<html><body><table><tr><td></td><th>Western Australia
CRICKER
THE UNIVERSITY OF</th><td>Perth Oral Medicine &
Dental Sleep Centre</td><td>Perth Children's Hospital</td><td>PERIOGOLD®
Pelw
Helps Improve Oral Health</td><td>OMIAA
Oral Medicine Academy of Australasia</td><td>DSSWA</td><td>ADA
AUSTRALIAN DENTAL
ASSOCIATION</td><td>sleep
AUSTRALASIAN
ASSOCIATION</td></tr></table></body></html>
The University of Western Australia
Perth Oral Medicine & Dental Sleep Centre
Perth Children's Hospital
PERIOGOLD® - Helps Improve Oral Health
OMIAA - Oral Medicine Academy of Australasia
DSSWA
ADA - Australian Dental Association
Australasian Sleep Association
# Disclosure
**_Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation._**
#### Disclosure
Neither I nor my immediate family have any financial interests that would create a conflict of interest or restrict my independent judgment with regard to the content of this presentation.
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**SPECIFIC LEARNING OUTCOMES**
Understand common intracapsular disorders with regards to aetiology, pathophysiology, diagnosis, clinical features and management including subluxation and luxation of the TMJs.
Understand common extracapsular disorders with regards to aetiology, pathophysiology, diagnosis, clinical features and management.
Outline the rationale for splint therapy including mechanisms of action, various types of splint designs, indications, and the evidence supporting their use in managing temporomandibular disorders and bruxism.
Discuss the indications, mechanism of action, contraindications, side effects, and complications of neuromodulators.
Outline the aetiology, pathogenesis, clinical features, diagnosis and management of neuropathic orofacial pain conditions.
#### Clinical Knowledge and Management
- Understand common intracapsular disorders with regards to aetiology, pathophysiology, diagnosis, clinical features and management including subluxation and luxation of the TMJs.
- Understand common extracapsular disorders with regards to aetiology, pathophysiology, diagnosis, clinical features and management.
- Outline the rationale for splint therapy including mechanisms of action, various types of splint designs, indications, and the evidence supporting their use in managing temporomandibular disorders and bruxism.
- Discuss the indications, mechanism of action, contraindications, side effects, and complications of neuromodulators.
- Outline the aetiology, pathogenesis, clinical features, diagnosis and management of neuropathic orofacial pain conditions.
# SPECIFIC LEARNING OUTCOMES
Describe prevalence, aetiology, pathophysiology, clinical features, diagnosis and management of various conditions that may present as non-odontogenic toothache.
Describe evolution, epidemiology, risk factors, aetiology and pathophysiology, clinical features, diagnosis and management of bruxism.
Understand the relationship between sleep and overall health, identify risk factors for sleep-disordered breathing, recognise tools for evaluating sleep disorders, and understand available treatment options, including effective management with oral appliance therapy.
**Unit Learning Outcome 27:**
Explain the clinical examination and tests required to diagnose orofacial pain, including temporomandibular disorders, and explain their management.
#### Advanced Diagnostics and Sleep Medicine
- Describe prevalence, aetiology, pathophysiology, clinical features, diagnosis and management of various conditions that may present as non-odontogenic toothache.
- Describe evolution, epidemiology, risk factors, aetiology and pathophysiology, clinical features, diagnosis and management of bruxism.
- Understand the relationship between sleep and overall health, identify risk factors for sleep-disordered breathing, recognise tools for evaluating sleep disorders, and understand available treatment options, including effective management with oral appliance therapy.
#### Unit Learning Outcome 27
Explain the clinical examination and tests required to diagnose orofacial pain, including temporomandibular disorders, and explain their management.
| Date | Day | Start Time | Finish Time | Venue | Lecture / Tutorial Topic | Lecturer |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| 17/4/25 | Friday | 9 | 10 | 211 | Defining Orofacial Pain | A/Prof Ramesh Balasubramaniam |
| 17/4/25 | Friday | 10 | 11 | 211 | History and Examination including DC/TMD | A/Prof Ramesh Balasubramaniam |
| 17/4/25 | Friday | 11 | 12 | 211 | Temporomandibular Disorders: Intracapsular Disorders | Supetha Suntharamoorthy<br>supeetha@pomds.com.au |
| 24/4/26 | Friday | 8 | 9 | 211 | Temporomandibular Disorders: Extracapsular Disorders | Dr. Lalima Tiwari<br>lalima.tiwari@uwa.edu.au |
| 24/4/26 | Friday | 9 | 10 | 211 | Occlusal Splint Therapy | A/Prof Ramesh Balasubramaniam |
| 24/4/26 | Friday | 10 | 11 | 211 | Botulinum Toxin for Orofacial Pain | Lasanthini Weerakkody<br>lasanthini@pomds.com.au |
| 24/4/26 | Friday | 11 | 12 | 211 | Neuropathic Orofacial Pain including Burning Mouth Syndrome | Dr. Amanda Phoon Nguyen<br>amanda.phoonnguyen@uwa.edu.au |
| 1/5/26 | Friday | 9 | 10 | KJG S | Non-Odontogenic Toothache | A/Prof Ramesh Balasubramaniam |
| 1/5/26 | Friday | 10 | 11 | KJG S | Bruxism | Dr. Amanda Phoon Nguyen<br>amanda.phoonnguyen@uwa.edu.au |
| 1/5/26 | Friday | 11 | 12 | KJG S | Oral Appliance Therapy for Snoring and Obstructive Sleep Apnoea | A/Prof Ramesh Balasubramaniam |
| 15/5/26 | Friday | 8 | 12 | 211 | **TUTORIAL**: Clinical cases in temporomandibular disorders, orofacial pain and dental sleep medicine 1<br>Timetable Hours: 4 | A/Prof Ramesh Balasubramaniam |
| 22/5/26 | Friday | 8 | 12 | 211 | **TUTORIAL**: Clinical cases in temporomandibular disorders, orofacial pain and dental sleep medicine 2.<br>Timetable Hours: 4 | A/Prof Ramesh Balasubramaniam |
#### Course Schedule
| Date | Day | Start | Finish | Venue | Lecture / Tutorial Topic | Lecturer |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| 17/4/25 | Friday | 9 | 10 | 211 | Defining Orofacial Pain | A/Prof Ramesh Balasubramaniam |
| 17/4/25 | Friday | 10 | 11 | 211 | History and Examination including DC/TMD | A/Prof Ramesh Balasubramaniam |
| 17/4/25 | Friday | 11 | 12 | 211 | Temporomandibular Disorders: Intracapsular Disorders | Supetha Suntharamoorthy |
| 24/4/26 | Friday | 8 | 9 | 211 | Temporomandibular Disorders: Extracapsular Disorders | Dr. Lalima Tiwari |
| 24/4/26 | Friday | 9 | 10 | 211 | Occlusal Splint Therapy | A/Prof Ramesh Balasubramaniam |
| 24/4/26 | Friday | 10 | 11 | 211 | Botulinum Toxin for Orofacial Pain | Lasanthini Weerakkody |
| 24/4/26 | Friday | 11 | 12 | 211 | Neuropathic Orofacial Pain including Burning Mouth Syndrome | Dr. Amanda Phoon Nguyen |
| 1/5/26 | Friday | 9 | 10 | KJG S | Non-Odontogenic Toothache | A/Prof Ramesh Balasubramaniam |
| 1/5/26 | Friday | 10 | 11 | KJG S | Bruxism | Dr. Amanda Phoon Nguyen |
| 1/5/26 | Friday | 11 | 12 | KJG S | Oral Appliance Therapy for Snoring and Obstructive Sleep Apnoea | A/Prof Ramesh Balasubramaniam |
| 15/5/26 | Friday | 8 | 12 | 211 | **TUTORIAL**: Clinical cases in TMD, OFP and DSM 1 | A/Prof Ramesh Balasubramaniam |
| 22/5/26 | Friday | 8 | 12 | 211 | **TUTORIAL**: Clinical cases in TMD, OFP and DSM 2 | A/Prof Ramesh Balasubramaniam |
![]()
A structured table titled 'LECTURE TOPICS' listing an academic schedule. The columns are: Date, Day, Start Time, Finish Time, Venue, Lecture / Tutorial Topic, and Lecturer. Rows detail sessions from 17/4/25 to 22/5/26. Specific entries include topics like 'Temporomandibular Disorders: Intracapsular Disorders', 'Botulinum Toxin for Orofacial Pain', and 'Oral Appliance Therapy for Snoring'. The last two rows highlight 4-hour tutorials on clinical cases in yellow-highlighted cells.
# AGENDA
**Pain Definition**
**Is Pain Good or Bad?**
**3 Pains**
**Biopsychosocial Model for Pain**
**Definition & Classification of Orofacial Pain**
**Take Home Message**
#### Presentation Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
AGENDA
- <b>Pain Definition</b>
- <b>Is Pain Good or Bad?</b>
- <b>3 Pains</b>
- <b>Biopsychosocial Model for Pain</b>
- <b>Definition & Classification of Orofacial Pain</b>
- <b>Take Home Message</b>
#### Presentation Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
![]()
Agenda timeline diagram showing a vertical sequence of six topics. The visual structure consists of circular nodes connected by lines on the left, with corresponding rectangular text blocks extending to the right. The first node is red and labeled 'Pain Definition'. The subsequent five nodes are grey and labeled 'Is Pain Good or Bad?', '3 Pains', 'Biopsychosocial Model for Pain', 'Definition & Classification of Orofacial Pain', and 'Take Home Message' respectively.
![]()
Clinical photo: A woman with short dark hair is shown in profile, leaning forward and clutching her lower back with one hand. She has a pained facial expression, indicating distress. The image serves as a visual demonstration of the symptom associated with the slide title 'NEW DEFINITION OF PAIN'.
NEW DEFINITION OF “PAIN”
Four Decades Later: Revision of the IASP Definition of Pain and Notes
The currently accepted definition of pain was originally adopted in 1979 by the International Association for the Study of Pain (IASP)
1979 Definition of Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
In 2018, IASP constituted a 14-member multi-national task force with expertise in clinical and basic science related to pain, which sought input from multiple stakeholders to determine:
“Does the progress in our knowledge of pain over the years warrant a re-evaluation of the definition?”
2020 Revised Definition of Pain
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage
2020 Revised Definition of Pain Notes
Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors
Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons
Through their life experiences, individuals learn the concept of pain
A person’s report of an experience as pain should be respected
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being
Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain
The revised IASP definition of pain: concepts, challenges, and compromises
Raja et al. (2020) | Pain
DOI: 10.1097/j.pain.0000000000001939
#### Historical Context and Revision
The currently accepted definition of pain was originally adopted in 1979 by the International Association for the Study of Pain (IASP). In 2018, the IASP constituted a 14-member multi-national task force with expertise in clinical and basic science to determine if progress in the knowledge of pain warranted a re-evaluation of the definition.
#### Comparison of Definitions
**1979 Definition of Pain**
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
**2020 Revised Definition of Pain**
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
#### Key Clinical Notes on the 2020 Definition
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
- Through their life experiences, individuals learn the concept of pain.
- A person’s report of an experience as pain should be respected.
- Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
- Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.
*Source: Raja et al. (2020) | Pain. DOI: 10.1097/j.pain.0000000000001939*
![]()
Diagram of the '1979 Definition of Pain' presented as a white paper note pinned to a blue background. The text reads: 'An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.'
![]()
Diagram of the '2020 Revised Definition of Pain' presented as an open book held by a figure on the right. A magnifying glass highlights the year '2020'. The text reads: 'An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.'
![]()
Infographic panel titled '2020 Revised Definition of Pain Notes'. It contains six circular icons with orange backgrounds arranged in two columns. Each icon is accompanied by explanatory text regarding pain being a personal experience, the difference between pain and nociception, learning concepts of pain, respecting patient reports, adverse effects of pain, and non-verbal expression of pain.
**NEW DEFINITION OF “PAIN”**
“An unpleasant sensory and
emotional experience
associated with, or resembling
that associated with, actual or
potential tissue damage.”
Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
*Source: Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.*
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- <b>Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.</b>
Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.
<img style="display:none" src="file:///C:/Users/Петербуржек/AppData/Local/Temp/177505361-1498-4d48-897b-f3b57a07ec93.ws.gif" alt="" loading="lazy"></img>
#### Biological and Psychological Factors
- Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
- Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
*Source: Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.*
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.
#### Learning and Communication
- Through their life experiences, individuals learn the concept of pain.
- A person’s report of an experience as pain should be respected.
*Source: Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982.*
![]()
Clinical photo of a young girl with long dark hair sitting on an examination table in a medical setting. She is looking down and appears to be in discomfort or distress, illustrating the concept that individuals learn the concept of pain through life experiences.
#### The 2020 Revised Definition
In 2020, the International Association for the Study of Pain (IASP) revised the definition of pain to better reflect the current understanding of the condition. Pain is defined as:
> "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."
#### Accompanying Key Notes
To provide further clarity and clinical context, the IASP included six key notes with the revised definition:
1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
3. Through their life experiences, individuals learn the concept of pain.
4. A person’s report of an experience as pain should be respected.
5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
6. Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a non-human animal experiences pain.
**AGENDA**
- Pain Definition
- **Is Pain Good or Bad?**
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
#### Presentation Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
*RB*
**IS PAIN GOOD OR BAD?**
**No one**
**wants to**
**be in pain**
**Important**
**for health**
**& survival**
#### The Dual Nature of Pain
While no one wants to be in pain, it is important for health and survival.
![]()
Educational diagram illustrating the dual nature of pain. The image features a person ironing with their hand placed near the hot plate to demonstrate thermal sensation. A large orange upward arrow is labeled 'No one wants to be in pain', representing aversive or unpleasant pain. A green downward arrow is labeled 'Important for health & survival', representing protective pain signals (nociception). The visual uses the burning hand scenario to contrast between unwanted discomfort and necessary biological warning.
# IS PAIN PHYSIOLOGICAL OR PATHOPHYSIOLOGICAL?
## Physiological Pain
- Consequence of tissue injury or noxious stimuli
- Site of injury = source of pain
- "Normal Pain" / protective
- When noxious stimuli is removed, inflammation resolves and pain ceases
<!-- Image shows a person with their arm in a splint and sling, illustrating physiological pain. -->
#### Characteristics of Physiological Pain
- Consequence of tissue injury or noxious stimuli
- Site of injury is the source of pain
- Considered "Normal Pain" and serves a protective function
- Pain ceases when the noxious stimuli is removed and inflammation resolves
![]()
Clinical photo of a person with their right arm in a white cast and supported by a blue triangular sling. The image visually illustrates the concept of 'Physiological Pain' as described in the adjacent text, showing a consequence of tissue injury (casted wrist) and demonstrating the protective response where the site of injury is immobilized.
# **IS PAIN PHYSIOLOGICAL OR PATHOPHYSIOLOGICAL?**
## **Pathophysiological Pain**
- Pain persist after noxious stimuli has ceased and tissue healed
- Lesion / dysfunction of the PNS or CNS
- Chronic pain
- No protective or reparative role
#### Characteristics of Pathophysiological Pain
- Pain persists after the noxious stimuli has ceased and tissue has healed
- Involves a lesion or dysfunction of the Peripheral Nervous System (PNS) or Central Nervous System (CNS)
- Categorized as chronic pain
- Serves no protective or reparative role
**IS PAIN BIOLOGICAL OR PSYCHOLOGICAL?**
**Biomedical Pain**
* Pain is primarily a sensory experience signaling tissue damage
* Somatosensory cortex of brain perceives the pain
* Pain = tissue damage / stimuli
**Biopsychosocial Pain**
* Biological, psychological, social and cultural
* Mind – body connection
* Interaction of the higher centres accounts for psychological aspects
* Influenced by genetics, conditioning, context, emotion, mood, expectation of pain
#### Biomedical Perspective
- Pain is primarily a sensory experience signaling tissue damage
- The somatosensory cortex of the brain perceives the pain
- Pain is directly equated to tissue damage or stimuli
#### Biopsychosocial Perspective
- Pain involves biological, psychological, social, and cultural factors
- Emphasizes the mind-body connection
- Interaction of higher brain centers accounts for psychological aspects
- Influenced by genetics, conditioning, context, emotion, mood, and expectation of pain
# IS PAIN BIOLOGICAL OR PSYCHOLOGICAL?
```mermaid
graph TD
A("My 10 is not the same as your 10.") --> D
B("In spite of same noxious stimuli") --> D
C("Particularly influence by childhood experiences") --> D
D(("Pain is an individual experience"))
```
### Sir William Osler
"It is more important to know what type of individual has the pain rather the type of pain the patient has."
#### Pain as an Individual Experience
Pain is a subjective, individual experience characterized by the following:
- Individual thresholds vary (e.g., "My 10 is not the same as your 10")
- Experiences differ in spite of receiving the same noxious stimuli
- Perception is particularly influenced by childhood experiences
#### Clinical Insight
Sir William Osler noted: "It is more important to know what type of individual has the pain rather the type of pain the patient has."
![]()
A conceptual diagram titled 'IS PAIN BIOLOGICAL OR PSYCHOLOGICAL?' illustrating the subjective nature of pain. The visual features a background image of a patient in a dental chair receiving treatment. Overlaid on this are several text boxes connected by arrows to a central circular node labeled 'Pain is an individual experience'. Three input factors are shown: 'My 10 is not the same as your 10.', 'In spite of same noxious stimuli', and 'Particularly influence by childhood experiences'. To the right, there is a section featuring a historical black and white photograph of Sir William Osler with his name captioned above, accompanied by a quote box at the bottom containing his famous statement about understanding the type of individual with pain rather than just the type of pain.
# PAIN & SUFFERING
## Pain experience have 2 distinct components:
| Component | Description |
| :--- | :--- |
| **Sensory-Discriminative** | Localisation, intensity discrimination, quality of noxious stimulus |
| **Motivational-Affective** | Emotion, arousal and pain behaviour<br>How the individual reacts<br>Influenced by prior experience, expectations, possible misconceptions |
#### Dual Components of the Pain Experience
The experience of pain consists of two distinct components:
1. **Sensory-Discriminative**
- Relates to the localization, intensity discrimination, and quality of the noxious stimulus.
2. **Motivational-Affective**
- Relates to emotion, arousal, and pain behavior.
- Concerns how the individual reacts.
- Influenced by prior experience, expectations, and possible misconceptions.
![]()
A dual-panel diagram illustrating the two components of pain experience. The left panel, titled 'Sensory-Discriminative', lists localisation, intensity discrimination, and quality of noxious stimulus. The right panel, titled 'Motivational-Affective', details emotion/arousal, individual reactions, and influences like prior experience and misconceptions.
### AGENDA
- Pain Definition
- Is Pain Good or Bad?
- **3 Pains**
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
#### Presentation Agenda
- Pain Definition
- Is Pain Good or Bad?
- **3 Pains**
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
Nociceptive Pain: Pain that arises from actual or threatened
damage to non-neural tissue and is due to the activation of
nociceptors.
•
Normally functioning somatosensory nervous system
https://www.iasp-pain.org/resources/terminology/
Renton T. Tooth-Related Pain or Not?. Headache. 2020;60(1):235-246.
*
**THE 3 PAINS: NOCICEPTIVE PAIN**
The multiple ‘faces’ of toothache
**Healthy tooth**
In health allodynia is felt to cold, electrical and mechanical stimuli
Image showing a healthy tooth cross-section.
**Insult to tooth**
**Trauma**
**Cracked tooth syndrome** as shown above
**Caries**
**Hyperaemia of the pulp**
Pulpal Inflammation causes sensitivity of A delta fibers allodynic pain with cold and sugary stimuli
**Pulpal ischaemia**
Pulpal ischaemia causes sensitivity of C fibers and allodynia to heat and spontaneous episodic throbbing pain
**Pulpal necrosis**
Pulpal death causes periapical tissue inflammation. Episodic spontaneous throbbing pain and allodynia on biting
**1**
Nociceptive Pain is defined as pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. It involves a normally functioning somatosensory nervous system.
#### Clinical Manifestations in Dentistry: The Multiple Faces of Toothache
- **Healthy Tooth**
- In health, allodynia is felt to cold, electrical, and mechanical stimuli.
- **Insult to Tooth**
- **Trauma and Cracked Tooth Syndrome**: Physical damage to the tooth structure.
- **Caries and Hyperaemia of the Pulp**: Pulpal inflammation causes sensitivity of A-delta fibers, resulting in allodynic pain with cold and sugary stimuli.
- **Pulpal Ischaemia**: Causes sensitivity of C fibers and allodynia to heat, characterized by spontaneous episodic throbbing pain.
- **Pulpal Necrosis**: Pulpal death causes periapical tissue inflammation, leading to episodic spontaneous throbbing pain and allodynia on biting.
![]()
Labeled diagram illustrating 'The multiple faces of toothache' and the progression of nociceptive pain. The visual displays five sequential cross-sections of a tooth: 1) Healthy tooth (showing normal red pulp with allodynia to cold/electrical stimuli); 2) Cracked tooth syndrome (blue arrow indicating trauma, showing intermittent neuralgic pain on biting); 3) Hyperaemia of the pulp (orange arrow indicating caries, showing sensitivity of A delta fibers); 4) Pulpal ischaemia (showing reduced blood flow, sensitivity of C fibers and spontaneous throbbing pain); 5) Pulpal necrosis (showing periapical inflammation and death). Text annotations below each section detail the specific symptoms like allodynia and spontaneous pain.
RB
**THE 3 PAINS: NOCICEPTIVE PAIN**
1
Noxious stimuli may be mechanical, thermal, chemical resulting in damage or potential damage
Only when it reaches CNS = Pain
Prevent further injury
Nociception modified on the way to CNS: amplified, reduced or inhibited.
#### Characteristics of Nociception
- **Stimuli**: Noxious stimuli may be mechanical, thermal, or chemical, resulting in damage or potential damage.
- **Perception**: Only when the signal reaches the Central Nervous System (CNS) is it perceived as pain.
- **Function**: Serves to prevent further injury.
- **Modulation**: Nociception is modified on the way to the CNS; it can be amplified, reduced, or inhibited.
![]()
Composite photograph illustrating nociceptive pain. The image is split into two distinct scenes: on the left, soldiers in tactical gear are shown in a combat environment; on the right, two women wearing boxing gloves are sparring. This visual context supports the slide's text regarding noxious stimuli (mechanical) resulting in damage.
# THE 3 PAINS: NEUROPATHIC PAIN
Neuropathic Pain: Pain caused by a lesion or disease of the somatosensory nervous system.
2
<img>Neurons and trigeminal nerve<img>
https://www.iasp-pain.org/resources/terminology/
Renton T. Tooth-Related Pain or Not?. *Headache*. 2020;60(1):235-246.
Neuropathic Pain is defined as pain caused by a lesion or disease of the somatosensory nervous system.
![]()
Labeled anatomical figure demonstrating the trigeminal nerve and neurons. The image features a large central neuron cell body with dendrites and axons on the left side, alongside a human head profile on the right showing the yellow-highlighted trigeminal nerve branching across the face and neck. A teal circle with the number '2' is overlaid on the left, indicating this is part of a series. The visual connects the microscopic neuron structure to its macroscopic location in the human anatomy.
# THE 3 PAINS: NEUROPATHIC PAIN
* Abnormality of the nervous system
* May be spontaneous
* No need for noxious stimuli
* No protective role
**2**
Episodic vs Continuous Neuropathic Pain
#### Clinical Features of Neuropathic Pain
- Represents an abnormality of the nervous system.
- May occur spontaneously.
- No need for noxious stimuli to trigger the sensation.
- Does not serve a protective role.
- Can be categorized as Episodic vs. Continuous Neuropathic Pain.
![]()
Flowchart diagram illustrating the characteristics of neuropathic pain. A large blue arrow curves downwards from 'Abnormality of the nervous system' to 'Episodic vs Continuous Neuropathic Pain'. Along the arrow path are key features: 'May be spontaneous', 'No need for noxious stimuli', and 'No protective role'. A dark teal circle with the number '2' is located at the start of the flow.
![]()
Clinical photo of a woman in distress holding her cheek/jaw area, visually demonstrating the symptom or sensation associated with the topic of pain discussed in the slide.
```html
<table border="1">
<tr>
<th colspan="4">THE 3 PAINS: NOCIPLASTIC PAIN</th>
</tr>
<tr>
<td colspan="4">Nociplastic Pain: Pain that arises from altered nociception<br>despite no clear evidence of actual or threatened tissue damage<br>causing the activation of peripheral nociceptors or evidence for<br>disease or lesion of the somatosensory system causing the pain.</td>
</tr>
<tr>
<td colspan="2"><b>3</b><br><br><b>Maladaptive Plasticity</b></td>
<td colspan="2"><b>Central Sensitization (Hyperexcitability)</b><br><br>
<i>(Primary Afferent Terminal)</i> AP -> Glu, SP
<br>
<i>NMDAR</i><br><i>VGCC</i> -> Ca2+ -> ERK (CREB)<br>
<i>NK1</i><br>
<i>CAMKII PKA / PKC</i><br>
<i>IP3</i><br>
<br>
<i>AMPA R</i><br>
<i>mGluR</i>
<br><br><br></td>
</tr>
<tr>
<td colspan="4">
[Intense Tissue Injury and Inflammation] -> Peripheral Nociceptors -> Primary Afferent -> DRG (Dorsal Horn) -> Spinal Cord -> Projection to Brain (Secondary Afferent) -> Brain (Altered Connectivity)<br><br>
<b>Peripheral Sensitization (Hypersensitivity)</b>
</td>
</tr>
</table>
```
Nociplastic Pain is defined as pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors, or evidence for disease or lesion of the somatosensory system causing the pain.
#### Mechanisms of Nociplastic Pain
- **Maladaptive Plasticity**: Changes in the nervous system that lead to chronic pain states.
- **Central Sensitization (Hyperexcitability)**:
- Involves the Primary Afferent Terminal.
- Neurotransmitters and receptors involved: Glutamate (Glu), Substance P (SP), NMDAR, NK1, AMPA R, and mGluR.
- Intracellular signaling: VGCC (Voltage-Gated Calcium Channels) leading to Ca2+ influx, ERK (CREB), CAMKII, PKA / PKC, and IP3.
- **Pathways**: Intense tissue injury and inflammation trigger a cascade from Peripheral Nociceptors to the Primary Afferent, through the DRG (Dorsal Horn) and Spinal Cord, projecting to the Brain (Secondary Afferent), resulting in altered connectivity.
- **Peripheral Sensitization (Hypersensitivity)**: Increased responsiveness of peripheral neurons.
![]()
Labeled diagram illustrating the pathophysiology of nociplastic pain. The image is divided into three main sections: 'Peripheral Sensitization (Hypersensitivity)' at the bottom showing a cross-section of the spinal cord with red arrows indicating signal transmission from peripheral nociceptors through the DRG and Dorsal Horn to the brain; 'Central Sensitization (Hyperexcitability)' in the center, detailing synaptic mechanisms including NMDAR, VGCC, AMPAR, mGluR, and intracellular signaling pathways like Ca2+, ERK, and CREB; and 'Brain Remodeling (Altered Connectivity)' on the right, depicting a brain with altered connectivity highlighted by a red dot and a projection line labeled 'Projection to Brain Secondary Afferent'.
|THE 3 PAINS: NOCIPLASTIC PAIN|
|:-:|
|Pain without evidence of of tissue damage or physiological cause|
|**3**|
|Caused by psychological stress?|
|Neurophysiological basis for pain|
|Pain is “real”|
#### Clinical Understanding of Nociplastic Pain
- Characterized by pain without evidence of tissue damage or a clear physiological cause.
- Question of whether it is caused by psychological stress.
- Possesses a distinct neurophysiological basis for pain.
- The pain is "real" despite the lack of visible tissue injury.
![]()
Educational infographic titled 'THE 3 PAINS: NOCIPLASTIC PAIN'. The diagram illustrates the concept of pain without tissue damage. On the left is a photo of a woman with grey hair and an uncomfortable expression. In the center, text defines the condition as 'Pain without evidence of tissue damage or physiological cause' and asks if it is 'Caused by psychological stress?'. A large yellow arrow labeled 'Neurophysiological basis for pain' points from the text to a split-brain illustration on the right. The brain image shows the left side as normal grey matter and the right side filled with colorful cartoon characters representing thoughts and emotions. A central circle highlights the number '3', and the bottom text concludes 'Pain is "real"'.
<BR>
# DON'T GET FANCY: THE 3 PAINS
<tableinjau>
<thead><tr><td><B>THREE TYPES OF PAINS</B></td></tr></thead>
<tbody>
<tr><td><B></B></td><td><B>NOCICEPTIVE / INFLAMMATORY</B></td><td><B>NEUROPATHIC</B><B></B></td><td><B>NOCIPLASTIC/CENTRAL SENSITISATION</B></td></tr>
<tr><td><B>Stimulus</B></td><td>Injury or Inflammation<br>(tissue injury)</td><td>Neural damage, pinching, irritation<br>(nerve injury)</td><td>Central nervous system dysfunction<br>(sensitised nervous system)</td></tr>
<tr><td><B>Neuron</B></td><td>Nociceptor and non-nociceptor</td><td>Nociceptor and non-nociceptor</td><td>Non-nociceptor</td></tr>
<tr><td><B>Site</B></td><td>Peripheral and central nervous system</td><td>Peripheral and central nervous system</td><td>Central nervous system</td></tr>
<tr><td><B>Clinical / Dentistry</B></td><td>Pulpitis, jaw fracture, acute periodonttis</td><td>Trigeminal neuralgia, anaesthesia dolorosa, post-herpetic neuralgia</td><td>Burning mouth syndrome, persistent facial pain, persistent dentoalveolar pain</td></tr>
<tr><td><B>Function</B></td><td>Protective, healing / repair, pathological</td><td>Pathological</td><td>Pathological</td></tr>
<tr><td><b>Pain</b><b>Sensitivity</B></td><td>High or low threshold</td><td>Low threshold</td><td>Low threshold</td></tr>
</tbody>
</table>
#### Comparative Overview of Pain Types
| Feature | Nociceptive / Inflammatory | Neuropathic | Nociplastic / Central Sensitisation |
| :--- | :--- | :--- | :--- |
| **Stimulus** | Injury or Inflammation (tissue injury) | Neural damage, pinching, irritation (nerve injury) | Central nervous system dysfunction (sensitised nervous system) |
| **Neuron** | Nociceptor and non-nociceptor | Nociceptor and non-nociceptor | Non-nociceptor |
| **Site** | Peripheral and central nervous system | Peripheral and central nervous system | Central nervous system |
| **Clinical / Dentistry** | Pulpitis, jaw fracture, acute periodontitis | Trigeminal neuralgia, anaesthesia dolorosa, post-herpetic neuralgia | Burning mouth syndrome, persistent facial pain, persistent dentoalveolar pain |
| **Function** | Protective, healing / repair, pathological | Pathological | Pathological |
| **Pain Sensitivity** | High or low threshold | Low threshold | Low threshold |
![]()
A structured table titled 'THREE TYPES OF PAINS' comparing three categories: Nociceptive/Inflammatory, Neuropathic, and Nociplastic/Central Sensitisation. The table includes rows for Stimulus (e.g., tissue injury vs nerve injury), Neuron types, Site of occurrence (Peripheral vs Central nervous system), Clinical/Dentistry examples (e.g., pulpitis, trigeminal neuralgia, burning mouth syndrome), Function (protective/pathological), and Pain Sensitivity thresholds.
# AGENDA
## Pain Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- **Biopsychosocial Model for Pain**
- Definition & Classification of Orofacial Pain
- Take Home Message
#### Pain Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- **Biopsychosocial Model for Pain**
- Definition & Classification of Orofacial Pain
- Take Home Message
ACUTE VS CHRONIC PAIN
Chronic Pain is pain beyond normal healing time • Neuroplasticity may prolong and maintain pain. Chronic vs recurrent pain disorders • Behavioural and psychological changes begin
#### Characteristics of Chronic Pain
- Chronic Pain is pain beyond normal healing time.
- Neuroplasticity may prolong and maintain pain.
- Distinction between chronic vs. recurrent pain disorders.
- Behavioral and psychological changes begin to manifest.
![]()
Biopsychosocial Model of Pain diagram showing the relationship between somatosensory input (Axis I, green area) and psychosocial input (Axis II, brown area) over time. The diagram includes two distinct phases: 'Acute pain' (orange label) dominated by somatosensory input, and 'Chronic pain' (red label) where psychosocial input becomes dominant. Arrows point from the combined inputs to 'Suffering and Pain Behaviour' on the right.
# Biopsychosocial Model of Pain
| Statistic | Value |
|---|---|
| 1 in 15 Australians live with chronic pain | Cost $22,588 - $44,979 / year |
**Acute Pain:** unpleasant, dynamic psychophysiological process, response to tissue trauma and related inflammatory processes.
* Survival value
* Role in healing
**Chronic pain =** little evolutionary benefit (maladaptive)
* **Shift mindset from eradicating problem to management (functional and emotional resilience)**
**Biological Factors**
* Disease severity
* Nociception
* Inflammation
* Brain function
**Psychological Factors**
* Mood/affect
* Catastrophizing
* Stress
* Coping
**Social Factors**
* Cultural factors
* Social Environment
* Economic factors
* Social support
*Flor H, Noguchi K, Treede RD, Turk DC. The role of evolving concepts and new technologies and approaches in advancing pain research, management, and education since the establishment of the International Association for the Study of Pain. Pain. 2023 Nov 1;164(11S):S16-S21.*
*Fillingim RB. Individual differences in pain: understanding the mosaic that makes pain personal. Pain. 2017 Apr 158 Suppl 1(Suppl 1):S11-S18.*
*Deloitte Access Economics. The cost of pain in Australia. March, 2019.*
#### Economic Impact in Australia
- 1 in 15 Australians live with chronic pain.
- Estimated cost: $22,588 - $44,979 per year.
#### Acute vs. Chronic Pain Paradigms
- **Acute Pain:** An unpleasant, dynamic psychophysiological process occurring in response to tissue trauma and related inflammatory processes.
- Possesses survival value.
- Plays a role in healing.
- **Chronic Pain:** Offers little evolutionary benefit (maladaptive).
- Requires a shift in mindset from eradicating the problem to management (focusing on functional and emotional resilience).
#### Components of the Biopsychosocial Model
- **Biological Factors:**
- Disease severity
- Nociception
- Inflammation
- Brain function
- **Psychological Factors:**
- Mood/affect
- Catastrophizing
- Stress
- Coping
- **Social Factors:**
- Cultural factors
- Social environment
- Economic factors
- Social support
![]()
Conceptual diagram illustrating the Biopsychosocial Model of Pain. The central node is labeled 'PAIN'. Three surrounding circles connected by green arrows represent the influencing factors: 'Biological Factors' (listing Disease severity, Nociception, Inflammation, Brain function), 'Psychological Factors' (listing Mood/affect, Catastrophizing, Stress, Coping), and 'Social Factors' (listing Cultural factors, Social Environment, Economic factors, Social support). The visual structure demonstrates the interconnectedness of these three domains in pain management.
## BIOPSYCHOSOCIAL MODEL OF PAIN
***
### Longitudinal (Motion Picture) vs Cross-Sectional (Snapshot) Perspective
---
**SOCIOECONOMIC & HEALTH CARE CONTEXTS**
| **Premorbid characteristics** | **Age at symptom onset** | **Consult age** | **Life expectancy** |
| :--- | :--- | :--- | :--- |
| • Demographics | • Pathology | • Change in pathology | • Aging |
| • Genes | • Treatments | • Expectancies | • Change in pathology |
| • Lifestyle | • Beliefs | • Behaviour | |
| • Learning history | • Behaviour | • Consequences | |
| • Culture | | | |
*Timeline Arrows:* 0 --> 37** --> 44* --> 76+
**Resources:**
* Interpersonal support
* Economic
Flor H, Noguchi K, Treede RD, Turk DC. The role of evolving concepts and new technologies and approaches in advancing pain research, management, and education since the establishment of the International Association for the Study of Pain. Pain. 2023 Nov 1;164(11S):S16-S21.
#### Longitudinal (Motion Picture) vs. Cross-Sectional (Snapshot) Perspective
This perspective evaluates pain within socioeconomic and health care contexts across a timeline (0 to 76+ years).
- **Premorbid Characteristics:**
- Demographics
- Genes
- Lifestyle
- Learning history
- Culture
- **Age at Symptom Onset (approx. age 37):**
- Pathology
- Treatments
- Beliefs
- Behavior
- **Consult Age (approx. age 44):**
- Change in pathology
- Expectancies
- Behavior
- Consequences
- **Life Expectancy (76+):**
- Aging
- Change in pathology
#### Available Resources
- Interpersonal support
- Economic resources
![]()
A composite diagram illustrating the 'BIOPSYCHOSOCIAL MODEL OF PAIN', specifically comparing Longitudinal (Motion Picture) vs Cross-Sectional (Snapshot) Perspectives. The visual includes a timeline at the bottom showing developmental stages: 0, 37**, 44*, and 76+. Above the timeline are four columns of bullet points representing different life phases: Premorbid characteristics (Demographics, Genes, Lifestyle, etc.), Age at symptom onset (Pathology, Treatments, Beliefs), Consult age (Change in pathology, Expectancies, Behaviour), and Life expectancy (Aging, Change in pathology). Arrows indicate relationships between these factors across time. Two photos on the right side illustrate the concept: an upper photo shows a child with a bicycle accident (snapshot of acute event), and a lower photo shows an older couple embracing (longitudinal view of aging and chronic pain).
#PAIN IS PAIN BUT OROFACIAL PAIN ......
**Facial pain & headache more severe & emotionally draining compared to bodily pain.**
• Smith JG, Elias LA, Yilmaz Z, Barker S, Shah K, Shah S, Renton T. The psychosocial and affective burden of posttraumatic neuropathy following injuries to the trigeminal nerve. J Orofac Pain. 2013 Fall;27(4):293-303.
**Craniofacial pain qualitatively different from bodily nociception. Repeated noxious heat to face = sensitisation (not habituation).**
• Schmidt K, Schunke O, Forkmann K, Bingel U. Enhanced short-term sensitization of facial compared with limb heat pain. J Pain. 2015 Aug;16(8):781-90.
**Fear related to facial pain higher compared to bodily pain for same pain intensity.**
• Schmidt K, Forkmann K, Sinke C, Gratz M, Bitz A, Bingel U. The differential effect of trigeminal vs. peripheral pain stimulation on visual processing and memory encoding is influenced by pain-related fear. Neuroimage. 2016 Jul 1;134:386-395.
#### Psychosocial and Sensory Distinctions
- **Emotional Burden:** Facial pain and headaches are often more severe and emotionally draining compared to bodily pain.
- **Sensitization:** Craniofacial pain is qualitatively different from bodily nociception. Repeated noxious heat to the face results in sensitization rather than habituation.
- **Pain-Related Fear:** Fear related to facial pain is higher compared to bodily pain even when the pain intensity is identical.
# PAIN IS PAIN BUT OROFACIAL PAIN ......
fMRI showed higher amygdala activation for facial pain compared to hand for same pain intensity.
• Moulton EA, Pendse G, Morris S, Strassman A, Aiello-Lammens M, Becerra L, Borsook D. Capsaicin-induced thermal hyperalgesia and sensitization in the human trigeminal nociceptive pathway: an fMRI study. Neuroimage. 2007 May 1;35(4):1586-600.
Lateral parabrachial nucleus ($PBL$) is activated more strongly by noxious facial stimulation. Monosynaptic connection between cranial sensory neurons & $PBL$-nociceptive neurons.
• Rodriguez E, Sakurai K, Xu J, Chen Y, Toda K, Zhao S, Han BX, Ryu D, Yin H, Liedtke W, Wang F. A craniofacial-specific monosynaptic circuit enables heightened affective pain. Nat Neurosci. 2017 Dec; 20(12):1734-1743.
#### Neurological Mechanisms
- **Amygdala Activation:** fMRI studies show higher amygdala activation for facial pain compared to hand pain for the same intensity.
- **Craniofacial-Specific Circuits:** The lateral parabrachial nucleus (PBL) is activated more strongly by noxious facial stimulation. A monosynaptic connection exists between cranial sensory neurons and PBL-nociceptive neurons, enabling heightened affective pain.
# BIOPSYCHOSOCIAL MODEL EXPLAINED
**RB**
**33 year old female presents with the complaint of TMJ Clicking and pain**
![Arthroscopic view of a disc displaced into the retrodiscal tissues]
* **Disk displacement with reduction**
* **Anxiety**
* **Catastrophising**
---
### DIAGNOSIS TORQUES BIOPSYCHOSOCIAL MODEL
| Description | Biological | Psychological | Social |
| :--- | :--- | :--- | :--- |
| **Clinical Presentation** | Pain and loud noise | Worrier | Self-conscious when eating |
**Dr Per-Lennard Westesson, University of Lund 1985**
#### Case Study: RB
- **Patient Profile:** 33-year-old female.
- **Chief Complaint:** TMJ clicking and pain.
- **Clinical Findings:**
- Disk displacement with reduction.
- Anxiety.
- Catastrophizing.
#### Biopsychosocial Presentation
- **Biological:** Pain and loud noise.
- **Psychological:** Identified as a "worrier."
- **Social:** Self-conscious when eating.
![]()
A composite medical illustration demonstrating the Biopsychosocial Model for a 33-year-old female with TMJ clicking and pain. The image features a central anatomical view of a temporomandibular joint showing 'Disk displacement with reduction'. Overlaid on the left are three distinct categories: Biological (pain and loud noise), Psychological (worrier), and Social (self-conscious when eating). On the right, an inset shows an arthroscopic view of displaced disc tissue into retrodiscal tissues. A caption credits Dr Per-Lennard Westesson, University of Lund 1985.
**BIOPSYCHOSOCIAL MODEL EXPLAINED**
**Empathy**
**Social Bonding**
**Isolation Induced Suffering**
**Depression**
**Anxiety**
**Somatisation**
**Mechanism & Mediators**
**Clinical Pain, Clicking, Locking**
**Occlusion & Asymmetries**
Carr & Bradshaw (2014) Anesthesiology 120(1):12-4
#### Interconnected Factors in Patient Suffering
- **Psychosocial Elements:**
- Empathy and Social Bonding
- Isolation Induced Suffering
- Depression and Anxiety
- Somatisation
- **Clinical and Physical Elements:**
- Mechanisms and Mediators
- Clinical Pain, Clicking, and Locking
- Occlusion and Asymmetries
![]()
A labeled diagram illustrating the Biopsychosocial Model. The visual consists of three nested circles representing 'Biomedical' (inner, light blue), 'Psychological' (middle, brown), and 'Social' (outer, teal). On the left, three text boxes with arrows point to these respective layers: the top box lists social factors (Empathy, Social Bonding, Isolation Induced Suffering) pointing to 'Social'; the middle box lists psychological factors (Depression, Anxiety, Somatisation) pointing to 'Psychological'; and the bottom box lists biomedical factors (Mechanism & Mediators, Clinical Pain/Clicking/Locking, Occlusion & Asymmetries) pointing to 'Biomedical'. A citation is visible at the bottom.
# AGENDA
**RB**
* **Pain Definition**
* **Is Pain Good or Bad?**
* **3 Pains**
* **Biopsychosocial Model for Pain**
* **Definition & Classification of Orofacial Pain**
* **Take Home Message**
#### Presentation Agenda
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
### Oral Health Definitions
**Objectives:**
- Define Orofacial Pain
- Define Temporomandibular Disorders (Temporomandibular Joint Disorders)
- Define Correct Head and Posture
---
### Orofacial Pain
**Definition:**
Orofacial pain is pain perceived in the face and/or oral cavity.
**Prevalence:**
- **17-26%**
(Porporatti AL et al. J Oral Facial Pain Headache. 2024 Sep;38(3):1-14.)
---
### Temporomandibular Disorders (TMD)
**Definition:**
- TMDs describe a diverse group of musculoskeletal and neuromuscular conditions involving the TMJs, masticatory muscles, and associated structures.
**Prevalence:**
- **4.6%** (Isong et al., 2008)
- Ref: Klasser & Romero Reyes (2023). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 6th Ed. Quintessence Publishing.
Systemation of Orofacial Pain (2023).
#### Oral Health Objectives
- Define Orofacial Pain
- Define Temporomandibular Disorders (Temporomandibular Joint Disorders)
- Define Correct Head and Posture
#### Orofacial Pain
**Definition:**
Orofacial pain is pain perceived in the face and/or oral cavity.
**Prevalence:**
- 17-26% (Porporatti AL et al. J Oral Facial Pain Headache. 2024 Sep;38(3):1-14.)
#### Temporomandibular Disorders (TMD)
**Definition:**
- TMDs describe a diverse group of musculoskeletal and neuromuscular conditions involving the TMJs, masticatory muscles, and associated structures.
**Prevalence:**
- 4.6% (Isong et al., 2008)
**References:**
- Klasser & Romero Reyes (2023). Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 6th Ed. Quintessence Publishing.
- Systemation of Orofacial Pain (2023).
```mermaid
graph TD
Title[CLASSIFICATION OF OROFACIAL PAIN]
AxisI[Axis I Physical Conditions]
AxisII[Axis II Psychological Conditions]
Title --> AxisI
Title --> AxisII
%% Axis I
AxisI --> SomaticPain[Somatic Pain]
AxisI --> NeuropathicPain[Neuropathic Pain]
SomaticPain --> SuperficialPain[Superficial Pain]
SomaticPain --> DeepPain[Deep Pain]
SuperficialPain --> CutaneousPain[Cutaneous Pain]
SuperficialPain --> MucogingivalPain[Mucogingival Pain]
DeepPain --> MusculoskeletalPain[Musculoskeletal Pain]
DeepPain --> VisceralPain[Visceral Pain]
MusculoskeletalPain --> MusclePain[Muscle Pain]
MusculoskeletalPain --> TMJPain[TMJ Pain]
MusculoskeletalPain --> OsseousPain[Osseous Pain]
MusculoskeletalPain --> ConnectTissuePain[Connect. Tissue Pain]
MusculoskeletalPain --> PeriodontalPain[Periodontal Pain]
MusclePain --> CentralMediatedMyalgia[Central Mediated Myalgia]
MusclePain --> Myospasm[Myospasm]
MusclePain --> MyofascialPain[Myofascial Pain]
MusclePain --> LocalMuscleSoreness[Local Muscle Soreness]
MusclePain --> ProtectiveCoContraction[Protective Co-Contraction]
TMJPain --> ArthriticPain[Arthritic Pain]
TMJPain --> CapsularPain[Capsular Pain]
TMJPain --> RetrodiscalPain[Retrodiscal Pain]
TMJPain --> LigamentousPain[Ligamentous Pain]
VisceralPain --> GlandularENTPain[Glandular, ENT Pain]
VisceralPain --> VisceralMucosalPain[Visceral Mucosal Pain]
VisceralPain --> PulpalPain[Pulpal Pain]
VisceralPain --> VascularPain[Vascular Pain]
VisceralPain --> NeurovascularPain[Neurovascular Pain]
VascularPain --> Carotidynia[Carotidynia]
VascularPain --> ArteritisPain[Arteritis Pain]
NeurovascularPain --> NeurovascularVariants[Neurovascular Variants]
NeurovascularPain --> OtherPrimaryHeadache[Other Primary Headache]
NeurovascularPain --> ClusterOtherTCA[Cluster and other TCA]
NeurovascularPain --> TensionType[Tension-Type]
NeurovascularPain --> Migraine[Migraine]
NeuropathicPain --> EpisodicPain[Episodic Pain]
NeuropathicPain --> ContinuousPain[Continuous Pain]
EpisodicPain --> ParoxysmalNeuralgia[Paroxysmal Neuralgia]
ParoxysmalNeuralgia --> TrigeminalNeuralgia[Trigeminal Neuralgia]
ParoxysmalNeuralgia --> OtherNeuralgias[Other Neuralgias]
ContinuousPain --> MetabolicPolyneuropathies[Metabolic Polyneuropathies]
ContinuousPain --> PeripheralMediatedPain[Peripheral Mediated Pain]
ContinuousPain --> CentralMediatedPain[Central Mediated Pain]
PeripheralMediatedPain --> EntrapmentNeuropathy[Entrapment Neuropathy]
PeripheralMediatedPain --> DeafferentationPain[Deafferentation Pain]
PeripheralMediatedPain --> NeuriticPain[Neuritic Pain]
PeripheralMediatedPain --> BurningMouthDisorder[Burning Mouth Disorder]
PeripheralMediatedPain --> TraumaticNeuroma[Traumatic Neuroma]
PeripheralMediatedPain --> PeripheralNeuritis[Peripheral Neurits]
PeripheralMediatedPain --> HerpesZoster[Herpes Zoster]
CentralMediatedPain --> AtypicalOdontalgia[Atypical Odontalgia Phantom Pain]
CentralMediatedPain --> PostHerpeticNeuralgia[Post Herpetic Neuralgia]
CentralMediatedPain --> ChronicRegionalPainSyndrome[Chronic Regional Pain Syndrome]
PeripheralNeuritis -.-> SMP[Sympathetically Maintained Pain]
HerpesZoster -.-> SMP
PostHerpeticNeuralgia -.-> SMP
ChronicRegionalPainSyndrome -.-> SMP
%% Axis II
AxisII --> MoodDisorders[Mood Disorders]
AxisII --> AnxietyDisorders[Anxiety Disorders]
AxisII --> SomatoformDisorders[Somatoform Disorders]
AxisII --> OtherConditions[Other Conditions]
MoodDisorders --> MoodMedCondition[Mood Disorder due to a Medical Condition]
MoodDisorders --> BipolarDisorder[Bipolar Disorder]
MoodDisorders --> DepressiveDisorder[Depressive Disorder]
AnxietyDisorders --> AnxietyMedCondition[Anxiety Disorder due to a Medical Condition]
AnxietyDisorders --> PTSD[Posttraumatic Stress Disorder]
AnxietyDisorders --> GAD[Generalized Anxiety Disorder]
SomatoformDisorders --> Hypochondriasis[Hypochondriasis]
SomatoformDisorders --> PainDisorder[Pain Disorder]
SomatoformDisorders --> ConversionDisorder[Conversion Disorder]
SomatoformDisorders --> UndifferentiatedSomatoform[Undifferentiated Somatoform Disorder]
OtherConditions --> OtherCondSub[Other Conditions]
OtherConditions --> PsychFactorsMed[Psychological Factors Affecting Med Condition]
OtherConditions --> Malingering[Malingering]
PsychFactorsMed --> StressResponse[Stress-Related Physiological Response]
PsychFactorsMed --> MaladaptiveBehavior[Maladaptive Health Behavior]
PsychFactorsMed --> PersonalityTraits[Personality Traits or Coping Style]
%% Final Diagnosis
AxisI --> Diagnosis[Diagnosis]
AxisII --> Diagnosis
subgraph Legend
Okeson2020[Okeson, 2020]
end
```
#### Axis I: Physical Conditions
**1. Somatic Pain**
- **Superficial Pain**
- Cutaneous Pain
- Mucogingival Pain
- **Deep Pain**
- **Musculoskeletal Pain**
- Muscle Pain (Central Mediated Myalgia, Myospasm, Myofascial Pain, Local Muscle Soreness, Protective Co-Contraction)
- TMJ Pain (Arthritic, Capsular, Retrodiscal, Ligamentous)
- Osseous Pain
- Connective Tissue Pain
- Periodontal Pain
- **Visceral Pain**
- Glandular, ENT Pain
- Visceral Mucosal Pain
- Pulpal Pain
- Vascular Pain (Carotidynia, Arteritis Pain)
- Neurovascular Pain (Migraine, Tension-Type, Cluster and other TCA, Neurovascular Variants, Other Primary Headache)
**2. Neuropathic Pain**
- **Episodic Pain**
- Paroxysmal Neuralgia (Trigeminal Neuralgia, Other Neuralgias)
- **Continuous Pain**
- Metabolic Polyneuropathies
- Peripheral Mediated Pain (Entrapment Neuropathy, Deafferentation Pain, Neuritic Pain, Burning Mouth Disorder, Traumatic Neuroma, Peripheral Neuritis, Herpes Zoster)
- Central Mediated Pain (Atypical Odontalgia/Phantom Pain, Post Herpetic Neuralgia, Chronic Regional Pain Syndrome)
- **Sympathetically Maintained Pain (SMP)**
- Associated with Peripheral Neuritis, Herpes Zoster, Post Herpetic Neuralgia, and Chronic Regional Pain Syndrome.
#### Axis II: Psychological Conditions
- **Mood Disorders:** Mood Disorder due to a Medical Condition, Bipolar Disorder, Depressive Disorder.
- **Anxiety Disorders:** Anxiety Disorder due to a Medical Condition, Posttraumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD).
- **Somatoform Disorders:** Hypochondriasis, Pain Disorder, Conversion Disorder, Undifferentiated Somatoform Disorder.
- **Other Conditions:**
- Psychological Factors Affecting Medical Condition (Stress-Related Physiological Response, Maladaptive Health Behavior, Personality Traits or Coping Style)
- Malingering
*Source: Okeson, 2020*
![]()
Labelled hierarchical diagram titled 'CLASSIFICATION OF OROFACIAL PAIN' which divides conditions into Axis I (Physical) and Axis II (Psychological). Axis I branches into Somatic Pain (subdivided into Superficial and Deep pain with specific conditions like Myofascial Pain and TMJ Pain) and Neuropathic Pain (subdivided into Episodic and Continuous pain including Trigeminal Neuralgia and Migraine). Axis II branches into Mood Disorders, Anxiety Disorders, Somatoform Disorders, and Other Conditions. The diagram includes arrows indicating connections to 'Sympathetically Maintained Pain' and a final 'Diagnosis' step.
| TMD Diagnosis | | Sensitivity | Specificity |
| :--- | :--- | :--- | :--- |
| **Pain related temporomandibular disorders** | A. Myalgia | 0.90 | 0.99 |
| | 1. Local myalgia | Not established | |
| | 2. Myofascial pain | Not established | |
| | 3. Myofascial pain with referral | 0.86 | 0.98 |
| | B. Arthralgia | 0.89 | 0.98 |
| | C. Headache attributed to TMD | 0.89 | 0.87 |
| **Intra-articular temporomandibular disorders** | A. Disc displacement with reduction | 0.34 | 0.92 |
| | B. Disc displacement with reduction with intermittent locking | 0.38 | 0.98 |
| | C. Disc displacement without reduction with limited opening | 0.80 | 0.97 |
| | D. Disc displacement without reduction without limited opening | 0.54 | 0.97 |
| | E. Degenerative joint disease | 0.55 | 0.61 |
| | F. Subluxation | 0.98 | 1.00 |
Schiffman et al. *J Oral Facial Pain Headache* 2014;28:6–27.
#### Diagnostic Validity of TMD Classifications
| TMD Diagnosis | Sensitivity | Specificity |
| :--- | :--- | :--- |
| **Pain related temporomandibular disorders** | | |
| A. Myalgia | 0.90 | 0.99 |
| 1. Local myalgia | Not established | |
| 2. Myofascial pain | Not established | |
| 3. Myofascial pain with referral | 0.86 | 0.98 |
| B. Arthralgia | 0.89 | 0.98 |
| C. Headache attributed to TMD | 0.89 | 0.87 |
| **Intra-articular temporomandibular disorders** | | |
| A. Disc displacement with reduction | 0.34 | 0.92 |
| B. Disc displacement with reduction with intermittent locking | 0.38 | 0.98 |
| C. Disc displacement without reduction with limited opening | 0.80 | 0.97 |
| D. Disc displacement without reduction without limited opening | 0.54 | 0.97 |
| E. Degenerative joint disease | 0.55 | 0.61 |
| F. Subluxation | 0.98 | 1.00 |
*Source: Schiffman et al. J Oral Facial Pain Headache 2014;28:6–27.*
![]()
A structured table titled 'DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS (DC/TMD)' displaying diagnostic data from Schiffman et al. The table is organized into columns for 'TMD Diagnosis', 'Sensitivity', and 'Specificity'. It categorizes disorders into two main groups: 'Pain related temporomandibular disorders' (highlighted in green) and 'Intra-articular temporomandibular disorders' (highlighted in yellow). Specific conditions listed include Myalgia, Arthralgia, Headache attributed to TMD, Disc displacement variations, Degenerative joint disease, and Subluxation, with corresponding numerical sensitivity and specificity values.
| International classification of orofacial pain 1st edition |
| :--- |
| Orofacial Pain attributed to disorders of dentoalveolar and anatomically related structures |
| Myofascial orofacial pain |
| Temporomandibular joint pain |
| Orofacial pain attributed to lesion or disease of the cranial nerves |
| Orofacial pains resembling presentation of primary headache |
| Idiopathic orofacial pain |
| Psychosocial assessment of patients with orofacial pain |
#### International Classification of Orofacial Pain (1st Edition)
- Orofacial Pain attributed to disorders of dentoalveolar and anatomically related structures
- Myofascial orofacial pain
- Temporomandibular joint pain
- Orofacial pain attributed to lesion or disease of the cranial nerves
- Orofacial pains resembling presentation of primary headache
- Idiopathic orofacial pain
- Psychosocial assessment of patients with orofacial pain
![]()
Flowchart titled 'INTERNATIONAL CLASSIFICATION OF OROFACIAL PAIN 1ST EDITION'. The diagram displays a vertical hierarchy of orofacial pain categories connected by downward arrows. From top to bottom, the sequence includes: 'Orofacial Pain attributed to disorders of dentoalveolar and anatomically related structures', 'Myofascial orofacial pain', 'Temporomandibular joint pain', 'Orofacial pain attributed to lesion or disease of the cranial nerves', 'Orofacial pains resembling presentation of primary headache', 'Idiopathic orofacial pain', and 'Psychosocial assessment of patients with orofacial pain'. A citation at the bottom reads 'Cephalalgia 2020, Vol. 40(2): 129-221'.
**AGENDA**
Pain Definition
Is Pain Good or Bad?
**3 Pains**
Biopsychosocial Model for Pain
Definition & Classification of Orofacial Pain
**Take Home Message**
#### Presentation Overview
- Pain Definition
- Is Pain Good or Bad?
- 3 Pains
- Biopsychosocial Model for Pain
- Definition & Classification of Orofacial Pain
- Take Home Message
The provided prompt requests the extraction of text from an image that contains only a "Take Home Message" title and a man shrugging.
Based on the rules provided:
- **Figure/Image Rules:** "If the text on the page only makes sense in the context of a figure or image (labels, names with no context), treat the whole page as a figure: wrap a single brief description in tags and output NOTHING ELSE."
The text "TAKE HOME MESSAGE" is a generic header that defines the slide but does not provide a standalone message or answer. The visual content (a man shrugging) is the primary information carrier. Therefore, the entire page is treated as a figure.
<figure>A slide titled "TAKE HOME MESSAGE" featuring an image of a man shrugging.</figure>
![]()
A presentation slide featuring a 'Take Home Message' header. The primary visual is a black and white photo of a man with a beard shrugging his shoulders in confusion or uncertainty, serving as an illustrative figure for the concept.
<img style="z-index:-9999;position:absolute; left:-10000px;">
**RB**
TAKE HOME
MESSAGE
1. There is a new definition of pain.
2. 3 types of pain enveloped around the biopsychosocial model.
3. Always conduct a psychosocial history with empathy.
4. If you don’t believe the pain, believe the suffering.
5. Orofacial pain . . . . . never a boring day.
#### Key Takeaways
1. There is a new definition of pain.
2. 3 types of pain enveloped around the biopsychosocial model.
3. Always conduct a psychosocial history with empathy.
4. If you don’t believe the pain, believe the suffering.
5. Orofacial pain . . . . . never a boring day.
THANK YOU!!!
Ramesh Balasubramaniam OAM
DENT5310
Orofacial Pain and Dental Sleep Medicine Module
16th April 2026
**THE UNIVERSITY OF WESTERN AUSTRALIA**
**PERTH ORAL MEDICINE &
DENTAL SLEEP CENTRE**
**Perth Children's Hospital**
**PERIOGOLD®**
Helps Improve Oral Health
**OMAA**
Oral Medicine Academy of Australasia
**DSSWA**
**ADA**
AUSTRALIAN DENTAL
ASSOCIATION
**AUSTRALASIAN SLEEP ASSOCIATION**
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