The Occlusal Splint Fit Notes Template

Supplying a soft bite guard without a documented TMD diagnosis OR documented temporary/palliative intent is a key risk in occlusal therapy. Below is a template for UK clinicians to paste into their PMS for every splint fit.

Why this occlusal splint fit template wins

• Diagnosis confirmation from assessment — defends against "splint without diagnosis" indemnity issue.
• Splint type rationale documented — defends against subsequent challenge of choice.
• Conservative trial outcome recorded before progressing to splint — RCS 2024 compliance.
• Baseline outcome measures (pain CPI, MCO) — enables objective review.
• Wear instructions specifically include "nightly not continuous" — prevents over-wearing complications.

The template (paste into your PMS notes field)

Paste the occlusal splint fit template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

DIAGNOSIS (confirmed from TMJ assessment): [Reference assessment date / specific TMD diagnosis per DC/TMD]
INDICATION: [Failed conservative trial / specific TMD subtype / bruxism with tooth wear progression]

SPLINT TYPE SELECTED: [Stabilisation / Michigan-type / Tanner / soft EVA — note: no superiority between types per RCS 2024]
ARCH: [Upper / lower]
RATIONALE: [Why this type — patient comfort / tooth coverage / bruxism wear / parafunction control]

LABORATORY-MADE OR DIRECT? [Lab-processed acrylic / direct chairside soft EVA]

FIT ASSESSMENT:
- Visual fit: [Snug, retentive / loose / over-extended]
- Extension: [Adequate / over-extended in vestibule / inadequate posterior coverage]
- Patient comfort: [Comfortable / pressure spots — identified]
- Speech: [Acceptable / lisp]
- Removal / insertion: [Easy / requires modification]

OCCLUSAL ADJUSTMENT (under articulating paper):
- ICP contacts: [Even bilateral / single-point identified — adjusted]
- Lateral excursion contacts L: [Canine-guided / group function / cusp interferences — adjusted to canine guidance / smooth excursion]
- Lateral excursion contacts R: [Same approach]
- Protrusive contacts: [Anterior-guided / posterior interferences — adjusted]
- Adjustments documented per site

ADJUSTMENTS MADE:
- Relief areas: [Sites]
- Occlusal equilibration: [Specific surfaces adjusted, depth approximate]
- Polish after adjustment: [Confirmed]

WEAR INSTRUCTIONS (verbal + written):
- When to wear: [Nightly / daytime stress / 24/7 acute phase — specify]
- Hygiene: [Brush daily with soft brush + denture cleaner / soak weekly]
- Storage: [Dry container with ventilation / never hot water]
- What to expect: [Initial bite difference resolves in 1-2 weeks / occasional adjustment expected]

BASELINE OUTCOME MEASURES (for review comparison):
- Pain score (CPI): [Pre-splint score recorded]
- MCO: [Recorded]
- Specific concern: [E.g. "morning headaches frequency: __ per week"]

REVIEW INTERVAL: [4-6 weeks initial] — review specifically for: pain improvement / MCO change / occlusal changes / wear pattern on splint

POST-OP ADVICE:
- Continue self-management (exercises, warm compresses, soft diet)
- Use ibuprofen PRN for breakthrough pain
- Contact if: worsening pain / new symptoms / splint damage / changes in bite when not wearing splint

Try the occlusal splint fit note in the live demo → No account needed.

What good looks like — a worked example

The same occlusal splint fit template, completed for a realistic case.

DIAGNOSIS: Myalgia (right masseter + temporalis) + disc displacement with reduction right TMJ + sleep bruxism. Confirmed at assessment 5 weeks ago. Conservative management trial (education, exercises, soft diet, NSAIDs) showed partial improvement (pain CPI 6→4) but persistent morning symptoms.
INDICATION: Failed conservative trial alone. Sleep bruxism continuing with morning pain. Stabilisation splint indicated.

SPLINT TYPE SELECTED: Upper stabilisation splint (Michigan-style)
ARCH: Upper
RATIONALE: Upper splint preferred for patient comfort during sleep and aesthetics (less visible). Full-coverage hard acrylic stabilisation splint for bruxism protection AND occlusal stabilisation. No evidence soft splint would be superior per RCS 2024.

LABORATORY-MADE OR DIRECT? Lab-processed acrylic (impressions taken at previous visit).

FIT ASSESSMENT:
- Visual fit: Snug, retentive, no overextension
- Extension: Adequate buccal and palatal coverage, no vestibular interference
- Patient comfort: Comfortable. Slight pressure spot identified at UL7 region — relieved.
- Speech: Slight initial lisp — patient told this resolves within hours/days
- Removal / insertion: Easy

OCCLUSAL ADJUSTMENT:
- ICP contacts: Initially uneven. Adjusted to even bilateral light contact on all posterior teeth.
- Lateral excursion L: Group function with cusp interference on UR6. Adjusted to canine-disclusion in lateral movement.
- Lateral excursion R: Similar — adjusted to canine guidance.
- Protrusive: Anterior guidance achieved on canines + lateral incisors. No posterior interference.
- Adjustments documented above per site.

ADJUSTMENTS MADE:
- Relief area: UL7 pressure point (small adjustment with bur)
- Occlusal equilibration: ICP balanced; canine guidance established
- Polish after adjustment: Confirmed smooth surfaces

WEAR INSTRUCTIONS (verbal + written leaflet):
- When to wear: Nightly while sleeping (every night). Optional daytime use during high-stress periods. NOT continuous wear.
- Hygiene: Brush with soft toothbrush + cool water + denture cleaner solution. Avoid hot water (warps). Daily cleaning.
- Storage: In ventilated dry container during day. Never in hot water or sunlight.
- What to expect: Slight bite-feel different for 1-2 weeks while adapting. Bruxism likely on splint — wear is normal and protects teeth. Patient may need adjustment at 2 weeks for occlusal settlement.

BASELINE OUTCOME MEASURES:
- Pain score (CPI): 4/10 (current — was 6/10 at assessment, partial response to conservative)
- MCO: 38mm (improved from 35mm at assessment)
- Morning headaches: 4-5/week (was 6-7/week at assessment)

REVIEW INTERVAL: 4 weeks

POST-OP ADVICE:
- Continue jaw exercises and warm compresses
- Continue stress management
- Ibuprofen 400mg TDS PRN for breakthrough pain
- Contact if: pain worsens / new symptoms develop / splint damage / persistent bite difference when not wearing splint (would indicate occlusal change requiring adjustment).

Compliance: the medico-legal angle

• RCS England FDS TMD Guideline (2024) — conservative trial first, splint for failed/persistent cases.
• BSOS guidance on occlusal therapy.
• GDC Principle 4 — splint provision must be diagnostically justified.
• Montgomery — splint is occlusal therapy with potential for irreversible changes; patient must understand the indication and alternatives.

Common documentation mistakes

• Splint provided without confirmed TMD diagnosis — a serious record gap.
• No conservative trial before splint — RCS 2024 non-compliance.
• No baseline pain or MCO recorded — no objective outcome at review.
• No wear instructions given (or not documented) — patient may over-wear or under-wear, both problematic.
• Generic "occlusal splint" with no type / arch / rationale — indefensible.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• NHS England GIRFT and RCS England FDS: Management of painful temporomandibular disorder in adults (v1.0 March 2024, v1.1 August 2025) (accessed 18 October 2026)

Frequently asked questions

Patient leaflets for this treatment

• Understanding Tooth Grinding (Bruxism)
• Understanding TMJ Problems

Related dental note templates

Browse the full set of free dental notes templates.