Axis II: Biobehavioral Considerations










12
Key Points
The biobehavioral model of pain is the foundation for clini-
cal assessment and pain management.
Core biobehavioral principles include multifactorial assess-
ment; the role of learning patient history; and the interplay
between biologic, psychologic, and social factors.
It is necessary to screen for biobehavioral risk factors in-
cluding pain, distress, and pain-related disability as well
as pain history. Be sure to note red and yellow ags for
patient care.
A comprehensive evaluation of biobehavioral factors in-
cludes pain location and intensity, pain-related disability,
psychologic distress, sleep dysfunction, posttraumatic
stress disorder (PTSD), alcohol or drug abuse, limitations
in use and movement of structures associated with oro-
facial pain conditions including the temporomandibular
joint (TMJ) and masticatory muscles, and parafunctional
activities.
The most common psychiatric disorders encountered in the
orofacial pain practice include depression, anxiety, PTSD,
somatic symptom disorders, and personality disorders.
Following referral to mental health care providers, the cli-
nician should expect a comprehensive evaluation, a treat-
ment plan targeting skills acquisition, and feedback, which
should all be provided in a timely manner.
The standard of care is integrated care among health care
professionals.
Axis II:
Biobehavioral
Considerations

250
Axis II: Biobehavioral Considerations
12
Foundation of the Biobehavioral
Model
Scientic advances have been made in under-
standing modulatory control of ascending and
descending neural circuits involved in pain pro-
cessing, including the role of glial cells and gut
microbiome inuences on neural functioning.
Variables such as emotion, cognition (including
attention and expectation), and behavior are
now understood to play very important roles
in pain transmission, awareness, and suffer-
ing. Because emotions, cognitions, and be-
haviors can facilitate or inhibit orofacial pain, it
is necessary to adopt a biobehavioral model of
disease. Behavioral factors encompass a broad
spectrum of behavioral science theory and
techniques for change. Examples of behav-
ioral science theory include principles of learn-
ing, cognitions and memory, interpersonal
processes, family systems, and social learn-
ing; techniques for change may be relaxation
training, interpersonal psychotherapy, biofeed-
back, cognitive therapy, and breathing training.
When behavioral factors are discussed in the
context of how they contribute to the function-
ing of biologic systems, it is appropriate to use
the term biobehavioral.
As discussed in chapter 1, Engel
1
noted that
the biomedical model, with its focus on patho-
biology, does not fully explain the development
of disease states. Therefore, he introduced the
term biopsychosocial to describe the complex
interactions between biology, psychologic
states, and social conditions that bring about
and/or maintain function or dysfunction. The
term biobehavioral is parallel to the word bio-
medical, and both concepts are subsumed in
Engel’s biopsychosocial model. While the term
biopsychosocial is often used because it is
more globally accepted, biobehavioral calls at-
tention to behavioral factors as they contribute
to the functioning of biologic systems.
Adopting the biobehavioral model of oro-
facial pain requires that linear, unidirectional
models of causation and of treatment be re-
placed with a bidirectional approach to under-
standing disease etiology and delivering treat-
ment. Whether the practitioner provides dental
or psychologic treatment, a mechanistic linear
model (eg, identify the cause, treat the cause,
observe recovery) for understanding orofacial
pain conditions is an incomplete model that
will yield incomplete, inappropriate, and mis-
directed clinical care. Unless behavioral, psy-
chologic, and social dimensions of a patient’s
presenting complaints and current adaptive
strategies are addressed in the treatment
plan, effective management of the pain con-
dition will likely not be achieved, especially in
chronic pain conditions. This multidisciplinary
philosophy of treatment does not necessarily
require a multispecialty clinic with dentists,
psychologists, physical therapists, and physi-
cians; it rather requires individual practitioners
themselves to possess a worldview that em-
braces the biobehavioral perspective. From
there, appropriate integration of diverse treat-
ment strategies can be implemented instanta-
neously as patient circumstances, the symp-
tom picture, and the case conceptualization
evolve over the course of treatment as well as
over the course of the disorder.
Pain is a complex phenomenon inuenced
by multiple biologic, psychologic, and social
factors. The sensation of pain is evoked when
nociception reaches thalamocortical-basal gan-
glia circuitry in the brain; however, because
pain is a personalized perceptual experience,
it can be modied by factors other than the
intensity of the nociceptive stimuli them-
selves. For example, excitatory factors that
could amplify the pain experience include fear,
anxiety, attention, and expectations of pain.
Conversely, reports of pain may reduce as a
result of self-condence, positive emotional
states, relaxation, and belief that the pain is
manageable.
2
Importantly, these modifying
factors not only affect the perceptual aspects
of what denes pain at any moment for an
individual; they also contribute to descending
251
modulation. These examples highlight the con-
cept that nociception is the result of a dynamic
balance between peripheral input and ongoing
central nervous system (CNS) regulation of
that input at the level of the dorsal horn entry
into the CNS.
The biobehavioral approach to orofacial
pain disorders involves assessing not only the
underlying behavioral and psychologic distur-
bances but also the physiologic disturbances
that may be associated with the pain condi-
tion. The patient may need to learn new skills
for managing these disturbances and should
be able to rely on his or her care provider for
help. The need for skill acquisition can range
from simple to complex, and the latter may
involve referral to a mental health care profes-
sional. Effective symptom management, both
physical and psychologic, may be elusive for
many patients, especially those whose pain
has become chronic (ie, lasting longer than
3 to 6 months). These patients may have ad-
opted coping patterns to maintain some level
of functioning, but their efforts should be as-
sessed by the clinician to ensure they remain
in the patient’s best interest. Certain coping
strategies, while perhaps successful in the
early stage of an illness, may eventually con-
tribute to the development of maladaptive pat-
terns that extend beyond the pain condition
and into multiple aspects of daily life. For ex-
ample, a patient who stops engaging in plea-
surable daily activities because of pain upon
movement may be prone to depression. When
maladaptive patterns emerge, it is important
that the clinician be prepared to recognize and
manage them appropriately, because failure to
do so will likely prolong suffering (ie, an individ-
ual’s negative emotional reaction to pain) and
prevent effective symptom management. It is
also possible that maladaptive coping patterns
were in practice before the onset of the pain
condition and may have intensied the prob-
lem. Such coping patterns may also be associ-
ated with a variety of psychopathologic con-
ditions (these are discussed in later sections
of this chapter). The psychopathology may be
actively preexisting, it may be subclinical until
the onset of an intractable problem, or it may
be emergent in response to a new illness.
The biobehavioral perspective introduces
a model whereby the assessment process in-
cludes an interview component that focuses
not only on the biologic aspects of the present-
ing condition but also on the psychosocial pro-
cesses, thus providing a broader perspective
from which to understand and conceptualize
treatment for a patient’s presenting pain symp-
toms. It is rare that pain reports are based
solely on psychologic or so-called psychogenic
factors.
3
It is equally rare, however, to nd that
pain—especially chronic pain of at least 3 to
6 months’ duration—is not inuenced by psy-
chologic and social factors to some degree.
Such factors may also account for the individ-
ual differences in response to similar levels of
pain. Because there can be substantial individ-
ual variability in response to painful conditions
and a variety of social factors (eg, modeling,
litigation, compensation), the reported inten-
sity of pain may not necessarily be linked to
an individual’s expressed reaction to the pain.
It is common for both clinicians and patients
to be confused regarding the relative nature
of reported pain intensities; one reaction is to
dismiss such reports as “subjective” (often
with the intended meaning of irrelevant or im-
aginary). The relative nature of pain intensity
does not diminish its validity; rather, it requires
the clinicians active interpretation to make it
meaningful. In short, it is the task of the clini-
cian to understand the patient’s story and to
make sense of his or her pain reports.
For many chronic pain conditions, it may
be difcult to predict treatment outcomes
without knowing the full psychosocial history
of the patient. Learning to manage ones oro-
facial pain conditions for extended periods of
time can help patients considerably, but ongo-
ing biobehavioral issues may either promote
or prevent the use of such skills for symptom
management, leading to the common pattern
Foundation of the Biobehavioral Model

252
Axis II: Biobehavioral Considerations
12
of remission–relapse. The reality is that “cur-
ing” pain is often not a viable clinical treatment
goal, whereas learning to manage pain with
the physical and psychologic tools developed
and rened through the practice of science
can be a viable goal. A major long-term goal is
nding the dynamic balance of input and CNS
control at the dorsal horn level. Stress reactiv-
ity is one of the factors that often contribute
to relapse and can be one of the most difcult
skills to master. To prevent relapse as a result
of stress, patients should work toward experi-
ential understanding of allostasis, another ex-
ample of a dynamic balance among systems.
In recognition of these complexities,
Dworkin et al
4–7
proposed several models for
capturing the dimensions of pain over time.
Inherent in these models is the simultane-
ous consideration of both the physical status
and the biobehavioral status for every patient.
For assessment of both types of status to be
equally useful in the clinic, reliable assess-
ment methods are needed for the physical
examination (using an operationalized frame-
work) and the biobehavioral screening (using
standardized, validated instruments). Extensive
research has demonstrated the value of these
core components in terms of clinical trials and
modeling disease progression and response
to treatment.
8–11
The current versions of diag-
nostic and biobehavioral assessments are
emerging from structured assessments for
which reliability and validity has been previ-
ously demonstrated.
8,12–15
A recent develop-
ment has been the Orofacial Pain: Prospective
Evaluation and Risk Assessment (OPPERA)
studies that place due recognition on the
genetic underpinnings of neuroplasticity, on
biobehavioral factors, and on their interactions
in shaping risk for developing a pain disor-
der.
16–35
A primary overarching conclusion from
the OPPERA studies is that temporomandib-
ular disorders (TMDs) are seldom a simple
localized condition and are far more often a
result of complex multiple risk determinants.
36
Consistent with that conclusion, the biobehav-
ioral model for the clinical care of patients with
pain disorders is intended to encompass all as-
pects of neurobiology associated with health
and disease. For example, when patients tell
their doctors that they are depressed, they are
informing them of the state of their brain and
how the resultant behavior is recursively fur-
ther shaping that brain state. Assuming that
reliable and valid methods are used for the as-
sessment, this type of information gathered
via self-report instruments and interviews is
no less valuable than that obtained from a
clinical examination.
Implementing a Biobehavioral
Framework: Dual-Axis Coding
A multiaxial nosology has been created, imple-
mented, and rened on a broad scale to recog-
nize behavioral and psychologic dimensions in
the etiology of orofacial pain disorders. Similar
to the development of axial coding systems for
psychiatric disorders created by the American
Psychiatric Association
37
and pain disorders
developed by the International Association for
the Study of Pain, the Research Diagnostic Cri-
teria for Temporomandibular Disorders (RDC/
TMD) were developed by a group of scientists
and clinicians in 1992.
38
Axis I focuses on the
physical nature of the disease and includes the
variety of orofacial pain conditions discussed
in earlier chapters of this text. Axis II focuses
on the patient’s adaptation to the pain experi-
ence and pain-related disability that may result
from the pain itself. It also uses standardized
and validated methods to assess the extent to
which the orofacial pain condition is associated
with psychologic distress, disability, or impair-
ment in functioning (ie, signicant disruption in
normal activities) (Table 12-1).
The RDC/TMD Axis II was an attempt to
codify the emotional sequelae and functional
limitations that accompany chronic orofacial
pain conditions and to determine whether
there is a need to refer patients to additional

253
providers. Psychiatrists or clinical psycholo-
gists may perform a formal assessment of
cognitive, emotional, and behavioral sources
of disruption in normal functioning due to or
associated with the pain problem. This coding
system was rened with the Diagnostic Cri-
teria for Temporomandibular Disorders (DC/
TMD) project to update the RDC/TMD, but the
two-axis coding strategy has remained a cen-
tral feature of the nosological framework.
38,39
In 2010, an international consensus work-
shop
12
agreed on the minimal basic compo-
nents that should be assessed for a sufcient
biobehavioral evaluation: pain, physical func-
tion, overuse behaviors, comorbid physical
symptoms, and emotional and psychosocial
function. Another workshop
40
claried the
distinction between what is needed for initial
screening, what is needed for more compre-
hensive assessment in a clinical setting, and
what might be of value in a specialist biobe-
havioral setting. Ongoing workshops spon-
sored by the International RDC/TMD Con-
sortium (now known as INfORM) continue to
develop Axis II assessment strategies.
It is the responsibility of the clinician to
judge the level of complexity of the patient’s
clinical presentation and to decide whether
the treatment plan should include additional
resources outside the scope of the dental
practice. The task is not to develop a psychi-
atric diagnosis (eg, major depression second-
ary to the loss of a spouse) but to develop a
treatment plan that includes appropriate care
for the unique features of the presenting pa-
tient. There are various self-report instruments
that have demonstrated reliability and validity
in identifying potential psychologic dysfunc-
tion that can interfere with pain management
from the physical medicine perspective, and
Table 12-1Axis II assessment instruments
Domain Instrument No. of items Level of screening
Based on DC/TMD recommendations
Pain location Pain manikin drawing 1 UB, B, C
Pain intensity GCPS 3 UB, B, C
Pain disability GCPS 4 UB, B, C
Distress PHQ-4
PHQ-9 Depression
GAD-7 Anxiety
4
9
7
UB, B
C
C
Physical symptoms PHQ-15 15 C
Limitation JFLS 8 or 20 B (8), C (20)
Parafunction OBC 21 B, C
Other instruments for pain-relevant constructs
Sleep Pittsburgh Sleep Quality Index
PROMIS
18
43
C
C
PTSD PTSD Checklist 17 C
Alcohol use AUDIT-C 3 C
Stress Perceived Stress Scale 10 C
AUDIT-C, Alcohol Use Disorders Identication Test; B, brief; C, comprehensive; DC/TMD, Diagnostic Criteria for
Temporomandibular Disorders; GAD, generalized anxiety disorder; GCPS, graded chronic pain scale; JFLS, jaw functional
limitation scale; OBC, oral behaviors checklist; PHQ, Patient Health Questionnaire; PROMIS, Patient-Reported Outcome
Measures Information System; UB, ultra brief.
Implementing a Biobehavioral Framework: Dual-Axis Coding

254
12
Axis II: Biobehavioral Considerations
these can be used to augment the screening.
Standardized instruments provide the clinician
with an actuarial approach to decision making.
This will ensure more information is gathered
than the limited amount provided by the initial
interview and prevent inherent clinician-based
personal biases from clouding clinical judg-
ments. Health care providers can have dif-
culty in making accurate judgments of the
psychologic status of pain patients and may
tend to overreport psychopathology.
41,42
The
results of these studies suggest that the use
of screening instruments may help improve
the accuracy of clinical decision making in the
orofacial pain setting.
Brief Screening for Biobehavioral
Factors
It is necessary for clinicians to conduct an as-
sessment of biobehavioral factors in the initial
consultation session.
39,43–45
In terms of which
factors should be evaluated, the degree of
the assessment should depend on the setting
(eg, general dental or medical ofce, orofacial
pain specialist ofce, research clinic, psycholo-
gist ofce) and purpose (eg, initial screen-
ing, more in-depth evaluation by the orofacial
pain specialist, comprehensive evaluation by
a consulting psychologist) of the evaluation.
The selection of the level of the biobehavioral
focus implies that the clinician understands
the importance of biobehavioral factors in the
patient’s presentation and the context in which
the patient evaluations occur. When it comes
to the rst line of screening, however, the criti-
cal dimensions include (1) some means of as-
sessing multiple pain conditions or complaints
in addition to the orofacial pain that gener-
ated the initial clinical visit, (2) pain intensity
and pain-related disability, and (3) psychologic
distress.
8,14,44,46,47
One of the strongest and most consistent
predictors of the onset of a new orofacial pain
condition is the presence of other ongoing
pain complaints.
36
Multiple pain conditions also
appear to be a strong predictor of the transi-
tion from acute pain to chronic pain. Presence
of multiple pain complaints can be assessed
with a drawing of the full human body (pain
manikin), front and back, where the patient can
note areas of ongoing pain. Other initial strat-
egies for assessing multiple pain conditions
include using a checklist or specic questions
concerning pain in other regions of the body.
Both the intensity of pain and the impact of
the pain on functioning can be obtained with
the Graded Chronic Pain Scale (GCPS).
48
This
brief, eight-item screening instrument includes
an assessment of number of pain days in the
last 6 months; current pain intensity, worst
pain intensity, and average pain intensity using
a scale of 0 to 10 (where 0 represents “no
pain” and 10 represents “pain as bad as can
be”); and four questions concerning disability
related to the pain. When averaged together,
the pain intensity items provide an excellent
overall index of pain intensity. Based on the
intensity and disability ratings, patients can be
classied into one of ve categories, grades
0 to IV. Grade 0 represents being pain free,
grade I represents low intensity of pain and
low disability, grade II represents high inten-
sity of pain and low disability, grade III repre-
sents moderately limiting disability, and grade
IV represents severely limiting disability. Pain
intensity is not considered in grades III and
IV because poor functional status, as repre-
sented by the disability grade, becomes sub-
stantially more important than pain intensity.
The GCPS is recommended for regular use in
the orofacial pain setting because it is a reli-
able, valid, and brief screening tool for pain and
pain-related disability. High self-rated levels of
pain, interference, and impact, along with low
ability to control pain, suggest the need for fur-
ther biobehavioral evaluation and appropriate
referral for consultation.
48,49
The more common forms of distress pre-
senting in the orofacial pain clinic include
depression and anxiety, ranging from mild
255
symptoms to severe disorders.
49
Depression
and anxiety are described in detail in later
sections of this chapter to provide a broader
understanding of these conditions within the
context of the orofacial pain setting. How-
ever, the immediate concern of the clinician
is to screen patients and identify those who
need further consultation and care by a quali-
ed mental health care provider. While there
are a variety of screening instruments, a very
brief measure for screening distress is the Pa-
tient Health Questionnaire four-item (PHQ-4),
50
which assesses both depression and anxiety.
The PHQ-4 evaluates functioning over the past
2 weeks with a scale ranging from 0, meaning
“not at all” to 3, meaning “nearly every day.
It requires about 1 minute for administration.
This brief instrument yields a rating of nor-
mal, mild, moderate, or severe distress. Any
nonnormal rating is an indication for further
evaluation by a qualied mental health care
provider. This instrument is ideally suited for
the screening of distress in the orofacial pain
environment.
Several other standardized screening ques-
tionnaires are available for depression and
anxiety that can enable the clinician to make
informed decisions about the need for more
extensive diagnostic decision making and
treatment planning.
51–53
In clinical settings, the
choice of one instrument over another is far
less important than knowing the instrument
and knowing the distribution of scores in ones
clinical population. The Jaw Functional Limita-
tion Scale (JFLS) has been recommended as
a primary assessment tool for evaluating the
impact of pain on core functions of the mas-
ticatory system.
54
The JFLS may be adminis-
tered as a 20-item instrument yielding three
subscales (masticatory limitation, jaw mobility
limitation, and verbal and emotional expres-
siveness limitation) or as an eight-item global
limitation scale.
The information obtained from the patient
should be consistent with any physical diagno-
sis, and when it is not, other questions should
be raised in the clinical interview. For example,
reported severe limitation in both mastication
and jaw mobility simultaneous with minimal
clinical signs may point toward catastrophiz-
ing or symptom amplication, or it may point
toward an incomplete understanding of what
has happened to the patient. In contrast, mini-
mal limitation despite severe reported pain and
signicant clinical signs may indicate a patient
who is trying to overcompensate. Assessment
instruments also provide important functional
evidence in situations when the provider must
demonstrate treatment efcacy.
The clinician should consider whether the
screening assessment should also address
oral behaviors. The Oral Behaviors Checklist
(OBC)
55,56
is a 21-item scale that was devel-
oped during the DC/TMD validation study to
identify common oral behaviors associated
with TMDs. This scale provides the clinician
with a patient’s perspective on a broad sample
of oral behaviors (eg, chewing gum, clenching
teeth, pressing tongue forcibly against teeth)
that may inuence orofacial pain. It has dem-
onstrated acceptable validity and reliability for
the measurement of oral behaviors over time.
While this brief comprehensive screening
battery (ie, the pain manikin, GCPS, PHQ-4,
JFLS, and OBC) provides the clinician with
initial data to guide case conceptualization
and treatment planning, there may be circum-
stances where there is not sufcient time or
resources to use all of these measures. In
these cases, it is recommended to at least
perform an ultra-brief screening comprising
the pain manikin, GCPS, and PHQ-4.
Comprehensive Evaluation of
Biobehavioral Factors
In addition to depression and anxiety, stud-
ies have identied the important roles of
sleep disturbances, somatic awareness,
perceived stress, and PTSD as strong pre-
dictors of distress and pain in orofacial pain
Comprehensive Evaluation of Biobehavioral Factors

256
Axis II: Biobehavioral Considerations
12
Box 12-1 Red and yellow ags for referral
of orofacial pain patients
Red ag: Refer immediately
Suicidal thoughts or plans
Yellow ag: Proceed with caution
and consider referral
Alcohol or drug use
Persistent beliefs about pain
Illness behaviors
Problems in compensation or claims
Time off work
Problems at work
Overprotection from family
members
Lack of social support
Chronicity of pain
Functional limitations
Discrepancies in findings
Overuse of medications
Inappropriate behavior, expectations,
or responsiveness to prior treatment
patients.
23–25,29,33,36,56–59
There are brief, reli-
able paper-and-pencil screening instruments
available to assess sleep (eg, Pittsburgh Sleep
Quality Index, Patient-Reported Outcome Mea-
sures Information System sleep instruments),
somatic awareness (90-item Symptom Check
List Revised [SCL-90-R], Pennebaker Inventory
of Limbic Languidness), perceived stress (Per-
ceived Stress Scale), and PTSD (PTSD check-
list). Moreover, clinicians may use the PHQ-9
for a more detailed screening for depression,
the Generalized Anxiety Disorder 7 (GAD-7) for
anxiety, and the PHQ-15 for an evaluation of
physical symptoms.
Many clinicians may nd the information
from these instruments helpful in the pro-
cesses of evaluation and treatment planning.
Overall, it is important that dentists and other
health care clinicians be able to recognize
maladaptive coping mechanisms and direct
patients to appropriate evaluation and treat-
ment programs to address these dysfunctions.
Stressful life events, such as conicts in home
or work relationships, nancial problems, and
cultural readjustment may contribute to illness
and chronic pain.
60,61
Environmental stressors
may heighten tensions, insecurities, and dys-
phoric affects that may in turn lead to increased
adverse loading (clenching or grinding) of the
masticatory system as stress is converted to
muscle tension and increased parafunctional
behavior.
62
Stressors will not always lead to
increases in muscle tension, and increases
in muscle tension will not always create pain,
but it is a distinct possibility to consider when
evaluating an individual’s clinical presentation.
The use of a pain manikin, the GCPS, and the
PHQ-4 serves as an acceptable initial minimum
screening for all orofacial pain patients to deter-
mine if they should be referred for further evalu-
ation by qualied mental health care providers.
In addition to pain-relevant biobehavioral
constructs, Turner and Dworkin
44
noted the
value in screening for prolonged and/or ex-
cessive use of opiate medications, benzodi-
azepines, alcohol, and other addictive medica-
tions. Clinicians can screen for these problems
in the course of their initial evaluation inter-
view. When screening for alcohol use, one re-
liable instrument is the Alcohol Use Disorders
Identication Test (AUDIT-C).
63
This three-item
questionnaire is a reliable means of identifying
whether an individual should be referred for
careful evaluation of alcohol abuse.
Health care providers working with patients
with chronic back pain use a strategy in the
initial evaluation process to identify red and
yellow ags: Red ags are those representing
a potentially serious condition for which im-
mediate attention is needed, and yellow ags
represent potential psychologic or social bar-
riers to full recovery (Box 12-1). Clinicians in
the orofacial pain setting should also use a red
and yellow ag identication strategy when
implementing a biobehavioral approach. Red
ags in the psychosocial history of the orofa-
cial pain patient demand immediate attention;
these primarily focus on signs of suicide. The
257
most common signs of potential suicide in-
clude talking about suicide, either generally or
specically, and/or actual plans for taking ones
own life (suicidal ideation) and hopelessness.
There are other warning signs for suicide, in-
cluding persistent and despairing mood, sig-
nicant weight loss or gain, change in appetite,
withdrawal and social isolation, and change in
sleep pattern—all symptoms that are associ-
ated with depression as well. Any patient who
presents with thoughts about suicide, plans
for suicide, or hopelessness should be evalu-
ated for risk assessment as soon as possible
by qualied mental health care professionals.
Yellow ags for treatment may include per-
sistent beliefs about pain, illness behaviors,
problems in compensation/claims, time off
from work, problems at work, overprotection
from family members, or lack of social sup-
port. Additional factors include chronicity of
pain, functional limitations, discrepancy in
ndings, overuse of medication, inappropriate
behavior (often including items from the rst
list, but not exclusively), inappropriate expec-
tations, and inappropriate responsiveness to
any prior treatment
40,64
(see Box 12-1). Any of
these issues can interfere with treatment, and
the orofacial pain specialist needs to be wary
of initiating treatment in individuals with these
concerns. When possible, a careful and thor-
ough evaluation should be performed by a psy-
chologist, psychiatrist, psychiatric nurse prac-
titioner, or other appropriately trained mental
health care provider before treatment begins.
Psychiatric Disorders
Orofacial pain patients, particularly those with a
history of signicant pain over 3 months in du-
ration, may experience signicant psychologic
distress that complicates the management of
their presenting complaints. A distinction can
be drawn between the role of pain psychology
and the use of diagnostic psychiatric disor-
ders in a clinical setting for orofacial pain. One
difference is that pain psychology places an
emphasis on dimensional assessment rather
than classication (diagnosis). Furthermore,
pain psychology is interested in the detailed
integration of specic domains of functioning
known to be important in a pain patient’s expe-
rience and the incorporation of the biobehav-
ioral domain into the clinical arena and decision
making. This approach to patient management
focuses on the identication of problem areas
that lend themselves to structured, empiri-
cally supported therapies (eg, cognitive behav-
ioral therapy) that will facilitate referrals when
needed. Pain clinicians will encounter patients
whose functioning is severely compromised,
and knowing when to refer to a mental health
care provider benets the patient and the cli-
nician alike. The description of mental states
provided by the classic psychiatric disorders
captures the many ways in which human sys-
tems undergo dysregulation. It is essential to
recognize these in patients so that the founda-
tions of a dual-axis classication system can be
better understood and applied clinically.
Although many mental conditions can be
inuenced by or result from orofacial pain
disorders, only a select group is addressed in
this chapter. This section highlights the more
common mental disorders that clinicians are
likely to encounter; the comprehensive evalua-
tion of psychologic status should be conducted
by appropriately trained mental health care
providers.
65
Gatchel et al
66–68
have reported
that the most frequently occurring problems
include major depression, anxiety disorders,
and personality disorders. The other disorders
presented in this chapter have a much lower
frequency of occurrence, but orofacial pain cli-
nicians should be aware of them to make a
successful referral for denitive diagnosis and
treatment. For a description of other mental
conditions, the reader is encouraged to review
the current Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5).
37
Each disorder is accompanied by its codes
Psychiatric Disorders

258
Axis II: Biobehavioral Considerations
12
from the DSM-5 and/or The International Clas-
sication of Diseases, Tenth Edition (ICD-10).
Major depressive disorder (DSM-5 296.2x;
ICD-10 F32)
37
Major depression has been identied as one
of the most common mental disorders occur-
ring in the orofacial pain environment.
68
Clinical
data suggest that almost one-third of patients
presenting for treatment of orofacial pain may
be experiencing symptoms consistent with
a diagnosis of depression.
69
The diagnosis of
major depression requires at least ve of the
following symptoms over a 2-week period,
with at least one of the symptoms being de-
pressed mood or loss of interest/pleasure:
Depressed mood most of the day
Decreased interest or pleasure in all or
most daily activities
Weight loss or change in appetite
Insomnia or hypersomnia
Daily psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Reduced ability to think or concentrate
Thoughts of death or suicide
When these symptoms cause distress and
impair functioning and are not due to a medical
condition or substance use, the diagnosis of
major depression is likely. Major depression is
a serious, potentially life-threatening condition,
and referral to appropriate health care provid-
ers for effective treatment is essential in addi-
tion to care for the pain disorder itself.
Anxiety disorders
Generalized anxiety disorder (DSM-5 300.02;
ICD-10 F41.1)
37
GAD is diagnosed when an individual has per-
sistent and excessive anxiety or worry for a
period of 6 months or longer. The person who
is experiencing GAD is not able to control the
feelings of anxiety or worry, and at least three
of the following symptoms are present: rest-
lessness, fatigue, difculty concentrating, irri-
tability, muscle tension, and sleep disturbance.
In addition, the symptoms cause signicant im-
pairment of interpersonal functioning or work
performance, and the anxiety and worry are
not associated with another mental disorder
(eg, obsessive-compulsive disorder), substance
use (drugs or alcohol), or another medical con-
dition. It is estimated that between 10% and
30% of the orofacial pain population may be
experiencing GAD.
68
Anxiety is particularly im-
portant to identify during acute phases of a pain
disorder because it leads to nonadaptive behav-
iors, which may promote chronicity.
2
Referral
for treatment of GAD may be delayed based on
whether treatment of the orofacial pain condi-
tion itself may begin to alter symptoms.
Panic disorder (DS M-5 300.01; ICD-10 F41.0)
37
Although much less common than GAD, panic
disorder involves a sudden, intense onset of
fear and terror that is often accompanied by
thoughts of impending disaster. It can include
chest pain, palpitations, and shortness of
breath, which can be so severe that the indi-
viduals may feel as though they are dying. Indi-
viduals having a panic attack report sensations
of choking/smothering and are afraid of losing
control of their thoughts. Panic disorder is di-
agnosed when a panic attack has occurred and
when at least one of the following criteria pre-
sent for at least 1 month: persistent concern
about having another attack, worry about the
implications or consequences of the attack,
and a notable change in behavior related to the
attacks or fear thereof. In addition, the panic
attacks must not be due to a medical condition
or substance use. Even though panic disorder
is uncommon, it is a condition that requires
immediate attention and coping skills. There-
fore, if panic disorder is suspected, appropriate
referral should be made immediately.
259
Posttraumatic stress disorder (DSM-5 309.81;
ICD-10 F43.1)
37
Considerable professional interest and bur-
geoning public concern have focused on the
sequelae of traumatic experiences. It is now
well recognized that physical and sexual abuse
are implicated in the etiology of a broad spec-
trum of physical and emotional symptoms. The
essential feature of PTSD is the onset of char-
acteristic symptoms following exposure to a
traumatic event either involving direct personal
experience or the witnessing of such an event.
Traumatic events usually involve actual or
threatened death or serious injury or a threat
to one’s physical and psychologic integrity. Typ-
ical symptoms include persistent reexperienc-
ing of the traumatic event, persistent avoid-
ance of stimuli associated with the trauma
and numbing of general responsiveness, and
persistent symptoms of increased arousal. The
full symptom picture must be present for more
than 1 month, and the disturbance must cause
clinically signicant distress or impairment in
daily functioning. For children, sexually trau-
matic events may include developmentally in-
appropriate sexual experiences without threat-
ened or actual violence or injury. The disorder
may be especially severe or long-lasting when
the traumatic experience has been created by
deliberate human intent (eg, torture or rape) as
contrasted with naturally occurring disasters.
The likelihood of developing this disorder may
increase as the intensity of and physical prox-
imity to the event increases.
Psychologic reexperiencing of the traumatic
event may occur in several ways, commonly
as recurrent and intrusive recollections, dis-
tressing dreams, and, in rare instances, brief
dissociative states or ashbacks during which
components of the event are relived and the
person behaves as though experiencing the
event at that moment. Intense psychologic
distress or physiologic reactions often occur
when the person is exposed to triggering
events that resemble or symbolize an aspect
of the traumatic event (eg, entering an elevator
for a person who may have been assaulted or
raped in an elevator; or any intraoral pain or ma-
nipulation for individuals who may have been
sexually violated or traumatized in the mouth).
Typically, individuals suffering from this
condition make deliberate efforts to avoid
thoughts, feelings, or conversations about the
traumatic event and, in some instances, may
develop amnesia for important aspects of the
traumatic experience. Diminished psychologic
responsiveness, referred to as psychic numb-
ing or emotional anesthesia, may be accompa-
nied by markedly diminished interest in previ-
ously enjoyed activities and markedly reduced
capacity for emotional responsiveness. The
individual has persistent symptoms of anxiety
or increased arousal that were not present
before the trauma; the arousal symptoms are
frequently associated with sleep disturbance,
nightmares, hypervigilance, and an exagger-
ated startle response. This increased arousal
is often accompanied by activation of the auto-
nomic nervous system as measurable by elec-
trocardiography, electromyography, and sweat
gland activity. In younger children, distressing
dreams of the event may change into general-
ized nightmares. Rather than having a sense of
reliving the past as a memory, young children
often re-create versions of the trauma through
repetitive play. For example, a child involved in
a motor vehicle accident may reenact scenes
of toy cars crashing, or sexually traumatized
children may depict genital contact occurring
between toy animals.
It should be emphasized that not all psycho-
pathology occurring in individuals exposed to
extreme stress should necessarily be attributed
to PTSD. Symptoms of avoidance, numbing,
and increased arousal that are present before
exposure to the stressor require consideration
of other diagnostic alternatives (eg, a mood dis-
order or an anxiety disorder). Acute stress dis-
order is distinguished from PTSD because the
symptoms appear and subsequently resolve
within 4 weeks of the trauma. Adjustment dis-
Psychiatric Disorders

260
Axis II: Biobehavioral Considerations
12
order is the appropriate diagnosis for situations
in which the response to a stressor does not
meet the criteria for PTSD or when the stressor
itself is not judged to be that threatening.
A signicant proportion of orofacial pain
patients are likely to meet lifetime criteria for
having experienced PTSD.
58,59
This relatively
high rate of occurrence is consistent with
other data, suggesting that exposure to trau-
matic life events is common among orofacial
pain patients and patients with other pain
conditions as well.
58,70
It is therefore neces-
sary that clinicians have an awareness of the
signs and symptoms of PTSD and are able to
make appropriate referrals for treatment. The
characteristics of this disorder (ie, autonomic
activation, perceptual distortion, and denial
of one’s own needs) may prevent signicant
therapeutic gains unless the underlying disor-
der is addressed.
Substance use disorders (DSM-5 291-305
and ICD-10 F10-19)
37
It is not uncommon for patients with oro-
facial pain to have ongoing or previous
substance-related disorders. These disorders
include dependence, abuse, intoxication, and
withdrawal. Substance dependence is dened
as a pattern of substance use that leads to
clinically signicant impairment or distress.
The term substance abuse refers to a pattern
of substance use that has signicant negative
consequences, such as failure to meet obliga-
tions of work, school, or home; behaviors that
are physically hazardous like driving a car when
impaired; legal problems; or interpersonal prob-
lems related to the continued substance use.
Substance intoxication refers to the reversible
signs and symptoms associated with the in-
take of a substance that can produce physi-
cal, behavioral, or psychologic changes. With-
drawal refers to substance-specic physical,
behavioral, or psychologic changes that occur
with the reduction or stoppage of a substance
that has been used over a period of time.
Clinicians should also be familiar with the
terms addiction and pseudoaddiction. Addic-
tion involves one or more of the following
characteristics: impaired control over drug
use, compulsive use of drug(s), continued
use despite harm, and craving. A person with
an addiction often does not take medications
according to prescription or schedule, has
multiple visits to multiple practitioners, and
likely reports on a frequent basis that his or
her prescriptions have been lost or stolen.
It is important to distinguish addiction from
pseudoaddiction in chronic pain patients.
71,72
Pseudoaddiction looks like addiction in that the
same behaviors are typically present, but the
patient has identiable nociception (eg, cancer
pain, neuropathic pain, postsurgical pain) that
is undermedicated, so he or she is in constant
search of effective treatment to control the
pain. When such a person is given adequate
medication, the addiction-like behaviors cease.
Distinguishing addiction from pseudoaddiction
requires good knowledge of the patient by the
clinician and is greatly facilitated by careful his-
tory taking, comprehensive and standardized
physical examinations, and use of biobehav-
ioral assessment instruments. In the case of
pseudoaddiction in particular, progress notes
should clearly document the contingent nature
of the medication seeking along with the ap-
propriateness of the medication to the identi-
ed or suspected nociception.
Substance abuse disorders can occur within
broad classes of substances that include al-
cohol, amphetamines or similar compounds,
caffeine, cannabis, cocaine, hallucinogens,
inhalants, nicotine, opioids, phencyclidine or
similar compounds, and sedatives/hypnotics/
anxiolytics. The clinician must be alert to po-
tential abuse disorders and be able to develop
a treatment plan that is in the best interests of
patients and their health care providers. Un-
less the clinician has specialty training in the
management of addiction disorders, the appro-
priate standard of care is referral to a health
care provider who does have specialty train-
261
ing. It is important to develop a rapport with
patients who have problems with substance
abuse to foster successful referral.
Sleep disorders
37
Sleep disorders are common in patients with
chronic pain, and there are two major sleep dis-
orders that the clinician is likely to encounter:
primary insomnia (DSM-5 780.52; ICD-10 F51.0)
and breathing-related sleep disorders (eg, sleep
apnea, DSM-5 327; ICD-10 G47.3). Other sleep
disorders, such as narcolepsy or night terrors,
are not as common in the chronic pain envi-
ronment. Primary insomnia involves difculty
in initiating or maintaining sleep, and it must
have persisted for at least 1 month. The sleep
problem results in distress or difculties in the
individual’s life that could include interpersonal
or work-related issues. For primary insomnia to
be diagnosed, it must be clear that depression,
anxiety, or medication/substance use is not
contributing to the disruptions in sleep. Primary
insomnia can be managed with behavioral med-
icine strategies playing primary roles.
Breathing-related sleep disorders involve
being sleepy or experiencing insomnia as a
result of a breathing problem that disrupts
regular sleep. The breathing problem is usu-
ally the result of either obstructive or central
sleep apnea, but it can be the result of central
alveolar hypoventilation syndrome. These latter
conditions represent medical disorders that
merit immediate referral to physicians trained
in sleep medicine. Breathing-related sleep dis-
orders require medical evaluation, and biobe-
havioral approaches should also be considered
as appropriate interventions.
Somatic symptom and related disorders
37
Clinicians should recognize and appreciate so-
matic symptom and related disorders because
they represent an extremely important group
of mental conditions in which the patient
reports somatic complaints and yet has no
physical evidence of organic disease. Somatic
symptom and related disorders are subdivided
into the following categories: somatic symp-
tom disorder, illness anxiety disorder, conver-
sion disorder, factitious disorder, unspecied
somatic symptom and related disorders, other
specied somatic symptom and related disor-
ders, and psychologic factors affecting other
medical conditions.
Somatic symptom disorder (DSM-5 300.82; ICD-10
F45.0)
The essential features of somatic symptom
disorder are recurrent and multiple somatic
complaints of at least several years’ duration
for which treatment has been sought and sig-
nicant disarray or distress in the persons life
for which no treatment is sought. Clinical char-
acteristics include preoccupation with somatic
complaints, amplication of symptoms, denial
of difculty in life, and a high level of treatment
seeking for somatic complaints accompanied
by poor adherence and compliance to that
treatment. The disorder classically begins be-
fore age 30 years and has a chronic but uc-
tuating course. Historically, this condition was
previously referred to as hysteria or Briquet
syndrome, and the history of medicine clearly
demonstrates that its presentation is anchored
into the current values and beliefs of the host
culture.
73
Complaints are often presented in
a dramatic, vague, or exaggerated manner or
are part of a complicated dental and/or medical
history in which many physical diagnoses have
been considered. The individuals frequently re-
ceive dental care from a number of practitio-
ners, sometimes simultaneously. Complaints
often extend to multiple organ systems. The
term hypochondriasis is no longer used in the
diagnostic nosology because approximately
75% of hypochondriasis patients match the
diagnostic criteria for somatic symptom disor-
der, while the remaining 25% have elevated
levels of anxiety such that they are more ap-
propriately diagnosed with illness anxiety dis-
order (DSM-5 300.7; ICD-10 F45.21).
Psychiatric Disorders

262
Axis II: Biobehavioral Considerations
12
To diagnose somatic symptom disorder,
there must be a history of the report of so-
matic symptoms that are distressing, along
with thoughts, feelings, and/or behaviors that
are out of proportion with the symptoms,
and an inordinate amount of time and energy
must be devoted to addressing these health
concerns. Individuals with this disorder, for
example, complain of abdominal bloating and
nausea, while vomiting, diarrhea, and food
intolerance are less frequent symptoms. It
should be emphasized that the unexplained
symptoms in somatic symptom disorder are
not intentionally feigned or produced.
Because of the highly restrictive charac-
ter of the required symptom pattern, somatic
symptom disorder is not common, but soma-
tization as a style or as a major characteristic
about a person is fairly common in the oro-
facial pain population.
74
For example, the so-
matization scale scores on the SCL-90-R have
a signicant relationship with the number of
muscles reported as tender during an RDC/
TMD examination.
75
These clinical data high-
light the necessary attention needed to con-
sider somatization as a way of coping among
patients in an orofacial pain practice.
Anxiety and depressed mood are common,
and suicide threats or attempts; antisocial
behavior; and occupational, interpersonal,
and marital difculties frequently accompany
somatization. The clinical course is typically
chronic but uctuating in nature and rarely re-
mits spontaneously. Through seeking numer-
ous evaluations, diagnostic tests, and multiple
trials on medication and frequently submitting
unwittingly to unnecessary surgery, these pa-
tients often experience iatrogenic complica-
tions both in and out of the hospital.
The differential diagnosis necessitates rul-
ing out physical disorders that present with
vague, multiple, and confusing somatic symp-
toms. In addition, schizophrenia with multiple
somatic delusions, dysthymic disorder, GAD,
panic disorder, and conversion disorder need
to be excluded from this specic diagnostic
classication. Because pathophysiology has
yet to be identied, myofascial pain could
qualify as a disorder without clear organic
pathology for clinicians; according to the
description presented here, such a patient
would qualify for a diagnosis of at least so-
matic symptom disorder as a method of cop-
ing. Before neuropathic mechanisms were
suspected to underlie burning mouth–disorder
types of conditions, somatization was a diag-
nostic label unfortunately applied to such indi-
viduals for many years. Because many chronic
pain disorders do not have obvious pathology
responsible for the inferred nociception, dis-
tinguishing such functional disorders from
somatization is not conceptually simple but is
critically important for both the patient and the
clinician. These disorders may include non-
specic lower back pain and irritable bowel
syndrome, for example, and they represent
at least a disorder of psychophysiologic dys-
regulation. The distinction is also not clinically
simple, but a comprehensive history and at-
tention to the biobehavioral screening and
identied yellow ags (see Box 12-1) are an
excellent and essential starting point.
Conversion disorder (functional neurologic
symptom disorder) (DSM-5 300.11; ICD-10 F44.x)
Patients with conversion disorder present with
a loss of or alteration in physical functioning
that suggests a physical disorder but instead is
an expression of psychologic conict or need.
The disturbance is not under voluntary control
and cannot be explained by any physical dis-
order or known pathophysiologic mechanism.
Conversion disorder is not diagnosed when
conversion symptoms are limited to pain (see
somatoform pain disorder) or to a circum-
scribed disturbance in sexual functioning.
Factitious disorder (DSM-5 300.19; ICD-10 F68.1)
37
Factitious means not real, genuine, or natural.
Factitious disorders are therefore character-
ized by physical and/or psychologic symptoms
that are produced by the individual and are
263
under voluntary control. The judgment that
the patient is willfully creating the symptoms
is based, in part, on the patient’s ability to
simulate illness in such a way as to avoid de-
tection. However, such acts also have a com-
pulsive quality because the individual is unable
to refrain from a particular behavior even if its
dangers are known. These conditions should
therefore be considered voluntary only in the
sense that they are deliberate and purposeful
but not in the sense that the patient adopts or
sustains the pathologic behavior intentionally.
The presence of factitious psychologic or phys-
ical symptoms does not preclude the coexis-
tence of true psychologic or physical illness.
Factitious disorder is distinguished from
acts of malingering. Whereas in malingering,
the patient is in pursuit of obvious and recog-
nizable benets through willful falsication, in
a factitious disorder, there is no apparent goal
other than to assume the patient role. An act
of malingering may be considered adaptive
under certain circumstances, but a diagnosis
of a factitious disorder implies psychopathol-
ogy (often a severe personality disturbance).
According to the DSM-5, malingering is not
considered a mental illness.
Unspecied somatic symptom and related
disorder (DSM-5 300.82; ICD -10 F45.9)
The essential feature of unspecied somatic
symptom and related disorder is one or more
physical complaints that persist for 6 months
or longer. These symptoms cannot be fully
explained either by any known physical condi-
tion or by the direct effects of an incident or
substance (eg, the effects of injury, substance
use, or medication side effects). Alternatively,
the physical complaints or resultant impair-
ment are grossly in excess of what would be
expected from the history, physical examina-
tion, or laboratory ndings. The symptoms
must cause clinically signicant distress or
impairment in social, occupational, or other
areas of adaptive functioning. This is a residual
category for those persistent somatoform pre-
sentations that do not meet the full criteria for
other somatic symptom disorders.
Psychologic factors aecting other medical
conditions (DSM-5 316; ICD-10 F54)
37
When the primary presenting complaint is a
medical (ie, physical) condition inuenced by
one or more psychologic or behavioral issues,
psychologic factors affecting other medical con-
ditions can be diagnosed. Typically, the diagno-
sis will link the psychologically related issues
with the physical condition, as in the example,
“stress and anger toward signicant other af-
fecting masticatory muscle pain.The issues
identied must be contributing to the disor-
der by (1) having a close connection in terms
of time between the beginning of the physical
condition and the onset of the psychologic or
behavioral factors, (2) interfering with the treat-
ment of the condition, (3) increasing health
risk, or (4) increasing physiologic activation that
brings on or intensies the physical condition.
This diagnostic category provides the prac-
titioner with the means to codify a comorbid
psychologic condition that may be contributing
to the patient’s capacity to manage a medical
problem. Because chronic pain complaints
represent a complex interaction between psy-
chologic and physiologic factors, the use of
this diagnostic category is common. This label
also may be more acceptable to some patients
than other labels of psychiatric conditions.
Personality disorders
37
Generally speaking, a personality disorder is
a long-term pattern of thinking and acting that
is signicantly different from that of the gen-
eral population and results in signicant con-
sequences to the individual or those around
the individual. These abnormal patterns may
manifest as exaggerations or dysfunction of
certain dimensions of personality. For exam-
ple, it is normal to have occasional moments of
not trusting another person, but it is abnormal
to live with a consistent pattern of suspicious-
Psychiatric Disorders

264
Axis II: Biobehavioral Considerations
12
ness and mistrust. An orofacial pain condition
is most likely to appear after the individual has
already been displaying a pattern of thinking
and behaving characteristic of a personality
disorder. These patterns, however, may or may
not have interfered with daily functioning prior
to the development of the orofacial pain con-
dition. Recent data suggest that a signicant
number of orofacial pain patients have coexist-
ing personality disorders.
67,68
There are three basic groups of personal-
ity disorders that each share common clinical
presentations (Table 12-2). Cluster A includes
odd or eccentric disorders and schizotypal dis-
orders. Cluster B includes emotional, dramatic,
or unpredictable disorders like antisocial, bor-
derline, or histrionic disorders. Cluster C in-
cludes anxious and fearful disorders like avoid-
ant, dependent, and obsessive-compulsive
disorders.
37
Cluster A
Within Cluster A, paranoid personality disorder
describes an individual who does not trust oth-
ers and is very suspicious. These patients may
overinterpret what the clinician says or may
be unforgiving of others for perceived injury
or insult. Patients with schizoid personality
disorder are detached from others and have
very limited emotional expression. A person
with this disorder has few, if any, close friends
or family and usually does things alone. The
schizotypal personality disorder shares the
features of detachment and limited emotional
expression but is also characterized by sub-
stantial distortions of thought and very unusual
behavior. Thought distortions include magical
thinking, belief in telepathy, and weird fanta-
sies. Unusual behaviors might involve acting
out the use of “special powers” or listening to
“voices for direction.
Cluster B
Within Cluster B, the antisocial personality
disorder is characterized by little or no regard
for the rights of others. The diagnosis of this
personality disorder involves the individual
committing crimes, lying, not planning ahead,
being irritable and aggressive to the point of
getting into ghts, disregarding safety for self
Table 12-2Personality disorders
Disorder DSM-5 code ICD-10 code
Cluster A: Odd or eccentric disorders
Paranoid 301.0 F60.0
Schizoid 301.20 F60.1
Schizotypal 301.22 F60.3
Cluster B: Emotional, dramatic, or unpredictable disorders
Antisocial 301.7I F60.2
Borderline 301.83 F60.3
Histrionic 301.50 F60.4
Narcissistic 301.81 F60.81
Cluster C: Anxious and fearful disorders
Avoidant 301.82 F60.6
Dependent 301.6 F60.7
Obsessive-compulsive 301.4 F60.5
265
and others, being irresponsible, and/or not ex-
pressing remorse or sorrow for behavior that
hurts others. In short, the antisocial personality
disorder involves behavior that is self-centered
and does not conform to the general rules and
expectations of society.
Borderline personality disorder represents
a repeated pattern of instability of relation-
ships and impulsivity in action. The instabil-
ity takes the form of leaving and entering
relationships in a recurrent pattern as well as
frequent changes in the nature of the relation-
ship. The patient with borderline personality
disorder often has an inordinate fear of being
abandoned and exhibits extremes of think-
ing. For example, the relationship with the
health care provider may involve the patient
holding the provider in highest regard and
later accusing them of incompetency. These
patients exhibit impulsive, self-destructive
behavior such as substance abuse, unsafe
sex, binge eating, and reckless driving, and
they engage in repeated threats and gestures
of self-harm, including suicide. There is also
marked emotional instability and intense, in-
appropriate anger. The borderline personality
can also manifest as paranoid thoughts or dis-
sociative symptoms. A borderline personality
disorder can present an extremely difcult
case management challenge to the unwary
practitioner.
Histrionic personality disorder is character-
ized as pronounced emotional expression and
attention seeking. Patients with this disorder
can be provocative and sexually seductive and
easily suggestible, and they may perceive re-
lationships as more intimate than they really
are. In other words, they think and act in ways
that are inconsistent with boundaries normally
maintained by orofacial pain patients. Patients
with narcissistic personality disorder act in a
grandiose manner and have an intense need
for the admiration of others while displaying
little empathy. These individuals expect the cli-
nician to respond to their needs at all hours,
including during the weekend.
Cluster C
Cluster C personality disorders involve pa-
tients who are overly anxious or afraid as a
predominant feature of their everyday expe-
rience. Avoidant personality disorder is as-
sociated with feeling socially inhibited and
inadequate and being overly sensitive to any
criticism. Patients with dependent personal-
ity disorder have a pervasive need to be taken
care of, so there is excessive clinging and fear
of being abandoned. These individuals will
continue to seek care for their orofacial pain
condition despite lack of improvement over
time or even harm done. With obsessive-
compulsive personality disorder, the pa-
tient’s day-to-day life is ruled by a drive for
perfection, orderliness, and being in control.
There is limited openness to new ideas, and
rules, details, and lists are very important. In-
dividuals with obsessive-compulsive personal-
ity disorder do not like to work with others,
keep everything they have owned (even worth-
less items), and hoard their resources in case
something should happen in the future.
This last cluster of personality disorders can
present a very real challenge to effective oro-
facial pain management. Patients can be so in-
tently focused on personal criticism, symptom
improvement, or support from providers that
anxiety and nervousness interfere with obtain-
ing positive treatment outcomes. Body dys-
morphic disorder has been reclassied into the
category of obsessive-compulsive personality
disorder, which is particularly relevant to the
orofacial pain clinician because it causes the
individual to experience extreme anxiety over
a real or imagined physical aw. For example,
this diagnostic category could be applied to a
patient who is convinced that there is a slight
angle of a canine tooth that is responsible for
his or her pain condition.
Psychiatric Disorders

266
Axis II: Biobehavioral Considerations
12
Consultation and Referral
Strategies
Chronic orofacial pain management requires
the availability of a multidisciplinary team that
includes competent mental health care provid-
ers. Development of professional relationships
with such providers should be a high priority
for clinicians practicing in this eld because it
facilitates the implementation of informed re-
ferrals when necessary. Patients may present
with red or yellow ags prompting more exten-
sive evaluation or could need skills training or
psychotherapy related to cognitive, behavioral,
or emotional issues.
One effective approach for making a referral
focuses on the patient’s need for assistance
with stress management. This strategy helps
alleviate a patient’s concerns about “being
crazy” or being labeled as having a psychiatric
disorder. The clinician should reassure the pa-
tient with statements such as the following to
assuage any concerns:
The referral is intended to address better
ways of managing the consequences of
pain.
All pain is real.
The relationship with the referring pro-
vider will continue through and beyond
any referral therapy.
The patient’s physical status will continue
to be monitored to detect any change
that would warrant a different direction
in treatment.
The referral is not in any way a sugges-
tion that the patient is “crazy.
Another effective strategy is to focus on
getting help for physical self-regulation skills
training. Patients will often be much more
willing to visit with a mental health care pro-
vider when the referral focuses on learning
how to better manage stress or learning new
skills for controlling physical functioning. Bio-
feedback and its grounded focus on physical
self-regulation is a topic dentists often discuss
with their patients when arranging referrals.
Comprehensive Axis II Evaluation
The assessment of Axis II status must be a
standard and routine part of the clinicians initial
evaluation of the patient, even if only a brief as-
sessment is used. Self-report screening instru-
ments can be administered through a mailed
packet or forms lled out while the patient is in
the reception area; however, the interview por-
tion is best deferred until the clinician has ob-
tained enough pain and health history to form
a matrix within which biobehavioral aspects
can be anchored and appropriately interpreted.
This part of the evaluation includes the range of
biobehavioral factors and their interconnection
with the standard pain history and typical re-
view of systems, past medical history, and any
family or social history. In addition, the clinician
needs time to build rapport and trust with the
patient before asking questions about personal
functioning, and such questions need to t into
the overall sequence of information gathering.
For example, everyone experiences stress (ie,
the sense of being threatened or overwhelmed
by events or the common daily hassles), so it
is not enough to simply identify that a patient
experiences stress, or even how often and to
what extent. The stress experience has to be
anchored into the pain and health histories for
temporal and causal relationships to be identi-
ed, and thus the pain and health histories need
to be rst explored and understood. This part of
an interview is often referred to as the causal
reasoning portion.
76
The goal is to bring different
parts together into a coherent network.
When a patient is referred to a mental health
care provider for evaluation, the clinician can
expect that the mental health care provider will
perform a complete assessment and provide
appropriate feedback in a timely manner. Typi-
cally, the evaluation can be performed within a
267
50- to 75-minute period and will include a re-
view of the presenting complaints and history
of onset from the perspective of the mental
health care provider. The mental health care
provider will also likely assess conditions that
intensify or reduce the pain complaints as well
as typical antecedents and consequences. It
is not uncommon for the clinician to explore a
typical day in the life of the patient. Pain cog-
nitions, operant and respondent behavioral
factors, activity management, and methods
of coping are common features of a pain psy-
chology evaluation. This may be followed by a
careful review of the physical history including
medication use; sleep issues; tobacco, caf-
feine, and alcohol use; and physical activity
level. Mental status, mood, and ongoing emo-
tional state are then assessed along with risks
for harm to self and harm to others. This is typi-
cally followed by a review of any psychiatric his-
tory or hospitalizations. Then the current social
support system, marital history, work history,
and exposure to signicant stressors or trauma
are reviewed, as well as other relevant issues
related to the patient’s presentation (eg, spiri-
tual or religious issues, compensation issues,
legal issues). The data should be summarized
in a readable report with appropriate recom-
mendations for the clinician.
Biobehavioral Care: Integrated
Care as the Standard of Care
While acute pain patients may respond to
treatment in a linear and perhaps even dose-
dependent manner, chronic pain patients typi-
cally do not. But even an acute pain patient
with an obvious etiology and disorder may
not respond to treatment in a linear manner
if preinjury risk factors (eg, signicant oral
parafunctional behaviors, fear of reinjury) are
present; in fact, the simple injury may result
in further activation of those preinjury factors.
Unless the initial evaluation sufciently encom-
passes both the physical and the biobehavioral
domains, the clinician will not know or suspect
if there are other factors that might interfere
with treatment response. Furthermore, that
level of assessment must be maintained at
each follow-up as indicated based on patient
response to treatment; otherwise, the poor
treatment response can be accompanied by
more physical treatments, medications, surgi-
cal referrals, and so forth.
If the patient’s response to treatment can-
not be expected to unfold in a linear manner,
then the clinician must link the outcomes as-
sessment goals for the primary physical do-
main with biobehavioral processes. This means
that biobehavioral assessment is ongoing—at
every follow-up visit, if necessary—just as
physical assessment is. When properly done,
this ongoing dual-axis assessment allows both
the patient and the clinician to see whether
the patient is responding appropriately to cur-
rent treatment; if not, the direction for addi-
tional treatments or consultations should be
evident to both the patient and the clinician.
In conclusion, the biobehavioral aspect of
care must be viewed as central to patient care,
not an optional add-on. For example, if physi-
cal exercise is part of the treatment but the
patient’s mobility is not improving, then the
clinician should query this outcome. Consider-
ations include inadequate assessment of the
physical condition and incorrect execution of
the exercises. Other possible causes should
also be considered, such as depression, poor
time management, avoidance behavior, per-
sonality disorder, and a passive coping style,
among others. Without an adequate initial
biobehavioral assessment, these possible
causes of poor treatment outcome cannot be
adequately interpreted and managed.
Biobehavioral models used in pain medicine
across all disorders emphasize the partnership
between provider and patient and the critical
role that patient behavior plays in managing
pain. TMD management can be likened to the
management of hypertension in that it is en-
hanced through the simultaneous implementa-
Biobehavioral Care: Integrated Care as the Standard of Care

268
12
Axis II: Biobehavioral Considerations
12
268
tion of multiple treatments. For hypertension,
these treatments include stress reduction, ex-
ercise, weight control, sodium restriction, re-
laxation training and biofeedback, and medica-
tions. Similarly, for a myofascial pain disorder,
multiple self-administered treatments are ef-
fective: short-term analgesics, jaw use reduc-
tion, and thermal agents as well as longer-term
stretching, parafunction control, relaxation
training and biofeedback, and stress reduction.
Each of these management strategies, from
medication to stress reduction, is ultimately
about behavioral self-regulation. For a patient to
develop mastery in behavioral self-regulation,
a biobehavioral model is needed to integrate
all aspects of evaluation and treatment into an
understandable framework.
References
1. Engel GL. The need for a new medical model: A chal-
lenge for biomedicine. Science 1977;196:129–136.
2. Carlson CR. Psychological factors associated with oro-
facial pain. Dent Clin North Am 2007;51:145–160.
3. Doleys DM. Pain: Dynamics and Complexities. New
York: Oxford, 2014.
4. Dworkin SF. Illness behavior and dysfunction: Review of
concepts and application to chronic pain. Can J Physiol
Pharmacol 1991;69:662–671.
5. Dworkin SF, LeResche L. Research diagnostic criteria
for temporomandibular disorders: Review, criteria, ex-
aminations and specications, critique. J Craniomandib
Disord 1992;6:301–355.
6. Dworkin SF, Von Korff MR, LeResche L. Epidemiologic
studies of chronic pain: A dynamic-ecologic perspec-
tive. Ann Behav Med 1992;14:3–11.
7. Dworkin SF, Massoth DL. Temporomandibular disorders
and chronic pain: Disease or illness? J Prosthet Dent
1994;72:29–38.
8. Ohrbach R, List T, Goulet JP, Svensson P. Recommenda-
tions from the International Consensus Workshop: Con-
vergence on an orofacial pain taxonomy. J Oral Rehabil
2010;37:807–812.
9. Dworkin SF, Turner JA, Mancl L, et al. A randomized
clinical trial of a tailored comprehensive care treatment
program for temporomandibular disorders. J Orofac
Pain 2002;16:259–276.
10. Dworkin SF, Huggins KH, Wilson L, et al. A randomized
clinical trial using research diagnostic criteria for tem-
poromandibular disorders-axis II to target clinic cases
for a tailored self-care TMD treatment program. J Oro-
fac Pain 2002;16:48–63.
11. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis
EI. Efcacy of an early intervention for patients with
acute temporomandibular disorder-related pain: A
one-year outcome study. J Am Dent Assoc 2006;137:
339–347.
12. Dworkin SF, Sherman JJ, Mancl L, Ohrbach R,
LeResche L, Truelove E. Reliability, validity, and clinical
utility of the research diagnostic criteria for temporo-
mandibular disorders Axis II scales: Depression,
non-specic physical symptoms, and graded chronic
pain. J Orofac Pain 2002;16:207–220.
13. Ohrbach R, Turner JA, Sherman JJ, et al. Research di-
agnostic criteria for temporomandibular disorders. IV:
Evaluation of psychometric properties of the Axis II
measures. J Orofac Pain 2010;24:48–62.
14. Truelove E, Pan W, Look JO, et al. The research diagnos-
tic criteria for temporomandibular disorders. III: Validity
of Axis I diagnoses. J Orofac Pain 2010;24:35–47.
15. Schiffman EL, Ohrbach R, Truelove EL, et al. The re-
search diagnostic criteria for temporomandibular disor-
ders. V: Methods used to establish and validate revised
Axis I diagnostic algorithms. J Orofac Pain 2010;24:
63–78.
16. Maixner W, Diatchenko L, Dubner R, et al. Orofacial
pain prospective evaluation and risk assessment study:
The OPPERA study. J Pain 2011;12(11 suppl):T4–T11.
17. Greenspan JD, Slade GD, Bair E, et al. Pain sensitivity
risk factors for chronic TMD: Descriptive data and em-
pirically identied domains from the OPPERA case
control study. J Pain 2011;12(11 suppl):T61–T74.
18. Maixner W, Greenspan JD, Dubner R, et al. Potential
autonomic risk factors for chronic TMD: Descriptive
data and empirically identified domains from the
OPPERA case-control study. J Pain 2011;12(11 suppl):
T75–T91.
19. Slade GD, Bair E, By K, et al. Study methods, recruit-
ment, sociodemographic ndings, and demographic
representativeness in the OPPERA study. J Pain 2011;
12(11 suppl):T12–T26.
20. Smith S, Maixner D, Greenspan JD, et al. Potential ge-
netic risk factors for chronic TMD: genetic associations
from the OPPERA case control study. J Pain 2011;12(11
suppl):T92–T101.
21. Fillingim RB, Slade GD, Diatchenko L, et al. Summary
of ndings from the OPPERA baseline case-control
study: Implications and future directions. J Pain 2011;
12(11 suppl):T102–T107.
22. Fillingim RB, Ohrbach R, Greenspan JD, et al. Potential
psychosocial risk factors for chronic TMD: Descriptive
data and empirically identified domains from the
OPPERA case-control study. J Pain 2011;12(11 suppl)
T46–T60.
23. Ohrbach R, Fillingim RB, Mulkey F, et al. Clinical nd-
ings and pain symptoms as potential risk factors for
chronic TMD: Descriptive data and empirically identi-
ed domains from the OPPERA case-control study. J
Pain 2011;12(11 suppl):T27–T45.
269269
References
24. Ohrbach R, Bair E, Fillingim RB, et al. Clinical orofacial
characteristics associated with risk of rst-onset TMD:
The OPPERA prospective cohort study. J Pain
2013;14(12 suppl):T33–T50.
25. Smith SB, Mir E, Bair E, et al. Genetic variants associ-
ated with development of TMD and its intermediate
phenotypes: The genetic architecture of TMD in the
OPPERA prospective cohort study. J Pain 2013;14(12
suppl):T91–T101.
26. Bair E, Brownstein NC, Ohrbach R, et al. Study proto-
col, sample characteristics and loss to follow-up: The
OPPERA prospective cohort study. J Pain 2013;14(12
suppl):T2–19.
27. Bair E, Ohrbach R, Fillingim RB, et al. Multivariable
modeling of phenotypic risk factors for rst-onset
TMD: The OPPERA prospective cohort study. J Pain
2013;14(12 suppl):T102–115.
28. Fillingim RB, Ohrbach R, Greenspan JD, et al. Psycho-
social factors associated with development of TMD:
The OPPERA prospective cohort study. J Pain 2013;
14(12 suppl):T75–90.
29. Greenspan JD, Slade GD, Bair E, et al. Pain sensitivity
and autonomic factors associated with development of
TMD: The OPPERA prospective cohort study. J Pain
2013;14(12 suppl):T63–74.
30. Slade GD, Bair E, Greenspan JD, et al. Signs and symp-
toms of rst-onset TMD and sociodemographic predic-
tors of its development: The OPPERA prospective co-
hort study. J Pain 2013;14(12 suppl):T20–T32.
31. Slade G, Sanders A, Bair E, et al. Preclinical episodes of
orofacial pain symptoms and their association with
healthcare behaviors in the OPPERA prospective co-
hort study. Pain 2013;154:750–760.
32. Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea
symptoms and risk of temporomandibular disorder:
OPPERA cohort. J Dent Resh 2013;92(7 suppl):
70S–77S.
33. Slade GD, Fillingim RB, Sanders AE, et al. Summary of
ndings from the OPPERA prospective cohort study of
incidence of rst-onset temporomandibular disorder:
Implications and future directions. J Pain 2013;14(12
suppl):T116–T124.
34. Slade GD, Smith SB, Zaykin DV, et al. Facial pain with
localized and widespread manifestations: Separate
pathways of vulnerability. Pain 2013;154:2335–2343.
35. Sanders AE, Slade GD, Bair E, et al. General health sta-
tus and incidence of rst-onset temporomandibular
disorder: The OPPERA prospective cohort study. J Pain
2013;14(12 suppl):T51–62.
36. Slade GD, Ohrbach R, Greenspan JD, et al. Painful tem-
poromandibular disorder: Decade of discovery from
OPPERA studies. J Dent Res 2016;95:1084–1092.
37. American Psychiatric Association. Diagnostic and Sta-
tistical Manual of Mental Disorders, ed 5. Washington,
DC: American Psychiatric Association, 2013.
38. Ohrbach R, Dworkin SF. The evolution of TMD Diagno-
sis: Past, present, future. J Dent Res 2016;95:1093–1101.
39. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic
criteria for temporomandibular disorders (DC/TMD) for
clinical and research applications: Recommendations of
the International RDC/TMD Consortium Network and
Orofacial Pain Special Interest Group. J Oral Facial Pain
Headache 2014;28:6–27.
40. Cairns B, List T, Michelotti A, Ohrbach R, Svensson P.
JOR-CORE recommendations on rehabilitation of tem-
poromandibular disorders. J Oral Rehabil 2010;37:
481–489.
41. Epker J, Gatchel RJ, Ellis EI. A model for predicting
chronic TMD: Practical application in clinical settings. J
Am Dent Assoc 1999;130:1470–1475.
42. Oakley ME, McCreary CP, Flack VF, Clark GT, Solberg
WK, Pullinger AG. Dentists’ ability to detect psychologi-
cal problems in patients with temporomandibular dis-
orders and chronic pain. J Am Dent Assoc 1989;118:
727–730.
43. Schiffman E, Ohrbach R. Executive summary of the
diagnostic criteria for temporomandibular disorders for
clinical and research applications. J Am Dent Assoc
2016;147:438–445.
44. Turner JA, Dworkin SF. Screening for psychosocial risk
factors in patients with chronic orofacial pain: Recent
advances. J Am Dent Assoc 2004;135:1119–1125.
45. Durham J, Raphael KG, Benoliel R, Ceusters W,
Michelotti A, Ohrbach R. Perspectives on next steps in
classication of oro-facial pain: Part 2: Role of psycho-
social factors. J Oral Rehabil 2015;42:942–955.
46. Anderson GC, Gonzalez YM, Ohrbach R, et al. The re-
search diagnostic criteria for temporomandibular disor-
ders. VI: Future directions. J Orofac Pain 2010;24:
79–88.
47. Palla S. Biopsychosocial pain model crippled? J Orofac
Pain 2011;25:289–290.
48. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading
the severity of chronic pain. Pain 1992;50:133–149.
49. Dworkin SF. Psychosocial issues. In: Sessle B, Lavigne
GJ, Lund JP, Dubner R (eds). Orofacial Pain: From Basic
Science to Clinical Management. Chicago: Quintes-
sence, 2001:115–127.
50. Kroenke K, Spitzer RL, Williams JB, Löwe B. An
ultra-brief screening scale for anxiety and depression:
The PHQ-4. Psychosomatics 2009;50:613–621.
51. Beck AT, Steer RA. Beck Anxiety Inventory. San
Antonio, TX: The Psychological Corporation, 1993.
52. Spielberger CD, Gorsuch RL. State-Trait Anxiety Inven-
tory. Palo Alto, CA: Consulting Psychologists Press,
1983.
53. Steer RA. Beck Depression Inventory. San Antonio, TX:
The Psychological Corporation; 1978.
54. Ohrbach R, Larsson P, List T. The jaw functional limita-
tion scale: Development, reliability, and validity of
8-item and 20-item versions. J Orofac Pain 2008;
22:219–230.

270
12
Axis II: Biobehavioral Considerations
12
270
55. Markiewicz MR, Ohrbach R, McCall WD Jr. Oral behav-
iors checklist: Reliability of performance in targeted
waking-state behaviors. J Orofac Pain 2006;20:
306–316.
56. Ohrbach R, Markiewicz MR, McCall WD Jr. Waking-
state oral parafunctional behaviors: Specicity and va-
lidity as assessed by electromyography. Eur J Oro Sci
2008;116:438–444.
57. Curran SL, Sherman JJ, Cunningham LL, Okeson JP,
Reid KI, Carlson CR. Physical and sexual abuse among
orofacial pain patients: Linkages with pain and psycho-
logic distress. J Orofac Pain 1995;9:340–346.
58. De Leeuw R, Bertoli E, Schmidt JE, Carlson CR. Preva-
lence of post-traumatic stress disorder symptoms in
orofacial pain patients. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2005;99:558–568.
59. Sherman JJ, Carlson CR, Wilson JF, Okeson JP,
McCubbin JA. Post-traumatic stress disorder among
patients with orofacial pain. J Orofac Pain 2005;19:
309–317.
60. Dworkin SF, Burgess JA. Orofacial pain of psychogenic
origin: Current concepts and classication. J Am Dent
Assoc 1987;115:565–571.
61. Rugh JD, Davis SE. Temporomandibular disorders: Psy-
chological and behavioral aspects. In: Sarnat BG, Laskin
DM, eds. The Temporomandibular Joint: A Biological
Basis for Clinical Practice. Philadelphia: WB Saunders,
1992:329–345.
62. Bertrand PM. Management of facial pain. Oral Maxil-
lofacial Surgery Knowledge Update 2001;3:79–109.
63. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley
KA. The AUDIT alcohol consumption questions
(AUDIT-C): An effective brief screening test for problem
drinking. Ambulatory Care Quality Improvement Proj-
ect (ACQUIP). Alcohol Use Disorders Identication
Test. Arch Intern Med 1998;158:1789–1795.
64. Durham J, Ohrbach R. Oral rehabilitation, disability and
dentistry. J Oral Rehabil 2010;37:490–494.
65. Romano JM, Turner JA, Moore JE. Psychological evalu-
ation. In: Tollison CD, Satterthwaite JR, Tollison JW,
Trent CG (eds). Handbook of Chronic Pain Manage-
ment. Baltimore: Williams & Wilkins, 1989:38–51.
66. Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major psycho-
logical disorders in acute and chronic TMD: An initial
examination. J Am Dent Assoc 1996;127:1365–1374.
67. Kinney RK, Gatchel RJ, Ellis E, Holt C. Major psycho-
logical disorders in chronic TMD patients: Implications
for successful management. J Am Dent Assoc 1992;
123:49–54.
68. Kight M, Gatchel RJ, Wesley L. Temporomandibular
disorders: Evidence for signicant overlap with psycho-
pathology. Health Psychol 1999;18:177–182.
69. Korszun A, Hinderstein B, Wong M. Comorbidity of de-
pression with chronic facial pain and temporomandibu-
lar disorders. Oral Surg Oral Med Oral Pathol Oral Ra-
diol Endod 1996;82:496–500.
70. Wurtele SK, Kaplan GM, Keairnes M. Childhood sexual
abuse among chronic pain patients. Clinical J Pain
1990;6:110–113.
71. Heit HA. The truth about pain management: The differ-
ence between a pain patient and an addicted patient.
Eur J Pain 2001;5(suppl A):27–29.
72. Weissman DE. Understanding pseudoaddiction. J Pain
Symptom Manage 1994;9:74.
73. Shorter E. From Paralysis to Fatigue: A History of Psy-
chosomatic Illness in the Modern Era. New York: The
Free Press, 1992.
74. Dworkin SF. Somatization, distress and chronic pain.
Qual Life Res 1994;3(suppl 1):S77–S83.
75. Wilson L, Dworkin SF, Whitney C, LeResche L. Somati-
zation and pain dispersion in chronic temporomandibu-
lar disorder pain. Pain 1994;57:55–61.
76. Kassirer JP, Kopelman RI. Learning Clinical Reasoning.
Baltimore: Williams & Wilkins, 1991.

G
Ant, antonym
Syn, synonym
A
abducens nerve motor cranial nerve (CN VI) supplying the lateral
rectus muscle of the eye
abduction turning outward or laterally. Ant: Adduction.
ablation removal or detachment of a body part, usually by surgery
abrasion, tooth wearing away of the tooth structure by
tooth-to-tooth contact; in contrast with chemical erosion or
attrition
abscess localized collection of pus within preformed cavities
formed by tissue disintegration
acceleration-deceleration injury. See Flexion-extension injury.
accommodation adjustment of the focus of the eye for various
distances; also the rise in threshold of a nerve during constant,
direct stimulation
acoustic meatus external cartilaginous and internal bony auditory
canal that leads to the tympanic membrane. Syn: External audi-
tory meatus.
acoustic myography electronic recording of muscle sounds, re-
ecting the mechanical component of muscle contraction
acoustic nerve sensory cranial nerve (CN VIII) with cochlear (hear-
ing) and vestibular (equilibrium) bers
acoustic neuroma benign tumor within the auditory canal arising
from the acoustic nerve (CN VIII); frequently causes headache,
hearing loss, tinnitus, facial pain, or numbness
acquired disorder postnatal aberration, change, or disturbance of
normal development or condition that is not congenital but in-
curred after birth
acromegaly chronic metabolic condition caused by overproduction
of growth hormone in the anterior pituitary gland and charac-
terized by a gradual and marked elongation and enlargement of
bones and soft tissues of the distal portion of the face, maxilla
and mandible, and extremities
activation, muscle energy release in muscle tissue resulting in
muscle contraction
activation, nerve depolarization of a neuron
active resistive stretch motion voluntarily forced against resist-
ance of muscle, tendons, capsule, or intra-articular structures
active trigger point. See Myofascial trigger point: active.
Glossary

272
Glossary
G
acupuncture traditional Chinese practice
of inserting needles into specic points
along the meridians of the body to induce
anesthesia, to alleviate pain, or for thera-
peutic purposes; experimental evidence
shows that acupuncture produces an an-
algesic effect by triggering the release of
enkephalin, a naturally occurring endorphin
that has opiate-like effects. See Endorphin,
Enkephalin.
acute malocclusion sudden alteration in the
occlusal condition secondary to a disorder
that is either perceived by the patient or
clinically apparent
acute onset development that is sudden and
recent. Ant: Insidious onset.
acute pain unpleasant sensation with a dura-
tion limited to the normal healing time or
the time necessary for neutralization of the
initiating or causal factors
adamantinoma. See Ameloblastoma.
adaptation the progressive adjustive changes
in sensitivity that regularly accompany con-
tinuous sensory stimulation or lack of stim-
ulation; the process by which an organism
responds to stress in its environment
adaptive capacity relative ability to adjust to
any type of change. Syn: Adaptive potential,
Adaptive response.
adaptive potential. See Adaptive capacity.
adaptive response. See Adaptive capacity.
addiction, substance a state characterized by
an overwhelming compulsion to continue
use of a substance and to obtain it by any
means, with a tendency to increase the
dosage; a psychologic and usually a physi-
cal dependence on its effects; a detrimental
effect on the individual and society; com-
pare with dependence
adduction turning inward or medially. Ant:
Abduction.
A𝛅 pain fibers thinly myelinated pain-
conducting nerve bers 1 to 4 µm in diam-
eter
adenocarcinoma malignant adenoma
adenopathy any disease of the glands, espe-
cially of the lymphatic system, usually char-
acterized by enlargement
adherence binding, clinging, or sticking to-
gether of opposing surfaces
adhesion molecular attraction between ad-
jacent surfaces in contact; the abnormal
brous joining of adjacent structures fol-
lowing an inammatory process or as the
result of injury repair
capsular a. brosis of the capsular tissues
of a joint
brous a. See Adhesion: intracapsular.
intracapsular a. brosis between intra-
articular surfaces within a joint capsule,
resulting in reduced mobility of the joint.
Syn: Fibrous ankylosis.
adjunctive therapy a supplemental proce-
dure beyond the primary course of therapy
affect in psychology, the emotional reactions
or feelings associated with an experience
or mental state
afferent neural pathway nerve impulses
transmitted from the periphery toward the
central nervous system
agenesis defective development or absence
of a body part
ageusia absence or impairment of the sense
of taste
agonist muscle principally responsible for a
particular movement; in pharmacology, a
drug that acts at receptors on cells that are
normally activated by a natural substance.
Ant: Antagonist.
-al [sufx] pertaining to
-algia [sufx] pain
algogenic causing pain
algometer instrument for measuring the de-
gree of sensitivity to painful stimuli
pressure a. instrument for reliably record-
ing the pain pressure reaction point or
pain pressure threshold
allo- [prex] other
allodynia pain due to a stimulus that does not
normally provoke pain
allostasis adaptation of neural, neuroendo-
crine, and immune mechanisms in the face
of stressors
alveolar pertaining to the alveolar process of
the mandible, including the tooth sockets,
supporting bone, and associated connec-
tive tissues
ameloblastoma benign tumor of odonto-
genic epithelial origin. Syn: Adamantinoma.
273
Glossary
analgesia absence of pain in response to
stimulation that would normally be painful
analgesic agent that removes pain without
loss of consciousness; relieving pain or in-
sensitive to pain
anamnestic pertaining to medical and psy-
chosocial history and past or current symp-
tom state as recalled by the patient
Anamnestic Dysfunction Index epidemio-
logic symptom severity scale based on the
history of disease or injury (Helkimo index)
anastomosis a connection between two sep-
arate structures
anesthesia absence of all feeling or sensa-
tion, especially pain
a. dolorosa pain in an area or region that
is anesthetic
block a. regional anesthesia resulting from
an anesthetic injected into or near a
nerve trunk
central a. anesthesia due to central block-
ing of nerve impulses or a disease of the
nerve centers
general a. drug-induced unconscious state
typically used for surgical procedures
local a. anesthesia due to local blocking of
nerve impulses in a limited part of the
body
regional a. analgesia of a body part due to
proximal blocking of nerve impulses by
local anesthetic
aneurysm a sac lled with uid or clotted
blood formed by widening of the wall of an
artery, a vein, or the heart
saccular a. an unusual, localized widened
area affecting only part of the circumfer-
ence of the arterial wall
angular cheilitis inammation of the corners
of the mouth usually due to candidiasis
ankylosing spondylitis ossication of the
spinal ligament resulting in a bony encase-
ment of the joint; more common in boys;
onset most often between 9 and 12 years
of age. Syn: Spondylosis.
ankylosis stiffening or immobilization of a
joint as the result of disease, trauma, or
congenital process with bony union across
the joint; also, brosis without bony union;
compare with adhesion
bony a. osseous union of adjacent, usually
movable, body parts. Syn: Synostosis,
True ankylosis.
dental a. fusion of the tooth to the sur-
rounding bony alveolus due to ossica-
tion of the periodontal membrane
extracapsular a. rigidity of the periarticular
tissues resulting in joint stiffness or im-
mobilization. Syn: False ankylosis.
brous a. See Adhesion: intracapsular.
osseous a. characterized by radiographic
evidence of bone proliferation with
marked deection to the affected side
and marked limited laterotrusion to the
contralateral side
anorexia diminished appetite or aversion to
food
a. nervosa psychiatric disorder character-
ized by distortions in body image and
aversion to food, resulting in extreme
weight loss and amenorrhea in women;
usually occurring in young women
ANS. See Autonomic nervous system.
ansa hypoglossi also known as the ansa cer-
vicalis; a nerve loop supplying the infrahy-
oid muscles formed by descending bers of
the hypoglossal nerve, the superior nerve
root to C1 and C2, and inferior root to C2
and C3
antagonist muscle whose function is oppo-
site the agonist or prime mover; in phar-
macology, a drug that diminishes the ef-
fect of another drug or naturally occurring
substance through stimulation at the same
receptor sites. Ant: Agonist.
anterior bite plate a hard acrylic resin appli-
ance that provides for occlusal contact only
between the anterior teeth
anterior repositioning appliance, mandibu-
lar intraoral device that guides or positions
the mandible to a position forward of maxi-
mal intercuspation
anticholinergic an agent that blocks the ac-
tion of acetylcholine in the central and pe-
ripheral parasympathetic nerves; the action
of that agent
anticonvulsant an agent used to control
or prevent convulsions; the action of that
agent

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12Key Points◊ The biobehavioral model of pain is the foundation for clini-cal assessment and pain management.◊ Core biobehavioral principles include multifactorial assess-ment; the role of learning patient history; and the interplay between biologic, psychologic, and social factors.◊ It is necessary to screen for biobehavioral risk factors in-cluding pain, distress, and pain-related disability as well as pain history. Be sure to note red and yellow ags for patient care.◊ A comprehensive evaluation of biobehavioral factors in-cludes pain location and intensity, pain-related disability, psychologic distress, sleep dysfunction, posttraumatic stress disorder (PTSD), alcohol or drug abuse, limitations in use and movement of structures associated with oro-facial pain conditions including the temporomandibular joint (TMJ) and masticatory muscles, and parafunctional activities.◊ The most common psychiatric disorders encountered in the orofacial pain practice include depression, anxiety, PTSD, somatic symptom disorders, and personality disorders.◊ Following referral to mental health care providers, the cli-nician should expect a comprehensive evaluation, a treat-ment plan targeting skills acquisition, and feedback, which should all be provided in a timely manner.◊ The standard of care is integrated care among health care professionals.Axis II: Biobehavioral Considerations 250Axis II: Biobehavioral Considerations12Foundation of the Biobehavioral ModelScientic advances have been made in under-standing modulatory control of ascending and descending neural circuits involved in pain pro-cessing, including the role of glial cells and gut microbiome inuences on neural functioning. Variables such as emotion, cognition (including attention and expectation), and behavior are now understood to play very important roles in pain transmission, awareness, and suffer-ing. Because emotions, cognitions, and be-haviors can facilitate or inhibit orofacial pain, it is necessary to adopt a biobehavioral model of disease. Behavioral factors encompass a broad spectrum of behavioral science theory and techniques for change. Examples of behav-ioral science theory include principles of learn-ing, cognitions and memory, interpersonal processes, family systems, and social learn-ing; techniques for change may be relaxation training, interpersonal psychotherapy, biofeed-back, cognitive therapy, and breathing training. When behavioral factors are discussed in the context of how they contribute to the function-ing of biologic systems, it is appropriate to use the term biobehavioral.As discussed in chapter 1, Engel1 noted that the biomedical model, with its focus on patho-biology, does not fully explain the development of disease states. Therefore, he introduced the term biopsychosocial to describe the complex interactions between biology, psychologic states, and social conditions that bring about and/or maintain function or dysfunction. The term biobehavioral is parallel to the word bio-medical, and both concepts are subsumed in Engel’s biopsychosocial model. While the term biopsychosocial is often used because it is more globally accepted, biobehavioral calls at-tention to behavioral factors as they contribute to the functioning of biologic systems.Adopting the biobehavioral model of oro-facial pain requires that linear, unidirectional models of causation and of treatment be re-placed with a bidirectional approach to under-standing disease etiology and delivering treat-ment. Whether the practitioner provides dental or psychologic treatment, a mechanistic linear model (eg, identify the cause, treat the cause, observe recovery) for understanding orofacial pain conditions is an incomplete model that will yield incomplete, inappropriate, and mis-directed clinical care. Unless behavioral, psy-chologic, and social dimensions of a patient’s presenting complaints and current adaptive strategies are addressed in the treatment plan, effective management of the pain con-dition will likely not be achieved, especially in chronic pain conditions. This multidisciplinary philosophy of treatment does not necessarily require a multispecialty clinic with dentists, psychologists, physical therapists, and physi-cians; it rather requires individual practitioners themselves to possess a worldview that em-braces the biobehavioral perspective. From there, appropriate integration of diverse treat-ment strategies can be implemented instanta-neously as patient circumstances, the symp-tom picture, and the case conceptualization evolve over the course of treatment as well as over the course of the disorder.Pain is a complex phenomenon inuenced by multiple biologic, psychologic, and social factors. The sensation of pain is evoked when nociception reaches thalamocortical-basal gan-glia circuitry in the brain; however, because pain is a personalized perceptual experience, it can be modied by factors other than the intensity of the nociceptive stimuli them-selves. For example, excitatory factors that could amplify the pain experience include fear, anxiety, attention, and expectations of pain. Conversely, reports of pain may reduce as a result of self-condence, positive emotional states, relaxation, and belief that the pain is manageable.2 Importantly, these modifying factors not only affect the perceptual aspects of what denes pain at any moment for an individual; they also contribute to descending 251modulation. These examples highlight the con-cept that nociception is the result of a dynamic balance between peripheral input and ongoing central nervous system (CNS) regulation of that input at the level of the dorsal horn entry into the CNS.The biobehavioral approach to orofacial pain disorders involves assessing not only the underlying behavioral and psychologic distur-bances but also the physiologic disturbances that may be associated with the pain condi-tion. The patient may need to learn new skills for managing these disturbances and should be able to rely on his or her care provider for help. The need for skill acquisition can range from simple to complex, and the latter may involve referral to a mental health care profes-sional. Effective symptom management, both physical and psychologic, may be elusive for many patients, especially those whose pain has become chronic (ie, lasting longer than 3 to 6 months). These patients may have ad-opted coping patterns to maintain some level of functioning, but their efforts should be as-sessed by the clinician to ensure they remain in the patient’s best interest. Certain coping strategies, while perhaps successful in the early stage of an illness, may eventually con-tribute to the development of maladaptive pat-terns that extend beyond the pain condition and into multiple aspects of daily life. For ex-ample, a patient who stops engaging in plea-surable daily activities because of pain upon movement may be prone to depression. When maladaptive patterns emerge, it is important that the clinician be prepared to recognize and manage them appropriately, because failure to do so will likely prolong suffering (ie, an individ-ual’s negative emotional reaction to pain) and prevent effective symptom management. It is also possible that maladaptive coping patterns were in practice before the onset of the pain condition and may have intensied the prob-lem. Such coping patterns may also be associ-ated with a variety of psychopathologic con-ditions (these are discussed in later sections of this chapter). The psychopathology may be actively preexisting, it may be subclinical until the onset of an intractable problem, or it may be emergent in response to a new illness.The biobehavioral perspective introduces a model whereby the assessment process in-cludes an interview component that focuses not only on the biologic aspects of the present-ing condition but also on the psychosocial pro-cesses, thus providing a broader perspective from which to understand and conceptualize treatment for a patient’s presenting pain symp-toms. It is rare that pain reports are based solely on psychologic or so-called psychogenic factors.3 It is equally rare, however, to nd that pain—especially chronic pain of at least 3 to 6 months’ duration—is not inuenced by psy-chologic and social factors to some degree. Such factors may also account for the individ-ual differences in response to similar levels of pain. Because there can be substantial individ-ual variability in response to painful conditions and a variety of social factors (eg, modeling, litigation, compensation), the reported inten-sity of pain may not necessarily be linked to an individual’s expressed reaction to the pain. It is common for both clinicians and patients to be confused regarding the relative nature of reported pain intensities; one reaction is to dismiss such reports as “subjective” (often with the intended meaning of irrelevant or im-aginary). The relative nature of pain intensity does not diminish its validity; rather, it requires the clinician’s active interpretation to make it meaningful. In short, it is the task of the clini-cian to understand the patient’s story and to make sense of his or her pain reports.For many chronic pain conditions, it may be difcult to predict treatment outcomes without knowing the full psychosocial history of the patient. Learning to manage one’s oro-facial pain conditions for extended periods of time can help patients considerably, but ongo-ing biobehavioral issues may either promote or prevent the use of such skills for symptom management, leading to the common pattern Foundation of the Biobehavioral Model 252Axis II: Biobehavioral Considerations12of remission–relapse. The reality is that “cur-ing” pain is often not a viable clinical treatment goal, whereas learning to manage pain with the physical and psychologic tools developed and rened through the practice of science can be a viable goal. A major long-term goal is nding the dynamic balance of input and CNS control at the dorsal horn level. Stress reactiv-ity is one of the factors that often contribute to relapse and can be one of the most difcult skills to master. To prevent relapse as a result of stress, patients should work toward experi-ential understanding of allostasis, another ex-ample of a dynamic balance among systems.In recognition of these complexities, Dworkin et al4–7 proposed several models for capturing the dimensions of pain over time. Inherent in these models is the simultane-ous consideration of both the physical status and the biobehavioral status for every patient. For assessment of both types of status to be equally useful in the clinic, reliable assess-ment methods are needed for the physical examination (using an operationalized frame-work) and the biobehavioral screening (using standardized, validated instruments). Extensive research has demonstrated the value of these core components in terms of clinical trials and modeling disease progression and response to treatment.8–11 The current versions of diag-nostic and biobehavioral assessments are emerging from structured assessments for which reliability and validity has been previ-ously demonstrated.8,12–15 A recent develop-ment has been the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) studies that place due recognition on the genetic underpinnings of neuroplasticity, on biobehavioral factors, and on their interactions in shaping risk for developing a pain disor-der.16–35 A primary overarching conclusion from the OPPERA studies is that temporomandib-ular disorders (TMDs) are seldom a simple localized condition and are far more often a result of complex multiple risk determinants.36 Consistent with that conclusion, the biobehav-ioral model for the clinical care of patients with pain disorders is intended to encompass all as-pects of neurobiology associated with health and disease. For example, when patients tell their doctors that they are depressed, they are informing them of the state of their brain and how the resultant behavior is recursively fur-ther shaping that brain state. Assuming that reliable and valid methods are used for the as-sessment, this type of information gathered via self-report instruments and interviews is no less valuable than that obtained from a clinical examination.Implementing a Biobehavioral Framework: Dual-Axis CodingA multiaxial nosology has been created, imple-mented, and rened on a broad scale to recog-nize behavioral and psychologic dimensions in the etiology of orofacial pain disorders. Similar to the development of axial coding systems for psychiatric disorders created by the American Psychiatric Association37 and pain disorders developed by the International Association for the Study of Pain, the Research Diagnostic Cri-teria for Temporomandibular Disorders (RDC/TMD) were developed by a group of scientists and clinicians in 1992.38 Axis I focuses on the physical nature of the disease and includes the variety of orofacial pain conditions discussed in earlier chapters of this text. Axis II focuses on the patient’s adaptation to the pain experi-ence and pain-related disability that may result from the pain itself. It also uses standardized and validated methods to assess the extent to which the orofacial pain condition is associated with psychologic distress, disability, or impair-ment in functioning (ie, signicant disruption in normal activities) (Table 12-1). The RDC/TMD Axis II was an attempt to codify the emotional sequelae and functional limitations that accompany chronic orofacial pain conditions and to determine whether there is a need to refer patients to additional 253providers. Psychiatrists or clinical psycholo-gists may perform a formal assessment of cognitive, emotional, and behavioral sources of disruption in normal functioning due to or associated with the pain problem. This coding system was rened with the Diagnostic Cri-teria for Temporomandibular Disorders (DC/TMD) project to update the RDC/TMD, but the two-axis coding strategy has remained a cen-tral feature of the nosological framework.38,39In 2010, an international consensus work-shop12 agreed on the minimal basic compo-nents that should be assessed for a sufcient biobehavioral evaluation: pain, physical func-tion, overuse behaviors, comorbid physical symptoms, and emotional and psychosocial function. Another workshop40 claried the distinction between what is needed for initial screening, what is needed for more compre-hensive assessment in a clinical setting, and what might be of value in a specialist biobe-havioral setting. Ongoing workshops spon-sored by the International RDC/TMD Con-sortium (now known as INfORM) continue to develop Axis II assessment strategies. It is the responsibility of the clinician to judge the level of complexity of the patient’s clinical presentation and to decide whether the treatment plan should include additional resources outside the scope of the dental practice. The task is not to develop a psychi-atric diagnosis (eg, major depression second-ary to the loss of a spouse) but to develop a treatment plan that includes appropriate care for the unique features of the presenting pa-tient. There are various self-report instruments that have demonstrated reliability and validity in identifying potential psychologic dysfunc-tion that can interfere with pain management from the physical medicine perspective, and Table 12-1 Axis II assessment instrumentsDomain Instrument No. of items Level of screeningBased on DC/TMD recommendationsPain location Pain manikin drawing 1 UB, B, CPain intensity GCPS 3 UB, B, CPain disability GCPS 4 UB, B, CDistress PHQ-4PHQ-9 DepressionGAD-7 Anxiety497UB, BCCPhysical symptoms PHQ-15 15 CLimitation JFLS 8 or 20 B (8), C (20)Parafunction OBC 21 B, COther instruments for pain-relevant constructsSleep Pittsburgh Sleep Quality IndexPROMIS1843CCPTSD PTSD Checklist 17 CAlcohol use AUDIT-C 3 CStress Perceived Stress Scale 10 CAUDIT-C, Alcohol Use Disorders Identication Test; B, brief; C, comprehensive; DC/TMD, Diagnostic Criteria for Temporomandibular Disorders; GAD, generalized anxiety disorder; GCPS, graded chronic pain scale; JFLS, jaw functional limitation scale; OBC, oral behaviors checklist; PHQ, Patient Health Questionnaire; PROMIS, Patient-Reported Outcome Measures Information System; UB, ultra brief.Implementing a Biobehavioral Framework: Dual-Axis Coding 25412Axis II: Biobehavioral Considerationsthese can be used to augment the screening. Standardized instruments provide the clinician with an actuarial approach to decision making. This will ensure more information is gathered than the limited amount provided by the initial interview and prevent inherent clinician-based personal biases from clouding clinical judg-ments. Health care providers can have dif-culty in making accurate judgments of the psychologic status of pain patients and may tend to overreport psychopathology.41,42 The results of these studies suggest that the use of screening instruments may help improve the accuracy of clinical decision making in the orofacial pain setting. Brief Screening for Biobehavioral FactorsIt is necessary for clinicians to conduct an as-sessment of biobehavioral factors in the initial consultation session.39,43–45 In terms of which factors should be evaluated, the degree of the assessment should depend on the setting (eg, general dental or medical ofce, orofacial pain specialist ofce, research clinic, psycholo-gist ofce) and purpose (eg, initial screen-ing, more in-depth evaluation by the orofacial pain specialist, comprehensive evaluation by a consulting psychologist) of the evaluation. The selection of the level of the biobehavioral focus implies that the clinician understands the importance of biobehavioral factors in the patient’s presentation and the context in which the patient evaluations occur. When it comes to the rst line of screening, however, the criti-cal dimensions include (1) some means of as-sessing multiple pain conditions or complaints in addition to the orofacial pain that gener-ated the initial clinical visit, (2) pain intensity and pain-related disability, and (3) psychologic distress.8,14,44,46,47One of the strongest and most consistent predictors of the onset of a new orofacial pain condition is the presence of other ongoing pain complaints.36 Multiple pain conditions also appear to be a strong predictor of the transi-tion from acute pain to chronic pain. Presence of multiple pain complaints can be assessed with a drawing of the full human body (pain manikin), front and back, where the patient can note areas of ongoing pain. Other initial strat-egies for assessing multiple pain conditions include using a checklist or specic questions concerning pain in other regions of the body. Both the intensity of pain and the impact of the pain on functioning can be obtained with the Graded Chronic Pain Scale (GCPS).48 This brief, eight-item screening instrument includes an assessment of number of pain days in the last 6 months; current pain intensity, worst pain intensity, and average pain intensity using a scale of 0 to 10 (where 0 represents “no pain” and 10 represents “pain as bad as can be”); and four questions concerning disability related to the pain. When averaged together, the pain intensity items provide an excellent overall index of pain intensity. Based on the intensity and disability ratings, patients can be classied into one of ve categories, grades 0 to IV. Grade 0 represents being pain free, grade I represents low intensity of pain and low disability, grade II represents high inten-sity of pain and low disability, grade III repre-sents moderately limiting disability, and grade IV represents severely limiting disability. Pain intensity is not considered in grades III and IV because poor functional status, as repre-sented by the disability grade, becomes sub-stantially more important than pain intensity. The GCPS is recommended for regular use in the orofacial pain setting because it is a reli-able, valid, and brief screening tool for pain and pain-related disability. High self-rated levels of pain, interference, and impact, along with low ability to control pain, suggest the need for fur-ther biobehavioral evaluation and appropriate referral for consultation.48,49The more common forms of distress pre-senting in the orofacial pain clinic include depression and anxiety, ranging from mild 255symptoms to severe disorders.49 Depression and anxiety are described in detail in later sections of this chapter to provide a broader understanding of these conditions within the context of the orofacial pain setting. How-ever, the immediate concern of the clinician is to screen patients and identify those who need further consultation and care by a quali-ed mental health care provider. While there are a variety of screening instruments, a very brief measure for screening distress is the Pa-tient Health Questionnaire four-item (PHQ-4),50 which assesses both depression and anxiety. The PHQ-4 evaluates functioning over the past 2 weeks with a scale ranging from 0, meaning “not at all” to 3, meaning “nearly every day.” It requires about 1 minute for administration. This brief instrument yields a rating of nor-mal, mild, moderate, or severe distress. Any nonnormal rating is an indication for further evaluation by a qualied mental health care provider. This instrument is ideally suited for the screening of distress in the orofacial pain environment. Several other standardized screening ques-tionnaires are available for depression and anxiety that can enable the clinician to make informed decisions about the need for more extensive diagnostic decision making and treatment planning.51–53 In clinical settings, the choice of one instrument over another is far less important than knowing the instrument and knowing the distribution of scores in one’s clinical population. The Jaw Functional Limita-tion Scale (JFLS) has been recommended as a primary assessment tool for evaluating the impact of pain on core functions of the mas-ticatory system.54 The JFLS may be adminis-tered as a 20-item instrument yielding three subscales (masticatory limitation, jaw mobility limitation, and verbal and emotional expres-siveness limitation) or as an eight-item global limitation scale. The information obtained from the patient should be consistent with any physical diagno-sis, and when it is not, other questions should be raised in the clinical interview. For example, reported severe limitation in both mastication and jaw mobility simultaneous with minimal clinical signs may point toward catastrophiz-ing or symptom amplication, or it may point toward an incomplete understanding of what has happened to the patient. In contrast, mini-mal limitation despite severe reported pain and signicant clinical signs may indicate a patient who is trying to overcompensate. Assessment instruments also provide important functional evidence in situations when the provider must demonstrate treatment efcacy.The clinician should consider whether the screening assessment should also address oral behaviors. The Oral Behaviors Checklist (OBC)55,56 is a 21-item scale that was devel-oped during the DC/TMD validation study to identify common oral behaviors associated with TMDs. This scale provides the clinician with a patient’s perspective on a broad sample of oral behaviors (eg, chewing gum, clenching teeth, pressing tongue forcibly against teeth) that may inuence orofacial pain. It has dem-onstrated acceptable validity and reliability for the measurement of oral behaviors over time.While this brief comprehensive screening battery (ie, the pain manikin, GCPS, PHQ-4, JFLS, and OBC) provides the clinician with initial data to guide case conceptualization and treatment planning, there may be circum-stances where there is not sufcient time or resources to use all of these measures. In these cases, it is recommended to at least perform an ultra-brief screening comprising the pain manikin, GCPS, and PHQ-4.Comprehensive Evaluation of Biobehavioral FactorsIn addition to depression and anxiety, stud-ies have identied the important roles of sleep disturbances, somatic awareness, perceived stress, and PTSD as strong pre-dictors of distress and pain in orofacial pain Comprehensive Evaluation of Biobehavioral Factors 256Axis II: Biobehavioral Considerations12Box 12-1 Red and yellow ags for referral of orofacial pain patientsRed ag: Refer immediately• Suicidal thoughts or plansYellow ag: Proceed with caution and consider referral• Alcohol or drug use• Persistent beliefs about pain• Illness behaviors• Problems in compensation or claims• Time off work• Problems at work• Overprotection from family members• Lack of social support• Chronicity of pain• Functional limitations• Discrepancies in findings• Overuse of medications• Inappropriate behavior, expectations, or responsiveness to prior treatmentpatients.23–25,29,33,36,56–59 There are brief, reli-able paper-and-pencil screening instruments available to assess sleep (eg, Pittsburgh Sleep Quality Index, Patient-Reported Outcome Mea-sures Information System sleep instruments), somatic awareness (90-item Symptom Check List Revised [SCL-90-R], Pennebaker Inventory of Limbic Languidness), perceived stress (Per-ceived Stress Scale), and PTSD (PTSD check-list). Moreover, clinicians may use the PHQ-9 for a more detailed screening for depression, the Generalized Anxiety Disorder 7 (GAD-7) for anxiety, and the PHQ-15 for an evaluation of physical symptoms. Many clinicians may nd the information from these instruments helpful in the pro-cesses of evaluation and treatment planning. Overall, it is important that dentists and other health care clinicians be able to recognize maladaptive coping mechanisms and direct patients to appropriate evaluation and treat-ment programs to address these dysfunctions. Stressful life events, such as conicts in home or work relationships, nancial problems, and cultural readjustment may contribute to illness and chronic pain.60,61 Environmental stressors may heighten tensions, insecurities, and dys-phoric affects that may in turn lead to increased adverse loading (clenching or grinding) of the masticatory system as stress is converted to muscle tension and increased parafunctional behavior.62 Stressors will not always lead to increases in muscle tension, and increases in muscle tension will not always create pain, but it is a distinct possibility to consider when evaluating an individual’s clinical presentation. The use of a pain manikin, the GCPS, and the PHQ-4 serves as an acceptable initial minimum screening for all orofacial pain patients to deter-mine if they should be referred for further evalu-ation by qualied mental health care providers.In addition to pain-relevant biobehavioral constructs, Turner and Dworkin44 noted the value in screening for prolonged and/or ex-cessive use of opiate medications, benzodi-azepines, alcohol, and other addictive medica-tions. Clinicians can screen for these problems in the course of their initial evaluation inter-view. When screening for alcohol use, one re-liable instrument is the Alcohol Use Disorders Identication Test (AUDIT-C).63 This three-item questionnaire is a reliable means of identifying whether an individual should be referred for careful evaluation of alcohol abuse.Health care providers working with patients with chronic back pain use a strategy in the initial evaluation process to identify red and yellow ags: Red ags are those representing a potentially serious condition for which im-mediate attention is needed, and yellow ags represent potential psychologic or social bar-riers to full recovery (Box 12-1). Clinicians in the orofacial pain setting should also use a red and yellow ag identication strategy when implementing a biobehavioral approach. Red ags in the psychosocial history of the orofa-cial pain patient demand immediate attention; these primarily focus on signs of suicide. The 257most common signs of potential suicide in-clude talking about suicide, either generally or specically, and/or actual plans for taking one’s own life (suicidal ideation) and hopelessness. There are other warning signs for suicide, in-cluding persistent and despairing mood, sig-nicant weight loss or gain, change in appetite, withdrawal and social isolation, and change in sleep pattern—all symptoms that are associ-ated with depression as well. Any patient who presents with thoughts about suicide, plans for suicide, or hopelessness should be evalu-ated for risk assessment as soon as possible by qualied mental health care professionals. Yellow ags for treatment may include per-sistent beliefs about pain, illness behaviors, problems in compensation/claims, time off from work, problems at work, overprotection from family members, or lack of social sup-port. Additional factors include chronicity of pain, functional limitations, discrepancy in ndings, overuse of medication, inappropriate behavior (often including items from the rst list, but not exclusively), inappropriate expec-tations, and inappropriate responsiveness to any prior treatment40,64 (see Box 12-1). Any of these issues can interfere with treatment, and the orofacial pain specialist needs to be wary of initiating treatment in individuals with these concerns. When possible, a careful and thor-ough evaluation should be performed by a psy-chologist, psychiatrist, psychiatric nurse prac-titioner, or other appropriately trained mental health care provider before treatment begins.Psychiatric DisordersOrofacial pain patients, particularly those with a history of signicant pain over 3 months in du-ration, may experience signicant psychologic distress that complicates the management of their presenting complaints. A distinction can be drawn between the role of pain psychology and the use of diagnostic psychiatric disor-ders in a clinical setting for orofacial pain. One difference is that pain psychology places an emphasis on dimensional assessment rather than classication (diagnosis). Furthermore, pain psychology is interested in the detailed integration of specic domains of functioning known to be important in a pain patient’s expe-rience and the incorporation of the biobehav-ioral domain into the clinical arena and decision making. This approach to patient management focuses on the identication of problem areas that lend themselves to structured, empiri-cally supported therapies (eg, cognitive behav-ioral therapy) that will facilitate referrals when needed. Pain clinicians will encounter patients whose functioning is severely compromised, and knowing when to refer to a mental health care provider benets the patient and the cli-nician alike. The description of mental states provided by the classic psychiatric disorders captures the many ways in which human sys-tems undergo dysregulation. It is essential to recognize these in patients so that the founda-tions of a dual-axis classication system can be better understood and applied clinically.Although many mental conditions can be inuenced by or result from orofacial pain disorders, only a select group is addressed in this chapter. This section highlights the more common mental disorders that clinicians are likely to encounter; the comprehensive evalua-tion of psychologic status should be conducted by appropriately trained mental health care providers.65 Gatchel et al66–68 have reported that the most frequently occurring problems include major depression, anxiety disorders, and personality disorders. The other disorders presented in this chapter have a much lower frequency of occurrence, but orofacial pain cli-nicians should be aware of them to make a successful referral for denitive diagnosis and treatment. For a description of other mental conditions, the reader is encouraged to review the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).37 Each disorder is accompanied by its codes Psychiatric Disorders 258Axis II: Biobehavioral Considerations12from the DSM-5 and/or The International Clas-sication of Diseases, Tenth Edition (ICD-10).Major depressive disorder (DSM-5 296.2x; ICD-10 F32)37Major depression has been identied as one of the most common mental disorders occur-ring in the orofacial pain environment.68 Clinical data suggest that almost one-third of patients presenting for treatment of orofacial pain may be experiencing symptoms consistent with a diagnosis of depression.69 The diagnosis of major depression requires at least ve of the following symptoms over a 2-week period, with at least one of the symptoms being de-pressed mood or loss of interest/pleasure:• Depressed mood most of the day• Decreased interest or pleasure in all or most daily activities• Weight loss or change in appetite• Insomnia or hypersomnia• Daily psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness or guilt• Reduced ability to think or concentrate• Thoughts of death or suicideWhen these symptoms cause distress and impair functioning and are not due to a medical condition or substance use, the diagnosis of major depression is likely. Major depression is a serious, potentially life-threatening condition, and referral to appropriate health care provid-ers for effective treatment is essential in addi-tion to care for the pain disorder itself.Anxiety disordersGeneralized anxiety disorder (DSM-5 300.02; ICD-10 F41.1)37GAD is diagnosed when an individual has per-sistent and excessive anxiety or worry for a period of 6 months or longer. The person who is experiencing GAD is not able to control the feelings of anxiety or worry, and at least three of the following symptoms are present: rest-lessness, fatigue, difculty concentrating, irri-tability, muscle tension, and sleep disturbance. In addition, the symptoms cause signicant im-pairment of interpersonal functioning or work performance, and the anxiety and worry are not associated with another mental disorder (eg, obsessive-compulsive disorder), substance use (drugs or alcohol), or another medical con-dition. It is estimated that between 10% and 30% of the orofacial pain population may be experiencing GAD.68 Anxiety is particularly im-portant to identify during acute phases of a pain disorder because it leads to nonadaptive behav-iors, which may promote chronicity.2 Referral for treatment of GAD may be delayed based on whether treatment of the orofacial pain condi-tion itself may begin to alter symptoms.Panic disorder (DS M-5 300.01; ICD-10 F41.0)37Although much less common than GAD, panic disorder involves a sudden, intense onset of fear and terror that is often accompanied by thoughts of impending disaster. It can include chest pain, palpitations, and shortness of breath, which can be so severe that the indi-viduals may feel as though they are dying. Indi-viduals having a panic attack report sensations of choking/smothering and are afraid of losing control of their thoughts. Panic disorder is di-agnosed when a panic attack has occurred and when at least one of the following criteria pre-sent for at least 1 month: persistent concern about having another attack, worry about the implications or consequences of the attack, and a notable change in behavior related to the attacks or fear thereof. In addition, the panic attacks must not be due to a medical condition or substance use. Even though panic disorder is uncommon, it is a condition that requires immediate attention and coping skills. There-fore, if panic disorder is suspected, appropriate referral should be made immediately. 259Posttraumatic stress disorder (DSM-5 309.81; ICD-10 F43.1)37Considerable professional interest and bur-geoning public concern have focused on the sequelae of traumatic experiences. It is now well recognized that physical and sexual abuse are implicated in the etiology of a broad spec-trum of physical and emotional symptoms. The essential feature of PTSD is the onset of char-acteristic symptoms following exposure to a traumatic event either involving direct personal experience or the witnessing of such an event. Traumatic events usually involve actual or threatened death or serious injury or a threat to one’s physical and psychologic integrity. Typ-ical symptoms include persistent reexperienc-ing of the traumatic event, persistent avoid-ance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal. The full symptom picture must be present for more than 1 month, and the disturbance must cause clinically signicant distress or impairment in daily functioning. For children, sexually trau-matic events may include developmentally in-appropriate sexual experiences without threat-ened or actual violence or injury. The disorder may be especially severe or long-lasting when the traumatic experience has been created by deliberate human intent (eg, torture or rape) as contrasted with naturally occurring disasters. The likelihood of developing this disorder may increase as the intensity of and physical prox-imity to the event increases.Psychologic reexperiencing of the traumatic event may occur in several ways, commonly as recurrent and intrusive recollections, dis-tressing dreams, and, in rare instances, brief dissociative states or ashbacks during which components of the event are relived and the person behaves as though experiencing the event at that moment. Intense psychologic distress or physiologic reactions often occur when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (eg, entering an elevator for a person who may have been assaulted or raped in an elevator; or any intraoral pain or ma-nipulation for individuals who may have been sexually violated or traumatized in the mouth).Typically, individuals suffering from this condition make deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event and, in some instances, may develop amnesia for important aspects of the traumatic experience. Diminished psychologic responsiveness, referred to as psychic numb-ing or emotional anesthesia, may be accompa-nied by markedly diminished interest in previ-ously enjoyed activities and markedly reduced capacity for emotional responsiveness. The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma; the arousal symptoms are frequently associated with sleep disturbance, nightmares, hypervigilance, and an exagger-ated startle response. This increased arousal is often accompanied by activation of the auto-nomic nervous system as measurable by elec-trocardiography, electromyography, and sweat gland activity. In younger children, distressing dreams of the event may change into general-ized nightmares. Rather than having a sense of reliving the past as a memory, young children often re-create versions of the trauma through repetitive play. For example, a child involved in a motor vehicle accident may reenact scenes of toy cars crashing, or sexually traumatized children may depict genital contact occurring between toy animals.It should be emphasized that not all psycho-pathology occurring in individuals exposed to extreme stress should necessarily be attributed to PTSD. Symptoms of avoidance, numbing, and increased arousal that are present before exposure to the stressor require consideration of other diagnostic alternatives (eg, a mood dis-order or an anxiety disorder). Acute stress dis-order is distinguished from PTSD because the symptoms appear and subsequently resolve within 4 weeks of the trauma. Adjustment dis-Psychiatric Disorders 260Axis II: Biobehavioral Considerations12order is the appropriate diagnosis for situations in which the response to a stressor does not meet the criteria for PTSD or when the stressor itself is not judged to be that threatening.A signicant proportion of orofacial pain patients are likely to meet lifetime criteria for having experienced PTSD.58,59 This relatively high rate of occurrence is consistent with other data, suggesting that exposure to trau-matic life events is common among orofacial pain patients and patients with other pain conditions as well.58,70 It is therefore neces-sary that clinicians have an awareness of the signs and symptoms of PTSD and are able to make appropriate referrals for treatment. The characteristics of this disorder (ie, autonomic activation, perceptual distortion, and denial of one’s own needs) may prevent signicant therapeutic gains unless the underlying disor-der is addressed. Substance use disorders (DSM-5 291-305 and ICD-10 F10-19)37It is not uncommon for patients with oro-facial pain to have ongoing or previous substance-related disorders. These disorders include dependence, abuse, intoxication, and withdrawal. Substance dependence is dened as a pattern of substance use that leads to clinically signicant impairment or distress. The term substance abuse refers to a pattern of substance use that has signicant negative consequences, such as failure to meet obliga-tions of work, school, or home; behaviors that are physically hazardous like driving a car when impaired; legal problems; or interpersonal prob-lems related to the continued substance use. Substance intoxication refers to the reversible signs and symptoms associated with the in-take of a substance that can produce physi-cal, behavioral, or psychologic changes. With-drawal refers to substance-specic physical, behavioral, or psychologic changes that occur with the reduction or stoppage of a substance that has been used over a period of time. Clinicians should also be familiar with the terms addiction and pseudoaddiction. Addic-tion involves one or more of the following characteristics: impaired control over drug use, compulsive use of drug(s), continued use despite harm, and craving. A person with an addiction often does not take medications according to prescription or schedule, has multiple visits to multiple practitioners, and likely reports on a frequent basis that his or her prescriptions have been lost or stolen. It is important to distinguish addiction from pseudoaddiction in chronic pain patients.71,72 Pseudoaddiction looks like addiction in that the same behaviors are typically present, but the patient has identiable nociception (eg, cancer pain, neuropathic pain, postsurgical pain) that is undermedicated, so he or she is in constant search of effective treatment to control the pain. When such a person is given adequate medication, the addiction-like behaviors cease. Distinguishing addiction from pseudoaddiction requires good knowledge of the patient by the clinician and is greatly facilitated by careful his-tory taking, comprehensive and standardized physical examinations, and use of biobehav-ioral assessment instruments. In the case of pseudoaddiction in particular, progress notes should clearly document the contingent nature of the medication seeking along with the ap-propriateness of the medication to the identi-ed or suspected nociception. Substance abuse disorders can occur within broad classes of substances that include al-cohol, amphetamines or similar compounds, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine or similar compounds, and sedatives/hypnotics/anxiolytics. The clinician must be alert to po-tential abuse disorders and be able to develop a treatment plan that is in the best interests of patients and their health care providers. Un-less the clinician has specialty training in the management of addiction disorders, the appro-priate standard of care is referral to a health care provider who does have specialty train- 261ing. It is important to develop a rapport with patients who have problems with substance abuse to foster successful referral.Sleep disorders37Sleep disorders are common in patients with chronic pain, and there are two major sleep dis-orders that the clinician is likely to encounter: primary insomnia (DSM-5 780.52; ICD-10 F51.0) and breathing-related sleep disorders (eg, sleep apnea, DSM-5 327; ICD-10 G47.3). Other sleep disorders, such as narcolepsy or night terrors, are not as common in the chronic pain envi-ronment. Primary insomnia involves difculty in initiating or maintaining sleep, and it must have persisted for at least 1 month. The sleep problem results in distress or difculties in the individual’s life that could include interpersonal or work-related issues. For primary insomnia to be diagnosed, it must be clear that depression, anxiety, or medication/substance use is not contributing to the disruptions in sleep. Primary insomnia can be managed with behavioral med-icine strategies playing primary roles. Breathing-related sleep disorders involve being sleepy or experiencing insomnia as a result of a breathing problem that disrupts regular sleep. The breathing problem is usu-ally the result of either obstructive or central sleep apnea, but it can be the result of central alveolar hypoventilation syndrome. These latter conditions represent medical disorders that merit immediate referral to physicians trained in sleep medicine. Breathing-related sleep dis-orders require medical evaluation, and biobe-havioral approaches should also be considered as appropriate interventions.Somatic symptom and related disorders37Clinicians should recognize and appreciate so-matic symptom and related disorders because they represent an extremely important group of mental conditions in which the patient reports somatic complaints and yet has no physical evidence of organic disease. Somatic symptom and related disorders are subdivided into the following categories: somatic symp-tom disorder, illness anxiety disorder, conver-sion disorder, factitious disorder, unspecied somatic symptom and related disorders, other specied somatic symptom and related disor-ders, and psychologic factors affecting other medical conditions.Somatic symptom disorder (DSM-5 300.82; ICD-10 F45.0) The essential features of somatic symptom disorder are recurrent and multiple somatic complaints of at least several years’ duration for which treatment has been sought and sig-nicant disarray or distress in the person’s life for which no treatment is sought. Clinical char-acteristics include preoccupation with somatic complaints, amplication of symptoms, denial of difculty in life, and a high level of treatment seeking for somatic complaints accompanied by poor adherence and compliance to that treatment. The disorder classically begins be-fore age 30 years and has a chronic but uc-tuating course. Historically, this condition was previously referred to as hysteria or Briquet syndrome, and the history of medicine clearly demonstrates that its presentation is anchored into the current values and beliefs of the host culture.73 Complaints are often presented in a dramatic, vague, or exaggerated manner or are part of a complicated dental and/or medical history in which many physical diagnoses have been considered. The individuals frequently re-ceive dental care from a number of practitio-ners, sometimes simultaneously. Complaints often extend to multiple organ systems. The term hypochondriasis is no longer used in the diagnostic nosology because approximately 75% of hypochondriasis patients match the diagnostic criteria for somatic symptom disor-der, while the remaining 25% have elevated levels of anxiety such that they are more ap-propriately diagnosed with illness anxiety dis-order (DSM-5 300.7; ICD-10 F45.21). Psychiatric Disorders 262Axis II: Biobehavioral Considerations12To diagnose somatic symptom disorder, there must be a history of the report of so-matic symptoms that are distressing, along with thoughts, feelings, and/or behaviors that are out of proportion with the symptoms, and an inordinate amount of time and energy must be devoted to addressing these health concerns. Individuals with this disorder, for example, complain of abdominal bloating and nausea, while vomiting, diarrhea, and food intolerance are less frequent symptoms. It should be emphasized that the unexplained symptoms in somatic symptom disorder are not intentionally feigned or produced. Because of the highly restrictive charac-ter of the required symptom pattern, somatic symptom disorder is not common, but soma-tization as a style or as a major characteristic about a person is fairly common in the oro-facial pain population.74 For example, the so-matization scale scores on the SCL-90-R have a signicant relationship with the number of muscles reported as tender during an RDC/TMD examination.75 These clinical data high-light the necessary attention needed to con-sider somatization as a way of coping among patients in an orofacial pain practice.Anxiety and depressed mood are common, and suicide threats or attempts; antisocial behavior; and occupational, interpersonal, and marital difculties frequently accompany somatization. The clinical course is typically chronic but uctuating in nature and rarely re-mits spontaneously. Through seeking numer-ous evaluations, diagnostic tests, and multiple trials on medication and frequently submitting unwittingly to unnecessary surgery, these pa-tients often experience iatrogenic complica-tions both in and out of the hospital.The differential diagnosis necessitates rul-ing out physical disorders that present with vague, multiple, and confusing somatic symp-toms. In addition, schizophrenia with multiple somatic delusions, dysthymic disorder, GAD, panic disorder, and conversion disorder need to be excluded from this specic diagnostic classication. Because pathophysiology has yet to be identied, myofascial pain could qualify as a disorder without clear organic pathology for clinicians; according to the description presented here, such a patient would qualify for a diagnosis of at least so-matic symptom disorder as a method of cop-ing. Before neuropathic mechanisms were suspected to underlie burning mouth–disorder types of conditions, somatization was a diag-nostic label unfortunately applied to such indi-viduals for many years. Because many chronic pain disorders do not have obvious pathology responsible for the inferred nociception, dis-tinguishing such functional disorders from somatization is not conceptually simple but is critically important for both the patient and the clinician. These disorders may include non-specic lower back pain and irritable bowel syndrome, for example, and they represent at least a disorder of psychophysiologic dys-regulation. The distinction is also not clinically simple, but a comprehensive history and at-tention to the biobehavioral screening and identied yellow ags (see Box 12-1) are an excellent and essential starting point.Conversion disorder (functional neurologic symptom disorder) (DSM-5 300.11; ICD-10 F44.x) Patients with conversion disorder present with a loss of or alteration in physical functioning that suggests a physical disorder but instead is an expression of psychologic conict or need. The disturbance is not under voluntary control and cannot be explained by any physical dis-order or known pathophysiologic mechanism. Conversion disorder is not diagnosed when conversion symptoms are limited to pain (see somatoform pain disorder) or to a circum-scribed disturbance in sexual functioning.Factitious disorder (DSM-5 300.19; ICD-10 F68.1)37Factitious means not real, genuine, or natural. Factitious disorders are therefore character-ized by physical and/or psychologic symptoms that are produced by the individual and are 263under voluntary control. The judgment that the patient is willfully creating the symptoms is based, in part, on the patient’s ability to simulate illness in such a way as to avoid de-tection. However, such acts also have a com-pulsive quality because the individual is unable to refrain from a particular behavior even if its dangers are known. These conditions should therefore be considered voluntary only in the sense that they are deliberate and purposeful but not in the sense that the patient adopts or sustains the pathologic behavior intentionally. The presence of factitious psychologic or phys-ical symptoms does not preclude the coexis-tence of true psychologic or physical illness.Factitious disorder is distinguished from acts of malingering. Whereas in malingering, the patient is in pursuit of obvious and recog-nizable benets through willful falsication, in a factitious disorder, there is no apparent goal other than to assume the patient role. An act of malingering may be considered adaptive under certain circumstances, but a diagnosis of a factitious disorder implies psychopathol-ogy (often a severe personality disturbance). According to the DSM-5, malingering is not considered a mental illness.Unspecied somatic symptom and related disorder (DSM-5 300.82; ICD -10 F45.9)The essential feature of unspecied somatic symptom and related disorder is one or more physical complaints that persist for 6 months or longer. These symptoms cannot be fully explained either by any known physical condi-tion or by the direct effects of an incident or substance (eg, the effects of injury, substance use, or medication side effects). Alternatively, the physical complaints or resultant impair-ment are grossly in excess of what would be expected from the history, physical examina-tion, or laboratory ndings. The symptoms must cause clinically signicant distress or impairment in social, occupational, or other areas of adaptive functioning. This is a residual category for those persistent somatoform pre-sentations that do not meet the full criteria for other somatic symptom disorders. Psychologic factors aecting other medical conditions (DSM-5 316; ICD-10 F54)37When the primary presenting complaint is a medical (ie, physical) condition inuenced by one or more psychologic or behavioral issues, psychologic factors affecting other medical con-ditions can be diagnosed. Typically, the diagno-sis will link the psychologically related issues with the physical condition, as in the example, “stress and anger toward signicant other af-fecting masticatory muscle pain.” The issues identied must be contributing to the disor-der by (1) having a close connection in terms of time between the beginning of the physical condition and the onset of the psychologic or behavioral factors, (2) interfering with the treat-ment of the condition, (3) increasing health risk, or (4) increasing physiologic activation that brings on or intensies the physical condition. This diagnostic category provides the prac-titioner with the means to codify a comorbid psychologic condition that may be contributing to the patient’s capacity to manage a medical problem. Because chronic pain complaints represent a complex interaction between psy-chologic and physiologic factors, the use of this diagnostic category is common. This label also may be more acceptable to some patients than other labels of psychiatric conditions.Personality disorders37Generally speaking, a personality disorder is a long-term pattern of thinking and acting that is signicantly different from that of the gen-eral population and results in signicant con-sequences to the individual or those around the individual. These abnormal patterns may manifest as exaggerations or dysfunction of certain dimensions of personality. For exam-ple, it is normal to have occasional moments of not trusting another person, but it is abnormal to live with a consistent pattern of suspicious-Psychiatric Disorders 264Axis II: Biobehavioral Considerations12ness and mistrust. An orofacial pain condition is most likely to appear after the individual has already been displaying a pattern of thinking and behaving characteristic of a personality disorder. These patterns, however, may or may not have interfered with daily functioning prior to the development of the orofacial pain con-dition. Recent data suggest that a signicant number of orofacial pain patients have coexist-ing personality disorders.67,68There are three basic groups of personal-ity disorders that each share common clinical presentations (Table 12-2). Cluster A includes odd or eccentric disorders and schizotypal dis-orders. Cluster B includes emotional, dramatic, or unpredictable disorders like antisocial, bor-derline, or histrionic disorders. Cluster C in-cludes anxious and fearful disorders like avoid-ant, dependent, and obsessive-compulsive disorders.37Cluster AWithin Cluster A, paranoid personality disorder describes an individual who does not trust oth-ers and is very suspicious. These patients may overinterpret what the clinician says or may be unforgiving of others for perceived injury or insult. Patients with schizoid personality disorder are detached from others and have very limited emotional expression. A person with this disorder has few, if any, close friends or family and usually does things alone. The schizotypal personality disorder shares the features of detachment and limited emotional expression but is also characterized by sub-stantial distortions of thought and very unusual behavior. Thought distortions include magical thinking, belief in telepathy, and weird fanta-sies. Unusual behaviors might involve acting out the use of “special powers” or listening to “voices for direction.” Cluster BWithin Cluster B, the antisocial personality disorder is characterized by little or no regard for the rights of others. The diagnosis of this personality disorder involves the individual committing crimes, lying, not planning ahead, being irritable and aggressive to the point of getting into ghts, disregarding safety for self Table 12-2 Personality disordersDisorder DSM-5 code ICD-10 codeCluster A: Odd or eccentric disordersParanoid 301.0 F60.0Schizoid 301.20 F60.1Schizotypal 301.22 F60.3Cluster B: Emotional, dramatic, or unpredictable disordersAntisocial 301.7I F60.2Borderline 301.83 F60.3Histrionic 301.50 F60.4Narcissistic 301.81 F60.81Cluster C: Anxious and fearful disorders Avoidant 301.82 F60.6Dependent 301.6 F60.7Obsessive-compulsive 301.4 F60.5 265and others, being irresponsible, and/or not ex-pressing remorse or sorrow for behavior that hurts others. In short, the antisocial personality disorder involves behavior that is self-centered and does not conform to the general rules and expectations of society.Borderline personality disorder represents a repeated pattern of instability of relation-ships and impulsivity in action. The instabil-ity takes the form of leaving and entering relationships in a recurrent pattern as well as frequent changes in the nature of the relation-ship. The patient with borderline personality disorder often has an inordinate fear of being abandoned and exhibits extremes of think-ing. For example, the relationship with the health care provider may involve the patient holding the provider in highest regard and later accusing them of incompetency. These patients exhibit impulsive, self-destructive behavior such as substance abuse, unsafe sex, binge eating, and reckless driving, and they engage in repeated threats and gestures of self-harm, including suicide. There is also marked emotional instability and intense, in-appropriate anger. The borderline personality can also manifest as paranoid thoughts or dis-sociative symptoms. A borderline personality disorder can present an extremely difcult case management challenge to the unwary practitioner.Histrionic personality disorder is character-ized as pronounced emotional expression and attention seeking. Patients with this disorder can be provocative and sexually seductive and easily suggestible, and they may perceive re-lationships as more intimate than they really are. In other words, they think and act in ways that are inconsistent with boundaries normally maintained by orofacial pain patients. Patients with narcissistic personality disorder act in a grandiose manner and have an intense need for the admiration of others while displaying little empathy. These individuals expect the cli-nician to respond to their needs at all hours, including during the weekend.Cluster CCluster C personality disorders involve pa-tients who are overly anxious or afraid as a predominant feature of their everyday expe-rience. Avoidant personality disorder is as-sociated with feeling socially inhibited and inadequate and being overly sensitive to any criticism. Patients with dependent personal-ity disorder have a pervasive need to be taken care of, so there is excessive clinging and fear of being abandoned. These individuals will continue to seek care for their orofacial pain condition despite lack of improvement over time or even harm done. With obsessive- compulsive personality disorder, the pa-tient’s day-to-day life is ruled by a drive for perfection, orderliness, and being in control. There is limited openness to new ideas, and rules, details, and lists are very important. In-dividuals with obsessive-compulsive personal-ity disorder do not like to work with others, keep everything they have owned (even worth-less items), and hoard their resources in case something should happen in the future. This last cluster of personality disorders can present a very real challenge to effective oro-facial pain management. Patients can be so in-tently focused on personal criticism, symptom improvement, or support from providers that anxiety and nervousness interfere with obtain-ing positive treatment outcomes. Body dys-morphic disorder has been reclassied into the category of obsessive-compulsive personality disorder, which is particularly relevant to the orofacial pain clinician because it causes the individual to experience extreme anxiety over a real or imagined physical aw. For example, this diagnostic category could be applied to a patient who is convinced that there is a slight angle of a canine tooth that is responsible for his or her pain condition. Psychiatric Disorders 266Axis II: Biobehavioral Considerations12Consultation and Referral StrategiesChronic orofacial pain management requires the availability of a multidisciplinary team that includes competent mental health care provid-ers. Development of professional relationships with such providers should be a high priority for clinicians practicing in this eld because it facilitates the implementation of informed re-ferrals when necessary. Patients may present with red or yellow ags prompting more exten-sive evaluation or could need skills training or psychotherapy related to cognitive, behavioral, or emotional issues.One effective approach for making a referral focuses on the patient’s need for assistance with stress management. This strategy helps alleviate a patient’s concerns about “being crazy” or being labeled as having a psychiatric disorder. The clinician should reassure the pa-tient with statements such as the following to assuage any concerns:• The referral is intended to address better ways of managing the consequences of pain.• All pain is real.• The relationship with the referring pro-vider will continue through and beyond any referral therapy.• The patient’s physical status will continue to be monitored to detect any change that would warrant a different direction in treatment.• The referral is not in any way a sugges-tion that the patient is “crazy.” Another effective strategy is to focus on getting help for physical self-regulation skills training. Patients will often be much more willing to visit with a mental health care pro-vider when the referral focuses on learning how to better manage stress or learning new skills for controlling physical functioning. Bio-feedback and its grounded focus on physical self-regulation is a topic dentists often discuss with their patients when arranging referrals.Comprehensive Axis II EvaluationThe assessment of Axis II status must be a standard and routine part of the clinician’s initial evaluation of the patient, even if only a brief as-sessment is used. Self-report screening instru-ments can be administered through a mailed packet or forms lled out while the patient is in the reception area; however, the interview por-tion is best deferred until the clinician has ob-tained enough pain and health history to form a matrix within which biobehavioral aspects can be anchored and appropriately interpreted. This part of the evaluation includes the range of biobehavioral factors and their interconnection with the standard pain history and typical re-view of systems, past medical history, and any family or social history. In addition, the clinician needs time to build rapport and trust with the patient before asking questions about personal functioning, and such questions need to t into the overall sequence of information gathering. For example, everyone experiences stress (ie, the sense of being threatened or overwhelmed by events or the common daily hassles), so it is not enough to simply identify that a patient experiences stress, or even how often and to what extent. The stress experience has to be anchored into the pain and health histories for temporal and causal relationships to be identi-ed, and thus the pain and health histories need to be rst explored and understood. This part of an interview is often referred to as the causal reasoning portion.76 The goal is to bring different parts together into a coherent network. When a patient is referred to a mental health care provider for evaluation, the clinician can expect that the mental health care provider will perform a complete assessment and provide appropriate feedback in a timely manner. Typi-cally, the evaluation can be performed within a 26750- to 75-minute period and will include a re-view of the presenting complaints and history of onset from the perspective of the mental health care provider. The mental health care provider will also likely assess conditions that intensify or reduce the pain complaints as well as typical antecedents and consequences. It is not uncommon for the clinician to explore a typical day in the life of the patient. Pain cog-nitions, operant and respondent behavioral factors, activity management, and methods of coping are common features of a pain psy-chology evaluation. This may be followed by a careful review of the physical history including medication use; sleep issues; tobacco, caf-feine, and alcohol use; and physical activity level. Mental status, mood, and ongoing emo-tional state are then assessed along with risks for harm to self and harm to others. This is typi-cally followed by a review of any psychiatric his-tory or hospitalizations. Then the current social support system, marital history, work history, and exposure to signicant stressors or trauma are reviewed, as well as other relevant issues related to the patient’s presentation (eg, spiri-tual or religious issues, compensation issues, legal issues). The data should be summarized in a readable report with appropriate recom-mendations for the clinician. Biobehavioral Care: Integrated Care as the Standard of CareWhile acute pain patients may respond to treatment in a linear and perhaps even dose- dependent manner, chronic pain patients typi-cally do not. But even an acute pain patient with an obvious etiology and disorder may not respond to treatment in a linear manner if preinjury risk factors (eg, signicant oral parafunctional behaviors, fear of reinjury) are present; in fact, the simple injury may result in further activation of those preinjury factors. Unless the initial evaluation sufciently encom-passes both the physical and the biobehavioral domains, the clinician will not know or suspect if there are other factors that might interfere with treatment response. Furthermore, that level of assessment must be maintained at each follow-up as indicated based on patient response to treatment; otherwise, the poor treatment response can be accompanied by more physical treatments, medications, surgi-cal referrals, and so forth. If the patient’s response to treatment can-not be expected to unfold in a linear manner, then the clinician must link the outcomes as-sessment goals for the primary physical do-main with biobehavioral processes. This means that biobehavioral assessment is ongoing—at every follow-up visit, if necessary—just as physical assessment is. When properly done, this ongoing dual-axis assessment allows both the patient and the clinician to see whether the patient is responding appropriately to cur-rent treatment; if not, the direction for addi-tional treatments or consultations should be evident to both the patient and the clinician. In conclusion, the biobehavioral aspect of care must be viewed as central to patient care, not an optional add-on. For example, if physi-cal exercise is part of the treatment but the patient’s mobility is not improving, then the clinician should query this outcome. Consider-ations include inadequate assessment of the physical condition and incorrect execution of the exercises. Other possible causes should also be considered, such as depression, poor time management, avoidance behavior, per-sonality disorder, and a passive coping style, among others. Without an adequate initial biobehavioral assessment, these possible causes of poor treatment outcome cannot be adequately interpreted and managed. Biobehavioral models used in pain medicine across all disorders emphasize the partnership between provider and patient and the critical role that patient behavior plays in managing pain. TMD management can be likened to the management of hypertension in that it is en-hanced through the simultaneous implementa-Biobehavioral Care: Integrated Care as the Standard of Care 26812Axis II: Biobehavioral Considerations12268tion of multiple treatments. For hypertension, these treatments include stress reduction, ex-ercise, weight control, sodium restriction, re-laxation training and biofeedback, and medica-tions. Similarly, for a myofascial pain disorder, multiple self-administered treatments are ef-fective: short-term analgesics, jaw use reduc-tion, and thermal agents as well as longer-term stretching, parafunction control, relaxation training and biofeedback, and stress reduction. Each of these management strategies, from medication to stress reduction, is ultimately about behavioral self-regulation. For a patient to develop mastery in behavioral self-regulation, a biobehavioral model is needed to integrate all aspects of evaluation and treatment into an understandable framework. References1. Engel GL. The need for a new medical model: A chal-lenge for biomedicine. Science 1977;196:129–136.2. Carlson CR. Psychological factors associated with oro-facial pain. Dent Clin North Am 2007;51:145–160.3. Doleys DM. Pain: Dynamics and Complexities. New York: Oxford, 2014.4. Dworkin SF. Illness behavior and dysfunction: Review of concepts and application to chronic pain. Can J Physiol Pharmacol 1991;69:662–671.5. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: Review, criteria, ex-aminations and specications, critique. J Craniomandib Disord 1992;6:301–355.6. Dworkin SF, Von Korff MR, LeResche L. Epidemiologic studies of chronic pain: A dynamic-ecologic perspec-tive. Ann Behav Med 1992;14:3–11.7. Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: Disease or illness? J Prosthet Dent 1994;72:29–38.8. Ohrbach R, List T, Goulet JP, Svensson P. Recommenda-tions from the International Consensus Workshop: Con-vergence on an orofacial pain taxonomy. J Oral Rehabil 2010;37:807–812.9. Dworkin SF, Turner JA, Mancl L, et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain 2002;16:259–276.10. Dworkin SF, Huggins KH, Wilson L, et al. A randomized clinical trial using research diagnostic criteria for tem-poromandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Oro-fac Pain 2002;16:48–63.11. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis EI. Efcacy of an early intervention for patients with acute temporomandibular disorder-related pain: A one-year outcome study. J Am Dent Assoc 2006;137: 339–347.12. Dworkin SF, Sherman JJ, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity, and clinical utility of the research diagnostic criteria for temporo-mandibular disorders Axis II scales: Depression, non-specic physical symptoms, and graded chronic pain. J Orofac Pain 2002;16:207–220.13. Ohrbach R, Turner JA, Sherman JJ, et al. Research di-agnostic criteria for temporomandibular disorders. IV: Evaluation of psychometric properties of the Axis II measures. J Orofac Pain 2010;24:48–62.14. Truelove E, Pan W, Look JO, et al. The research diagnos-tic criteria for temporomandibular disorders. III: Validity of Axis I diagnoses. J Orofac Pain 2010;24:35–47.15. Schiffman EL, Ohrbach R, Truelove EL, et al. The re-search diagnostic criteria for temporomandibular disor-ders. V: Methods used to establish and validate revised Axis I diagnostic algorithms. J Orofac Pain 2010;24: 63–78.16. Maixner W, Diatchenko L, Dubner R, et al. Orofacial pain prospective evaluation and risk assessment study: The OPPERA study. J Pain 2011;12(11 suppl):T4–T11.17. Greenspan JD, Slade GD, Bair E, et al. Pain sensitivity risk factors for chronic TMD: Descriptive data and em-pirically identied domains from the OPPERA case control study. J Pain 2011;12(11 suppl):T61–T74.18. Maixner W, Greenspan JD, Dubner R, et al. Potential autonomic risk factors for chronic TMD: Descriptive data and empirically identified domains from the OPPERA case-control study. J Pain 2011;12(11 suppl): T75–T91.19. Slade GD, Bair E, By K, et al. Study methods, recruit-ment, sociodemographic ndings, and demographic representativeness in the OPPERA study. J Pain 2011; 12(11 suppl):T12–T26.20. Smith S, Maixner D, Greenspan JD, et al. Potential ge-netic risk factors for chronic TMD: genetic associations from the OPPERA case control study. J Pain 2011;12(11 suppl):T92–T101.21. Fillingim RB, Slade GD, Diatchenko L, et al. Summary of ndings from the OPPERA baseline case-control study: Implications and future directions. J Pain 2011; 12(11 suppl):T102–T107.22. Fillingim RB, Ohrbach R, Greenspan JD, et al. Potential psychosocial risk factors for chronic TMD: Descriptive data and empirically identified domains from the OPPERA case-control study. J Pain 2011;12(11 suppl)T46–T60.23. Ohrbach R, Fillingim RB, Mulkey F, et al. Clinical nd-ings and pain symptoms as potential risk factors for chronic TMD: Descriptive data and empirically identi-ed domains from the OPPERA case-control study. J Pain 2011;12(11 suppl):T27–T45. 269269References24. Ohrbach R, Bair E, Fillingim RB, et al. Clinical orofacial characteristics associated with risk of rst-onset TMD: The OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T33–T50.25. Smith SB, Mir E, Bair E, et al. Genetic variants associ-ated with development of TMD and its intermediate phenotypes: The genetic architecture of TMD in the OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T91–T101.26. Bair E, Brownstein NC, Ohrbach R, et al. Study proto-col, sample characteristics and loss to follow-up: The OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T2–19.27. Bair E, Ohrbach R, Fillingim RB, et al. Multivariable modeling of phenotypic risk factors for rst-onset TMD: The OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T102–115.28. Fillingim RB, Ohrbach R, Greenspan JD, et al. Psycho-social factors associated with development of TMD: The OPPERA prospective cohort study. J Pain 2013; 14(12 suppl):T75–90.29. Greenspan JD, Slade GD, Bair E, et al. Pain sensitivity and autonomic factors associated with development of TMD: The OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T63–74.30. Slade GD, Bair E, Greenspan JD, et al. Signs and symp-toms of rst-onset TMD and sociodemographic predic-tors of its development: The OPPERA prospective co-hort study. J Pain 2013;14(12 suppl):T20–T32.31. Slade G, Sanders A, Bair E, et al. Preclinical episodes of orofacial pain symptoms and their association with healthcare behaviors in the OPPERA prospective co-hort study. Pain 2013;154:750–760.32. Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Resh 2013;92(7 suppl): 70S–77S.33. Slade GD, Fillingim RB, Sanders AE, et al. Summary of ndings from the OPPERA prospective cohort study of incidence of rst-onset temporomandibular disorder: Implications and future directions. J Pain 2013;14(12 suppl):T116–T124.34. Slade GD, Smith SB, Zaykin DV, et al. Facial pain with localized and widespread manifestations: Separate pathways of vulnerability. Pain 2013;154:2335–2343.35. Sanders AE, Slade GD, Bair E, et al. General health sta-tus and incidence of rst-onset temporomandibular disorder: The OPPERA prospective cohort study. J Pain 2013;14(12 suppl):T51–62.36. Slade GD, Ohrbach R, Greenspan JD, et al. Painful tem-poromandibular disorder: Decade of discovery from OPPERA studies. J Dent Res 2016;95:1084–1092.37. American Psychiatric Association. Diagnostic and Sta-tistical Manual of Mental Disorders, ed 5. Washington, DC: American Psychiatric Association, 2013.38. Ohrbach R, Dworkin SF. The evolution of TMD Diagno-sis: Past, present, future. J Dent Res 2016;95:1093–1101.39. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6–27.40. Cairns B, List T, Michelotti A, Ohrbach R, Svensson P. JOR-CORE recommendations on rehabilitation of tem-poromandibular disorders. J Oral Rehabil 2010;37: 481–489.41. Epker J, Gatchel RJ, Ellis EI. A model for predicting chronic TMD: Practical application in clinical settings. J Am Dent Assoc 1999;130:1470–1475.42. Oakley ME, McCreary CP, Flack VF, Clark GT, Solberg WK, Pullinger AG. Dentists’ ability to detect psychologi-cal problems in patients with temporomandibular dis-orders and chronic pain. J Am Dent Assoc 1989;118: 727–730.43. Schiffman E, Ohrbach R. Executive summary of the diagnostic criteria for temporomandibular disorders for clinical and research applications. J Am Dent Assoc 2016;147:438–445.44. Turner JA, Dworkin SF. Screening for psychosocial risk factors in patients with chronic orofacial pain: Recent advances. J Am Dent Assoc 2004;135:1119–1125.45. Durham J, Raphael KG, Benoliel R, Ceusters W, Michelotti A, Ohrbach R. Perspectives on next steps in classication of oro-facial pain: Part 2: Role of psycho-social factors. J Oral Rehabil 2015;42:942–955.46. Anderson GC, Gonzalez YM, Ohrbach R, et al. The re-search diagnostic criteria for temporomandibular disor-ders. VI: Future directions. J Orofac Pain 2010;24: 79–88.47. Palla S. Biopsychosocial pain model crippled? J Orofac Pain 2011;25:289–290.48. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–149.49. Dworkin SF. Psychosocial issues. In: Sessle B, Lavigne GJ, Lund JP, Dubner R (eds). Orofacial Pain: From Basic Science to Clinical Management. Chicago: Quintes-sence, 2001:115–127.50. Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics 2009;50:613–621.51. Beck AT, Steer RA. Beck Anxiety Inventory. San Antonio, TX: The Psychological Corporation, 1993.52. Spielberger CD, Gorsuch RL. State-Trait Anxiety Inven-tory. Palo Alto, CA: Consulting Psychologists Press, 1983.53. Steer RA. Beck Depression Inventory. San Antonio, TX: The Psychological Corporation; 1978.54. Ohrbach R, Larsson P, List T. The jaw functional limita-tion scale: Development, reliability, and validity of 8-item and 20-item versions. J Orofac Pain 2008; 22:219–230. 27012Axis II: Biobehavioral Considerations1227055. Markiewicz MR, Ohrbach R, McCall WD Jr. Oral behav-iors checklist: Reliability of performance in targeted waking-state behaviors. J Orofac Pain 2006;20: 306–316.56. Ohrbach R, Markiewicz MR, McCall WD Jr. Waking- state oral parafunctional behaviors: Specicity and va-lidity as assessed by electromyography. Eur J Oro Sci 2008;116:438–444.57. Curran SL, Sherman JJ, Cunningham LL, Okeson JP, Reid KI, Carlson CR. Physical and sexual abuse among orofacial pain patients: Linkages with pain and psycho-logic distress. J Orofac Pain 1995;9:340–346.58. De Leeuw R, Bertoli E, Schmidt JE, Carlson CR. Preva-lence of post-traumatic stress disorder symptoms in orofacial pain patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:558–568.59. Sherman JJ, Carlson CR, Wilson JF, Okeson JP, McCubbin JA. Post-traumatic stress disorder among patients with orofacial pain. J Orofac Pain 2005;19: 309–317.60. Dworkin SF, Burgess JA. Orofacial pain of psychogenic origin: Current concepts and classication. J Am Dent Assoc 1987;115:565–571.61. Rugh JD, Davis SE. Temporomandibular disorders: Psy-chological and behavioral aspects. In: Sarnat BG, Laskin DM, eds. The Temporomandibular Joint: A Biological Basis for Clinical Practice. Philadelphia: WB Saunders, 1992:329–345.62. Bertrand PM. Management of facial pain. Oral Maxil-lofacial Surgery Knowledge Update 2001;3:79–109.63. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Proj-ect (ACQUIP). Alcohol Use Disorders Identication Test. Arch Intern Med 1998;158:1789–1795.64. Durham J, Ohrbach R. Oral rehabilitation, disability and dentistry. J Oral Rehabil 2010;37:490–494.65. Romano JM, Turner JA, Moore JE. Psychological evalu-ation. In: Tollison CD, Satterthwaite JR, Tollison JW, Trent CG (eds). Handbook of Chronic Pain Manage-ment. Baltimore: Williams & Wilkins, 1989:38–51.66. Gatchel RJ, Garofalo JP, Ellis E, Holt C. Major psycho-logical disorders in acute and chronic TMD: An initial examination. J Am Dent Assoc 1996;127:1365–1374.67. Kinney RK, Gatchel RJ, Ellis E, Holt C. Major psycho-logical disorders in chronic TMD patients: Implications for successful management. J Am Dent Assoc 1992; 123:49–54.68. Kight M, Gatchel RJ, Wesley L. Temporomandibular disorders: Evidence for signicant overlap with psycho-pathology. Health Psychol 1999;18:177–182.69. Korszun A, Hinderstein B, Wong M. Comorbidity of de-pression with chronic facial pain and temporomandibu-lar disorders. Oral Surg Oral Med Oral Pathol Oral Ra-diol Endod 1996;82:496–500.70. Wurtele SK, Kaplan GM, Keairnes M. Childhood sexual abuse among chronic pain patients. Clinical J Pain 1990;6:110–113.71. Heit HA. The truth about pain management: The differ-ence between a pain patient and an addicted patient. Eur J Pain 2001;5(suppl A):27–29.72. Weissman DE. Understanding pseudoaddiction. J Pain Symptom Manage 1994;9:74.73. Shorter E. From Paralysis to Fatigue: A History of Psy-chosomatic Illness in the Modern Era. New York: The Free Press, 1992.74. Dworkin SF. Somatization, distress and chronic pain. Qual Life Res 1994;3(suppl 1):S77–S83.75. Wilson L, Dworkin SF, Whitney C, LeResche L. Somati-zation and pain dispersion in chronic temporomandibu-lar disorder pain. Pain 1994;57:55–61.76. Kassirer JP, Kopelman RI. Learning Clinical Reasoning. Baltimore: Williams & Wilkins, 1991. GAnt, antonymSyn, synonymAabducens nerve motor cranial nerve (CN VI) supplying the lateral rectus muscle of the eyeabduction turning outward or laterally. Ant: Adduction.ablation removal or detachment of a body part, usually by surgeryabrasion, tooth wearing away of the tooth structure by tooth-to-tooth contact; in contrast with chemical erosion or attritionabscess localized collection of pus within preformed cavities formed by tissue disintegrationacceleration-deceleration injury. See Flexion-extension injury.accommodation adjustment of the focus of the eye for various distances; also the rise in threshold of a nerve during constant, direct stimulationacoustic meatus external cartilaginous and internal bony auditory canal that leads to the tympanic membrane. Syn: External audi-tory meatus.acoustic myography electronic recording of muscle sounds, re-ecting the mechanical component of muscle contractionacoustic nerve sensory cranial nerve (CN VIII) with cochlear (hear-ing) and vestibular (equilibrium) bersacoustic neuroma benign tumor within the auditory canal arising from the acoustic nerve (CN VIII); frequently causes headache, hearing loss, tinnitus, facial pain, or numbnessacquired disorder postnatal aberration, change, or disturbance of normal development or condition that is not congenital but in-curred after birthacromegaly chronic metabolic condition caused by overproduction of growth hormone in the anterior pituitary gland and charac-terized by a gradual and marked elongation and enlargement of bones and soft tissues of the distal portion of the face, maxilla and mandible, and extremitiesactivation, muscle energy release in muscle tissue resulting in muscle contractionactivation, nerve depolarization of a neuronactive resistive stretch motion voluntarily forced against resist-ance of muscle, tendons, capsule, or intra-articular structuresactive trigger point. See Myofascial trigger point: active.Glossary 272GlossaryGacupuncture traditional Chinese practice of inserting needles into specic points along the meridians of the body to induce anesthesia, to alleviate pain, or for thera-peutic purposes; experimental evidence shows that acupuncture produces an an-algesic effect by triggering the release of enkephalin, a naturally occurring endorphin that has opiate-like effects. See Endorphin, Enkephalin.acute malocclusion sudden alteration in the occlusal condition secondary to a disorder that is either perceived by the patient or clinically apparentacute onset development that is sudden and recent. Ant: Insidious onset.acute pain unpleasant sensation with a dura-tion limited to the normal healing time or the time necessary for neutralization of the initiating or causal factorsadamantinoma. See Ameloblastoma.adaptation the progressive adjustive changes in sensitivity that regularly accompany con-tinuous sensory stimulation or lack of stim-ulation; the process by which an organism responds to stress in its environmentadaptive capacity relative ability to adjust to any type of change. Syn: Adaptive potential, Adaptive response.adaptive potential. See Adaptive capacity.adaptive response. See Adaptive capacity.addiction, substance a state characterized by an overwhelming compulsion to continue use of a substance and to obtain it by any means, with a tendency to increase the dosage; a psychologic and usually a physi-cal dependence on its effects; a detrimental effect on the individual and society; com-pare with dependenceadduction turning inward or medially. Ant: Abduction.A𝛅 pain fibers thinly myelinated pain- conducting nerve bers 1 to 4 µm in diam-eteradenocarcinoma malignant adenomaadenopathy any disease of the glands, espe-cially of the lymphatic system, usually char-acterized by enlargementadherence binding, clinging, or sticking to-gether of opposing surfacesadhesion molecular attraction between ad-jacent surfaces in contact; the abnormal brous joining of adjacent structures fol-lowing an inammatory process or as the result of injury repaircapsular a. brosis of the capsular tissues of a jointbrous a. See Adhesion: intracapsular.intracapsular a. brosis between intra- articular surfaces within a joint capsule, resulting in reduced mobility of the joint. Syn: Fibrous ankylosis.adjunctive therapy a supplemental proce-dure beyond the primary course of therapyaffect in psychology, the emotional reactions or feelings associated with an experience or mental stateafferent neural pathway nerve impulses transmitted from the periphery toward the central nervous systemagenesis defective development or absence of a body partageusia absence or impairment of the sense of tasteagonist muscle principally responsible for a particular movement; in pharmacology, a drug that acts at receptors on cells that are normally activated by a natural substance. Ant: Antagonist.-al [sufx] pertaining to-algia [sufx] painalgogenic causing painalgometer instrument for measuring the de-gree of sensitivity to painful stimulipressure a. instrument for reliably record-ing the pain pressure reaction point or pain pressure thresholdallo- [prex] otherallodynia pain due to a stimulus that does not normally provoke painallostasis adaptation of neural, neuroendo-crine, and immune mechanisms in the face of stressors alveolar pertaining to the alveolar process of the mandible, including the tooth sockets, supporting bone, and associated connec-tive tissuesameloblastoma benign tumor of odonto-genic epithelial origin. Syn: Adamantinoma. 273Glossaryanalgesia absence of pain in response to stimulation that would normally be painfulanalgesic agent that removes pain without loss of consciousness; relieving pain or in-sensitive to painanamnestic pertaining to medical and psy-chosocial history and past or current symp-tom state as recalled by the patientAnamnestic Dysfunction Index epidemio-logic symptom severity scale based on the history of disease or injury (Helkimo index)anastomosis a connection between two sep-arate structuresanesthesia absence of all feeling or sensa-tion, especially paina. dolorosa pain in an area or region that is anestheticblock a. regional anesthesia resulting from an anesthetic injected into or near a nerve trunkcentral a. anesthesia due to central block-ing of nerve impulses or a disease of the nerve centersgeneral a. drug-induced unconscious state typically used for surgical procedureslocal a. anesthesia due to local blocking of nerve impulses in a limited part of the bodyregional a. analgesia of a body part due to proximal blocking of nerve impulses by local anestheticaneurysm a sac lled with uid or clotted blood formed by widening of the wall of an artery, a vein, or the heartsaccular a. an unusual, localized widened area affecting only part of the circumfer-ence of the arterial wallangular cheilitis inammation of the corners of the mouth usually due to candidiasisankylosing spondylitis ossication of the spinal ligament resulting in a bony encase-ment of the joint; more common in boys; onset most often between 9 and 12 years of age. Syn: Spondylosis.ankylosis stiffening or immobilization of a joint as the result of disease, trauma, or congenital process with bony union across the joint; also, brosis without bony union; compare with adhesionbony a. osseous union of adjacent, usually movable, body parts. Syn: Synostosis, True ankylosis.dental a. fusion of the tooth to the sur-rounding bony alveolus due to ossica-tion of the periodontal membraneextracapsular a. rigidity of the periarticular tissues resulting in joint stiffness or im-mobilization. Syn: False ankylosis.brous a. See Adhesion: intracapsular.osseous a. characterized by radiographic evidence of bone proliferation with marked deection to the affected side and marked limited laterotrusion to the contralateral sideanorexia diminished appetite or aversion to fooda. nervosa psychiatric disorder character-ized by distortions in body image and aversion to food, resulting in extreme weight loss and amenorrhea in women; usually occurring in young womenANS. See Autonomic nervous system.ansa hypoglossi also known as the ansa cer-vicalis; a nerve loop supplying the infrahy-oid muscles formed by descending bers of the hypoglossal nerve, the superior nerve root to C1 and C2, and inferior root to C2 and C3antagonist muscle whose function is oppo-site the agonist or prime mover; in phar-macology, a drug that diminishes the ef-fect of another drug or naturally occurring substance through stimulation at the same receptor sites. Ant: Agonist.anterior bite plate a hard acrylic resin appli-ance that provides for occlusal contact only between the anterior teethanterior repositioning appliance, mandibu-lar intraoral device that guides or positions the mandible to a position forward of maxi-mal intercuspationanticholinergic an agent that blocks the ac-tion of acetylcholine in the central and pe-ripheral parasympathetic nerves; the action of that agentanticonvulsant an agent used to control or prevent convulsions; the action of that agent 274GlossaryGantidepressant an agent used to treat de-pression; the action of that agentantidromic conducting impulses in the direc-tion opposite normalantidromic release secretion of chemicals and neurotransmitters at the receptor that occurs with antidromic nerve activityantinuclear antibody (ANA) antibody di-rected against nuclear antigens, found primarily in the serum of patients with systemic lupus erythematosus but also in patients with rheumatoid arthritis, scle-roderma, and other connective tissue disordersantipyretic an agent that brings about fever reduction; the action of that agentanxiety feeling of apprehension, uncertainty, or dread of a future threat or danger, ac-companied by tension or uneasinessanxiety disorder a category of mental illness that includes obsessive-compulsive disor-der, posttraumatic stress disorder, phobia, and panic disorder, the symptoms of which are not relieved by reassurance, with result-ing limitations in adaptive functioningaphasia inability to speak or comprehend written or spoken language; caused by brain injury or lesions or of psychogenic originaplasia incomplete or arrested development of a structure due to failure of normal devel-opment of the embryonic primordiumapnea temporary cessation of breathingaponeurosis at, brous tendon sheath that invests and attaches muscle to bone or other tissueappliance device or prosthesis used to pro-vide or facilitate a particular function or therapyArnold-Chiari malformation a structural mal-formation of the brainstem and dura caused by herniation of the cerebellar tonsils 3 to 5 mm below the foramen magnum or cau-dally to C2arteriovenous malformation altered mor-phology, weakening, or distension of an artery or vein; arteritis; inammation of an arteryarteritis cranial manifestation of giant cell arteritis characterized by fever, anorexia, weight loss, leukocytosis, tenderness over the scalp and along facial and temporal arteries, headache, and jaw claudication; may lead to blindness; uncommon before the age of 60 years; associated with signi-cantly elevated erythrocyte sedimentation rate. Syn: Cranial arteritis, Giant cell arteri-tis, Temporal arteritis.arthralgia pain of joint origin affected by jaw movement, function, or parafunction and replication of this pain with provocation testingarthritis [pl: arthritides] pain of joint origin with clinical characteristics of inammation or infection: edema, erythema, and/or in-creased temperaturearthrocentesis puncture of a joint with a nee-dle or a catheter, followed by removal of uidarthrodial pertaining to gliding movement by two adjacent surfacesarthrodial joint joint that allows gliding move-ment of the partsarthrogenous pain pain originating from joint structuresarthrogram radiograph of a jointarthrography visualization of a joint by radio-paque contrast and radiographyarthrogryposis xation of a joint in a exed or contracted position that may be related to innervation, muscles, or connective tissuearthrokinematics, TMJ the description of the movement between joint surfacesarthrokinetics, TMJ temporomandibular joint motion. Syn: Arthrokinematics, TMJ.arthropathy any disease or disorder that af-fects a jointarthroplasty surgical repair or plastic recon-struction of a jointarthroscopy direct visualization of a joint with an endoscopearthrosis disease of a joint evidenced by bony alterations of a joint or articulationarthrotomography tomographic radiography of a jointarthrotomy surgical incision of a jointarticular pertaining to a jointa. disc. See Disc: intra-articular.a. remodeling. See Remodeling. 275Glossarya. capsule brous connective tissue sac that encloses a synovial joint and limits its motionarticulate in dentistry, the state of the teeth being brought together into occlusionarticulation, TMJ. See Temporomandibular joint.articulator mechanical device for attachment of dental casts that allows movement of the casts into various eccentric relation-ships to represent jaw movementasthenia weakness or lack of energyasymmetry lack of symmetry due to inequal-ity in size, shape, movement, or function between two corresponding parts on op-posite sides of the bodyataxia impaired ability to coordinate move-ment or neuromuscular dysfunctionatrophy progressive decline in size or wasting away of tissue, organ, or body part, often due to denervation, disease, aging, lack of use, or malnutrition. Ant: Hypertrophy.attrition wearing away by friction or rubbing; a wearing away of tooth structures due to bruxismatypical facial pain. See Persistent idiopathic facial pain.atypical odontalgia. See Persistent idio-pathic facial pain.atypical tooth pain. See Persistent idiopathic facial pain.aura a subjective sensation (as of voices, colored lights, or crawling and numbness) experienced at the onset of a neurologic condition and especially a migraine or epi-leptic seizureauricle visible portion of the external ear. Syn: Pinna.auriculotemporal nerve sensory branch of the mandibular division of the trigeminal nerve; innervates the external acoustic meatus, the tympanic membrane, the lat-eral aspect of the TMJ capsule, the parotid sheath, the skin of the auricle, and the templeauriculotemporal neuralgia. See Neuralgia: auriculotemporal.auscultation the diagnostic technique of lis-tening for sounds within the bodyautogenous graft graft using one part of a patient’s body for anotherautoimmune disorder disease in which the body produces a disordered immunologic response against itself, causing tissue in-jury; eg, rheumatoid arthritis, sclerodermaautologous occurring naturally or normally within a structure or tissueautonomic effects of central excitation sec-ondary stimulation of internuncial neurons during pain, leading to transmission of ef-ferent autonomic impulses that produce effects that differ from those normally as-sociated with the physiology of painautonomic nervous system (ANS) a division of the peripheral nervous system distrib-uted to smooth muscle and glands through-out the body, comprising the sympathetic and parasympathetic nervous systems, involved in motor (efferent) transmission, functioning independently of conscious controlavascular lacking in blood vesselsavascular necrosis (AVN) bone infarction not associated with asepsis but with circulatory impairment (vascular occlusion), leading to bone necrosis and collapse of joint surface into underlying infarctionaxon long myelinated or unmyelinated portion of a nerve cell that transmits information from the nerve cell bodyBbehavior actions or reactions under specic circumstancesbehavior modication psychotherapy that attempts to modify observable patterns of behavior by the substitution of a new re-sponse to a given stimulusBell’s palsy peripheral facial paralysis due to lesion of the facial nerve (CN VII)benign mild, nonprogressive, nonrecurrent, and nonmalignant character of a tumorbenign masseteric hypertrophy nonma-lignant increase in size or bulk of masse-ter muscles of unknown etiology, usually bilateralbenign migratory glossitis. See Geographic tongue. 276GlossaryGbiobehavioral behavioral factors as they contribute to the functioning of biologic systemsbiofeedback training therapy that teaches the voluntary modication of physiologic activity or autonomic function using equip-ment that gives a visual or auditory repre-sentation of the activity or functionbiomechanical pertaining to the application of mechanical laws, such as those relating to intrinsic or extrinsic force, to living struc-tures, in particular, the locomotor systembiopsychosocial the complex interactions between biology, psychologic states, and social conditions that bring about and/or maintain function and dysfunctionbite guard misnomer. See Stabilization appli-ance.blepharospasm tonic spasm of the orbicula-ris oculi producing more or less complete closure of the eyelidbody dysmorphic disorder (BDD) preoccu-pation with a defect in appearance that is imagined; markedly excessive concern over a slight physical anomalyborder movements movements of the man-dible at the boundary or margin of the en-velope of movement as determined by the joint anatomy, joint capsule, ligaments, and associated musclesbrachycardia. See Bradycardia.brachycephalic head form that is rounded and short in the anteroposterior direction and broad in widthbracing. See Bruxism.bradycardia abnormally slow pulse rate (< 60 beats/min) bradykinesia abnormally slow movementbradykinin plasma kinin that is a potent vaso-dilator and incites painbrainstem neural tissue that connects cer-ebral hemispheres with the spinal cord, comprising the medulla oblongata, pons, and midbrainbreathing-related sleep disorder disorder characterized by interruptions of sleep due to breathing-related medical condi-tions such as obstructive or central sleep apnea or central alveolar hypoventilation syndromeBriquet syndrome. See Somatic symptom disorder.bruxism a repetitive jaw-muscle activity char-acterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible; can occur during sleep (sleep bruxism) or during wakefulness (awake bruxism)burning mouth syndrome (BMS) dyses-thesia described as a burning sensation in the oral cavity occurring in the absence of clinically apparent mucosal abnormalities or laboratory ndings and often perceived as painful bursa saclike cavity found in connective tis-sue at places where friction would other-wise develop; lined with synovial mem-brane and lled with viscous synovial uid. See Synovial joint.bursitis inammation of a bursaCcalcied cartilage zone calcied tissue be-tween the articular soft tissue and the sub-chondral bone in synovial jointscalcium pyrophosphate dehydrate crystals mineral deposits in synovial uid of joints with chondrocalcinosiscanine rise. See Canine-protected occlusion.canine-protected occlusion occlusion where the canine acts as the sole discluder in latero-trusion. Syn: Canine-protected articu lation.capsular pertaining to the joint capsulecapsular brosis. See Adhesion: capsular.capsular ligament, TMJ a ligament that sep-arately encapsulates the upper and lower TMJ synovial membranecapsule, joint. See Articular capsule.capsulitis inammation of a capsule, its as-sociated capsular ligaments, or the disc at-tachments in response to mechanical irrita-tion or systemic diseaseadhesive c. adhesion and restriction of joint motion due to reduced joint space volume and swollen synovial mem-branes during a joint capsulitis conditioncarotid artery principal artery of the neck supplying the neck, face, skull, brain, mid-dle ear, pituitary gland, orbit, and choroid 277Glossaryplexus of the lateral ventricle; the paired common carotid divides at the upper border of the thyroid cartilage into the external and internal carotid arteriescarotidynia pain due to inammation of the carotid artery, usually self-limitingcartilage dense brous connective tissue covering most articular surfaces and some parts of the skeletonarticular c. a thin layer of cartilage located on the joint surfaces of some bonesbrous c. the articulating surface cartilage found in the TMJ, which has a greater ability to repair itself and is more resist-ant to stress, also called brocartilage hyaline c. the articulating surface cartilage found in most synovial jointscast, dental a model or representation of the teeth and supporting bone, usually made of stone or plaster. Syn: Diagnostic cast, Study cast, Study model.catecholamines biogenic amines with a sym-pathomimetic actioncaudal inferior, toward the tail. Syn: Inferior; Ant: Cephalad.causalgia. See Complex regional pain syn-drome II (CRPS II).cellulitis a diffuse inammatory process that spreads along fascial planes and through cellular tissue spaces, especially the sub-cutaneous tissuesacute c. cellulitis accompanied by swelling, suppuration, and painchronic c. cellulitis with little swelling or paincentral excitation effects. See Autonomic ef-fects of central excitation.central nervous system (CNS) the brain and spinal cordcentral pain pain initiated or caused by a pri-mary lesion or dysfunction in the central nervous system1; also, pain resulting from damage to the central nervous system; eg, thalamic syndrome and spinal cord injury paincentric occlusion (CO) the occlusion of op-posing teeth when the mandible is in cen-tric relation; this may or may not coincide with the maximal intercuspal position2centric relation (CR) a maxillomandibular relationship, independent of tooth con-tact, in which the condyles articulate in the anterior-superior position against the poste-rior slopes of the articular eminences2cephalad superior, toward the head. Syn: Cra-nial rostral, superior; Ant: Caudal.cephalalgia pain or ache in the head. Syn: Headache.cephalic pertaining to the head or structure of the headcephalogram radiograph of the headcerebral ischemia deciency in blood supply to part of the brain due to constriction or actual obstruction of blood vesselcerebral palsy motor function disorder caused by a permanent, nonprogressive brain defect or lesion present at birth or shortly thereafter; deep tendon reexes are exaggerated, ngers are often spastic, and speech may be slurredcervical pertaining to the neckcervical plexus network of nerves formed by the ventral branches of the upper four cervi-cal nervescervical spine disorder (CSD) a category of disorders involving the muscles, facet joints, discs, and nerves of the cervical spine cervicalgia pain of the structures of the neck, including referred pain from noncervical origin cervicogenic originating in the structures of the neckcervicogenic headache headache character-ized by a moderately severe, dull, dragging, unilateral headache without side-shift, pro-voked or aggravated by neck movements and accompanied by any of the following symptoms: lacrimation, conjunctival hyper-emia, dizziness, nausea, vomiting, and sen-sitivity to light and noisechief complaint (CC) the patient’s statement of the main problem or primary concernchondritis inammation of cartilagechondroblastoma benign tumor, derived from precursors of cartilage cells, some-times showing scattered areas of calcica-tion and necrosis 278GlossaryGchondrocalcinosis a recurrent arthritic dis-ease in which calcied deposits of calcium hypophosphate crystals collect in synovial uid, articular cartilage, and adjacent soft tissues, leading to gout-like attacks of pain and swelling of the involved joints. Syn: Pseudogout, Pyrophosphate arthropathy.chondroma benign cartilaginous tumorchondromalacia softening of cartilage, some-times accompanied by swelling, pain, and degenerationchondron cell cluster in the cartilaginous zone of the articular cartilagechondrosarcoma malignant tumor of carti-laginous cells or their precursors that may contain nodules of calcied hyaline cartilagechorea a convulsive nervous disease with in-voluntary and irregular jerking movementschronic overlapping pain conditions (COPCs) common coexisting pain conditions; eg, TMD, fibromyalgia, headache, irritable bowel syndromechronic pain pain that persists when other as-pects of disorder or disease have resolved and typically lasts more than 6 months or beyond the normal time for healing of an acute injury or pain; may have associated unpleasant sensory, perceptual, and emo-tional experiences accompanied by behav-ioral and psychosocial responsesclaudication muscle ischemia due to de-creased arterial blood ow to an area caus-ing intermittent painclenching. See Bruxism.clicking joint noise, TMJ distinct snapping or popping sound emanating from the TMJ during joint movement or with joint compressionreciprocal c.j.n., TMJ a pair of clicks, one of which usually occurs during opening at a different location than the second one, which occurs during closing move-ments of the jaw; associated with disc displacement with reductionclock-regulated treatment at regular inter-vals; eg, every 6 hoursclosed lock. See Disc displacement: without reduction with limited opening.cluster headache severe unilateral head and facial pain, often accompanied by involun-tary lacrimation, with localized extracranial vasodilatation in the periorbital region con-tributing to the pain and conjunctival con-gestion; occurs in bouts or clusters, some-times with clockwork regularity, usually occurring during the night and lasting 30 to 120 minutes. Syn: Histaminic cephalalgia, Horton headache, Horton syndrome.CNS. See Central nervous system.cocontraction reexive contraction of antag-onist muscles resulting from noxious stim-uli of a sensory eld of a joint, soft tissue, or other structure to prevent movement or provide stabilization of the painful area tis-sues. Syn: Protective muscle splinting.cognition the mental process of knowing, thinking, learning, and judgingcognitive behavioral therapy (CBT) therapy focused on changing attitudes, assump-tions, perceptions, and patterns of thinkingcollagen disease. See Connective tissue: disorders.collateral ligaments, TMJ paired supportive ligaments on the lateral and medial aspects of the TMJ capsule, attaching the articular disc to the mandibular condyle; the liga-ments allow rotational disc movement in an anterior-posterior axis onlycomplex regional pain syndrome I (CRPS I) pain syndrome with onset often after trau-matic event; symptoms are not limited to the distribution of a peripheral nerve and are disproportional to the injury; edema, decreased cutaneous blood ow, atrophy of the skin, hair, and nails, autonomic changes in the region of the pain, hyperalgesia, or allodynia may occur at some time in the course of development; formerly reex sympathetic dystrophy (RSD)complex regional pain syndrome II (CRPS II) a syndrome of persistent severe burning sensation, allodynia, and hyperpathia, usu-ally following partial injury of a peripheral nerve and combined with vasomotor and pseudomotor dysfunction; later, the con-dition is usually accompanied by trophic changes to the skin, hair, and nails; formerly causalgia1compression of joint pressing together of joint surfaces 279Glossarycomputer-assisted tomography misnomer. See Tomography: computed.computerized axial tomography misnomer. See Tomography: computed.computerized tomography (CT) misnomer. See Tomography: computed.computerized transaxial tomography mis-nomer. See Tomography: computed.conditioned pain modulation a neuronal mechanism where pain inhibits pain at all levels in the CNScondylar agenesis developmental abnor-mality characterized by the absence of a condylecondylar fracture fracture of the head or neck of the mandibular condyle, further charac-terized as intracapsular or extracapsular, displaced or nondisplacedcondyle rounded, articular end of a bonecondylectomy surgical removal of the entire condylecondylolysis. See Condylysis.condylotomy surgical division or reshaping of a condylecondylysis idiopathic resorption or dissolu-tion of a condyle. Syn: Condylolysis.congenital disorder developmental disorder present at or before birthconjunctiva mucous membrane covering the anterior surface of the eyeball and lining the eyelidsconjunctival injection dilation of the vascula-ture of the conjunctivaconnective tissue tissue of mesodermal ori-gin that supports and binds other tissues; includes elastic or collagenous brous con-nective tissue, bone, and cartilage; con-nective tissues are highly vascular with the exception of cartilagec.t. disorders a group of connective tis-sue diseases of unknown etiology shar-ing common anatomical and clinical features. Syn: Collagen disease, Mixed connective tissue disease. continuous passive motion (CPM) cyclic motion of a body part caused by another in-dividual or machine that moves an articula-tion through a determined range of motioncontraction normal shortening, tightening, or reduction in size or length of a muscle bercontracture abnormal shorteningcapsular c., TMJ. See Adhesion: capsular.muscular c. sustained increased resist-ance to passive muscle stretch due to reduced muscle lengthmyobrotic c. muscular contracture re-sulting from excessive brosis of the muscle, usually as a sequela of trauma or infectionmyostatic c. muscular contracture result-ing from reduced muscle stimulationcontralateral pertaining to the opposite side. Ant: Ipsilateral.contrast medium radiopaque material in-jected before imaging that renders certain tissues or spaces opaquecontributing factor condition or action that contributes to the occurrence or aggrava-tion of a disease or disordercontusion of joint traumatic joint bruising characterized by acute synovitis, effusion, and possible hemarthrosis, but without fractureconvergence, neural the synapsing of a neu-ron with several othersconversion disorder mental disorder char-acterized by disturbances in sensory and motor function, due to unconscious needs and conicts, in the absence of organic diseasecoping mechanisms cognitive and behavioral efforts to manage specic tasks, problems, or situationscordotomy an operation to divide bundles of nerve bers within the spinal cord to relieve chronic pain; usually performed in cases where pain has not responded to more conservative treatmentscoronal pertaining to the crown of the head or tooth or the coronal suture of the skullcoronal plane. See Frontal plane.coronoid hyperplasia benign overgrowth of the coronoid process of the mandible that may result in limited jaw opening when its movement is obstructed by the zygomatic processcoronoid process conical process on the anterosuperior surface of the mandibular ramus that serves as the attachment of the temporalis muscle 280GlossaryGcoronoid process impingement restricted jaw movement due to coronoid hyperplasiacortical bone dense, solid outer layer of a bone that surrounds the medullary cavitycorticosteroid a crystalline steroid found in the adrenal cortexCosten syndrome syndrome of dizziness, tinnitus, earache, stufness of the ear, dry mouth, burning in the tongue and throat, sinus pain, and headaches that an otolaryn-gologist in 1934 attributed to overclosure of the bite and posterior displacement of the mandibular condylecracked tooth syndrome set of symptoms including sporadic, sharp, momentary pain on biting or releasing along with occasional pain from cold food or drink due to incom-plete fracture of the toothcranial. See Cephalad. cranial arteritis. See Arteritis. cranial nerves (CNs) twelve pairs of nerves that have their origin in the braincranial neuralgia. See Neuralgia: cranial.craniocervical relating to both the cranium and the neckcraniofacial relating to both the face and the craniumcraniomandibular. See Temporomandibular.craniomandibular disorders (CMDs). See Temporomandibular disorders.cranium the bones of the skull that encase the braincrepitation rough, sandy, diffuse noise or vi-bration produced by the rubbing together of irregular bone or cartilage surfaces, usually identied with osteoarthritic changes when heard in joints. Syn: Crepitus, Grating.crepitus. See Crepitation.crossbite condition in which normal labiolin-gual or buccolingual relationship between the maxillary and mandibular teeth is reversedcryoanalgesia application of extreme cold to an affected nerve to deliberately disrupt its ability to transmit pain signalscryotherapy a peripheral ablative procedure in which the offending trigeminal branch is frozen under general or local anesthesiaC T. See Tomography: computed. CT scan. See Tomography: computed.cutaneous relating to the skincycle a succession of events or symptomsDdeafferentation partial or total loss of affer-ent neural activity to a particular body re-gion through removal of part of the neural pathwaydeafferentation pain usually constant pain perceived in a localized area resulting from the loss or disruption of afferent neural pathwaysdebridement excision of devitalized tissue and foreign matter from a diseased area or wounddecompression of a joint removal or release of pressure on a jointdeep brain stimulation (DBS) a type of neu-rostimulation that uses electrical signals from an implanted generator to stimulate targeted nerves or structures in the brain to relieve neurologic symptoms such as motor dysfunctiondeep-heat therapy diathermy and ultrasounddegeneration tissue deterioration with soft tissue, cartilage, and bone converted into or replaced by tissue of inferior quality; failure of articulation to adapt to loading forces, re-sulting in impaired function; degenerative arthritis. See Osteoarthritis.degenerative joint disease (DJD). See Osteoarthritis.deglutition the act of swallowingdelayed-onset muscle soreness muscle pain caused by interstitial inammation after in-termittent overuse𝛅 sleep a state of deep usually dreamless sleep that is characterized by δ waves and a low level of autonomic physiologic activitydemyelination loss of myelin from the sheath of a nervedenervation resection or removal of nerve tissuedentofacial orthopedics. See Orthodontics.dentulous with teethdependence use of a chemical substance resulting in the development of a physi-ologic need to the extent that withdrawal symptoms occur when the substance is re- 281Glossarymoved; to be distinguished from addiction, in which psychologic reliance also occursdepression, major psychiatric disorder char-acterized by prolonged periods of depres-sion and often with associated symptoms of poor appetite or overeating, insomnia, hypersomnia, low energy or fatigue, low self-esteem, poor concentration, and feel-ings of hopelessnessdepression of mandible movement of the mandibular alveolar processes away from the maxilla; a component of normal jaw opening. Ant: Elevation of mandible, Man-dibular closure.depression, psychologic mood character-ized by feelings of sadness, helplessness, hopelessness, guilt, despair, and futility. Syn: Dysthymia.deprogrammer an appliance used to interfere with the proprioceptive mechanism during chewing or mandibular closurederangement a disturbed arrangement of body partsdermatome supercial zone of reference on the skin where pain is felt with stimulation of a single posterior spinal nerve root or cra-nial neural segmentdevelopmental disorder. Ant: Acquired disor-der. See Congenital disorder.deviation in form irregularities or aberrations in the form of soft and hard intracapsular articular tissuesdeviation on mandibular opening notice-able departure from the midline of the man-dible of ≥ 2 mm to either the right or left during maximum unassisted opening, with or without correctiondiagnosis distinguishing one disease from another or determining the nature of a disease from a study of the history, signs, symptoms, and physical examination resultsdiagnostic cast. See Cast, dental.diarthrodial joint a freely moving joint en-closed in a uid-lled synovial cavity and limited variously by muscles, ligaments, and bonediathermy deep-heat therapy from high- frequency electric currentdifferential diagnosis differentiation of two or more diseases with similar symptoms to determine which is the correct diagnosisdisability alteration of the patient’s capac-ity to meet personal, social, and/or occu-pational responsibilities as determined by behavioral, psychologic, and psychosocial assessments; disability is a social and not a medical termdisc circular, rounded, at plateintra-articular d. intra-articular, circular, rounded, platelike fibrocartilaginous structure in some synovial joints. Syn: Articular disc; Misnomer: Meniscus.disc derangement. See Disc displacement.disc detachment a peripheral separation of the disc from its capsular, ligamentous, or osseous attachmentsdisc dislocation. See Disc displacement.disc displacement in the TMJ, an abnormal position of the intra-articular disc relative to the mandibular condyle and the temporal fossa. Syn: Disc derangement, Disc inter-ference disorder.d.d. with reduction a disc displacement at the intercuspal position, with reestab-lishment of a normal anatomical relation-ship between the disc and condyle dur-ing condylar rotation or translation. Syn: Reducing disc.d.d. with reduction with intermittent locking an intracapsular biomechanical disorder in which the condition changes between a disc displacement with re-duction and a disc displacement without reduction with limited openingd.d. without reduction with limited opening in the closed mouth position, the disc is in an anterior position rela-tive to the condylar head, and the disc does not reduce with opening of the mouth; the patient has a maximum as-sisted opening (passive stretch) of less than 40 mmd.d. without reduction without limited opening in the closed mouth position, the disc is in an anterior position relative to the condylar head, and the disc does not reduce with opening of the mouth; the patient has a maximum assisted 282GlossaryGopening (passive stretch) of 40 mm or greaterdisc interference disorder. See Disc dis-placement.disc perforation a circumscribed tear in the articular disc permitting communication be-tween the superior and inferior joint spaces, with no disruption at the peripheral attach-ments to the capsule, ligaments, or bonedisc space radiolucent area in a TMJ radio-graph between the mandibular condyle and the articular fossadisc thinning degenerative decrease in the thickness of the articular discdisc-condyle complex in the TMJ, the articu-lation of the condyle with the disc, which functions as a simple hinge jointdiscectomy arthrotomy with complete re-moval of the intra-articular discdiscoplasty correction or improvement in the contour of an intra-articular discdisc-repositioning surgery, TMJ arthrotomy with intent of reestablishing normal ana-tomical disc-condyle relationshipdisk misnomer. See Disc.dislocation of condyle. See Luxation, Sub-luxation.disorder disturbance of function, structure, or mental statedisplacement removal from the normal or usual position or placedistraction of the condyle separation or forced downward movement of the con-dyle from the articular fossa without injury or dislocation of the partsdiurnal pertaining to or occurring in the day-light hours. Ant: Nocturnal.dizziness a disturbed sense of relationship to space and unsteadiness with a feeling of movement within the head; to be distin-guished from vertigodolichocephalic head shape that is oval and long anteroposteriorly and narrow in widthDoppler effect the apparent change in the frequency of a wave resulting from rela-tive motion of the source in relation to the receiverDoppler ultrasonography the application of the Doppler effect to ultrasonic scanning, with ultrasound echoes converted to (ampli-ed) sound or graphic wavesdorsal column stimulator electric stimula-tion of nervous tissues to produce pares-thesia in a specic portion of the spinal cord known as the dorsal column; also called spi-nal cord stimulationdrug pump a small device surgically placed under the skin to deliver microdoses of medication, usually to the intrathecal space (space surrounding the spinal cord contain-ing uid); because the drug is delivered directly to the spinal cord, a smaller dose is required, which helps minimize systemic side effectsdys- [prex] bad, disordered, difcultdysarthria defective articulation secondary to motor decit involving the lips, tongue, pal-ate, or pharynxdysarthrosis deformity or malformation of a joint whereby there is impairment of joint motiondysautonomia malfunctioning of the auto-nomic nervous system that hinders nor-mal activities of daily living or causes total disability; dysautonomia can interfere with the ability of the cardiovascular system to compensate for changes in posture, es-pecially when changing rapidly from a su-pine to standing posture, and dizziness or syncope results; systemic effects can also cause tachycardia or diabetes insipidus; dysautonomias can occur from trauma to the autonomic nervous system, viral infec-tion, genetic disorders, chemical exposure, pregnancy, or autoimmune disorders dyscrasia morbid condition referring to an im-balance of the component partsdysesthesia an unpleasant abnormal sensa-tion, whether spontaneous or evoked1dysfunction abnormal, impaired, or altered functiondysfunction index system of quantifying the severity of dysfunctionclinical d.i. a severity index developed by Helkimo and based on the symp-toms and signs found during a clinical examinationdysgeusia distortion of the sense of taste 283Glossarydyskinesia motor function disorder with impairment of voluntary movement, char-acterized by spontaneous, imprecise, in-voluntary, irregular movements with ste-reotypical patternstardive d. drug-induced dyskinesiadysmasesis difculty with masticationdysostosis abnormal condition characterized by defective ossication, especially involv-ing fetal cartilagedysphagia difculty in swallowingdysphasia speech impairment due to cen-trally induced lack of coordination, includ-ing failure to arrange words in proper orderdysphonia impairment of the voice; speaking difcultiesdysphoria emotional distress, disquiet, rest-lessness, or malaisedysplasia abnormality of developmentdysthymia. See Depression, psychologic.dystonia excessive, involuntary and sus-tained muscle contractions that may in-volve the face, lips, tongue, and/or jawfocal d. localized dystonia characterized by momentary sustained contracture of in-volved musclesdystrophy developmental change in muscles resulting from defective nutrition, charac-terized by fatty degeneration and increased size but decreased strength, and not involv-ing the central nervous systemEeccentric jaw relation mandibular posture that is peripheral or away from a centered jaw position or intercuspal positionedema abnormal accumulation of fluid in cells, tissue spaces, or cavitiesedentulous without teethefferent neural pathway neural impulse transmitted away from the central nervous systemefcacy ability of a drug or treatment to pro-duce a resulteffusion escape of uid from blood vessels or lymphatics into a body cavity or tissueEhlers-Danlos syndrome autosomal-dominant inherited disorder of connective tissues characterized by lax joints, skin elasticity, fragility, and pseudotumorselastic tissue connective tissue with ap-proximately 30% elastin, a yellow brous mucoproteinelectrodiagnostic testing use of electrical devices to assist in diagnosiselectrogalvanic stimulation (EGS) electro-therapy using direct current (galvanism) to produce muscle ber contraction; also used in iontophoresis and as a pain-relieving modalityelectromyography (EMG) graphic recording of the intrinsic change in the electric poten-tials of musclesneedle e. graphic recording of electrical ac-tivity in muscle obtained by insertion of a needle electrodesurface e. graphic recording of electrical activity in muscle obtained by placement of an electrode on the skin overlying the muscleelectrotherapy treating disease by use of electrical direct current (galvanism) or alter-nating current (faradism)elevator masticatory muscles paired masse-ter, medial pterygoid, and temporalis mus-cles, the main action of which is to elevate the mandibleeminence prominence or projection of a bone. Syn: Tubercle.emission scintigraphy imaging process to show areas of relatively rapid bone turnover by administration of radiolabeled materialemotional motor system theory contend-ing that thoughts and emotions create neuroendocrine-mediated motor responsesenarthrosis joint joint with a ball and socket arrangement. Syn: Spheroidal joint.end-feel quality of resistance felt during joint manipulation from full active stretch to full passive stretchendocrine secreting a hormone from a gland directly into the circulatory or lymphatic systemendogenous produced or originating from within a tissue or organismendorphin endogenous antinociceptive opi-oid substance in the cerebral spinal uid that is synthesized in the nerve cells and 284GlossaryGacts as an inhibiting neurotransmitter on no-ciceptive pathways. Syn: Enkephalin.endoscope instrument for examining the inte-rior of a body cavity enkephalin. See Endorphin.enophthalmos posteriorly positioned eye-balls within the orbitenvelope of motion the three-dimensional space circumscribed by border mandibular movements and by the incisal and occlusal contacts of a given point of the mandibleephapsis electric cross-talk between nerve bersepidemiology science concerned with den-ing and explaining the interrelationships of factors that determine disease frequency and distributionepigenetics an emerging area of research that focuses on the impact of environ-mental factors on the global expression of genesepilepsy group of neurologic disorders char-acterized by recurrent seizures, at times accompanied by sensory disturbance, ab-normal behavior, alterations in level of con-sciousness, and electroencephalographic changesequilibration, occlusal. See Occlusal equili-bration.Erb palsy a condition that is mainly due to birth trauma; it can affect one or all ve pri-mary cervical nerves that supply the move-ment and feeling to an arm; the paralysis can be partial or complete; the damage to each nerve can range from bruising to tear-ing; also called brachial plexus paralysiserosion of teeth wearing away of the nonoc-cluding surfaces of the dentition, especially by chemical meanserythema migrans. See Geographic tongue.erythema multiforme an acute skin and mucous membrane disease characterized by papules, tubercles, and macules lasting for several days, with burning, itching, and sometimes headache symptomserythrocyte sedimentation rate (ESR) rate at which red blood cells settle in a tube of unclotted blood, expressed in millimeters per hour; elevated ESR indicates the pres-ence of inammation but is not specic for any disorderetiology cause of a specic disordereuryprosopic having a facial form that is short, broad, and atEustachian tube opening from the middle ear cavity into the pharynxEwing sarcoma endothelial myeloma, a ma-lignant bone tumor that develops from bone marrow; most frequently in long bones, with pain, fever, and leukocytosisexacerbating factor factor that increases the seriousness of a disease or disorder as marked by greater intensity or frequency in the signs or symptomsexcursion of mandible movement of the mandible away from the median or inter-cuspal occlusion positionexophthalmos protrusion of eyeballsextension unbending movement of a joint. Ant: Flexion.external away from the center of the body or outside a structureexternal auditory meatus. See Acoustic meatus.extracapsular outside or external to the cap-sule, usually of a joint. Ant: Intracapsular.extracranial outside or external to the craniumextrinsic originating outside of a part where it is found or on which it actsextrinsic trauma trauma originating from out-side an organ system or individualextrusion expulsion by force, thrusting, or pushing outFfacet small, smooth planar area on a hard surfacef. joint. See Zygapophyseal.facial pertaining to the face or anterior part of the head from forehead to chin; direction of the outer surfaces of the teethfacial nerve mixed sensory and motor cra-nial nerve (CN VII) that innervates the scalp, forehead, eyelids, muscles of facial expression, platysma muscle, posterior digastric muscle, stylohyoid muscle, lip, chin, and nose muscles, submaxillary and 285Glossarysubmandibular salivary glands, and the af-ferent bers from taste buds of the anterior two-thirds of the tonguefacial plane. See Frontal plane.facial tic any spasmodic movement or twitch-ing of the facefacilitation intensication of response; dimin-ished nerve tissue resistance after passage of an impulse so that a second stimulus will evoke a reaction more easily. Ant: Inhibition.factitious disorder mental disorder character-ized by the compulsive, voluntary produc-tion of signs and symptoms of a disease for the sole purpose of assuming a patient role and in the absence of other secondary gainfalx cerebelli a small fascial membrane ex-tending from the tentorium cerebelli to the posterior cranial cavity; it attaches posteri-orly to the internal occipital crest and mar-gins of the occipital sinusfascia brous band or sheath of collagenous connective tissue that encloses muscles and certain organs and separates them sub-cutaneously into various groupsfascicle. See Muscle compartment.fasciculation involuntary contraction of a group of muscle bers supplied by a single nerve ber; a coarser form of muscle con-traction than brillationbrillation spontaneous, involuntary contrac-tion of individual muscle bersbrocartilage type of cartilage characterized by a large amount of brous tissue in the cartilage matrix and an ability for adaptive remodeling; found in the intervertebral discs, pubic symphysis, mandibular sym-physis, sternoclavicular joint, and certain regions of the TMJbrocartilaginous joint. See Symphysis.bromyalgia (FM) characterized by wide-spread body pain, multiple tender points over the body, poor sleep, stiffness, and generalized fatiguebrosarcoma sarcoma that contains brous connective tissuebrosis formation of brous connective tis-sue to replace normal tissue lost through injury or infectionbrositis misnomer. See Fibromyalgia.brous composed of or containing bers of connective tissuebrous dysplasia abnormal brous replace-ment of bone marrow with onset usually during childhoodliform thread-shaped or extremely slenderrst-bite syndrome pain in the parotid (sali-vary) gland or mandibular region at the rst bite that subsequently improves with each bite; the cause is unclear but may be re-lated to nerve impairment from surgery or other conditionsat-plane appliance misnomer. See Stabili-zation appliance.exion a motion that reduces the joint angle; the act of bending or the condition of being bent. Ant: Extension.exion-extension injury traumatic, sudden, exaggerated movement of joints through the extremes of their range of motion in hy-perexion and then hyperextension, result-ing in ligamentous sprain, muscular strain, inammation, and subsequent reex mus-cle splintinguoroscopy radiographic technique providing immediate dynamic images for visualizing the contours and function of a deep struc-ture such as an organ or jointfocal highly localizedfocal plane tomography. See Tomography: focal plane.foraminal encroachment stenosis of the opening for the passage of the spinal nerve from the spinal cord to the periphery. Syn: Foraminal stenosis.fos the cellular analog of a viral oncogene, which is composed of genetic protein within a cell (c-fos), designed to prevent abnormal growth leading to cancer; cel-lular oncogenes function as a molecular marker of pain in that their presence within the nociceptive transmission system is in-duced by noxious stimulation; also called proto-oncogene, representative of normal genetic expressionfossa [pl: fossae] hollow pit, concavity, or de-pression, especially on the surface of the end of a bone or a tooth. Syn: Fovea.fovea. See Fossa. 286GlossaryGfracture a break or rupture of a part, especially a bonefreeway space interocclusal distance or sepa-ration between the dental arches when the mandible is in its rest positionfremitus vibration, especially when palpablefrontal plane vertical plane, perpendicular to the sagittal plane, dividing the body into front to back portions. Syn: Coronal plane, Facial plane.functional mandibular disorder a disorder relating to abnormal mandibular move-ments or actionsfunctional mandibular movement a natural, proper, or characteristic movement or ac-tion of the mandible made during speech, mastication, yawning, swallowing, respira-tion, and other proper activitiesfungiform mushroom-shaped or bulbousGgamma knife surgery precisely focused ra-diation of 40 to 90 Gy emitted from 201 photon beams applied to the trigeminal root entry zone. Syn: Stereotactic neurosurgery, Stereotactic radiosurgery.ganglion a collection or mass of nerve cells serving as a center of nervous inuencegeneralized anxiety disorder (GAD) dis-order characterized by persistent and ex-cessive uncontrolled feelings of anxiety or worry for a period of 6 months or longer ac-companied by at least three of the following symptoms: restlessness, fatigue, difculty concentrating, irritability, muscle tension, and sleep disturbance, and not associated with another mental disorder, substance use, or medical condition3genetic pertaining to reproduction, birth, ori-gin, or hereditygeniculate neuralgia. See Neuralgia: genicu-late.genioplasty plastic surgery of the chingeographic tongue occasionally symp-tomatic, inflammatory disorder of the tongue mucosa characterized by multiple, well-demarcated zones of erythema lo-cated on the dorsum and lateral border of the tongue. Syn: Benign migratory glossitis, Erythema migrans.giant cell arteritis. See Arteritis.Gilles de la Tourette syndrome. See Tourette syndrome.ginglymoarthrodial joint paired joint like the TMJ that is both a hinged (ginglymoid) and a gliding (arthrodial) jointginglymoid joint hinging joint with one con-vex and one concave surface, with move-ment in only one plane of spacegliding of condyle. See Translation of condyle.globus the feeling that there is a lump in the throat without the presence of a physical objectglossalgia. See Glossodynia.glossodynia painful or burning tongue. Syn: Glossalgia.glossopharyngeal nerve mixed cranial nerve (CN IX) carrying somatosensory information from the posterior pharyngeal tissues and somatosensory and taste information from the posterior one-third of the tongue; the motor bers supply the pharyngeal musclesglossopharyngeal neuralgia. See Neuralgia: glossopharyngeal.glossopyrosis burning tonguegnathic pertaining to the jaw or cheekgnathologic pertaining to the science of the dynamics of the jawsgout disorder of purine metabolism character-ized by hyperuricemia and the deposition of monosodium urate crystals in joints, result-ing in acute attacks of arthritis with red, hot, and swollen joints, especially the big toe; gout occurs primarily in men older than 30 years. Syn: Arthritis urica.grating joint sound. See Crepitation.grinding of teeth. See Bruxism.Hhard tissue relatively rigid skeletal tissue in-cluding bone, hyaline cartilage, and bro-cartilageheadache pain or ache in the head. Syn: Cephalalgia.headache attributed to TMD pain located in the temple with provocation testing of the 287Glossarytemporalis muscle(s) replicating the head-ache and a temporal relationship to any pain-related TMD; jaw movement, function, or parafunction affects the headachehemarthrosis bloody effusion into cavity of a jointhematoma swelling or mass of blood con-ned to a tissue or spaceepidural h. collection of blood in epidural space due to damage and leakage of blood from the middle meningeal arterysubdural h. collection of blood in subdural space from laceration of the brain or rup-ture of the bridging veinshemifacial microsomia condition in which one side of the face is abnormally small and underdeveloped, yet normally formedhemifacial spasm involuntary unilateral sud-den contraction of the muscles in the facial nerve distributionhemiparesis unilateral muscular weakness or paralysishemiplegia loss of motor function and sensa-tion on one side of the bodyhemorrhage abnormal internal or external dis-charge of blood; bleedingherpes zoster varicella zoster virus infec-tion of the cranial or spinal nerve ganglia and cutaneous areas they supply, causing acute inammation, characterized by pain-ful vesicular skin or mucosal eruptions. Syn: Zoster. Misnomer: Shingles.heterogenous derived from different sourcesheterophoria deviation of an eye only when it is coveredheterotopic pain pain occurring at a site dif-ferent from that of the causeheterotropia a constant lack of parallel-ism of the visual axes of the eyes. Syn: Strabismus.high condylectomy surgical removal of only a portion of the superior mandibular condylehistaminic cephalalgia. See Cluster head-ache.histochemical pertaining to the chemical sub-stances in the body tissues on a cytologic scalehistology anatomical study of the minute structure, composition, and function of the tissueshistory of present illness (HPI) narrative re-port of each symptom or complaint, includ-ing the onset, duration, and character of the present illnessholocephalic headache headache that is felt in the entire head; from Greek holos (entire) and cephale (head)homogenous having a similar structure or characteristichomolateral. See Ipsilateral.homologous corresponding or alike in critical attributes such as structure, position, and origin, but not necessarily functionhorizontal plane. See Transverse plane.Horner syndrome neurologic condition char-acterized by a small pupil and ptosis on the side of the headache. Syn: Oculosympa-thetic paresis.Horton headache. See Cluster headache.Horton syndrome. See Cluster headache.humoral relating to or arising from any of the body uidshyaline cartilage type of cartilage found on the articular surfaces of most bones, char-acterized by exibility, glasslike appearance, and network of connective tissue bers; forms a template for endochondral bone formationhydrocephalus an excessive accumulation of cerebrospinal uid in the brain, causing cer-ebral ventricular dilation, elevated intracra-nial pressure, and enlargement of the skullhypalgesia diminished sensibility to pain. Syn: Hypoalgesia.hyperactivity exaggerated amount of func-tional movementhyperacusis painful or abnormally acute sen-sitivity to soundhyperalgesia an increased response to a stimulus that is normally painful1primary h. See Primary hyperalgesia.secondary h. See Secondary hyperalgesia.hyperesthesia increased sensitivity to stimu-lation, excluding the special senses1hyperextension extreme extension of a limb or jointhyperextension-hyperflexion injury. See Flexion-extension injury.hyperexion extreme exion of a limb or joint 288GlossaryGhyperfunction of muscle excessive function of musclehypermobility excessive mobility; dened by extreme ranges of joint movement or lax-ity in a specic minimal number of dened joints. Syn: Hypermobility syndrome (mis-nomer); Ant: Hypomobility.monoarticular h. involving only one jointoligoarticular h. involving two to four jointspolyarticular h. hypermobility involving more than four jointshyperpathia a painful syndrome character-ized by an abnormally painful reaction to a stimulus, especially a repeated stimulus, as well as an increased threshold1hyperplasia overdevelopment of tissue or structure with an increase in the number of normal cells in a normal arrangementhypertonicity of muscle excess muscular tonus, tension, or activityhypertranslation excessive or exaggerated gliding movement range of a body part, such as the mandibular condylehypertrophic arthritis. See Osteoarthritis.hypertrophy increase in size of an organ or structure but not in the number of its con-stituent cells. Ant: Atrophy.hyperuricemia abnormal amount of uric acid in the blood, found in gout but also in many other conditionshypesthesia. See Hypoesthesia.hypoalgesia diminished pain in response to a normally painful stimulus.1 See Hypalgesia.hypochondriasis somatoform disorder marked by the preoccupation with and anxi-ety over one’s health, with exaggeration of normal sensations and misinterpretation of normal physical signs and minor complaints as serious illness or diseasehypoesthesia decreased sensitivity to stimu-lation, excluding the special senses.1 Syn: Hypesthesia.hypogeusia diminished sensibility to tastehypoglossal nerve mixed cranial nerve (CN XII) carrying afferent proprioceptive im-pulses as well as efferent motor impulses to the intrinsic and extrinsic muscles of the tongue, with communication to the vagus nerve (CN X)hypomobility reduced or restricted range of motion. Ant: Hypermobility.hypoplasia incomplete or defective devel-opment or underdevelopment of a tissue or structure; implies fewer than the usual number of cellshypoxia deciency of oxygenhysteria. See Somatic symptom disorder.hysterical trismus severe restriction of man-dibular motion due to acute psychologic distressIiatrogenic condition caused by medical per-sonnel during examination, diagnostic tests, or treatment proceduresidioglossia imperfect articulation with mean-ingless vocalizationidiopathic of unknown etiologyidiopathic continuous neuropathic pain constant unremitting pain from dysfunction in the nervous system without obvious pa-thology and of unknown etiologyidiopathic odontalgia. See Persistent idi-opathic facial pain.idiopathic pain painful disease or disorder without obvious pathology and of unknown etiology illness condition characterized by a pro-nounced deviation from a normal healthy stateillness behavior alterations in behavior in re-sponse to an actual or perceived illnessimaging hard-record representation or visual reproduction of a structure for the purpose of diagnosis, including radiographs, ultra-sound, computed tomography, and mag-netic resonance imagingimpairment a medical determination of the amount of deterioration from a state of nor-mal health; a measure of the loss of use or abnormality of psychologic, physiologic, or anatomical structure or functionincidence number of new cases of a condi-tion that occur during a specied period of time; compare with prevalenceincoordination inability to move in a smooth, controlled, symmetric, and harmonious motion 289Glossaryinfarct area of tissue necrosis following ces-sation or interruption of blood supplyinfection invasion of a tissue by pathogenic microorganisms that reproduce and multi-ply, causing disease by local cellular injury, secretion of toxin, or antigen-antibody reac-tion in the hostinfectious arthritis acute inammatory con-dition of a joint caused by bacterial or viral infectioninferior. Ant: Cephalad, Superior. See Caudal.inferior retrodiscal lamina the most inferior border of the retrodiscal tissues or poste-rior attachment; this tissue is predominantly dense brous connective tissue and func-tions as a ligament to restrict anterior rota-tion of the disc on the condyleinammation protective normal response of tissue to irritation or injury, characterized by redness, heat, swelling, and paininhibition suppression or arrest of a processinitiating factors factors that cause the onset of a disease or disorderinsidious onset development of a disorder that is gradual, subtle, or imperceptible. Ant: Acute onset.insomnia abnormal wakefulness or inabil-ity to sleep during the period when sleep should occurinterceptive occlusal contact. See Supracontact.intercuspal position (ICP) the complete in-tercuspation of the opposing teeth inde-pendent of condylar position, sometimes referred to as the best t of the teeth re-gardless of the condylar position.2 Syn: Centric occlusion, Maximal intercuspal po-sition, Maximal intercuspation.intercuspation the proximity of cusps of op-posing teeth.2 Syn: Interdigitation.maximal i. See Intercuspal position.interdigitation. See Intercuspation.interdisciplinary the coordinated effort of two or more professions building on each other’s expertise to achieve an individual-ized care planinternal inside the body or within a structure. Ant: External.internal derangement disturbed arrange-ment of intracapsular joint parts causing in-terference with smooth joint movement; in the TMJ it can relate to elongation, tear, or rupture of the capsule or ligaments, causing altered disc position or morphologyinterocclusal between the opposing dental archesinterocclusal appliance an intraoral device that provides an articial occlusal surface, designed to t over either the maxillary or mandibular teethinterstitial pertaining to the space between tissuesintra-arch within either the mandible or the maxillaintra-articular located within a jointintra-articular disc. See Disc: intra-articular.intracapsular located within the capsule of a joint. Ant: Extracapsular.intracapsular adhesion. See Adhesion: intracapsular.intracondylar within the condyleintracranial within the cranium or skull. Ant: Extracranial.intractable resistant to treatmentintrameatal within the auditory canal or meatusintraoral within the oral cavityintrathecal drug infusion medication de-livered directly to the intrathecal space through a small catheter; because the drug is delivered directly to the spinal cord, a smaller dose is required, which helps mini-mize systemic side effectsintrinsic originating from or situated en-tirely within an organ, tissue, or part. Ant: Extrinsic.intrinsic trauma. Ant: Extrinsic trauma. See Trauma: microtrauma.intrusion inward projection; movement of the tooth in an apical directionionizing radiation radiation created by dis-locating negatively charged electrons from atoms by the application of an electrical currentiontophoresis introduction of ions of solu-ble salts into tissues through intact skin by means of direct electric currentipsilateral pertaining to the same side. Syn: Homolateral; Ant: Contralateral. 290GlossaryGischemia local and temporary inadequate blood supply to a specic organ or tissueisokinetic exercises dynamic muscle activity performed at a constant angular velocityisometric exercises active exercise per-formed against stable resistance without change in the length of the muscleisotonic exercises active exercise that short-ens the muscle without appreciable change in the force of muscle contractionJjaw either the maxilla or mandiblejaw tracking. See Mandibular movement recording.j.t. devices instruments used to quantify mandibular movements joint the place of union or junction between two or more bonesjuvenile rheumatoid arthritis (JRA) idi-opathic arthritis that begins before the age of 16 years, with rheumatoid factor found in 70% of cases; more common in girls, with onset most often between ages 12 and 15 years. Syn: Still disease.juxtaposed positioned adjacently or in appositionKkinesiograph instrument used to record and provide graphic representation of move-mentkinesiography used to detect and record three-dimensional motion of the mandible. See Mandibular movement recording.kinesiology the science or study of human movementkinetic pertaining to, characterized by, or pro-ducing motionLlabial of, pertaining to, or toward the liplabioversion condition of being displaced la-bially from the normal line of occlusionlacrimation secretion of tears by the lacrimal glandslarynx musculocartilaginous structure lined with a mucous membrane, located below the dorsal root of the tongue and the hyoid bone at the top of the trachea; the organ of voicelatent disease dormant condition existing as a potential disorderlateral away from the midline of the body; to the side. Ant: Medial.lateral excursion of mandible. See Latero-trusion of mandible.laterotrusion of mandible movement of the mandible away from the median or toward the sidelavage the process of washing out or irrigat-ing a cavity or an organleaf gauge set of blades used to provide a metered separation or measure of the dis-tance between two parts, such as the inci-sorsleptoprosopic having a facial form that is long, narrow, and protrusiveleukocytosis increase in the number of circu-lating white blood cellslichen planus an inammatory skin disease with wide, at, irregular, often persistent circumscribed papules, with keratotic pluggingligament flexible band of fibrous tissue, slightly elastic and composed of parallel collagenous bundles, binding joints to-gether and connecting various bones and cartilagesl. laxity excessive looseness in ligamen-tous attachmentlingual of, pertaining to, or toward the tongueloading, joint increasing the compressive force on a jointlocal myalgia pain in a muscle with location of the pain only at the site of palpating nger(s); a subcategory of myalgialocking of joint misnomer. See Disc dis-placement: without reduction with limited opening.longitudinal plane. See Sagittal plane.low-level laser therapy (LLLT) nonthermal therapy using a laser light in the red or infra-red rangelupus erythematosus. See Systemic lupus erythematosus. 291Glossaryluxation a condition in which the disc-condyle complex is anterior to the articular emi-nence and is unable to return to the man-dibular fossa without a maneuver by a clini-cian. Syn: Open lock.lys- [prex] break apartlysis dissolution, decomposition, or loosening of tissueslytic pertaining to lysisMmacroglossia excessive tongue sizemacrotrauma. See Trauma: macrotrauma.magnetic resonance imaging (MRI) non-invasive, nonionizing imaging method that uses the signals from resonating hydrogen nuclei after they have been subjected to a charge in a magnetic eld; their relaxa-tion and resultant resonant frequency is detected, measured, and converted by a computer into an imagemalformation failure of proper or normal de-velopment, a primary structural defect, or deformity that results from a localized error of morphogenesismalinger to voluntarily feign or exaggerate an illness, usually to deliberately escape responsibility, provoke sympathy, or gain compensation; deliberate attempt to de-ceive in the absence of any psychiatric disordermalocclusion. See Occlusal variation.mandible horseshoe-shaped lower jawbone, consisting of the horizontal body joined at the symphysis and two vertical rami with the anterior coronoid process and the pos-terior condylar process, separated by the mandibular notch; the superior border of the body, the alveolus, contains sockets for the mandibular teethmandibular pertaining to the mandiblemandibular movement recording kinesio-graphic recording of the movement of the mandiblemandibular nerve the third division of the trigeminal nerve, which leaves the skull through the foramen ovale and provides motor innervation to the muscles of mas-tication, the tensor veli palatini, the tensor tympani, and the anterior belly of the digas-tric and mylohyoid muscles; it provides the general sensory innervation to the teeth and gingiva, the mucosa of the cheek and oor of the mouth, the epithelium of the anterior two-thirds of the tongue, the me-ninges, and the skin of the lower portion of the facemandibular orthopedic repositioning appli-ance (MORA) an interocclusal appliance that covers only the posterior mandibular teeth to temporarily alter the mandibular positionmandibular trismus. See Trismus.Marfan syndrome autosomal-dominant con-nective tissue disorder, characterized by ab-normal length of extremities, cardiovascular abnormalities, and other deformitiesmastication process of chewing food in prep-aration for deglutitionmasticatory muscles muscles responsible for masticatory motion, including the paired masseter, temporalis, lateral pterygoid, and medial pterygoid musclesmasticatory pain pain or discomfort about the face and mouth induced by chewing or other use of the jaws but independent of local disease involving the teeth and the mouthmaxilla paired upper jawbone that inferiorly forms the palate and the alveolus with the upper teeth, superiorly forms part of the orbit, and medially creates the walls of the nasal cavitymaxillary pertaining to the maxillamaxillofacial pertaining to the maxillary and mandibular dental arches and the facemaxillomandibular pertaining to the maxilla and mandiblemaximal intercuspal position. See Intercus-pal position.maximal intercuspation. See Intercuspal position.medial toward the midline of the body. Ant: Lateral.mediate auscultation listening to sounds with the use of an instrumentmediation bringing about a result, conveying an action, communicating information, or serving as an intermediary 292GlossaryGmediotrusion movement of the mandible mediallymediotrusion of mandible movement of the mandible toward the median or centermedullary dorsal horn. See Spinal trigeminal nucleus.meniscectomy, TMJ misnomer. See Discec-tomy.meniscus crescent-shaped brocartilaginous structure found in some synovial joints but not in the TMJmeniscus, TMJ misnomer. See Disc: intra- articular.mental disorder a disorder of cognition, af-fect, or behavior that impairs adaptive func-tioning that may be of organic or psycho-logic originmesencephalic nucleus a nucleus located at the mesopontine junction that contains cell bodies of primary afferent propriocep-tors that innervate the jaw-closing muscles (masseter, temporalis and medial ptery-goid) and the periodontiummesial toward the median sagittal plane of the face following the curvature of the den-tal archmesocephalic having a head shape that is neither long nor short, narrow nor wide, oval nor roundedmesoprosopic having a facial form that is neither long nor short, narrow nor broad, protrusive nor atmetaboreceptor receptor that responds to an increase in metabolic productsmetaplasia conversion of one tissue type into a form that is not normal for that tissuemetastatic shifting of a disease or its mani-festation from one part of the body to an-other; in cancer, the appearance of neo-plasms in parts of the body remote from the seat of the primary tumormicroglossia abnormally small tonguemicrognathia abnormal smallness of the jaw, especially the mandiblemicrostomia abnormally small mouthmicrotrauma. See Trauma: microtrauma.midline of teeth interproximal contact zone between the central incisor teeth of the maxillary or mandibular dental archmigraine periodic, recurrent, intense throb-bing headache, frequently unilateral and often accompanied by phonophobia, photo-phobia, and nausea or vomiting and aggra-vated by routine physical activity; classied by descriptive characteristics rather than by known physiologic mechanismschronic m. migraine occurring for at least 15 days per month for more than 3 months, not related to medication over-useclassic m. See M. with aura.common m. See M. without aura.hemiplegic m. headache associated with oculomotor nerve palsy and partial to complete unilateral paralysis of motor functionm. with aura headache with associated premonitory sensory, motor, or visual symptoms (prodrome). Previously used term: Classic migraine.m. with brainstem aura disturbance of brainstem function with dramatic but slowly evolving neurologic events, often involving total blindness, altered consciousness, confusional states, and subsequent headachem. without aura condition in which no focal neurologic disturbance precedes the headache but all other migraine with aura characteristics are the same. Syn: Common migraine.probable m. migraine-like headache not completely fullling all criteria for mi-graine headacheretinal m. repeated attacks of monocular scotoma or blindness lasting less than 1 hour and associated with headache; normal ndings on examination and MRI or CTtransformed m. headache that changes from episodic to dailymiosis pupillar contractionmixed connective tissue disease. See Con-nective tissue: disorders.mobilization, joint the process of restoring motion to a jointmononeuropathy neuropathy in a single nerve, also called mononeuritis 293Glossarymonosynaptic reex simplest and fastest reex involving one motor and one sen-sory neuron with one synapse; eg, muscle stretch reexmood disturbance persistent disturbance of the emotional statemorphology form or structure of an organismmotor neuron neuron carrying efferent im-pulses that initiate muscle contractionmouth guard plastic intraoral appliance that covers and protects the teeth during con-tact sportsMRI. See Magnetic resonance imaging.multidisciplinary use of multiple specialties building individual care goals based on their area of expertisemultifactorial resulting from the combined action of several factorsmultiple myeloma malignant neoplasm of bone marrowmultiple sclerosis (MS) chronic, slowly pro-gressive disease of the central nervous sys-tem of unknown etiology, characterized by demyelinated glial patches called plaquesmuscle tissue composed of contractile bers that effect movements of an organ or part of the body; muscle types include striated skeletal and cardiac muscles and smooth nonstriated visceral musclesdigastric m. originates on the digastric notch of the mastoid process and inserts on the mandible near the symphysis; raises the hyoid bone and base of the tongue and depresses the mandiblelateral (external) pterygoid m. muscle with two heads, with a single origin on the lateral pterygoid plate and greater wing of the sphenoid; insertion is on the fovea of the condyle and capsule of the TMJ, and the other insertion may be partially on the intra-articular disc; this muscle of mastication translates the mandible and is active in mouth opening and near-nal mouth closuremasseter m. supercial masseter originates on the zygomatic process and arch and inserts on the ramus and the angle of the mandible; the deep masseter origi-nates on the zygomatic arch and inserts on the upper half of the ramus and the coronoid process of the mandible; pow-erful muscle of mastication that elevates the mandiblemedial pterygoid m. originates on the maxillary tuberosity and medial surface of the lateral pterygoid plate and inserts on the medial surface of the ramus and angle of the mandible; during mastica-tion, elevates and protrudes the mandi-ble and, during speech, is active in man-dibular movementsscalene m. these three muscles originate on the transverse process of the cervical vertebrae and insert on the ribs; act to stabilize the cervical vertebrae or incline the neck to the side and are accessory muscles to respirationsternocleidomastoid m. muscle with two heads, one originating on the sternum and the other on the clavicle, and insert-ing onto the mastoid process and su-perior nuchal line of the occipital bone; rotates and extends the head and exes the vertebral columnsuboccipital m. muscles situated below the occipital bone that act to stabilize the cervical vertebrae and head position and to extend or rotate the head and necksuprahyoid m. digastric, geniohyoid, mylo-hyoid, and stylohyoid; all attach to the upper part of the hyoid bone and act to stabilize and elevate the hyoid bone and depress the mandibletemporalis m. fan-shaped muscle with its origin on the temporal fossa and in-sertion on the coronoid process and anterior aspect of the ramus; elevates and retrudes the mandible during masticationtrapezius m. originates on the superior nuchal line of the occipital bone and spinous process of the seventh cervi-cal and all of the thoracic vertebrae and inserts on the clavicle and scapula; el-evates the shoulder and rotates the scapulamuscle compartment muscle bundle en-closed within a single sheath. Syn: Fascicle. 294GlossaryGmuscle compartment syndrome pain and stiffness in a muscle due to oxygen depri-vation within the muscle compartmentacute m.c.s. oxygen deprivation due to capillary compression from an acute in-crease in volume in the muscle compart-ment secondary to fracture, edema, or bleedingchronic m.c.s. oxygen deprivation during muscle contractions secondary to re-duced muscle relaxation time between contractionsmuscle contraction the shortening or devel-opment of tension in musclemuscle contracture. See Contracture.muscle cramp misnomer. See Spasm, muscle.muscle hypertonia increased tone of skeletal muscle or increased resistance to passive stretchmuscle hypertonicity. See Muscle hypertonia.muscle relaxation appliance misnomer. See Stabilization appliance.muscle splinting. See Protective muscle splinting.muscular dystrophy group of genetically transmitted diseases characterized by pro-gressive atrophy of symmetric groups of skeletal muscles without evidence of de-generation of neural tissuemusculoskeletal relating to the muscles (in-cluding fascial sheaths and tendons) and jointsmusculoskeletal pain deep somatic pain that originates in skeletal muscles, fascial sheaths, and tendons (myogenous pain), bones and periosteum (osseous pain), joint, joint capsules, and ligaments (arthralgic pain), and in soft connective tissuesmyalgia pain in a muscle affected by jaw movement, function, or parafunction, and replication of this pain with provocation testingmyelin lipid that forms a major component of the sheath that surrounds and insulates the axon of some nerve cellsmyelomeningocele a congenital develop-mental defect of the neural tube causing a malformation or incomplete closure; also known as spina bida; most commonly oc-curs in the lumbosacral regionmyelopathy functional disturbance or change in the spinal cordmyoclonus clonic spasm or twitching that re-sults from the contraction of one or more muscle groupsmyofascial pertaining to muscle and its at-taching fasciamyofascial pain pain in a muscle as described by myalgia with pain spreading beyond the location of the palpating nger(s) but within the muscle; a subcategory of myalgiamyofascial pain dysfunction syndrome mis-nomer. See Myalgia.myofascial pain with referral pain in a mus-cle as described by myalgia with pain re-ferred beyond the muscle; a subcategory of myalgiamyofascial trigger point hyperirritable spot, usually within a taut band of skeletal mus-cle or in the muscle fascia, that is painful on compression and can give rise to character-istic referred pain, tenderness (secondary hyperalgesia), and autonomic phenomena; subdivided into active and latentactive m.t.p. myofascial trigger point re-sponsible for local or referred current pain or symptoms without stimulation through palpationlatent m.t.p. myofascial trigger point with all the characteristics of an active myo-fascial trigger point, including referred pain with palpation, but not currently causing spontaneous clinical pain or symptomsmyofascitis inammation of muscle and its fasciamyobrosis replacement of muscle tissue by brous tissuemyobrositis inammation of the perimy-sium, the connective tissue separating in-dividual muscle fasciclesmyofunctional therapy use of exercises to improve the function of a group of musclesmyogenous of muscular originmyogenous pain deep somatic musculoskel-etal pain originating in the skeletal muscles, fascial sheaths, or tendons 295Glossarymyositis pain in a muscle with clinical char-acteristics of inammation or infection, ie, edema, erythema, and/or increased temperaturemyositis ossicans ossication of muscle tis-sue, usually after injurymyxoma neoplasm derived from primi-tive connective tissue, composed of a stoma-resembling mesenchymeNnarcotic any drug that produces sleep, insen-sibility, or stupor; more commonly, opium or any of its derivatives (morphine, heroin, codeine, etc)natural history of disorder natural sequence, duration, transitional stages, and nature of change of a disease or disorder over time, without external interference such as trauma or treatmentneck-tongue syndrome rare disorder charac-terized by infrequent short-lasting attacks of unilateral pain in the upper neck radiating toward the ear and associated with numb-ness, paresthesia, or the sensation of invol-untary movement of the ipsilateral half of the tonguenecrosis tissue deathnegative predictive value (NPV) measure of the probability that a person does not have the disease, given a negative result neoplasm abnormal, uncontrolled, progres-sive growth of new tissue; designated as benign or malignant. Syn: Tumor.nerve a cordlike structure, made up of numer-ous nerve bers, that conveys impulses from one part of the body to anothernerve block injection of local anesthetics or steroids into the epidural space for ex-tended pain reliefnervus intermedius smaller root of the facial nerve that merges with the facial nerve at the level of the geniculate ganglion and in-nervates the lacrimal, nasal, palatine, sub-mandibular, and sublingual glands and the anterior two-thirds of the tongueneural pertaining to one or more nervesneural pathway the nerve structures through which an impulse is conductedneuralgia paroxysmal or constant pain, typically with sharp, stabbing, shooting, electric-like, itching, or burning character, in the distribution of a nerve or nervesauriculotemporal n. paroxysmal pain with refractory periods involving the au-riculotemporal branch of the trigeminal nervecranial n. neuralgia along the course of a cranial nervegeniculate n. painful disturbance of the sensory portion of the facial nerve char-acterized by lancinating pain in the mid-dle ear and the auditory canal. Syn: Ner-vus intermedius neuralgia, Ramsay Hunt syndrome.glossopharyngeal n. severe, paroxysmal, lancinating pain due to a lesion in the petrosal and jugular ganglion of the glos-sopharyngeal nerve (CN IX) that radiates to the throat, ear, teeth, and tongue and is triggered by movement in the tonsil-lar region by swallowing or coughing; branches to the carotid artery can trigger a vasovagal response, including altered respiration, blood pressure, and cardiac output; rare, unilateral condition; usually in men older than 50 years nervus intermedius n. See Geniculate n.occipital n. neuralgia involving the greater occipital nerve (C2 or C3)postherpetic n. neuralgia following out-break of the herpes zoster viruspostsurgical n. pain of neuralgic charac-ter secondary to inadvertent damage to sensory nerves during a surgical procedurepretrigeminal n. syndrome of dull aching or burning pain, often in the oral cavity or teeth, which precedes true paroxysmal trigeminal neuralgia; pain duration varies widely from hours to months, with vari-able periods of remission; onset of true neuralgic pain may be quite suddensuperior laryngeal n. condition charac-terized by sharp, paroxysmal, unilateral submandibular pain that may radiate to the ear, eye, or shoulder, a distribution indistinguishable from glossopharyngeal neuralgia; the superior laryngeal nerve is 296GlossaryGa branch of the vagus nerve (CN X) and innervates the cricothyroid muscle of the larynxtraumatic n. deafferentation pain second-ary to disruption of normal sensory path-ways from traumatic or surgical injurytrigeminal n. (TN) disorder of the sensory divisions of the trigeminal nerve (CN V), characterized by recurrent paroxysms of sharp, stabbing pains in the distribution of one or more branches of the nerve, often precipitated by stimulation of spe-cic trigger zones. Syn: Tic douloureux.neurasthenia syndrome of chronic mental and physical fatigue and weakness; term virtually obsolete in Western medicineneurectomy peripheral ablative procedure in which the offending trigeminal nerve branch is avulsed under local or general anesthesianeuritis inammation of a nerve or nerves1neuroablative procedures irreversible pro-cedures performed to interrupt sensory pathways to the brain or in the brainstem by severing or destroying the appropriate pathology; examples include cordotomy, rhizotomy, thalamotomy, or chemical de-struction of neural structuresneuroaugmentation use of medications or electrical stimulation to supplement activ-ity of the nervous systemneurogenic pain pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.1 Syn: Neuropathic pain.neurogenous. See Neuropathic pain.neurolepsis altered state of consciousness characterized by quiescence, reduced motor activity, anxiety, and indifference to surroundings, induced by a neuroleptic medicationneuroleptic drug with antipsychotic propertiesneurologic pertaining to the nervous system and its disordersneurolysis longitudinal surgical incision to free a nerve sheath, surgical loosening of brous nerve adhesions, or destruction of nerve tissuesympathetic n. See Sympathectomy.neuromodulation a group of medical thera-pies that use drugs or electricity to regu-late pain or minimize dysfunction, including drug pumps and neurostimulationneuromuscular concerning both nerves and musclesneuron nerve cellneuropathic pertaining to neuropathyneuropathic pain pain initiated or caused by a primary lesion or dysfunction in the nerv-ous system. Syn: Neurogenic pain.neuropathy disturbance of function or patho-logic change in a nerve; in one nerve, mono-neuropathy; in several nerves, mononeu-ropathy multiplex; if diffuse and bilateral, polyneuropathy1neuroplasticity dynamic ability of the central nervous system to alter central processing of impulses secondary to ongoing afferent impulses usually thought to be nociceptiveneurostimulation low-level electrical pulses delivered by an implanted pacemaker-type device that stimulate various tissues of the nervous system, including the spinal cord, peripheral nerves, and brainneurotransmitter any biochemical substance that mediates the passage of an impulse across the synapse from one nerve cell to anotherneurovascular concerning both the nervous and vascular systemsnightguard appliance misnomer. See Inter-occlusal appliance.NMRI nuclear magnetic resonance imaging. See Magnetic resonance imaging.nocebo negative treatment effects induced by a substance or procedure containing no toxic or detrimental substancenociception stimulation of specialized nerve endings designed to transmit information to the central nervous system concerning potential or actual tissue damagenociceptive capable of receiving and trans-mitting painful sensationnociceptive pain pain resulting from tissue damage and the subsequent release of chemicals that act as noxious stimuli and are perceived by the brain as pain; also called somatic painnociceptive pathway an afferent neural path-way that transmits pain impulses to the central nervous system 297Glossarynociceptor a specialized nerve ending that senses painful or harmful sensationsprimary afferent n. one of three major groups of peripheral nerves capable of transmitting the presence of a noxious stimulus to the skin or the spinal cord; these include the Aβ mechanosensi-tive nociceptors, the Aδ mechanother-mal nociceptors, and the unmyelinated C-polymodal nociceptorsnocturnal pertaining to or occurring in the hours of darkness. Ant: Diurnal.noma rapidly progressive necrotizing infec-tion of the mouth and face usually seen in malnourished children; may also affect im-munocompromised individualsnoninnervated tissue that is lacking in sen-sory or motor nerve supplynoninvasive denoting diagnostic or therapeu-tic procedures that do not require penetrat-ing the skin or entering a cavity or organ of the bodynonodontogenic toothache pain presenting as a toothache but originating from a source other than dental and periodontal tissuesnonreducing disc. See Disc displacement: without reduction.nonrestorative sleep. See Sleep: nonrestora-tive.nonsteroidal anti-inflammatory drugs (NSAIDs) class of anti-inammatory medi-cations that also provide analgesia but lack the detrimental side effects associated with steroid usenoradrenalin. See Norepinephrine.norepinephrine biogenic amine released as a hormone by the adrenal medulla that acts as a neurotransmitter in the central nerv-ous system and the sympathetic nervous system; differs from epinephrine in the ab-sence of an N-methyl groupnorepinephrinergic relating to any drug that stimulates the production of norepinephrinenoxious stimulus a stimulus that is poten-tially or actually damaging to tissuesnuchal line bony ridge at the nape or back of the skullnuchal rigidity resistance to exion of the neck; often seen in meningitisOoccipital pertaining to the back of the headocclude bringing the maxillary and mandibular teeth together; obstruct or close offocclusal pertaining to the masticatory sur-faces of teethocclusal adjustment. See Occlusal equilibration.occlusal appliance. See Interocclusal appliance.occlusal contact. See Occlusion.occlusal equilibration irreversible adjust-ment of the coronal portion of the tooth by abrasive instruments, usually to more evenly distribute the vertical and excursive forces of occlusionocclusal interference. See Supracontact.occlusal splint. See Interocclusal appliance.occlusal trauma injury to the periodontium resulting from occlusal forces in excess of the reparative capacity of the attachment apparatus; contrast with primary occlusal trauma, secondary occlusal trauma. Syn: Occlusal traumatism, Periodontal trauma, Periodontal traumatism.occlusal traumatism. See Occlusal trauma.occlusal variation unusual biologic or func-tional relationship between the maxillary and mandibular teethocclusal vertical dimension. See Vertical di-mension of occlusion. occlusal wear. See Attrition.occlusion the act or process of closure or of being closed or shut off; the static relation-ship between the incising or masticating surfaces of the maxillary and mandibular teeth or tooth analogsocular pertaining to the eyeoculomotor nerve cranial nerve (CN III) aris-ing in the midbrain and supplying the leva-tor palpebrae, superior rectus, recti, and inferior oblique muscles of the eye; the sphincter pupillae and ciliary muscles of the orbit; and the nasal mucosaoculosympathetic paresis. See Horner syn-drome.odontalgia pain felt in a tooth or teethodontogenic derived from or produced in the teeth or tissues that produce the teeth 298GlossaryGodontogenic pain deep somatic pain arising or originating in the teeth or periodontal ligamentsolfactory nerve sensory cranial nerve (CN I) supplying the nasal mucosaopen lock. See Luxation, Subluxation.openingassisted mouth o. the maximal mouth opening that is attained with gentle stretching by the examiner after the pa-tient has reached maximum unassisted mouth opening, also called passive range of motionmaximal pain-free mouth o. the maximal mouth opening that is attained without painmaximum unassisted mouth o. the mouth opening the patient can achieve regard-less of pain, also called active range of motionophthalmic. See Ocular.optic nerve sensory cranial nerve (CN II) sup-plying the retina of the eyeoral apraxia inability to carry out purposeful oral movements in the absence of paralysis or other motor sensory impairmentorganic related to the organs of the body; pertaining to an organized structure; arising from an organismorofacial relating to the mouth and faceorthodontics specialty of dentistry dealing with the development, prevention, and correction of occlusal maxillomandibular irregularitiesorthodromic impulses conducted in normal directions along nerve pathsorthognathic pertaining to malposition of the bones of the jawsorthognathic surgery. See Surgery, orthog-nathic.orthopedic relating to correction of form and function of the locomotor structures, espe-cially the extremities, spine, and associated structures, including bones, joints, mus-cles, fascia, ligaments, and cartilageorthopedic appliance. See Interocclusal appliance. orthosis orthopedic appliance or interocclusal appliance used to support or improve func-tion of moveable parts of the body. Syn: Orthopedic appliance. See Interocclusal appliance.orthostatic relating to an erect or upright positionorthotic. See Interocclusal appliance.osseous bonyossification development or formation of boneosteoarthritis a degenerative condition of the TMJ characterized by deterioration and abrasion of articular tissue and concomitant remodeling of the underlying subchondral bone due to overload of the remodeling mechanism. Syn: Degenerative joint dis-ease, Osteoarthrosis.osteoarthrosis. See Osteoarthritis.osteoblast bone-forming cell derived from mesenchymeosteoblastoma benign, vascularized tumor of poorly formed bone and brous tissue that causes resorption of native bone. Syn: Giant osteoid osteoma.osteochondral junction the interface be-tween the calcied cartilage zone and the subchondral bone in synovial jointsosteochondritis dissecans a joint condition in which a piece of cartilage, along with a small bone fragment, breaks loose from the end of the bone, resulting in loose osteo-chondral fragments within the jointosteoclast multinucleated cell that causes ab-sorption and removal of boneosteoma benign, slow-growing mass of ma-ture bone, usually found on a bone and sometimes on another structureosteomyelitis inammation of bone, espe-cially of the marrow, caused by pathogenic organismsosteonecrosis a painful condition most com-monly affecting the ends of long bones such as the femurosteophyte bony outgrowthosteoporosis thinning of boneosteosarcoma malignant bone tumor com-posed of anaplastic cells derived from mesenchymeosteotomy surgical incision or cutting through a boneotolaryngology division of medical science concerned with diseases of the ear, larynx, 299Glossaryupper respiratory tract, and other associ-ated head and neck structuresotologic pertaining to the earPPaget disease disorder of unknown etiology with inammation of one or many bones, resulting in thickening and softening of bones with unorganized bone repair; also called osteitis deformanspain an unpleasant sensory and emotional ex-perience associated with actual or potential tissue damage, or described in terms of such damage4p. behavior visible actions that communi-cate suffering or pain to othersp. detection threshold. See P. threshold.p. disorder. See Somatic symptom disor-der.p. map a diagram showing the areas of pain on a patientp. mediators neurovascular substances activated by noxious stimuli that trigger or sustain painp. modulation the suppression of pain within a nervous system networkp. pathway. See Nociceptive pathway.p. receptor a specialized nerve ending that senses painful or harmful sensations and transmits them to a nervep. threshold the least experience of pain that a subject can recognize1p. tolerance level the greatest level of pain that a subject can tolerate1 palatal pertaining to the roof of the mouthpalate the roof of the mouthpalliative mitigating, reducing the severity of, or denoting the elimination of symptoms without curing the underlying diseasepallidotomy a surgical procedure in which a wire probe is inserted into the globus pal-lidus of the brain to heat the surrounding tissue and destroy nerves with the goal of helping reduce uncontrollable movements caused by neurologic conditions such as Parkinson diseasepalpation examination by feeling with the hands or ngers or to produce pain that is commonly performed during TMD evalua-tion in an attempt to reproduce the patient’s pain complaintpalsy paralysis or paresispanic disorder an anxiety disorder associated with recurrent, unexpected panic attacks characterized by intense apprehension, fearfulness, or terror and often accompa-nied by palpitations, accelerated heart rate, sweating, tremulousness, sensations of shortness of breath, choking, chest pain, abdominal distress, nausea, dizziness, de-realization, fear of dying, and fear of losing control or going crazy; at least 1 month of persistent concern about having recurrent panic attacks and a signicant alteration in adaptive functioning due to such worry are included in the criteria3panoramic radiograph circular tomography that images the jaws and related structuresparafunction nonfunctional activity; in the orofacial region, clenching and bruxing, nail biting, lip or cheek chewing, etcparalysis palsy; loss of power or voluntary movement in muscle through injury or dis-ease of its nerve suppliesparasympathetic nervous system division of the autonomic nervous system arising from preganglionic cell bodies in the brain-stem and the middle three segments of the sacral cord; cranial nerves III, VII, and IX distribute parasympathetics to the head; cranial nerve X distributes to the thoracic and abdominal viscera via the prevertebral plexuses; and the pelvic nerve (nervus erigens) distributes its autonomic bers to most of the large intestine and to the pel-vic viscera and genitalia via the hypogastric plexus. Syn: Craniosacral division.paratrigeminal syndrome. See Raeder syndrome. paravertebral alongside or near the vertebral columnparesis partial or incomplete paralysisparesthesia abnormal sensation, whether spontaneous or evoked; unlike dysesthesia, paresthesia includes all abnormal sensa-tions whether unpleasant or not; dysesthe-sias are a subset of paresthesia specically including those abnormal sensations that are unpleasant1 300GlossaryGparotid gland paired salivary gland located supercial to the masseter muscle and extending from in front of the ear to down below the angle of the mandibleparoxysm sudden sharp spasm, convulsion, or attackparoxysmal referring to a spasm, convulsion, or sudden short-lasting onset or change in symptomsparoxysmal hemicrania rare form of consist-ently unilateral headache centered around the eye and radiating to the cheek or tem-ple, with attacks lasting 5 to 60 minutes and occurring 4 to 12 times per day for years without remission; like cluster headache, may include associated conjunctival con-gestion and clear nasal dischargepassive range of motion motion imparted to an articulation, associated capsule, liga-ments, and muscles by another individual, machine, or outside forcepassive resistive stretch activity designed to increase muscle length by activating the reciprocal muscle against an opposing force and then stretchingpathogenic condition giving rise to pathologypathognomonic specifically distinctive or characteristic of a disease or pathologic condition; a sign or symptom on which a diagnosis can be madepathologic indicative of or caused by a dis-easepathologic condition diseased state or con-ditionpathophysiology the study of how nor-mal, physiologic processes are altered by diseasepathosis misnomer. See Pathologic condition.pemphigus a group of skin diseases charac-terized by successive crops of bullae that may leave pigmented spots after resolution and are often accompanied by itching and burningpercutaneous performed through the skinpercutaneous balloon microcompres-sion neurosurgical procedure in which the trigeminal nerve is compressed by inating a tiny balloon in the area of the involved nerve berspercutaneous glycerol rhizotomy neurosur-gical procedure in which nerve bers are destroyed by injection of anhydrous glycerolpercutaneous radiofrequency thermocoag-ulation neurosurgical procedure in which nerve fibers are destroyed by thermal lesioningperiarticular surrounding a jointpericranium brous membrane surrounding the cranium; periosteum of the skullperiodontal trauma. See Occlusal trauma.periodontalgia pain that emanates from the periodontal ligamentsperiodontium the investing tissue surround-ing the teeth, including the connective tis-sues, alveolar bone, and gingiva; anatomi-cally used to denote the connective tissue between the tooth and the alveolar bone; also called periodontal ligamentperipheral nerve stimulation a type of neu-rostimulation that uses electrical signals from an implanted generator to stimulate targeted nerves that lie outside the spine to relieve pain; eg, sacral nerve stimulationperipheral nervous system the motor, sen-sory, sympathetic, and parasympathetic nerves and the ganglia outside the brain and spinal cordperipheral neurogenic pain pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral nervous system1peripheral neuropathic pain pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system1peripheral sensitization an increased sensi-tivity to an afferent nerve stimuliperpetuating factors factors that inter-fere with healing or exacerbate a disease processpersistent idiopathic facial pain tooth pain without obvious pathology and of unknown etiologypersonality disorder disorder characterized by a long-term pattern of thinking and act-ing that is signicantly different from the general population and results in signicant adverse consequences to the individual and those around the individual 301Glossaryantisocial p.d. disorder characterized by a pervasive pattern of disregard for and vi-olation of the rights of others described by the presence of at least three of the following: doing things that could lead to arrest, lying, not planning ahead, being irritable and aggressive to the point of getting into ghts, disregarding safety of self and others, being irresponsible, and not expressing remorse or sorrow for behavior that hurts others3avoidant p.d. disorder characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensi-tivity to any criticism3borderline p.d. disorder characterized by a pervasive pattern of instability of inter-personal relationships, self-image, af-fects, and impulsivity in action3dependent p.d. disorder characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behaviors and separation anxiety3histrionic p.d. disorder characterized by pronounced emotional expression and attention-seeking behavior of often in-appropriate, provocative, and sexually seductive nature3narcissistic p.d. disorder characterized by a pervasive pattern of grandiosity and an intense need for the admiration of oth-ers while displaying little empathy for others3obsessive-compulsive p.d. disorder char-acterized by a drive for perfection, order-liness, and interpersonal control, with limited openness and exibility3paranoid p.d. disorder characterized by pervasive distrust and suspiciousness of others such that their motives are in-terpreted as malevolent3schizoid p.d. disorder characterized by a pervasive pattern of detachment from social relationships and very limited emotional expression in interpersonal settings3schizotypal p.d. disorder characterized by substantial distortions of thought and very unusual behavior in addition to per-vasive pattern of detachment from social relationships and very limited emotional expression3PET scan. See Tomography: positron emission.phantom limb pain a condition in which a patient senses that a missing body part is still attached and subsequently feels pain in that areapharmacotherapy drug treatment of a dis-ease or disorderpharyngeal plexus comprises cranial nerves IX to XI and provides innervation of the pharynx as well as the upper trapezius and sternocleidomastoid musclespharynx musculomembranous sac between the mouth, nasal cavities, and esophagusphoenix abscess abscess originating from a suddenly symptomatic previously dormant chronic periapical granulomaphonophobia abnormal fear of or exagger-ated sensitivity to soundphotophobia abnormal fear of or exagger-ated sensitivity to lightphotopsia the presence of perceived ashes of light, possibly associated with migraines; also associated with serious ophthalmo-logic conditionsphysical dependence pharmacologic prop-erty of a drug resulting in the occurrence of an abstinence syndrome following abrupt discontinuation of the agentphysical therapy treatment of disease or dis-order with physical and mechanical means such as massage, manipulation, exercise, heat, cold, ultrasound, and electricity; in-cludes (re)education in correct posture, body mechanics, and movement. Syn: Physiotherapy.physiologic pertaining to normal function of a tissue or organ. Ant: Pathologic.physiotherapy. See Physical therapy.pinna. See Auricle.pivot appliance hard acrylic resin appliance with a single unilateral or bilateral poste-rior contact designed to provide condylar distractionplacebo substance, device, or behavior that supercially resembles and is believed by the patient to be an active substance, mate-rial, or behavior but has no inuence 302GlossaryGplacebo effect physical or emotional change in a patient occurring after a placebo is pro-vided, with the change not directly attribut-able to any specic property or effect of the substance, behavior, or therapeutic agentplanar scintigraphy two-dimensional imag-ing process in which the area of interest is scanned with a γ-camera 2 to 4 hours after the administration of a radioactive material; increased uptake of the radioisotope in the tissue scanned indicates an increase in cel-lular activity. Syn: Scintigraphy, Scintiscan.platelet-aggregating factor (PAF) sub-stance produced in the blood by the action between an antigen and immunoglobulin E–sensitized basophiles; PAF aggregates platelets and is a factor in producing inam-mationplication the stitching of folds or tucks in a tis-sue to reduce its size, as in the retrodiscal tissues of the TMJ or the walls of a hollow viscuspolyarthritis simultaneous inammation of several jointspolymyalgia rheumatica self-limiting syn-drome in elderly people characterized by progressive pain and stiffness of the proxi-mal limbs after acute onset, with myalgia, fever, and an elevated ESR; onset may be unilateral but invariably becomes bilateral, resulting in successive involvement of mus-cle groups with morning stiffnesspolyneuropathy disease involving several nerves, usually bilateral and diffusepolysynaptic reex a reected movement resulting from neural conduction along a pathway formed by a chain of synaptically connected nerve cellspositive predictive value (PPV) a measure of the probability that a person has the dis-ease, given a positive resultpositron emission tomography (PET). See Tomography: positron emission.posterior attachment, TMJ loose connec-tive tissue attached to the posterior region of the brous portion of the articular disc and extending to and lling the posterior capsule, rich in interstitial collagen bers, adipose tissue, arteries, and elastin, and possessing a venous plexus. Syn: Retrodis-cal tissue.posterior cranial fossa the largest cranial fossa, formed by the basilar, lateral, and squamous sections of the occipital; the pe-trous section of the temporal; the mastoid sections of the temporal and parietal; and the posterior body of the sphenoidposterior ligament misnomer. See Posterior attachment, TMJ.posterior open bite lack of posterior tooth contact in the intercuspal positionposterior overclosure a presumed subnor-mal vertical dimension of occlusion due to factors such as attrition, erosion, or intru-sion of posterior teeth or developmental ir-regularities preventing full eruption of pos-terior teeth. Syn: Overclosed bite.postganglionic situated posterior or distal to a ganglionpostherpetic neuralgia. See Neuralgia: postherpetic.postsurgical neuralgia. See Neuralgia: postsurgical.posttraumatic stress disorder (PTSD) dis-order characterized by the development of a specic set of symptoms following exposure to a traumatic event through di-rect personal experience or witnessing of an event that involves actual or threatened death or serious injury or the threat to one’s physical and psychologic integrity3postural pertaining to the attitude or position of the bodypreauricular located in front of the earpredisposing indicating a tendency or sus-ceptibility to develop a disease or conditionpredisposing factors factors that increase the risk of developing a disease or conditionpreganglionic situated anterior or proximal to a ganglionpremature occlusal contact. See Supracon-tact.prematurity. See Supracontact.pretreatment records any records made for the purpose of diagnosis, recording of pa-tient history, or treatment planning in ad-vance of therapypretrigeminal neuralgia. See Neuralgia: pretrigeminal. 303Glossaryprevalence number of cases of a disease or disorder for a given area and population at a given point in time, usually measured as the percentage of positive cases; compare with incidenceprimary afferent nociceptor. See Nociceptor: primary afferent.primary hyperalgesia hypersensitivity to nox-ious stimuli at a site of primary nociception and tissue damageprimary occlusal trauma injury to the peri-odontium from excessive occlusal forces in teeth with normal supporting structuresprimary pain pain located over the true source of nociceptive inputprimary stabbing headache spontaneous short-lasting stabs of pain felt in the head, not usually unilateral or localized to one area. Syn: Jabs and jolts syndrome.principal sensory nucleus a group of second-order neurons that have cell bodies in the caudal pons; it receives information about discriminative sensation and light touch of the face as well as conscious pro-prioception of the jaw via rst-order neu-rons of cranial nerve Vprodrome symptom indicating the onset of a disorderprognathic having a forward-projecting jaw. Syn: Prognathous.prognosis a prediction of the course of the outcome of a disease or conditionprogressive supranuclear palsy spastic weakness of facial, masticatory, and oro-pharyngeal muscles due to a lesion in the corticospinal tract; may cause spontaneous laughing or crying. Syn: Pseudobulbar pa-ralysis, Spastic bulbar palsy, Supranuclear paralysis.projected pain neurogenic pain that is felt in the anatomical peripheral distribution of a nerve while the stimulus occurs along the pathway from the nerve to the cortexproprioception reception and interpretation of stimulation of sensory nerve terminals within the tissues of the body that provides information concerning movements and po-sitions of the bodyprostaglandins fatty acids that serve as ex-tremely active biologic substances, with ef-fects on the cardiovascular, gastrointestinal, respiratory, and central nervous systemsprosthesis cosmetic or functional articial substitute of a missing body part, including teeth, eyes, and limbsprosthetic pertaining to the replacement of a missing body part or augmentation of a decient part by an articial substituteprotective muscle splinting reexive con-traction of adjacent muscles resulting from noxious stimuli of a sensory eld of a joint, soft tissue, or other structure to prevent movement or provide stabilization to the painful surrounding tissues; differs from muscle spasm in that the contraction is not sustained when the muscle is at rest. Syn: Muscle guarding, Protective cocontraction, Reex muscle splinting.proteoglycan mucopolysaccharides bound to protein chains in covalent complexes within the extracellular matrix of connective tissueprotrusion state of being thrust forward or projected; in the head and neck area, re-ects movement of the mandible forward of the intercuspal positionprotrusion of mandible anterior mandibular movement with bilateral forward condylar translationprovisional appliance any appliance for time-limited useprovocation test diagnostic method of at-tempting to induce a disease episode or aggravate a symptom by provoking a tissue or systemproximal closer to a point of reference. Ant: Distal.pseudoaddiction phenomenon resembling typical behaviors associated with addiction but due to undermedication of an identi-able pain complaint; behaviors will cease when pain is adequately controlledpseudoankylosis a false ankylosis. See Ad-hesion: intracapsular. pseudobulbar paralysis. See Progressive su-pranuclear palsy. pseudogout. See Chondrocalcinosis. psoriatic arthritis polyarticular, progressive erosive joint inammation with associated scaly, red skin lesions and usually involving the distal interphalangeal joints 304GlossaryGpsychoactive medication drug that affects the mental functioning of an individualpsychogenic pain disorder. See Somatic symptom disorder.psychomotor retardation a slowing of both thoughts and physical activity often seen with depression and other psychiatric disorderspsychosocial involving both psychologic and social aspects of functioningpsychosomatic referring to both mind and body; pertaining to the inuence of the mind or higher functions of the brain (emo-tions, fears, desires, etc) on the functions of the body, especially in relation to bodily disorders or diseasepsychotic pertaining to severe mental disor-ders characterized by disorganized thought processes and loss of reality testing; such illnesses typically include hallucinations, delusions, disorganized speech, and grossly impaired adaptive functioningpsychotropic medication. See Psychoactive medication.ptosis prolapse or drooping of an organ or part; for example, the upper eyelid due to altered third cranial nerve function or cervi-cal sympathectomyeyelid p. droopiness of the upper eyelid as seen in Horner syndrome; functional def-icit of the levator palpebrae superior due to palsy of the oculomotor nerve; ptosis may also be a sign of other syndromespulpal pain odontogenic pain that emanates from the dental pulppulpitis inammation of the dental pulppumping procedure passive joint mobiliza-tion after intracapsular addition of uid into the jointpyrophosphate arthropathy. See Chondro-calcinosis.Rradiculalgia pain in the distribution of one or more sensory nervesradiculitis inammation of one or more nerve roots.4 See Radiculopathy.radiculopathy a disturbance of function or pathologic change in one or more nerve roots4; disease of a nerve that results from mechanical nerve root compression and may lead to pain, numbness, weakness, and paresthesiaradiofrequency lesioning uses high- frequency energy to produce heat and thermal coagulation of affected nerves to disrupt their ability to transmit pain signalsradiograph image of internal structures pro-duced by radioactive rays striking a sensi-tized lm after passing through a body partradionuclides atoms that disintegrate with emission of electromagnetic radiation, used in radiographic studiesradiopaque not permitting the passage of ra-diation energy and registering white or light on radiographradiovisiography (RVG) digital imaging tech-nique using radiation but not lm, with computer storage of imagesRaeder syndrome characterized by severe, unilateral craniofacial pain or dysesthesia that is usually in the V1 or V2 distribution. Syn: Paratrigeminal syndrome.Ramsay Hunt syndrome. See Neuralgia: geniculate.range of motion (ROM) the range, typically measured in degrees of a circle, through which a joint can be extended or exed; with reference to the TMJ, usually reported as millimeters of interincisal distancerapid eye movement (REM) active stage of deep sleep, characterized by prominent in-crease in the variability of heart rate, respi-ration, and blood pressure, including peri-ods of rapid eye movements and muscle twitching; the stage of sleep during which dreaming and muscle hypotonia occursreciprocal clicking. See Clicking joint noise, TMJ: reciprocal.recruitment of muscle gradual increase in the number of active muscle units to a max-imum in response to prolonged stimulusred ear syndrome rare disorder of unknown etiology that has the dening symptoms of redness of one or both external ears ac-companied by a burning sensationreducing disc. See Disc displacement: with reduction. 305Glossaryreduction restoration of a part to its normal anatomical location by surgical or manipula-tive procedures; eg, a fracture or dislocationreferral zone site at which referred (hetero-topic) pains or symptoms are perceivedreferred pain pain perceived in a site distant from the nociceptive source. Syn: Hetero-topic pain.reex the sum total of any particular involun-tary activityreex muscle splinting. See Protective mus-cle splinting.reex sympathetic dystrophy (RSD) sym-pathetically maintained burning and hy-peresthesic deafferentation pain typically initiated by trauma or surgical procedure, often accompanied by vasomotor, sudomo-tor, and later trophic changes in the skin; preferred term: complex regional pain syn-drome. Syn: Causalgia, Shoulder-hand syn-drome, Sudeck atrophy.refractory resistant to treatmentrefractory period a period of time during which pain cannot be triggered againReiter syndrome triad of polyarticular arthri-tis, urethritis, and conjunctivitis that usually follows nonspecic nongonococcal urethri-tis, predominantly in men; may be associ-ated with stomatitis and ulceration of the glans penisremodeling adaptive alteration of tissue form in response to functional demands through a cellular response of articular brocartilage and subchondral bonerepositioning appliance. See Anterior repo-sitioning appliance, mandibular.repositioning, jaw the changing of any rela-tive position of the mandible to the maxilla, usually through alteration of the occlusion of the natural or articial teeth or through the use of an interocclusal applianceresorption loss of tissue substance by physi-ologic or pathologic processesrestorative sleep See Sleep: restorative. retrodiscal pad misnomer. See Posterior at-tachment, TMJ.retrodiscal tissue. See Posterior attachment, TMJ.retrodiscitis inammation of the retrodiscal tissues within the TMJretrognathia facial disharmony in which the jaw, usually the mandible, is receded posterior to normal in their craniofacial relationshipretruded contact position (RCP) point of initial tooth contact when the condyles are guided along the posterior slope of the ar-ticular eminence into their most superior position on jaw closure. Syn: Centric rela-tion, Centric relation occlusion.retrusion posterior location or movement; in the orofacial region, posterior positioning of a tooth or mandible from normalretrusion of mandible posterior mandibular movement with bilateral retrusive condylar translationreversible treatment any therapy that does not cause permanent changereview of systems (ROS) system-by-system review of body functioning while com-pleting the health history and physical examinationrheumatic pertaining to rheumatismrheumatism a group of disorders character-ized by degeneration, metabolic change, or inammation of the connective tissues, particularly those associated with muscles and jointsrheumatoid arthritis chronic polyarticular erosive inammatory disease, more com-mon in women, characterized by bilateral involvement with proliferative synovitis, at-rophy, and rarefaction of bonesrheumatoid factor (RhF) anti–γ globulin anti-bodies found in the serum of most patients with rheumatoid arthritis but also found in a small percentage of apparently normal patients as well as patients with other col-lagen vascular diseases, chronic infections, and noninfectious diseasesrhizotomy an operation to cut or destroy nerve bers close to the spinal cord to re-lieve chronic pain or treat movement disor-ders that have not responded to more con-servative treatmentsrisk factor factor that causes an individual or a group to be vulnerable to a disease or dis-order, resulting in increased incidence or severity for the susceptible population 306GlossaryGrostral. Syn: Superior; Ant: Caudal. See Cephalad.rostrum beaklike appendage or partSsagittal pertaining to an anteroposterior plane or section parallel to the long axis of the bodysagittal plane vertical reference plane paral-lel to the long axis of the body, situated in an anterior-posterior direction, dividing the body into right and left halves saline solution containing sodium chloride and puried water sarcoidosis chronic progressive disease of unknown cause marked by granulomatous lesions in the skin, lymph nodes, salivary glands, eyes, lungs, and bonesscintigraphy. See Planar scintigraphy.scintillation perception of twinkling light of varying intensity that can occur during a migraine auras. detector device for measuring radioac-tivity that relies on the emission of light or ultraviolet radiation from a crystal sub-jected to ionizing radiationscintiscan. See Planar scintigraphy.scleroderma disease characterized by thick-ening and hardening of connective tissue in any part of the body, including skin, heart, lungs, and kidneys; skin may be thickened and hard with pigmented patches. Syn: Sys-temic sclerosis.scotoma isolated area of varying size and shape within the visual eld in which vision is absent or depressedsecondary gain indirect benet, usually ob-tained through an illness or debility, that al-lows an individual to avoid responsibility or an activity that is noxious to him or her and/or to obtain support from others that would not ordinarily be forthcomingsecondary hyperalgesia increased sensitiv-ity to normally painful stimuli outside and surrounding a zone of primary hyperalgesiasecondary occlusal trauma injury to the peri-odontium from excessive occlusal forces in teeth already affected with periodontal diseasesecondary pain. See Referred pain.sedimentation rate. See Erythrocyte sedi-mentation rate.sella turcica a saddle-shaped section of the sphenoid bone located in the middle cranial fossa that houses the pituitary glandsensitivity a measure of how well a certain test is able to identify a disease when the disease is actually present, also called the true positive rate; if a highly sensitive test is negative, it rules out the diseasesensitization the increased sensitivity of afferent receptors following repeated ap-plication of a noxious stimulus; a lowering of the pain threshold; psychologically, a defensive hyperarousal, induced by repeti-tive exposure to a noxious stimulus; also, development of lowered pain threshold in unstimulated undamaged regions adjacent to an area of primary nociception and hy-peralgesia. Syn: Secondary hyperalgesia.sensory nerve afferent bers of a peripheral nerve that conduct sensory impulses from the periphery of the body to the brain or spinal cordserology study of in vitro antigen-antibody reactionsserotonergic encouraging the production of serotonin; cells that contain or are activated by serotoninserotonin biogenic amine produced from tryptophan; found in serum and many other tissues, including mucosa, pineal body, and the central nervous system; acts as a vasoconstrictor, neurotrans-mitter, and pain-sensitizing agent. Syn: 5-hydroxytryptamine, 5-HT.shingles misnomer. See Herpes zoster.shoulder-hand syndrome. See Reex sym-pathetic dystrophy.sialography radiographic technique in which a salivary gland is lmed after an opaque substance is injected into its ductsign any objective evidence of a diseasesilent period, masticatory muscle momen-tary electromyographically observable de-crease in elevator muscle activity on initial tooth contact, presumably the inhibitory effect of stimulated periodontal membrane receptors 307Glossarysingle-photon emission computed tomog-raphy (SPECT). See Tomography: single- photon emission computed.sinusitis inammation, either purulent or non-purulent, of the mucosa of the sinusessinuvertebral nerve formed by mixed spinal and sympathetic branches that anastomose contralaterally; provides innervation to the vertebral periosteum, outer bers of the annulus brosus, posterior longitudinal liga-ment, dura mater, and epidural blood vessel walls. Syn: Recurrent meningeal nerve.Sjögren syndrome idiopathic collagen disor-der, more common in middle-aged or older women, that is characterized by atrophic changes of the lacrimal and salivary glands, resulting in dryness of the eyes and mouth, sometimes associated with polyarthritisskeletal pertaining to the bony, hard frame-work of the animal bodysleep nonrestorative s. sleep that leaves the individual feeling unrefreshed upon awakeningrestorative s. sleep that leaves the indi-vidual feeling refreshed, rested, and reenergized s. apnea breathing abnormality during sleep, characterized by cessation of air-ow secondary to a lack of respiratory effort; commonly related to upper air-way obstruction but may be related to central causesSNOOP4 mnemonic tool of the American Headache Society that outlines aspects of a patient’s signs and symptoms that indicate a severe or life-threatening disordersoft tissue nonbony or noncartilaginous tis-sue, including muscles and their fascial envelopes, tendons, tendon sheaths, liga-ments, joint capsule, bursae, fat, skin, etcsomatic pertaining to the body as distinct from the mind or psyche; pertaining to the structures of the body wall; eg, skeletal tis-sue in contrast with visceral structuressomatic pain pain resulting from tissue dam-age and the subsequent release of chemi-cals that act as noxious stimuli that are perceived by the brain as pain; also called nociceptive painsomatic symptom disorder diagnosis is made based on the signs and symptoms of distressing somatic symptoms plus ab-normal thoughts, feelings, and behaviors in response to the somatic symptoms, rather than the absence of a medical explanation for the somatic symptoms; the prominent characteristic of these individuals is not the somatic symptoms, but the way these indi-viduals present and interpret themsomatization in psychiatry, the process whereby a mental condition is experienced as a bodily symptomsomatosensory related to somatic afferent neural systemssonography. See Ultrasonography.space-occupying lesion abnormal mass or tumor that distends adjacent tissue as it enlargesspasm, muscle involuntary, sudden revers-ible tonic contraction of a musclespastic bulbar palsy. See Progressive supra-nuclear palsy.specicity a measure of how well a test, when negative, identies those who do not have the disorder, also called the true nega-tive rate; a test with high specicity, when positive, can rule in the diseaseSPECT. See Tomography: single-photon emis-sion computed.speculum appliance that allows for opening a body cavity or passage for inspectionsphenoid bone compound, unpaired wedge- shaped bone at the base of the cranium, separating the frontal and ethmoid bones and the maxilla frontally from the temporal and occipital bones. Syn: Sphenoid.sphenopalatine ganglion a parasympathetic ganglion found in the pterygopalatine fossa; it is largely innervated by the greater pet-rosal nerve (a branch of the facial nerve), and its axons project to the lacrimal glands and nasal mucosa. Syn: Meckel ganglion, Pterygopalatine ganglion.spheroidal joint. See Enarthrosis joint.spinal accessory cranial nerve motor cranial nerve (CN XI) comprising cranial and spinal branches that supply the trapezius and ster-nocleidomastoid muscles and the pharynx 308GlossaryGspinal anesthesia type of medication that produces temporary loss of sensation below the area of injection into the spinal cord without loss of consciousness; also called epidural anesthesiaspinal cord stimulation electrical stimulation of nervous tissues on a specic portion of the spinal cord to produce paresthesiaspinal nerves nerves that emerge from the spinal cord and innervate the organs and tissues; there are 31 pairs of spinal nerves, each attached to the cord by two roots, ven-tral and dorsalspinal trigeminal nucleus one of the nuclei of the trigeminal nerve, consisting of three subnuclei: subnucleus oralis, subnucleus interpolaris, and subnucleus caudalis. Syn: Medullary dorsal horn.spine. Syn: Spinal column, Vertebral column.splint. See Interocclusal appliance.splinting, muscle. See Protective muscle splinting.spondyloarthropathy disease of the spinal or intervertebral articulationsspondylosis. See Ankylosing spondylitis.spontaneous remission resolution of signs or symptoms of disease occurring unaided and without treatmentspray and stretch physical therapy technique using vapocoolant spray followed by pas-sive muscle stretchSpurling test used in conrming the diagno-sis of cervical radiculopathy; involves side bending and extending the patient’s head to the side of involvement, and pressure may or may not be applied; the nding is positive if the patient’s upper extremity par-esthesia or pain is intensied or reproducedstabilization appliance a at-plane intraoral appliance tted over either the maxillary or mandibular teeth without signicant man-dibular repositioning, used to control joint or muscle symptoms or to protect against damage or injury to the teeth or prosthetic placementsstandard of care established model or guide-lines of diagnostic and therapeutic manage-ment in a given community or settingstatus migrainosus severe unrelenting mi-graine headache associated with nausea and vomiting that lasts longer than 72 hours; may not be manageable under out-patient carestellate ganglion star-shaped sympathetic ganglion located between the transverse process of the seventh cervical vertebra and the head of the rst rib, with postgan-glionic bers running to the carotid, middle ear, salivary, and lacrimal glands, and the ciliary ganglion via cranial nerves IX, X, and XI and the upper three cervical nervesstenosis narrowing or stricture of a duct or canalstent device used to hold medication in contact with a mucosal site, hold a skin or mucosal graft in place, provide support for tubular structures, or facilitate radiation therapyantihemorrhagic s. controls bleeding dur-ing surgeryburn s. minimizes contraction of burned tissue during healingmedication s. holds topical medication in contact with a mucosal sitenasal s. supports the form of the nosepalatal s. protects a palatal surgical site during healing or keeps a mucosal ap or skin graft in close apposition to the surgical bedradiation s. used in the process of delivery of radiation therapy; protects healthy tis-sues, displaces such tissues away from the eld of radiation, or directs the radia-tion beam to the target sitestethoscope instrument for performing medi-ate auscultationstereotactic neurosurgery. See Gamma knife surgery.stereotactic radiosurgery. See Gamma knife surgery.Still disease seronegative arthritis, often ac-companied by fever and lymphadenopathy, representing 70% of cases of arthritis that begin before the age of 16 years. Syn: Ju-venile rheumatoid arthritis.stimulation the action of a stimulus on a receptor stimulation coverage the amount of a pa-tient’s pain pattern that is converted by stimulation 309Glossarystimulus anything that arouses action in the muscles, nerves, or other excitable tissuestomatognathic denoting the mouth and jaws collectivelystomatognathic system the functional and anatomical relationships among the teeth, jaws, TMJs, and muscles of masticationstomatology study of structures, functions, and diseases of the mouthstrabismus. See Heterotropia.stress the challenge for adaptation created by the sum of physical, mental, emotional, internal, or external stimuli that tend to disturb the homeostasis of an organism; inappropriate reactions can lead to disease statesstressor cause of stress; any factor that dis-turbs homeostasisstudy cast. See Cast, dental.study model. See Cast, dental.stump pain pain located in the amputated limb’s remaining stumpsubchondral beneath cartilagesubchondral bone bone beneath cartilagesubcutaneous beneath the skinsublingual pertaining to the regions or struc-tures beneath the tonguesubluxation, TMJ a condition in which the disc-condyle complex is anterior to the ar-ticular eminence and is unable to return to the mandibular fossa without a maneuver by the patientsubmandibular situated below the mandiblesubnucleus caudalis one of the subnuclei of the spinal trigeminal nucleus; the main terminus for most slow rst-order neurons conveying potential pain impulses from trigeminal receptive eldssubnucleus interpolaris one of the subnu-clei of the spinal trigeminal nucleus that receives some peripheral nociceptive input but mostly relays temperature and touch impulsessubnucleus oralis (SNO) one of the subnu-clei of the spinal trigeminal nucleus that receives some peripheral nociceptive input but mostly relays temperature and touch impulsesSudeck atrophy. See Reflex sympathetic dystrophy.suffering a state of severe distress associated with events that threaten the intactness of the person; may be associated with painsummation progressive increase of pain intensity with repeated noxious stimula-tion; depends on activity in unmyelinated nociceptorsSUNCT syndrome short-lasting, unilateral, neuralgiform pain with conjunctival injec-tion and tearing superior. See Cephalad.superior laryngeal neuralgia. See Neuralgia: superior laryngeal.superior retrodiscal lamina the most su-perior surface of the retrodiscal tissues or posterior attachmentsuperior sagittal sinus one of a series of ve-nous sinuses situated between the menin-geal and endosteal layers of the dura mater that drain blood from the brain and cranial bones; the superior sagittal sinus attaches to the falx cerebri and enlarges posteriorly at the internal occipital protuberance to form the conuence of sinusessupraclusion occlusal relationship where an occluding surface extends beyond the nor-mal occlusal plane. Syn: Overeruption of teeth.supracontact posterior occlusal contact before maximal intercuspation. Syn: Pre-mature occlusal contact, Prematurity; Misnomers: Interceptive occlusal contact, Occlusal interference.supranuclear paralysis. See Progressive su-pranuclear palsy.surgery, orthognathic surgical repositioning of all or parts of the maxilla or mandible to correct malpositions or deformitiessymmetry correspondence in size, shape, and relative position around an axis or on each side of a plane of the body. Ant: Asymmetry.sympathectomy excision or interruption of some portion of the sympathetic nerv-ous system pathway. Syn: Sympathetic neurolysis.sympathetic pertaining to the sympathetic nervous systemsympathetic nervous system division of the autonomic nervous system originating in 310GlossaryGthe thoracic and upper three or four lum-bar segments of the spinal cord, respon-sible for the regulation of vasomotor tone, temperature, blood sugar levels, and other aspects of the “ght or ight” reaction to stress. Syn: Thoracolumbar division.sympathetic neurolysis. See Sympathectomy.sympathetically maintained pain pain sus-tained through activity of the sympathetic nervous system; may accompany disorders such as complex regional pain syndrome and reex sympathetic dystrophysymphysis the fused immovable cartilaginous junction between two originally distinct bones. Syn: Fibrocartilaginous joint.mandibular s. the midline symphysis of the right and left halves of the fetal mandiblesymptom any subjective experience perceived as evidence of a disease by a patientSymptom Check List Revised, 90-item (SCL-90-R) 90-item multidimensional self- report measure of nine dimensions of psychologic functioningsynapse junction between the processes of two adjacent neurons where a neural im-pulse is transmitted from one neuron to another. Syn: Synaptic junction.synaptic junction. See Synapse.syndrome set of symptoms or signs that to-gether dene a disordersynkinesis unintentional movement accom-panying a volitional movementsynostosis. See Ankylosis: bony.synovia clear, thick lubricating uid in a joint, bursa, or tendon sheath secreted by the membrane lining the cavity or sheath. Syn: Synovial uid.synovial pertaining to or secreting synoviasynovial chondromatosis rare condition in which cartilage nodules develop in the con-nective tissue below the synovial mem-branes; the cartilage foci on the surface of the synovium may detach and result in loose bodies within the joint. Syn: Synovial osteochondromatosis.synovial uid. See Synovia.synovial joint joint possessing a synovial linings.j. lining membrane lining synovial joints that secretes synoviasynovial osteochondromatosis. See Syno-vial chondromatosis.synovitis inammation of the synovial lining of a joint due to infection, an immunologic condition, or secondary to cartilage degen-eration or trauma; usually painful, especially with movementsyringomyelia characterized by longitudinal cavities (syrinx) within the spinal cord that cause pain and paresthesia, atrophy of the hands and lower extremities, and spastic paralysissystemic arthritides joint inammation re-sulting in pain or structural changes caused by a generalized systemic inammatory disease, including rheumatoid arthritis, ju-venile idiopathic arthritis, spondyloarthropa-thies, and crystal-induced diseasesystemic disease disease affecting the entire organism as distinguished from any of its individual partssystemic lupus erythematosus (SLE) gen-eralized connective tissue disorder affect-ing primarily middle-aged women, causing among other things, lesions of the skin, vasculitis, arthralgia, and leukopenia; usu-ally associated with evidence of autoim-mune dysfunction such as elevated antinu-clear antibodiessystemic sclerosis. See Scleroderma.Ttachycardia excessively rapid pulse rate (ie, >100 beats/min)tardive dyskinesia involuntary, repetitious movements of the muscles of the face, limbs, and trunk, most often related to the use of neuroleptic medications and persist-ing after withdrawalteichopsia a transient visual sensation of bright shimmering colorstemporal pertaining to the temples; also, lim-ited in timetemporal arteritis. See Arteritis.temporal bone paired, irregular bone forming part of the lower and lateral surfaces of the cranium; consists of four portions: mastoid, 311Glossarysquama, petrous, and tympanic; contains the hearing apparatustemporomandibular relating to the TMJtemporomandibular disorders (TMDs) a number of clinical problems that involve the masticatory muscles, the TMJ, or bothtemporomandibular joint (TMJ) paired syn-ovial joint capable of both gliding and hinge movements, articulating the mandibular condyle, articular disc, and squamous por-tions of the temporal bonet.j. dysfunction abnormal, incomplete, or impaired function of the TMJ(s)t.j. hypermobility excessive mobility of the TMJt.j. syndrome misnomer. See Temporo-mandibular disorders.tendomyositis inammatory condition of a tendon and its associated muscletendon strong, exible, and inelastic brous band of tissue attaching muscle to bonetendonitis pain within a tendon affected by jaw movement, function, or parafunction, and replication of this pain with provocation testing of the masticatory tendonTENS. See Transcutaneous electrical nerve stimulation.tension act or condition of being stretched, strained, or extended. Syn: Stress.tension-type headache (TTH) dull, aching, pressing, usually bilateral headache of mild to moderate intensity; when severe, may include photophobia or phonophobia and, rarely, nausea; may be intermittent, last-ing minutes to days, or chronic without remissionchronic t.h. average of 15 or more head-ache days per month for at least 3 monthsfrequent episodic t.h. number of head-ache days averages more than 1 but less than 15 per month for at least 3 monthsinfrequent episodic t.h. number of head-ache days averages less than 1 per monthprobable t.h. headaches fullling all but one of the criteria for specied typetentorium cerebelli fascial membrane that separates the cerebellum from the cerebral hemispheres and forms a crescent-shaped tent or roof to the posterior cranial fossatherapeutic relating to treatment or the art of healing; producing improvement or cure of an illnesstherapeutic prosthesis prosthesis used to transport and retain some agent for thera-peutic purposesthermography technique using an infrared camera that provides a graphic represen-tation of the skin temperature variations between adjacent tissues or between the same area on two sides of the bodythoracic outlet syndrome (TOS) condition in which pressure exerted on nerve roots in the thoracic area (including the brachial plexus) causes painthreshold smallest stimulus that can be per-ceived; the minimum level required to pro-duce a resultthunderclap headache abruptly starting headache, reaching most severe intensity usually within 1 minute and lasting from 1 hour to 10 daystic douloureux. See Neuralgia: trigeminal.tidemark the demarcation line between the calcied cartilage zone and the brocarti-laginous zone of synovial jointstime-contingent treatment. See Clock- regulated treatment.tinnitus presence of any subjective noise, such as a ringing, buzzing, or roaring sound in the ear or headTMJ. See Temporomandibular joint.tolerance physiologic state requiring increas-ing doses of agents to produce a sustained desired effecttomography radiographic technique that shows structural images of the internal body lying within a predetermined plane of tissues while blurring or eliminating images of structures lying in other planescomputed t. (CT) imaging method that uses a narrowly collimated radiographic beam that passes through the body and is recorded by an array of scintil-lation detectors; the computer calcu-lates tissue absorption, with the lm images reecting the densities of vari-ous structures. Misnomers: CAT scan, 312GlossaryGComputer-assisted tomography, Com-puterized axial tomography, Computer-ized tomography, Computerized transax-ial tomography.cone-beam computed t. (CBCT) imaging method that uses divergent radiographic beams, thus forming a cone; provides transaxial, axial, and panoramic images that can be reconstructed in two- and three-dimensional layersfocal plane t. imaging method that shows a detailed cross section of a body part at a predetermined depth and thickness of cut; accomplished by moving the lm and the x-ray source in opposite direc-tions during the exposure, blurring the structures in front of and behind the area of interestpositron emission t. (PET) imaging method based on detection of positron emission from decaying radionuclides within a pa-tient; provides information on both tis-sue density and metabolismsingle-photon emission computed t. (SPECT) imaging method based on de-tection of single g photons emitted by radionuclides within a patient; provides information on location of these radionu-clides, which, depending on the type of scan desired, are taken up by inamma-tory cells or metabolizing bone cells, etctorticollis contracted state of cervical mus-cles producing twisting of the neck and an unnatural head posturespasmodic t. intermittent torticollis due to tonic, clonic, or tonicoclonic spasm in cervical musclesTourette syndrome syndrome with juvenile onset and including facial tics; purposeless, uncoordinated, voluntary movements; and involuntary vocalisms. Syn: Gilles de la Tourette syndrome.Towne radiograph fronto-occipital plain lm projection of the skull, with the patient su-pine and chin depressed; allows visualiza-tion of the occipital and petrous bones as well as condyles of the mandibletranscranial radiograph plain-lm projection of the contralateral TMJ condyle from a su-peroposterior angulationtranscutaneous electric nerve stimulation (TENS) low-voltage electrical stimulation used as therapytranslation of condyle mandibular condylar movement that occurs during protrusion, lateral excursion, or mouth opening, primar-ily involving the superior aspect of the disc and the articular tubercle; usually mixed with some degree of condylar rotation. Syn: Gliding of condyle, Sliding condylar movement.transverse plane horizontal plane dividing the body into upper and lower portionstrauma an injury or wound to a part of the liv-ing body; also, acute or chronic psychologic shock that exceeds the individual’s coping capacities and that may cause lasting del-eterious effects on the personalitymacrotrauma injury to the body from an external source, involving large or exces-sive forcemicrotrauma repetitive, low-level, poten-tially injurious force to the body, usually internal to the organism, as with chronic habits such as poor posture or clenching of the teethtraumatic arthritis arthritis that is the direct result of a macrotrauma, affecting normal joints or aggravating existing joint disease or derangementTreacher Collins syndrome inherited disor-der characterized by mandibular and facial dysostosistreatment plan the sequence of procedures planned for a patient’s treatment after a diagnosistremor involuntary trembling or quivering, re-petitive and rhythmicessential t. benign hereditary familial ex-trapyramidal tremor; worsens with age and stressmovement-induced t. tremor triggered by a particular body movementparkinsonian t. slow tremor associated with Parkinson disease; worse with cold, fatigue, and stressresting t. tremor at rest that disappears with body movement. Syn: Static tremor.static t. See Resting t. 313Glossarytrigeminal autonomic cephalalgias (TACs) a group of headaches characterized by the presence of autonomic featurestrigeminal nerve mixed cranial nerve (CN V) comprising three main branches: ophthal-mic (V1), maxillary (V2), and mandibular (V3); responsible for somatosensory inner-vation of structures embryologically derived from the rst brachial arch, including the oral cavity and the face; the motor bers principally supply the muscles of mastica-tion as well as the mylohyoid, anterior belly of the digastric, the tensor veli palatini, and the tensor tympani musclestrigeminal neuralgia (TN). See Neuralgia: trigeminal.trigger point (TP) a hypersensitive area in muscle or connective tissue that, when palpated, produces pain. See Myofascial trigger point.trismus condition of being unable to open the mouth fully; may be due to multiple con-ditions, including but not limited to spasm of masticatory muscles, early symptom of tetanus, inammatory response (ie, peri-coronitis), or radiation therapy. Syn: Man-dibular trismus.trochlear nerve motor cranial nerve (CN IV) supplying the superior oblique muscle of the eyetrophic pertaining to nutrition or nourishmenttubercle characteristic lesion of tuberculosis; nodule on skin or bone. See Eminence.tumor. See Neoplasm.Uultrasonic referring to ultrasoundultrasonography visualization of deep struc-tures of the body by directing ultrasonic waves into the tissues and recording the reections. Syn: Sonography.ultrasound sound waves (mechanical radiant energy) beyond the upper frequency limit of the human ear (> 20,000 vibrations per second Hz)uncinate processes located in the cervical re-gion of the spine between C3 and C7 and formed by uncinate processes that are lo-cated laterally on the vertebral body, which project upward from the vertebral body below and downward from the vertebral body above and allow for exion and exten-sion and limit lateral exion in the cervical spine; though referred to as joints, they are not true diarthrodial joints. Syn: Joints of Luschka.unilateral occurring on one side only. Ant: Bilateral.urate crystal salt of uric acid that may be de-posited in gouty jointsVvagus nerve mixed cranial nerve (CN X) that exits the cranium via the jugular foramen and supplies sensory bers to the ear, tongue, pharynx, and larynx; parasympa-thetic and visceral afferents to the viscera; as well as motor bers to the muscles of the pharynx, esophagus, and larynxvapocoolant spray highly volatile liquid that evaporates quickly when sprayed on warm skin, causing immediate cooling; used in spray-and-stretch therapyvapocoolant spray–stretch procedure. See Spray and stretch.vascular pertaining to a blood vesselvascular pain deep somatic pain of visceral origin that emanates from the afferent nerves that innervate blood vesselsvasculitis inammatory condition of a blood vesselvasoconstriction narrowing of blood vessels, causing reduced blood ow to part of the bodyvasodilatation widening of blood vessels, causing increased blood ow to part of the bodyvasomotor effecting changes in the diameter of a blood vesselvasospasm sudden decrease in the internal diameter of a blood vessel, caused by the contraction of the muscle within the wall of the vessel, resulting in decreased blood owvertical dimension of occlusion (VDO) ver-tical distance between any two arbitrary points when the teeth are in intercuspal 314GlossaryGposition; one point is on the mandible and the other is on the facevertical plane sagittal or frontal plane; per-pendicular to the transverse planevertigo hallucination of movement; a sensa-tion as if the external world were revolving around the patient (objective vertigo) or as if the patient were revolving in space (subjec-tive vertigo); sometimes erroneously used as a synonym for dizziness; vertigo may result from disease of the inner ear; from cardiac, gastric, or ocular disorders; from organic brain disease; or from other causesvestibular nucleus a cluster of nerve cells within the medulla that has extensive neu-ronal connections to and from the head, neck, trunk, eyes, and ears, serving to co-ordinate reexive control of balance, gaze, equilibrium, and posture; descending tracts synapse within the cervical spine and rep-resent another aspect of the relationship between the head and neckvibration analysis method to measure min-ute vibrations of the condyle on transla-tion to aid with the diagnosis of internal derangementsvisceral pain deep somatic pain that origi-nates in visceral structures, such as mu-cosal linings, walls of hollow viscera, pa-renchyma of organs, glands, dental pulps, and vascular structuresWWaldeyer tonsillar ring ring of lymphoid tis-sues surrounding the upper airway, consist-ing of adenoid, tubal, palatine, and lingual tonsilsWallerian degeneration a process that re-sults when a nerve ber is cut or crushed and the part of the axon distal to the injury (ie, farther from the neuron’s cell body) degenerateswhiplash misnomer. See Flexion-extension injury.windup repetitive nerve stimulation leading to exuberant response in the central nerv-ous systemXxerostomia subjective dryness of the mouthx-ray. See Radiograph.Zzoster. See Herpes zoster.zygapophyseal the articulation (moving) of facet joints of the spine that enable exten-sion, exion, and rotation. Syn: Facet joint.zygoma area formed by the union of the zy-gomatic bone and the zygomatic process of the temporal bone and the maxillary boneReferences1. IASP Subcommittee on Taxonomy. https://www.iasp-pain.org/Taxonomy. Accessed 10 November 2017.2. The glossary of prosthodontic terms: Ninth edition. J Prosthet Dent 2017;117:e1 e105.3. Diagnostic and Statistical Manual of Mental Disorders, ed 5. Washington, DC: American Psychiatric Associa-tion, 2013.4. Fishman SM, Ballantyne JC, Rathmell JP (eds). Bonica’s Management of Pain, ed 4. Philadelphia: Lippincott Williams & Wilkins, 2010. 315GlossaryTable G-1 Terms to avoid and preferred termsTerms to Avoid Preferred Termsarthritis deformans rheumatoid arthritis bilaminar zone posterior attachment bite guard stabilization appliance computer-assisted tomography computed tomography computerized axial tomography computed tomography computerized transaxial tomography computed tomography CT scan computed tomography disk discbrositis bromyalgia at-plane appliance stabilization appliance locked joint disc displacement without reduction with limited opening or closed lockmeniscectomy, TMJ discectomy meniscus, TMJ intra-articular disc muscle cramp spasm muscle relaxation appliance stabilization appliance myofascial pain dysfunction syndrome temporomandibular disorders pathosis pathologic condition posterior ligament posterior attachment psychogenic pain disorder somatoform disorder reex sympathetic dystrophy complex regional pain syndromeretrodiscal pad posterior attachment shingles herpes zoster sliding condylar movement translation of condyle temporomandibular joint syndrome temporomandibular disorders whiplash exion-extension injury Page references followed by “t” denote tables; “f” denote gures; and “b” boxesAA AOP. See American Academy of Orofacial Pain.AAOP Guidelines, 39Abducens nerve, 34tAβ bers, 7, 12Abscessgingival, 125headache caused by, 72periodontal, 125–126periradicular, 126Acceleration-deceleration injury, 148, 215Accessory nerve, 8, 34tActive range of motion, 36ACTTION. See Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks.ACTTION-APS Pain Taxonomy, 53Acupuncture, 180–181Acute pain, 12, 17Acute periodontal pain, 124–129Acute stress disorder, 259Addiction, 260Aδ bers, 4, 7, 9, 102, 123Adhesions, 158Adjustment disorder, 259–260Aggravating factors, 31Airway patency, 37Alcohol Use Disorders Identication Test, 256Allodynia, 7, 210, 217Allostasis, 16, 252Allostatic load, 16Amelogenesis imperfecta, 128American Academy of Head, Neck, Facial Pain and TMJ Orthopedics, 52American Academy of Orofacial Pain, 52–53American Pain Society, 53AMPA receptors. See α-Amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid receptors.Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks, 53Analgesics, 80, 174Anesthesia, diagnostic, 42t, 42–43Anesthesia dolorosa, 102Anesthetic agents, 180Angular cheilitis, 135Ankylosis, 158–159, 230ANS. See Autonomic nervous system.Ansa cervicalis, 8Anterior positioning appliances, 183–184Anticonvulsants, 78Antidepressants, 176Antinuclear antibody, 44tAntiresorptive agent-related bone necrosis, 130Antisocial personality disorder, 264b, 264–265Anxiety/anxiety disorders, 255, 258–260, 262Aphthous stomatitis, 131–132Aplasia, 164APS. See American Pain Society.Arnold-Chiari malformation, 71Arousals, 241, 243Arteritis, 67Artery palpation, 35Arthralgia, 154Arthritis, 154, 156Arthrocentesis, 187–188Arthrography, 41Arthroscopy, 188Arthrotomy, 188–189Index 317317IndexArticular disc displacement, 39Aseptic meningitis, 70Aspirin, 174Assessmentscomprehensive evaluation. See Comprehensive evaluation.overview of, 26–27screening evaluation, 27b, 27–28Assisted mouth opening, 36Astrocytes, 13–14Atypical facial pain, 53, 111Atypical odontalgia, 53, 102AUDIT-C. See Alcohol Use Disorders Identication Test.Aura, migraine with, 75Auriculotemporal nerve, 5, 42tAutonomic nervous system, 8–9Avoidant personality disorder, 264b, 265Axis I, 16, 37, 55Axis IIassessment instruments, 253tbiobehavioral model. See Biobehavioral model.comprehensive evaluation, 266–267description of, 16, 37, 55psychologic factors, 57–58BBarré-Liéou syndrome, 234Benign migratory glossitis. See Geographic tongue.Benzodiazepines, 175Berlin questionnaire, 32Biobehavioral factorscomprehensive evaluation of, 255–257screening for, 254–255Biobehavioral modelfoundation of, 250–252implementation of, 252–254as standard of care, 267–268Biobehavioral therapy, 172–173Biofeedback, 173Biopsychosocial model, 15–17, 19β-blockers, 78BMS. See Burning mouth syndrome.Bony ankylosis, 159, 230Borderline personality disorder, 264b, 265Borrelia burgdorferi, 228Botulinum toxindysphagia caused by, 217migraine treated with, 79painful posttraumatic trigeminal neuropathy treated with, 105temporomandibular joint disorders treated with, 180Breathing-related sleep disorders, 261Briquet syndrome, 261Brudzinski sign, 71Bruxism, 144, 149, 173, 176, 229, 229b, 243Bupivacaine, 43Burning mouth syndrome, 106–109, 107bCCADASIL. See Cerebral autosomal dominant arteriopathy with subcortical infarcts.Calcitonin gene-related peptide, 13, 13fCancer pain, 136–137Candida albicans, 134Candidiasis, 134–135Capsulitis. See Arthritis.Carbamazepine, 44, 95–96, 109Carotid artery disorder, 68Casts, diagnostic, 43Catechol-O-methyltransferase, 152, 211Causal reasoning, 266CBCT. See Cone beam computed tomography.CBT. See Cognitive behavioral therapy.Central alveolar hypoventilation syndrome, 261Central nervous systemastrocytes in, 13–14C-bers, 4chronic pain caused by, 91glial cells in, 13–14nociception, 10Central neuropathic pain, 109Central poststroke pain, 109Central sensitization, 7, 11–13, 15, 17, 19, 92, 210–211Centrally mediated myalgia, 169Cerebral autosomal dominant arteriopathy with subcortical infarcts, 69Cerebral venous thrombosis, 68Cerebrospinal uidleakage of, 64pressure of, 69–70Cervical collars, 215Cervical dystonia, 217Cervical pain disorders, 57Cervical plexus, 8Cervical radiculopathy, 213t, 216Cervical spinal disordersdenition of, 209epidemiology of, 209–210genetics of, 211orofacial pain and, 210–212referrals for, 214screening of, 212–214subclassication of, 209Cervical spineosteoarthritis of, 216range of motion, 35–36screening of, 212–214sprain and strain of, 215Cervicalgia, 214–215Cervicogenic headache, 218C-bers, 4, 9, 102CGRP. See Calcitonin gene-related peptide.Charcot-Marie-Tooth disease, 94Chemical burns, 135Chiari malformation type I, 71Chicken pox, 105Chief complaint, 28–31, 29bChondroitin, 177 318318IndexChronic migraine, 76Chronic overlapping pain conditions, 3Chronic painacute pain versus, 17categories of, 54–55central sensitization in, 12classication system for, 55denition of, 91economic costs of, 3etiology of, 91–92prevalence of, 2violence and, 18Chronic Pain Research Alliance, 3Circadian phase delayed, 241Civamide nasal spray, 82Clinician’s role, in orofacial pain, 2, 18Clonazepam, 109Closed lock, 157Cluster headache, 80–83, 82b, 85tCNS. See Central nervous system.CODA. See Commission on Dental Accreditation.Coexisting pain conditions, 3Cognitive behavioral therapy, 246Cognitive impairment, 45Combined periodontal-endodontic lesions, 127Commission on Dental Accreditation, 2Comorbid conditionspain and sleep interaction affected by, 243–245pain and suffering as, 17–18psychologic, 19with temporomandibular disorders, 3, 7, 18–20, 146–147Complex regional pain syndrome, 110–111Comprehensive evaluationAxis II, 266–267description of, 28diagnostic tests. See Diagnostic tests.history taking. See History taking.physical examination. See Physical examination.Computed tomography, 40Conditioned pain modulation, 10Condylar fractures, 148, 163Condylar hyperplasia, 163Condylectomy, 188Condyle–disc complex, 144, 145fCondylosis, 161Condylotomy, 188–189Cone beam computed tomography, 40Connective tissue diseases, 229–231Consultation strategies, 266Contracture, 167Convergence, 14–15Conversion disorder, 262Coronoid hyperplasia, 170Corrected deviation, 36Cortical spreading depression, 77Corticosteroids, 175Costen syndrome, 51CPSP. See Central poststroke pain.Cranial bones, 224Cranial nervesdescription of, 5facial nerve, 7, 34tfunctions of, 34fglossopharyngeal nerve, 7–8, 34tlist of, 34fparasympathetic preganglionic neurons, 9screening of, 33, 34tspinal accessory nerve, 8, 34ttrigeminal nerve, 5–7, 34tvagus nerve, 8, 34tCraniocervical mandibular system, 211Craniofacial pain, 210Craniomandibular disorders, 51Craze lines, 128C-reactive protein, 44t, 64, 67Crepitus, 161Crossbite, 150CRPS. See Complex regional pain syndrome.Cryotherapy, 97CSD. See Cervical spinal disorders; Cortical spreading depression.CSF. See Cerebrospinal uid.Cyclobenzaprine, 175Cytokines, 126Cytomegalovirus, 132DDC/TMD. See Diagnostic Criteria for Temporomandibular Disorders.Degenerative joint disease, 160–161Demyelination, 94–95Dental attrition, 149Dental block, 42tDental examination, 37Dental history, 31–32Dental infection, 128–129Dental occlusionanalysis of, 43evaluation of, 37Dentin sensitivity, 124Dependent personality disorder, 264b, 265Depression, 255, 258Descending motor neurons, 6fDiagnosis. See also specic diagnosis.classication systems. See Diagnostic classication systems.clinician’s responsibility for, 2goal after, 26gold standard for, 37Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 54, 257Diagnostic classication systemsdevelopment of, 51history of, 52–53overview of, 50–51purpose of, 51terminology, 51 319319IndexDiagnostic Criteria for Temporomandibular Disordersdescription of, 35–37expanding of, 54future directions for, 54history of, 53–54Diagnostic imagingarthrography, 41computed tomography, 40magnetic resonance imaging, 40–41nuclear medicine, 41of temporomandibular joint, 40–41ultrasonography, 41Diagnostic testsanesthesia, 42t, 42–43casts, 43electrodiagnostic, 38–40electromyography, 39imaging, 40–41jaw-tracking devices, 38–39laboratory tests, 43, 44tneurosensory testing, 41–42overview of, 37–38pretreatment, 43–45reliability of, 38scientic merit of, 38sensitivity of, 38sonography, 39–40specicity of, 38thermography, 39validity of, 38vibration analysis, 40Differential diagnosis. See also specic diagnosis.clinician’s responsibility for, 2overview of, 55–56Diffuse noxious inhibitory controls, 10Direct trauma, 148Disc displacementcondylar and subcondylar fractures as cause of, 148osteoarthritis progression of, 152with reduction, 151, 156–157with intermittent locking, 157without reductionwith limited opening, 157–158without limited opening, 158Discectomy, 188Distress, 153, 254DJD. See Degenerative joint disease.DN4. See Douleur Neuropathique.DNICs. See Diffuse noxious inhibitory controls.Doppler sonography, 39Douleur Neuropathique, 30Dual-axis coding, 252–254Duration of pain, 31Dystonia, oromandibular, 227EEagle syndrome, 217Ear(s)pain associated with, 225, 225bphysical examination of, 36–37EGS. See Electrogalvanic stimulation.Electrodiagnostic testselectromyography, 39jaw-tracking devices, 38–39sonography, 39–40thermography, 39vibration analysis, 40Electrogalvanic stimulation, 179Electromyography, 39Electrotherapy, 179EMG. See Electromyography.Emotional anesthesia, 259Emotional motor system, 16End-stage renal disease, 44Enteric system, 9Epidural hematoma, 66Epigenetics, 17Epinephrine, 9Epstein-Barr virus, 132Epworth Sleepiness Scale, 32Erythema migrans, 228. See also Geographic tongue.Erythematous candidiasis, 134–135Erythrocyte sedimentation rate, 44t, 64, 67ESR. See Erythrocyte sedimentation rate.Exercise, 178–179External auditory canal, 36Extracranial disorders, 57, 223–227Extractable nuclear antigens, 44tEye pain, 224–225FFacial nerve, 7, 34tFacial painatypical, 53, 111persistent idiopathic, 111stylohyoid ligament inammation as cause of, 217–218Factitious disorder, 262–263Familial hemiplegic migraine, 76–77Familiar pain, 34Ferritin, 44tFibromyalgia, 165, 169, 231Fibrous ankylosis, 159, 230Fight-or-ight response, 8, 18, 242First-bite syndrome, 227First-order neurons, 6f, 14First-order nociceptive nerves, 9Flashbacks, 259Fluconazole, 135Folate, 44tFracturescondylar, 148, 163subcondylar, 148, 164Frequency of pain, 31Full blood count, 44tFunctional neuroimaging, 41Functional temporomandibular joint disturbances, 51Fungal meningitides, 72 320320IndexGGABA. See γ-aminobutyric acid.Gabapentin, 97, 106, 247Gabapentinoids, 176GAD. See Generalized anxiety disorder.Gait, 34γ-aminobutyric aciddescending inhibition mediated by, 11receptors, 108GCPS. See Graded Chronic Pain Scale.General inspection, 33–34Generalized anxiety disorder, 258Genetic vasculopathy, 69Geniculate neuralgia, 100Geographic tongue, 137Giant cell arteritis, 35, 67, 232Gingival abscess, 125Glial cells, 13–14, 20Glossal pain, 129–132Glossodynia, 107Glossopharyngeal nerve, 7–8, 34tGlossopharyngeal neuralgia, 99–100Glucocorticoid receptor gene, 152Glucosamine, 177Graded Chronic Pain Scale, 33, 212, 254, 256Graft versus host disease, 137Greater auricular nerve, 8Greater occipital block, 42tHHeadgeneral inspection of, 33palpation of muscles of, 35Head pain, 217–218, 224–227Headachecervicogenic, 218cluster, 80–83, 82b, 85tcraniofacial symptoms of, 12functional neuroimaging of, 41infection as cause of, 71–72migraine. See Migraine.neurologic signs and symptoms of, 62neurovascular, 56in older patients, 64papilledema in, 65pattern change for, 64postural, 64–65precipitants of, 65preliminary investigation for, 62prevalence of, 19sinus, 226sudden-onset, 62, 64SUNA, 83–84, 85t, 95SUNCT, 83–84, 85t, 95in temporomandibular disorders, 20, 169–170tension-type, 79–80vascular disorders as cause of. See Vascular disorders.Heart rate variability, 19Hemicrania continua, 84Hemoglobin A1c, 44tHemorrhageintracranial, 65–67subarachnoid, 62, 66–67Hepatic function, 44Herpes simplex virus, 72, 132Herpes zosterdescription of, 100painful trigeminal neuropathy caused by, 105Herpetic gingivostomatitis, 132–133, 138Heterotopic pain, 14–15History takingchief complaint, 28–31, 29bdental history, 29b, 31–32history format, 29bmedical history, 29b, 31–32previous treatments, 31psychosocial history, 29b, 32–33, 33bHistrionic personality disorder, 264b, 265Human immunodeciency virus, 138Hyperalgesia, 7, 210Hyperexcitability, 18Hypermobility disorders, 159–160Hyperplasia, 165Hypertrophy, 167Hypochondriasis, 261Hypoglossal nerve, 34tHypomobility, 158–159Hypoplasia, 164–165Hypothyroidism, 44tHysteria, 261IICD -11, 5 4– 55ICHD. See International Classication of Headache Disorders.Idiopathic condylar resorption, 161Idiopathic orofacial pain disorders, 52ID-Pain, 30Immune-mediated inammatory conditions, 137–138Indirect trauma, 148Infectionscandidiasis, 134–135headache caused by, 71–72primary herpetic gingivostomatitis, 132secondary herpetic gingivostomatitis, 132varicella zoster, 132–133Inferior lateral pterygoid muscle, 34Inammatory pain, 90–91, 91fINfORM. See International Network for Orofacial Pain and Related Disorders Methodology.Insomnia, 242, 261Intensity of pain, 31Interdisciplinary team, 2Interincisal mouth opening measurements, 36International Association for the Study of Pain, 2, 52International Classication of Headache Disordershistory of, 53 321321Indexprimary headache categories, 74International Network for Orofacial Pain and Related Disorders Methodology, 37Interneurons, 11, 14Intracapsular block, 42tIntracerebral hematoma, 66Intracranial arterial disorder, 68Intracranial hematoma, 66Intracranial hemorrhage, 65–67Intracranial neoplasia, 70–71Intracranial pressure, increased, 69–70Intraoral painacute periodontal pain, 124–129aphthous stomatitis, 131–132combined periodontal-endodontic lesions, 127description of, 57gingival abscess, 125glossal pain, 129–132infections. See Infections.mucogingival pain, 129–132necrotizing pain, 130–131nonodontogenic toothache, 129odontogenic pain, 121–129oral mucosal pain, 129–138pericoronitis, 126–127periodontal abscess, 125–126periradicular abscess, 126pulpal pain, 122–124, 127–129Iontophoresis, 180Irreversible pulpitis, 122Ischemic stroke, 65JJaw Functional Limitation Scale, 255“Jaw opening pattern,” 36Jaw-tracking devices, 38–39Joint palpation, 35Joint sounds, 35Jugulodigastric node, 232Juvenile rheumatoid arthritis, 44tKKidneys, 44LLaboratory tests, 43, 44tLamotrigine, 96–97LANSS. See Leeds Assessment of Neuropathic Symptoms and Signs.Leeds Assessment of Neuropathic Symptoms and Signs, 30Lesser occipital block, 42tLichen planus, oral, 138Lidocaine, 42–43, 104Liver, 44Local mucogingival pain, 129–132Local myalgia, 166Location of pain, 28, 30Long-term potentiation, 12Low cerebrospinal uid pressure, 70Low-level laser therapy, 181Lucid interval, 66Luxation, 159–160Lyme disease, 44t, 228Lymph node palpation, 35Lymphadenopathy, 232, 233bLymphatic system, 231–232MMagnetic resonance imaging, 40–41Magnetic resonance spectroscopy, 41Main sensory nucleus, 6Major depressive disorder, 258Malingering, 263Mandiblemovement measurements, 38opening range for, 35Mandibular branch, of trigeminal nerve, 5–6MAPI. See Multivariable apnea prediction index.Marfan syndrome, 70Masseter muscle palpation, 27, 28bMasticatory muscle(s)anatomy of, 144palpation of, 34tenderness of, 151Masticatory muscle disorders. See also specic disorder.contracture, 167mechanisms of, 165movement-related, 168–169neoplasms, 167–168orofacial region, 165–166systemic/central disorders as cause of, 169taxonomy of, 155bMaxillary branch, of trigeminal nerve, 5Maxillary tooth pain, 36Maximal pain-free opening, 36Maximal unassisted mouth opening, 36MDCT. See Multidetector computed tomography.Medical history, 31–32Medicationscluster headache treated with, 82, 82bmigraine treated with, 78–79, 79btension-type headache treated with, 80MELAS. See Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes.Meningococcal meningitis, 72Meniscus, 144Mental neuropathy, 101Mesencephalic nucleus, 6Metaboreceptors, 4Microtrauma, 148–149Microvascular decompression, 97–98MIDAS. See Migraine disability assessment.Migrainewith aura, 75characteristics of, 56chronic, 76 322322Indexclinical presentation of, 75–76diagnosis of, 75–76epidemiology of, 76familial hemiplegic, 76–77management of, 77–79, 78bmedications for, 78–79, 79bneurotransmitters involved in, 77in older patients, 64pathogenesis of, 76–77prevalence of, 76sinus headache versus, 226temporomandibular disorders and, 20treatment of, 20Migraine disability assessment, 20Mind/body dualism, 15Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes, 69Mobilization, 179MRI. See Magnetic resonance imaging.MRS. See Magnetic resonance spectroscopy.Mucogingival pain, 129–132Mucosal pain, oral, 129–138Mucositis, 135–136Multidetector computed tomography, 40Multiple sclerosiscentral neuropathic pain caused by, 109description of, 44thead and facial pain associated with, 227–228painful trigeminal neuropathy caused by, 106Multisystem Dysregulation Index, 147Multivariable apnea prediction index, 32Muscle overuse, 165Muscle palpation, 34–35. See also specic muscles.Muscle relaxants, 175Musculoskeletal pain, 30t, 42MVD. See Microvascular decompression.Myalgia, 165–166, 169Myofascial pain, 39, 42, 146, 166, 268Myofascial trigger points, 34Myositis, 166–167NNarcissistic personality disorder, 264b, 265Nasal cavity, 226National Institute of Dental and Craniofacial Research, 3Near-infrared spectroscopy, 41Neckgeneral inspection of, 33palpation of muscles of, 35Neck Bournemouth Questionnaire, 212Neck Disability Index, 212, 215Neck distraction test, 213, 213tNeck pain, 15, 209b, 212b, 213–215, 214t. See also Cervical spinal disorders.Neck-tongue syndrome, 218Necrotizing pain, 130–131Necrotizing ulcerative gingivitis, 130Necrotizing ulcerative periodontitis, 130Negative predictive value, 38Neoplasmsmasticatory muscle, 167–168temporomandibular joint, 163Nerve(s)compression of, 213, 213tdescription of, 5facial, 7, 34tglossopharyngeal, 7–8, 34tspinal accessory, 8, 34ttrigeminal, 5–7, 34tupper cervical, 8vagus, 8, 34tNervus intermedius neuralgia, 100Neuralgiasdescription of, 92glossopharyngeal, 99–100nervus intermedius, 100trigeminal. See Trigeminal neuralgia.Neurectomy, 97Neurodegenerative diseases, 110–112Neurologic screening, 33, 34tNeurolysis, 42Neuromatrix theory, 15Neuropathic paincentral, 109denition of, 92description of, 30t, 41, 56neuralgias as cause of. See Neuralgias.neurodegenerative diseases as cause of, 110–112posttraumatic, 104–105Neuropathic Pain Questionnaire, 30Neurosarcoidosis, 70Neurosensory testing, 41–42Neurotransmitters, 8–9, 77Neurovascular headache, 56Neurovascular pain, 30tNIDCR. See National Institute of Dental and Craniofacial Research.90-item Symptom Check List Revised, 32, 256, 262Nociception, 9–11, 14, 20Nociceptive pain, 90, 91fNociceptors, 4, 12Noninfectious inammatory diseases, 70Nonodontogenic toothache, 129Non–rapid eye movement sleep, 241Nonrestorative sleep, 243Nonsteroidal anti-inammatory drugs, 174Nonvascular intracranial disordersChiari malformation type I, 71description of, 56increased cerebrospinal uid pressure, 69–70intracranial neoplasia, 70–71low cerebrospinal uid pressure, 70noninfectious inammatory diseases, 70types of, 63b–64bNonvital tooth pain, 122Norepinephrine, 8–9Nosehead and facial pain arising from, 226physical examination of, 36–37 323323IndexNPQ. See Neuropathic Pain Questionnaire.NREM sleep. See Non–rapid eye movement sleep.Nuclear medicine, 41NUG. See Necrotizing ulcerative gingivitis.Numb chin syndrome, 101NUP. See Necrotizing ulcerative periodontitis.OObsessive-compulsive personality disorder, 264b, 265Occipital neuralgia, 217Occlusal adjustment, 185Occlusal dysesthesia, 111–112Occlusal relationships, 149–150Occlusal therapy, 184–187Ocular pain, 224–225Oculomotor nerve, 34tOD. See Occlusal dysesthesia.Odontalgia, atypical, 53Odontogenic painacute periodontal pain, 124–129description of, 37, 121–122pulpal pain, 122–124, 127–129Olfactory nerve, 34tOnset of pain, 30Ontology, 53Open lock, 159Ophthalmic branch, of trigeminal nerve, 5Opioidscognitive impairment caused by, 45migraine treated with, 78scheduled drug agreement for, 44–45OPPERA study, 3, 7, 17, 152–153, 252Optic nerve, 34tOral mucosapain of, 129–138trauma to, 135Oral squamous cell carcinoma, 136Orbital infarctions, 225Orbital lymphomas, 225Orbital schwannomas, 225Orofacial dyskinesia, 168Orofacial pain. See also Pain.anatomy of, 4–9cervical spinal disorders and, 210–212clinician’s responsibility in, 2denition of, 1–2, 4epidemiology of, 2–4functional neuroimaging of, 41health care professional’s responsibility in, 2neurophysiology of, 9–15pathology associated with, 1–2pathways of, 9–10physiology of, 4–9referrals for, 256bresidency training programs for, 2Oromandibular dystonia, 168, 227Orthodontic-orthognathic therapy, 186–187Orthopantography, 40Orthopedic appliances, 181–184Osteoarthritiscervical spine, 216disc displacement progression to, 152temporomandibular joint, 151, 160Osteochondritis dissecans, 161–162Osteogenesis imperfecta, 128Osteonecrosis, 162Otalgia, 225Otoscope, 36Overlapping pain conditions, 3Oxcarbazepine, 96Oxidative stress, 152PPainchronic. See Chronic pain.coexisting conditions. See Comorbid conditions.denition of, 4, 17duration of, 31familiar, 34frequency of, 31heterotopic, 14–15inammatory, 90–91, 91fintensity of, 31location of, 28, 30modulating factors for, 31myofascial, 39, 42, 146, 166, 268neck, 15neuropathic. See Neuropathic pain.nociceptive, 90, 91fodontogenic. See Odontogenic pain.onset of, 30orofacial. See Orofacial pain.pathologic, 91fperception of, 10persistent, 15–16primary, 14psychosomatic, 15quality of, 30, 30breferred. See Referred pain.shoulder, 15suffering and, 17–18symptoms associated with, 31types of, 90Pain modulation, 10–11PainDETECT, 30Painful neuropathy, 41Painful peripheral sensory neuropathies, 101Painful trigeminal neuropathiesburning mouth syndrome, 106–109, 107bherpes zoster as cause of, 105multiple sclerosis as cause of, 106numb chin syndrome, 101overview of, 100postherpetic trigeminal neuropathy, 105–106posttraumatic, 100, 102–105Palpation, 34–35Panic disorder, 258Panoramic radiography, 40Papilledema, 65 324324IndexParafunctional habits, 148–149, 172–173Paranasal sinuses, 226Paranoid personality disorder, 264, 264bParasympathetic nervous system, 8–9, 18Parkinson disease, 110Paroxysmal hemicrania, 83, 85tPartial-coverage appliances, 182–183Passive range of motion, 36Patient Health Questionnaire-4, 32, 255–256PDA P. See Persistent dentoalveolar pain disorder.Penciclovir, 134Percutaneous balloon microcompression, 98Pericoronitis, 126–127Periodic limb movements, 243–244Periodontal abscess, 125–126Periodontal pain, acute, 124–129Peripheral sensitization, 11, 13, 92, 210–211Periradicular abscess, 126Persistent dentoalveolar pain disorder, 101Persistent idiopathic facial pain, 111Persistent pain, 15–16Personality disorders, 263–265, 264bPhantom tooth pain, 102Phenytoin, 97PHQ-4. See Patient Health Questionnaire-4.Physical examinationdental examination, 37ear, nose, and throat, 36–37general inspection, 33–34neurologic screening, 33, 34toropharynx, 37palpation, 34–35procedures in, 29trange of movement, 35–36vital signs, 33Physiotherapy, 171Pittsburgh Sleep Quality Index, 32Pituitary apoplexy, 69Platelet-rich plasma, 175Positive predictive value, 38Posterior cervical sympathetic syndrome, 234Posterior circulation dysfunction, 65Postganglionic neurons, 8Postherpetic neuralgia, 133–134Postherpetic trigeminal neuropathy, 105–106Postsurgical neuropathy, 103Posttraumatic stress disorder, 259–260Posttraumatic trigeminal neuropathy, 55Posttraumatic wounds, 12Postural headache, 64–65Posture training, 178PPSNs. See Painful peripheral sensory neuropathies.PPTTN. See Painful trigeminal neuropathies, posttraumatic.Precipitating factors, 31Pregabalin, 97, 104, 176, 247Preganglionic neurons, 8Pretreatment tests, 43–45Previous treatments, 31Primary headache disorderscategories of, 74–75cluster headache, 80–83, 82b, 85tdenition of, 56migraine. See Migraine.paroxysmal hemicrania, 83, 85ttension-type headache, 79–80Primary pain, 14, 42Prosthodontic therapy, 185–186Pseudoaddiction, 260Pseudomembranous candidiasis, 134Psychiatric disorders, 257–265Psychic numbing, 259Psychogenic factors, 251Psychogenic pain, 30tPsychologic factors affecting other medical conditions, 263Psychosocial history, 32–33, 33bPsychosomatic pain, 15PTSD. See Posttraumatic stress disorder.Pulpal necrosis, 122Pulpal pain, 122–124, 127–129Pulpitis, 122Pulpo-dentinal complex, 123QQST. See Quantitative sensory testing.Qualitative sensory testing, 102Quality of pain, 30, 30bQualST. See Qualitative sensory testing.Quantitative sensory testing, 42, 102–103RRadiculopathy, cervical, 213t, 216Ramsay Hunt syndrome. See Nervus intermedius neuralgia.Range of movement, 35–36Rapid eye movement sleep, 241RCVS. See Reversible cerebral vasoconstriction syndrome.RDC. See Research Diagnostic Criteria.Receptor activator of nuclear factor κB ligand inhibitors, 130Red ags, for referrals, 256, 256bReferralsfor cervical spinal disorders, 214for orofacial pain, 256b, 266for sleep disorders, 32Referred painconvergence in, 14denition of, 14motor response to, 6fneuroanatomy of, 14sensory pathways of, 6fReex sympathetic dystrophy. See Complex regional pain syndrome.Refractory period, 95Regional blocks, 43 325325IndexReliability, 38REM sleep. See Rapid eye movement sleep.Renal function, 44Renal insufciency, 44Research Diagnostic Criteria, 54Research Diagnostic Criteria/Temporomandibular Disorders, 16, 53–54Restorative sleep, 243Restorative therapy, 185–186Reversible cerebral vasoconstriction syndrome, 68–69Reversible pulpitis, 122, 124Rheumatoid arthritis, 162, 230Rhinosinusitis, 226SSaccular aneurysm, 66SAH. See Subarachnoid hemorrhage.Salivary glands, 37, 227Scheduled drug agreement, 44–45Schizoid personality disorder, 264, 264bSchizotypal personality disorder, 264, 264bScintigraphy, 41SCL- 90 -R. See 90-item Symptom Check List Revised.Screeningcervical spinal disorders, 212–214cranial nerves, 33, 34tneurologic, 33, 34tsleep, 256temporomandibular disorders, 27b–28b, 27–28Second-order neurons, 6f, 7, 9–10, 12Selective serotonin reuptake inhibitors, 176Selective serotonin-noradrenaline reuptake inhibitors, 176Self-management, 171–172Self-regulation skills, 266, 268Sensitivity, 38Sensitizationcentral, 11–13, 15, 17, 19, 210–211development of, 12peripheral, 11, 13, 210–211physiology of, 11f, 11–14Sensory nuclei, 6f, 6–7Serotonin, 123Serotonin receptor gene, 152Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. See SUNCT.Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms. See SUNA.Shoulder pain, 15Single-nucleotide polymorphisms, 152Single-photon emission computed tomography, 41Sinus headache, 226Sinusitis, 226Sjögren syndrome, 230–231SJS. See Stevens-Johnson syndrome.Skull lesions, 224Sleepdescription of, 240–241history-taking about, 32nonrestorative, 243overview of, 241–243pain and, 242–245polysomnographic recording of, 244fpsychometric instruments for assessing, 32quality of, 57restorative, 243screening instruments for, 256Sleep apnea/hypopnea, 244Sleep bruxism, 20, 149, 173, 176, 229, 229b, 243Sleep cycles, 241, 242fSleep disordersassessment of, 245bbreathing-related, 261description of, 57, 261history-taking about, 32management of, 246b, 246–247referrals for, 32SNOOP4, 62, 63bSodium hyaluronate, 175Somatic nerve blocks, 42Somatic symptom disorder, 261–262Somatization, 262Somatoform disorders, 17Sonography, 39–40SPA. See Stimulation-produced analgesia.Spasmodic torticollis. See Cervical dystonia.Spasms, 167Specicity, 38SPECT. See Single-photon emission computed tomography.Sphenopalatine block, 42tSphenopalatine ganglion block, 43Sphenopalatine ganglion stimulator, 83Spinal accessory nerve, 8, 34tSpinal trigeminal nucleus, 7Spurling test, 213, 213tStabilization appliances, 181–182Status migrainosus, 76Stellate ganglion block, 42t, 43Stereotactic neurosurgery, 98–99Stevens-Johnson syndrome, 95Stimulation-produced analgesia, 10–11Stomatodynia, 107Stomatognathic system, 211Stomatopyrosis, 107STOP questionnaire, 32STOP-Bang questionnaire, 32Stress, 32Stressors, 32, 57Stylohyoid ligament inammation, 217–218Subarachnoid hemorrhage, 62, 66–67Subcondylar fractures, 148, 164Subdural empyema, 72Subdural hematoma, 66Sublingual gland, 227Subluxation, 159–160Submandibular gland, 227 326326IndexSubnucleus caudalis, 7Subnucleus interpolaris, 7, 12Subnucleus oralis, 7, 11–12Substance abuse, 260Substance dependence, 260Substance intoxication, 260Substance use disorders, 260–261Sudden-onset headache, 62, 64Sufferingdenition of, 17pain and, 17–18Suicide/suicidal risks, 32, 256–257Sumatriptan, 82SUNA, 83–84, 85t, 95SUNCT, 83–84, 85t, 95Supraclavicular nerve, 8Surgerycluster headache treated with, 82–83posttraumatic neuropathic pain treated with, 104temporomandibular disorders treated with, 187–189trigeminal neuralgia treated with, 97–99Sympathetic nervous system, 8–9Synovial chondromatosis, 163Synovitis. See Arthritis.Systematic lupus erythematosus, 44tSystemic arthritides, 162Systemic disordersdental infection associated with, 128–129description of, 57head and facial pain caused by, 227–235, 235bsigns and symptoms of, 235bSystemic lupus erythematosus, 230Systemic sclerosis, 231TTemporal arteries, 35Temporal arteritis, 232Temporalis muscle, 27, 28bTemporomandibular disordersanatomical factors, 149categories of, 52chronic, 18–19comorbid conditions with, 3, 7, 18–20, 146–147congenital, 164–165contiguous tissue components for, 18contributing factors, 3, 4fdening/denition of, 18, 57, 144, 146developmental, 164–165diagnostic criteria for, 35–36epidemiology of, 146–147etiology of, 147–154general distress associated with, 153genetic factors, 152–153headache associated with, 20, 169–170initiating factors of, 147local factors, 151–152management of, 170–189migraine and, 20occlusal relationships, 149occlusal therapy for, 184–187origin of term, 51orthopedic appliance therapy for, 181–184painful, 146–147parafunctional habits as cause of, 148–149, 172–173pathophysiologic factors, 150–153patient complaints associated with, 146patient education about, 171–172perpetuating factors of, 147pharmacologic management of, 173–178physical therapy for, 178–181predisposing factors of, 147psychosocial factors, 153–154research diagnostic criteria for, 16risk factors for, 17screening evaluation for, 27b–28b, 27–28self-management of, 171–172skeletal factors, 149sleep bruxism and, 20surgery for, 187–189systemic factors, 150–151taxonomy of, 155bterminology of, 51thermographic assessment of, 39trauma as cause of, 147–149Temporomandibular jointadhesions in, 158anatomy of, 144, 145fankyloses of, 158–159arthrography of, 41articular disc displacement of, 39articular disorders, 52clicking, 28, 171diagnostic imaging of, 40–41diseases of, 160–163disorders of, 155b, 156–160fractures of, 163–164hypermobility of, 159–160hypomobility of, 158–159internal derangement of, 151laxity of, 150luxation of, 159–160movement of, 144neoplasms of, 163overuse of, 172palpation of, 27, 35subluxation of, 159–160Temporomandibular joint dysfunction syndrome, 51Temporomandibular joint painprevalence of, 3types of, 154–156Temporomandibular joint pain-dysfunction syndrome, 52TEN. See Toxic epidermal necrolysis.Tendonitis, 166TENS. See Transcutaneous electrical nerve stimulation.Tension-type headache, 79–80Thermal burns, 135Thermography, 39 327327IndexThird-order neurons, 6f, 10Throathead and facial pain arising from, 227, 228bphysical examination of, 36–37Tic douloureux. See Trigeminal neuralgia.TMDs. See Temporomandibular disorders.TMJ. See Temporomandibular joint.Tolosa-Hunt syndrome, 110Tooth fractures, 127–128Toothache, 3, 12Topical medications, 177Topiramate, 97Toxic epidermal necrolysis, 96Transcutaneous electrical nerve stimulation, 179Transverse cervical nerve, 8Traumadirect, 148indirect, 148microtrauma, 148–149mucosal, 135neck pain after, 215orofacial pain and, 19pain caused by, 30pulpal pain caused by, 123soft tissue pain caused by, 37temporomandibular disorders caused by, 147–149Trigeminal autonomic cephalgiasclinical features of, 85tcluster headache, 80–83, 82b, 85themicrania continua, 84paroxysmal hemicrania, 83, 85tSUNA, 83–84, 85t, 95SUNCT, 83–84, 85t, 95Trigeminal ganglion, 97–98Trigeminal nervebranches of, 5–6, 224sensory nuclei, 6f, 6–7Trigeminal neuralgiaage of onset, 228characteristics of, 92–93classic, 92, 94bclassication of, 92denition of, 92idiopathic, 95medical management of, 95–96pathogenesis of, 56, 94–95surgical management of, 97–99treatment of, 95–99Trigeminal pain, 20Trigeminal system, 4–5Trigger point injections, 42, 42t, 180Trigger zone inltration, 42tTrochlear nerve, 34tTrue negative rate, 38True positive rate, 38TTH. See Tension-type headache.Tympanic membrane, 36UUltrasonography, 41Ultrasound, 179–180Uncorrected deviation, 36Unruptured vascular malformation, 67Unspecied somatic symptom and related disorder, 263Upper cervical nerves, 8Upper limb tension test, 213, 213tVVagus nerve, 8, 34tValidity, 38Valsalva maneuver, 213, 213tVaricella zoster virus, 132–133Vascular disordersarteritis, 67carotid artery disorder, 68cerebral venous thrombosis, 68cervical, 65–69cranial, 65–69description of, 56genetic vasculopathy, 69head and facial pain caused by, 232, 233bintracranial arterial disorder, 68intracranial hemorrhage, 65–67ischemic stroke, 65pituitary apoplexy, 69subarachnoid hemorrhage, 66types of, 63b–64bunruptured vascular malformation, 67vertebral artery disorder, 68Venous thrombosis, cerebral, 68Verbal rating scale, 31Vertebral artery disorder, 68Vertebral artery syndrome, 234Vestibulocochlear nerve, 34tVibration analysis, 40Vital signs, 33Vitamin B12, 44tVitamin C, 177Vitamin D, 177Vitamin E, 177WWAD. See Whiplash-associated disorder.Whiplash-associated disorder, 215Wide-dynamic range neurons, 9Withdrawal, 260World Health Organization, 54YYellow ags, for referrals, 256, 256bZZinc, 44tZolmitriptan, 79, 82 Contents1 Introduction to Orofacial Pain2 General Assessment of the Orofacial Pain Patient3 Diagnostic Classifi cation of Orofacial Pain4 Vascular and Nonvascular Intracranial Causes of Orofacial Pain5 Primary Headache Disorders6 Neuropathic Pain7 Intraoral Pain Disorders8 Differential Diagnosis and Management of TMDs9 Cervical Spinal Disorders and Headaches10 Extracranial and Systemic Causes of Head and Facial Pain11 Sleep and Orofacial Pain12 Axis II: Biobehavioral Considerations

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