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Assessment and Treatment of Temporomandibular Disorders

Original Editor - Ewa Jaraczewska based on the course by Micaela Weinberg Top Contributors - Ewa Jaraczewska and Jess Bell

Introduction

Successful management of temporomandibular disorders (TMD) requires a comprehensive assessment and individualised treatment. TMD typically responds well to conservative management,[1] with many patients experiencing significant improvement within three to six weeks. This page covers the TMD subjective and objective assessments and introduces essential treatment principles.

Subjective Assessment

The subjective assessment begins with broad, open-ended questioning (e.g., "Tell me why you're here today"). This approach allows patients to share their experience.[2] [3] Once the patient has shared their initial complaint, guide them to elaborate. Avoid leading questions initially; instead, let the patient provide details before narrowing the focus to specifics.[2]

The subjective assessment for TMD should cover three key areas: the temporomandibular joint, the muscles of mastication, and associated conditions. Be thorough and make sure you explore everything before progressing to the next area.[2]

TMJ: ask about pain, sounds (including clicks, crepitus, squelches, or grating sensations) and other symptoms.[2]

Muscles of mastication: ask about masseter (cheek) symptoms, including fatigue after prolonged talking or chewing of specific food or for prolonged periods of time, pain, and swelling. For temporalis, ask about headaches, tenderness, and unusual sensations.[2]

Associated conditions: including headaches, ear symptoms and cervical spine symptoms.

Headaches: ask about headache location, unilateral vs bilateral and if it often occurs on one particular side, character (pulsating versus tension-type[4]), onset, and aggravating or relieving factors. Look for connections between the headache and the TMJ—does the headache worsen after prolonged talking, singing, or eating? Does it present on waking? These questions help identify the full scope of the problem.[2]

Ear symptoms: three key symptoms from the jaw include pain, tinnitus, and a sensation of fullness or blocked ears. When present, establish onset, timing, and perceived connections to jaw symptoms.[2]

Cervical spine symptoms: ask broadly about neck issues (pain, stiffness, etc.). Establish timing relative to the onset of jaw symptoms.[2]

Contextual Factors in TMD

Contextual factors are defined as "any aspects of the environment or surrounding circumstances that may influence, shape, or modify an event, decision, or outcome. These factors can be social, cultural, economic, political, environmental, or organisational in nature, and they vary depending on the specific setting or situation."[5]

Past history: provides context for current TMD symptoms. Ask about previous trauma, such as whiplash injuries, dental history (wisdom tooth extraction or extensive dental work) and facial trauma.[2][4]

Occupational and lifestyle factors: assess workstation ergonomics (e.g., screen position, desk set-up and phone use during the day)[6]; consider driving positions and mobile phone use[7]; find out about specific dietary habits (e.g., consuming a lot of tough or chewy foods).[8]

Parafunctional habits: inquire about jaw clenching, teeth grinding, jaw bracing, propping the chin on the hand, excessive gum chewing, nail biting, cheek biting, and pen chewing.[9] It's important to ask about sleep bruxism, but remember that patients are often unaware of nocturnal grinding or clenching. Signs include waking with clenched teeth, morning muscle soreness or temporal headaches, excessive tooth wear, scalloped lateral borders of the tongue, and indentations on the tongue or cheeks.

Sleep pattern/sleep problems: ask about sleep quality, duration, pillow type and height, and bite plate use.[10] Ask patients to bring their pillows and bite plate to the assessment.

Psychosocial factors: anxiety and depression can contribute to and result from TMD. [11] Explore these factors with compassion. If patients don't have anxiety or depression, move on to the functional impact of TMD. This helps patients recognise the broader impact of the condition. Questionnaires can help quantify the functional limitations and psychological impact of TMD.[12]

Medication history: this provides information about general health and factors that may be contributing to TMD. Note that selective serotonin reuptake inhibitors (SSRIs) and stimulant medications, such as Vyvanse, have been linked to bruxism.[13]

Previous treatment history: ask about prior treatments and outcomes to understand each patient's response to interventions, their motivation and expectations. Understanding prior interventions informs the current treatment approach.[2]

Red Flags in TMD

Red flags in TMD are relatively uncommon but must be identified. The following findings require immediate medical referral for further investigation.[14]

Temporal arteritis (also known as giant cell arteritis) is a systemic autoimmune vasculitis that causes rapid, irreversible blindness.[15] Patients present with a new-onset headache in the temporal region, marked tenderness, general malaise and fatigue. This condition predominantly affects women aged 50 years and older.

Jaw claudication is characterised by pain or fatigue in the masseter during clenching. It can be associated with temporal arteritis.[16]

Other red flags include recurrent tumours, cervical lymphadenopathy, facial asymmetry or swelling, a history of malignancy, and changes in facial nerve distribution.

Objective Assessment

The objective assessment can begin in the waiting room. Observe the patient’s natural postures and habits, such as head position while using a phone, bag carrying habits (e.g., side preference/dominance and the weight of the bag). Continue observing during the subjective interview.[2]

The formal objective assessment should evaluate posture, movement, range of motion, and palpation of the joint and muscles. It should also include a cervical spine assessment.

Postural Observation

Assess for facial muscle symmetry. Unilateral hypertrophy of the masseter suggests asymmetrical loading; bilateral hypertrophy with a rectangular jaw contour indicates chronic clenching. Check for masseter swelling or redness. Inspect teeth for craze lines, attrition, mandibular tori, and gum recession. Assess for kyphosis, scoliosis, forward head posture, and breathing patterns, including accessory muscle use and nose versus mouth breathing.

Movement and Range of Motion Assessment

Ask the patient to open their mouth, with them giving you feedback on the presence and location of any pain or sounds. Observe the range of motion and presence of mandibular deviation on opening.[17] Range of motion varies depending on the underlying pathology: patients with hypermobility have excessive opening, while those with capsular restriction or disc displacement have limited excursion. Mandibular deviation during opening could indicate a range of conditions, including disc displacement, capsulitis, or asymmetrical muscular activation.[17] A clicking sound at the TMJ indicates disc displacement, and crepitus indicates arthritic changes.   A popping sensation at the coronoid process indicates poor control of the temporalis muscle rather than a disc issue.

This optional video demonstrates how to measure TMJ range of motion.

[18]

Palpation

Palpate the joint at rest and during opening. Palpate/feel for symmetry and control: does one condyle move excessively compared to the other? Do they move together smoothly, or do they lack coordination? Palpate for clicking or crepitus. Assess all movements of the TMJ, including: lateral excursion, protrusion, and retrusion.[17]

Next, palpate directly into the joint space to identify inflammation, capsulitis, and other intra-articular pathology. Then palpate the masseter, temporalis, and medial pterygoid, asking about symptom reproduction.[4]

Cervical Spine Assessment

Assess active range of motion, particularly rotation. Palpate C1 through C3 and the muscles of the cranium and cervical spine. Hypertrophy of the cervical muscles may indicate a compensatory response to TMD. Trigger points in these muscles may refer pain to the jaw region.[19]  

Outcome Measures

Treatment Considerations

Treatment must address all issues identified during the assessment.

Arthrogenous TMD: optimising joint space may facilitate disc relocation or improve movement. If the joint is tight, create space using manual therapy techniques, including distractions, lateral glides, and protrusion with specific soft-tissue mobilisations. Note that patients with joint hypermobility require stability training.[17][27]

Myogenous TMD: address muscular dysfunction using trigger point release, specific soft tissue mobilisation, dry needling, or therapeutic taping based on assessment findings and patient response.[27] Introduce stretches and strengthening exercises where appropriate.

Addressing underlying causes is essential for long-term success. Discuss stress management strategies where relevant. For clenching, regular reminders to relax the jaw (such as phone alarms), stretching exercises, appropriate pillow selection, and sleep hygiene can help.[17] To address postural habits, correct screen and phone positioning and use visual reminders about posture (e.g., Post-it notes).

The Role of Botox in TMD

Botox, or botulinum toxin, blocks acetylcholine release at neuromuscular junctions, preventing muscle contraction. Botox should be used selectively in patients with TMD.[28] [29] [30] It may facilitate treatment in patients with severe hypertrophy or provide rapid symptomatic relief when needed. However, not all TMD involves overcontraction of the masticatory muscles. Injecting the masseter and temporalis muscles reduces their function, affecting chewing, yawning, and breathing. This forces compensatory patterns in other muscles, which could create secondary dysfunction.[2]

Bite Plates

A properly fitted bite plate (occlusal splint) reduces muscle activity during clenching and grinding, including in the masseter, temporalis, sternocleidomastoid, and trapezius muscles.[31] It protects teeth from excessive wear and reduces the impact of bruxism on muscles and joints.[32]

Bite plates don't work in isolation—underlying joint and muscle pathology must be addressed first. Consider waiting several treatment sessions before introducing a bite plate, allowing joint space to increase and muscles to relax. This makes the bite plate more tolerable for patients who initially find it too bulky. Gradual introduction (wearing for one to two hours during the day before progressing to night use) may improve tolerance.[2]

Remember, bite plates are not universally required. Clinical signs indicating their use include mandibular tori, craze lines, gum recession, masseter hypertrophy, or lack of progress despite treatment when clenching persists.

Conclusion

Successful TMD management requires thorough assessment of the joint, muscles, and contributing factors, followed by targeted treatment that addresses both the physical findings and underlying causes and habits.

Resources

References

  1. ↑ Ferrillo M, Nucci L, Giudice A, Calafiore D, Marotta N, Minervini G, d’Apuzzo F, Ammendolia A, Perillo L, de Sire A. Efficacy of conservative approaches on pain relief in patients with temporomandibular joint disorders: A systematic review with network meta-analysis. Cranio®. 2025 Mar 4;43(2):258-74.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Weinberg M. Assessment and Treatment of Temporomandibular Disorders Course. Physiopedia Plus, 2026.
  3. ↑ Karibe H, Goddard G, Aoyagi K, Kawakami T, Warita S, Shimazu K, Rudd PA, McNeill C. Comparison of subjective symptoms of temporomandibular disorders in young patients by age and gender. CRANIO®. 2012 Apr 1;30(2):114-20.
  4. ↑ 4.0 4.1 4.2 4.3 Harrison AL, Thorp JN, Ritzline PD. A proposed diagnostic classification of patients with temporomandibular disorders: implications for physical therapists. Journal of orthopaedic & sports physical therapy. 2014 Mar;44(3):182-97.
  5. ↑ Contextual Factors. Available from https://omeract.org/glossary/contextual-factors/ [last accessed 10.01.2026]
  6. ↑ Toko B, Parihar A, Reddy P, Mandlik R, Kewalramani Y, Patel M, Khairwar A. The modern epidemic—digital era bad posture and its musculoskeletal consequences: A questionnaire-based study. Journal of Family Medicine and Primary Care. 2025 Oct 1;14(10):4187-92.
  7. ↑ Hanweet DM, Mahdi KA, Khalel AM, Ibrahim SM. Effectiveness of Behavioural and Lifestyle Changes in Reducing TMD Symptoms: Evidence from a Structured Intervention. Dentistry. 2025;3000(1):a001.
  8. ↑ Deng M, Xie T, Kan C, Yao J. Association Between Dietary Habits and the Risk of Temporomandibular Disorders: A Bidirectional Mendelian Randomisation Study. Journal of Oral Rehabilitation. 2025 Nov;52(11):2124-30.
  9. ↑ Zemowski M, Yushchenko Y, Wieczorek A. The impact of parafunctional habits on temporomandibular disorders in medical students. Journal of Clinical Medicine. 2025 Jul 27;14(15):5301.
  10. ↑ Lee YH, Auh QS, An JS, Kim T. Poorer sleep quality in patients with chronic temporomandibular disorders compared to healthy controls. BMC Musculoskeletal Disorders. 2022 Mar 14;23(1):246.
  11. ↑ Sójka A, Stelcer B, Roy M, Mojs E, Pryliński M. Is there a relationship between psychological factors and TMD?. Brain and behaviour. 2019 Sep;9(9):e01360.
  12. ↑ Fillingim RB, Ohrbach R, Greenspan JD, Knott C, Diatchenko L, Dubner R, Bair E, Baraian C, Mack N, Slade GD, Maixner W. Psychological factors associated with development of TMD: the OPPERA prospective cohort study. The Journal of Pain. 2013 Dec 1;14(12):T75-90.
  13. ↑ Wallem A, Felipe-Spada N, Tomàs-Aliberas J. Influence of selective serotonin reuptake inhibitors (SSRIs) in the development of bruxism. CRANIO®. 2025 Mar 4;43(2):236-42.
  14. ↑ Karegeannes M. Red Flags (2018). Available from https://www.treatingtmj.com/symptoms/red-flags/ [last accessed 11/01/2026]
  15. ↑ Ling ML, Yosar J, Lee BW, Shah SA, Jiang IW, Finniss A, et al. The diagnosis and management of temporal arteritis. Clin Exp Optom. 2020 Sep;103(5):572-582.
  16. ↑ Palmer J, Durham J. Temporomandibular disorders. BJA education. 2021 Feb 1;21(2):44-50.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Fernández-de-Las-Peñas C, Von Piekartz H. Clinical reasoning for the examination and physical therapy treatment of temporomandibular disorders (TMD): a narrative literature review. Journal of Clinical Medicine. 2020 Nov 17;9(11):3686.
  18. ↑ Physio Network. How to measure TMJ range of motion | Dr Alana Dinsdale | Practical TMJ Course. Available from:https://www.youtube.com/watch?8vwU_TOKweA [last accessed 15/01/2026]
  19. ↑ Armijo-Olivo S, Magee D. Cervical musculoskeletal impairments and temporomandibular disorders. Journal of oral & maxillofacial research. 2013 Jan 1;3(4):e4.
  20. ↑ Koo M, Yang SW. Visual Analogue Scale. Encyclopedia. 2025 Nov 7;5(4):190.
  21. ↑ Voog U, Alstergren P, Leibur E, Kallikorm R, Kopp S. Impact of temporomandibular joint pain on activities of daily living in patients with rheumatoid arthritis. Acta Odontol Scand. 2003 Oct;61(5):278-82.
  22. ↑ Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res. 2011 Nov;90(11):1264-70.
  23. ↑ Borg-Bartolo R, Roccuzzo A, Tennert C, Prasinou M, Jäggi M, Molinero-Mourelle P, Bornstein MM, Campus G. Oral health-related quality of life of community-dwellers in the canton of Bern, Switzerland. Acta Odontologica Scandinavica. 2025 Jan 16;84:42707.
  24. ↑ Mittal H, John MT, Sekulić S, Theis-Mahon N, Rener-Sitar K. Patient-Reported Outcome Measures for Adult Dental Patients: A Systematic Review. J Evid Based Dent Pract. 2019 Mar;19(1):53-70.
  25. ↑ Ohrbach R, Larsson P, List T. The jaw functional limitation scale: development, reliability, and validity of 8-item and 20-item versions. Journal of Orofacial Pain. 2008 Jul 1;22(3).
  26. ↑ Von Korff M, DeBar LL, Krebs EE, Kerns RD, Deyo RA, Keefe FJ. Graded chronic pain scale revised: mild, bothersome, and high-impact chronic pain. Pain. 2020 Mar;161(3):651-661.
  27. ↑ 27.0 27.1 Patra RC, Kanungo B, Yashudas A, Mohanty P, Kaur G. Multimodal physical therapy approach for the management of patients with temporomandibular disorder: Randomized control trial. Journal of Oral Biology and Craniofacial Research. 2025 May 1;15(3):515-24.
  28. ↑ Ataran R, Bahramian A, Jamali Z, Pishahang V, Sadeghi Barzegani H, Sarbakhsh P, Yazdani J. The Role of Botulinum Toxin A in Treatment of Temporomandibular Joint Disorders: A Review. J Dent (Shiraz). 2017 Sep;18(3):157-164.
  29. ↑ Kahn A, Bertin H, Corre P, Praud M, Paré A, Kün-Darbois JD. Assessing the effectiveness of botulinum toxin injections into masticatory muscles in the treatment of temporomandibular disorders. Journal of Oral Medicine and Oral Surgery. 2018 Oct 1;24(3):107-11.
  30. ↑ Saini RS, Ali Abdullah Almoyad M, Binduhayyim RI, Quadri SA, Gurumurthy V, Bavabeedu SS, Kuruniyan MS, Naseef PP, Mosaddad SA, Heboyan A. The effectiveness of botulinum toxin for temporomandibular disorders: A systematic review and meta-analysis. PLoS One. 2024 Mar 14;19(3):e0300157.
  31. ↑ Ferrillo M, Giudice A, Marotta N, Gallelli L, Sadeh S, Mazzei M, Inzitari MT, Fortunato L, Ammendolia A, de Sire A. Effects of occlusal splint therapy in addition to physical therapy on pain in patients affected by myogenous temporomandibular disorders: A pilot randomized controlled trial. CRANIO®. 2025 Jun 28:1-8.
  32. ↑ Zhang Y, Zhang H, Liu R, Jin S, Huo T, Wei H, Qin L. The efficacy of treatments for temporomandibular disorders with occlusal splints versus other conservative therapies: a meta-analysis of randomized controlled trials. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2025 May 1;139(5):509-20.
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