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Musculoskeletal Oral health

Temporomandibular disorders (TMDs)

Last revised in May 2026

Temporomandibular disorders are a group of conditions affecting the masticatory muscles, the temporomandibular joint and associated structures.

Temporomandibular disorders: Summary

  • Temporomandibular disorders (TMDs) are a group of related musculoskeletal conditions affecting the masticatory muscles, the temporomandibular joint (TMJ), and associated structures.
  • Clinical features shared by TMDs include pain in the TMJ and surrounding structures, headache, limitation of jaw movements, and/or sounds (such as clicking, popping, or crepitus) from the TMJ.
  • They are a common cause of chronic orofacial pain.
  • Subtypes of TMDs may be grouped as:
    • Myogenous — involving the muscles of mastication (including myalgia and headache attributed to TMD).
    • Arthrogenous — involving the bones of the TMJ and/or articular cartilaginous disc. 
    • Combination — involving both myogenous and arthrogenous components.
  • TMDs may also be classified according to the duration of symptoms.
    • Acute TMD pain is often of short duration, self-limiting, and may be related to a specific initiating or precipitating event.
    • Chronic TMD pain is defined as lasting for more than 3 months.
  • A TMD should be suspected in people with one or more of the following clinical features:
    • Pain in and around the TMJ and/or muscles of mastication, which may radiate within the head and neck, be provoked by palpation of the TMJ or masticatory muscles, and be exacerbated by jaw movement or function.
    • Reproducible joint noise of the TMJ (clicking, popping, or crepitus) with any jaw movements, with or without restricted movement or locking of the TMJ.
    • Headache limited to the temporal region and exacerbated by jaw function.
    • Otalgia in the absence of ear disease, which is reproducible by palpation of the TMJ. 
  • A biopsychosocial approach to assessment and management is recommended. Other causes of symptoms should be excluded and red flags identified.
  • Referral should be arranged to oral and maxillofacial surgery for specialist investigations and management, depending on clinical judgement, if a person has:
    • A history of trauma or fracture to the TMJ complex.
    • Markedly limited mouth opening (closed lock).
    • Recurrent dislocation of TMJ.
    • Persistent or worsening symptoms.
    • Persistent inability to manage a normal diet. 
    • Severe pain and dysfunction unresponsive to conservative measures.
  • Referral to an appropriate specialist should be made if:
    • The person has/is suspected of having an associated condition such as inflammatory joint disease. 
  • For all other people with a suspected TMD, management may include:  
    • Dental and TMJ assessment by a general dental practitioner.
    • Reassurance that TMDs are usually non-progressive and symptoms should improve.
    • Supported self-management involving education about the condition, advice on eating a soft diet, avoiding parafunctional activities, thermal modalities, massaging affected muscles and resting the jaw if there is acute pain.
    • Reinforcement of positive lifestyle strategies.
    • Management of comorbid conditions.
    • Consideration of analgesics such as paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs). In specific clinical circumstances and in consultation with dental services, other medications, such as a neuromodulatory agent or a short course of diazepam, may be appropriate.
  • Referral to additional services such as psychology, physiotherapy or acupuncture may be helpful, depending on clinical judgement.

Have I got the right topic?

From age 12 years onwards.

This CKS topic covers the diagnosis and management of temporomandibular disorders (also known as temporomandibular joint [TMJ] disorders, TMJ dysfunction, or craniomandibular disorders).

This CKS topic does not cover the management of TMJ dislocation, fractures, congenital or developmental disorders, other masticatory muscle disorders (for example myospasm and myositis), ankylosis, or synovitis.

There are separate CKS topics on Dental abscess, Giant cell arteritis, Gingivitis and periodontitis, Head and neck cancers - recognition and referral, Headache - assessment, and Trigeminal neuralgia.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2026 — reviewed. A literature search was conducted in March 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Previous changes

May 2024 — minor update. This topic has been updated in line with the NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’ Faculty of Dental Surgery guideline Management of painful temporomandibular disorder in adults. 

July to August 2021 — reviewed. A literature search was conducted in July 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

November to December 2016 — reviewed. A literature search was conducted in November 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic title has been changed from TMJ disorders to Temporomandibular disorders, in line with current nomenclature in the literature. The topic has undergone minor restructuring, and the recommendations on management have been updated in line with the Royal College of Surgeons Faculty of Dental Surgery publication Temporomandibular disorders (TMDs): an update and management guidance for primary care from the UK Specialist Interest Group in Orofacial Pain and TMDs (USOT) (2013).

April 2015 — minor update. Update to the text to reflect Guidance for health professionals on drug driving published by the Department for Transport.

June 2013 — minor update. Update to the text to reflect the Medicines and Healthcare products Regulatory Agency (MHRA) publication (2013) Drug Safety Update Diclofenac: new contraindications and warnings.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. Issued in June 2011.

June to October 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2026.

New policies

No new national policies or guidelines since 1 March 2026.

New safety alerts

No new safety alerts since 1 August 2021.

Changes in product availability

No changes in product availability since 1 August 2021.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of temporomandibular disorders.
  • Offer appropriate initial management and self-care advice.
  • Offer referral to an appropriate specialist, if needed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Temporomandibular disorders (TMDs) are a group of related musculoskeletal conditions affecting the masticatory muscles, the temporomandibular joint (TMJ), and associated structures.
    • The TMJ is formed by the articulation of the mandibular condyle with the mandibular fossa of the temporal bone. The muscles of mastication (masseter, temporalis, medial and lateral pterygoids) are primarily responsible for movement of the TMJ.
  • TMDs share clinical features, such as pain in the TMJ and surrounding structures, headache, limitation of jaw movements, and/or sounds (such as clicking, popping, or crepitus) from the TMJ.
    • They are one of the most common causes of chronic orofacial pain.
    • TMDs have previously been referred to as TMJ disorders or TMJ dysfunction. The current term of TMDs is more clinically accurate as it encompasses disorders of associated structures as well as the TMJ itself.
  • The subtypes of TMDs may be broadly grouped as:
    • Myogenous — involving the muscles of mastication (for example, myalgia, myofascial pain, and headache attributed to TMD).
    • Arthrogenous — involving the bones of the TMJ and/or the articular cartilaginous disc. 
    • Combination — involving both myogenous and arthrogenous components.
  • TMDs may also be classified according to the duration of symptoms.
    • Acute TMD pain is often of short duration, self-limiting, and may be related to a specific initiating or precipitating event (for example, prolonged jaw opening following dental treatment or trauma).
    • Chronic TMD pain is defined as lasting for more than 3 months.

[Zakrzewska, 2013; Schiffman, 2014; Durham, 2015; Gauer, 2015; ; AAOMS, 2024; AAPD, 2024; Beecroft, 2025]

How common are temporomandibular disorders?

  • The exact prevalence of temporomandibular disorders (TMDs) is difficult to establish, as the majority of people do not seek help from a healthcare professional [Ghurye, 2015].
    • In the UK, TMDs are estimated to affect up to 1 in 15 people and are most common in the 20-40 years age group [Beecroft, 2025].
  • A large US prospective cohort study (n = 2737 adults) found the incidence of first-onset painful TMD to be 3–4% per year [Slade, 2013]. Incidence was found to increase with age, peaking in the second and third decades:
    • 2.5% of people aged 18–24 years.
    • 3.7% of people aged 25–34 years.
    • 4.5% of people aged 35–44 years.
  • A recent meta-analysis of 74 studies (n = 35,259 with TMDs) identified [Zieliński, 2024]:
    • A global incidence of TMDs of 34%.
    • A prevalence of 27% in people aged up to 18 years, 41% in people aged 18 to 60 years and 36% in people aged over 60 years.
    • Marked variation in prevalence by geographical location — 47% in South America, 33% in Asia and 29% in Europe.
  • Some studies suggest that females may be affected up to twice as often as males in the general population [Gauer, 2015], [Bueno, 2018]. However, in other studies, females have only a slightly greater incidence than males [Slade, 2013; Slade, 2016].
  • In young people, incidence varies widely in the literature due to variations in the population studied, diagnostic criteria, and study methods.
    • A systematic review of 21 studies (n = 11,535) found that the prevalence of TMD in the general population was approximately 31% for adults and 11% for children [Valesan, 2021].
    • In five cross-sectional studies that reported prevalence of TMD diagnoses in children and adolescents based on clinical examination, prevalence ranged from 7.3–30.4%, while in four studies based on self-reported TMD pain, prevalence ranged from 4.2–32.3% [Christidis, 2018]. 
    • Available data suggest that prevalence in children and adolescents increases with age; however, few studies include children under 9 years of age [AAPD, 2024].
    • A systematic review of 3 studies (n = 1914) on the prevalence of TMDs in children and adolescents demonstrated a higher prevalence of TMD in females (44.7%) than males (30%) [Minervini, 2023].

What causes it?

  • The causes of temporomandibular disorders (TMDs) are not fully understood. They are likely to be complex and multifactorial, involving the interaction of anatomical, physiological, and psychosocial risk factors. 
    • Anatomical factors — internal derangement of the temporomandibular joint (TMJ), such as disc displacement or degenerative joint disease.
    • Macrotrauma — for example, a fall onto the chin, a motor vehicle accident, or a sports injury. 
    • Microtrauma — parafunctional habits (such as tooth grinding or clenching) may overload the TMJ, leading to cartilage breakdown, alterations in the synovial fluid and anatomical changes within the joint.
      • Note: in otherwise healthy people, bruxism (grinding or clenching of the teeth) is no longer considered a parafunctional activity. The association between bruxism and TMD is unclear. 
    • Psychosocial factors — stress, anxiety, and depression are significant predictors for the development and chronification of TMDs.
    • Systemic and pathologic factors — several small cross-sectional studies have found associations of chronic TMD with other chronic pain conditions, such as chronic fatigue syndrome, fibromyalgia, migraine, irritable bowel syndrome, and widespread chronic pain. People with these conditions may have increased generalized pain sensitivity ('central sensitization'). Systemic factors contributing to TMD include connective tissue diseases such as rheumatoid arthritis, systemic lupus erythematosus, juvenile idiopathic arthritis, and psoriatic arthritis. 
    • Genetic factors — these have been identified in relation to neurotransmission.
    • Hormonal factors — the role of hormones is unclear. Some studies have shown that TMJ pain and other symptoms vary in relation to the menstrual cycle or pregnancy, while others have not.

[Zakrzewska, 2013; Durham, 2015; Gauer, 2015; Ghurye, 2015; Slade, 2016; List, 2017; Lomas, 2018; ; AAOMS, 2024; AAPD, 2024; Beecroft, 2025]

What are the complications of temporomandibular disorders?

  • Complications of temporomandibular disorders (TMDs) include:
    • Chronic pain.
    • Psychosocial distress, including anxiety and depression.
    • Reduced quality of life.
    • Speech problems related to exacerbation of pain when speaking.
    • Swallowing and chewing difficulties due to pain, which may lead to inadequate food intake and weight loss.

[Durham, 2015; Ghurye, 2015; Michelotti, 2016; Pigozzi, 2021; ; AAOMS, 2024; Beecroft, 2025]

What is the prognosis?

  • Early intervention with simple management techniques results in resolution or improvement of intermittent manageable symptoms in 75-90% of people with temporomandibular disorders (TMDs) [Beecroft, 2025].
    • Arthrogenous TMDs generally have a good prognosis and remain stable over time — around 1 in 7 cases will show progression.
    • Myogenous TMDs are more likely to become chronic.
  • A large US prospective cohort study (n = 2737 adults) identified 260 people with symptoms related to TMD. In those with TMD-related symptoms [Slade, 2013]:
    • Pain occurred as a: 
      • Single episode in 12% of people.
      • Recurrent episode in 65% of people.
      • Persistent episode in 19% of people.
    • The duration of pain was not known for 4% of people.
  • Factors associated with the development of chronic TMD pain and a worse prognosis include [Zakrzewska, 2013; Durham, 2015]:
    • Being female.
    • Increasing age at presentation.
    • Higher reported pain intensity.
    • More widespread non-specific symptoms.
    • Myogenous TMD.
    • Comorbid psychosocial factors, such as anxiety or depression.

Diagnosis

When should I suspect a temporomandibular disorder?

  • Suspect a temporomandibular disorder (TMD) in people with one or more of the following clinical features:
    • Pain in and around the temporomandibular joint (TMJ) and/or muscles of mastication, which may radiate to other structures in the head and neck — this is the main symptom and usually the reason people seek medical care. 
      • Pain typically affects the pre-auricular region and may radiate around the ear to the temple, teeth, cheek, or angle of the jaw.
      • Pain may be provoked by palpation of the masseter and/or temporalis muscles, or the TMJ, and may be provoked or modified by jaw movement or function (such as opening or closing the mouth, or chewing) or parafunction.  
      • Pain not related to using the jaw is unlikely to be due to TMD. 
      • Note: there is no clear correlation between self-reported pain severity or functional impairment and pathological changes in the TMJ or musculature.
    • Reproducible joint noise of the TMJ (clicking, popping, or crepitus) on any jaw movements, with or without restricted movement or locking of the TMJ.
      • People with arthrogenous TMD involving the articular cartilaginous disc may report palpable or audible joint clicks in that area as the jaw is opened and closed.
      • Clicking may indicate disc displacement with reduction. An inability to open the mouth wide may indicate disc displacement with reduction, with intermittent, limited opening.
      • Persistent closed lock (inability to open more than 25mm) may indicate disc displacement without reduction with limited opening.
      • There may be repeated dislocation of the TMJ.
        • Joint noise can be detected in people who are pain-free, as disc displacement with reduction is present in 12-35% of the population. In this situation, the person can be reassured that no intervention is required.
    • Headache limited to the temporal region and exacerbated by jaw function.
    • Otalgia in the absence of ear disease.
  • See the section on Classification of temporomandibular disorders for more information on the clinical features of TMDs.

Classification of temporomandibular disorders

The main groups of temporomandibular disorder (TMD) can be further classified into subgroups. The following list is not exhaustive. Be aware that a person may have more than one type of TMD simultaneously:

  • Myogenous TMDs
    • Myalgia and myofascial pain
      • Pain is provoked on palpation of the masseter or temporalis masticatory muscles; pain within the body of the muscle or radiating beyond this.
      • Pain with maximum unassisted or assisted mouth opening. 
      • Pain in the jaw, temples, pre-auricular area, or inside the ear, and pain is modified with jaw movements, function, or parafunction. 
      • Myofascial pain with referral may have active muscle trigger points generating pain.
    • Headache attributable to TMD 
      • Headache in the temporalis area, which is modified with jaw movement, function, or parafunction. 
      • Headache is reproduced with palpation of the temporalis muscle or with jaw movements.
  • Arthrogenous TMDs
    • Disc displacement with reduction
      • Reproducible joint noise (clicking, popping, or snapping) occurs during mouth opening and closing (usually without significant restriction in jaw movement).
      • Pain, when present, is precipitated by TMJ movement, but it may be asymptomatic.
      • There may be deviation of the mandible during mouth opening that coincides with a click.
      • In a minority of people, it may progress to a 'closed lock' state.
    • Disc displacement without reduction ('closed lock') with or without limited opening
      • There is persistent, markedly limited mouth opening and lateral jaw movement with a history of sudden onset ('locking').
      • Deviation of the mandible towards the affected side during mouth opening often occurs.
      • Typically, pain is precipitated if forced mouth opening is attempted, and there is often tenderness of the TMJ.
      • The onset of locking may be preceded by a period of clicking.
    • Degenerative joint disease
      • Crepitus (related to articular surface disruption) with any jaw movement, often not associated with pain.
      • Pain from the TMJ occurs on jaw movement and there is point tenderness of the TMJ.
      • There may be restricted jaw movement; deviation of the mandible towards the affected side; and crepitus or grating noises.
    • Subluxation
      • History of locking open and need for self-manipulation to achieve closure.
      • Often present in people with hypermobility, associated with deviation of the mandible on mouth opening.
    • Arthralgia (may overlap with degenerative joint disease)
      • Pain in the TMJ region produced by palpation or assisted/unassisted jaw movements.
      • May be due to factors other than arthritis, for example overstretching of the TMJ.  

[Zakrzewska, 2013; Schiffman, 2014; Durham, 2015; Gauer, 2015; Ghurye, 2015; Lomas, 2018; Beecroft, 2025]

Basis for recommendation

These recommendations are largely based on the NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’  Faculty of Dental Surgery guideline on Management of painful Temporomandibular disorder in adults [Beecroft, 2025]; the American Association of Oral and Maxillofacial Surgeons (AAOMS) statement on Temporomandibular disorders [AAOMS, 2024]; the American Academy of Pediatric Dentistry (AAPD) guideline Temporomandibular disorders in children and adolescents including those with special health care needs [AAPD, 2024]; the International Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Consortium Network and Orofacial Pain Special Interest Group recommendations on Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications [Schiffman, 2014] and expert opinion in narrative reviews [Durham, 2015; Ghurye, 2015; List, 2017; Gil-Martínez, 2018; ].

How should I assess a person with a suspected temporomandibular disorder?

When assessing a person with a suspected temporomandibular disorder (TMD), take a biopsychosocial approach:

  • Ask about:
    • The location, radiation, onset, character, intensity and duration of any orofacial pain. 
      • Check for any precipitating factors or triggers, such as a complicated dental extraction or other facial trauma.
      • Ask if the pain is bilateral or unilateral.
      • Ask if the pain is in the morning. 
      • Check for any exacerbating factors, such as chewing, talking, kissing, yawning, or prolonged mouth opening. 
      • If there is pain on biting or chewing, ask about any parafunctional activities (such as nail biting or excessive mouth opening during yawning).
      • Ask about any relieving factors.
      • Consider using a validated pain questionnaire to assess the intensity of pain.
    • Any associated pain (for example, head and neck pain or ear pain) or other features (such as locking or clicking of the jaw, difficulty opening the mouth, altered skin sensation, or any nasal or ear symptoms).
    • Any recent injuries to the jaw, head, or neck.
    • The impact of symptoms on the person's quality of life (for example, on sleep, eating, mood, concentration, energy levels, and pain beliefs).
    • Any associated comorbid conditions (such as fibromyalgia, widespread chronic pain, migraine, obstructive sleep apnoea, or inflammatory joint diseases). 
    • Any psychosocial factors that may be contributing to symptoms (such as stress, anxiety, depression, or insomnia). 
    • The person's pain beliefs and expectations, and social support available.
    • Any previous treatments and duration, if appropriate.
  • Consider using the validated 3 question TMD screening tool — this can be completed by patients in advance of an appointment. 
    • Two or more positive responses suggest TMD is more likely.
    • The 3-question TMD screening tool can be used to support clinical history and examination findings — it cannot diagnose TMD.
  • Examine the person's head and neck:
    • Assess for facial or mandible asymmetry or any facial swelling.
    • Assess for any cranial nerve deficits.
    • Exclude any obvious dental pathology by examining the mouth to assess the hard and soft palate, the teeth, tongue and gums.
    • Palpate the temporomandibular joint (TMJ) by pressing anteriorly to the tragus of the ear bilaterally. Assess for TMJ tenderness; the range of movement of the mandible; pain on movement or on maximum mouth opening; and for any associated joint noises or crepitus.
      • Maximal mouth opening varies substantially, but ranges from 35 to 55 mm, but may be reduced to less than 35 mm in people with TMD. 
    • Palpate the masseter and temporalis muscles to assess for tenderness, trigger points, or hypertrophy. Examination of the muscles of mastication is best performed with the person's teeth clenched.
    • Check for lymphadenopathy.
    • In people aged over 50 years with new onset TMD symptoms, palpate the superficial temporal vessels and assess the appearance. 
  • Exclude other causes of orofacial pain; check for red flags, and manage accordingly.
  • Imaging investigations are not routinely recommended in primary care unless they are necessary to exclude red flags or differential diagnoses. 

Red flag symptoms and signs

  • Red flags for orofacial pain include:
    • Previous history of malignancy — may indicate a new primary, recurrence, or metastases. 
    • Persistent or unexplained neck lump or cervical lymphadenopathy — may indicate a neoplastic, infective, or autoimmune cause. See the CKS topic on Neck lump for more information.
    • Persistent and worsening pain.
    • Pain with exertion, coughing or sneezing (indicating potential raised intracranial pressure).
    • Jaw pain in people taking bisphosphonates (or other medicines where osteonecrosis is known to be an adverse effect). 
    • Concurrent infection.
    • History of recent head or neck trauma. 
    • Neurological symptoms such as headache (for example, progressive, abrupt onset, or posture-related headache) or signs such as cranial nerve abnormalities with sensory or motor function changes (for example, unilateral hearing loss, new onset or unilateral tinnitus, vestibular dysfunction) — may indicate an intracranial cause, or malignancy affecting cranial nerve peripheral branches. See the CKS topic on Headache - assessment for more information on clinical features that may indicate a serious secondary cause for headache.
    • Facial asymmetry, facial or neck mass or swelling, or profound trismus — may indicate a neoplastic, infective, or inflammatory cause. See the CKS topic on Head and neck cancers - recognition and referral for more information.
    • Recurrent epistaxis, purulent nasal discharge, persistent anosmia (loss of smell) or reduced hearing on the ipsilateral side — may indicate nasopharyngeal carcinoma. See the CKS topic on Head and neck cancers - recognition and referral for more information.
    • Reduced hearing, new onset or unilateral tinnitus – consider acoustic neuroma, or other ear disease as part of differential diagnoses. See the CKS topics on Hearing loss in adults and Tinnitus for more information.
    • Unexplained fever or weight loss — may indicate malignancy, immunosuppression, or an infective cause such as septic arthritis, osteomyelitis, intracranial abscess, or mastoiditis.
    • New-onset unilateral headache or scalp tenderness, jaw claudication, visual disturbance and/or general malaise, especially if the person is over 50 years of age — may indicate giant cell arteritis. See the CKS topic on Giant cell arteritis for more information on diagnosis and management.
    • Occlusal (bite of teeth) changes — may indicate neoplasia, rheumatoid arthritis, trauma, or bone growth around the temporomandibular joint (for example in acromegaly). See the CKS topic on Rheumatoid arthritis for more information on the diagnosis and management of inflammatory arthropathies. Note: synovitis of the TMJ may not present with classical joint tenderness or swelling.
    • Persistent hoarseness, dysphagia, or persistent mouth ulcers (for 3 weeks or more). See the CKS topic on Head and neck cancers - recognition and referral for more information.

[Schiffman, 2014; Durham, 2015; Ghurye, 2015; Lomas, 2018; AAOMS, 2022; Beecroft, 2025; NICE, 2026a]

Basis for recommendation

These recommendations are largely based on the NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’  Faculty of Dental Surgery guideline on Management of painful Temporomandibular disorder in adults [Beecroft, 2025]; the American Association of Oral and Maxillofacial Surgeons (AAOMS) statement on Temporomandibular disorders [AAOMS, 2024]; the American Academy of Pediatric Dentistry (AAPD) guideline Temporomandibular disorders in children and adolescents including those with special health care needs [AAPD, 2024]; the International Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Consortium Network and Orofacial Pain Special Interest Group recommendations on Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications [Schiffman, 2014] and expert opinion in narrative reviews [Zakrzewska, 2013; Durham, 2015; Gauer, 2015; Ghurye, 2015; Ghurye, 2017; List, 2017; Conville, 2019; ]. 

Assessing clinical features

  • Recommendations on clinical assessment are largely based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery [Beecroft, 2025] and the American Academy of Pediatric Dentistry (AAPD) [AAPD, 2024]. In addition:
    • The RDC/TMD Consortium Network provide a validated set of criteria to physically assess the temporomandibular joint (TMJ) and associated structures, and to screen for psychosocial comorbidity [Schiffman, 2014].
    • A six-item self-completed questionnaire has been developed in conjunction with the RDC/TMD to assess the nature of TMJ pain [Gonzalez, 2011], which is well validated and has shown 99% sensitivity and 98% specificity for diagnosing painful TMDs in orofacial pain clinics [Durham, 2015].

Biopsychosocial approach

  • The recommendation to take a biopsychosocial approach to assessment is based on expert opinion in the GIRFT and Royal College of Surgeons’ Faculty of Dental Surgery guideline [Beecroft, 2025] and narrative reviews [Zakrzewska, 2013; Durham, 2015; Ghurye, 2015; List, 2017; ].
    • As TMDs have a biopsychosocial aetiology a biopsychosocial and holistic approach to management is essential to maximize prognosis [Beecroft, 2025].
    • The cause of temporomandibular disorders (TMDs) is likely to be both multifactorial and biopsychosocial, consisting of initiating, predisposing, and perpetuating factors. More complex patients or those with persistent TMDs require a biopsychosocial approach delivered by a multidisciplinary pain team [Durham, 2015]. 
    • Screening for psychosocial comorbidity is important, as this may impact on the person's prognosis, experience of pain, and treatment outcomes [Zakrzewska, 2013; Durham, 2015; Ghurye, 2015; Beecroft, 2025].

What else might it be?

  • See the section on red flags for information on serious or life-threatening conditions that may mimic temporomandibular disorders (TMDs), and manage accordingly.
  • Other possible causes of orofacial pain include:
    • Dental causes
      • Caries. 
      • Periodontal disease — see the CKS topic on Gingivitis and periodontitis for more information.
      • Tooth abscess (can restrict mouth opening) — see the CKS topic on Dental abscess for more information.
      • Wisdom tooth eruption. 
    • Disorders of other facial structures
      • Parotitis (infective or non-infective) — see the CKS topic on Neck lump for more information on parotid gland swellings.
      • Other salivary gland disorders such as inflammation (sialadenitis), infection, or obstruction (sialolithiasis) — see the CKS topic on Neck lump for more information on submandibular gland swellings.
      • Sinusitis — see the CKS topic on Sinusitis for more information.
    • Headache disorders — see the CKS topic on Headache - assessment for more information.
    • Neuralgias and neuropathic pain disorders
      • Trigeminal neuralgia and other facial neuralgias — see the CKS topic on Trigeminal neuralgia for more information. 
      • Post-herpetic neuralgia — see the CKS topic on Post-herpetic neuralgia for more information.
      • Post-traumatic and post-surgical neuralgia. 
    • Ear conditions
    • Other viral infections
      • Mumps — see the CKS topic on Mumps for more information. 
      • Shingles — see the CKS topic on Shingles for more information.
    • Autoimmune disorders
      • Rheumatoid arthritis. 
      • Systemic lupus erythematosus. 
      • Sjögren's syndrome.
    • Other disorders
      • Giant cell arteritis — see the CKS topic on Giant cell arteritis for more information.
      • Osteonecrosis of the jaw — this can be a rare and serious adverse effect of some drugs, such as bisphosphonates.

Basis for recommendation

This information is based on the American Association of Oral and Maxillofacial Surgeons (AAOMS) statement on Temporomandibular disorders [AAOMS, 2024]; the American Academy of Pediatric Dentistry (AAPD) guideline Temporomandibular disorders in children and adolescents including those with special health care needs [AAPD, 2024]; and expert opinion in narrative reviews [Zakrzewska, 2013; Durham, 2015; Gauer, 2015; Lomas, 2018; ]. 

Management

Scenario: Management

From age 12 years onwards.

How should I manage a person with a suspected temporomandibular disorder?

  • If a serious or life-threatening condition is suspected following an assessment for red flags, manage appropriately using clinical judgement.
  • Refer people to oral and maxillofacial surgery for specialist investigations and management, depending on clinical judgement, if they have:
    • A history of trauma or fracture to the temporomandibular joint (TMJ) complex.
    • Markedly limited mouth opening (closed lock), suggesting disc displacement without reduction. Refer urgently if:
      • The person is young (under 25 years of age) and has substantially decreased mouth opening (less than 25 mm) — early arthrocentesis is more likely to be curative.
      • Locking is affecting the ability to maintain nutritional requirements at any age.
    • Recurrent dislocation of TMJ and/or associated syndromes (for example, Ehlers-Danlos).
  • If the person is suspected of having an associated condition, such as inflammatory joint disease:
    • Refer to an appropriate secondary care specialist for further assessment and management
  • For all other people with a suspected TMD, take a biopsychosocial approach to management: 
    • Acknowledge that TMD pain can be intense and debilitating.
    • Reassure the person that the condition is usually non-progressive and that symptoms may fluctuate but should improve. 
    • Where appropriate, consider advising the person to see a general dental practitioner for a thorough dental and temporomandibular joint examination.
    • Educate the person 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. 
    • Encourage supported 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 avoid caffeine, as this may increase muscle tension.
      • To try to avoid parafunctional activities that may exacerbate symptoms, such as wide yawning, teeth grinding or jaw clenching, chewing gum or pencils, and nail biting.
      • To keep teeth apart when not eating.
      • That local measures, such as applying covered ice or a warm flannel or heat pad, or massaging affected muscles may be helpful. 
    • Reinforce positive lifestyle strategies — for example, undertaking regular exercise, relaxation techniques, maintaining social interactions, stress management, maintaining a healthy weight and positive sleep habits. 
    • Consider the need for oral medications:
    • Consider the need for additional drug treatment where appropriate:
      • In specific circumstances where pain is acute, severe and myogenous in origin with limited opening (with/without disc displacement and without reduction) the dental team may consider a short course of a low-dose benzodiazepine such as diazepam 2 mg up to three times daily, for a maximum of 5 days.
        • Be aware that evidence on the effectiveness of benzodiazepines in the treatment of TMD is lacking and that use may be associated with significant adverse effects. For more information, see the section on Diazepam in Prescribing information.
      • If TMD pain is persistent and confirmed to be of myogenous origin, use of neuromodulator agents may be appropriate, for example:
        • A trial of amitriptyline, gabapentin or duloxetine for adults with chronic pain — for prescribing information, see the CKS topic on Neuropathic pain - drug treatment.
        • Be aware that neuromodulatory agents have not been shown to be effective in treatment of arthrogenous TMD.
    • Manage comorbid conditions: 
      • 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 comorbid depression. See the CKS topics on Generalized anxiety disorder and Depression for more information.
      • Give advice on sleep hygiene. See the CKS topic on Insomnia for more information.
    • Provide sources of information and advice, such as:
    • 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.
  • Review the person at 6–8 weeks:
    • If symptoms have improved, reinforce self-supported management strategies.
    • Arrange referral to oral and maxillofacial surgery; ear, nose, and throat (ENT) surgery; neurology; or a multidisciplinary pain clinic for specialist investigations and management, depending on clinical judgement, if a person has:
      • Worsening symptoms.
      • Persistent symptoms despite 6–8 weeks of primary care treatment. For information on management of chronic pain in primary care, see the CKS topic Chronic pain.
      • Persistent inability to manage a normal diet. 
      • Severe pain and dysfunction from internal derangement that does not respond to conservative measures. 
      • An uncertain diagnosis.
      • Other chronic pain-related comorbidities. 

Specialist investigations and management

Specialist investigations and management may be considered for people with significant functional impairment of the temporomandibular joint (TMJ), and/or an intra-articular disorder such as anterior disc displacement or degenerative joint disease.

Depending on the specific clinical situation:

  • Investigations may include:
    • Plain or panoramic X-rays to identify dental pathology, fractures, dislocations, or severe degenerative joint disease. 
    • Computerized tomography (CT) scan to assess for degenerative joint disease or subluxation of the TMJ. 
    • Magnetic resonance imaging (MRI) to assess for TMJ disc displacement, subluxation, arthrosis, or synovial proliferation.
  • Management options may include:
    • Local anaesthetic trigger point injections — may be beneficial in some people with myogenous TMD with well-defined muscular trigger points.
    • Botulinum toxin A — however, there is currently a lack of evidence to support the use in the management TMD and further research is needed to clarify benefits and risks.
    • Intra-articular injections — there is some evidence for use of hyaluronic acid as an intra-articular injection in surgical TMJ procedures (such as arthrocentesis). Evidence on the beneficial effects of intra-articular corticosteroid injection is lacking.
    • Surgical options for severe arthrogenous TMD and specific cases of disc displacement without reduction, for example:
      • Arthrocentesis or arthroscopy.
      • Total prosthetic TMJ replacement for selected patients where all alternative treatments have failed.

[Schiffman, 2014; Durham, 2015; Gauer, 2015; Ghurye, 2015; Ghurye, 2017; AAPD, 2020; ; AAPD, 2024; Beecroft, 2025; NICE, 2026b]

Basis for recommendation

These recommendations are largely based on the NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’  Faculty of Dental Surgery guideline on Management of painful Temporomandibular disorder in adults [Beecroft, 2025]; the British Association of Oral and Maxillofacial Surgeons (BAOM) and Royal College of Surgeons (RCS) Commissioning guide: temporomandibular joint disorders [BAOMS, 2014]; the American Academy of Pediatric Dentistry (AAPD) guideline Temporomandibular disorders in children and adolescents including those with special health care needs [AAPD, 2024]; the International Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Consortium Network and Orofacial Pain Special Interest Group recommendations on Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications [Schiffman, 2014] and expert opinion in narrative reviews [Zakrzewska, 2013; Durham, 2015; Gauer, 2015; Ghurye, 2015; Ghurye, 2017; List, 2017; Lomas, 2018; Gil-Martínez, 2018; Conville, 2019; ].

Referral to oral and maxillofacial surgery
  • The recommendations on referral to oral and maxillofacial surgery are based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery [Beecroft, 2025]; the BAOM and RCS [BAOMS, 2014] and expert opinion in review articles [Lomas, 2018; ].
Biopsychosocial approach
  • The recommendation to take a biopsychosocial approach to management is largely based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery guidelines [Beecroft, 2025] and the AAPD [AAPD, 2024] and expert opinion in narrative reviews [Zakrzewska, 2013; Durham, 2015]  [List, 2017; ].
    • The cause of temporomandibular disorders (TMDs) is likely to be both multifactorial and biopsychosocial, consisting of initiating, predisposing, and perpetuating factors, for example, macrotrauma or microtrauma, linked to a failure to heal appropriately because of the underlying psychosocial profile of the patient, failed treatment, or genotype. More complex patients or those with persistent TMDs require a biopsychosocial approach delivered by a multidisciplinary pain team [Durham, 2015]. 
    • The overall management strategy for orofacial pain may be extrapolated from the British Pain Society guidelines for the management of adults with chronic pain. These principles follow a biopsychosocial approach and consist of three domains: physical exercise/relaxation, pharmacotherapy, and clinical psychology [Ghurye, 2017].
General dental assessment
  • The recommendation on advising the person to see a general dental practitioner is based on a commissioning guide from the British Association of Oral and Maxillofacial Surgeons (BAOM) and Royal College of Surgeons (RCS) [BAOMS, 2014] and expert opinion in narrative reviews [Ghurye, 2015]  [Conville, 2019]. 
Supported self-management
  • Recommendations on supported self-management including lifestyle measures are based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery guideline [Beecroft, 2025], the AAPD [AAPD, 2024], a narrative review [] and an expert reviewer of this topic.
    • There is strong evidence for the use of supported self-management for all TMDs as this allows people to gain ownership of their condition; take positive steps to manage their own discomfort; and reduces pain intensity and pain related disability with no reported adverse effects. Other options are supported by less robust evidence, but can be discussed with patients in a process of shared decision making if further (adjunctive) management is required or indicated [Beecroft, 2025].
    • Conservative and reversible therapies are effective in reducing most TMD symptoms in most patients including children [AAPD, 2024].
    • A systematic review, meta-analysis and meta-regression (including 14 trials) on the effectiveness of self-management interventions in adults with chronic orofacial pain found that self-management interventions are effective for patients with chronic orofacial (principally TMD) pain [Aggarwal, 2019].
Analgesics
  • The recommendation to consider short-term analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol is based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery guidelines [Beecroft, 2025] and the AAPD [AAPD, 2024] and expert opinion in narrative reviews [Durham, 2015; Ghurye, 2017; Gil-Martínez, 2018; Lomas, 2018; Dammling, 2022; ].
  • Effective early management of acute TMD (including use of anti-inflammatory medication and education) can reduce the potential for developing chronic pain [AAPD, 2024].
Diazepam
  • The GIRFT and Royal College of Surgeons’ Faculty of Dental Surgery guideline [Beecroft, 2025] highlights the absence of robust evidence on effectiveness of oral benzodiazepines and advises that the therapeutic role of oral benzodiazepines is restricted to instances of acute and severe myogenous pain with limited opening (with or without disc displacement without reduction).
    • The guideline states that medical and social contraindications must be adequately assessed prior to prescribing and duration of use kept to a minimum (2 mg up to three times daily, for 5 days initially, up to a total maximum duration of 2 weeks if symptoms remain at the 5-day review).
  • The lack of robust evidence on effectiveness of diazepam in the management of TMD in addition to significant risks of use (such as potential for dependance and serious side effects) is also highlighted in a Cochrane review [Mujakperuo, 2010] and in several review articles [Gauer, 2015; Ghurye, 2015; Dammling, 2022; Garstka, 2023; ].
Amitriptyline or gabapentin 
  • The recommendation to consider prescribing amitriptyline, duloxetine or gabapentin for myogenous TMD is based on expert opinion in the GIRFT and Royal College of Surgeons’ Faculty of Dental Surgery guideline [Beecroft, 2025] and narrative reviews [Gauer, 2015; Ghurye, 2015; ].
  • Guidance from the Royal College of Surgeons’ Faculty of Dental Surgery states that [Beecroft, 2025]:
    • Neuromodulatory agents may be used for pain management in persistent myogenous TMD in specialist dental and primary general medical settings. 
    • Initiation, monitoring and eventual withdrawal will often come under the remit of the individual’s GP, either directly or in consultation with specialist teams. 
    • The evidence base for effectiveness of neuromodulatory agents in the management of myogenous TMD is building, but remains weak, historically effectiveness has been extrapolated from other persistent pain conditions.
    • Neuromodulatory agents have not been shown to be beneficial for arthrogenous TMD and their use in such situations is not recommended. 
  • A Cochrane systematic review of 11 small randomized controlled trials (n = 496) which assessed drug treatments for people with chronic TMD-related pain found insufficient evidence for the use of analgesics (including NSAIDs), benzodiazepines (including diazepam), and anticonvulsants (gabapentin) [Mujakperuo, 2010]. 
  • CKS considers that it may be appropriate to offer amitriptyline, gabapentin or duloxetine to some people with chronic TMD-related pain who have not responded to initial treatments, but clinical judgement should be used to determine whether referral is more appropriate.
Managing comorbid conditions
  • The recommendation on treating comorbid conditions for example anxiety, depression, and insomnia is based on guidance from GIRFT and the Royal College of Surgeons’ Faculty of Dental Surgery [Beecroft, 2025]. Management of TMD in isolation from associated conditions may be associated with poorer prognosis.
  • Expert opinion in review articles states that early psychological intervention in people at risk of chronic TMDs may reduce the risk of chronic TMDs in those with predisposing factors (such as mood disorders, pain catastrophizing, somatic preoccupation and poor coping skills). Techniques such as Cognitive Behaviour Therapy may identify factors which precipitate, or exacerbate a person’s TMD and help them to implement techniques, such as relaxation, to manage pain [Durham, 2015; Gauer, 2015; Ghurye, 2015].  
  • A systematic review evaluating the association between painful TMD and sleep quality in adults found that an association exists and the presence of pain seems to strongly impact the sleep quality in people with TMD [Dreweck, 2020].
  • Another systematic review found that sleep dysfunction was a predictive factor to the onset of painful TMDs and advised that healthcare providers should routinely screen for the presence of sleep dysfunction in these people [Burr, 2020]. 
Physiotherapy and acupuncture
  • The recommendation to consider referring to physiotherapy is based on limited evidence that massage or targeted exercises may provide short-term relief for acute TMD symptoms and improve joint function [Durham, 2015]. In addition, acupuncture (if available) may reduce pain intensity and masseteric tenderness by treating muscle trigger points in cases of myogenous TMD [Durham, 2015; Gauer, 2015; Ghurye, 2015], but it may have limited long-term benefits [Zakrzewska, 2013].
  • The GIRFT and Royal College of Surgeons’ Faculty of Dental Surgery guideline [Beecroft, 2025] states that acupuncture or dry needling for people with myogenous TMD is likely to have a positive effect on pain symptoms. Short-term pain relief offered through acupuncture may support active engagement in self-supported management in the post needling window of improved clinical symptoms. Acupuncture should be seen as an adjunctive treatment alongside supported self-management and/or other interventions [Beecroft, 2025].
  • Physiotherapy has been shown to be effective in the management of all TMD subtypes, especially with improving joint range of motion [Lomas, 2018].
  • Therapeutic jaw exercises can provide coordination training, relaxation, and strengthening of the muscles. Passive stretching may improve muscle mobility and range of movement of the TMJ and, in addition, may also help patients overcome fear of moving their jaws. Therapeutic jaw exercises are often part of self-care programs for patients with TMD pain, however evidence suggests low to moderate effects for these treatments [List, 2017].
Cognitive behavioural therapy
  • The recommendation to consider referral for cognitive behavioural therapy (CBT) and anxiety management is based on evidence that it may help chronic pain management and help the person identify factors which may precipitate or exacerbate TMD symptoms [Durham, 2015; Gauer, 2015; Beecroft, 2025]. 
  • Behavioural therapies, such as counselling, education, biofeedback, CBT, habit reversal, self-treatment at home after instruction, and relaxation techniques have been shown to be effective at treating TMD, although systematic reviews have indicated low to moderate evidence for treatment effects [List, 2017].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Simple analgesia

Diazepam

Adverse effects

  • Common or very common adverse effects include:
    • Confusion (more common in older people).
    • Drowsiness, ataxia, impaired motor ability, impaired concentration, amnesia, tremor, dizziness, dysarthria, headache, hypotension, muscle weakness, nausea/vomiting, decreased appetite and palpitations.
    • Withdrawal symptoms (for example, anxiety, panic, palpitations, sweating).
    • In overdose — drowsiness, ataxia, dysarthria, nystagmus, and occasionally respiratory depression, and coma.
  • Other adverse effects include:
    • Hallucination, vertigo.
    • Skin reactions.
    • Decreased libido, erectile dysfunction, gynaecomastia.
    • Urinary retention, incontinence.
    • Constipation, diarrhoea, hypersalivation.
    • Paradoxical effects such as restlessness, agitation, irritability, aggression.
    • Suicidal ideation.
    • Tolerance and dependence — chronic use (even at therapeutic doses) may lead to the development of physical and psychic dependence: discontinuation of the therapy may result in withdrawal.
  • Rare or very rare adverse effects include:
    • Bradycardia.
    • Cardiac arrest.
    • Increased bronchial secretion.
    • Respiratory arrest.
  • Diazepam may cause drowsiness, impair judgement and increase reaction time, and therefore affect ability to drive or perform skilled tasks.
    • Road safety risk is significantly greater when taken in combination with alcohol, even in small amounts.
    • The hangover effects of a night dose may impair performance on the following day.
  • Give the following advice to a person taking diazepam who drives:
    • You should not drive if you feel drowsy, dizzy, have visual problems or poor co-ordination, are unable to concentrate or make decisions.
    • It is now an offence to drive if you have more than a specified amount of benzodiazepine in your body whether your driving is impaired or not.
    • Roadside drug screening tests have been introduced in the UK since March 2015. These test the saliva for drugs that impair driving. If you have a positive roadside drug test for benzodiazepines, the police may ask you to provide a blood sample to measure the amount of benzodiazepine in your body.
    • If you are found to have more than the specified amount of benzodiazepine, as long as your driving is not impaired, you are taking your medicine on the advice of your GP or pharmacist, you will be able to raise a 'statutory defence' and the police may not prosecute you.
    • It may be helpful to keep evidence with you while you are driving, that you are taking a benzodiazepine in accordance with medical advice. Suitable evidence may include:
      • Your medication box with the pharmacy label on.
      • The other half of your prescription with the list of medicines prescribed by your doctor.

[Department for Transport, 2014; BNF, 2026; EMC, 2026]

Contraindications and cautions

  • Do not prescribe diazepam to people with:
    • Phobic or obsessional states; chronic psychosis, hyperkinesis — paradoxical reactions may occur. 
    • Acute pulmonary insufficiency — respiratory depression, acute or chronic severe respiratory insufficiency. 
    • Myasthenia gravis — may exacerbate condition. 
    • Sleep apnoea — may exacerbate condition. 
    • Severe hepatic impairment — the elimination half-life of diazepam may be prolonged. Use of diazepam in hepatic impairment may precipitate coma.
    • Acute porphyria. 
    • Depression (as monotherapy) or in people with anxiety associated with depression due to risk of suicide. 
  • Prescribe diazepam with caution to people with:
    • Respiratory disease — risk of respiratory depression.
    • Organic brain disease.
    • Renal impairment — risk of increased cerebral sensitivity to benzodiazepines.
    • Mild to moderate hepatic impairment. 
    • Dependent, obsessive-compulsive, or avoidant-type personality disorders — extreme caution advised. 
    • Elderly or debilitated — if possible, avoid due to risk of falls. If based on clinical need, a decision to treat is taken, reduce the dose. 
    • A history of drug and/or alcohol misuse or dependency. 
  • Do not prescribe diazepam to pregnant women unless unavoidable (for example, for seizure control) — risk of neonatal withdrawal symptoms.
  • Do not prescribe diazepam to breastfeeding women if possible — diazepam is excreted in breast milk with the potential to cause infant sedation.

 [BNF, 2026; EMC, 2026]

Drug interactions

  • The following drug interactions may occur with diazepam:
    • Alcohol and opioids — advise against concomitant use with diazepam, as they can induce lethal sedation by potentiating the effects of diazepam.
    • Antihypertensives, vasodilators, and diuretics — concomitant use with diazepam may enhance the hypotensive effects of these drugs.
    • Drugs that inhibit cytochrome P450 enzyme (for example cimetidine, azole antifungals) — exposure to diazepam is increased. Concurrent use may lead to increased diazepam effects. Dose reduction may be required.
    • Drugs that induce cytochrome P450 enzyme (for example rifampicin) — exposure to diazepam is reduced. Concomitant use of rifampicin and diazepam should be avoided. 
    • HIV protease inhibitors (ritonavir and indinavir) — concurrent use with diazepam is contraindicated.
    • Cisapride — absorption of diazepam is accelerated. Be aware that sedation may occur more quickly.  
    • Modafinil — monitor for adverse effects of diazepam as modafinil may increase the effects of diazepam.
    • Phenytoin — monitor phenytoin concentrations as concomitant use with diazepam may increase or decrease serum concentrations of phenytoin.

[Preston, 2021; BNF, 2026; EMC, 2026]

Amitriptyline and gabapentin

Supporting evidence

This CKS topic is largely based on the NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’  Faculty of Dental Surgery guideline on Management of painful Temporomandibular disorder in adults [Beecroft, 2025]; the American Association of Oral and Maxillofacial Surgeons (AAOMS) statement on Temporomandibular disorders [AAOMS, 2024] and the American Academy of Pediatric Dentistry (AAPD) guideline Temporomandibular disorders in children and adolescents including those with special health care needs [AAPD, 2024]. The rationale for individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of temporomandibular joint dysfunction, searching for evidence of treatment and referral in primary care.

Search dates

July 2021 - March 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp temporomandibular joint disorders/, diagnosis* etiology* therapy* exp temporomandibular joint dysfunction syndrome/, temporomandibular.tw., temporomandibular joint.tw.
  • facial pain*
  • (temporomandibular disorder).ti,ab.
  • (temporomandibular joint disorder).ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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    • The British National Formulary team.
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Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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