Classification of Orofacial Pain
Gary D. Klasser, Jean-Paul Goulet, Antoon De Laat, and
Daniele Manfredini
Abstract
Designing a classification system for any dis-
ease entity, let alone orofacial pain and more
specifically for temporomandibular disorders,
is quite the task. Unfortunately, this is made
even more difficult due to the many conditions,
both physical and psychosocial, that must be
accounted for when undertaking this challenge
for these aforementioned entities. In order to
appreciate the utility of classification systems,
it is first necessary to gain an understanding
and comprehension as to their importance and
how it may be optimally operationalized for
both clinical and research activities. Other con-
siderations that must be taken into account are
G.D. Klasser (*)
Department of Diagnostic Sciences, School of Dentistry,
Louisiana State University Health Sciences Center, New
Orleans, LA, USA
e-mail: gklass@lsuhsc.edu
J.-P. Goulet
Faculté de Médecine dentaire, Université Laval, Québec,
QC, Canada
e-mail: jean-paul.goulet@fmd.ulaval.ca
A. De Laat
Department of Oral Health Sciences, K.U. Leuven,
Leuven, Belgium
Department of Dentistry, University Hospitals Leuven,
Leuven, Belgium
e-mail: antoon.delaat@uzleuven.be
D. Manfredini
School of Dentistry, University of Padova, Padova, Italy
e-mail: daniele.manfredini@tin.it
# Springer International Publishing AG 2016
C.S. Farah et al. (eds.), Contemporary Oral Medicine,
DOI 10.1007/978-3-319-28100-1_29-1
past and present classification systems that
have been espoused by various organizations.
Each of these needs to be carefully evaluated
within a framework of their inherent advan-
tages while exposing their limitations. These
previously established classification systems
must then be integrated with newly proposed
expanded upon or modified systems as a result
of recent findings from contemporary
evidenced-based scientific literature. Hope-
fully, this will lead to an “ideal classification
system” whereby other factors such as genetics
and neurobiological process can be reviewed
for inclusion in this expanded schema. Addi-
tionally, adopting newer approaches, such as
following ontological principles, will result in
a more thorough and comprehensive classifi-
cation system which ultimately will assist the
clinician in providing improved diagnosis, the
researcher in studying more homogenous
groups, and the patient in receiving more
directed and individualized interventions.
Keywords
Orofacial pain • Temporomandibular disor-
ders • Classification systems • Taxonomy •
Ontology
1
2 G.D. Klasser et al.

For the patient, receiving a clear and definitive

Contents
diagnosis allows for a better understanding and
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 acceptance of aspects related to etiology and path-
Development Strategies Towards a Classification ophysiology, promotes inclusion to a specific
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 group instead of feeling “in the dark,” and facili-
Current Orofacial Pain Classification Systems tates acceptance of the different steps of manage-
(General) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 ment. For researchers, it is imperative to have
International Association for the Study of Pain . . . . . . 4 homogenous groups when designing clinical
International Headache Society . . . . . . . . . . . . . . . . . . . . . . . 5
American Academy of Craniofacial Pain . . . . . . . . . . . . . 8 studies, and for communication among each other.
An ideal classification system would need to
Current TMD Classification Systems . . . . . . . . . . . . . . 9
RDC-TMD to DC-TMD and the Expanded TMD
satisfy several requirements (Fillingim et al.
Taxonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2014): it should be exhaustive (comprising all
clinical diseases or disorders belonging to the
Proposed Classification Systems . . . . . . . . . . . . . . . . . . . . 12
Classification of Chronic Idiopathic Orofacial Pain: field of interest), biologically plausible (the symp-
Woda et al. (2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 toms and signs should match with known biolog-
Classification of TMJ Disorders: Stegenga (2010) . . . 12 ical processes), mutually exclusive (there should
Classification Profile of TMD Patients: be no overlap between disease entities because of
Machada et al. (2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Classification of Orofacial Pains: Okeson (2014) . . . . 13 common symptoms), clinically useful (so that it
Psychosocial Subtyping of TMD Patients: can be used to help in treatment and prognosis),
Suvinen et al. (2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 reliable (consistently applicable in a reproducible
Advantages and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . 15 way between clinicians and over time), and simple
Futures Classification Systems . . . . . . . . . . . . . . . . . . . . . . 15 for practical use. Most of the current classification
Axis III: Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 systems regarding OFP suffer from deficits in at
Axis IV: Neurobiological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
least one of these qualities. In addition, since
Taxonomy and Ontology: A New Approach several independent groups of clinicians (originat-
for Classification Systems . . . . . . . . . . . . . . . . . . . . . . . 18
ing from different disciplines) try to build a clas-
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 sification, several disease entities have been
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 defined differently, and this is further complicated
when attempts are made to implement new
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
insights resulting from ongoing research (Woda
and De Laat 2014).
Introduction As pointed out further in this chapter, there is
no consensus (yet) regarding a universal and
A classification is defined as a “systematic unique classification of OFP. Such a classification
arrangement in groups or categories according to requests the support of a majority of clinicians and
established criteria” (Merriam-Webster 2015). researchers and would ideally also implement
A classification allows the definition of specific newer insights regarding the individual differ-
entities according to specific characteristics. In ences at a patient level to an otherwise identical
general medicine and thus for orofacial pain diagnosis. The most recent attempt to start this
(OFP), the characteristics of such an ideal diag- process is made by the ACTTION-AAPT
nostic system could be derived from the etiology, approach (Fillingim et al. 2014) where – in line
pathophysiology, diagnosis, and/or management with the biopsychosocial model for pain – the
of a specific disease or disorder. For the clinician, importance of a multiaxial evaluation and charac-
a correct definition and classification is important terization is advocated.
to name and classify the specific disease entity
since it will assist in planning the management
and in discussing the prognosis with the patient.
Classification of Orofacial Pain
Development Strategies Towards
a Classification System
Over time, several strategies have been developed
in order to build a classification system for OFP,
all with their advantages and limitations (Woda
and De Laat 2014). This section will attempt to
provide an overview of these ongoing efforts.
Traditionally, the oldest attempts to classify
diseases or disorders were based upon expert
opinion, and an authority-based consensus,
mostly focused on particular organ-systems or
pathophysiological processes. Several societies
and medical subdisciplines created task forces of
experts to share their knowledge and experience
and develop a restricted set of criteria to denom-
inate a set of particular diagnoses. These clinical
entities were, to the extent possible, organized in a
hierarchical way so as to create the classification.
Examples of this approach are the classification
systems of the International Headache Society
(IHS) (Headache Classification Committee of the
International Headache Society 2013), the Inter-
national Association for the Study of Pain (IASP)
(Merskey and Bogduk 1994), and the Research
Diagnostic Criteria for Temporomandibular Dis-
orders (RDC-TMD) (Dworkin and LeResche
1992). Using diagnostic criteria can facilitate the
search for homogeneous groups that would be
beneficial for both clinicians and researchers.
However, certain inherent problems arise
whereby a selected set of signs and symptoms is
used to characterize an already selected group as
this does not prevent the overlapping of disease
entities. In addition, if a group of patients is
selected on the basis of the criteria, it is not
known whether they all belong to a single disease
or that it is a sample of (partially) overlapping
disease entities. The specific criteria in such a
diagnostic system, however, can be evaluated
and tested for their reliability, specificity, and sen-
sitivity, and this has been done (e.g., RDC-TMD)
resulting in refinement and adjustment of some of
the criteria (Schiffman et al. 2010a). Unfortu-
nately, this method has also the limitation that
“circular reasoning” is possible since the
3
validation is done on the basis of an “a priori”
set of inclusion criteria.
In contrast to the method of diagnostic criteria,
the methodology of cluster analysis does not
depart from an already existing disease entity,
organ system, or pathophysiological process, but
allows for statistical grouping within a dataset of
signs and symptoms (Woda et al. 2005). This
technique to classify groups of patients surpasses
the organ system/specific tissue involved in the
pain and might better approach a mechanism-
based classification. In a next step, diagnostic
criteria for each cluster are necessary, which in
turn need to be tested for validity, specificity, and
sensitivity.
Recently, a more theoretical reflection on the
basis of ontological principles has been advocated
(further discussion presented in section “Taxonomy
and Ontology: A New Approach for Classification
Systems) (Nixdorf et al. 2012). Applying this the-
oretical approach helps in the development of clear
taxonomy, irrespective of new developments in
etiological or pathophysiological issues. Ideally,
this methodology would be applied to the disease
entities emerging from previous cluster analysis.
In order to address the existing confusion cre-
ated by the many pain classifications, to imple-
ment also the new developments regarding the
paradigm used to explain the genesis and experi-
ence of pain (the biopsychosocial model) as well
as the call for a mechanism-based approach to
diagnosis, a large-scale multidisciplinary public-
private partnership was established (Fillingim
et al. 2014). The ultimate goal of the ACTTION-
AAPT project is to satisfy the urgent need to
develop a systematic, standardized, and
evidence-based pain classification system appli-
cable to all common chronic pain syndromes that
also takes into account the biopsychosocial mech-
anisms. Such classification, integrating neurobio-
logical and biopsychosocial mechanisms, would
improve management selection and patient out-
come, would facilitate communication between
clinicians and researchers, and would be of benefit
in research design and in education.
4 G.D. Klasser et al.
Current Orofacial Pain Classification
Systems (General)
International Association for the Study
of Pain
Thirty years ago the IASP became the first inter-
national organization to introduce a provisional
compilation of chronic pain syndromes that can
affect any part of the body. The Subcommittee on
Taxonomy recognized this as the beginning of a
continuous review process that would address
gaps, inaccuracies, and inconsistencies raised by
anyone with expertise in the field of pain for future
modifications and improvements. While this first
edition provided an overall acceptable classifica-
tion of relevant chronic pain syndromes to many, a
number of changes were introduced in the second
iteration published in 1994 and this was followed
by more recent updates in 2011 and 2012
(Merskey and Bogduk 1994). New conditions
were added, names were changed, and terms not
describing specific syndromes were rejected. In
spite of significant advances in classifying many
conditions, very few changes were introduced to
the head and face pain syndromes.
This IASP classification system adopted an
arrangement of pain syndromes in nine major
categories regrouped either under generalized
conditions that can affect various parts of the
body or more localized conditions found at spe-
cific body sites. More than 400 pain syndromes
are listed in 33 subcategories. The taxonomy
includes a systematic description of pain syn-
dromes with specific emphasis placed on the
case definition and main pain features. In addition,
the IASP developed a scheme enabling the codi-
fication of each diagnosis in a more detailed man-
ner on the basis of five axes that include: (1) body
region, (2) systems involved, (3) temporal char-
acteristic of pain in terms of pattern of occurrence,
(4) patient’s statement of intensity coupled with
time since onset of the pain, and (5) etiology.
Clinical phenotypes of OFP-related disorders
are found under the major category “Relatively
localized syndromes of the head and neck” that is
further divided in seven subcategories. Almost
two-third of the 66 pain-related syndromes listed
represent an OFP condition and depending on the
source and structure involved these are classified
into one of the five subcategories presented in
Table 1. While the purpose of the IASP is to
offer a compilation of chronic pain syndromes, a
few acute conditions are interwoven into the clas-
sification scheme with the purpose of pointing out
contrast with other chronic pain entities. This is
particularly true for Group IV “Lesions of the ear,
nose, and oral cavity” that includes conditions like
maxillary sinusitis, odontalgia “toothache 1, 2,
and 3,” respectively, due to dentino-enamel
defects, pulpitis, periapical periodontitis or
abscess, and dry socket for which the usual course
will rarely exceed a week or so.
More recently, the IASP interacting with the
World Organization (WHO) established a Task
Force to develop a new pragmatic classification
of chronic pain after noticing the discrepancies
between the actual epidemiology of chronic pain
and the diagnostic codes included in the current
version of the International Classification of Dis-
eases (ICD) of the WHO. The aim is to simplify
and better standardize the categorization of
chronic pain conditions so it could be used in
primary care as well in clinical settings for spe-
cialized pain management, while also fitting into
the general framework of the upcoming 11th revi-
sion of the ICD. The new ICD scheme categorizes
chronic pain into seven (7) groups of disorders
with priority given first to pain etiology, then to
underlying pathophysiological mechanisms, and
lastly to body sites. Moreover, the principle of
multiple parenting that allows the same diagnosis
to be assigned to more than one category is
applied when needed. The seven groups of
chronic pain disorders serving as an umbrella
are: (1) chronic primary pain, (2) chronic cancer
pain, (3) chronic posttraumatic and postsurgical
pain, (4) chronic neuropathic pain, (5) chronic
headache and orofacial pain, (6) chronic visceral
pain, and (7) chronic musculoskeletal pain
(Treede et al. 2015).
Classification of Orofacial Pain
Table 1 IASP subcategories of “Relatively localized syn-
dromes of the head and neck” that include orofacial pain-
related disorders with the list of conditions for Group III
and IV (Merskey and Bogduk 1994)
Relatively localized syndromes of the head and neck
Group II: Neuralgia of the head and face
Group III: Craniofacial pain of musculoskeletal origin
1. Acute tension headache
2. Tension headache: Chronic form (Scalp muscle
contraction headache)
3. Temporomandibular pain and dysfunction syndrome
(also called Temporomandibular disorder)
4. Osteoarthritis of the temporomandibular joint
5. Rheumatoid arthritis of the temporomandibular joint
6. Dystonic disorders, facial dyskinesia
7. Crushing injury of head and face
Group IV: Lesions of the ear, nose, and oral cavity
1. Maxillary sinusitis
2. Odontalgia: Toothache 1. Due to dentino-enamel
defects
3. Odontalgia: Toothache 2. Pulpitis
4. Odontalgia: Toothache 3. Periapical periodontitis and
abscess
5. Odontalgia: Toothache 4. Tooth pain not associated
with lesion (Atypical odontalgia)
6. Glossodynia and sore mouth (aka Burning tongue or
Oral dysesthesia)
7. Cracked tooth syndrome
8. Dry socket
9. Gingival disease, Inflammatory
10. Toothache, cause unknown
11. Diseases of the jaw, inflammatory conditions
12. Other and unspecified pain in the jaw
13. Frostbite of face
Group V: Primary headache syndromes, vascular
disorders, and cerebrospinal fluid syndromes
Group VI: Pain of psychological origin in the head, face,
and neck
Advantages and limitations: The classifica-
tion of chronic pain in the ICD is in the process of
being overseen by peer review. As for the current
IASP classification, with its five axes, it offers the
most exhaustive and elaborate system for coding
chronic pain cases. As many as ten different
entries are possible per diagnosis within each
axis, however, the coding is not necessarily a
user friendly task. The IASP places emphasis on
the description of pain syndromes and diagnostic
criteria are provided only when possible and in
5
various formats. While they may have face and
content validity there are no data yet on their
accuracy. Within the context of OFP-related dis-
orders, the IASP classification has very limited
value for the diagnosis of temporomandibular dis-
orders (TMDs). Beside the arthritides, all the other
conditions are collapsed under the old denomina-
tion “Temporomandibular Pain and Dysfunction
Syndrome.” The reluctance of the IASP to adopt
and integrate the classification criteria of other
organizations with special interest for pain diag-
nosis in specific body parts has significant draw-
backs. For categories like primary headaches and
neuralgias of the head and neck, similar condi-
tions can have different names and diagnostic
criteria. In addition, there are conditions for
which no counterpart exists in the IASP scheme.
Even though the IASP provides a crosswalk to the
IHS coding system for headaches, it nevertheless
creates some confusion. It is hard to dismiss any
of the current five axes of the IASP classification,
but the addition of one giving due consideration to
the biopsychosocial and behavioral factors of the
patient’s pain experience would certainly be use-
ful (Turk and Rudy 1987; Turk 1990; Fillingim
et al. 2014). We know that regardless of the bio-
medical diagnosis these may influence treatment
outcomes in subgroups of chronic pain patients
(Turk 1990).
International Headache Society
Not long after the IASP created their classification
system, the IHS published the International Clas-
sification of Headache Disorders (ICHD) in 1988.
It was first updated in 2004 and more recently in
2013 (ICHD-3) based on changes supported by
quality published evidence (Headache Classifica-
tion Committee of the International Headache
Society 2013). The IHS offers a compilation of
all headache-related disorders and painful cranio-
facial neuropathies along with other facial pains in
a three part classification system. Part I and Part II
are, respectively, devoted to primary and second-
ary headaches and composed of 12 major catego-
ries. Part III is a repertory of painful cranial
neuropathies, other facial pains, and headaches
6 G.D. Klasser et al.
Table 2 Classification system of the International Head-
ache Society for headaches and facial pains (ICHD-3)
(Headache Classification Committee of the International
Headache Society 2013)
Part one: Primary headaches
1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
4. Other primary headache disorders
Part two: Secondary headaches
5. Headache attributed to trauma or injury to the head
and/or neck
6. Headache attributed to cranial or cervical vascular
disorder
7. Headache attributed to nonvascular intracranial
disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homeostasis
11. Headache or facial pain attributed to disorder of the
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or
other facial or cervical structure
12. Headache attributed to psychiatric disorder
Part three: Painful cranial neuropathies, other pains
and other headaches
13. Painful cranial neuropathies and other facial pains
14. Other headache disorders
arranged in two distinctive categories, one for the
primary painful craniofacial neuralgias and
related facial pain and the other for headaches
not elsewhere classified or unspecified (Table 2).
The ICHD is primarily a hierarchical classifi-
cation system for headaches with well-
operationalized diagnostic criteria. Interestingly,
it allows the clinician to decide how detailed the
diagnosis should be within each of the 12 major
headache categories when looking through the
subtypes of headache disorders. Thus, the coding
can range from one digit up to five depending
upon the detail of the criteria employed in the
diagnosis. Clinical features and diagnostic criteria
are provided for more than 200 subforms of
headache-related disorders with the goal of hav-
ing the coding system eventually synchronized
with the World Health Organization’s ICD-11.
Of particular interest for oral medicine special-
ists are Category 11 within Part II and more spe-
cifically Category 13 within Part III. Category
11 focuses on secondary headache as a
comorbidity of pain disorders arising from
orofacial and neck structures while subcategories
11.6 and 11.7 includes, respectively, diagnostic
criteria for headache attributed to disorder of the
teeth or jaw, and headache attributed to TMDs. As
for Category 13, it provides a list and a detailed
description along with diagnostic criteria for cod-
ing the painful craniofacial neuropathies and
related facial pain conditions. Upon viewing
Table 3 one can better appraise similarities and
differences between the ICHD-3 and the IASP for
the classification scheme and denomination of
craniofacial neuralgias.
Advantages and limitations: The IHS classi-
fication is easy to use and depending on how
specific one needs to rule-in a diagnosis it offers
a flexible hierarchical coding system and diagnos-
tic criteria for all the conditions in a standardized
format. The diagnostic criteria are clearly pre-
sented and easy to follow. These are empirically
derived and have good face and content validity,
but their accuracy has yet to be tested in field
studies. The ICHD-3 is mostly useful for patients
with headache, facial neuralgia, or painful trigem-
inal neuropathy. All the other clinical phenotypes
of OFP-related disorders are not described in this
classification system, thus limiting its general use
in clinical situations involving a spectrum of OFP
patients (Zebenholzer et al. 2005; Benoliel et al.
2008, 2010). One can overcome this limitation by
referring to other classification systems. As men-
tioned previously for the IASP axes, no due con-
sideration is given to the biopsychosocial and
behavioral factors in any part of the ICHD-3.
American Academy of Orofacial Pain
The American Academy of Orofacial Pain
(AAOP) and its worldwide sister organizations
regroup dentists and allied professional practi-
tioners with interest in TMDs and face pain. In
1990, the AAOP published its first handbook and
guidelines that focused solely on the diagnosis
and management of TMDs. From the second to
the present fifth edition (2013) however, the
AAOP have broadened its guidelines for assess-
ment, diagnosis, and management to include all
clinical phenotypes of OFP-related disorders
whether it is acute or chronic (De Leeuw and
Classification of Orofacial Pain 7

Table 3 ICHD-3 Category 13 listing for painful cranial neuropathies and other facial pains and IASP Group II listing for
Neuralgia of the Head and Neck (Merskey and Bogduk 1994; Headache Classification Committee of the International
Headache Society 2013)
ICHD-3 IASP
13.1 Trigeminal neuralgia 1. Trigeminal neuralgia
13.1.1 Classical trigeminal neuralgia 2. Secondary trigeminal neuralgia from the
13.1.1.1 Classical trigeminal neuralgia, purely paroxysmal central nervous system
13.1.1.2 Classical trigeminal neuralgia with concomitant 3. Secondary trigeminal neuralgia from facial
persistent facial pain trauma
13.1.2 Painful trigeminal neuropathy 4. Acute herpes zoster
13.1.2.1 Painful trigeminal neuropathy attributed to acute 5. Postherpetic neuralgia
Herpes zoster 6. Geniculate neuralgia (Ramsey-Hunt
13.1.2.2 Postherpetic trigeminal neuropathy Syndrome)
13.1.2.3 Painful posttraumatic trigeminal neuropathy 7. Neuralgia of the nervous intermedius
13.1.2.4 Painful trigeminal neuropathy attributed to multiple 8. Glossopharyngeal neuralgia
sclerosis (MS) plaque 9. Neuralgia of the Superior laryngeal nerve
13.1.2.5 Painful trigeminal neuropathy attributed to a space- 10. Occipital neuralgia
occupying lesion 11. Hypoglossal neuralgia
13.1.2.6 Painful trigeminal neuropathy attributed to other 12. Glossopharyngeal pain from trauma
disorders 13. Hypoglossal pain from trauma
13.2 Glossopharyngeal neuralgia 14. Tolosa-hunt Syndrome
13.3 Nervus intermedius (facial nerve) neuralgia 15. SUNCT Syndrome
13.3.1 Classical nervus intermedius neuralgia 16. Reader’s (paratrigeminal) Syndrome
13.3.2 Nervus intermedius neuropathy attributed to Herpes
zoster
13.4 Occipital neuralgia
13.5 Optic neuritis
13.6 Headache attributed to ischemic ocular motor nerve palsy
13.7 Tolosa-Hunt syndrome
13.8 Paratrigeminal oculosympathetic (Raeder’s) syndrome
13.9 Recurrent painful ophthalmoplegic neuropathy
13.10 Burning mouth syndrome (BMS)
13.11 Persistent idiopathic facial pain (PIFP)
13.12 Central neuropathic pain
13.12.1 Central neuropathic pain attributed to multiple sclerosis
(MS)
13.12.2 Central post-stroke pain (CPSP)

Klasser 2013). Except for TMDs, no detailed
classification and listing are provided by the
AAOP for other subtypes of OFP disorders.
Nevertheless, how the AAOP handbook is orga-
nized enables one to capture the scope and breadth
of OFP conditions while also providing an infor-
mal classification scheme mainly based on a topo-
graphical approach and various tissue, structures,
or organ systems that can give rise to oral and
craniofacial pain. The chapter headings listed in
Table 4 presents the different categories of cranio-
facial pain phenotypes that exemplifies what is
considered as the AAOP classification scheme.
Of particular interest is the designation provided
by the AAOP when referring to neuropathic pain
and primary headache disorders. The
endorsement of the ICHD-3 scheme and denom-
inations developed by the IHS avoid confusion
and lack of concordance. As for TMDs, the
AAOP uses the expanded taxonomy developed
jointly with the International RDC-TMD Consor-
tium Network that is presented in Table 5 (Peck
et al. 2014). The expanded taxonomy is however a
compilation of all types of TMD and hence it
includes painful and non-pain conditions.
Advantages and limitations: Although the
AAOP guidelines do not offer a comprehensive
classification scheme and specific listing of
OFP-related conditions but for TMDs, it never-
theless provides a taxonomic structure that covers
the entire spectrum of OFP conditions (Peck et al.
2014). Choosing to refer to the ICHD-3 for
8 G.D. Klasser et al.
Table 4 Classification structure of orofacial pain condi-
tions from the 5th edition of the American Academy of
Orofacial Pain guidelines (De Leeuw and Klasser 2013)
Vascular and nonvascular intracranial cause of
orofacial pain
Headache associated with vascular intracranial
disorders (IHS/ICHD-3 code 6.1 to 6.6)
Headache associated with nonvascular intracranial
disorders (IHS/ICHD-3 code 7.1 to 7.8)
Primary headache disorders
Migraine (IHS/ICHD-3 code 1.1 to 1.6)
Tension-type headache (IHS/ICHD-3 code 2.1 to 2.4)
Cluster headache and other trigeminal autonomic
cephalalgias (IHS/ICHD-3 code 3.1 to 3.5)
Neuropathic pain
Episodic neuropathic pain (IHS/ICHD-3 code 13.1.1,
13.2, 13.3, 13.9)
Continuous neuropathic pain (IHS/ICHD-3 code
13.1.2, 13.10, 13.11, 13.12.2)
Dysesthesia
Intraoral pain disorders
Odontogenic pain
Non odontogenic pain
Oral mucosal pain
Temporomandibular disorders (see Table 5)
Temporomandibular joint disorders
Masticatory muscle disorders
Extracranial causes of orofacial pain and headaches
Pain stemming from tissues or organs in the head and
neck (IHS/ICHD-3 code 11.1, 11.3 to 11.5)
Pain stemming from systemic disease (IHS/ICHD-3
code 13.12.1)
Cervicogenic mechanisms of orofacial pain and
headaches
Common cervical spine disorders (IHS/ICHD-3 code
11.2, 11.8, 13.2, 13.4)
IHS International Headache Society, ICHD-3 International
Classification of Headache Disorders
headaches and craniofacial neuralgia, the AAOP
ensures better communication through already
recognized denominations of entities thus reduc-
ing confusion and misunderstandings. Clear
operationalized and validated diagnostic criteria
are only available for the most common pain-
related TMDs through the Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD) classi-
fication system embedded in the expanded TMD
taxonomy. While there is an enormous task ahead
regarding the validation of existing empirically
derived diagnostic criteria for other OFP
conditions, the fact that pain-related TMDs repre-
sent the most common type of nondental OFP
makes the validated DC/TMD highly useful for
patient triage and clinical decision making. As for
the psychological and behavioral factors that may
impact on the patient’s pain experience and
response to treatment, the AAOP fully recognizes
the importance of implementing a dual-axis diag-
nostic framework but does not recommend any
specific classification system for that matter.
American Academy of Craniofacial Pain
The American Academy of Craniofacial Pain
(AACP) is another professional organization
with interest in the assessment, diagnosis, and
management of craniofacial pain disorders that
published its own guidelines in 2009 (American
Academy of Craniofacial Pain 2009). The AACP
has not developed its own classification system
but uses existing taxonomies. Hence, for neural-
gias of the head and neck and for headache disor-
ders, the AACP follows the classification by the
IASP for the former, and the IHS classification
schemes for the latter. As for TMDs it uses the
classification proposed by Pertes and Gross for
masticatory muscle and joint disorders (Pertes
and Gross 1995). Craniofacial pain disorders
stemming from other structures or anatomical
parts are specifically addressed throughout the
AACP handbook in dedicated chapters (Table 6).
When comparing Tables 4 and 6, one can see
some similarities on how the AACP and the
AAOP categorize oral and craniofacial pain dis-
orders, but discrepancies are unveiled upon closer
inspection at the list of clinical entities included in
each pain sub-category.
Advantages and limitations: There is no real
advantages for use of the AACP classification struc-
tures considering it refers to existing taxonomy
whenever possible and for TMDs, the expanded
taxonomy developed jointly by the RDC-TMD
International Consortium integrates all musculo-
skeletal disorders and provides unambiguous
operationalized diagnostic criteria with known
validity for the most common disorders. For exam-
ple, there are two different listings of masticatory
Classification of Orofacial Pain 9

Table 5 Expanded taxonomy for temporomandibular disorders (Peck et al. 2014)

I. Temporomandibular joint disorders II. Masticatory muscle disorders
1. Joint pain 1. Muscle pain
A. Arthralgiaa A. Myalgiaa
B. Arthritisa 1. Local myalgiaa
2. Joint disorders 2. Myofascial paina
A. Disk disorders 3. Myofascial pain with referrala
1. Disk displacement with reduction B. Tendonitisa
2. Disk displacement with reduction with C. Myositisa
intermittent locking D. Spasma
3. Disk displacement without reduction with 2. Contracture
limited opening 3. Hypertrophy
4. Disk displacement without reduction without 4. Neoplasm
limited opening 5. Movement disorders
B. Hypomobility disorders other than disk disorders A. Orofacial dyskinesia
1. Adhesions/adherence B. Oromandibular dystonia
2. Ankylosis 6. Masticatory muscle pain attributed to systemic/central
a. Fibrous pain disorders
b. Osseous A. Fibromyalgia/widespread paina
C. Hypermobility disorders III.Headache
1. Dislocations 1. Headache attributed to TMDa
a. Subluxation IV.Associated structures
b. Luxation 1. Coronoid hyperplasia
3. Joint diseases
A. Degenerative joint disease
1. Osteoarthrosis
2. Osteoarthritisa
B. Systemic arthritidesa
C. Condylysis/Idiopathic condylar resorption
D. Osteochondritis dissecans
E. Osteonecrosis
F. Neoplasm
G. Synovial chondromatosis
4. Fracturea
5. Congenital/developmental disorders
A. Aplasia
B. Hypoplasia
C. Hyperplasia
a
Pain-related TMD

muscle conditions in the AACP guidelines, one

under the heading of “Extracapsular Temporoman-
dibular Disorders” and the other under “Temporo-
mandibular Disorders” as classified by Pertes and
Gross (1995; American Academy of Craniofacial
Pain 2009). Moreover, diagnostic criteria are pro-
vided in various formats that go from a precise list of
clinical features (muscle disorders) to a more narra-
tive description of the condition (joint disorders).
Current TMD Classification Systems
RDC-TMD to DC-TMD
and the Expanded TMD Taxonomy
In 1992 Dworkin and LeResche published the
“Research Diagnostic Criteria for Temporoman-
dibular Disorders” (RDC-TMD), a dual-axis
assessment protocol with operationalized diag-
nostic algorithms for the most common TMDs
(Dworkin and LeResche 1992). The RDC-TMD
is an empirically derived classification system
10
Table 6 Classification structure of orofacial pain
according to the American Academy of Craniofacial Pain
guidelines (American Academy of Craniofacial Pain 2009)
Extracapsular temporomandibular disorders
Muscle disorders
Ligament/tendon disorders
Headache pain
Primary (IHS/ICHD-3 Part one)
Secondary (IHS/ICHD-3 Part two)
Other headache (IHS/ICHD-3 Part three code 14)
Neuralgias, nerve trunk and deafferentation pain
Neuralgia of the head and face (IASP Group II)
Viral neuralgia
Miscellaneous facial pain
Central cause of craniofacial pain
Sympathetically maintained pain/Complex regional
pain syndromes
Temporomandibular disorders (Adapted from Pertes
and Gross 1995)
Temporomandibular joint disorders
Masticatory muscle disorders
Congenital and developmental disorders
Myofascial pain
Additional structures that can cause craniofacial pain
Eye, ear, hamulus process, hyoid bone, salivary
glands, lymph nodes, occipital nerve, temporal, and
carotid artery.
Non odontogenic intraoral pain disorders
Mucogingival pain
Glossal pain
IHS International Headache Society, ICHD-3 International
Classification of Headache Disorders, IASP International
Association for the Study of Pain
based on the biopsychosocial model of pain that
was primarily intended for research purposes.
Axis I allows the rendering of a physical diagnosis
for the most common pain and nonpain-related
TMDs using a standardized and reliable examina-
tion protocol. On the other hand, Axis II tools
enable one to identify the relevant psychosocial
characteristics of the patients through the assess-
ment of the psychological status and the grading
of TMD pain-related disability. The growing
appreciation for the RDC-TMD has made it a
reference protocol for TMD research and that led
to their translation into more than 20 languages
(http://www.rdc-tmdinternational.org/). With
time, the RDC-TMD gained acceptance among
clinicians who began to implement their use in a
G.D. Klasser et al.
clinical setting (Manfredini et al. 2006). A number
of authors started questioning the validity of the
diagnostic criteria for an Axis I physical diagnosis
and showed the need to improve the original
RDC-TMD (Ohlmann et al. 2006; De Boever
et al. 2008; Schmitter et al. 2008; Steenks and de
Wijer 2009). This led to the funding of a carefully
planned multisite Validation Project to assess the
criterion validity of the RDC-TMD Axis I physi-
cal diagnosis for the most common TMDs and
reviewed all Axis II screening tools for the eval-
uation of psychosocial and behavioral factors
(Schiffman et al. 2010a). The results of this land-
mark study initiated the transition towards the
new evidence-based diagnostic criteria for the
most common pain and nonpain-related TMDs
(DC-TMD) that were recently implemented for
utilization in research and clinical settings
(Schiffman et al. 2014; Schiffman and Ohrbach
2016). Table 7 presents the list of Axis I physical
diagnoses that were part of the original
RDC-TMD and compares that to the new
DC-TMD along with the sensitivity and specific-
ity establishing the level of accuracy for the new
diagnostic criteria.
While the DC-TMD for the most common
TMDs were finalized, a joint effort by the
RDC-TMD International Consortium Network
and the AAOP led to the development of an
expanded taxonomy (see Table 5) with the inclu-
sion of empirically derived expert-based diagnos-
tic criteria for the less common TMDs (Peck et al.
2014). As mentioned previously, the expanded
taxonomy is inclusive for all subtypes of TMD
whether it causes pain or not. It is important to
know that within this framework, multiple diag-
noses are also allowed except for conditions
belonging to the same subgroup of disorders. For
example, arthralgia and arthritis are mutually
exclusive diagnoses within the joint pain category
and so are the four muscle pain entities and the
myalgia subtypes. Hence, that means for joint
conditions where pain is not part of the diagnostic
algorithm such as degenerative joint disorder and
disk displacement with or without reduction, a
diagnosis of arthralgia or arthritis can also accom-
pany the primary diagnosis if joint pain is present.
Classification of Orofacial Pain 11

Table 7 Original Axis I RDC/TMD and validated Axis I DC/TMD with sensitivity (Sens.) and specificity (Spec.) values
(Dworkin and LeResche 1992; Schiffman et al. 2014)
RDC/TMD (1992) DC/TMD (2014)
I. Muscle disorders I. Pain-related temporomandibular disorders
A. Myofascial pain A. Myalgia (Sens. 0.90/Spec. 0.99)
B. Myofascial pain with limitation 1. Local myalgia
II. Disk displacement disorders 2. Myofascial pain
A. Disk displacement with reduction 3. Myofascial pain with referral (Sens. 0.86/Spec. 0.98)
B. Disk displacement without reduction with B. Arthralgia (Sens. 0.89/Spec. 0.98)
limited opening C. Headache attributed to TMD (Sens. 0.89/Spec. 0.87)
C. Disk displacement without reduction II.Intra-articular temporomandibular disorders
without limited opening A. Disk displacement with reduction (Sens. 0.34/Spec. 0.92)
III. Arthralgia and other joint disorders B. Disk displacement with reduction with intermittent locking
A. Arthralgia (Sens. 0.38 Spec. 0.98)
B. Osteoarthritis C. Disk displacement without reduction with limited opening
C. Osteoarthrosis (Sens. 0.80/Spec. 0.97)
D. Disk displacement without reduction without limited opening
(Sens. 0.54/Spec. 0.79)
E. Degenerative joint disease (Sens. 0.55/Spec. 0.61)
F. Subluxation (Sens. 0.98/Spec. 1.00)

What mostly distinguishes the DC-TMD from
other classification systems is Axis II aimed to
assess the psychosocial and behavioral factors
that impact on the patients’ pain and can influence
treatment outcome and chronicity (Dworkin et al.
2002). One of the Axis II tools is the Graded
Chronic Pain Scale (available for download at:
http://www.rdc-tmdinternational.org/), a simple
seven items questionnaire that measures pain-
related disability and intensity (Von Korff et al.
1992). This is a simple and easy to use question-
naire that can assist the clinician in identifying
patients with high pain-related disability profile
and decreased functioning which then usually
requires additional expertise for the implementa-
tion of more comprehensive management strate-
gies (Kotiranta et al. 2015).
Advantages and limitations: The DC-TMD
is the only system that uses standardized and
reliable self-report questionnaires, clinical exami-
nation procedures, scoring systems, and decision
trees while also providing estimates regarding the
diagnostic accuracy of the history and examina-
tion criteria for the most common pain-related and
intra-articular TMDs. No other system integrates
biophysical diagnosis to a disability index that
measures the impact the pain has on the patient’s
behavior. In addition, the assessment tools for
implementing this dual-axis framework and a
short TMD pain screener questionnaire with very
good sensitivity and specificity are made available
for download on the International RDC-TMD
Consortium Network website (available for
download at: http://www.rdc-tmdinternational.
org/) (Gonzalez et al. 2011).
Except for two subtypes of myalgia (local
myalgia and myofascial pain) what can be
expected in terms of true- and false-positive diag-
nosis when using the DC-TMD assessment pro-
tocol for pain-related TMD is somewhat
predictable. Sensitivity and specificity that reach
80% and 95%, respectively, make the DC-TMD
scheme highly recommended to render a defini-
tive clinical diagnosis for myalgia, myofascial
pain with referral, arthralgia, disk displacement
without reduction with limited opening, and sub-
luxation. On the other hand, because the
DC-TMD relies solely on clinical examination
procedures, the utility is limited regarding the
other disk displacement disorders and degenera-
tive joint disease that are best assessed with Cone
Beam CT and MRI imaging of the joint. With a
diagnostic accuracy that is below 70% for true
positive diagnosis (sensitivity), the respective
DC-TMD for the above mentioned disorders can
be used only to render a preliminary clinical diag-
nosis. Finally, it is premature to recommend using
the operationalized diagnostic criteria that were
12
developed for the less common disorders listed in
the expanded TMD taxonomy other than for a
preliminary diagnosis. This is because none have
been tested yet against an acceptable reference
standard. Nevertheless, the expanded TMD tax-
onomy still represents the most validated refer-
ence classification system for TMDs.
Proposed Classification Systems
Over the years, several classification systems have
been proposed as alternative options or integra-
tions to currently adopted schemes. Some of them
focused on chronic idiopathic OFP (Woda et al.
2005), some other addressed specifically the field
of TMDs (Stegenga 2010; Machado et al. 2012),
and others more embedded an all-inclusive pro-
posal for OFP (Okeson 2014). They will be
reviewed briefly below.
Classification of Chronic Idiopathic
Orofacial Pain: Woda et al. (2005)
Based on purported shortcomings of the literature
on the taxonomy of the different forms of chronic
idiopathic OFP, a prospective multicenter study
was performed to provide a better framework for
introducing entities such as stomatodynia, atypi-
cal odontalgia, atypical facial pain, and facial
arthromyalgia within the broader context of OFP
(Woda et al. 2005). The authors pointed out that
those forms of idiopathic OFP are sometimes
grouped together and sometimes considered sep-
arate conditions, and so, developed a new taxon-
omy based on the results of cluster analysis.
The underlying premise of this proposal was
rather intriguing, since the authors hypothesized
that the main subgroups of OFP syndromes (i.e.,
atypical facial pain, atypical odontalgia,
stomatodynia, temporomandibular disorders),
which display some common clinical features,
may correspond to a single disease expressed in
different tissues: teeth, bone, oral mucosa, muscle,
and joint. Based on that, they assessed the possi-
bility of proposing a classification that takes into
account the presence of similar signs/symptoms
G.D. Klasser et al.
and thus reflects similar pathophysiological mech-
anisms and treatment approaches, rather than
topography, organs, or tissues. In short, the clas-
sification system results from a 111-item self-
reported questionnaire including questions on
pain evaluation, impact of pain on health-related
quality of life, and psychological self-evaluation.
Furthermore, an experienced examiner completed
an 8-item record that exited in a tentative diagno-
sis. A multivariate analysis trying to identify clus-
ters of self-reported and clinically recorded signs
and symptoms led to the identification of very
similar and common mechanisms between condi-
tions affecting the different stomatognathic struc-
tures. Three subgroups of idiopathic disorders
were thus identified: stomatodynia,
arthromyalgia, and atypical facial pain, whose
differences are essentially based on topographic
criteria.
A notable feature of this proposal is that the
term arthromyalgia is introduced to discriminate
those idiopathic conditions, viz., joint and/or mus-
cle pain of uncertain or unknown origin, from
TMD symptoms of certain origin, such as condi-
tions linked to general diseases.
Classification of TMJ Disorders:
Stegenga (2010)
An interesting proposal for the classification of
TMJ disorders was proposed by Stegenga
(2010), who suggested that instead of positional
classification relating the presence of joint pathol-
ogy to the position of the disk, a classification
system based on the actual intra-articular struc-
tural changes could be more suitable for clinical
purposes. The point of this classification system
was that, even if many clinical signs, and most
notably joint sounds, are explainable with the
presence of disk displacement, the increasing
amount of knowledge on the actual pathologic
changes occurring within the joint should have
led to more structurally oriented classification
systems.
Based on that, two major categories of struc-
tural disorders have been identified by the author,
viz., the arthritic disorders (i.e., inflammatory
Classification of Orofacial Pain
disorders affecting the joint, which are mainly
characterized by pain and function impairment)
and the growth disorders (which are mainly char-
acterized by facial asymmetry). In short, the
author proposed that mechanical derangements
are only one of the possible consequences of
pathological changes occurring in temporoman-
dibular joints with a maladaptive load response.
Thus, the author suggested classifying TMJ dis-
orders into three main categories: arthritic disor-
ders, growth disorders, and nonarthritic disorders.
The latter are noninflammatory in nature, contrary
to the arthritic disorders, which may have a
mechanical component (i.e., disk displacement),
but are related to a joint disease due to tissue
changes at the molecular level and present with
pain as the main symptom.
This classification has merits, and years after
its proposal some evidence is developing in sup-
port of this concept, but it should be considered a
hypothesis-driven, opinion-based, taxonomy that
was not supported with any specific investigation.
Classification Profile of TMD Patients:
Machada et al. (2012)
Also in the TMD field, Machado and colleagues
(Machado et al. 2012) performed a large-sample
investigation attempting to profile the clinical pre-
sentation of diagnostic characteristics of TMD
patients. The authors aimed to simultaneously
classify symptomatic patients diagnosed with a
variety of TMD subtypes into homogeneous
groups based on their clinical presentation and
occurrence of comorbidities. The study design
involved a retrospective assessment of more than
300 clinical records based on the AAOP guide-
lines published in 2008 (De Leeuw 2008), and the
resulting diagnoses were clustered into groups
based on symptoms occurrence.
Based on this analysis, four main symptomatic
profiles were identified: acute muscle pain
(35.0%), nonpainful articular impairment
(33.9%), acute articular pain (21.0%), and chronic
facial pain (10.1%). Those groups are homoge-
neous as for their clinical presentation, and their
names were suggested by the authors as being
13
intuitively linked to the time of onset, the location,
the presence of pain, and extent of the symptoms.
According to the authors, this proposal may shed
light on the most suitable strategy that should be
adopted to manage TMD patients seeking
treatment.
Classification of Orofacial Pains:
Okeson (2014)
A broadly diffused, opinion-based, comprehen-
sive classification scheme for OFP came from
the work(s) of Okeson (2014). The concept
behind the proposal is that a reliable pain classifi-
cation needs to be based on symptomatology.
Based on that, pain conditions may be grouped
into somatic and neurogenous. Somatic pains
occur in response to the stimulation of normal
neural receptors, while neurogenous pains origi-
nate due to dysfunctional neurologic structures.
According to the proposed classification,
somatic pain may be superficial or deep. The
former may originate from cutaneous or
mucogingival sources, which share the following
clinical features: (a) the pain has a bright, stimu-
lating quality; (b) subjective localization of the
pain is excellent and anatomically accurate;
(c) the site of pain identifies the correct location
of its source; (d) response to provocation at the
site of pain is faithful in incidence, intensity, and
location; (e) the application of a topical anesthetic
at the site temporarily arrests the pain. Alterna-
tively, deep somatic pain may be visceral or mus-
culoskeletal in origin, is less accurately
localizable by the patient than superficial pain,
and may not be proportionally related to the nox-
ious stimulus. As a general remark, deep somatic
pains share the following features: (a) the pain has
a dull, depressing quality; (b) subjective localiza-
tion of the pain is variable and somewhat diffuse;
(c) the site of pain may or may not identify the
correct location of its true source; (d) response to
provocation at the source of pain is fairly faithful
in incidence and intensity; and (e) secondary cen-
tral excitatory effects frequently accompany the
deep pain.
14
Sometimes, the pain felt in somatic structures
may be actually originating in neurogenous tis-
sues. Such conditions have been grouped together
by the author as neuropathic pains. Those pains
usually feature a burning sensation and can pre-
sent as either episodic or continuous pain. In his
proposal, the author posited that at least two
groups of episodic neuropathic pains can be iden-
tified (i.e., neurovascular pain such as headaches;
paroxysmal neuralgic pain such as neuralgias) as
well as three groups of continuous neuropathic
pains (i.e., metabolic polyneuropathies; peripheral
mediated pain such as deafferentation pain; cen-
tral mediated pain such as atypical odontalgia,
burning mouth syndrome, and complex regional
pain syndromes).
This classification also encompasses a group of
so-called Axis II psychological conditions, com-
prising mood, anxiety, somatoform, and other
disorders of the psychosocial spectrum that may
complicate the history taking and clinical exami-
nation and should most certainly be taken into
account for a definitive diagnosis especially with
the chronification of pain.
Psychosocial Subtyping of TMD
Patients: Suvinen et al. (2005)
The importance of Axis II profiling of pain
patients has been highlighted in several seminal
papers on TMD, which have been summarized in
the classification proposal of Suvinen and col-
leagues (Suvinen et al. 2005). They emphasized
and highlighted that despite variability in termi-
nology provided by authors as well as methodol-
ogies employed as to how the patients are
categorized, there appears to be at least three
main groups or subtypes of TMD patients based
on the importance of physical versus psychosocial
impairment: (i) a biologically/somatically defined
TMD patient group; (ii) an intermediate group,
with patients who report fluctuating or recurrent
symptoms of TMD, but are generally viewed as
G.D. Klasser et al.
adaptive copers; and (iii) a complex/psycho-
socially dysfunctional TMD patient group.
This identification of patients according to a
tri-axial schematic may allow more “keys” as to
what is the appropriate method of treatment for
each patient group, but it should be noted that the
method is not directly applicable in a clinical
setting, since it involves the use of multiple psy-
chometric evaluations and needs further valida-
tion to be more globally accepted. Interestingly,
according to the therapeutic model associated
with this classification proposal, it is suggested
that the assessment and subtyping of patients can
indicate the most appropriate form of treatment. In
short, the “simple TMD subtype” appears to be
more biomedically defined and therefore is most
likely to benefit from relatively simple forms of
conservative management, such as counseling,
physical therapies, oral appliances, and medica-
tions for the acute phase. The “intermediate TMD
subtype” appears biobehaviorally functional and
is likely to benefit from combined biomedical and
biobehavioral approaches of management, based
on the appropriate assessment of possible contrib-
uting, aggravating, and maintaining factors. The
“complex TMD subtype” appears similar to the
minority of patients who may report psychologi-
cal distress and psychosocial dysfunction that is
poorly correlated with biomedical and physical
findings. This group of patients also appears to
be unable to cope and present with higher rates for
depression, somatization, maladaptive coping
strategies, sick-leave, and health care utilization.
These patients may be most appropriately man-
aged in multidisciplinary pain management
clinics, with appropriate skills to assess also indi-
cators for hypochondriasis, somatoform disor-
ders, and severe life stress, as well as general
vulnerability to possible idiopathic pain disorders
in general. Based on estimates in epidemiological
and clinical studies, the distribution of these sub-
types within the community differs from those in
the tertiary referral clinics, with a preponderance
in the simple/intermediate groups and a small
minority in the complex group.
Classification of Orofacial Pain
Advantages and Limitations
The above proposals for classification schemes
integrate well the currently available standard of
reference, and all of them feature some strengths
as well as interesting underlying concepts. Not-
withstanding, some general remarks are worthy to
discuss.
In the light of currently increasing evidence on
the diminished role of mechanical/occlusal con-
cepts for the onset of TMJ disorders (Klasser and
Greene 2009; Manfredini et al. 2016) as well as
the poor correlation between disk position and
clinical pain symptoms (Manfredini et al. 2009),
the suggestion of prolonging the assumption of
the disk position as a central factor for classifying
painful (may not be true for purely dysfunctional
conditions) TMJ disorders is not correct seems to
be logical. In addition, improvement in diagnosis
and classification as well as knowledge on the
pathophysiology of muscle disorders leading to
persistent OFP presents another compelling need
for a better understanding of patients’ symptoms
(Benoliel et al. 2011). On the other hand, there are
some other relevant factors that are likely more
important in the clinical setting. In particular, the
importance of Axis II psychosocial assessment at
the treatment outcome level cripples all “Axis
I-alone” classification schemes and limits their
usefulness for clinical use. In addition, the simi-
larities of chronic TMD patients’ symptoms pro-
file with those of patients receiving other OFP
diagnoses support the view that subtyping TMDs
based only on the location of symptoms (i.e., joint
versus muscles) does not take into account for the
possible underlying pathophysiology, which may
be much more similar than believed in the past.
Thus, it is remarkable to point out that the
search for a suitable classification scheme for
TMD and OFP is leading outside the boundaries
of the dental profession. Dental occlusion can no
longer viewed as a main factor for the onset of any
of the above pain conditions. The amount of liter-
ature suggesting that the association of dental
occlusion features with TMDs is, at best, very
weak, is so important to auspice that classic,
mechanical views of TMDs as occlusion-related
disorders will be definitively abandoned (Turp
15
et al. 2008). The ethical concerns related with
this issue have been recently debated (Manfredini
et al. 2011; Reid and Greene 2013).
Futures Classification Systems
In 2009, a momentous two and a half day work-
shop was held in Miami, Florida, involving
36 invited participants from 12 countries
representing 11 international organizations. The
workshop was organized by the International
RDC ⁄TMD Consortium Network of the Interna-
tional Association for Dental Research (IADR)
and the Orofacial Pain Special Interest Group
(SIG) of the IASP. One of the many objectives
of this workshop is to provide a broad foundation
for the further development of suitable diagnostic
systems for TMD and, at the same time, to also
include discussion regarding the creation and
implementation for a dedicated OFP diagnostic
system. Currently, the DC-TMD is a dual axis
system based upon the biopsychosocial model of
pain (Engel 1977) with Axis I representing phys-
ical assessment and Axis II assessing psychoso-
cial status and pain disability (Schiffman et al.
2014). The main purpose for constructing and
employing a diagnostic and classification system
with two axes for TMD was to provide a more
comprehensive picture of how pain affected the
individual on multiple levels encompassing vari-
ous physical and psychosocial domains. The
thought was this approach would be able to pro-
vide a more comprehensive representation than
what could be obtained by limiting diagnostic
assessment based only on organ system pathosis.
This dual-axis system would permit early-on
identification of TMD subtypes which reflects
the already well-established fact that emotional,
cognitive, behavioral, and psychosocial dimen-
sions of personal functioning is as much a factor
in progression of chronicity and disablement due
to TMD-related pain as were physical findings,
perhaps even more so. Specifically, a dual axis
DC-TMD would allow clinicians/researchers to
locate each patient in a space coordinated by
determinants from each axis, with each axis cap-
turing clinically meaningful levels of functioning
16
along their respective dimensions. The intent to
locate a person and the pain disorder within a
2-dimensional space reflects the principle that
the physical aspects (disease) and psychosocial
and behavioral aspects (illness) of the person are,
in principle, integrated despite the limitations in
the methods used for assessing these two very
different levels of biological organization (Inter-
national RDC/TMD Consortium Network 2009).
However, to achieve true integration of physical
and behavioral data associated with the disorder, it
was ultimately identified that this would require
more than a two-dimensional plot. Due to this
deficiency in the current schema, many recom-
mendations were proposed to enhance this mind-
body dualism thereby acknowledging a legitimate
underlying unitary process. Some of the recom-
mendations from this international consensus
workshop to address this issue and to be included
in subsequent revisions to the existing DC-TMD
and future OFP diagnostic systems were to create
an Axis III specifically devoted to genetics and to
incorporate diagnostic aids (e.g., quantitative sen-
sory testing and biomarkers) based on clinical
neurobiology for comprehensive assessment of
the individual with pain on an Axis IV (Ohrbach
et al. 2010).
Axis III: Genetics
Individuals are not equally susceptible to OFP
including TMD. Genetic and epigenetic factors
involving susceptibility and/or vulnerability to a
particular clinical course of the disease and/or
treatment response including the development of
complications (e.g. unfavorable response to envi-
ronmental challenge, material) contribute to the
patient’s symptoms. Therefore, the resulting pain
condition should be understood as the individual’s
complex response trait with specific complaints
being either amplified or attenuated by their
unique genetic makeup and/or prior life experi-
ences (Stohler 2004). An example of the influence
of genetic makeup occurs in relation to the func-
tion of the endogenous mu-opioid system
(Zubieta et al. 2001). The effects of this system
are significantly influenced by the enzyme,
G.D. Klasser et al.
catechol-O-transferase (COMT). Variability of
this enzyme’s genotype can result in differences
in the synaptic availability of various neurotrans-
mitters (catecholamines such as dopamine,
epinephrine, and norepinephrine) which are sub-
sequently linked to distinct traits of pain percep-
tion and brain activation (Zubieta et al. 2003). The
downstream signaling consequences can influ-
ence pain sensitivity, thereby increasing suscepti-
bility or providing greater resistance to chronic
painful conditions (Diatchenko et al. 2005).
Prior life experiences may alter an individual’s
adaptive response, thereby modifying the state of
activation of pain-stress response systems such as
those involving the autonomic nervous and
immune systems, the hypothalamic-pituitary-
adrenal axis, and the antinociceptive systems
including the endogenous opioid system (Gupta
et al. 2007; Slavich et al. 2014). Furthermore, it is
understood that genetic factors play a role in the
etiology of persistent pain conditions, putatively
by modulating underlying processes such as noci-
ceptive sensitivity, psychological well-being,
inflammation, and autonomic response (Smith
et al. 2011). However, to properly apply this
knowledge, we ideally need to identify
genotype-phenotype linkages relevant to the indi-
vidual. A phenotype is an individual’s observable
traits, such as height, eye color, and blood type.
The genotype is the genetic contribution to the
phenotype. Some traits are largely determined by
the genotype, while other traits are largely deter-
mined by environmental factors.
Conceptually, in order to integrate Axis II self-
report experiences of the subjective state with
Axis I assessment of the physical state, a modifi-
cation and/or expansion in Axis I dimensions to
include planes devoted to assessment of relevant
genetic or epigenetic components of the human
genome, thereby creating an Axis III, is required.
This process of thinking is further supported by
increasing evidence that the search for genotypes
in the absence of clear and operationally func-
tional phenotypes may not be productive. Thus,
phenotyping of the patient according to Axis II
assessment of self-reported depression, anxiety,
etc., requires a complete understanding of how
the person is functioning with the simultaneous
Classification of Orofacial Pain
assessment of the relevant active genetic
components.
As previously stated, it is currently acknowl-
edged that genetic factors play a clear role in the
expression of chronic pain states. However, less
evident is how genetic components (e.g., gene
variants of different genes) suspected of influenc-
ing pain expression also play a role in psycholog-
ical and emotional distress manifesting as
depression, anxiety, and the presence of wide-
spread unexplained medical symptoms, including
widespread chronic pains. Even more enigmatic is
how the genetic components play a role in the
expression of the physical symptoms and findings
associated with a clinical examination. While
genotyping has progressed substantially, linking
genotype to phenotype representation for pain
disorders has not kept pace because of the diffi-
culty in identifying a pain disorder phenotype.
Phenotyping of disorders in general has lagged
largely because the traditional methods of aggre-
gating characteristics based on the clinicopatho-
logical method of medicine have not been
particularly successful for these complex disor-
ders associated with pain as a dominant symptom.
Furthermore, available clinical findings are usu-
ally not in accord with the number and extent of
reported symptoms and associated suffering. Col-
lectively, the aggregate of some or all behavioral
factors with the physical characteristics associated
with a given disorder represent our best under-
standing of the clinical phenotype, yet a precise
identification of what is included in a phenotype
has not yet been achieved. Improved phenotyping
of the clinical characteristics and biobehavioral
characteristics associated with OFP disorders
and TMD is needed in order to further the research
regarding etiological mechanisms, mechanisms
underlying the progression of pain from acute to
chronic, the role that genetics plays in pain per-
ception, environmental contributions, and the
complex interactions among these different levels.
Axis IV: Neurobiological
Neurobiology, as it applies to classification of
OFP, involves central neural information
17
processing (e.g., learning, memory). It is
envisioned that the implementation of Axis IV
will assist clinicians in capturing the dynamic
and longitudinal changes that characterize the
OFP patient including TMD over time. The
majority of these conditions are chronic in nature
yet longitudinal (i.e., temporal) dimensions have
been largely neglected in the diagnosis of chronic
pain. It is rather paradoxical that a condition that is
so strongly associated with being extended over a
long period of time, hence assignment of the term
chronic, that the impact of the chronicity is not
adequately reflected on the clinical presentation.
Chronic pain patients, and more specifically TMD
patients, change in their descriptive characteristics
over time. Some changes may occur along the
Axis I or physical assessment planes while it is
widely accepted that with chronicity comes the
much greater risk for profound and debilitating
changes best captured by assessment within the
Axis II planes or dimensions. There is growing
scientific evidence that the dynamic and longitu-
dinal parameters of change over time are major
factors in how chronic pain patients change
(Diatchenko et al. 2006; Apkarian et al. 2013;
Bourne et al. 2014). From a biological perspec-
tive, these changes have been ascribed to plastic-
ity within the nervous system, especially higher
brain centers. The influence of central neural
information processing involving learning and
memory is now invoked to better explain and
describe chronic pain’s capability for endurance
(Price and Inyang 2015), and growing evidence is
demonstrating how these dimensions exert
top-down influences on the rest of physiology
(Reichling and Levine 2009). Therefore, it only
seems reasonable to require a diagnostic classifi-
cation scheme to be able to capture dynamic and
longitudinal changes during diagnostic
re-evaluations and to use this dynamic data to
evolve longitudinally derived evidence-based
changes in treatment decision criteria.
Another dimension regarding neurobiological
processes to be considered in Axis IV is the use of
diagnostic aids including biomarkers. Over the
years, research has enriched medical practice
with the use of specific diagnostic aids which
assist in diagnosis and enable assessment of
18
disease control or as a measure of intensity and
severity (Ceusters et al. 2015a). In particular, bio-
markers, which are any measurable characteristics
of an organism that reflect a particular physiolog-
ical state, may be useful as indicators of the pres-
ence or severity of a particular disease state.
Biomarkers can also be used to assess the effec-
tiveness of particular therapies in ameliorating the
effects of a disease. By using easily obtained and
assayed biomarkers to monitor a patient’s reaction
to a particular drug, it is possible to determine
whether treatment is effective for that individual
by measuring drug response rate or toxic effects
associated with the drug. This information could
eventually lead to earlier detection of adverse drug
response, thereby decreasing cost to the medical
system. Overall, biomarkers hold great promise
for personalized medicine as information gained
from diagnostic or progression markers can be
used to tailor treatment to the individual for highly
efficient intervention in the disease process. Can-
didate biomarkers and potential applicable tests
that should be considered within Axis IV can be
categorized by the method used to measure them:
(i) physiological (e.g., reflex responses, pressure
pain thresholds, quantitative sensory testing);
(ii) psychological or behavioral characteristics
(e.g., dynamic pain psychophysical testing); (iii)
radiological [computed tomography (CT), mag-
netic resonance imaging (MRI), functional MRI
(fMRI), positron emission tomography (PET)];
and (iv) molecular [small molecules (amino
acids, prostaglandins, leukotrienes) and proteins
(e.g., cytokines, COX)] (Ceusters et al. 2015b).
Each one of these modalities has supporting evi-
dence as being used either clinically and/or exper-
imentally for the diagnosis, measurement of
burden of disease, or determination of the prog-
nosis or efficacy of treatment for OFP conditions
including TMD (Ceusters et al. 2015b). Currently,
the predictive value of available biomarkers in
diagnosing OFP is rather low (Ceusters et al.
2015b) despite ongoing research which is contin-
ually attempting to change this situation
(Fillingim et al. 2011; Maixner et al. 2011a).
Additionally, it is unfortunate that other
G.D. Klasser et al.
diagnostic aids, be it laboratory and/or imaging
studies, are also largely only research based in the
field of OFP (Maixner et al. 2011b; Slade et al.
2011; Smith et al. 2011). Therefore, due to the
limitations in our current knowledge of neurobio-
logical processes, the diagnosis of OFP continues
to be mainly based upon the clinician’s ability to
recognize particular combinations of signs and
symptoms in the patient. Diagnosis therefore
remains heavily reliant on patient self-report as
the proxy for the full symptom profile of the
phenotype, the way in which it is related and the
how the clinician interprets this information. This
makes diagnosis of OFP much as an art form
rather than a pure science (Ceusters et al. 2015a).
With the development of multiaxial systems
(beyond Axes I and II), there will be a major
improvement in disease conceptualization leading
to advancement in enhanced patient care.
Taxonomy and Ontology: A New
Approach for Classification Systems
In 1676, Thomas Syndenham, considered the
father of English medicine or also known as the
English Hippocrates, introduced the concept of
classification using nosological methodology to
the field of medicine. The objective at that time
was to identify the disease in order to predict the
prognosis. As time and scientific discovery pro-
gressed, the framework for classification also
changed; however, the main purpose remained
stagnant. Hence, in order for the science of med-
icine to evolve an alternative method of thought
was needed requiring a shift from existing para-
digms. This ultimately developed into the use of a
taxonomic approach. The word taxonomy is
derived originally from Greek from the combina-
tion of the words “taxis” (order or arrangement)
and “nomos” (law or science). Taxonomy is
essentially a simple hierarchical arrangement of
entities listing of all of the elements in the hierar-
chy with the purpose of providing a classification
of knowledge or simplistically, arrangement of
science. From a clinical perspective, taxonomy
Classification of Orofacial Pain
implies the “systemic classification of subjects,”
sorted into groups to reflect similarity, with gen-
erally broader groups residing over those that are
more restricted (Raj 2007). Accordingly, taxon-
omy is defined as the theory and practice of clas-
sification (Merskey 2007). It has been further
commented that “For an ideal classification each
item to be considered should be independent of all
other items so that it stands in its own place in the
classification.” (Merskey 2007). Ideally, classifi-
cation using taxonomic principles should be
mutually exclusive and simultaneously exhaus-
tive. Therefore, a question arises as to the purpose
and utility of taxonomy. The necessity for its use
is that health practitioners and more specifically
those involved with OFP face issues related to the
complexities of chronic pain on a daily basis.
Therefore, this requires a clear understanding of
pain syndromes thus enabling practitioners in the
provision of effective and reliable management
approaches. Unfortunately, when confronting
pain, there are many obstacles to this approach
and they include: a lack of a clear and definitive
definition of pain, difficulties, and unreliable
methods to quantify or measure pain and observer
bias when assessing patient’s pain behavior which
quantifies pain intensity (Raj 2007). Originally,
taxonomy utilized a single axis classification sys-
tem that was only able to classify acute from
chronic pain. This simplistic approach becomes
rather inadequate when descriptors and qualifiers
are required beyond the elementary, primary des-
ignation for the purpose of facilitating exchange
of ideas and thoughts among clinicians and
researchers. Bonica, in 1979, echoed similar con-
cerns by stating “The development and wide-
spread adoption of universally accepted
definitions of terms and a classification of pain
syndromes are among the most important objec-
tives and responsibilities of the IASP. It is possible
to define terms and develop a classification of pain
syndromes which are acceptable to many, albeit
not all, readers and workers in the field; even if the
adopted definitions and classifications are not per-
fect, they are better than the Tower of Babel con-
ditions that currently exist” (Bonica 1979;
Merskey and Bogduk 1994). This inspired the
IASP to establish a subcommittee on taxonomy
19
and led to the creation of the first multiaxial sys-
tem. This system was based upon the following
parameters: region of the body involved in
chronic pain, the organ system affected, the tem-
poral characteristics and pattern of the pain, the
duration and intensity, and the etiology. Despite
being an improvement over previously used
methods, it was not without its shortcomings and
its applicability in the clinical environment. (Turk
and Rudy 1990; Procacci and Maresca 1991;
Ventafridda and Caraceni 1991). Similar issues
exist within classification systems related to
TMD as evidenced by the older RDC-TMD and
the more contemporary DC-TMD. Despite the
benefits of these systems and attempts to address
their inadequacies, each system has its shortcom-
ings (Schiffman et al. 2010b). The reasons why
this may be occurring are because of the excessive
detail needed in the diagnostic process to arrive at
a diagnosis within a clinical environment, lack of
consensus within and between different clinician
groups, a lack of a coherent overarching taxon-
omy based on ontological principles, and the dif-
ficulty to prognosticate treatment outcomes
(Nixdorf et al. 2012).
A possible alternative, and perhaps a solution,
may be to consider the use of an ontological
approach. In general, ontology is the study or
concern about what kinds of things exist, what
entities there are in the universe, and how they
relate to each other. Ontology essentially is a more
complex variation of taxonomy. Besides having
the hierarchical arrangement of the classes that
represent entities, each class affords several
restrictions on its relationships to other classes or
on the properties a particular class is allowed to
possess. The purpose of this approach is to
enhance knowledge representation. The word
ontology derives from the Greek “onto” (being)
and “logia” (written or spoken discourse). Histor-
ically, it is a branch of metaphysics, the study of
first principles or the essence of things. Ontology
as a methodology in the classification of pain
provides methods of distinguishing among cate-
gories and describing data in uniform and formal
ways. The goal for its application is to enhance the
definitions as it relates to pain in general and more
specifically to chronic pain conditions. Ontologies
20
tend to be more about the relationships between
things (in addition to their properties) than taxon-
omies that are generally limited to classification
only. An easy to understand difference among
these concepts is as follows: taxonomy assigns a
label to the pain condition, while ontology pro-
vides information regarding the pain and how it
relates.
Issues related to difficulties in providing diag-
nostic criteria for various OFP disorders due to an
overall lack of structure have been identified. Fur-
thermore, differential diagnosis of OFP condi-
tions is challenging for practitioners because
patients often present with overlapping signs and
symptoms in addition to having comorbidities.
This has prompted the International RDC-TMD
Consortium to initiate the development of a tax-
onomy for OFP disorders based on ontology. The
goal of the Consortium was to initially focus on
clarifying terminology and their relationships, so
that standardized multisite data collection can
occur and future research, such as cluster analysis
methods, can be applied to refine these criteria
(Nixdorf et al. 2012). In order to promote the
utility of following ontological principles and to
showcase its improvement in developing diagnos-
tic criteria, the methodology was applied to the
disorders that manifest themselves through the
symptom of persistent OFP. Presently, diagnosing
chronic OFP disorders is based mainly on clinical
signs and symptoms, since the mechanisms
underlying the pathophysiological processes are
largely unknown. This results in diagnosis by
exclusion which creates difficulty in achieving
standardization and often exposes the patient to
inappropriate treatments or misdiagnosis
(Durham et al. 2013). Unfortunately, with the
exception of TMD, there is a lack of research
assessing the validity of such diagnoses and
existing classification systems. It is therefore
unclear how various disorders relate to each
other, since there is no over-arching taxonomy,
and this is likely to perpetuate discipline-based
diagnostic thinking (Nixdorf and Moana-Filho
2011). Therefore, the advantages of employing
ontological methodology to the diagnostic criteria
include being (i) anatomically defined, (ii) in
accordance with other classification systems for
G.D. Klasser et al.
the provision of clinical care, (iii) descriptive and
succinct, (iv) easy to adapt for applications in
varying settings, (v) scalable, and
(vi) transferable for the description of pain disor-
ders in other orofacial regions of interest (Nixdorf
et al. 2012).
An example of how ontology may be applied
in a clinical setting is the reclassification of “atyp-
ical odontalgia” which often presents as a persis-
tent pain disorder. Using ontology methodology
affords the ability for criteria to be concisely and
operationally defined and provides the potential
for the development for subtypes of a disorder
such as has been employed with the term persis-
tent dento-alveolar pain disorder (PDAPD). Per-
sistent dento-alveolar pain disorder is an
ontologically adequate description because it
removes ambiguity thereby preventing misinter-
pretation as to what each term used in that descrip-
tion corresponds to in reality. For example, the
pain that patients with PDAPD suffer from is
persistent, is constant over time, occurs in the
dento-alveolar tissues, and surely, is a pain. The
use of the word disorder at the end of PDAPD is
important because it expresses that when the term
is used as a diagnosis relative to some patient, it
does not refer to that patient’s pain, but to the
disorder which forms the physical basis for that
pain (Ceusters et al. 2015a). However, noted lim-
itations associated with this approach are that the
criteria introduce new terminology which do not
have widespread acceptance, are expert-derived
and not evidence-based, and are yet to be tested
(Nixdorf et al. 2012). Hopefully, by following
taxonomy using ontological metrics is an initial
first step towards a paradigm shift in the develop-
ment of a harmonized taxonomy for OFP disor-
ders, which is a necessary for the improvement of
clinical research and patient care.
Conclusions
This chapter has provided an insight into the clas-
sification of OFP including the topic of TMD by
reviewing the available diagnostic/classification
schemes and commenting on the constructs on
which they are based. From a quick overview, it
Classification of Orofacial Pain
is apparent that none of the available classification
systems has emerged as clearly superior to others
in terms of potentially relevant impact on the
clinical practice. In particular, there is still a strong
need to improve knowledge on the pathophysiol-
ogy of many OFP conditions and to weigh the
relative importance of the different evaluation
axes as far as the treatment outcome is concerned.
This means that even if there is no doubt that
topographically or Axis I (i.e., “physical”
diagnosis)-based diagnoses are not enough to
explain the severity of the symptoms and the
predictability of their decrease with treatment,
other constructs based on a more thorough evalu-
ation are difficult to introduce in the clinical prac-
tice due to the complexity of the derived
assessment in the clinical setting. This clinical
uncertainty mirrors in the available classification
schemes and may be best exemplified by thinking
about an imaginary patient with TMD seeking for
advice for his/her symptoms.
A 35-years-old female complains of pain in the
right TMJ area and has positive palpation of the
ipsilateral masseter, temporalis and lateral ptery-
goid muscles as well as the TMJ. Pain onset dated
back to a couple of years ago and the patient has
moderate depression and somatization levels.
Leaving apart all other possible information, the
discussion of which is beyond the scope of this
chapter, the key question from a classification
viewpoint is: which are the evaluation axis that
prevails in determining the clinical picture?
Should this patient be classified as having a
myofascial pain plus right TMJ arthralgia (Axis
I) or a moderate depression and somatization
(Axis II)? And what about the possibility of her
symptoms undergoing modulation due to the
expression of her specific genome (Axis III) as
well as her particular neurobiology makeup of her
pain (Axis IV)?
Over the years, improvement in pain medicine
knowledge has progressively shifted the focus of
targeted treatment from the topographic or organ
specific “diagnosis” to a more globally oriented
approach towards personality and psychosocial
issues. The literature has shown that, for instance,
Axis II findings are more predictive of treatment
outcomes than Axis I diagnoses (Manfredini et al.
21
2013; Suvinen et al. 2013). This information has
to be integrated with progressive increases in
knowledge on pain genetics and neurobiology,
and the resulting comprehensive picture should
be the basis for an ideal classification.
In summary, the ultimate goal of a classifica-
tion is to provide clinically useful schemes for an
easier management of patients in the clinical set-
ting. Until now, despite all efforts by the several
international experts and organizations, none of
the proposed classifications of OFP is free of any
shortcomings. However, the recently proposed
ontology-based approach could represent a prom-
ising step toward an archetypal treatment-oriented
classification.
Cross-References
▶ Arthritic Diseases Affecting the TMJ
▶ Biopsychosocial Considerations for Orofacial
Pain
▶ Internal Derangements of the Temporomandib-
ular Joint
▶ Masticatory Muscle Pain
▶ Neuropathic Orofacial Pain
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