Temporo-Mandibular Joint Dysfunction

With rising referrals for TMJD, please find below the link to the East Kent University NHS foundation trusts referral information page. To access the information regarding TMJD advice please select ‘Maxillofacial – Oral Surgery’ and scroll down to the section TMJD; alternatively, the information is below.

https://www.ekhuft.nhs.uk/health-professionals/referrals/

Taken from EKUFT website:

TMJD:

EKUFT follows the current 2024 TMJD guidelines published by Royal College of Surgeons.

Our strict acceptance criteria for TMJD include:

1. Refractory TMJD- (failed to respond to non-surgical conservative management for 6 months (including advice, self-care management strategies and bite guard made by GDP and worn by the patient for a few months at least).
2. Limitation or progressive difficulty in mouth opening
3. Persistent inability to manage a normal diet
4. Pain or reduced jaw function in patients with known rheumatic joint disease
5. Recurrent dislocation of TMJ and or associated syndromes (e.g. Ehlers-Danlos)

Patients who do not need management within the Hospital setting will be discharged back to the referring practitioner with advice based on non-invasive management strategies. Referrers are encouraged to seek guidance using 2021 NICE guidelines on TMJD and 2024 Royal College of Surgeons guidelines for TMJD. The key advice is provided below for your reference:

TMJD advice for PRIMARY CARE GPs and Dentists 

• Provide reassurance the condition is usually non-progressive, and that symptoms may fluctuate, but should improve.
• Educating the patient about the condition, including the nature of the disorder, the significance of predisposing, precipitating and perpetuating factors, the anatomy of the temporomandibular joint, management options, and therapy goals.
• Encouraging self-management to help control symptoms and limit functional impairment. Advise them:
  • To eat a soft diet and rest the jaw if there is acute pain.
  • To try to avoid parafunctional activities that may exacerbate symptoms, such as wide yawning, teeth grinding or jaw clenching, chewing gum or pencils/pens, and nail biting, using teeth to open bottles.
  • Local measures such as applying covered ice or a warm flannel or heat pad, or massaging affected muscles may be helpful.
• GPs should advise the patient they must see a primary care dentist — to check dental health or dental pathology, or for consideration of an intra-oral device (an occlusal splint).
• GPs and Dentists – to assess patient’s stress levels and provide advice on stress management in helping manage TMJD.
• Primary care Dentists – provide the patient with a lower bilaminate splint or soft bite raising appliance (ensure all posterior teeth are covered with the splint to avoid over-eruption of teeth).
• GPs and Dentists – Consider prescribing:
  • Simple analgesia for short-term use, such as paracetamol or a nonsteroidal anti-inflammatory drug (NSAID).
  • GPs can consider prescribing additional drug treatment if appropriate:
    • A short course of a low-dose benzodiazepine such as diazepam 2 mg up to three times daily, for a maximum of 2 weeks if symptoms are acute and severe.
    • A trial of amitriptyline or gabapentin for people with chronic pain
  • Manage comorbidities:
    • Try to identify sources of stress, and give advice on relaxation techniques, setting realistic targets, pacing activities, and getting social support where available. Manage any depression
    • Understand that certain SSRI anti-depressants can cause parafunctional behaviour and initial clenching and grinding for patients – consider alternative anti-depressant medication which do not initiate these side effects.
    • Give advice on sleep hygiene.
• Provide sources of information and advice, such as:
  • The NHS patient information leaflet Temporomandibular disorder. – https://www.nhs.uk/conditions/temporomandibular-disorder-tmd/

• • The British Association of Oral Surgeons leaflet Temporomandibular (jaw) joint problems. – https://www.baos.org.uk/resources/Temporomandibular(Jaw)JointProblems.pdf

• • East Kent Hospitals University Foundation Trust patient information leaflets on TMJD and jaw joint exercises
• Consider referral to additional specialists if appropriate, for example:
  • Psychology services — for cognitive behavioural therapy (CBT), if there is marked psychological distress associated with symptoms, or to help with pain-related anxiety.
  • Physiotherapy — for advice on passive jaw stretching exercises, posture training, and massage or acupuncture to help relax muscle spasm, if available.

RCS patient summary guide with exercises and QR code for YouTube videos:

https://www.rcseng.ac.uk/-/media/FDS/TMD-Patient-support-document.pdf

RCS comprehensive guide to TMJD:

https://www.rcseng.ac.uk/-/media/FDS/Comprehensive-guideline-Management-of-painful-Temporomandibular-disorder-in-adults.pdf