The TMJ / TMD Assessment Notes Template

Fitting an occlusal splint without a documented TMD diagnosis and conservative management trial is medico-legally indefensible. Below is a template for UK clinicians to paste into their PMS for every TMD assessment.

Why this TMJ / TMD assessment template wins

• Pain history structured (SOCRATES-equivalent for TMD) — defines the clinical picture.
• 3Q/TMD + CPI + PHQ-4 screening — RCS 2024 recommends formal psychosocial screening for TMD.
• Muscle palpation graded 0-3 per site bilaterally — quantifies the diagnosis.
• Mouth opening measured (MCO + MAO) — objective outcome measure for review.
• DC/TMD classification — universal taxonomy.
• Conservative-first plan documented — defends against premature splint provision claims.

The template (paste into your PMS notes field)

Paste the TMJ / TMD assessment template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

PRESENTING COMPLAINT: [Patient's own words]

PAIN HISTORY (TMD-specific):
- Site of pain: [Pre-auricular / temporal / masseter / TMJ / referred]
- Onset: [Sudden trauma / gradual / morning / evening / continuous]
- Character: [Dull ache / sharp / burning / throbbing]
- Severity (CPI 0-10): [Pain intensity scale]
- Modifying: [Worse with chewing / jaw movement / stress / morning grinding signs]
- Duration: [Days / weeks / months / years]
- Previous TMD treatment: [Y/N — outcome]

SCREENING:
- 3Q/TMD: [Y/N for each — pain in jaw/temple/ear/cheek >1/week, pain in jaw on opening, jaw locking/limited opening]
- PHQ-4 psychosocial screen: [Score / interpretation — TMD is often associated with stress/anxiety/depression]
- Sleep / bruxism: [Witness of grinding / morning headaches / fatigue]

PARAFUNCTIONAL HABITS:
- Bruxism: [Sleep / awake / both]
- Clenching: [Daytime stress / hidden / focal]
- Nail biting / pen chewing / chewing gum / hard food: [Habits]

EXTRA-ORAL EXAMINATION:
- Facial symmetry: [NAD / asymmetry]
- Muscle palpation tenderness (rate 0-3):
  - Masseter: L __  R __
  - Temporalis: L __  R __
  - Lateral pterygoid (try indirect via cheek pull): L __  R __
- TMJ palpation:
  - Lateral pole: L __  R __
  - Posterior wall (intra-auricular): L __  R __
- TMJ noises: [None / click on opening or closing — note timing / crepitation]
- TMJ pain on loading: [Y/N]

MOUTH OPENING:
- Maximum comfortable opening (MCO): __ mm
- Maximum assisted opening (MAO): __ mm
- Deviation on opening: [None / L / R — site of deviation]
- Lateral movement: L __ mm  R __ mm
- Protrusion: __ mm

INTRA-ORAL:
- Occlusion: [Class / interferences in excursion / cross-bite]
- Wear patterns: [Cuspal / incisal — pattern consistent with bruxism]
- Scalloped tongue: [Y/N — sign of tongue thrust or clenching]
- Cheek bite line: [Y/N — clenching sign]
- Damaged restorations from parafunction: [Y/N]

RADIOGRAPHIC ASSESSMENT (if indicated):
- OPG: [Justification — exclude pathology if persistent / atypical]
- CBCT or MRI: [Specialist setting if structural pathology suspected]

DIAGNOSIS (DC/TMD classification):
- Myalgia / myofascial pain / arthralgia / disc displacement with reduction / disc displacement without reduction / degenerative joint disease
- Acute / chronic

TREATMENT PLAN (conservative-first):
- Self-management: [Education leaflet / soft diet / warm compresses / jaw exercises / stress management]
- Pharmacological: [NSAIDs / paracetamol / amitriptyline low-dose if specialist]
- Splint therapy: [ONLY after conservative trial — type if planned, with separate splint fit note]
- Physiotherapy referral: [If indicated]
- Specialist referral: [Persistent / structural pathology / refractory]

REVIEW: [4-6 weeks for conservative management response]

Try the TMJ / TMD assessment note in the live demo → No account needed.

What good looks like — a worked example

The same TMJ / TMD assessment template, completed for a realistic case.

PRESENTING COMPLAINT: "Bad jaw pain on the right side, especially in the mornings. Lasted 3 months."

PAIN HISTORY:
- Site: Right pre-auricular and masseter region
- Onset: Gradual over 3 months, worse mornings
- Character: Dull ache, sometimes sharp on opening
- Severity (CPI): 6/10 in mornings, 3/10 by evening
- Modifying: Worse with chewing tough food, stress (work pressure increasing), upon waking. Better with rest and warm compresses.
- Duration: 3 months
- Previous TMD treatment: None.

SCREENING:
- 3Q/TMD: 3/3 positive (pain in jaw/temple >1/week, pain on opening, occasional brief locking)
- PHQ-4: 6/12 (mild-moderate anxiety/depression — work stress)
- Sleep: Partner reports grinding at night for past 6 months. Morning headaches frequent.

PARAFUNCTIONAL HABITS:
- Bruxism: Sleep — confirmed by partner
- Clenching: Awake — patient aware during work meetings
- Other: Nail biting, gum chewing

EXTRA-ORAL:
- Facial symmetry: NAD
- Muscle palpation tenderness:
  - Masseter: L 1, R 3 (significant)
  - Temporalis: L 1, R 2
  - Lateral pterygoid: L 0, R 2
- TMJ palpation:
  - Lateral pole: L 0, R 1
  - Posterior wall: L 0, R 1
- TMJ noises: Right click on opening at 25mm. No crepitation.
- TMJ pain on loading: Right tender

MOUTH OPENING:
- MCO: 35mm
- MAO: 42mm
- Deviation on opening: To right at click point
- Lateral movement: L 8mm, R 6mm (slight restriction R)
- Protrusion: 8mm

INTRA-ORAL:
- Occlusion: Class I. No anterior interferences. Slight working-side interference UL6 in left lateral excursion.
- Wear patterns: Mild cuspal wear UR6-7 (right working side preference)
- Scalloped tongue: Yes
- Cheek bite line: Yes bilaterally
- Damaged restorations: None.

RADIOGRAPHIC ASSESSMENT: OPG not indicated currently (no atypical features, no pathology suspected). May consider if persistent despite conservative management.

DIAGNOSIS (DC/TMD):
1. Myalgia (right masseter and temporalis muscle tenderness)
2. Disc displacement with reduction, right TMJ (click with reciprocal click on closing suggested)
3. Bruxism (sleep, confirmed)
4. Anxiety/stress (PHQ-4 positive, work-related)

TREATMENT PLAN (conservative-first per RCS 2024):
- Self-management: TMD education leaflet provided. Soft diet 2 weeks. Warm compresses 4x daily. Jaw exercises (provided leaflet — modified pencil exercise + lateral movement).
- Pharmacological: Ibuprofen 400mg TDS for 5 days for initial pain relief.
- Splint therapy: NOT today. Will reassess at 4-week review. If conservative management has limited effect, lower stabilisation splint will be considered.
- Physiotherapy referral: Considered if no improvement at review.
- Specialist referral: Not indicated currently.
- Stress management: Discussed mindfulness app + GP referral if work-related stress overwhelming.

REVIEW: 4 weeks — reassess pain (CPI), MCO, function, and splint need.

Compliance: the medico-legal angle

• RCS England FDS Comprehensive Guideline — Management of Painful TMD in Adults (2024) — current UK reference.
• BSOS (British Society for Occlusion Studies) guidance.
• GDC Principle 4 — diagnostic and treatment record sufficient for monitoring.
• Montgomery — splint and other irreversible occlusal therapies require failed conservative trial documentation.

Common documentation mistakes

• Fitting splint without formal TMD diagnosis — medico-legally indefensible.
• No psychosocial screening — TMD is biopsychosocial; missing this misses half the diagnosis.
• No mouth opening measurements — no objective outcome for review.
• No conservative management trial — RCS 2024 first-line is education + self-management.
• Soft bite guard "for grinding" without diagnosis or trial — common but indefensible if irreversible occlusal effects occur.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (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 TMJ Problems

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