Temporomandibular disorders (TMDs):

How should I assess a person with a

suspected temporomandibular
disorder?
Last revised in August 2021
When assessing a person with a suspected temporomandibular disorder (TMD) take
a biopsychosocial approach:
Ask about:
The location, radiation, onset, character, and duration of any orofacial pain.
Check for any precipitating factors or triggers, such as a complicated dental
extraction or other facial trauma.
Ask if the pain is bilateral or unilateral.
Ask if the pain is in the morning.
Check for any exacerbating factors, such as chewing, talking, kissing, yawning, or
prolonged mouth opening.
If there is pain on biting or chewing, ask about any parafunctional activities (such
as teeth clenching and grinding during sleep or when awake [bruxism], nail biting,
or excessive mouth opening during yawning).
Consider using a self-completed pain questionnaire
(https://buffalo.app.box.com/s/qh3s5y5yi1sjadyy7mmskjdtshpihc2e) such as that
developed by the International Association for Dental Research — a score of 3 or
more is a positive screening result indicative of a TMD.
Any associated pain (for example, head and neck pain) or other features (such as
locking or clicking of the jaw, difficulty opening the mouth, altered skin sensation, or
any nasal or ear symptoms).
Any recent injuries to the jaw, head, or neck.
The impact of symptoms on the person's quality of life (for example on sleep, mood,
concentration, energy levels, and pain beliefs).
Any associated comorbid conditions (such as fibromyalgia, widespread chronic pain,
migraine, or inflammatory joint diseases).
Any psychosocial factors that may be contributing to symptoms (such as stress,
anxiety, depression, or insomnia).
The person's pain beliefs and expectations, and social support available.
Any previous treatments and duration, if appropriate.
 Examine the person's head and neck:
Assess for facial or mandible asymmetry, or any facial swelling.
Assess for any cranial nerve deficits.
Exclude any obvious dental pathology by examining the mouth to assess the hard
and soft palate, the teeth, and gums.
Bruxism may be suggested by dental damage and enamel erosion.
Palpate the temporomandibular joint (TMJ) by pressing anterior to the tragus of the
ear bilaterally. Assess for TMJ tenderness; the range of movement of the mandible;
pain on movement or on maximum mouth opening; and for any associated joint
noises or crepitus.
Maximal mandibular opening is 42 to 55 mm, but may be reduced to less than 35
mm in people with TMD.
Palpate the muscles of mastication and head and neck muscles, to assess for
tenderness, trigger points, or hypertrophy. Examination of the muscles of
mastication is best performed with the person's teeth clenched.
Check for lymphadenopathy.
In people aged over 50 years with new onset TMD symptoms check the temporal
pulses.
Exclude other causes (/topics/temporomandibular-disorders-
tmds/diagnosis/differential-diagnosis/) of orofacial pain; check for red flags
(/topics/temporomandibular-disorders-tmds/diagnosis/assessment/#red-flag-
symptoms-signs), and manage accordingly.
Imaging investigations are not routinely recommended in primary care.

Red flag symptoms and signs

Red flags for orofacial pain include:
Previous history of malignancy — may indicate a new primary, recurrence, or
metastases.
Persistent or unexplained neck lump or cervical lymphadenopathy — may indicate a
neoplastic, infective, or autoimmune cause. See the CKS topic on Neck lump
(/topics/neck-lump/) for more information.
Persistent and worsening pain.
Jaw pain in people taking bisphosphonates (or other medicines where osteonecrosis
is known to be an adverse effect).
Concurrent infection.
History of recent head or neck trauma.
Neurological symptoms such as headache (for example progressive, abrupt onset,
or posture-related headache) or signs such as cranial nerve abnormalities with
sensory or motor function changes (for example, unilateral hearing loss, new onset
or unilateral tinnitus, vestibular dysfunction) — may indicate an intracranial cause, or
 malignancy affecting cranial nerve peripheral branches. See the CKS topic on
Headache - assessment (/topics/headache-assessment/) for more information on
clinical features that may indicate a serious secondary cause for headache.
Facial asymmetry, facial mass or swelling, or profound trismus — may indicate a
neoplastic, infective, or inflammatory cause. See the CKS topic on Head and neck
cancers - recognition and referral (/topics/head-neck-cancers-recognition-referral/)
for more information.
Recurrent epistaxis, purulent nasal discharge, persistent anosmia (loss of smell), or
reduced hearing on the ipsilateral side — may indicate nasopharyngeal carcinoma.
See the CKS topic on Head and neck cancers - recognition and referral
(/topics/head-neck-cancers-recognition-referral/) for more information.
Unexplained fever or weight loss — may indicate malignancy, immunosuppression,
or an infective cause such as septic arthritis, osteomyelitis, intracranial abscess, or
mastoiditis.
New-onset unilateral headache or scalp tenderness, jaw claudication, and general
malaise, especially if the person is over 50 years of age — may indicate giant cell
arteritis. See the CKS topic on Giant cell arteritis (/topics/giant-cell-arteritis/) for
more information on diagnosis and management.
Occlusal (bite of teeth) changes — may indicate neoplasia, rheumatoid arthritis,
trauma, or bone growth around the temporomandibular joint (for example in
acromegaly). See the CKS topic on Rheumatoid arthritis (/topics/rheumatoid-
arthritis/) for more information on the diagnosis and management of inflammatory
arthropathies. Note: synovitis of the TMJ may not present with classical joint
tenderness or swelling.
[Durham, 2013 (/topics/temporomandibular-disorders-tmds/references/); AAOMS,
2014 (/topics/temporomandibular-disorders-tmds/references/); Schiffman, 2014
(/topics/temporomandibular-disorders-tmds/references/); Durham, 2015
(/topics/temporomandibular-disorders-tmds/references/); Ghurye, 2015
(/topics/temporomandibular-disorders-tmds/references/); Lomas, 2018
(/topics/temporomandibular-disorders-tmds/references/); NICE, 2021
(/topics/temporomandibular-disorders-tmds/references/)]
Basis for recommendation
Show

© NICE (National Institute for Health and Care Excellence) 2022. All rights reserved. Subject to Notice of
rights (https://www.nice.org.uk/terms-and-conditions#notice-of-rights).