The American Academy of Orofacial Pain (AAOP) was founded in 1975, and its goal was to improve the understanding and quality of education in temporomandibular disorders (TMDs) and orofacial pain. The mission of the AAOP remains to be an organization of healthcare professionals dedicated to alleviating pain and suffering through the promotion of excellence in education, research, and patient care in the field of orofacial pain and associated disorders.


Five publications have preceded this current edition of what commonly is referred to as the AAOP Guidelines. Dr Charles McNeill spearheaded the first two editions called Craniomandibular Disorders: Guidelines for Evaluation, Diagnosis, and Management, (Quintessence, 1990) and Temporomandibular Disorders: Guidelines for Classification, Assessment, and Management (Quintessence, 1993).

These publications focused predominantly on TMDs. As healthcare professionals and researchers became more conscious of the relationship between TMDs and other disorders of the head and neck, there was a need to expand the Guidelines to include disorders presenting as or related to TMDs. These disorders included not only headaches and neck disorders but several neuropathic pain conditions as well as biobehavioral factors. In 1996, under the editorship of Dr Jeffrey Okeson, the third version of the AAOP Guidelines was published, titled Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management.

That edition used the term orofacial pain to echo the rapidly changing and expanding field of orofacial pain and to reflect the fact that TMDs and orofacial pain should not be regarded as separate conditions, but that TMDs should be considered part of the disorders that fall under the umbrella of orofacial pain. Under the editorship of Dr Reny de Leeuw, the fourth edition of the Guidelines was published, which started to express evidence-based concepts. This edition included a separate chapter on cervical disorders to emphasize the close relationships between some orofacial pain disorders and cervical pain disorders, and—more importantly—to call attention to the differences and similarities associated with these disorders. The fifth edition, published in 2013, adopted the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and the expanded TMD taxonomy based on the work of the International RDC-TMD Consortium. An updated definition of bruxism based on another inter- national consensus work group was also adopted. Moreover, a new chapter was added in the fifth edition dedicated to the relationship between pain disorders and sleep.

While the structure of the present work resembles previous editions, significant changes have been implemented in this current edition. All chapters contain essential updates, and some have undergone more changes than others. References have been updated throughout to reflect the most current literature. When available, evidence-based material has been included to provide the reader with scientifically sound and effective diagnostic procedures and treatment options. All references to the International Classification of Diseases, Ninth Edition (ICD-9 ) codes have been removed, and ICD-10 codes have been updated or added. In addition, references to the International Classification of Headache Disorders, third edition (beta version) (ICHD) have been updated in chapters 4 and 5 and added to chapter 6. Chapter 1 has been updated with the most recent knowledge from the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) studies, regarding genetics and epigenetics as well as expanded information about glial cells, neuropeptides, and their implications for pain. In chapter 2, the relationship between TMDs and otalgia has been elaborated upon, and additional measures for sleep apnea assessment have been included. In chapter 3, the newest versions of classification systems have been included.


Chapters 4 and 5 contain various general updates as well as updates to management.


Chapter 6 was completely renewed and now follows the ICHD. As a result, the description of superior laryngeal neuralgia was eliminated. Chapter 7 contains general updates to the references as well as management strategies for several disorders. The sections on viral infections, candidiasis, and pain due to cancer treatment contain the most notable updates. In chapter 8, the section on epidemiology was updated and expanded to include more information on TMDs and comorbid conditions.


The section on genetic factors has also been updated to reflect the work from the OPPERA studies. The section on diagnostic classification has been updated to more accurately describe the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for the most common TMDs and the expanded taxonomy including less common TMDs.


General updates have been provided for the management section of this chapter, and new sections include but are not limited to gabapentinoids, glucosamine and chondroitin, and topical medications. A summary of pharmacologic treatments is also new. Under the physical agents section, a separate paragraph is dedicated to the potential use of botulinum toxin for myofascial pain, indicating that there is currently insufficient evidence for its use.


The layout for chapter 9 has been changed, and sections emphasizing genetics and peripheral and central sensitization have been added. Sections have also been renamed to reflect the most up-to-date terminology. In chapter 10, benign disorders of the eyes and ears have been expanded on. A description of first-bite syndrome has also been added.


The descriptions of various connective tissue diseases have undergone major edits, and the section on blood vessels contains major improvements as well. The content of chapter 11 has been updated, specifically regarding comorbidities and bruxism. Chapter 12 provides updates on brief, ultra-brief, and comprehensive screening tools for biobehavioral factors in line with the recommendations from the DC/TMD. The chapter also includes major updates in the description of several psychiatric diseases in line with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Lastly, the glossary has undergone major updates to reflect the emerging and expanding field of orofacial pain. New terms have been added, and obsolete and superfluous terms have been removed.

Finally, a word of caution: This is not intended to be an all-encompassing textbook including complete details regarding all aspects of orofacial pain. Instead, it is meant to provide insight in and to assist the reader with the procedures of evidence-based assessment, diagnosis, and management of orofacial pain conditions, based on the latest scientific knowledge.

Reny de Leeuw and Gary D. Klasser


Co-chairs, AAOP Guidelines Committee



Over the years, numerous AAOP members and nonmembers have participated in the evolution of the AAOP Guidelines, resulting in the sixth edition of this publication. The contributors to the current edition of the AAOP Guidelines are listed on a separate page. Each new edition has reflected the emerging and expanding field of orofacial pain. Based on these developments, new and evidence-based materials have been added. However, this ever-evolving work has built on and edited the work others have done in the past. As such, some parts of previous contributions may still be intact. We therefore want to extend our sincere appreciation to all of you who have contributed to any of the past editions, and especially to those of you who laid the foundation of this publication. We also would like to offer much gratitude to the publishers for providing us with timely advice and guidance so that deadlines could be met. The staff support at Quintessence has been incredibly accommodating and meticulous in their efforts and should be applauded. We truly hope that you will get great enjoyment and practical help from this new edition.



Preface vi Acknowledgments vii


1 Introduction to Orofacial Pain 1


2 General Assessment of the Orofacial Pain Patient 26


3 Diagnostic Classification of Orofacial Pain 50


4 Vascular and Nonvascular Intracranial Causes of


Orofacial Pain 61


5 Primary Headache Disorders 74


6 Neuropathic Pain 90


7 Intraoral Pain Disorders 121


8 Differential Diagnosis and Management of TMDs 143


9 Cervical Spinal Disorders and Headaches 208


10 Extracranial and Systemic Causes of Head and


Facial Pain 223


11 Sleep and Orofacial Pain 240


12 Axis II: Biobehavioral Considerations 249


Glossary 271 Index 316