The New Dental Specialty of Orofacial Pain
by James Fricton DDS, MS
The specialty of Orofacial Pain is the newest specialty in both Dentistry and Medicine.
There is a significant need for an Orofacial Pain specialist in each city across the United States.
The Orofacial Pain Speciality includes the diagnosis, management and prevention of pain disorders of the jaw, mouth, face and associated regions. These conditions affect over 25% of all people and include headache disorders, temporomandibular muscle and joint (TMJ) disorders, muscle pain, jaw and facial movement disorders such as clenching and grinding of the teeth, nerve pain, and sleep disorders. The American Dental Association’s National Commission on Recognition of Dental Specialties and Certifying Boards (NCRDSCB) in March of 2020 determined that the dental field of Orofacial Pain (OFP) through the American Academy of Orofacial Pain (AAOP) was recognized as the newest dental specialty to help patients with these conditions.
What Exactly is the Orofacial Pain Speciality?
The American Academy of Orofacial Pain (AAOP) defines OFP as “the specialty of dentistry that encompasses the diagnosis, management, and treatment of pain disorders of the jaw, mouth, face and associated regions.”
“Patients will TMJ and orofacial pain have been neglected for years because their condition falls between medicine and dentistry. As a result they are often subjected unsuccessful trial and error treatment without resolution of their pain that is not covered by either medical or dental insurance plans. Specialty recognition of Orofacial Pain is an important milestone for all patients who suffer from these disorders because these patients now know where to turn to receive high quality successful care from well-trained specialists who arerecognized by both Medicine and Dentistry.” – Dr. James Fricton, pain specialist at MN Head & Neck Pain Clinic and Chair of the Orofacial Pain Specialty Committee
Helping Patients with Orofacial Pain Disorders
Patients with these conditions often have:
- Jaw pain
- Facial pain
- Neck pain (often adding referred pain in a person’s shoulders)
- Tooth pain
- Clicking, popping, or locking in the temporomandibular jaw joints
- Ear pain, ringing in the ears, or plugged ears
These symptoms often result from many causes that may injure or strain the muscles, joints, and nerves of the face.
Consider the following case as an example.
A 32-year old female patient, Patricia, presented with a 5-year history of jaw pain, pain in multiple teeth, ear pain, and headaches with neck pain, limited jaw function, and TM joint noise. Her pain began after 3rd molar extractions when she was 20 years of age and then continued despite a series of treatments including endodontic treatment on painful teeth, dental crowns, chiropractic care, and multiple medications including opioid analgesics from her physician. Ultimately, she was referred to an Orofacial Pain Specialist. The specialist diagnosed multiple physical disorders which included masticatory and cervical myofascial muscle pain, temporomandibular joint disc disorder with joint pain, migraine headaches, and periodontal ligament strain of the teeth from clenching. She also had multiple contributing factors including opioid dependency, oral parafunctional habits including clenching and grinding, depression, work loss, and stress from finances, social situation, and others.
In cases like Patricia’s, patients report that they are often “shuttled” between multiple professionals; they are even abandoned with no referral options when their treatment did not work. Sometimes they receive multiple medications, dental treatment, orthodontics, injections, and surgeries that may only provide limited or temporary relief. This can lead to chronic pain and years of suffering.
For example, the average number of clinicians seen by orofacial pain patients prior to seeing an Orofacial Pain specialist can ranged from 4.5 to 5.3 in University study2-3. Studies have also shown that over 50% of people seeking care for orofacial pain still have pain 5 years later due to limited unsuccessful treatment4-8. The development of the specialty in Orofacial Pain was motivated by this need to improve successful care for these patients.
How can Specialists in Orofacial Pain Help?
Orofacial pain specialists are well-trained board-certified dentists who focus their care of patients with orofacial pain disorders. They are an integral part of our medical and dental healthcare system and provide high quality evidence-based care. Many states have determined that these are medical conditions, not dental, and cost of care is covered primarily under medical insurance companies. An orofacial pain specialist conducts an evaluation to identify all symptoms, diagnoses and causes of the pain based on this information. treatment plan is developed to treat the condition while training the patient to reduce the patient-centered causes of the condition. This will also prevent chronic pain and it’s consequences such as addiction to opioid and other medications, limitation in function, work loss, disability, and long-term dependency on treatments.
Most patients with TMJ and orofacial pain conditions have multiple symptoms jaw pain, facial pain, headaches, neck pain, tooth pain, and clicking, popping, or locking in the temporomandibular jaw joints. These symptoms can come from multiple overlapping orofacial pain disorders. Thus, the key to successful treatment by a specialist depends on identifying all of the patient’s symptoms and related physical diagnoses. In most patients, there are 3 or more conditions causing pain. Missing one diagnosis may lead to treatment failure. For this reason, a complete jaw, mouth, head, and neck evaluation is needed. In most cases, such as Patricia, imaging including a CT scan of the head, neck, jaws and teeth of the joints is needed.
It is also essential to identify and change all underlying patient-centered causes for orofacial pain conditions. If not, this will result in the development of pain cycles that perpetuate pain and lead to chronic pain and its consequences. Although a traumatic injury such as a blow, accident, and fall may lead to the onset of pain, factors that are under the control of patient such as repetitive strain, teeth clenching, tense posture, work, home, or relationship stress, poor sleeping, diet, and sustained negative emotions can lead to increased pain. Orofacial pain specialists work with a team including physical therapists, telehealth coaches, and health psychologists to help patients learn to reduce the causes of pain cycles.
Roles of the AAOP and the ABOP in Recognizing Dental Specialties
The American Academy of Orofacial Pain and the American Board of Orofacial Pain Support the Specialty of Orofacial Pain
A specialist in Orofacial Pain (OFP) is a licensed dentist (DDS, DMD or equivalent degree) who has broad understanding of the diagnosis, management and treatment of orofacial pain disorders.
An Orofacial Pain Specialist meets one or more of the following standards:
A. Is a Fellow of the American Academy of Orofacial Pain (AAOP)
B. Has successfully completed a formal advanced education program in Orofacial Pain of at least two years that is now accredited by the Commission on Dental Accreditation (CODA)
C. Has passed the American Board of Orofacial Pain (ABOP*) Certification Examination
The American Academy of Orofacial Pain (AAOP) is affiliated with CODA-accredited advanced education programs in orofacial pain and a well-validated certifying American Board of Orofacial Pain (ABOP). The AAOP is the sponsoring specialty organization for orofacial pain while the ABOP is the endorsed certification board.
The AAOP and ABOP work together to support this specialty. The AAOP endorses the ABOP Board Exam and encourages its members to take the exam and become Fellows of the AAOP. The ABOP endorses the Continuing Education provided at AAOP’s annual scientific meeting and encourages all diplomates to join the AAOP.
Orofacial Pain Specialists Improve Care for Patients with these Goals:
1. Increase access to care for patients with orofacial pain conditions by improving the knowledge base of Orofacial Pain, expanding the number of advanced education programs in Orofacial Pain, training all dentists and other health professionals in Orofacial Pain, and encouraging more dentists to pursue a career in Orofacial Pain.
2. Help patients identify Orofacial Pain Specialists with knowledge and experience in managing simple to complex orofacial pain problems and to provide a resource for patients and health professionals to refer patients.
3. Help address the chronic pain and opioid crisis by ensuring that the public is served and protected through recognition of an evidence-based standard of care for orofacial pain disorders.
4. Bring Dentistry and Medicine together in Healthcare. Since specialists in Orofacial Pain are primarily reimbursed by medical health plans instead of dental insurance plans, it allows Dentistry to be closer into Medicine and health care in general.
5. Support and expand the role of Dentistry in the rapidly evolving field of pain management and science and broaden the scope of practice and maintain a high profile in the rapidly evolving field of pain management.
Preventing Chronic Pain and Opioid Crisis
Chronic pain is the most significant problem in health care today. Among the chronic pain conditions, orofacial pain disorders including TMJ and headache disorders are one of the most common and complex disorders with a collective prevalence that ranges from 25% to 35% of the population (Table )8-12. Chronic pain is the leading reason to seek care, the dominant cause of disability and addiction, and the primary driver of healthcare utilization, resulting in greater expenditures than for cancer, heart disease, and diabetes11-12.
As a result, the nationwide chronic pain and opioid crisis is having a devastating effect on individuals, families, and communities, and imposing enormous financial costs on federal, state, and local governments. Since 1999, the number of deaths from prescription opioids has more than quadrupled and are now over 40,000 deaths per year, a greater number than from motor vehicle accidents.
It is estimated that the costs to our communities and governments is at least $80 billion annually while the financial impact on individuals and families is even more burdensome.4 The human toll is enormous and lamentable. To reverse the chronic pain and opioid crisis, respected institutions such as the Institute of Medicine, the National Pain Strategy, the Institute for Health Care Improvement, the Institute for Clinical System Integration, and U.S. Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force have recommended that health professionals including all dentists improve their recognition, training, and care of pain conditions11-12.
Table 1. The lifetime prevalence and need for treatment of orofacial pain disorders compared to caries and periodontal disease. This is compared to the annual prevalence and need for treatment of the most dental disorders of caries and periodontal disease, and missing teeth9-15.
|Orofacial Pain Disorders||% of Population|
|Orofacial pain disorders (burning mouth, neuropathic, atypical pain, neurovascular)||2-3%|
|Headache disorder (tension-type headaches, migraine, mixed, cluster)||20%|
|Orofacial sleep disorders (e.g. sleep apnea, snoring)||3-4%|
|Neurosensory/ chemosensory disorders (e.g. taste, paresthesias, numbness)||0.1%|
|Oromotor disorders (e.g. occusal dysethesias, dystonias, dyskinesias, severe bruxism)||4.2%|
|Total Prevalence of Orofacial Pain Disorders requiring care||30% to 40%|
Complexity of Orofacial Pain Disorders
Why is access to care for patients suffering from an orofacial pain disorder so difficult?
Because oral and facial structures have close associations with functions of eating, communication, sight, and hearing as well as form the basis for appearance, self-esteem and personal expression, persistent pain or disease in this area can deeply affect an individual both psychologically and systemically13. Furthermore, there is a higher degree of sensory innervation in the face and mouth than in any other area of the body. A national poll found more adults working full-time miss work from head and face pain than any other site of pain9.
Unfortunately, access to care for patients with these disorders is often difficult because the limited number of dentists who specialize in this area and the fact that the care often lies within both medicine and dentistry. A survey of 405 health professionals in the Midwest found that 90% of health professionals would choose to refer to an orofacial pain dental specialist if there was one available3.
The orofacial pain specialist brings together a patient-centered pain management program to both treat the conditions and address the many contributing factors that drive chronic pain, addiction, disability, and ongoing dependency on the healthcare system. The pain specialist could work with a team including a physical therapist to improve the musculoskeletal function, a pain coach to support self-care changes, a pain psychologist to provide counseling for depression and other psychosocial factors that complicate pain. It also often involves other health professionals including the patient’s primary care dentist and physician and a physician pain specialist to diagnosis and manage common widespread pain conditions such as fibromyalgiaas.
Evidence-based Treatment for Orofacial Pain
Orofacial pain dentists provide evidence-based treatments to improve orofacial pain conditions and prevent chronic pain and addiction while helping the health care system prevent the devastating escalation to chronic pain and addiction. Clinical trials and systematic reviews have shown that the long-term outcomes of patient-centered rehabilitation approaches such as splints, exercise, physical therapy, cognitive-behavioral training, mindfulness, and relaxation are excellent and able to prevent long-term chronic pain, addiction, and disability in nearly every patient10.
Table 2. Characteristics and scientific efficacy of different treatments of orofacial disorders including temporomandibular disorders, obstructive sleep disorders, orofacial pain, and other orofacial disorders.
|Intervention||Good scientific evidence with clinical trials and is covered by health plans1||Weak evidence, possible adverse events, and is not covered by health plans2|
|Self-management and preventive training||Systematic reviews of exercise and cognitive behavioral therapies||Cognitive-behavioral therapies
Mindfulness based stress reduction
Calming, meditation and relaxation
|Intra-oral splints||Full coverage stabilization at night
Repositioning splints at night.
Immediate quick splints short-term Partial coverage splints
|Partial coverage splints
24/7 repositioning splints
24/ splints that change dental occlusion
|Medications||Medications muscle relaxants
NSAIDs & Acetaminophen
|opioids except with intractable pain, and only under close monitoring with contract, urine testing, and periodic withdrawal.|
|Physical therapy||Therapeutic exercises
EGS, TENS and micro-current
|Injection and needle therapy||Acupuncture and dry needling
Trigger point and Botox injections
Steroid joint injections
|TMJ Surgery||Need to meet criteria for surgery including disk repair, arthroscopic surgery, discectomy, total joint prosthesis. Research is limited.||If patient does meet surgical criteria or
Orthognathic surgery for TMJ pain
1. Clinical trials and systematic reviews show evidence of efficacy with less risk of adverse events
2. Clinical trials, case series, and some systematic reviews show low evidence of efficacy with higher risk of adverse events
Orofacial Pain Clinical Guidelines for Care
The American Dental Association initially developed guidelines for temporomandibular disorders in the “Report on the President’s Conference on The Examination, Diagnosis, And Management of TM Disorders” in 198315 14 . Since then the AAOP has published more detailed clinical guidelines, first in 1989 and then updated regularly. The most current clinical guidelines are included in the publication entitled, “Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management” 154.
The guidelines were developed by a consensus panel after an exhaustive assessment of the scientific literature to educate clinicians, improve patient outcomes, enhance quality assurance, and reduce inappropriate treatment and the cost of Orofacial Pain care. All references used have been scientifically based. The members also continue to establish the standards of care for the field of Orofacial Pain in many institutions and journals.
So, let’s take a closer look at what types of pain are identified under this specialty.
2 Types of Orofacial Pain: Dentoalveolar & Musculoligamentous
What is dentoalveolar—pain?
Dentoalveolar—pain relates to pain within a tooth and it’s surrounding tissues. This includes dental and periodontal abscesses, irreversible pulpitis, and similiar tooth-related pain.
What is musculoligamentous—pain?
Musculoligamentous—pain is what we refer to as pain in the orofacial muscles, ligaments, and temporomandibular joints. It includes arthralgia, myalgia, or face pain aligned with temporomandibular disorders, capsulitis, and arthritis.
How often pain occured in the dentoalveolar tissues but not the musculoligamentous tissues is impacted by a person’s age and gender, according to a recent study. “Compared with patients 18 to 29 years old, the prevalence of dentoalveolar pain was significantly lower in patients 45 to 64 years old (PR, 0.59; 95% CI, 0.4–0.9) and those 65 years or older (PR, 0.5; 95% CI, 0.3–0.9)”, according to NIH. Orapin V. Horst, DDS, MS, MSD, PhD, authored the Jun 11, 2020 article title The Prevalence of pain in the orofacial regions in patients visiting general dentists in the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network.
Of additional interest, pain in the musculoligamentous tissues was reported 3 times more frequently by women (9.5%) than men (2.9%).
Given this information, how common is the need for an Orofacial Pain specialist?
The Need and Demand for an Orofacial Pain Specialist
Currently, there is a limited access to care for these patients.
This need is not being met with current dentists or dental specialties as documented by the high number of previous clinicians and treatments received by these patients, the high number of years with pain, and the lack of interest and training by current general dentists and dental specialists. Data Supporting the Need for Treatment According to the most conservative and reliable data on prevalence and treatment need, studies suggest that at least 7% or over 13 million Americans have a current orofacial pain disorder that is severe enough to warrant treatment each year.
Advanced Education Programs in Orofacial Pain
The AAOP is affiliated with 13 formal (two or more years) advanced education programs in Orofacial Pain that are in accredited Dental Schools to train future specialists in Orofacial Pain 1. Each of these programs are Accredited by the Commission on Dental Accreditation’s (CODA) Standards for Orofacial Pain. The total first year enrollments in all programs beginning the program is about 30 per year. With at least 13 million people with a severe orofacial pain disorder that requires care, there are over 9,750,000 people left untreated by OFP dentists and estimates the need for OFP dentists specialist is estimated to be about 13,000 specialists who are able to provide care to about 1000 new patients per year.
This is comparable to the number of oral and maxillofacial surgeons and endodontists in practice. Support for this new specialty in orofacial pain will increase the number of specialists and also highlight the importance of training other dentists to care for those patients with less complex orofacial pain disorders. It also suggests that we need to expand clinical fellowship within orofacial pain practice settings to train dentists in diagnosis and management of orofacial pain patients.
When did Orofacial Pain Officially Become a Specialty?
The monumental event happened on March 31, 2020; the National Commission on Recognition of Dental Specialties and Certifying Boards granted specialty status based on compliance with the ADA’s Requirements for Recognition of Dental Specialties. This means that the “ADA recognizes Orofacial Pain as Dentistry’s twelfth specialty“.
An June 1, 2020 article on Dentistry Today by Michael W. Davis, DDS shares the timeline: “The ADA’s recognition of OFP as a dental specialty comes on the heels of its recognition of oral medicine on March 2. A year earlier, on March 11, 2019, dental anesthesiology gained specialty status with the ADA.”
How do I get Help from an Orofacial Pain Specialist?
The MN Head and Neck Pain Clinic offers telemedicine; if you are seeking pain treatment, we can help with an office or remote doctor visit.
Call (763) 577-2484 or Schedule a Clinic Visit
About the Author
James Fricton DDS, MS is a leading pain specialist at the Minnesota Head and Neck Pain Clinic, Chair of the Specialty Committee for the AAOP, and University of Minnesota Professor Emeritus
1. Fricton, J (ed). National Commission on Recognition of Dental Specialties and Certifying Boards APPLICATION FOR RECOGNITION OF Orofacial Pain by the American Academy of Orofacial Pain (AAOP)
2. Fricton, J., Kroening, R., Haley, D., Siegert, R.: Myofascial pain and dysfunction of the head and neck: A review of clinical characteristics of 164 patients. Oral Surg., 57:615-627, 1985.
3. Look, J and Fricton, J Access to care for patients with orofacial pain: A survey of dentists. AAOP newsletter, 1999
4. LeResche L, Mancl LA, Drangsholt MT, Huang G, Von Korff M. Predictors of onset of facial pain and temporomandibular disorders in early adolescence. Pain. 2007;129(3):269-278.
5. Von Korff M, Le Resche L, Dworkin SF. First onset of common pain symptoms: a prospective study of depression as a risk factor. Pain. 1993;55(8309712):251-258.
6. Aggarwal VR, Macfarlane GJ, Farragher TM, McBeth J. Risk factors for onset of chronic oro-facial pain–results of the North Cheshire oro-facial pain prospective population study. Pain. 2010;149(2):354-359.
7. Magnusson T, Egermark I, Carlsson GE. A longitudinal epidemiologic study of signs and symptoms of temporomandibular disorders from 15 to 35 years of age. J Orofac Pain. 2000;14(4):310-319.
8. Von Korff, M., et al., Epidemiology of Temporomandibular Disorders: TMD Pain Compared to Other Common Pain Sites. Pain, 1987. 4(supp): p. S123.
9. Taylor, H. and N.M. Curran, The Nuprin Pain Report, 1985, Louis Harris and Associates: New York.
10. Temporomandibular Disorders (TMD): From Research Discoveries to Clinical Treatment. National Academy of Sciences, Medicine, and Engineering. 2020
11. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press, Washington, DC; June 29, 2011.
12. Interagency Pain Research Coordinating Committee. National pain strategy: a comprehensive population health-level strategy for pain. Washington, DC: US Department of Health and Human Services, National Institutes of Health; 2016.
13. Center for Disease Control and Prevention. Understanding the Epidemic at https://www.cdc.gov/drugoverdose/epidemic/index.html
14. Report on the President’s Conference on The Examination, Diagnosis, And Management of TM Disorders. J Am Dent Assoc. 1983, 106(1):75-7
15. de Leeuw, Reny and Klasser, Gary D. (editors) Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management, Fifth Edition. Quintessence Publishing Company, 2018AAOP
16. Lipton, J.A., J.A. Ship, and D. Larach-Robinson, Estimated prevalence and distribution of reported orofacial pain in the United States. Journal of the American Dental Association, 1993. 124(10): p. 115-21.
17. Riley JL 3rd(1), Gilbert GH, Heft MW Health care utilization by older adults in response to painful orofacial symptoms. Pain. 1999 May;81(1-2):67-75.