Clinical Handbook for Oral, Facial, and Head Pain

Introductory Remarks from the Authors

We have compiled this material to be used as a concise summary of common painful and nonpainful temporomandibular joint (TMJ) disorders, as well as painful disorders in the face and head. It is not intended to be comprehensive, nor is it intended to be used as a standalone reference—in fact, we encourage the reader to study the references listed at the end and have provided links for open access references where possible. Our goal is for this handbook to be used as a study reference tool and a quick-reference guide in the clinical setting. The therapeutic options offered herein are backed by evidence when possible but may reflect the authors’ personal opinions based on clinical experience when evidence is lacking. As such, the pharmacotherapeutic armamentarium is not intended to be all-inclusive but rather to represent current practices and first and second choices of medications for quick reference. The “differential diagnosis” row in each table lists conditions that should be considered to present similarly to the primary condition, but a true differential diagnosis should be patient- specific relative to the chief complaint. When possible, International Classification of Diseases (ICD)-10 codes have been included for clinical convenience. Where the orofacial pain (OFP) term varies from the ICD-10 terminology, those terms are included within the description of the condition.

All of the entities in this handbook are, in our opinion, within the scope of care of OFP specialists and appropriately trained dentists whose practice includes the diagnosis and management of OFP disorders. Nevertheless, we are aware that programs differ in their content and focus.

This is where continuing education is irreplaceable. It is the individual professional’s responsibility to remain knowledgeable and updated regarding disorders, testing that may be indicated, and evidence-based management via pharmacologic and other modalities. In the growing field of OFP, it is important to remember that the concept of evidence-based practice includes a dynamic interaction between the following elements: the available scientific literature base, patient factors (autonomy based on informed consent, physical and psychologic health, etc), and clinician experience. We acknowledge the significant relationship between sleep and pain; however, this topic was not included in this handbook because the scope of this project does not provide the attention that the topic of sleep as it relates to pain deserves.

How to Use This Handbook

The currently recognized diagnoses within the field of OFP have been grouped and categorized for ease of recognition based on clinical presentation: cutaneous pain, dental pain, periodontal pain, muscle disorders, TMJ disorders, neck pain, systemic disease, neuropathic pain, and primary headaches. Common medications for OFP conditions and appropriate serologic testing options are also included. The layout has been designed so that the pages may be printed out on a standard color printer and placed in a physical binder for desktop reference. Please note that all abbreviations used in a given section are spelled out at the end of that section. We recommend printing the document single-sided and then punching holes along the top of each page with a three-hole punch to place in a binder for use as a flip-chart. Alternatively, the handbook may be printed and bound by any professional printer because it is open access and free for reprinting. Of course, it is also useful as a digital resource.

Within each table, the terms Risk and BB may appear in the treatment or medication sections. Risk indicates the need for caution when prescribing—not the risk of developing those conditions, but rather the potential for complications. BB indicates an FDA Black Box Warning for that treatment or medication.

Once the general type of pain has been identified by clinical examination, the appropriate color-coded section should narrow the search for conditions described by that type of pain. For example, moderate pain that is nonpulsatile and dull in character should direct the clinician quickly to the section on muscle pain. From there, the diagnosis can be further refined.

Ananthan S, Benoliel R. Chronic orofacial pain. J Neural Transm

(Vienna) 2020;127:575–588.

Headache Classification Committee of the International

Headache Society (IHS). The International Classification of Headache Disorders, ed 3. Cephalalgia 2018;38:1–211.* International Classification of Orofacial Pain (ICOP). Cephalalgia

2020;40:129–221.*

Klasser G, Romero Reyes M (eds). Orofacial Pain: Guidelines for

Assessment, Diagnosis, and Management, ed 7. Quintessence, 2023.

May A, Benoliel R, Imamura Y, et al. Orofacial pain for clinicians: A review of constant and attack-like facial pain syndromes. Cephalalgia 2023;43:1–12.*

Menchel HF, Greene CS, Huff KD. Intraoral appliances for temporomandibular disorders: What we know and what we need to know. Front Oral Maxillofac Med 2021;3:6.*

National Academies of Sciences, Engineering, and Medicine.

Temporomandibular Disorders: Priorities for Research and Care. The National Academies Press, 2020.*

Okeson J (ed). Bell’s Oral and Facial Pain, ed 7. Quintessence,

2014.

Olesen J, Goadsby PJ, Ramadan NM, Tfelt Hansen P. Welch

KMA (eds). The Headaches, ed 3. Lippincott Williams & Wilkins, 2005.

Peck CC, Goulet JP, Lobbezoo F, et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil 2014;41:2–23.*

Peng K-P, Benoliel R, May A. A review of current perspectives

on facial presentations of primary headaches. J Pain Res 2022;15:1613–1621.*

Ponte C, Grayson PC, Robson JC, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Ann Rheum Dis 2022;81:1647–1653.*

Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6–27.

Sharav Y, Benoliel R (eds). Orofacial Pain and Headache, ed 2.

Quintessence, 2015.

Simons DG, Travell JG, Simons LS. Myofacial Pain and

Dysfunction: The Trigger Point Manual, Volume 1: Upper Half of Body, ed 2. Williams & Wilkins, 1999.

US Department of Health and Human Services, Centers for Disease Control and Prevention. Tickborne Diseases of the United States: A Reference Manual for Healthcare Providers, ed 5. CDC, 2018.*

*Open access, free PMC article, or otherwise available for download.