TMD Clinical Pathway & Referral Generator

Setup

Patient & Clinician Details

Used to populate the referral letter. All fields optional but improve letter quality.

Patient

Full name

DOB

NHS Number

Age

Sex

GP Practice

Referring Clinician

Your name

Role

Practice / Surgery

Contact / GMC

Date of consultation

Step 1a

Red Flag Screening

Check any present. One positive = urgent/2WW referral. Do not proceed with TMD pathway if red flags present.

Urgent referral criteria (non-red-flag)

Patient <25 years old with substantial decreased mouth opening (<25mm) → Urgent referral to maxillofacial surgery Severe disc displacement without reduction (closed lock) affecting nutrition → Urgent referral to maxillofacial surgery

Step 1b · Screening Tool

3Q/TMD Screener

Score ≥2 = positive screen for TMD. Complete at baseline.

Q1. Do you have pain in your temple, face, jaw, or jaw joint once a week or more?

No (0) Yes (1)

Q2. Do you have pain once a week or more when you open your mouth or chew?

No (0) Yes (1)

Q3. Does your jaw lock or become stuck once a week or more?

No (0) Yes (1)

3Q/TMD Score: —

Step 1c · Screening Tool

PHQ-4 Assessment

Formally assess symptoms and impact of anxiety and depression. Complete at baseline.

Step 1d & Follow-up · Pain Intensity

Characteristic Pain Intensity (CPI)

Record at baseline and each follow-up. CPI = (Q1 + Q2 + Q3) × 10 ÷ 3. Change from baseline drives pathway decisions.

Baseline CPI (appointment 1)

Q1 — Pain right now (0–10) 5

Q2 — Worst pain past month (0–10) 5

Q3 — Average pain past month (0–10) 5

Baseline CPI: 50

Follow-up CPI (6–8 weeks post-SSM)

ℹ️ Complete after 6–8 week SSM trial. CPI change determines next step: <10% change → refer; 10–30% → continue + adjunct; >30% → maintenance.

Q1 — Pain right now (0–10) 5

Q2 — Worst pain past month (0–10) 5

Q3 — Average pain past month (0–10) 5

Follow-up CPI: 50 Change: —

Step 1e · Clinical

Examination Findings

Document physical findings. Tick items examined and note abnormals.

Extra-oral / General

Visual exam of extra-oral tissues — face and neck Palpation to exclude lymphadenopathy or salivary gland masses Assessment of cranial nerve function (facial + trigeminal at minimum)

Extra-oral abnormal findings (if any)

Intra-oral / Dental

Intra-oral exam for soft tissue pathology Clinical ± radiological assessment to exclude dental/periodontal pathology

Intra-oral abnormal findings (if any)

TMJ Assessment

Palpation of lateral pole of TMJ Mandibular motion assessed (opening, closing, protrusion, lateral excursions) × 3 Joint noise assessed (positive if reported by patient in last 30 days) Mandibular deviation on opening assessed

Max inter-incisal opening (mm)
Normal ≥35mm

Protrusion (mm)
Normal 7–12mm

Left lateral excursion (mm)

Right lateral excursion (mm)

Joint noises / deviation notes

Muscles of Mastication (MOM)

Masseter examined origin to insertion, bimanual where possible Temporalis examined origin to insertion Familiar pain elicited on palpation of MOM

MOM findings (trigger points, radiation)

Step 2–3 · Management

Diagnosis & Supported Self-Management (SSM)

Record diagnosis, patient education given, and SSM components initiated.

Broad Group TMD Diagnosis

Myogenous TMD (M-TMD) — pain in muscles of mastication ± restricted opening, modified by jaw movement/parafunction Arthrogenous TMD (A-TMD) — familiar pain on palpating/moving joint ± joint noise, lock, deviation Combined Myogenous and Arthrogenous TMD TMD diagnosis under review / unclear

Additional diagnostic notes

SSM Components Initiated (record what was covered)

1. Diagnosis + education about condition and appropriate analgesic use 2. Self-exercise therapy (jaw exercises) 3. Thermal modalities (heat/ice application) 4. Self-massage therapy 5. Diet and nutrition advice 6. Parafunctional behaviour advice (clenching, bruxism)

SSM duration / review plan

Resources signposted

Comorbidities identified

Other comorbidities / notes

Step 5 · Adjunct Management

Adjuncts Considered / Tried

Document any adjuncts considered or initiated after initial SSM review (step 5 of pathway).

For Myogenous TMD (M-TMD)

Stabilisation splint — discussed / issued Acupuncture — discussed / referred Physiotherapy — discussed / referred

For Arthrogenous TMD (A-TMD)

Acupuncture — discussed / referred Physiotherapy — discussed / referred Topical NSAIDs — discussed / prescribed

Medication (secondary care, or following failure of above)

Amitriptyline (1st line M-TMD) — discussed / prescribed Gabapentin (2nd line M-TMD) — discussed / prescribed Duloxetine (M-TMD alternative) — discussed / prescribed

Reason for referral to secondary care

CPI unchanged or decreased <10% after SSM ± adjuncts CPI decreased <10% with continuing problems Severe arthrogenous TMD: CPI >50, dietary restriction, mouth opening <30mm, ± skeletal/occlusal derangement Persistent pain with significant patient distress despite full SSM trial Other (specify below)

Other reason / free text

Output

Referral Letter Generator

Based on your documented pathway. Copy and paste into your system.

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This tool generates a letter based on data entered. Clinicians are responsible for reviewing and supplementing the content prior to sending. This tool is a documentation aid only and does not constitute clinical advice.