Obese individuals demonstrate reduced pressure-pain thresholds, reduced pain
tolerance and higher pain sensitivity.

No positive association demonstrated between obesity and TMD at this time.

Positive weight management has been shown to beneficially impact pain intensity,
pain related disability and health related quality of life measures in some persistent
pain conditions, including primary headache conditions, known to be comorbid with
TMD. It also plays a role in helping manage sleep apnea.

Support and advice pertaining to healthy lifestyle habits should be routinely offered
to all patients as part of holistic care model
Hormones
Turner et al, 2011; Cheng et al, 2000; Berger et al, 2015; Okuda et al, 1996; Oestrogen deficiency has been associated with structural changes within the STRONG RECOMMENDATION MODERATE QUALITY
Wang et al, 2008; Lora et al 2016; Robinson et al, 2020; Nekora-Azak et al, temporomandibular joint in animal models. EVIDENCE
2008.
Oestrogen is thought to influence pain regulatory mechanisms both peripherally and MODERATE RECOMMENDATIONS MODERATE
centrally. QUALITY EVIDENCE

Evidence between oestrogen levels and TMD presentation is contradictory.

Studies involving pharmacological stabilization of oestrogen levels fail to demonstrate STRONG RECOMMENATIONS MODERATE QUALITY
improved outcomes when compared to self-management alone. EVIDENCE

Association between oestrogen and TMD is not clear at this time.

Assessment / Diagnosis / Imaging
Massaroto Barros B et al, 2020; Moreira A et al, 2021; Borges REA et al, 2021; The literature is unable to provide evidence to support the reliability and diagnostic STRONG RECOMMENDATION LOW QUALITY
de Melo DP et al, 2018; Costantinides F et al, 2020; Al-Saleh MA et al, 2016; validity of the joint vibration analysis, infrared thermography, or assessment of EVIDENCE
Abdalla-Aslan R et al, 2021; Al-Belasy FA et al, 2018; Almeida FT et al, 2019; Su electromyographic activity for TMD.
N et al, 2018; Fathima N et al, 2019; Gonzalez-Gonzalez AM et al, 2021;
Hilgenberg-Sydney PB et al, 2018; Lopez Panos R et al, 2019; Meng H et al, Routine imaging for diagnostic or management initiation for TMD is not advocated. STRONG RECOMMENDATION MODERATE EVIDENCE
2021; Naeije M et al, 2013; Olchowy A et al, 2020; Pelai EB et al, 2020; Sharma
S et al, 2013; Olchowy A et al, 2020.
In cases where imaging is justified CBCT is most accurate for DJD, US and MRI for MODERATE RECOMMENDATION MODERATE
Other: Schiffman E et al, 2014; Durham J et al, 2015; Durham J et al, 2011; internal derangements. EVIDENCE
Durham J et al, 2010; NICE [NG193] 2021; Woefel J b et al, 2014; Crawford C E
et al, 2022; Kroenke K et al, 2009; Lövgren a et al, 2016; Von Korff M et al,
1992; Bag a K at al, 2014; Mallya S M et al 2002
Supported Self-management
Aggarwal VR et al, 2019; Durham J et al, 2016; Storey WP et al, 2016; Supported self-management plan essential for all TMD patients. No reported adverse STRONG RECOMMENDATIONS BASED ON
Randhawa K et al, 2016; Kotiranta U et al, 2014; Miake-Lye I et al, 2016; Butts R effects of SM suggesting favourable risk: benefit ratio. MODERATE QUALITY EVIDENCE
et al, 2017; de Freitas RF et al, 2013, Palmer J et al, 2023; Aggarwal VR et al,
2021; . Self-management plans should be regularly reviewed and adapted subject to
changing pattern across course of individuals TMD.
Other: Peters S et al, 2015
Core components of supported self-management package

1. Education (Condition and appropriate analgesic use)

2. Self-exercise therapy
3. Thermal modalities
4. Self-massage therapy
5. Diet and nutrition
6. Parafunctional behavior
Psychological management
Kotiranta U et al, 2014; Roldán-Barraza C et al, 2014; Randhawa K et al, 2016; Biopsychosocial approach to management for TMD essential for positive outcome. STRONG RECOMMENDATIONS BASED ON
Penlington C et al, 2022; Häggman-Henrikson B et al, 2020; Kotiranta U et al, MODERATE/LOW QUALITY EVIDENCE
2014; Zhang Y et al, 2015; Galvez-Sánchez CM et al, 2021; Roldán-Barraza C et Psychological therapies show benefit in reduction of distress and pain intensity. Low
al, 2014; Randhawa K et al, 2016. risk of adverse events from psychological therapies.

Other: Peters S et al, 2015; NICE Depression in adults: treatment and Individuals displaying high psychosocial burden should receive specialist psychosocial
management 2022; Magesty R A, 2021 assessment and management to support their condition.

Manual therapy/physiotherapy /exercise/diet modification

de Melo LA et al, 2020; Armijo-Olivo S et al, 2016; Herrera-Valencia A et al, Manual therapy, mobility exercises (encouragement of normal functional jaw STRONG RECOMMENDATION MODERATE EVIDENCE
2020; Asquini, G. et al, 2021; Alves BM et al, 2013; van der Meer HA et al, movement), postural training, physiotherapy and therapeutic exercises should be
2020; Zhang L et al, 2021; Paco M et al, 2016; de Melo LA et al, 2020; Armijo- considered for all types of TMD.
Olivo S et al, 2016; Órla G et al, 2020; Calixtre LB et al, 2015; Amorim CSM et al,
2017; La Touche R et al, 2020; Brantingham JW et al, 2013; Dickerson SM et al, Physiotherapy, mobility or a mixed approach to exercise therapies may lead to MODERATE RECOMMENDATION MODERATE
2017 La Touche R et al, 2022. decreased pain and increased range of jaw movement. EVIDENCE

Low levels of adverse events from physiotherapy, postural training, manual

Other: Michelotti A et al, 2005; Wright E K G, 2020; Wänman A and Marklund STRONG RECOMMENDATION STRONG EVIDENCE
therapy support its use for patients whose TMD is not well controlled despite positive
S, 2020; Edwards D C, 2021; Nijs J et al, 2020; Lewis J A et al 2021; Nicolakis P
self-management strategies.
et al, 2002; Magesty R A, 2021
For individuals living with TMD building a routine of myofascial release and massage MODERATE RECOMMENDATION MODERATE
techniques twice daily as a component daily management is likely to provide EVIDENCE
symptomatic relief in the short and long term.

Acupuncture/electroacupuncture/dry needling/laser acupuncture

Sung SH et al, 2021; Fernandes AC et al, 2017; Peixoto KO et al, 2021; Evidence suggests acupuncture as an adjunctive treatment for individuals with STRONG RECOMMENDATION MODERATE EVIDENCE
Wu JY et al, 2017; Machado E et al, 2018; Vier C et al, 2018; Nowak Z et al, muscular TMD is likely to have a positive effect on pain symptoms.
2021; Gijon-Soriano AL et al, 2020; Liu G-F et al, 2021.
Referral for acupuncture either through NHS referral if available locally or privately by MODERATE RECOMMENDATION BASED ON EXPERT
Other: McMillan A S et al, 1997; Venancio Rde A et al, 2009 acupuncturist trained for orofacial pain management should be encouraged for those OPINION
with muscular TMD.
Splint therapy
Zhang C et al, 2016; Riley P et al, 2020; Zhang L et al, 2021; Kuzmanovic Pficer J Splint should be provided for myofascial TMDs, headache attributed to TMD or MODERATE RECOMMENDATION BASED ON
et al, 2017; Manrriquez SL et al, 2021; de Moraes Melo Neto CL et al, 2022[32]; individuals with TMD and concomitant headache but should not be used in isolation. MODERATE EVIDENCE
Fouda Atef Abdel Hameed. 2020.
Splints should not be provided to manage joint noises as a result of intra-articular STRONG RECOMMENDATIONS BASED ON
Other: Greene C S and Menchel H F, 2018; Moufti M A et al, 2007; Truelove E, TMD. MODERATE EVIDENCE
2006; Seifeldin S A and Elhayes K A, 2015; Poorna T A et al 2022
Full coverage splints only to be considered to prevent unfavourable dento-alveolar
compensation.

No evidence of increased efficacy between splint types (LSS/stabalisation splint). GDP

should provide splint of a design they feel comfortable providing and maintaining.

Where tolerated splint use should be prescribed for at least 3 months to assess full
benefit. If splints worsen discomfort their use should be ceased.

Once TMD stabilised splint use can be reduced to intermittent use to manage cyclical
symptomatic flair up.

Splints should not be provided to individuals with active dental disease (active decay, STRONG RECOMMENDATIONS BASED ON EXPERT
unstable periodontal condition) as risk of use outweigh potential benefits. OPINION

Low level laser therapy /photo biomodulation

Xu GZ et al, 2018; Sobral AP et al, 2021; Tuner J et al, 2019; Ren H et al, 2021; LLLT and photo biomodulation may offer benefit to myofascial TMD but the certainty WEAK RECOMMENDATION BASED ON MODERATE
Herpich CM et al, 2015; Ahmad S A, et al, 2021. of the effect is low. EVIDENCE
Pharmacological management
Mena M et al, 2020; Häggman-Henrikson B et al, 2017; Florent B et al, 2021; Topical application of medicaments externally over the TMD, if completed safely with WEAK RECOMMENDATION VERY LOW-QUALITY
Januzzi E et al, 2013; Kulkarni S et al, 2020; Kulkarni S et al, 2019; appropriate patch test pre-application is unlikely to be detrimental but may offer EVIDENCE
Nouged E et al, 2019; Srinivasulu Y et al, 2020. Pablo et al, 2007. mild, short-term relief in come TMD cases. Certainty of benefit of topical agents is
very low.
Other: Poluha R L et al, 2018; McMillan A S et al, 1997; Venancio Rde A et al,
2009; Oral NSAIDs are likely to positively affect pain reduction in the TMJ and masticatory MODERATE RECOMMENDATION MODERATE
muscles and range of jaw movement. Due to side effects, they are suitable for short EVIDENCE
term use during times of acute exacerbation only.

Duloxetine may be more efficacious at reducing pain for persistent TMD cases. Side WEAK RECOMMENDATION BASED ON LOW QUALITY
effect profile of duloxetine is advantageous over amitriptyline EVIDENCE
Botulinum toxin A
Thambar S et al, 2020; Machado D et al, 2019; Patel J et al, 2019; Ahmed S et Conservative options, such as self-management with explanation and physical MODERATE EVIDENCE OF BENEFICIAL EFFECT
al, 2019; Awan KH et al, 2019; Islam S, 2016; Khalifeh M et al, 2016; Losada therapies, should be exhausted first.
DCN et al, 2021; Moussa et al, 2023. STRONG RECOMMENDATION THAT BOTOX IS NOT A
FIRST LINE MANAGEMENT STRATEGY AND THAT
Other: Shofiq I 2016; De La Torre Canales G et al, 2020; Kűn-Darbois J D et al SHARED DECISION-MAKING AND INFORMED
2015; Venancio Rde A et al, 2009 CONSENT IS ENGAGED IN WITH PATIENTS,
PARTICULARLY WITH RESPECT TO CURRENT LACK OF
UNDERSTANDING ABOUT: THE SIGNIFICANCE OF
BONY CHANGES IN CONDYLE; DOSING SCHEDULE
AND END OF TREATMENT; (SUB-)POPULATION OF
PATIENTS WHO WILL BENEFIT.
Surgical Management
Goiato MC et al, 2016; Sabado-Bundo H et al, 2021; Goker F et al, 2021; Surgical managements not indicated for myogenous pain. STRONG RECOMMENDATIONS BASED ON
Iturriaga V et al, 2017; Bouchard C et al, 2017; Vos LM et al, 2013; Moldez MA MODERATE EVIDENCE
et al, 2017; Liapaki A et al, 2021; Ferreira N et al, 2018; Al-Hamed FS et al, There are a number of situations where surgical intervention may be
2021; Leung YY et al, 2020; Bousnaki M et al, 2017; Bermell-Baviera A et al, appropriate namely, severe arthrogenous TMD and disc displacement without
2015; Davoudi A et al, 2018; Guarda-Nardini L et al, 2021; Gutiérrez IQ et al, reduction.
2021; Abrahamsson H et al, 2020; Al-Moraissi EA, 2015; Al-Moraissi EA et al,
2015; Ma J et al, 2015; Tocaciu S et al, 2019; Varedi P et al, 2015; Al-Moraissi Where surgical management is advocated, it should be provided as an adjunct to
EA et al, 2017; De Roo N et al, 2016; Mittal N et al, 2019; Sakalys D et al, 2020; SSM and conservative treatment strategies and not as a sole or first line option.
Hu Y et al, 2020; Liu S et al, 2021; Machado E et al, 2013; Nagori SA et al, 2018;
Nagori SA et al, 2021; Nogueira EFC et al, 2021. If justified intra-articular injection using hyaluronic acid or platelet rich plasma
most likely to provide benefit over other medicaments.

Remote delivery of intervention

Walumbe J et al, 2020; Fernandes LG et al, 2022; Flodgren G et al, 2015. Remote delivery provides an opportunity for TMD patients to receive appropriate MODERATE RECOMMENDATION LOW QUALITY
targeted TMD pain management programmes and early intervention which has the EVIDENCE
potential to revolutionise care. Programmes would need to be adequately planned,
staff appropriately trained and access requirements for patients considered.

Tailored treatment/ MDT management

Kotiranta U et al, 2014; Dworkin, 2002 Utilising the entire clinical dental team to support pain management for patients STRONG RECOMMENDATION MODERATE EVIDENCE
living with persistent TMD patients would improve access to care, reinforce self-
management strategies and provide increased potential for positive impact on pain
and pain related disability.
Other
Porporatti AL et al, 2019; Talaván-Serna J et al, 2017; Bitiniene D et al, 2018; For individuals who live with or who are at risk of TMD additional care should be MODERATE RECOMMENDATION, LOW QUALTY
Carla Branco et al, 2021; Campos DES et al, 2021; Gewandter JS et al, 2015; taken to protect the TMJ complex during procedures which involve sedation or EVIDENCE
Helgeland E et al, 2018; Song YL et al, 2018; Yadav S et al, 2018; general anaesthesia due to drop in muscle tone caused by the drugs employed and
Herrero Babiloni A et al, 2018; Allison J et al, 2023; Tran et al, 2022. because of airway management manoeuvre’s involving the joint
Intra-articular TMDs
Al-Baghdadi et al, 2014; Al-Baghdadi M et al, 2014; Schiffman E L et al, 2014; Favourable expected natural course for disc displacements STRONG RECOMMENDATIONS BASED ON HIGH
Schiffman E L et al, 2013; Diraçoğlu D et al, 2009; Emshoff R. et al, 2005; QUALITY EVIDENCE
Yoshida H et al, 2005. No significant difference between non-invasive and more invasive treatment
modalities suggesting DDwoR should be managed in first instance with conservative
strategies escalating to more invasive treatments only if objective clinical need.

Arthrocentesis is more successful in subjects who are <25 years old and who exhibit
VAS pain scores >75 mm with MMO <25mm.
10.Background

TMD have a biopsychosocial aetiology with several perpetuating, predisposing, or precipitating factors with no single
‘cause’ identified (Figure 1).

Figure 1: Schematic summarizing the biopsychosocial model of TMD and examples of precipitating, predisposing and
potentiating factors.

Genetic and phenotypic vulnerability for TMD is not the same as causation and may therefore not directly link to the
development of TMD, nor always accurately predict its course or outcome. The current understanding, as
demonstrated by Figure 1, is that multiple biopsychosocial predisposing, precipitating, and perpetuating factors
interplay to result in painful TMD arising and being maintained in an individual. These can include a diverse range of
factors including: polymorphisms in Catechol-O-methyltransferase (COMT) associated with TMD [1, 33, 34];
functional changes with pain processing e.g., generalized hyper-excitability in the central nervous system [1, 35-38]
and then a combination of behavioural changes such as seeking physical interventions, and/or attempts to fight or
ignore pain may perpetuate the pain. Another individual may have phenotypic vulnerability in the form of pre-
existing widespread body pain, precipitation may result from a known mandibular clenching habit whilst
perpetuation may involve disruption to homeostatic patterns of sleep and activity. For readers who would like to
read more on pain pathways and processes, there is a freely accessible resource from NHS England (e-Learning for
health care, free once registered with the relevant healthcare regulator’s registration number) which has two dental-
specific modules on pain in the trigeminal system in e-Den Module 3: physiological and anatomical basis of pain;
central mediators of pain.
Comorbidities

There are several comorbidities consistently associated with persistent painful TMD that can be associated with a
poorer prognostic outcome (Table 4).[1, 39-44] Where a comorbidity exists management of TMD in isolation may be
less successful, but this does not mean that simpler management strategies should immediately be omitted as they
also serve as a foundation for more complex management. Dentally trained clinicians are not expected to manage
comorbidities but should be able to:

1. Identify comorbidities in an individual presenting with TMD through an appropriate history taking process.
2. Discuss comorbidities with the individual presenting with TMD.
3. Initiate access to management for comorbidity through referral to appropriate service which patients’ GPs
may gate-keep.

Table 4: Comorbid conditions associated with persistent painful TMD that may be associated with a poorer
prognosis[1, 39-44]

Systemic pain Psychological Primary headache Regional pain

comorbidities comorbidities comorbidities* comorbidities
Fibromyalgia Depression Migraine Irritable bowel syndrome
Myalgic Anxiety Chronic tension type Vulvodynia
Encephalomyelitis headache
/Chronic Fatigue
Syndrome
Inflammatory Arthritis Post-Traumatic Stress Interstitial cystitis/Painful
Disorder bladder syndrome
Endometriosis
Chronic lower back pain
*At present some of the other primary headache disorders such as Cluster headache and Paroxysmal hemicrania (Appendix 1) do not have a
proven association with painful TMD, however it is not unreasonable to hypothesise that they might. They are, however, rare but are always
worth considering if autonomic signs and symptoms co-present with more classical signs and symptoms of painful TMD. Please see headache
section following for guidance on how to seek further opinions/management in this instance.
Bruxism

Bruxism is repetitive masticatory muscle activity, characterised by clenching, grinding, bracing or thrusting, with or
without tooth contact. [45] Signs and symptoms suggestive of bruxism include, but are not limited to: masseteric
hypertrophy, reported clenching/grinding habit (self or family/friend/colleague), indentations and/or traumatic
lesions of intra oral soft tissues, evidence of occlusal wear or fracture of the dentition/restorations.[46] Bruxism
which occurs during sleep is termed sleep bruxism, and most commonly presents as grinding.[47, 48] When present
in the day it is defined as awake bruxism and most commonly involves clenching. [47, 48] Interestingly it seems that
individuals either present with awake or sleep bruxism and not both conditions. [47]

In otherwise healthy individuals’ bruxism is no longer considered a parafunctional activity or disorder but a
behaviour, which may act as a risk factor, or protective mechanism, for several clinical consequences e.g., tooth
wear, tooth fracture.[48-50]The relationship between bruxism and TMD is complex, and robust conclusions as to the
association of awake or sleep bruxism and TMD cannot be made at this time. [46, 48, 51-54] A direct causal
relationship between bruxism and TMD has not been confirmed.[48, 51, 54] Current evidence seems to suggest that
though in some individuals' bruxism may form one component of the multifactorial aetiology of TMD, bruxism in
isolation is unlikely to be responsible for onset or persistence of TMD pain in the absence of other risk factors. [45,
47, 52]

Obesity

The growing epidemic of obesity is a global health concern leading to increased risk of health conditions associated
with high levels of morbidity and mortality e.g., diabetes, stroke. [55] The prevalence of pain has been shown to be
higher in obese populations, with obese individuals demonstrating reduced pressure-pain thresholds, reduced pain
tolerance and higher pain sensitivity. [56-59] Surprisingly recent research exploring the relationship between obesity
and TMD does not demonstrate a positive association.[55, 60] One recent meta-analysis displayed the opposite, risk
of TMD significantly decreased in obese compared to normal weight individuals, and at the present time evidence
suggests that obesity appears not to be associated with increased risk of TMD.[60]

Positive weight management has been shown to beneficially impact pain intensity, pain related disability and health
related quality of life measures in some persistent pain conditions, including primary headache conditions, known to
be comorbid with TMD. [56, 57, 60] As with managing any chronic illness, with or without other comorbidities, a
holistic approach is advised when it is possible to appropriately support patients in this process. It is also important
to note the role of weight management in obstructive sleep apnoea which can be comorbid with TMD. Though the
certainty of the effect of weight management on TMD pain is currently low, support and advice pertaining to healthy
lifestyle habits should be routinely offered to all patients as part of a holistic care model.
Hormones

Oestrogen continues to be of interest when considering the pathogenesis of TMD due to the sex disparity shown in
TMD prevalence.[61] Oestrogen deficiency has been associated with structural changes within the
temporomandibular joint in animal models.[62-65] Furthermore, oestrogen is thought to influence pain regulatory
mechanisms both peripherally and centrally.[64] Despite such findings evidence between oestrogen levels and TMD
presentation is contradictory and studies involving pharmacological stabilization of oestrogen levels failed to
demonstrate improved outcomes when compared to self-management alone. [61, 65-68]Firm conclusions as to the
relationship cannot be drawn at the present stage.

Section 10 key points:

- Exclude other important or ‘red flag’ conditions by a through screening during the history
- Be aware of and describe painful TMD’s aetiology as multifactorial and biopsychosocial without one key
factor being identified as having a predominant association with painful TMD

11.History

TMD should be considered as a persistent health condition rather than an isolated dental condition. It is therefore
important for dental clinicians to be able to undertake a thorough history to allow identification of the physical
symptoms of TMD and related social and psychological factors that may be contributory. Undertaking a thorough
history will allow the dental clinician to identify those individuals who are at a higher risk of progressing to persistent
painful TMD.

Physical Symptoms of TMD

Common physical signs and symptoms of TMD are: pain in and around the TMJ and, or muscles of mastication, which
can worsen with jaw function (eating, chewing, teeth grinding/ clenching) and may be precipitated by touch to these
areas; joint noises (click, pop, crepitus [rustling or grinding]); restricted joint mobility.[1, 2]

Verbal exploration of pain intensity and of other comorbidities should be undertaken to ensure that a thorough
history is taken which will provide prognostic indication. Patients should be asked about pain in other areas of their
body and an exploration of any diagnosed conditions which are comorbid with persistent painful TMD (Table 4)
should be undertaken.

Clinicians should be aware of other physical presenting features including headaches and otological (ear) symptoms
such as otalgia (ear pain) and tinnitus.[2, 69-72] Dental extra and intra oral clinical examination is less likely to
provide additional information for such symptoms. It is therefore advised that consultation for any individual
presenting with TMD should include brief headache and ear symptom exploration.

Headache

Verbal brief exploration of headache symptoms should be completed, Appendix 1 outlines guidance on headache
questions which may aid consultation. Advice should be provided to individuals with positive headache findings
which do not appear to be related to TMD to seek attention from their medical practitioner should headache
symptoms persist or worsen. Appendix 2 provides an example letter which GDPs could utilize to aid onward
information transfer to GP.

Ear symptoms

Verbal brief exploration of ear symptoms (if present) should be undertaken. If ear symptoms form a major
presenting feature, pathology affecting the ear should be ruled out by GP in first instance or ear, nose and throat
(ENT) specialist should GP feel it is appropriate. Template letter to support referral to GP for ear related symptoms is
provided in Appendix 3. It is important to note that managing TMD will not necessarily reduce or eliminate ear-
based symptoms. Conversely, if a GP +/- ENT specialist has ruled out ear pathology consideration of TMD or
odontogenic pain as potential differential diagnoses and subsequent direction to GDP for further assessment is
sensible.

Psychological and Social Presenting Factors

Consultation should include assessment of psychological and social factors that can increase the risk of symptomatic
TMD becoming persistent. Careful observation and listening will frequently spotlight concerns about symptoms as
well as impact on mood, sleep, social activities and eating which are commonly present. Such impacts are often
caused by the pain and can also become powerful maintenance factors if they are not independently addressed.

From a social perspective people with painful TMD are often in intense pain and can feel invalidated and dismissed
unless this experience is recognised and explicitly acknowledged, leading to the possibility of feeling they need to
consult other practitioners to search for answers. In order for conservative management to be helpful it is important
that the patient can feel that their experiences have been acknowledged and understood. A plausible explanation is
important, both for the person themselves and also to share with family, friends and colleagues who might find it
difficult to understand the pain and how they can help.
Box 1: Template history for TMD

Complaint
[Can give suggestions for character of pain if patient struggling e.g., achy, throbby]

History of complaint (SOCRATEESS)

Site:

Onset:

Character:

Radiation/referral:

Associations with other symptoms:

• Joint noise Yes / No (provide detail if yes)
• Jaw lock – Open / Closed / None
• Headache associated: Yes / No (provide detail if yes)
• Ear symptoms: Yes / No (provide detail if yes)
• Other:

Time course:
[e.g., constant, intermittent]

Exacerbators/relievers:

Effects on everyday life?

Severity of pain out of 10 (10 worst imaginable):

Sleep – affected?
[e.g., woken from sleep or difficult to get to sleep with pain]

Psychological or social presenting factors?

[e.g., stressful work of home life, impact on mood or sleep?]

Any red flag signs or symptoms? Yes / No (Provide detail if yes)

Presence of comorbid conditions? Yes / No (Provide detail if yes)

Section 11 key points:

- Take a standardized pain history but be alert for comorbid headache arising within the history.
- Explore any ear symptoms to exclude the need for a further opinion from patient’s GP.
12.Examination

Every part of the consultation for a persistent pain condition should be person-centered.[21] Whilst a physical
examination is important to reach a physical diagnosis it is equally important throughout the consultation to be
aware of any psychological and social impacts and triggers.[21, 73, 74] This then allows the clinician to build up a
multidimensional perspective of the patient’s problem.[21]

Physical Examination

Clinical examination of an individual with suspected or known TMD should include visual examination of the extra-
oral tissues of the face and neck; palpation to rule out lymphadenopathy or salivary gland masses; intraoral
examination assessing for soft tissue pathology and clinical +/- radiological assessment of the dentition to rule out
dental or periodontal pathology.[10, 24] Assessment of cranial nerve function provides formal examination for a
focal neurological deficit. In cases of suspected TMD at the facial and trigeminal nerves should be tested as a
minimum in primary care whilst in specialist services all cranial nerves may be examined.[10] A revision resource to
support cranial nerve examination is available here. [75]

Examination of TMJ and muscles of mastication (MOM)

TMJ and MOM should be assessed clinically for “familiar” pain i.e., pain which is representative of the individual’s
normal pain.[5] If identified familiar pain helps to guide diagnosis as the structure that is painful is likely the origin of
the pain e.g., masseter palpation provokes familiar pain means it is likely a myogenous TMD at least in part. Familiar
pain also helps reduce the risk of false positives elsewhere in the examination creating a misdiagnosis. [5]

TMJ

The TMJ should be examined by palpating its lateral pole whilst normal functional mandibular movements (opening,
closing, protrusion and lateral excursions) are completed 3 times.[5] “Familiar” response during any single cycle of
movement represents a positive finding.[5] A record of deviation of mandibular opening and any mandibular motion
which is out of the normal ranges, shown in Table 5, should be documented. Such records aid diagnosis and allows
formative assessment of the condition longitudinally.
Table 5: Normal mandibular opening ranges. Table generated from information in [5, 76]

Motion Normala
Maximal unassisted inter incisal openingb ≥35mm
Protrusion 7 – 12 mm
Lateral Excursion 7 – 12 mm
aFor those concerned by trismus of an unknown cause a helpful screening tool is available ‘The Trismus checklist’[77, 78] a modified version of
which is available within Appendix 4.

b Reliable inter-incisal measurements are more difficult in those who are edentulous or partially dentate and there is no gold standard
proposed. For those who have well-fitting dentures with pontics of a size and shape representative of the natural dentition, inter-incisal
opening can be measured with dentures in situ, or adjacent natural teeth can be used e.g., incisal edge of lateral incisors. [79]

Joint noises

Whist palpating the TMJ through normal functional mandibular movement, joint noises should be felt and listened
for. Joint noises can be challenging to detect, and presentation may be sporadic.[5] To account for this, joint noises
can be documented as positive during clinical examination if the patient self-reports hearing joint noise(s) in the last
30 days and/or noise is heard by patient or clinician during examination. [5] Presence of noise, type of noise (click,
pop, crepitus) and location of noise (side and point in opening/closing cycle) should be documented. The prevalence
of asymptomatic (pain-free) disc displacement with reduction is around 1 in 3 (12-35%) of the population, joint
noises therefore will be detected in asymptomatic individuals.[80] In such situations reassurance only should be
provided, treatment to manage joint noise without pain is not justifiable as it cannot be guaranteed to eliminate
noise.
Muscles of mastication

Temporalis and masseter should be palpated from origin to insertion with masseter palpated bimanually (index
finger extra oral and thumb intra-oral) (Figure 2) [5]. Presence of “familiar pain” on palpation, the location of the
pain within the muscle and any radiation of this pain should be documented. Palpation of other muscles of
mastication e.g., lateral pterygoid and medial pterygoid has not been shown to improve diagnostic accuracy and so is
only advised when pain location is anatomically mapped directly to the muscle(s) of concern.[5]

Figure 2: Example photographs demonstrating technique for bimanual palpation of masseter.

Palpation of superior aspect (a), body (b) and inferior aspect (c) of masseter

Note: Index finger intra-orally, thumb extra orally allowing accurate masseteric palpation between the digits.
Psychological and Social Assessment

Social history

Taking a social history is good practice for routine clinical care however, for individuals at risk of a persistent pain
condition, an understanding of their social situation provides vital information. Who does an individual live with?
Who supports them? Have they explained their issues with any family or friends? What social stresses may they be
exposed to which could perpetuate their condition? Dependents (young and old in their care), employment or
unemployment concerns, financial worries, limited social support? Do they have concerns that their pain is affecting
others around them? Documentation of salient findings with relevance to TMD ensures holistic support for the
individual.

Patient Health Questionnaire 4 (PHQ4) [81] – Formative screening of anxiety and

depression

PHQ4 is a 4-item patient health questionnaire which supports recognition of symptoms of anxiety and depression,
supporting the biopsychosocial management of TMD.[81] It is advised that this questionnaire is completed in any
individual suspected of TMD in the first consultation and the results documented in the patient’s notes. Appendix 5
outlines PHQ4 questions and scoring. Scores are rated as: Normal (0-2), Mild (3-5), Moderate (6-8), and Severe (9-
12).[81] PHQ4 scores representative of symptoms of severe anxiety and/or depression (score 9-12) may warrant
early onward referral, further details are outlined in table 4 of this document. Appendix 6 provides additional
information with regards to mental health extremis and suicidal ideation.

Sleep

Sleep quality and painful TMD have a reciprocal relationship, sleep quality and quantity should be briefly discussed
with sign-posting to sleep hygiene advice provided for those who need additional support (Appendix 7).[53, 82-87]
For frank sleep disorders sleep hygiene advice will not be beneficial so any individual with significant sleep issues
should be advised to discuss this with their GP.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a sleep related breathing disorder associated with high levels of morbidity and
mortality.[88-92] Unfortunately, a significant number of those with OSA are undiagnosed and untreated and this can
result in life-threatening consequences. [93, 94] TMD has been shown to be more prevalent in those with OSA when
compared to the general population, a relationship clinicians should be aware of. [89, 95-97] Signs and symptoms
that may be suggestive of OSA (Box 2) include: excessive daytime sleepiness, morning headache, mood changes,
difficulty concentrating, bed partner reports gasping, snorting, choking noises, or stopping breathing during sleep. It
is important to explore these types of symptoms given the morbidity and mortality associated with this condition.
Any suspicion of OSA should trigger prompt referral to the individual's GP for assessment and management (table 7
and appendix 8). Management of OSA is guided by NICE guidelines (NICE 2021, NG202) and dependent on severity
ranges from lifestyle advice (foundation for all other management), through mandibular advancement splints, to
continuous positive airway pressure ventilation at night. [54] The STOP-bang questionnaire (included in appendix 8)
will provide an accurate, more formal OSA screening assessment, supporting onward referral. [93, 94, 98-102].

Box 2: Risk factors, signs and symptoms for obstructive sleep apnoea

Risk factors
Male
BMI >35 kg/m2
Age >50
Neck circumference > 16 inches (40 cm)
Hypertension

Signs and symptoms

Loud snoring
Observed episodes where breathing stops when asleep
Gasping, snorting or choking noises in sleep
Repeated night waking
Insomnia
Morning headaches
Excessive daytime sleepiness (hypersomnia)
Fatigue
Daytime concentration difficulties
Mood swings
 Section 12 key points:
- Elicit familiar pain to help attribute the origin of the pain and form a diagnosis
- Be aware of the range of ‘normal’ jaw movements
- Be mindful of risk of OSA in painful TMD and if suspicious it may be comorbid consider use of STOP-BANG
and liaison with patient’s GP
- Consider risk of suicide and do not be afraid to explore with patient if this is mentioned as you will not
increase their risk. The whole dental team may wish to consider completing the free basic level training
from the NHS on suicide awareness: Zero Suicide Alliance ‘Gateway’ module.

13.Further investigations

3 question TMD screener (3Q/TMD)[103]

The use of 3 screening questions in the primary care setting (3Q/TMD, Appendix 5) supports screening of individuals
presenting with painful TMD in relation to the DC/TMD. [103] Its use is advised to support clinical history and
examination findings and increase reliability when diagnosing individuals with painful TMD.

Characteristic Pain Intensity (CPI)[104]

The Characteristic pain intensity questions shown in Appendix 5 provides a numeric rating representing an
individual’s average pain score over the last 30 days ranging from 0 (lowest) to 100 (highest). It is advised that this is
recorded at first assessment and all subsequent reviews (Appendix 9) to formatively assess pain intensity.

Imaging

Plain film radiographic imaging of dentulous and edentulous regions may form a component of detailed investigation
to identify sources of odontogenic pain or referred pain which may mimic TMD.[105] Routine use of ionizing imaging
of the TMJ, specifically for diagnosis of painful TMD is not advocated and the appropriateness of any imaging should
be determined on a case-to-case basis.[106, 107] Conventional panoramic radiographs have a limited role in
evaluating the TMJ complex [105, 108] They do display gross bony form but condylar distortion, failure to visualize
the anterior surface of the condyle and superimposition of the zygomatic process limits such imaging.[105] In cases
where imaging is justified cone-beam computed tomography (CBCT) or conventional computed tomography (CT)
scanning is more accurate for hard tissue diagnosis of DJD.[105, 108, 109] CBCT offers appropriate image clarity with
lower radiation dose when compared to conventional CT of TMJ and so is preferred where available. The field of
view, however, must include the condyle, glenoid fossa and articular eminence.[105]
For internal derangements magnetic resonance imaging (MRI) is the only modality which accurately depicts position
of the articular disc.[105, 108, 110-112] For adequate diagnostic clarity, thin slice proton density or T1-weighted
images should be taken in multiple dimensions, in closed and open mouth positions.[105, 108] If effusion is
suspected additional T2-weighted imaging should be completed. [105] Contrast should only be utilised for suspected
inflammatory arthropathies or concerns about occult (mimicking) tumours.

Ultrasound scan (US) for internal derangements is a modality currently under investigation.[113, 114] Benefits of US
include lack of radiation dose, its relative low cost, and the fact it is readily available though, as yet, sensitivity and
specificity data to validate its use for TMD is lacking.[113, 114]

Other

The reliability and diagnostic validity of the joint vibration analysis, infrared thermography, ultrasound elastography,
qualitative sensory testing and assessment of electromyographic activity for TMD are unsupported by the current
literature.[115-122]

At present an international team of experts are developing a Standardised Tool for the Assessment of Bruxism
(STAB), including a two-part bruxism screener (BruxScreen) combining a patient completed self-assessment tool and
dental clinical assessment form. [46, 48, 123] Once validated such tools are likely to support identification of those
with bruxism as a component of their TMD and move towards standardized bruxism assessment and management
strategies in the future.

Section 13 key points:

- Remember that physical examination is the mainstay of diagnosis as imaging has the potential for false
positives and negatives. Imaging should therefore be considered an adjunct to a thorough clinical
examination and not a substitute for it.
- Consider use of screening instrument for TMD to help identify it easier and use pain intensity as a basic
patient reported outcome measure.
- Further validation of the BruxScreen may result in a simple and quick screening instrument for bruxism in
the future.
14.Diagnosis

Information gathered from a thorough patient history and comprehensive clinical examination should be used to
provide an individual with a TMD diagnosis at the earliest possible contact. Increased intensity and impact of TMD
symptoms are likely to be associated with delay in provision of a diagnosis or lack of diagnostic certainty.[16]

The internationally recognised Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) support the broad
grouping of the 12 different subtypes of TMD as: [5]
1. Myogenous affecting muscles of mastication.
2. Arthrogenous involving the temporomandibular joint complex.
3. Combination with myogenous and arthrogenous components

It is not unreasonable, outside of specialist units managing persistent orofacial pain regularly, to use the three broad
groupings as outlined above, as a diagnosis. To classify further Table 6 can be used to provide a more specific TMD
subdiagnosis, as per DC/TMD.[5] TMD should be treated as a potentially persistent health condition and not a dental
condition. It should have holistic management and any comorbidities that are related should be outlined in the
diagnosis to strengthen the patient’s appreciation of the relationship between conditions.
E.g.,
• Myogenous TMD affecting bilateral temporalis and comorbid chronic migraine.
• Arthrogenous TMD with comorbid chronic depression.
• Myogenous TMD affecting left masseter and comorbid fibromyalgia.
Table 6: Twelve most common TMD diagnostic subtypes shown in bold, linking clinical history and examination results to diagnosis. Luxation
(italicized) is not one of the 12 most common subtypes but is included for completeness. Adapted from [10], generated from information from[5];
TMD: temporomandibular disorders; TMJ: temporomandibular joint.

Specific findings related to pain or

Clinical history Clinical examination findings Diagnosis Group
complaint
Pain of muscular origin. Myalgia
Confirmation of pain in temporalis or masseter. Pain localised to site of palpation. Local myalgia
Pain in the jaw, temple, in the ear, or in front of the ear.
AND
AND Pain spreads beyond site of palpation but
“Familiar” pain in masseter or temporalis produced during Myofascial pain
Pain modified with jaw movement, function, or parafunction. within boundary of muscle.
examination. Myogenous
Pain reported at a site beyond the
Myofascial pain with referral
boundary of the muscle being palpated.
Headache of any type in the temple.
“Familiar” headache pain in the temple area produced during examination.
AND
AND Headache attributed to TMD
Headache modified with jaw movement, function, or
Confirmation of headache location in the area of temporalis muscles.
parafunction.
Any TMJ noise present with jaw movement or function in the
last 30 days.
Joint noise but no locking. Disc displacement with reduction
OR
Patient reports any TMJ noise during exam. (+/- TMJ pain)
Any TMJ noise present with jaw movement or function in the Clicking, popping, or snapping detected during at least one of
last 30 days. three repetitions of palpating the TMJ on opening/closing,
OR lateral excursion, or protrusion. Jaw locks with limited mouth opening
Disc displacement with reduction with intermittent
Patient reports any TMJ noise during exam. (+/- TMJ pain) even for a moment then unlocks in the
locking
AND last 30 days.
Jaw locks with limited mouth opening, even for a moment, in
the last 30 days.
Disc displacement without reduction with limited
Jaw locking so that mouth would not open all of the way. Maximum assisted opening with passive stretching less than 40 mm. The presence of TMJ noise on
opening
AND examination does not exclude this diagnosis. Arthrogenous
(i.e., “closed lock”)
Limitation in jaw opening severe enough to interfere with ability
Maximum assisted opening with passive stretching more than or equal to 40 mm. The presence of TMJ Disc displacement without reduction without limited
to eat.
noise on examination does not exclude this diagnosis. opening
Any TMJ noise present with jaw movement or function in the
last 30 days. Osteoarthritis and Osteoarthrosis
Crepitus detected during examination.
OR (Degenerative joint disease)
Patient reports any TMJ noise during exam. (+/- TMJ pain)
Self-manoeuvre required by patient to
Jaw locking or catching in a wide-open mouth position in the last Subluxation (i.e., “open lock”)
Positive finding of “open lock,” which requires manipulation (self reduce dislocation.
30 days, even for a moment, so it could not close from the wide-
or clinician) to reduce. Clinician manoeuvre required to reduce
open position (+/- TMJ pain). Luxation (i.e., “open lock”)
dislocation.
Pain in the jaw, temple, in the ear, or in front of the ear. Confirmation of pain in the area of the TMJ.
AND AND Arthralgia
Pain modified with jaw movement, function, or parafunction. “Familiar” pain in the TMJ produced during examination.
15.Early secondary care referral / Adjunctive medical referral
Early secondary care or adjunctive medical referral is advocated in a small number of clinical situations Table 7.
Table 7: Justification for early secondary care referral or adjunctive medical referral
Justification Action and advised referral location
Any positive red flag sign/symptom in history of 2 week-wait1 (if appropriate) or urgent referral to secondary care
clinical examination (see Table 2)
Young (<25 years old) [124] Urgent referral to maxillofacial surgery team for assessment and consideration of early
AND unlocking manoeuvre +/- arthrocentesis.
Substantial decreased mouth opening
(<25mm)[124]
Severe disc displacement without reduction Urgent referral to maxillofacial surgery team for assessment and consideration of early
(closed lock) affecting ability to maintain unlocking manoeuvre +/- arthrocentesis.
nutritional requirements.
Severe arthrogenous TMD with: Early referral to maxillofacial surgery team for assessment and consideration of surgical
• CPI pain score >50 management.
• Dietary restriction due to pain Patient should be counselled that surgery is not appropriate in all cases and referral does not
• Mouth opening <25mm guarantee surgical management will be recommended.
• +/- skeletal and/or occlusal derangement
(e.g., AOB, retrognathia, asymmetry)
Positive headache findings which do not appear TMD management initiated in primary dental setting.
to be related to TMD with no red flag features. Patient advised to discuss with GP should headache symptoms persist, information sharing
letter to GP could be considered if appropriate.
See Appendix 2 for template letter
Positive ear symptoms (pain, tinnitus, fullness) Non urgent referral to GP, requesting ear symptoms are explored comprehensively by medical
which do not appear to be related to TMD with team whilst TMD management initiated in primary dental setting.
no red flag features. See Appendix 3 for template letter
Mental distress and suicidal ideation Urgent (same day) assessment with GP, local CRISIS team or Emergency Department acute
(See Appendix 6) mental health team. Primary care clinician should telephone to arrange urgent assessment and
information share about disclosure.
If concern about immediate risk to life and the patient is not present or leaves abruptly the
clinician should contact 999 requesting police for immediate welfare check and should
telephone GP (if they are not the GP) to information share about disclosure and ensure urgent
follow up.
Positive OSA findings (Box 2) Urgent written referral to GP to assess, diagnose and manage OSA.
See Appendix 8 for template letter including STOP-BANG questionnaire.
AND
The referring clinician in primary care should provide TMD diagnosis and initiate SSM and
make arrangements for appropriate review.
PHQ4 score ≥ 9 [125] Urgent written referral to GP to assess, diagnose and manage anxiety and/or depression.
i.e., Severe anxiety and/or depression symptom See Appendix 10 for template letter.
score AND
The referring clinician in primary care should provide TMD diagnosis and initiate SSM and
make arrangements for appropriate review.
PHQ4 score 3-8 Discuss score with patient, ask if further support with regards to anxiety or depression would
i.e., mild-moderate anxiety and/or depression be helpful and explain it isn’t the cause of TMD but can make it worse and treatments can be
symptom score more effective by managing both. If patients indicate that a psychological assessment would
be helpful, consider advising them that they can search online and self-refer to their local NHS
Talking Therapies for Anxiety and Depression service accessed through this link. With their
permission write to inform their GP of this conversation. Alongside this TMD management
should be initiated in primary care setting. See appendix 10 for template letter

1 At the time of writing the NHS is changing its cancer care pathways through the ‘Faster Diagnosis Framework’. This will remove the ‘two-week rule’ from Oct 2023. This will include a 28-day diagnosis standard which
indicates a patient with suspected cancer should have it ruled out or diagnosed within 28 days. The new pathway for suspected head and neck malignancy will likely therefore demand the same urgency of referral and
bespoke pathway but its details are yet to be confirmed and may depend on local trust protocols. Clinicians are advised to check their local protocols but to remain aware that expedition of all parts of the patient’s
care journey to diagnosis is critical.
16.Management

As for any condition, clinicians should have an awareness of unconscious bias and its ability to impact on TMD
treatment planning and management.[3, 126, 127] Pain in black people has been shown to be underdiagnosed and
undertreated. [3, 126, 127] Clinicians should be aware of this, and steps should be taken to ensure bias does not
influence opportunity or quality of care provided.[3, 126, 127] Management should focus around reversible, non-
invasive conservative care which has been shown to be successful in 75-90% of cases.[12] Emphasis should be placed
on a partnership in management, the individual living with TMD engaging with self-management and practitioner(s)
supporting them in this with adjunctive reversible, non-invasive interventions. It is important to ensure that the
individual understands that without full engagement with self-management there will be no foundation for the
restoration of control over the signs and symptoms of TMD.

Management for TMD is not linear, “failure” of conservative management strategies is not a justification for
initiation of more invasive surgical or pharmacotherapeutic strategies. Similarly, there are a small number of
instances in which referral and consideration of more invasive management strategies may be appropriate at an
early stage, Table 7 and care pathway flow chart (Figure 3) highlight such cases. Following diagnostic confirmation
by an appropriately trained clinician, utilization of the entire clinical dental team to support pain management for
individuals living with TMD would improve access to care, reinforce self-management strategies and provide
increased potential for positive impact on pain and pain related disability. Of equal importance is the recognition of
comorbid illnesses or disorders that have a bearing on management of the painful TMD and appropriate liaison with
the clinician managing that comorbidity. For example, comorbid mental health illness with or without prescription of
psychotropic medications and liaising with the patient’s GP and or Psychiatry team before pursuing pharmacological
management of painful TMD.

Supported self-management.

All individuals diagnosed with painful TMD (any sub diagnosis) should be actively involved in the development of a
supported self-management (SSM) plan with their primary care practitioner. SSM allows an individual to gain
ownership of their condition and take positive steps to manage their own discomfort. SSM has been shown to
support reduction in pain intensity and pain related disability with no reported adverse effects, suggesting favorable
risk: benefit ratio, for low economic cost.[128-136] SSM plans should be regularly reviewed and adapted subject to
changing pattern across course of individuals TMD. Appendix 7 provides links to high quality resources for SSM
which practitioners can use, and patients can be signposted to, in addition to the patient support document
published with this guideline.

Supported self-management should include the following core components, which will address immediate
symptoms and pain exacerbations: [137]
 1. Diagnosis alongside education about condition and appropriate analgesic use
2. Self-exercise therapy
3. Thermal modalities
4. Self-massage therapy
5. Diet and nutrition
6. Parafunctional behavior

Wider lifestyle factors, such as monitoring and addressing sleep and any of its disorders (e.g., reducing weight
through dietetic support if excessive in cases of OSA), physical activity, mood, and relationships are important for
longer-term management.

SSM provides a healthy foundation that can promote both symptom improvement and reduced interference in
valued activities alone or alongside other management approaches. Clinicians can introduce SSM in three stages.

1. Education and explanation of the relevance of SSM.

2. Introducing recommendations for managing immediate symptoms or pain flare-up(s).
3. Introducing lifestyle-based recommendations for longer-term management.

Education and explanation of the relevance of SSM

Education

Following diagnosis, time should be spent educating an individual with regards to the aetiology and pathogenesis of
TMD in lay terminology. Acknowledgement that TMD pain can be intense, and debilitating is important to validate
patient symptoms. Clear explanations which relate the individual’s diagnosis to their symptoms can help positive
engagement with care (Appendix 11 provides support with such discussions). Reassurance should form a component
of patient education; individuals should be educated as to the benign and usually non progressive nature of TMD,
though expectations should be managed. There is no “cure” for persistent TMD, however the condition and its
impact can be successfully managed most effectively through active engagement in SSM by the individual. An
appreciation that symptoms can fluctuate and that there will be acute exacerbations of over time is important.
Advice to engage with SSM in times of flare up is likely to be beneficial in most cases.

Education around presenting comorbid conditions (Table 4) is essential in order to provide holistic care. It should be
highlighted that these conditions do not cause TMD but can perpetuate TMD. E.g., An individual who has myogenous
TMD affecting left masseter with comorbid chronic depression or chronic migraine might be explained as “whilst the
depression/migraine is not causing the TMD we do know that if we only treat one part of these two conditions we
don’t get as good as results as if both are actively managed, as each element can exacerbate the other”.
Explaining the relevance of SSM

Patients with TMD may present expecting passive forms of management to try and “fix” the problem’ for example a
dental treatment to “solve” the issue. It will therefore be important to carefully explain the relevance of supported
self-management to them so they understand why it might be helpful. One approach is to explain that established
TMD represents both a jaw problem and a pain problem and that it is important to address both. Supported self-
management is focused on the “pain problem” element and includes being supported to follow simple and active
management recommendations that can “turn down the volume” on pain over time. These include strategies
focused on the jaw and on directly managing pain and broader and more holistic strategies that aim to “calm” the
nervous and pain systems. Clinicians should explain that immediate pain relief is an unlikely outcome of using self-
management strategies but that their consistent use over a period of time will help the pain to gradually settle.
Clinicians should emphasize that supported self-management is an important part of the overall treatment plan and
will act as a foundation for other management options that may be indicated.

Recommendations for managing immediate flare up(s)

Self-exercise therapy

Self-exercise therapy facilitates relaxation and masticatory muscle inhibition, supporting jaw function and pain
reduction. Confidence to use the mandible normally reduces fear and anxiety improving pain related disabilities.
[138-151] Appendix 7 documents QR code link to videos demonstrating self-exercise techniques, Appendix 14
describes the self-care practices narratively.

Thermal modalities
Local application of moist heat (warm flannel/covered hot water bottle or proprietary heat pack) or covered ice pack
to affected structures daily supports relaxation, healing, and reduction of inflammation.[149, 150] Single application
will produce short lived symptomatic benefit but use long term as part of a continued self-care routine capitalizes on
the pain management potential. Individuals should be advised to trial a period of moist heat and covered ice and
utilize the strategy which is most effective for their pain. A QR code link to videos on this technique is available in
Appendix 7 whilst Appendix 14 describes these self-care practices narratively.
Self-massage therapy
For individuals living with TMD building a routine of myofascial release and massage techniques twice daily as a
component daily management is likely to provide symptomatic relief in the short and long term. [130, 139, 143-147,
149, 150] A QR code to links supplying videos on these techniques is available in Appendix 7 whilst Appendix 14
describes self-care practices narratively.

Diet and nutrition

Dietary restriction and nutritional deficiencies are secondary consequences of TMD because of painful jaw function,
functional limitation of jaw movements and fear of worsening pain.[152, 153] Individuals should be advised to eat an
inclusive diet containing all major food groups, in addition to ensuring adequate hydration with water. A nutritionally
complete diet can protect against exacerbation of neuroinflammation, and central sensitization associated with
initiation and maintenance of persistent pain conditions [154]. The global TMD patient advocacy agency the
“Temporomandibular Joint Association” have produced a useful diet and nutrition guide for individuals living with
TMD available here.

Parafunctional activities

Parafunctional activities e.g., nail biting, chewing gum, clenching and grinding, if pervasive (large number of different
parafunctional behaviours or very high frequency) can be implicated as part of the complex multifactorial
underpinnings of a presenting TMD.[155, 156] They are not, however, a singular ‘cause’.[155, 156] Exploring if an
individual has any parafunctional activities and if so, suggesting strategies to change behaviour may positively
influence TMD outcome.

Introduction of lifestyle based SSM recommendations for longer-term benefit.

Clinicians can also signpost patients to lifestyle-related self-management (Appendices 7 and 14) for longer-term
impact. Managing activity levels and mood and ensuring that enjoyable and meaningful activities are prioritized for
their beneficial impacts are key skills that become increasingly important when dealing with the discomfort and
stress of persistent pain. Live Well with Pain has good web resources for longer-term self-management available
here. Increasingly many GP practices also have links to social prescribers who may be able to help or may refer
locally to pain management groups or services.
Further management

Though SSM is the mainstay of care for many individuals there are a range of other management options which may
be beneficial on a case-to-case basis and should be discussed with patients in a process of shared-decision making
given the variability in the evidence supporting their effectiveness.

Physical Management Options

Manual therapy, exercise therapy and movement re-education

Manual therapy, therapeutic exercises and movement re-education should be considered for all types of TMD.
Musculoskeletal Physiotherapists with specific training in the management of TMD are well placed to deliver this
combination of treatments, however such treatments can also be offered by other trained practitioners (e.g.,
Chiropractors, osteopaths) with a special interest in the management of TMD should there be an absence of suitably
trained physiotherapists locally. Such physical forms of management should be individually tailored to the patient’s
presentation in keeping with a patient-centered care model of practice and can provide a short-term break in the
‘cycle of pain’ and stabilization of the neuromuscular function of the masticatory apparatus. [138-148]

Contemporary physiotherapy education advocates physiotherapists follow the principles of “high value care”
recommended in all persistent pain conditions.[157] This is delivered by incorporating education about the
biopsychosocial nature of pain, cultivating a strong clinical alliance with the patient through patient-clinician shared-
decision making and the delivery of coaching for a healthy lifestyle overall.[157] Such physical management
techniques may lead to decreased pain, increased range of jaw movement and function[139-142, 145, 146, 148] and
support increased self-efficacy. [138-148] Low levels of adverse events and generally positive outcomes from
physiotherapy support its use for individuals whose TMD is not well controlled despite positive SSM strategies.[138,
139, 142] Musculoskeletal Physiotherapists also offer the added opportunity to treat the primary headaches and
cervical spine disorders that frequently accompany and compound TMD symptomatology. [155]

Access to NHS physiotherapy varies with geographical location. Dental clinicians can contact local NHS physiotherapy
units to confirm appropriate referral protocols. In some areas, dental clinicians may need to request referral for
physiotherapy through GPs. Alternatively, when potential benefits are explained, an individual may choose to seek
care in the private setting. Dental clinicians or their patients may want to explore the availability of suitably trained
physiotherapists in the NHS and independent sector through the ‘Find a TMD Specialist’ section on the Association of
Chartered Physiotherapists in Temporomandibular Disorders (ACPTMD) website available here.
Acupuncture or dry needling

Evidence suggests acupuncture or dry needling for individuals with myogenous TMD is likely to have a positive effect
on pain symptoms.[158-164] The short-term pain relief offered through acupuncture supports active engagement in
SSM in the post needling window of improved clinical symptoms and acupuncture should be seen as an adjunctive
treatment alongside SSM and or other interventions. Referral for acupuncture either through NHS referral, if
available locally or privately by acupuncturist with experience in facial pain should be encouraged for those with
myogenous TMD. As for physiotherapy, dental clinicians can contact local NHS physiotherapy units to assess whether
acupuncture or dry needling is offered and confirm appropriate referral protocols. To make acupuncture more cost
effective and accessible, future service and research development should focus on nurse led care within the primary
care setting.

Splint therapy

Clinical evidence with regards to splints for the management of TMD is equivocal.[165-170] Although they may help
alleviate symptoms in some subtypes of TMD, they should generally be considered an adjunctive therapy rather than
a first-line treatment. SSM is the expected first-line standard management for TMD which may be supplemented,
where appropriate, with splint therapy. Splints should not be a sole management strategy. Splints are most likely to
be beneficial for myogenous TMD, headache attributed to TMD, and individuals with TMD and concomitant
headache.[165, 169] Splints should not be used with the sole purpose of treating joint noise associated with intra-
articular TMDs and ideally should be avoided in the presence of active dental disease (active decay, unstable
periodontal condition).[166] They should therefore only be used following review by an appropriately trained dental
professional.

There are a number of recognised terms used to identify splints of different types (Box 3). There is no evidence of
either increased efficacy between splint types (soft splint or stabilisation splint) or of superiority of effect of splints
covering maxillary or mandibular teeth.[171-173] GDPs should therefore use splints of a material and design they
feel comfortable providing and maintaining.

Soft splints and particularly part-coverage splints can produce changes in occlusion and may exacerbate
arthrogenous pain. If such appliances are prescribed, their use should be restricted to short term, under continual
clinical supervision and regular review. Full coverage stabilisation splints that provide equal bilateral contact with
teeth in the opposing arch are more robust and do not cause unfavourable occlusal changes.[174] Information on
how to make and fit a stabilisation splint is available here.[175]
Night-time splint use can be advised initially for at least 3 months to assess full benefit. Gradual improvement of
symptoms would be expected within this timeframe. Day time use might be of benefit for patients with awake
bruxism. For individuals with bruxism (sleep or awake) and TMD, splints may limit bruxism, support pain
management and in combination with restorative care and monitoring, protect against tooth surface loss/tooth
damage.[176] If splint therapy worsens the TMD symptoms, use of the splint use should be discontinued
immediately, and the exacerbation should resolve quite quickly. Once TMD symptoms are controlled, use of the
splint can be discontinued or be used intermittently to manage cyclical symptomatic flare-up.

Splints should be maintained regularly by primary care dental practitioners at routine dental health check
appointments where they should be reviewed to assess fit, stability of occlusion, effectiveness and whether the
patient has found the splint tolerable and been able to use it. It is important to note that some patients, for a variety
of reasons, may not find splints easy to tolerate and therefore different treatment avenues should be explored.
Splints that become damaged or experience excessive wear from parafunctional habits should be replaced.

Box 3: Terms used for two major splint types.

Soft splints Stabilisation splints
Soft bite appliance Hard splint
Bite guard Michigan splint (Upper arch)
Vacuum formed splint Tanner appliance (Lower arch)
Soft bite raising appliance Occlusal splint
Night guard Fox appliance
Soft acrylic splint Centric relation appliance

Low Level Laser Therapy/ Photo Biomodulation

LLLT (Low Level Laser Therapy) / photo biomodulation may offer benefit to myogenous TMD but the certainty of the
effect is low.[177-181] They involve using a low powered laser producing a monochromatic and coherent light of a
single wavelength. LLLT is applied to affected areas of muscle to cause a photochemical effect and modulate
biochemical pathways. Its actual mechanism of action is uncertain, but it is thought to potentially reduce
inflammation, cause the release of endogenous opioids, and help with healing and repair. [182].
Psychological management options

A biopsychosocial and holistic approach to the management of TMD from all encountering the patient is essential to
maximize prognosis. Psychological therapies e.g., Cognitive behavioural therapy, show benefit in reduction of
distress and pain intensity with a low risk of adverse events and is likely beneficial for all TMD subtypes. [22, 130,
131, 183, 184] Dependent on their training clinicians may not be equipped to manage the psychological components
of an individual’s presentation but with the support of PHQ4 questionnaire (Appendix 5) they should:

1. Be aware of the comorbid presentation of psychological conditions with TMD (Table3)

2. Show empathy for how living with persistent orofacial pain can affect an individual psychologically and
socially and ensure they are clear that comorbid anxiety or depression does not cause the pain but will tend
to potentate or prolong it if left unmanaged.
3. Appropriately refer individuals depending on PHQ4 rating (Table 7 and Appendix 10)

Supportive psychological and social advice can and should, be provided by all clinicians. Encouraging an individual
living with TMD to take 30 minutes out of each day to do something they enjoy, encouraging exercise, fresh air and
maintaining healthy social interactions and relationships are positive strategies which support all persistent health
conditions. Reaffirming simple advice such as this by all clinicians is an important part of supporting positive change.
Pharmacotherapy

There are several pharmacotherapeutic options, which may be appropriate for TMD and need to be considered on
an individual basis. All pharmacotherapeutic options come with a risk of adverse effects which should be openly
discussed prior to initiation of therapy. For a number of different reasons pharmacotherapy may not be an option
that an individual wishes to explore. The decision not to take medications should not be used by the clinical team as
a representative measure of the intensity of an individual’s pain and does not stop individuals from engaging with
other forms of treatment. For all individuals utilising pharmacotherapy, after an appropriate length of stabilisation of
TMD symptoms sensible review protocols should be in place to discuss efficacy and justification for continuation of
pharmacotherapy.

Topical medicaments

Topical application of Ibuprofen gel externally over the TMJ, if completed safely, with appropriate patch test pre-
application, is unlikely to be detrimental and may offer mild, short-term relief in some TMD cases. Certainty of
benefit of topical agents is very low.[185] Short-term use for not more than 2 weeks is advisable. If beneficial
repeated short-term application during cyclical periods of acute exacerbation is appropriate.

There is insufficient evidence to support the routine use of capsaicin, Theraflex-TMJ, bee venom, Ping On, or
Cannabidiol (CBD) topically at this time.[185, 186]

Oral medicaments

Oral analgesics

Oral NSAIDs (non-steroidal anti-inflammatory drugs) are likely to positively affect pain reduction in the TMJ and
masticatory muscles and range of jaw movement. [186, 187]Due to adverse effects, they are suitable for short term
use during times of acute exacerbation only. Table 8 offers short term dose suggestions subject to no relative and
absolute contraindications. The stepwise utilization of paracetamol alongside non-steroidal anti-inflammatory drugs
(NSAIDs) may help reduce dose and limit side effects of NSAIDs.[24, 188] For gastroprotection concomitant
prescription of proton pump inhibitor may be advisable for those at increased risk of gastrointestinal problems
(Table 9). [188]
Table 8: An appropriate 7-day regimen for oral analgesics during acute exacerbation of TMD

Medication Dose Frequency

Paracetamol 1g Four times daily
OR
Ibuprofen 400-600mg Three times daily
Preferably after food
Where paracetamol or ibuprofen alone is ineffective for acute TMD pain, they can both be used.
If both paracetamol and ibuprofen are being used:
1. They should be alternated. i.e., paracetamol 9am, ibuprofen 11am, paracetamol 1pm etc.
2. Dose and frequency should not exceed advice in this table.
Lansoprazole 15mg Once daily
OR For duration of ibuprofen course
Gastro-resistant Omeprazole 20mg
capsules
Concomitant prescription of proton pump inhibitor should be provided with ibuprofen for individuals with
increased risk of gastrointestinal problems (Table 9).

Table 9: Clinical circumstances associated with elevated risk of GI bleeding or dyspepsia. Figure generated from
information in [189]

Concomitant use of drugs that are known to increase the risk of GI bleeding e.g., NSAIDs and anticoagulants.

Excessive alcohol consumption

Heavy smoking

History of GI ulcer, GI bleeding or gastroduodenal perforation

Older age

Serious medical comorbidity such as advanced cancer

Neuromodulatory agents

The neuromodulatory agents advocated for pain management of persistent myogenous TMD, their mechanism of
action and common side effects are shown in Table 10. These agents may be used for myogenous TMD management
in specialist dental and primary general medical settings. Neuromodulatory agents have not been shown to be
beneficial for arthrogenous TMD sub diagnoses and their use in such situations is not advocated. The evidence base
for effectiveness in the management of myogenous TMD is building, but remains weak, historically effectiveness has
been extrapolated from other persistent pain conditions.[10, 24, 190-194] Should a patient opt for a
neuromodulatory agent, initiation, monitoring and eventual withdrawal will often come under the remit of the
individual’s GP, either directly or in consultation with specialist teams. Dosing advice for neuromodulatory agents for
TMD can be found in Appendix 12. The gold standard should be that individuals are slowly titrated off medications
after a 6-8month period of stable control of their TMD symptoms with minimal numbers remaining on long term
medication and if remaining on medication they should be at the lowest possible dose and be subject to periodic
medications review by their GP.

Table 10: Neuromodulatory agents supported for use in muscular TMD, their drug class, mechanism of action and
common side effects.

Drug† Class Main mechanism of action for persistent pain Common side effects
Amitriptyline Tricyclic Blocks voltage-gated sodium channels on Sedated state, nausea,
or antidepressant presynaptic terminals, stabilizing neurons and vomiting, drowsiness,
Nortriptyline reducing generation of action potentials. confusion, nightmares, dry
Inhibit reuptake of norepinephrine and mouth, headaches,
serotonin in neuronal cell membranes. arrhythmia, weight gain
Duloxetine Serotonin- Inhibits reuptake of serotonin and noradrenalin Urinary retention, nausea,
norepinephrine in the central nervous system. Supports constipation, diarrhoea,
reuptake descending inhibitory pain pathways in brain dizziness, fatigue, insomnia,
inhibitor * and spinal cord. sedated state, headache,
xerostomia.
Gabapentin Gabapentinoid Calcium channel inhibition resulting in Drowsiness, dizziness,
decreased activation of neurons. Additionally ataxia, fatigue,
reduces noradrenaline release in the brain – dependency.
linked to pain persistency
*Though rare, SNRIs and SSRIs have been linked to antidepressant associated bruxism, which could perpetuate TMD pain, close monitoring
for such adverse effects is advised. [195]
There is no current evidence to support the use of other SNRIs (e.g., Venlafaxine) or SSRIs (e.g., Citalopram, escitalopram, fluoxetine,
sertraline, paroxetine) for management of M-TMD.
†Always check BNF interactions and liaise with other prescribing clinician if patient on other psychotropic medication and or has significant
comorbid mental health illness.
Oral benzodiazepines

The effectiveness of oral benzodiazepines is difficult to determine from the literature. Their therapeutic role is
restricted to instances of acute and severe myogenous pain with limited opening (+/- disc displacement without
reduction). In such cases diazepam 2 mg up to three times daily, for 5 days initially, up to a total maximum duration
of 2 weeks if symptoms remain at the 5-day review may offer benefit for some cases. [11] Medical and social
contraindications must be assessed and National Institute for Health and Care Excellence (NICE) prescribing
information for Diazepam in TMD available here must be followed.[11]

Oral corticosteroids

The evidence suggests that oral corticosteroid use in the management of TMD is restricted to the specialist,
secondary care setting for management of some disc displacements without reduction presenting with severe
localized TMJ pain.[196] In such instances in addition to diazepam, a short course of oral prednisolone can be
prescribed, subject to no contraindications and following NICE prescribing information for oral corticosteroids
available here. [189, 196, 197] Table 11 outlines dose advice for oral prednisolone for such circumstances.
Individuals being prescribed prednisolone who are at elevated risk of gastrointestinal (GI) bleeding or dyspepsia
(Table 9) should be co-prescribed a proton-pump inhibitor (Lansoprazole 15 mg OD or Gastro-resistant omeprazole
capsules 20mg OD) for the duration of the course.[189, 198]

Table 11: Advised dose regime for oral prednisolone in instances of disc displacement without reduction [196, 197]

Oral Prednisolone 6-day course

Day Dose
1-6 20mg od
Advise dose is taken in the morning after breakfast.
As short course (<3 weeks) can be stopped abruptly i.e., Tapered reduction not required.
Injectable medicaments

Local Anaesthetic

Muscular trigger points are hyper-responsive points within skeletal muscles which when palpated cause local and or
referred pain.[199] For myogenous TMD with well-defined muscular trigger points, local anaesthetic trigger point
injections may be beneficial in some individuals.[161, 163, 200-202]

Botulinum toxin A

Botulinum toxin A is not expected to provide any benefit for painful arthrogenous TMD sub diagnoses although it
may have a role in recurrent dislocation when applied to the lateral pterygoids. Though Botulinum toxin A may be
effective in some individuals there is no clear evidence in favour or against the use of Botulinum toxin A in
myogenous TMD at the present time.[202-209] Muscle atrophy and reduction in coronoid and condylar bone
volume, cortical thickness and cancellous and trabecular density in the TMJ have been documented following
Botulinum toxin A placement, the potential impact of these changes has not yet been fully explored [210-213]. As
definitive evidence is lacking at this time, Botulinum toxin A should not be first line treatment. Any decision to move
forwards with Botulinum toxin A treatment should be made in a shared-decision making fashion with informed
consent from the patient especially relating to the uncertainty about bony changes,[213] who benefits, the dosing
schedule and stopping ‘rules’.

The authors acknowledge that the current situation may change, as the National Institute for Health and Care
Research (NIHR) in the UK has just commissioned the world’s largest ever trial into the use of Botulinum toxin A for
myogenous TMD (MitiGatE trial) which not only looks at effectiveness of Botulinum toxin, Amitriptyline/Gabapentin,
and Lignocaine in myogenous TMD but also their adverse effects profile in detail. An improved clinical evidence base
is therefore expected over the forthcoming years. At present a therapeutic trial of Botulinum toxin A may be
considered appropriate in individual myogenous TMD cases advocated by a senior clinician (consultant or specialist)
and may require individual pharmacy approval for funding at a local level. If approved, a detailed informed consent
process should include the requirement for repeated application, candid discussion of risks and uncertainties (as in
preceding paragraph and table 3), and advice that efficacy for pain management may reduce over time.

Hyaluronic Acid

There is evidence building for the use of hyaluronic acid as an intra-articular injection in surgical TMJ procedures
(e.g., arthrocentesis).[214-218] At present its use in TMJs remains off label and so appropriate approval from
relevant regulatory authorities would be needed and the off-license nature should be made clear in the consent
process.
Intra-articular corticosteroid

Evidence for the beneficial effects of intra-articular corticosteroid injection is weak.[219, 220] Recent literature (see
above) suggests intra-articular hyaluronic acid offers more potential benefit in terms of pain reduction and
functional improvement and avoids the risks associated with intra-articular corticosteroid deposition including
potential adrenal insufficiency and condylar lysis.[221-223]

Surgical Management

There are two situations where surgical intervention may be appropriate, severe arthrogenous TMD and disc
displacement without reduction with specific case features (see Table 7 and Figure 3). The informed consent process
should outline that conservative treatment may also help resolve symptoms in these situations. This document has
highlighted such circumstances in a bid to clarify patient pathway, expedite assessment in the oral and maxillofacial
setting and capitalize on potential surgical benefits within most appropriate clinical timeframe improving outcome.
The in-progress Oral & Maxillofacial Surgery GIRFT follow up report covers in detail all surgical management options
for TMD and their clinical evidence base and referral to this document once published is advised for further detail.
Where surgical management is advocated, it should be provided as an adjunct to SSM and conservative treatment
strategies and not as a sole or first line option. There remains no evidence that surgical management will provide
benefit in myogenous TMD.
Other considerations

Disc displacement without reduction with limited opening

As Table 7 highlights disc displacement without reduction with limited opening is a TMD sub diagnosis more likely to
justify earlier secondary care referral and consideration of early intervention. Appendix 13 documents evidence-
based management advice for disc displacement without reduction with limited opening from primary care,
secondary care and surgical perspective.

Dental care for those with known or suspected TMD

For individuals with known or suspected TMD additional care should be taken to protect the TMJ complex during all
dental procedures but particularly procedures which involve sedation or general anaesthesia due to drop in muscle
tone caused by the drugs employed and because of airway management manoeuvres involving the joint. The use of
bite blocks, minimizing jaw opening time and gentle manipulation of TMJ complex when required is advised. Positive
SSM strategies should be discussed as part of the consent process and post operatively to promote recovery and
reduce postoperative TMD discomfort following intervention. Contemporary guidance on the dental care of those
living with TMD has just been published [224] and is available here.

Remote delivery of care

For diagnosis of TMD face to face consultation remains gold standard. Remote delivery however offers a potential
opportunity for TMD patients to receive appropriate targeted supported self-management pain programs, early
intervention and flexible, accessible review opportunities with the potential to revolutionize care. [135, 225-227]
Regardless of location quality of consultation is the most important factor and programs would need to be
adequately planned, staff appropriately trained and access requirements for patients considered.
17. Development of service

This comprehensive review has highlighted important areas of cross sector development which if supported through
policy change have the potential to benefit individuals living with TMD, clinicians involved in the care of those living
with TMD, and the health service through rationalization of healthcare use and potential for economic savings.

Management of the vast majority of persistent TMD cases is both more appropriate and more accessible in the
primary care setting. For TMD, as with all other persistent pain conditions, consultation time and its representative
cost has been identified as a major driver of healthcare utilization costs.[228] Despite this, remuneration for time
required for such cases needs to be addressed.

Further areas of development and service improvement and investment in the below situations is recommended:

• Evidence of potential ethnic variations of TMD aetiology, pathogenesis and management is lacking and
should be prioritized as a research directive, as should obtaining truly representative samples from the
population of interest and then clearly reporting the variation in ethnicity within the sample in the most
granular manner.
• Further investigation in a qualitative and quantitative manner to understand the role of deprivation (and or
social factors) in the aetiology, pathogenesis and management of TMD.
• Review and reconsider appropriate remuneration in NHS dental contract for management of persistent
orofacial pain conditions.
• Under and post graduate dental education in persistent orofacial pain conditions for dentists and GPs
• Under and post graduate education into management of TMD for dental hygienists, dental therapists, clinical
dental technicians.
• Advanced training opportunity for dental nurses and general nurses into persistent orofacial pain
management
• Investment in acupuncture training and service development in primary care for persistent pain conditions
• Investment in training and service development of specialist pain management physiotherapists in primary
and secondary care, and their integration in orofacial pain multi-disciplinary teams.
• Investment in training and service development of specialist pain management clinical psychologists.
18. Suggested TMD Care Pathway

Individuals living with TMD are known to have had challenging care pathways with multiple unnecessary referrals
and visits due to the structure and lack of certainty within the healthcare system.[17] The evidence-based care
pathway, Figure 3, has been agreed with RCS FDS Eng., NHS England GIRFT and associate bodies of this guideline as
the standard pathway to follow for TMD management. Each step has explanatory notes and further information for
all healthcare providers provided as Appendix 14. The evidence base which informed this TMD care pathway are
summarized in Table 3. There is strong evidence for the use of SSM for all TMDs, other options are supported by less
robust evidence, but outline considerations to be discussed with patients in a process of shared decision making if
further (adjunctive) management is required or indicated.
Figure 3: Evidence based TMD care pathway

*If at any point the patient is comfortable and happy to move to maintenance there is no objective need to progress with further therapy and maintenance can be initiated

**Self-referral to GP if PHQ ≥6 <9 or to talking services for anxiety and depression which can be identified at: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-
counselling/nhs-talking-therapies/

***Unfortunately following step 6 management options there is likely to be little further that can be offered. A national virtual MDT opinion may be appropriate when there is substantial complexity or comorbidity
between a TMD and other conditions. This national MDT is currently being established and contact details are to follow.

Care pathway acronyms: Three question TMD screener (3Q/TMD); Arthrogenous TMD (A-TMD); Characteristic pain intensity (CPI); Mane (in the morning); Mouth opening (MO); Myogenous TMD (M-TMD); Once
daily (OD); Obstructive sleep apnea (OSA); Patient health questionnaire 4 (PHQ4); Supported self-management (SSM)
19. Conclusion

The authors hope that this updated guideline will support all clinical dental professionals, GPs and other healthcare
professionals to whom individuals living with TMD may present. This guidance is based upon the current available
evidence and should aid practitioners in assessment, diagnosis, and management of persistently painful TMD in
adult patients. The suggested care pathway should provide clarity of appropriate points and routes of onward
referral to ensure national consistency of care. Evidence supported development requirements locally and nationally
have the potential for improved patient outcome, rationalization of service use and economic savings for the health
service as a whole.
20. Appendices

Appendix 1: Headache exploration table developed from information gathered in [229]

Question Comments
Do you suffer with If no, no further questioning required.
headaches?
If yes but longstanding with formal diagnosis and active intervention e.g., known migraineur,
TMD management should be implemented. The association between TMD and primary
headache condition should be explained, and the individual counselled how their conditions can
precipitate and perpetuate each other. Positive management of the TMD or headache may
reduce but not eliminate the other issue.

If yes, new or changing, headache symptoms should be explored in detail and referral to GP for
further assessment considered if justifiable.
Can you describe your Headache attributed to TMD commonly throbbing ache which worsens with jaw movement
headache pain? (chewing, talking). It can be uni or bilateral depending on where TMD is presenting.

Migraine is more commonly described as pounding, pulsating or throbbing pain and is usually
unilateral (~60%). Bilateral presentation is more common in children.

Chronic tension type headaches are commonly described as tight bilateral pressure around the
head.

Cluster headache is described as severe strictly unilateral pain. Pain is associated with ipsilateral
conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating,
miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.
Where do your headaches Headache attributed to TMD most commonly presents in the regions of temporalis, masseter or
present? over the TMJ in the preauricular region.

Migraines are most common in the frontotemporal region.

Tension type headaches most commonly affect the frontal and occipital regions of the skull and
the posterior neck.

Cluster headaches present in orbital, supraorbital or temporal region(s).

Does anything make the Headache worsened by jaw function is likely to be headache attributed to TMD, positive TMD
headache worse? management would be expected to result in reduction in headache symptoms.

Headaches which occur when TMD pain is not present or is not worsened by jaw function are
unlikely to be associated with TMD and advice should be given for the individual to discuss this
with their GP if headache continues.
Do any features precede the Preceding sensory awareness (aura) more commonly associated with migraine
headache?
When you have a headache Positive response is suggestive of migraine
are you sensitive to bright
lights or loud noises?
Do you ever feel sick or be Positive response is suggestive of migraine.
sick when you have your
headaches?
Headache “red flag” signs and symptoms are documented below.[230] Any single headache red flag symptoms
warrants urgent assessment with GP.

• Sudden onset severe (“thunderclap”) headache

• New onset headache in person aged >50
• Progressive or persistent headache or headache which has changed dramatically.
• Headache with associated features such as: fever, impaired consciousness, seizure, neck pain/stiffness,
photophobia
• Papilloedema (optic disc swelling)
• New onset focal neurological deficit, change in personality, cognitive impairment, and/or altered
consciousness.
• Atypical aura (duration >60 minutes, or including motor weakness, double vision, visual symptoms affecting
only one eye, or impaired balance, new aura occurring in a person taking the oral contraceptive pill).
• Dizziness
• Visual disturbance
• Vomiting
• Preceding head trauma (last 3 months)
• Headache triggered by Valsalva (coughing, sneezing, bending or exertion)
• Headache which worsens on standing
• Headache which worsens with lying down
• Current or past malignancy (especially if <20 years old); a history of malignancy known to metastasize to the
brain (lung, breast, multiple myeloma)
• Current or recent pregnancy
Appendix 2: Template letter to facilitate TMD and headache symptom information sharing with GP.

Dear [insert GP’s name],

Re: Patient name, date of birth, NHS number

The above patient presented today due to a complaint relating to facial pain.

Clinical examination demonstrated:

Familiar pain from the muscles of mastication/TMJ [delete as required] on the left/right/both side(s) [delete as
required].

This would equate to a diagnosis of temporomandibular disorder (TMD), for which I have initiated conservative
management strategies including [insert details of initial management strategies suggested to patient]. Our review
plan is [insert details here].

The patient also, however, complains of headache symptoms which do not appear related to their TMD. Symptoms
include [Insert appropriate history and clinical findings as necessary].

This letter is to support information sharing of TMD diagnosis and current management strategies, I have advised the
patient to monitor their headache symptoms and seek advice from you should these persist or worsen.

Yours sincerely,
Appendix 3: Template letter to facilitate referral to GP for exploration of ear symptoms.

Dear [insert GP’s name],

Re: Patient name, date of birth, NHS number

The above patient presented today due to a complaint relating to facial pain and ear pain.

Clinical examination demonstrated:

Familiar pain from the muscles of mastication/TMJ [delete as required] on the left/right/both side(s) [delete as
required].

This would equate to a diagnosis of temporomandibular disorder (TMD), for which I have initiated conservative
management strategies including [insert details of initial management strategies suggested to patient]. Our review
plan is [insert details here].

The patient also, however, complains of ear pain/fullness, tinnitus affecting the left/right/both side [delete as
necessary]. As I am unable to examine aurally, the patient has been advised to book an appointment you to exclude
any potential otological problems contributing to the patient’s presentation.

Yours sincerely,
Appendix 4: Trismus checklist adapted from [77]

Trismus checklist: for completion in patients with reduced mouth opening

Yes No
Inter incisal opening ˂20mm
Progressively worsening trismus
Absence of history of TMD related symptoms (incl. Clicking)
Pain of non-myofascial origin (neuralgia etc.)
Swollen lymph glands
Suspicious intra-oral soft tissue lesion
Older than 45 years
Difficulty swallowing
Recent weight loss
Neurological signs/symptoms
• Acute onset loss of smell or hearing
• Acute onset visual problems
• Neurosensory change
• Motor function changes

If any of the answers are yes:

• Primary care setting: urgent oral and maxillofacial surgery referral
• Secondary care setting: urgent senior consultant assessment and urgent TMJ imaging as per senior
consultant advice.
Appendix 5: Formative screening questions which are advised for use at first assessment.

This page can be printed, provided to the patient to complete, and scanned into patient records.

1. 3Q/TMD - 3 questions temporomandibular disorder screening instrument [103]

Do you have pain in your temple, face, jaw, or jaw joint once a week or more? Score
a) No 0
b) Yes 1
Do you have pain once a week or more when you open your mouth or chew?
a) No 0
b) Yes 1
Does your jaw lock or become stuck once a week or more?
a) No 0
b) Yes 1
Total Score =
≥1 point = positive screen for TMD,

2. PHQ-4 - Patient Health Questionnaire 4 screening[81]

Over the past 2 weeks have you been bothered by these Not at all Several days More than Nearly every
problems? half of the day
Please tick ONLY one box for of the below questions 0 1 days
2 3
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Feeling down, depressed, or hopeless
4. Little interest or pleasure in doing things
Total Score = Total score is determined by adding together the scored of each of the 4 items.
Scores are rated as: Normal (0-2), Mild (3-5), Moderate (6-8), and severe (9-12)
Total score ≥3 for first 2 questions suggests anxiety. Total score ≥3 for last 2 questions suggests depression
Patients scoring 2 points or more from any single depression screen question (question 3 or 4) GP should be informed[125]

3. CPI - Characteristic pain intensity [104]

1. How would you rate your mouth and or face pain on a 0 to 10 scale AT THE PRESENT TIME, that is right now,
where 0 is “no pain” and 10 is “pain as bad as could be”. (Circle number)

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as it
could be

2. In the PAST MONTH, how intense was your WORST mouth and or face pain? (Circle number)

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as it
could be

3. In the PAST MONTH, on AVERAGE, how intense was your mouth and or face pain? (That is, your usual pain at
times you were experiencing pain.) (Circle number)

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as it
could be

Total Score:
CPI is calculated by summing the values from Q1-3 multiplying by 10 and dividing the product by 3
Appendix 6: Mental distress and suicidal ideation

Where patients present in significant distress or have indicated depressive symptoms on PHQ4 question 3 and 4, it is
recommended to directly ask if they have considered ending their life.[125] Talking to individuals about suicidal
intent does not increase the risk of the individual attempting or taking their own life.[231-233] Talking allows
valuable information to be gathered, protecting the individual and reducing their risk.[231]

Urgent assessment as outlined in Table 7 should be actioned immediately and documentation of all discussions
should be recorded within the clinical notes.

For further information please see the suicide alliance and Health Education England free online training packages:

Suicide awareness training - gateway module. (5-10 minutes)

Suicide awareness training - full version (20 minutes)

HEE - We need to talk about suicide e learning module

Appendix 7: Recommended links for SSM individuals diagnosed with TMD can be signposted to

Newcastle Upon Tyne NHS Hospitals foundation Trust TMD resources

Weblink: Here

QR code for self-physiotherapy, jaw exercise, thermal modalities, facial massage and TMD advice videos:

Temporomandibular joint association

Website: https://tmj.org/

TMD, nutrition and you: http://tmj.org/wp-content/uploads/2020/08/TMJ_nutrition_Guide.pdf or click this link.

Orofacial pain UK

Website: https://orofacialpain.org.uk/

Live well with pain

Website: https://livewellwithpain.co.uk/

Sleep well with pain leaflet available here.

The Leeds Teaching Hospital Trust/Leeds School of Dentistry

Patient experience video: here.

Downloadable TMD patient pain manual discussed in patient experience above:

https://licensing.leeds.ac.uk/product/self-management-of-chronic-orofacial-pain-including-tmd [234]

Association of Chartered Physiotherapists in Temporomandibular disorder

Weblink: here. This site, alongside other information can provides support helping to locate a physiotherapist with a
special interest in treatment of TMD in your area.
Appendix 8: Template letter to facilitate referral to GP for exploration of OSA signs and or symptoms.

Dear [insert GP’s name],

Re: Patient name, date of birth, NHS number

The above patient presented today due to a complaint relating to facial pain and potential obstructive sleep apnoea.

Clinical examination demonstrated:

Familiar pain from the muscles of mastication/TMJ [delete as required] on the left/right/both side(s) [delete as
required].

This would equate to a diagnosis of temporomandibular disorder (TMD), for which I have initiated conservative
management strategies including [insert details of initial management strategies suggested to patient]. Our review
plan is [insert details here].

The patient also, however, presented with features suggestive of sleep apnoea [insert details here], the patient has
been advised to book an appointment with you to formally assess and initiate management as appropriate for
obstructive sleep apnoea.

Below is their STOP-bang sleep apnoea questionnaire

STOP
Do you SNORE loudly (louder than talking or loud enough to be heard Yes No
through closed doors)?
Do you often feel TIRED, fatigued, or sleepy during daytime? Yes No
Has anyone OBSERVED you stop breathing during your sleep? Yes No
Do you have or are you being treated for high blood PRESSURE? Yes No
BANG
BMI more than 35kg/m2? Yes No
AGE over 50 years old? Yes No
NECK circumference > 16 inches (40cm)? Yes No
GENDER: Male? Yes No
Each Yes = 1
Total score =
High risk of OSA: 5 – 8, Intermediate risk: 3 – 4, Low risk: 0 -2

Yours sincerely,
Appendix 9: 6–8-week review documentation

This page can be printed, provided to patient to complete, and scanned into patient records.

Dental Clinician to complete: INITIAL CPI SCORE

Patient to complete: CPI - Characteristic pain intensity review [104]

1. How would you rate your mouth and or face pain on a 0 to 10 scale AT THE PRESENT TIME, that is right now,
where 0 is “no pain” and 10 is “pain as bad as could be”. (Circle number)

0 1 2 3 4 5 6 7 8 9 10

No pain Pain as bad as it

could be

2. In the PAST MONTH, how intense was your WORST mouth and or face pain? (Circle number)

0 1 2 3 4 5 6 7 8 9 10

No pain Pain as bad as it

could be

3. In the PAST MONTH, on AVERAGE, how intense was your mouth and or face pain? (That is, your usual pain at
times you were experiencing pain.) (Circle number)

0 1 2 3 4 5 6 7 8 9 10

No pain Pain as bad as it

could be

Total Review Score:

CPI is calculated by summing the values from Q1-3 multiplying by 10 and dividing the product by 3

Dental Clinician to complete: % CPI SCORE CHANGE

Subtract the Review CPI Score from Initial CPI score gives you the percentage change.

If it is positive, it is an improvement.

If it is negative, the pain has worsened.

See Figure 3 for suggested next stage of management.

Appendix 10: Template letter to facilitate referral to GP secondary to PHQ4 findings.

Dear [insert GP’s name],

Re: Patient name, dob, NHS number

The above patient presented today due to a complaint relating to facial pain.

Clinical examination demonstrated:

Familiar pain from the muscles of mastication/TMJ [delete as required] on the left/right/both side(s) [delete as
required].

This would equate to a diagnosis of temporomandibular disorder (TMD), for which I have initiated conservative
management strategies including [insert details of initial management strategies suggested to patient]. Our review
plan is [insert details here].

Upon assessment the patients PHQ4 (symptoms of anxiety and depression score) was [INSERT NUMERIC SCORE
HERE] suggesting symptoms of [delete as appropriate moderate, severe] anxiety and/or depression.

When discussed with the patient they reported feeling [document any pertinent information here]. I would be
grateful if you could arrange to assess, diagnose and manage their condition as you see appropriate.

Yours sincerely,
Appendix 11: Example patient explanations for aspects of TMD

What is TMD?
• TMD describes a variety of conditions which affect the jaw joints and or the muscles around the jaw.
• TMD is very common.
• Problems may occur on one or both sides of the jaw.
• Many people have some signs of TMD, but only a small number suffer pain or other symptoms because of
TMD.
• TMD can be mostly due to problems in the muscles or mostly due to problems in the joints or a bit of both.
• TMD is not usually serious, and symptoms usually only last a few months before getting better, though they
may come back from time to time.
• TMD is generally not a progressive disease and TMD is not linked with other serious illnesses.

What causes TMD?

• Today we believe that TMD is caused by many things acting together, some of which may have little or
nothing to do with your teeth. These may include changes in some of your body’s pain and flight or fight
(stress) systems.

Will it get worse?

• TMD does not usually keep getting worse. In the majority of cases the problem tends to come and go, often
feeling worse during times of emotional difficulty. Studies demonstrate that it does not tend to get worse
with age.
• Simple treatments and things you can do yourself will help resolve or control TMD in the vast majority of
cases.

Reassurance as to the benign nature of TMD

“With TMD the pain that you feel does not indicate that there is damage occurring within the jaw joint or the
structures surrounding it, continuing to use your jaw normally is unlikely to make the condition worse.”

Explanation of persistent myogenous TMD

“With your condition the main muscles which move the jaw are sending pain signals, which are real messages, but
they are not indicating injury. The pain nerves have become extra-responsive after things have healed and are being
over-protective producing significant pain when the muscle has no injury. It is a bit like when you stub your toe and
the whole toe goes red and sore despite only stubbing it in a small area. As it improves the toe no longer looks red but
will still be a bit sore in areas where you did not stub it. We know this extra-responsiveness is normal for a period but
that in some people it can last a longer time without any ongoing damage.”
“The good news is that everything is healthy, however the muscles around your jaw are very tender at present. This
can happen because the muscles are overworked from e.g., clenching and grinding your teeth and need a rest so
doing what we can to give them a break for a week or two may help. Pain like this can also be maintained by
overactivity of the pain signalling system itself – pain works like an alarm which can become highly sensitised in
certain conditions. We therefore need to look at ways to calm the overall alarm system alongside treating muscle
tension and reversing subconscious habits (clenching, grinding, chewing fingernails etc) that exacerbate the muscular
tension.”

Explanation of disc displacement with reduction

“The lower jaw sits in its socket in the skull with a flat cap of cartilage (like a cap on someone’s head) on top of it. This
cap is supposed to move in sync with the jaw as it hinges and then slides forwards. In some people the disc moves
further one way or another during opening or closing, and then clicks back into place. Approximately 30% of all adults
have a “clicky jaw”, the click itself is nothing to worry about. The click does not mean there is any damage taking
place to the disc or the jaw joint. We now understand that overtime the disc reshapes itself, for some people this
means a click may start or stop. The aim of management is to reduce the pain you feel and cannot be guaranteed to
eliminate your click.”

Explanation to manage expectations of the likely course for persistent TMD.

“TMD is a condition for which unfortunately there is no absolute cure. What I mean by that is that there is not one
single intervention that will eliminate all of your pain. For people who have TMD, they will likely have symptoms to
one degree or another throughout life. Symptoms will usually come in cycles with periods of no or significantly less
pain followed by short periods of flare up. Though I said there is no one thing we can do that can eliminate all of the
pain there are lots of management strategies we can utilise which can help reduce the frequency of flare up periods
and can also reduce how severe the pain is during times of flare up. It is possible to interrupt the vicious pain cycle
and block the pain response by understanding your condition and how simple self-management strategies like
regular use of massage and heat/ cold application to the overactive muscles can allow you to break the pain cycle
and ‘live well with TMD’ by reducing its impact on your activities of daily living”.
Appendix 12: Neuromodulatory agents suggested dosing regimens for myogenous TMDs for those experienced and
trained in their use.

Amitriptyline or Nortriptyline begun at 10mg with 10mg incremental tapers every 4-8weeks up to a maximum dose
of 50-75mg (50mg is the threshold where often patients report more intolerable side-effects).

The taper off is similarly as slow at 10mg increments every 4-8 weeks after 6-8 months of stable control or in
absence of positive effect.

Gabapentin begun either 100mg OD day 1, 100mg BD day 2, 100mg TDS day 3 or 300mg day 1, 300mg bd day 2,
300mg tds day 3. It can then be titrated across all 3 doses by 100-300mg increments every 4-8 weeks. If a
therapeutic effect hasn’t been achieved by 1200-1500mg total daily dose it is likely there will be more side-effects
reported rather than benefit above this dose.

The taper off mirrors the incremental taper upwards and is done slowly after 6-8 months stable control or in absence
of positive effect.

Duloxetine begun at 20mg OD, after 6-8 weeks increase to 30mg OD. If required at 6-8 weekly intervals dose can be
raised by additional 30 mg to a maximum of 90mg total daily dose. 90mg total daily dose is the threshold where
more side-effects are reported.

Tapering off the medication mirrors the incremental upwards approach in a slow manner and is done after 6-8
months of stable control or in absence of positive effect.

Anti-epileptics Antidepressants
If neither type are contraindicated shared decision making with patient should inform choice
1st line Amitriptyline*
nd
2 line Gabapentin 2nd line Duloxetine or
Nortriptyline**
Could add Duloxetine to Gabapentin
*A stronger evidence base for beneficial effect of amitriptyline for M-TMD exists supporting its position as first
line agent. [190-192]
**Risk of anti-cholinergic side effects, sedation and postural hypotension are expected to be lower with
secondary amines (nortriptyline) than tertiary amines (amitriptyline).[235] In some circumstances this may
mean nortriptyline is either prescribed in preference or switching from amitriptyline to nortriptyline to mediate
side effects may be advised.[236]

Appendix 13: Disc displacement without reduction with limited opening - Detailed evidence-based management
recommendations
Initial management for disc displacement without reduction with limited opening

1) Make diagnosis on clinical grounds.

Clinical history:

• Jaw locking so that mouth would not open all of the way AND Limitation in jaw opening
severe enough to interfere with ability to eat.[5]

Clinical examination findings:

• Maximum assisted opening with passive stretching less than 40 mm.[5]

• The presence of TMJ noise on examination does not exclude this diagnosis.[5]
2) Provide diagnosis, education and reassurance.
3) Initiate conservative management ASAP.
• Signpost patients to Supported self-management resources (Appendix 7)
• Initiate supported self-management practices (Appendix 14)
• Must include the joint exercises: Coordination training, static stretching, mobilisation
exercises (Appendix 14)
4) If symptoms are acute advise oral analgesics (Table 8 for suggested dose regimen)
5) Early provision of a stabilization splint as an adjunctive therapy may help alleviate symptoms[166]
6) If symptoms are acute and severe related to myogenous pain consider prescribing diazepam 2 mg up to
three times daily, for 5 days initially, up to a maximum/total of 2 weeks if issue remain at day 5 review.[11]
7) If any of the below criteria refer to OMFS at initial patent contact appointment:
• Any TMD red flag sign or symptom
• ≤25 years old (as early arthrocentesis more likely to be curative)
• Severe closed lock affecting ability to maintain nutritional requirements.
• Pain unmanageable
8) Review at 6-8/52 weeks assess CPI (Appendix 9)
• CPI improvement < 10% secondary care referral at this point
• Improvement in CPI >10% and improved mouth opening continue conservative
management strategies as it can take 6 to 18 months to completely form a pseudo disc and
functional limitation to resolve.

Secondary care management for disc displacement without reduction with limited opening

1. Confirm diagnosis on clinical grounds (MRI should be confirmatory only)

2. Provide diagnosis, education and reassurance.
3. Review conservative management that has been completed. (Type, duration, effectiveness.)
• Motivate with regards to supported self-management
• Emphasize joint exercises: Coordination training, static stretching, mobilisation exercises.
4. Assess requirement for multi-disciplinary team involvement E.g., Pain psychologist, specialist pain
management team, physiotherapy, and facilitate referral as appropriate.

If not already completed in primary care, consider:

a. Early provision of a stabilization splint as adjunctive therapy may help alleviate symptoms[166]
b. If symptoms are acute and severe consider prescribing diazepam, if appropriate, 2 mg up to three times
daily, for 5days initially, up to a maximum/total of 2 weeks if issue remains at day 5 review.[11]
c. If symptoms localized, TMJ pain severe and it is appropriate to do so consider prescribing in addition to
diazepam, oral prednisolone as per Table 11 (+/- proton pump inhibitor for gastroprotection as
required).[196, 197]
5. If improvement: Continue conservative management
6. If no improvement options:
• Ongoing conservative management
• Referral for surgical opinion

Surgical management of disc displacement without reduction with limited opening

a. Unlocking manoeuver is the most practical and realistic approach that can be attempted first in every closed
lock patient as an initial diagnostic/therapeutic approach.[237-239] Success of this procedure is possible
regardless of duration of lock but is more likely in those with a short lock duration <4weeks. “Success” is
normally an increased range of motion rather than a ‘recaptured’ disc. [237]
b. Arthroscopic surgery is recommended over arthroplasty since it is equally effective with regard to reducing
pain and dysfunction, it costs less and is less invasive.[238-240]
c. Arthrocentesis/scopy ideally planned for <6months [237, 239]
• Informed consent should include that pseudo disc nearly always forms and things regress back to
near normal from 6-18months and older patients and those with >6months of lock are less likely to
respond to arthrocentesis.
d. Early Arthrocentesis/scopy may be appropriate if:
• Unresponsive to conservative management at 6-8 weeks
• ≤25 years old and mouth opening <25mm[124]
• CPI pain scores >75 [124]
Appendix 14: Explanatory notes and supplemental materials for the steps of the care pathway

Step 1: Examination and screening

Assess for ref flags in medical and clinical history (Table 2)

Rule out dental pathology clinically and/or radiographically

Provide patient with screening documents to complete, 3Q/TMD, PHQ4, CPI (Appendix 5)

Record results of screening in patient records.

TMD focused clinical examination

Step 2: Diagnose, explain, and reassure.

Examples of lay descriptions which could be used to explain TMD aetiology and pathogenesis to patients are
provided in Appendix 11.

Step 3: Initiate Supported Self-Management

Step 3 instructions for professional:

Supported self-management begins with an individualized plan developed in collaboration with the individual
diagnosed with TMD. The clinician should introduce the individual to management techniques likely to benefit,
advise how to complete the management and why they may be beneficial.

Clinicians should feel confident to discuss that for many with persistent TMD elimination of symptoms is unrealistic
however management of symptoms and maintenance of function is very possible. All individuals diagnosed with
any TMD should have a review appointment 6-8 weeks following initiation of supported self-management to
assess for change and determine need for further care.

Clinicians can explain to patients that although there is not a guaranteed medical cure for TMD, there are simple and
active management recommendations available that are known to reduce the severity of pain and its impact.
Following these management recommendations over time, on a regular basis, is the single most important thing
likely create the best conditions for reduction of active symptoms and their impact. The benefits of self-management
are likely to occur over a period of time and may not be immediately evident.
Step 3 instructions for patients:

In addition to the information provided by your clinician, there are two excellent short animations that explain TMD
and its management at link 1 and link 2.

The following are some self-management techniques and home physiotherapy that your healthcare professional can
support you in completing.

The below QR code and link will direct you to a website containing supported the self-management techniques
outlined below.

QR code: Weblink: here

Supported self-management techniques expected to provide benefit for all TMD:

1. Changes to daily living and habits

a. Avoid caffeine as this is a stimulant and likely to increase stress and cause muscle tension
b. Give yourself time to perform self-care exercises and relaxation techniques throughout every day
c. When experiencing pain in the muscles or around the joint adapt your diet and take a softer diet
with the consistency of foods such as pasta, omelettes’ etc.
d. Do not chew gum, pen tops, pencils, nails etc. as these habits will all produce unneeded extra strain
in your chewing system.
e. Apart from when you are eating you should keep your teeth apart.
f. Examine your posture and try and maintain your head up and shoulders back. Examine your usual
positions during the day for instance working at a desk and ensure that they are ergonomic.

2. Practice diaphragmatic breathing to aid relaxation.

When first starting to learn how to perform this type of breathing it is easiest to practice it whilst lying down in a
dimly lit room without distractions. Concentrate on taking deep slow breaths in through your nose and feeling your
chest expand with your hands on your stomach. Your hands will move inwards and slightly upwards if you are doing
it correctly. Once you master the breathing there is no absolute need to lie down or be in a dimly lit room, you can
just use the technique for five minutes every two hours to aid relaxation and whenever you start to feel tension or
stress develop through the working day.
 3. Thermal modalities [149, 150] (demonstrated at this link.)

Apply moist heat or ice to affected muscles, areas on your head, face and neck where you feel pain. For some people
heat benefits, for others cold feels more effective. Trying heat for 3 days and then cold for 3 days may help provide
information as to which works for you. A warm moist flannel wrapped around a proprietary heat pack or warm hot
water bottle will provide moist heat. Apply for 15-20minutes twice daily to the affected muscles. You can then go
onto performing and prescribed exercises; if you have limited opening it will be beneficial to apply moist heat prior
to your stretching exercises.

Ice can be applied to affected muscles using an ice pack wrapped in a tea towel placed onto the skin overlying the
affected muscle until the muscle feels frozen and numb (usually within 5 -10 minutes of application of covered ice
pack).

4. Facial massage [149, 150](demonstrated at this link. )

Temporalis muscle (in your temple): Using index and middle fingers apply gentle pressure to temporal region either
side of the head. Make small circular motions applying pressure to any tender regions.

Masseter muscle (in your cheek in front of your ear): Place left thumb inside the right cheek, the left index finger
outside the right cheek. Between the thumb and index finger is the masseter muscle. Gentle squeeze thumb and
finger together to apply pressure to the muscle. The muscle should be stretched from top to bottom and back to
front.

Massages should be completed for one minute per muscle three times a day, using freshly washed (clean) hands.

5. Coordination training [149, 150, 241, 242](demonstrated at this link.)

i) Practice the retrusive position of your jaw (‘n-stretch’). Open normally and then curl your tongue to the top and
back of your mouth. You should feel your jaw move backwards slightly. Keeping your tongue in this position close in
a slow controlled manner over five-six seconds (one set). Complete 20 repetitions up to four times a day.

ii) Practice opening straight in the mirror and use a hand lightly on either side of your face to gently guide you to
straight opening if you are moving off to one side ('n-stretch combined"). Do this in a slow, controlled manner over
five-six seconds (one set). Complete five-six sets up to four times a day.
Additional techniques for use in specific circumstances

Isometric tension exercises [149, 150, 241](demonstrated at this link.)

Isometric tension exercises for use with muscular TMD

Only complete this if you have been told that your TMD has a muscular origin (M-TMD).

Place the back of your hand under your lower jaw and provide gentle resistance upwards as you try to open. Try and
open against this resistance and hold your opening against this resistance for five-six seconds (one set). Complete
five-six sets up to four times a day.

The same exercise is completed with gentle pressure placed to the side of your lower jaw while you open and move
your jaw to one side. Again, opening with lateral movement should be against gentle resistance and at maximum
opening laterally opening should be help against the resistance for five to six seconds. Complete five-six sets up to
four times a day.

Isometric tension exercises for disc displacement with reduction [151]

Only complete this if you have specifically been told you have a disc displacement with reduction.

Place the back of your hand under your lower jaw and provide gentle resistance upwards as you try to open and
push lower jaw forwards (protrude jaw) whilst opening. Complete 10 repetitions each held for 5-6 seconds 2-3 times
a day.

Static stretching for reduced mouth opening [149, 150, 241] demonstrated at this link.

Only complete these if you have been told by a professional that your mouth is not opening fully.

i) Apply thermal modality (as above) to jaw joints for 5 minutes prior to static stretch exercises.

ii) Gently open to point of maximum opening

iii) place your index fingers on the lower canine teeth and your thumbs on your upper canine teeth (fingers and
thumbs will be crossed)

iv) Stretch gently for 30 seconds to the point of discomfort and a small amount further and hold for 30 seconds

v) Complete 5-6 repetitions up to 3 times per day

Mobilisation for disc displacement with reduction and limited opening [149] demonstrated at this link.

Only use if you have been told by a professional that you have a diagnosis of disc displacement with reduction and
limited opening.

i) Lightly hold a small cotton wool roll between your upper and lower front incisor teeth.

ii) While gently holding the cotton wool roll move the lower jaw to one side then back to the center over 5-6 seconds

iii) Continue to gently hold the cotton wool roll and move to the lower jaw to the opposite side over 5-6 seconds

iv) 5-6 repetitions should be completed 3-4 times daily with each movement made over 5-6 seconds in a slow
controlled manner

Step 4: Review, reassess CPI and initiate onward management plan[243]

At 6–8-week review appointment CPI should be reassessed and compared to baseline. (Appendix 9)

At this point if CPI is worsened, unchanged or improved by <10% from baseline then onward referral to local unit
managing TMD is advised.

If CPI has decreased by 10-30% from baseline, then adjunctive care is advised as outlined in the below section.

If CPI has decreased by >30% from baseline the ongoing SSM should be advised for TMD maintenance and TMD
symptoms should be re-assessed at routine dental health check appointments.

Regardless with CPI change any individual who is comfortable and happy to go to maintenance there is no objective
need to progress with further therapy at that stage and maintenance can be initiated.

Step 5: Adjunct care

For individuals at review whose CPI has decreased by 10-30% from baseline additional adjunctive management to
support supported self-management strategies may be beneficial at this point. It is advised for myogenous TMDs
adjunctive options to discuss and plan in consultation with the patient include splint therapy, acupuncture or
physiotherapy (accessed as outlined in management section). For arthrogenous TMDs acupuncture, physiotherapy
or topical utilization of NSAIDS to skin overlying TMJ may provide additional relief and should be discussed openly.
Should adjunctive treatment be initiated a further 6–8-week review appointment should be made, at this point CPI
reassessed and ongoing management determined as step 4 of flowchart onwards.
Step 6: Onward management

Should shared decision making determine that pharmacological management is appropriate for an individual living
with myogenous TMD, subject to no contraindications neuromodulatory options, their risks, potential benefits and
side effects (outlined in Table 10) should be discussed. If the decision is made to utilise neuromodulatory agents,
Appendix 12 provides suggested dosing regimens.

Unfortunately, if all management step 6 management options there is likely to be little further that can be offered.

A national virtual MDT opinion may be appropriate, not in the case of exhaustion of management options but when
there is substantial complexity or comorbidity between a TMD and other conditions. This MDT is currently being
established and contact details will be provided in due course.
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