About Temporomandibular Disorders TMD

Temporomandibular disorders (TMD) are a group of common musculoskeletal conditions affecting the temporomandibular joint (TMJ), masticatory muscles, and associated structures. They are a frequent source of orofacial pain and dysfunction and most often affect adults, with a higher prevalence reported among women.

TMD typically presents with localized pain or tenderness in the jaw, face, or preauricular region, often accompanied by pain with jaw movement, restricted or asymmetric mandibular motion, and joint sounds such as clicking, popping, or crepitus. Symptoms may also include headaches, ear-related complaints (e.g., earache, fullness, tinnitus), and neck pain.

The etiology of TMD is multifactorial and reflects an interaction between mechanical loading, neuromuscular factors, central pain processing, and psychosocial influences. Contributing factors may include parafunctional behaviours (e.g., clenching, bruxism), sustained or repetitive jaw loading, trauma, postural factors, sleep disturbance, and psychological stress. Structural findings, including malocclusion or imaging abnormalities, do not consistently correlate with symptom severity or functional impact.

TMD is best understood within a biopsychosocial framework, as symptoms, recovery, and response to care are influenced by biological, psychological, and social factors. Clinical presentation and prognosis vary widely, and management should focus on pain reduction, restoration of function, and support for participation in daily life rather than correction of structural findings alone.

About CCG Care Pathways

Purpose

CCG is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Temporomandibular Disorders (TMD) Care Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent

Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
Key Aspects:
- Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
- Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
- Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
- Patient understanding and agreement:
  - Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
  - Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
  - Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
- Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic information: Age, gender, sex, race/ethnicity.
Main complaint: Location, onset, duration, and nature of orofacial, jaw, headache, or ear-related symptoms (e.g., ear pain, fullness, tinnitus); pain behavior with jaw movement (e.g., opening, chewing, yawning); presence of joint sounds (clicking, popping, crepitus); stiffness or restricted mandibular movement; and impact on eating, speaking, yawning, sleep, work, and daily activities.
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, and history: Past medical conditions; medications and supplements; history of facial, jaw, or cervical trauma; dental history (recent dental procedures, orthodontics); headache or migraine history; sleep quality and sleep disorders; parafunctional behaviors (e.g., clenching, bruxism, gum chewing); posture-related symptoms; physical activity and exercise history.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
Previous treatments and responses: Prior conservative, dental, or medical treatments (e.g., splints, medications, physical therapy), adherence, perceived benefit, and adverse effects.
Beliefs and expectations: Understanding of TMD, beliefs about causes (e.g., bite, stress), expectations regarding recovery, concerns about chronicity, and confidence in jaw use and activity.
Flag considerations: Screen for red flags, orange flags, and psychosocial (yellow) factors.

Outcomes Assessments: Prioritize outcome measures that align with the individual’s goals, symptom profile, and functional limitations.

Pain: Use pain scales (e.g., NRS) and diagrams.
Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS, MFIQ). Impact of symptoms on eating, communication, work, social participation, and daily activities.
Recovery: Use self-rated recovery scales.
Quality of life: Assess using tools such as SF-12.
Sleep quality: Assess using tools such as PSQI.
Work/school status: Monitor return to activities.
Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
Patient feedback: Gather and integrate patient experience and satisfaction.

4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

Suspected stroke or transient ischemic attack (TIA):
Sudden onset of facial or limb weakness, numbness, dysarthria, aphasia, visual changes, ataxia, dizziness, vertigo, confusion, or severe headache.
Suspected infection involving the TMJ or adjacent structures:
Acute onset of severe facial or jaw pain with redness, rapid swelling, warmth, fever, trismus, or systemic symptoms.
Suspected fracture or dislocation:
History of facial trauma with malocclusion, inability to open or close the mouth, deformity, or acute functional loss.

ACTION: Refer to appropriate medical provider:

Giant cell arteritis (temporal arteritis):
Age over 50 with new or atypical headache, jaw claudication, unexplained fever, scalp tenderness, or visual disturbance/loss.
Trigeminal neuralgia:
Severe, unilateral, electric shock–like facial pain in the distribution of one or more branches of the trigeminal nerve.
Inflammatory or systemic disease:
Features suggestive of inflammatory arthritis (e.g., rheumatoid arthritis, psoriatic arthritis), including prolonged morning stiffness, multi-joint involvement, or known systemic disease.
Neoplasm:
Persistent or progressive facial or jaw pain, unexplained swelling, night pain, weight loss, or cranial nerve involvement.
Otologic or dental pathology:
Persistent ear pain, hearing changes, vertigo, discharge, or dental symptoms inconsistent with referred pain.
Persistent or worsening symptoms:
Progressive pain or functional decline not responding to appropriate conservative care, where diagnosis remains uncertain.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

Suicide or self-harm thoughts: thoughts without immediate danger.
Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

7. Physical Examination

The physical examination should be guided by the individual’s history, symptom behavior, and functional limitations, and findings should be interpreted in combination.

Observation

Facial symmetry, mandibular posture at rest, and habitual jaw position.
Visible deviation or deflection during mouth opening and closing.
Signs of guarding, altered movement patterns, or parafunctional behaviors.

Mandibular range of motion

Active and passive mouth opening, lateral deviation, and protrusion.
Presence of pain, restriction, asymmetry, or end-range discomfort.
Observation of joint sounds (clicking, popping, crepitus) during movement.

Palpation

Palpation of the temporomandibular joints for tenderness, swelling, or pain reproduction.
Palpation of masticatory muscles (e.g., masseter, temporalis, medial and lateral pterygoids where accessible) for tenderness, tone, or symptom reproduction.
Palpation of relevant cervical musculature as indicated.

Joint sounds

Identification of clicking, popping, or crepitus during mandibular movement.
Correlation of joint sounds with pain or functional limitation, recognizing that joint sounds alone are not diagnostic.

Neurological screening

Cranial nerve screening as indicated, particularly when facial sensory changes, weakness, or atypical symptoms are reported.
Screening for cervical or referred pain contributions where relevant.

Functional assessment

Assessment of pain and control during functional tasks such as chewing, speaking, yawning, or sustained mouth opening.
Evaluation of tolerance to jaw use in activities relevant to the individual’s goals and daily demands.

Cervical and postural assessment

Screening of cervical spine mobility and posture where neck symptoms coexist or contribute to symptom presentation.
Integration of findings with orofacial symptoms rather than isolated interpretation.

Special/orthopedic tests

Special or orthopedic tests (e.g., joint loading, assisted movement tests) may be performed selectively to support clinical reasoning.
Findings should be interpreted cautiously and in combination with history, symptom behavior, and functional assessment, recognizing that no single test is diagnostic for TMD.

Imaging and diagnostics

Imaging is not routinely indicated for most presentations of TMD.
Radiography or advanced imaging may be considered when there is suspicion of fracture, dislocation, inflammatory, or when symptoms are atypical, progressive, or unresponsive to appropriate conservative care.
Imaging findings should be interpreted in clinical context, as structural changes do not consistently correlate with pain or dysfunction.

8. Clinical Presentations of TMD

There is no single, widely accepted test to definitively diagnose temporomandibular disorders. Clinical reasoning should be based on a combination of history, symptom behavior, and examination findings, recognizing that presentations often overlap and may change over time (Beaumont 2020).

Common clinical presentation patterns include:

Muscle-dominant presentations (myalgia / myofascial pain)

Pain localized to the masticatory musculature
Pain reproduced with palpation of muscles of mastication
Pain or limitation with mouth opening or lateral/protrusive movements
Jaw fatigue or stiffness with use

Joint-dominant presentations (arthralgia)

Pain localized to the temporomandibular joint
Pain reproduced with TMJ palpation
Pain with mouth opening, lateral deviation, or protrusion
Joint sounds may or may not be present

Disc-related mechanical presentations

Symptoms may fluctuate and are not always painful
Audible joint sounds (clicking, popping, snapping) during opening, closing, or lateral/protrusive movements
Episodes of jaw locking or limited opening
Symptoms may fluctuate and are not always painful

Degenerative joint presentations

Crepitus during active or passive jaw movement
Possible reduction in mandibular range of motion
Symptoms may or may not correlate with imaging findings

Hypermobility or instability presentations

History of joint “catching,” locking, or dislocation
Difficulty closing the mouth from a fully open position
In some cases, inability to return to a closed position without assistance

Headache attributed to TMD

Headache localized to the temporal region
Headache provoked or modified by jaw movement, sustained jaw use, or parafunctional behaviors
Familiar headache reproduced with palpation of the temporalis muscle or mandibular movements

These presentation patterns are not mutually exclusive, and individuals may demonstrate features of more than one pattern. Structural findings, occlusal characteristics, and imaging abnormalities do not reliably predict pain severity or functional impact.

9. Conservative Treatment Considerations for TMD

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently supported by high-quality clinical practice guidelines. Management should be individualized, taking into account symptom duration, clinical presentation, functional impact, patient goals, and response to care.

Not all domains are required for every individual or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most appropriate components of care.

This pathway is not prescriptive and does not list all possible interventions. Interventions with limited or inconsistent evidence (particularly passive or invasive procedures) are not recommended for routine use and, if considered, should be used only as adjuncts to core, evidence-based care.

Acute and Subacute TMD

Evidence specific to acute TMD is limited; however, expert consensus and extrapolation from chronic TMD and musculoskeletal pain literature support an initial conservative, low-risk approach.

Recommended early management

Education and reassurance regarding the generally favourable prognosis
Advice to avoid excessive jaw loading (e.g., prolonged chewing, clenching, gum chewing)
Gentle jaw range-of-motion and relaxation exercises within tolerance
Postural awareness and avoidance of sustained jaw or cervical strain
Short-term use of simple analgesics or NSAIDs, if appropriate and not contraindicated
Monitoring of symptom trajectory and functional impact

Early escalation to invasive or irreversible interventions is not recommended. Persistence of symptoms beyond several weeks, worsening pain, or increasing functional limitation should prompt reassessment and transition to a chronic-care framework.

Persistent TMD (Busse et al., 2023)

Strong recommendations in favour

Cognitive behavioural therapy (CBT)
Including CBT alone or CBT augmented with relaxation therapy or biofeedback. CBT targets pain coping, maladaptive beliefs, stress responses, and activity avoidance, and is associated with meaningful improvements in pain and function.
Therapist-assisted jaw mobilization
Gentle, guided mobilization aimed at improving jaw movement and reducing pain.
Manual trigger point therapy
Directed at masticatory muscles to reduce pain sensitivity and improve function.
Supervised postural exercise
Exercises addressing cervical and upper-quarter posture and movement control.
Supervised jaw exercise and stretching
With or without manual trigger point therapy, targeting jaw mobility, endurance, and control.
Usual care
Defined as education, reassurance, self-management advice, home exercises and stretching, and self-massage.

Conditional recommendations in favour

Manipulation
Considered selectively and integrated within a broader care plan.
Acupuncture
May provide modest benefit for pain and function in some individuals.
Jaw exercise combined with mobilization
Manipulation combined with postural exercise
CBT combined with NSAIDs
Where medication risks are acceptable and NSAIDs are used short-term.

Conditional recommendations against

The following are not recommended for routine use, due to limited benefit, potential harm, or unfavourable risk–benefit balance:

Reversible occlusal splints (alone or in combination)
Arthrocentesis (alone or in combination)
Low-level laser therapy
Transcutaneous electrical nerve stimulation (TENS)
Gabapentin
Botulinum toxin injections
Hyaluronic acid injections (with or without supplements)
Relaxation therapy alone or biofeedback alone
Trigger point injections
Acetaminophen (alone or combined with muscle relaxants or NSAIDs)
Topical capsaicin
Corticosteroid injections (with or without NSAIDs)
Benzodiazepines and beta-blockers

Strong recommendations against

Irreversible oral splints
Discectomy
NSAIDs combined with opioids

10. Risk and Prognostic Factors for TMD

(Beaumont et al., 2020; Durham et al., 2015; Busse et al., 2023; Felin et al., 2022)

TMD has a variable clinical course, with prognosis influenced by a combination of biological, psychological, and contextual factors rather than by structural findings alone

Common risk factors

History of trauma to the jaw, face, or neck, including falls, sports injuries, interpersonal violence, or prolonged dental procedures.
Parafunctional behaviours such as clenching or bruxism.

Psychological and pain-related factors

Psychological comorbidities, including anxiety, depression, and somatization, are common among individuals with TMD and are strongly associated with pain persistence and disability.
Psychological comorbidities, including anxiety, depression, and somatization, are common among individuals with TMD, particularly in those with persistent symptoms, and are associated with poorer outcomes and increased disability.

Prognostic considerations

While many individuals with acute TMD improve with conservative care, up to approximately 30% may develop persistent symptoms lasting longer than three months.
Poorer outcomes are associated with higher baseline pain, psychological distress, widespread pain, and maladaptive coping, rather than with imaging findings or occlusal characteristics.

Recognition of these factors can support early reassurance, appropriate expectation-setting, and timely integration of behavioural and self-management strategies for individuals at higher risk of persistent symptoms.

11. Ongoing Follow-up

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
Referral and co-management: arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.

12. Criteria for Discharge

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
Documentation: record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

Temporomandibular Disorders (TMD)