Temporomandibular Disorders (TMD)

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; language and communication needs; occupation or school; caregiving; and eating, communication, social, cultural, community, recreational or work activities important to the patient.

Primary concerns

• Context and onset: gradual or sudden onset; recent or remote jaw, facial, head or neck trauma; recent prolonged dental procedure or surgery; prior episodes; jaw locking or dislocation; training, work or other load change; and whether symptoms are improving, stable, fluctuating or worsening.
• Location and pattern: jaw, temple, face, preauricular, ear, dental, oral or neck symptoms; side; onset, duration, course, severity, irritability and pattern over the day and night; and whether pain spreads or occurs elsewhere in the body.
• Jaw symptoms: pain or stiffness with opening, chewing, biting, yawning, talking, singing or sustained mouth opening; limited or asymmetric movement; open or closed locking; clicking, popping or crepitus; jaw fatigue; and any change in how the teeth meet.
• Associated symptoms: headache, facial sensory change, weakness, dizziness, ear pain, pressure, tinnitus, hearing change, nasal or throat symptoms, oral lesions, fever, swelling, weight change, sleep disturbance, snoring, witnessed apnoea, daytime sleepiness and other systemic or neurological symptoms.
• Impact and participation: eating and nutrition, speaking, oral hygiene, sleep, intimacy, work, school, caregiving, exercise, recreation, social contact and other valued activities.
• Body systems review: constitutional and infectious; neurological and headache; eyes, ears, nose and throat; oral and dental; cardiovascular and vascular; respiratory and sleep-related breathing; gastrointestinal and genitourinary; inflammatory or immune; musculoskeletal and widespread pain; endocrine or metabolic; bone health; skin; haematologic; mental health; and reproductive systems when findings may change safety, the differential diagnosis, care or referral.
• Oral, dental and jaw history: dental pain or sensitivity, decay, periodontal concerns, recent dental care, orthodontic or occlusal treatment, dentures or appliances, oral lesions, bruxism or clenching, gum chewing, nail biting and other sustained or repetitive jaw activities. Explore behaviours without assuming that any one behaviour caused the TMD.
• Health, lifestyle and history: headache or migraine, inflammatory arthritis, sleep disorder, widespread pain, fibromyalgia, irritable bowel syndrome, mental-health concerns, cancer, infection and bone-health conditions; facial, jaw or cervical injury; surgery or radiation; medications and supplements, including antiresorptive drugs, anticoagulants and corticosteroids when relevant; allergies; physical activity; sleep; nutrition; smoking; alcohol; substance use; and relevant family history.
• Social determinants of health: work or school demands and supports, caregiving, income, housing, food security, transportation, safety, discrimination, social support and access to dental, medical, rehabilitation and mental-health care when these may shape health, care or participation (Public Health Agency of Canada, 2026a).
• Previous care and responses: education, self-management, exercise, hands-on care, medication, dental appliance, injection, investigation, surgery or other care tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, cultural context, concerns about pain, joint sounds, bite or damage, expectations, confidence with jaw use, strengths and previous experiences of care.
• Case identification: the TMD Pain Screener or 3Q/TMD can support history taking when TMD is suspected. A positive screen does not diagnose TMD and does not replace examination or the differential diagnosis (Beecroft et al., 2025; Schiffman et al., 2014).
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess if the symptom pattern, jaw movement, nutrition or general health changes.

Outcome measures

• Use a small set that reflects the patient’s goals and is practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF when it fits the clinical question.
• Jaw-specific functioning: the 8-item Jaw Functional Limitation Scale (JFLS-8) when a condition-specific measure will inform care.
• Symptoms and performance: a pain rating and a small number of repeatable findings or tasks relevant to the person’s goals, such as comfortable mouth opening, chewing, eating, speaking, yawning or sleep.
• Individual goals: agree on patient-defined goals and how progress will be recognized.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working presentation, care or referral. Adapt the pace, positioning and extent of examination to the patient’s symptoms, comfort, consent and abilities.

• Consent and comfort: explain the proposed head, neck, facial and intraoral examination, seek ongoing consent, use gloves for intraoral contact, and provide choices about positioning, pace, a support person or chaperone and any area the patient does not want examined.
• Observation and general assessment: general appearance, distress, facial symmetry, swelling, skin or oral change, jaw posture, speech, protective behaviour and opening or closing pattern. Assess vital signs when vascular, infectious or other systemic concern makes them relevant.
• Oral, dental and regional screening: inspect oral tissues and dentition within competence and scope; palpate for relevant face or neck mass, lymphadenopathy or salivary-gland change; and arrange dental or medical assessment when local pathology cannot be excluded.
• Mandibular movement: assess active opening, assisted opening when safe, protrusion and lateral excursion; note range, movement quality, deviation or deflection, end feel, familiar pain and open or closed locking. Use the same measurement method at follow-up when range will guide care (Schiffman et al., 2014; Beecroft et al., 2025).
• Temporomandibular joints and joint sounds: palpate the lateral joint region during repeated opening, closing, protrusion and lateral movement; record familiar pain, tenderness, swelling, clicking, popping or crepitus and whether joint noise is painful or limits activity. Painless noise alone does not establish a need for care (Schiffman et al., 2014; National Institute of Dental and Craniofacial Research, 2026).
• Masticatory muscles: palpate the temporalis and masseter in a standardized manner for familiar pain, local pain, spreading within the muscle or referral beyond the muscle. Routine palpation of inaccessible pterygoid regions adds limited diagnostic value (Schiffman et al., 2014; Beecroft et al., 2025).
• Neurological examination when indicated: facial movement and sensation, trigeminal sensory territories, relevant cranial nerves, limb findings, gait, balance and other neurological tests indicated by facial sensory change, weakness, dizziness, atypical pain, headache or another safety concern.
• Headache, ear and cervical assessment: assess headache features and whether familiar temporal headache is modified or reproduced by jaw use or examination; screen the ears, cervical spine, upper quarter and other relevant regions when symptoms suggest an overlapping or alternative source.
• Functional assessment: select safe tasks relevant to the patient’s goals, such as chewing foods of different consistency, speaking, yawning, oral hygiene or sustained mouth opening. Avoid unnecessary provocation in acute lock, dislocation, fracture or marked irritability.
• Imaging and investigations: imaging is not routine for an uncomplicated painful TMD presentation and does not replace history and examination. Coordinate imaging when fracture, tumour, inflammatory or degenerative disease, internal derangement or another diagnosis is suspected and the result is likely to change care. Cone-beam CT or CT is suited to osseous assessment; MRI is suited to the disc, joint effusion and other soft-tissue concerns (Mallya et al., 2022; Beecroft et al., 2025).
• Reassessment: repeat the findings and functional tasks needed to review progress, adverse effects, the working presentation and any change requiring dental, medical or specialist assessment.

Diagnostic framework

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) combines Axis I physical diagnoses with Axis II assessment of pain intensity, pain-related disability, jaw limitation and psychosocial functioning. Use the current DC/TMD instruments and examination specifications when applying the framework. A screening result alone does not establish a diagnosis (Schiffman et al., 2014).

• Pain-related TMD diagnoses: myalgia, including local myalgia, myofascial pain and myofascial pain with referral; arthralgia; and headache attributed to TMD. The required history and examination reproduce familiar pain or headache in the relevant region and show that jaw movement, use or parafunction modifies the symptoms (Schiffman et al., 2014).
• Common intra-articular TMD diagnoses: disc displacement with reduction; disc displacement with reduction with intermittent locking; disc displacement without reduction with limited opening; disc displacement without reduction without limited opening; degenerative joint disease; and subluxation. History and examination support the working diagnosis, and imaging is used selectively when confirmation will change care (Schiffman et al., 2014; Mallya et al., 2022).

Working clinical presentations

Outside a specialist diagnostic assessment, describe the dominant clinical features and uncertainty rather than implying a definitive disc, joint or muscle lesion. Presentations can overlap or change (Beecroft et al., 2025; National Institute of Dental and Craniofacial Research, 2026).

• Myogenous presentation: familiar pain in the masseter or temporalis that is modified by jaw use and reproduced with relevant movement or palpation. Stiffness, fatigue, headache or cervical symptoms may coexist.
• Arthrogenous presentation: familiar pain localized to the joint region and reproduced by palpation or jaw movement. Joint sounds, movement restriction or locking may be present but are not required for arthralgia.
• Combined myogenous and arthrogenous presentation: both masticatory-muscle and joint features contribute to symptoms or activity limitation.
• Headache attributed to TMD: familiar temporal headache is modified by jaw movement, use or parafunction and is reproduced by examination of the temporalis or jaw movement. Continue to assess primary and secondary headache causes rather than assuming all headache is TMD-related.
• Mechanical joint presentation: clicking, intermittent catching, closed lock, open lock or restricted movement may suggest disc displacement or subluxation. Painless joint noise is common, and the need for imaging or referral depends on pain, locking, nutritional impact, severity and whether the result will change care.
• Alternative or overlapping presentation: dental, oral, ear, nose, throat, headache, cervical, neuralgic, inflammatory, sleep-related breathing, systemic pain or other conditions may overlap with TMD. Refer or coordinate care when needs extend beyond the clinician’s role.

Develop care with the patient using the working presentation, safety, goals, preferences, culture, access, other health conditions, previous responses and observed change. Begin with reversible options and avoid treating one structure, bite feature or habit as the required treatment target (National Institute of Dental and Craniofacial Research, 2026; Beecroft et al., 2025).

Education, self-management and participation

• Explanation and reassurance: options include a clear explanation of the working presentation, the generally favourable course of many TMD presentations, the meaning of painless joint sounds, and the limited relationship between pain and bite or imaging findings (National Institute of Dental and Craniofacial Research, 2026; Beecroft et al., 2025).
• Supported self-management: options include comfortable jaw movement, self-massage, heat or cold, temporary food-texture changes during a flare, awareness of clenching or repetitive jaw activity, sleep support, pacing and a written flare plan. Select only the strategies that fit the presentation and patient (Beecroft et al., 2025; National Institute of Dental and Craniofacial Research, 2026).
• Participation planning: maintain or resume eating, communication, oral hygiene, work, school, caregiving, recreation and social activities using temporary adaptations when needed. Progress toward the patient’s usual activities as comfort, movement and confidence improve.

Protection and optimal loading

• Short-term load modification: reducing gum chewing, nail biting, prolonged mouth opening, very hard or chewy foods, sustained clenching or another clearly aggravating task can form part of care during an irritable period. Avoid prolonged restriction or a liquid-only diet unless medically or dentally required (Beecroft et al., 2025; National Institute of Dental and Craniofacial Research, 2026).
• Progressive jaw use: reintroduce food textures, comfortable range, speaking, yawning and other jaw tasks using symptom response, nutritional needs, activity demands and patient confidence. Acute lock, dislocation, fracture or marked nutritional restriction follows Red Flags.

Physical activity and exercise

• Jaw exercise and movement retraining: individualized coordination, relaxation, range-of-motion, stretching, endurance and graded chewing or task practice can form part of care. For persistent TMD, supervised jaw exercise and stretching are supported options. Type, amount and progression reflect the presentation, irritability, goals and response (Busse et al., 2023; Beecroft et al., 2025).
• Postural and cervical exercise: for persistent TMD, supervised postural exercise can accompany jaw-focused care when neck symptoms, movement findings or activity demands are relevant (Busse et al., 2023).
• General physical activity: maintain or gradually build physical activity that is safe, meaningful and feasible, particularly when sleep, mood, general conditioning or persistent pain affects participation.

Hands-on and symptom-relieving care

• Jaw mobilization and soft-tissue care: for persistent TMD, therapist-assisted jaw mobilization and manual trigger-point therapy can accompany active care when a short-term change in pain or movement helps participation. Avoid forceful techniques with acute lock, marked irritability or suspected serious pathology (Busse et al., 2023; Beecroft et al., 2025).
• Other symptom-relieving options: heat or cold, comfortable positioning and self-massage can be used when safe, acceptable and linked to a symptom or participation goal. Acupuncture is an option for persistent TMD. Review whether the option adds useful benefit (Busse et al., 2023; National Institute of Dental and Craniofacial Research, 2026).
• Culturally grounded and personal strategies: traditional, Indigenous, spiritual, community-based or other approaches identified by the patient can be included when safe, acceptable, within scope and coordinated with the patient’s chosen practitioners.

Psychological, social and interdisciplinary support

• Psychologically informed care: supportive communication, relaxation, graded exposure and coping skills can form part of care when distress, fear, low confidence, mood or sleep affects activity. Cognitive behavioural therapy is an option for persistent TMD. Coordinate mental-health care when needs extend beyond competence or scope (Busse et al., 2023; Beecroft et al., 2025).
• Social and practical support: workplace, school, caregiving, food access, financial, transportation and care-access barriers can be addressed through practical accommodations, community resources or another appropriate professional when possible.
• Interdisciplinary care: coordinated dental, primary-care, rehabilitation, oral medicine, neurology, headache, sleep, mental-health, dietetic or pain care can fit persistent disabling symptoms, comorbidity, nutritional restriction or diagnostic needs that one clinician cannot address.

Dental, medication and procedural shared care

• Medication review: review current use, intended benefit, adverse effects, interactions and relevant gastrointestinal, renal, cardiovascular, bleeding, sedation or dependence risk with an authorized prescriber or pharmacist. Evidence for medication in TMD is limited, and selection, prescribing and dosing remain with that provider. NSAIDs combined with opioids do not form part of care for chronic TMD pain (National Institute of Dental and Craniofacial Research, 2026; Busse et al., 2023).
• Reversible occlusal appliance: dentist-led shared decision-making about a full-coverage appliance can fit selected cases, but routine appliance use for chronic TMD pain is not supported. It is not stand-alone care, and fit, symptoms, tolerance and bite require monitoring. Stop use and arrange dental review if pain or bite changes worsen (Beecroft et al., 2025; Busse et al., 2023; Royal College of Dental Surgeons of Ontario, 2019).
• Irreversible or invasive procedures: routine conservative care does not include grinding teeth, crowns or orthodontic procedures intended to permanently change the bite, irreversible splints, discectomy, botulinum toxin, trigger-point or intra-articular injections, arthrocentesis or surgery. Arthrocentesis or another procedure can be assessed by an oral and maxillofacial specialist for selected severe closed-lock or structural presentations. Referral does not imply that a procedure is appropriate, and an informed second opinion can help clarify benefits, harms and alternatives (National Institute of Dental and Craniofacial Research, 2026; Busse et al., 2023; Beecroft et al., 2025).

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, nutritional impact, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, jaw movement, eating and speaking, sleep, relevant neurological or oral findings, functioning, participation, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, dental or medical differential, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: many TMD presentations improve or become manageable with time and conservative care, while some persist or recur. Joint sounds and disc or degenerative findings often remain stable and do not determine pain or activity. Use the person’s observed course rather than a promised timeline (National Institute of Dental and Craniofacial Research, 2026; Beecroft et al., 2025).
• Factors associated with a less favourable course: greater pain and interference, longer symptom duration, widespread pain, fibromyalgia, headache, sleep disturbance, anxiety, depression, post-traumatic stress, social stress and difficulty accessing coordinated care may be associated with persistent painful TMD. These factors do not prove cause or determine an individual’s outcome (Beecroft et al., 2025).
• Potential supports for recovery: a clear working diagnosis, confidence with safe jaw use, feasible self-management and exercise, supportive relationships, adequate nutrition and sleep, practical accommodations and access to coordinated dental, medical and rehabilitation care may support recovery (Beecroft et al., 2025).
• Discussing prognosis: validate the person’s experience, describe uncertainty in plain language, ask what they want to know, and update the outlook using repeated outcomes and observed change. Do not treat an imaging finding, bite feature, behaviour or screening score as a fixed prediction.