12-phase flow (12)

1. 1FRAME
   Frame as a CHRONIC outpatient engine for adult musculoskeletal TMD per DC/TMD axis-I + axis-II (Schiffman 2014 PMID 24482784) plus AAOP 2024 commentary. Two jobs: (A) confirm TMD diagnosis (myalgia / arthralgia / disc displacement / DJD) and rule out red-flag mimics (GCA, ACS, head/neck malignancy, trigeminal neuralgia, intracranial); (B) run conservative-first ladder — education + self-management + PT + CBT + stabilisation splint (option) + intra-articular for refractory + arthrocentesis for lock — AGAINST irreversible occlusal therapy as routine treatment.
   advance: TMD scope confirmed; red-flag mimics flagged for routing
2. 2ENTRY
   Capture pain location (preauricular / temple / masticatory), quality + jaw-movement modulation, click / crepitus / locking, limited-opening complaint. DC/TMD requires pain triggered or modulated by jaw movement / function / parafunction (Schiffman PMID 24482784).
   inputs: pain_location_quality_severity
   advance: DC/TMD axis-I pain pattern + functional features recorded
3. 3CONTEXT
   Build the context: chronicity (acute <3 mo vs chronic ≥3 mo — CBT priority), parafunctional habits (bruxism / clenching / nail-biting / gum), psychiatric comorbidity (anxiety / depression / somatic distress — axis-II), widespread pain / fibromyalgia phenotype, pregnancy. These drive the personalised ladder choice.
   inputs: pain_duration_chronicity, parafunctional_habits_bruxism_clenching_nail_gum, psychiatric_comorbidity_anxiety_depression_somatic_distress, widespread_pain_fibromyalgia_phenotype
   advance: chronicity + parafunction + psychosocial + widespread-pain context captured
4. 4RED_FLAGS
   Recognise can't-miss mimics — DO NOT manage here. Age ≥50 + jaw claudication + headache / scalp tenderness / visual change + raised ESR/CRP → GIANT-CELL ARTERITIS, vision-saving emergency, urgent rheumatology + high-dose corticosteroid. Exertional jaw pain without local findings + cardiac risk → ACS / angina, route to cardio. Unilateral persistent jaw pain + mass / ipsilateral lymphadenopathy / B symptoms → head/neck malignancy work-up. Severe new headache + neuro signs → intracranial pathway.
   inputs: red_flag_age_50_plus_jaw_claudication_headache_visual_change, red_flag_exertional_jaw_pain_cardiac, red_flag_unilateral_persistent_pain_mass_lymphadenopathy_b_symptoms
   actions: panel.inflammation, panel.cbc
   advance: red-flag screen completed; GCA / ACS / malignancy / intracranial mimics routed OUT if positive
5. 5INITIAL_WORKUP
   DC/TMD axis-I clinical exam (Schiffman PMID 24482784) — sensitivity ≥0.86 / specificity ≥0.98 for the common pain-related TMD: jaw range-of-motion (assisted + unassisted maximum opening, lateral excursions, protrusion); palpation of masseter / temporalis / lateral pterygoid / TMJ capsule; auscultation for click / crepitus during opening / closing / lateral excursion. Axis-II screening: pain intensity NRS, pain-related disability, psychological distress, jaw functional limitations, parafunctional behaviours — 41-question screening or 81-question comprehensive set. Routine bloods NOT required for primary TMD; ESR/CRP only if GCA suspicion.
   inputs: jaw_function_max_opening_deviation_deflection, tmj_click_crepitus_locking, masticatory_muscle_tenderness, tmj_arthralgia_capsule_palpation_tenderness
   actions: panel.inflammation
   advance: axis-I clinical exam complete; axis-II psychosocial screen completed; DC/TMD diagnosis assigned
6. 6BRANCHING_WORKUP
   Branch only when atypical or refractory: CT or cone-beam CT for DJD staging; MRI TMJ for disc-displacement-with-lock pre-surgical planning; rheumatologic work-up for inflammatory arthritis (RA, psoriatic, AS); routine imaging NOT recommended for typical pain-related TMD (Schiffman PMID 24482784).
   inputs: imaging_only_for_refractory_or_red_flag
   advance: atypical / refractory cases imaged appropriately; typical pain-related TMD does NOT need imaging
7. 7DIFFERENTIAL
   Terminal differential (DC/TMD + clinical): myalgia / myofascial pain (muscle palpation tenderness pivot) vs arthralgia (TMJ capsule tenderness pivot) vs disc displacement with reduction (click pivot) vs disc displacement WITHOUT reduction with limited opening (closed lock, no click, deflection pivot) vs DJD (crepitus + radiographic pivot) vs trigeminal neuralgia (paroxysmal lancinating + V2/V3 + trigger zone pivot — different pathway, carbamazepine) vs GCA (age + claudication + ESR/CRP pivot — emergency, route OUT) vs head/neck malignancy (mass / lymphadenopathy / B symptoms pivot — biopsy pathway) vs cardiac referred pain (exertional + cardiac risk pivot — cardio pathway) vs dental / sinus / otitis source (alternative anatomic source).
   inputs: red_flag_paroxysmal_lancinating_trigger_zone_trigeminal_neuralgia
   advance: best DC/TMD axis-I diagnosis + axis-II comorbidity profile assigned; non-TMD pathways routed OUT
8. 8RISK_STRATIFICATION
   Stratify by chronicity + axis-II distress: acute <3 mo with low distress (most resolve with self-management alone); chronic + low distress (PT + jaw exercise + CBT optional); chronic + high distress / disability (CBT + biofeedback / relaxation HIGHEST PRIORITY per Yao BMJ 2023 PMID 38101924 — RD 36% for clinically meaningful pain relief). Layer widespread-pain phenotype (centralised pain pathway).
   inputs: pain_duration_chronicity, psychiatric_comorbidity_anxiety_depression_somatic_distress
   advance: chronicity + axis-II distress band + widespread-pain status assigned
9. 9TREATMENT
   Conservative-first stepped ladder (Schiffman PMID 24482784 DC/TMD; Yao BMJ 2023 PMID 38101924 network meta-analysis; Al-Ani Cochrane 2004 PMID 14973990 stabilisation splint). Step 1 (ALL): education + self-management (soft diet, jaw rest, no gum, no clenching, no wide yawn), heat/cold, gentle jaw exercises, OTC NSAID or acetaminophen short course. Step 2: supervised PT (jaw exercises + stretching + manual therapy) + CBT-based interventions (CBT + biofeedback/relaxation showed RD 36% for MID pain relief, highest of all interventions per Yao BMJ 2023 NMA); manual trigger-point therapy RD 32%. Step 3 (selected): stabilisation splint (NOT repositioning splint) for bruxism / myalgia — low-certainty Cochrane evidence, OPTION not strong recommendation. Step 4 (arthralgia / DJD refractory): intra-articular triamcinolone or hyaluronate. Step 5 (refractory disc-displacement lock or end-stage DJD): arthrocentesis / arthroscopy / open arthroplasty (last resort). AGAINST IRREVERSIBLE OCCLUSAL THERAPY (occlusal adjustment, orthognathic surgery for routine TMD).
   inputs: parafunctional_habits_bruxism_clenching_nail_gum, pregnancy
   advance: appropriate ladder step started; CBT prioritised for chronic + high-distress; irreversible occlusal therapy explicitly avoided
10. 10DISPOSITION
    OUTPATIENT longitudinal management is the default — primary care + dentistry / orofacial-pain specialist + physical therapy + psychology / mental health if axis-II distress prominent. Maxillofacial surgery referral only for refractory cases with confirmed mechanical lock or end-stage DJD. GCA / ACS / malignancy / intracranial → emergency / specialist route OUT.
    inputs: red_flag_age_50_plus_jaw_claudication_headache_visual_change
    advance: outpatient multimodal team set; emergency referrals queued where indicated
11. 11MONITORING
    Track at each 6-12-week visit (more often early): pain NRS, maximum opening, parafunction status, PT engagement, CBT module completion, NSAID / acetaminophen use, sleep / mood comorbidity. Most patients improve within 3-6 months; persistent symptoms at 6 months prompt CBT escalation, splint trial, or imaging.
    inputs: psychiatric_comorbidity_anxiety_depression_somatic_distress
    advance: structured pain + function + PT/CBT engagement + parafunction review completed each visit
12. 12FOLLOWUP
    Longitudinal chronic-disease arc — 6-12-monthly stable; sooner for flare or worsening. Avoid scope creep into irreversible procedures (occlusal adjustment, orthognathic, total joint replacement) — counsel patient that AAOP 2024 commentary aligned is AGAINST these for routine TMD. Re-screen for axis-II distress at every visit. Maintain self-management foundation indefinitely.
    inputs: parafunctional_habits_bruxism_clenching_nail_gum
    advance: structured longitudinal + irreversible-procedure-counter-counselling + axis-II re-screen completed