Temporomandibular Joint Disorders

Overview

The following page is written to help General Practitioners and other Allied Health Professionals to recognise and support management of Temporomandibular Joint Disorders.

TMJ dysfunction/pain is a common symptom affecting up to 1 in 15 people in the UK (1) . If there are no red flags then this can usually be managed by General Dental Practitioners (GDPs) using conservative measures. There are useful guidelines on assessment and treatment in Clinical Knowledge Summaries (2):

• Temporomandibular disorders

Patients presenting to their GP should usually be advised to see a GDP in the first instance for analgesic advice and bite splints where required (3). If a patient is unable to access a GDP then please see the Dental Care page for options.

Patients presenting with red flags or a pre-existing history of inflammatory joint disease, should be referred directly to an appropriate secondary care specialist for investigation/ management.

Assessment

Signs and Symptoms

Physical

• Pain (mild to moderate intensity) affecting TMJ, muscles of mastication (MOM) and supporting structures.
• Pain can radiate widely in the head, face and neck region.
• Joint noises (click, pop, crepitus)
• Ear pain (otalgia)
• Headache

Psychological and social

The multifactorial aetiology of TMD means that several biological, psychological and social factors are expected to interplay in individuals living with TMD. It is important to assess psychological and social factors that can increase the risk of symptomatic TMD becoming persistent. Signs and symptoms include stressful home or work life, impact of pain on mood, sleep, social activities and eating. 

Comorbid conditions
There are several comorbidities consistently associated with persistent painful TMD that can be associated with a poorer prognostic outcome. Common comorbidities include: Fibromyalgia, ME/CFS, depression, anxiety, post traumatic stress disorder, migraine, chronic tension type headache, irritable bowel syndrome, vulvodynia, interstitial cystitis/painful bladder syndrome, endometriosis, chronic lower back pain.

Screening Tool

3Q/TMD - score 1 point if answering yes to the each of the following questions:

• Do you have pain in your temple, face, jaw, or jaw joint once a week or more? 
• Do you have pain once a week or more when you open your mouth or chew?
• Does your jaw lock or become stuck once a week or more?
• Total Score = ≥1 point = positive screen for TMD

If Score is 1 or more then this is a positive screen for TMD.

Examination

Examination by a GP should include an assessment of any lymphadenopathy or salivary gland/ neck lumps and intraoral examination assessing for soft tissue pathology. Otherwise the patient should be advised to see a General Dental Practitioner for a thorough dental and TMJ examination.

Red Flags

See the Red Flag symptoms and signs section of CKS.

See also the Head & Neck incl Thyroid - USC (2WW) page for advice on criteria for referral for suspected cancer.

Management

If there are no red flags, then initial  management of TMD is usually undertaken initially by Dental Practitioners.

General Practitioners may also be involved in patient care if required to identify and manage comorbid conditions.

The Royal College of Surgeons Faculty of Dental Surgeons has produced documents to support management (1):

• A Clinician Support Document has advice for clinicians and management flow chart.
• A Patient Support Document  has advice on self care and other resources.

Referral

Patients should see a General Dental Practitioner for initial assessment and advice on treatment (see above).

The Commissioning Guide (3) advises that consideration should be given to referring a patient to local Oral & Maxillofacial services (via dentist referral or via GP referral using eRS) if they meet any of the following criteria:

• Refractory TMJ dysfunction- defined as dysfunction that has failed to respond to conservative or primary care measures after 6 months
• Limitation or progressive difficulty in mouth opening
• Persistent inability to manage a normal diet
• Pain or reduced jaw function in patients with known rheumatic joint disease
• Recurrent dislocation of TMJ and or associated syndromes (e.g. Ehlers-Danlos)

Referral Forms

• NHS England — South West » Dental referral guidance and forms

Resources

(1) Clinical Guidelines — Royal College of Surgeons (2024). Links to comprehensive guidelines, clinician summary document, patient support document.

(2) CKS Temporomandibular disorders (2021)

(3) The British Association of Oral and Maxillofacial Surgeons and Royal College of Surgeons produced a Commissioning Guide for TMD in 2014.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.