Systemic Factors in Temporomandibular Disorder Pain.

The science of temporomandibular disorder (TMD) pain and its management has gone through significant changes during the last several decades. The authors strongly feel that the effect of systemic factors influencing TMD pain has been largely overlooked and poorly accounted for, even in established pain-management programs and protocols. The hope is that this article will act as a wake-up call for the pain management community to consider the importance of adequate knowledge of the systemic factors that affect the experience of TMD pain by the patient.

Temporomandibular Joint Disorders and the Eating Experience.

Temporomandibular joint disorder (TMD) is a chronic disorder that significantly affects oral function. It can affect appetite and the mechanical components involved with eating, including mandibular opening, biting, chewing, and even swallowing. Thus, dietary intake and, subsequently, nutrition status are affected. The functional challenges presented by the disorder affect eating-related quality of life and can affect food choices and diet quality and composition. This article addresses disorder-related factors affecting the eating experience of adults with TMDs and approaches to diet management.

Temporomandibular Joint Disorder Comorbidities.

Comorbidity is a distinct additional condition that either existed or exists during the clinical course of a patient afflicted by the condition/entity in question. The clinician attempting to manage temporomandibular joint disorder (TMD) and TMD pain must realize that recognition and management of the comorbidities are essential to the successful management of the same with optimal pain control. When TMD presents with multiple comorbidities, the task for the clinician becomes more complex. It is the hope of the authors that this condensed version of TMD-associated comorbidities acts as a primer for understanding the significance of the same in pain management.

Are YouTube Videos a Useful and Reliable Source of Information for Patients with Temporomandibular Joint Disorders?

Counseling is considered a first-line conservative therapy with respect to temporomandibular joint disorders (TMJD). Nowadays, 50 to 80% of patients acquire health information from the internet before turning to professionals. The purpose of this study has been to investigate the quality of information about TMJD that patients can obtain from YouTube. A YouTube.com search was conducted using the terms "temporomandibular joint disorder"; "limited movement of the mandible"; and "mandibular joint pain". The videos identified were assessed independently by two panels of three professional and lay reviewers with HONcode, modified DISCERN (MD) and the global quality scale (GQS). A total of 106 videos were included. The professional reviewers reported a mean HONcode score of 4.148 ± 1.314 and a mean MD score of 2.519 ± 1.267, testifying to a modest general quality of the videos. The mean GQS score was 2.987 ± 1.012 for the professional and 3.469 ± 0.891 for the lay reviewers (p < 0.001). The correlations between the ratings were significant between the reviewers within the same group but not between the two groups. The presence of animations significantly influenced the GQS score expressed by the lay reviewers (p = 0.011) but not that of the professionals (p = 0.640). The quality of the information on TMJD on YouTube is generally of poor quality. Healthcare systems and professionals should be prepared to correct misinformation and build trusting relationships with patients which are based on quality counseling. Similarly, academic institutions should produce quality content that leads patients with TMJD toward a correct diagnostic-therapeutic process.

Establishment of quantitative indicators for an efficient treatment on masticatory muscle pain.

BACKGROUND: Although several studies have investigated effective treatments for masticatory muscle pain (MMP), no unified conclusion has been drawn regarding the effectiveness of these treatments. OBJECTIVES: This study aimed to define quantitative indicators for predicting the outcome of MMP treatment. MATERIALS AND METHODS: In total, patients aged 20-70 years were recruited and divided into the MMP (n = 24) and control (n = 36) groups, based on the presence of MMP according to the Diagnostic Criteria for Temporomandibular Disorders. At pretreatment, the MMP group was assessed using quantitative indicators such as subjective pain levels, pain duration, graded chronic pain scale (GCPS), and perceived stress scale (PSS). Salivary alpha-amylase (sAA) and interleukin-6 (IL-6) levels were analyzed. The masticatory muscle palpation score and the range of mouth opening were measured. At posttreatment, subjective pain levels, mouth opening, and treatment/medication duration were examined. The PSS and sAA levels were assessed in the control group. RESULTS: sAA levels in the MMP group were significantly higher than those in the control group (p < .05). The masseter muscle palpation score (MPS) showed a positive correlation with IL-6 levels (ρ = 0.503, p < .05) and a negative correlation with nonsteroidal anti-inflammatory drug (NSAID) treatment period (ρ = -0.462, p < .05). The temporalis muscle palpation score (TPS) was positively correlated with pain duration and GCPS grade (ρ = 0.483, p < .05, and ρ = 0.445, p < .05, respectively). CONCLUSIONS: Treatment with NSAIDs was effective in the MMP group with high MPS and IL-6 levels, but not in the MMP group with high TPS, pain duration, and GCPS grade.

The Association Between Post-Traumatic Stress Disorder and Temporomandibular Disorders: A Systematic Review.

The purpose of this systematic study was to discover a connection between temporomandibular joint disorders and post-traumatic stress disorder. A systematic review of observational studies on post-traumatic stress disorder and the incidence of temporomandibular joint disorders (TMD) was conducted. Electronic searches of PubMed, the Saudi Digital Library, Science Direct, the Virtual Health Library (VHL), Scopus, Web of Science, Sage, EBSCO Information Services, and Ovid were performed. There was a consensus among the reviewing examiners. Only studies with the following Medical Subject Headings (MeSH) terms were included: "Posttraumatic stress disorder" combined with "temporomandibular joint disorder," "myofascial pain," "orofacial pain," "internal derangement," "disc displacement with reduction," or "disc displacement without reduction." Only full-text studies in the English language published between 2010 and June 2020 were considered. Of a total of 381 articles meeting the initial screening criteria, only eight were included in the qualitative analysis. Overall, pain is exacerbated in patients with PTSD; that is, their TMD is heightened in all aspects of pain, chronicity, decreased response to conventional therapies, and the need for more potent treatment options as compared with patients with just TMD. The evidence, albeit weak, obtained from the studies included in this review suggests a relationship between PTSD and TMDs.

Isolated Congenital Camptodactyly and Temporomandibular Joint Articular Disc Displacement.

The development of craniofacial structures is complex and involves multiple cellular and molecular interactions. We report a case of congenital camptodactyly in a female who subsequently developed chronic tinnitus and temporomandibular joint dysfunction. This report describes the clinicoradiographic features and surgical management of the facial skeletal manifestations, along with postoperative rehabilitation. Furthermore, a concise review of similar literature raises the question of whether this complex of manifestations represents a new entity or a minimal manifestation of a previously characterized syndrome. As such, a possible developmental association between camptodactyly and temporomandibular joint dysfunction is suggested.

Effects of food hardness on temporomandibular joint osteoarthritis: Qualitative and quantitative micro-CT analysis of rats in vivo.

BACKGROUND: Temporomandibular joint osteoarthritis (TMJ-OA) is a degenerative joint disease in which quantitative analysis based on magnetic resonance image (MRI) or cone-beam computed tomography (CBCT) remains limited. Moreover, the long-term effects of soft food on the adaptive condylar remodeling process in TMJ-OA remain unclear. This study aimed to assess the effects of food hardness on adaptive condylar remodeling in a healthy TMJ, TMJ-OA, and controlled TMJ-OA. METHODS: Complete Freund's adjuvant (CFA) was used for TMJ-OA induction and Link-N (LN) for TMJ repair. Eighteen mature rats were randomly divided into six groups: (1) control/normal diet (Ctrl-N); (2) control/soft diet (Ctrl-S); (3) TMJ-OA/normal diet (CFA-N); (4) TMJ-OA/soft diet (CFA-S); (5) Link-N-controlled TMJ-OA/normal diet (LN-N); and (6) Link-N-controlled TMJ-OA/soft diet (LN-S). Micro-CT was performed 14, 21, and 28 days after CFA injection to analyze the bone volume, bone volume fraction (BVF), bone mineral density (BMD), and trabecular bone number and thickness (Tb.N, Tb.Th). MRI and histological imaging were performed to support the analysis. RESULTS: Under CFA treatment, the BVF and BMD decreased significantly (p < 0.01) and later recovered to normal. However, more significant improvements occurred in normal-diet groups than soft-diet groups. Additionally, bone volume changes were more predictable in the normal-diet groups than in the soft-diet groups. The normal-diet groups presented a significant decrease and increase in the Tb.N and Tb.Th, respectively (p < 0.05), while the Tb.N and Tb.Th in the soft-diet groups remained largely unchanged. Furthermore, a significantly higher frequency of irregularities on the condylar articular surface was found in the soft-diet groups. CONCLUSIONS: Compared with a soft diet, a normal diet may be beneficial for preserving condyle articular surface and directing bone remodeling in TMJ-OA rats.

Peripheral muscle oxygenation and symptoms of stress in adolescents with and without temporomandibular disorder.

OBJECTIVE: To compare peripheral muscle oxygenation levels and the prevalence of psychological stress in adolescents with and without temporomandibular disorder (TMD). METHODS: A cross-sectional study was performed with adolescents submitted into two groups: those diagnosed with TMD (DG) and control (CG). Muscle oxygenation was measured by near-infrared spectroscopy in the masseter and upper trapezius muscles. Symptoms of stress were assessed by Lipp's Stress Symptom Inventory for Adults or Child Stress Scale. A Student t-test was used for intergroup comparisons and association between categorical variables by chi-square test, phi coefficient of correlation, odds ratio, and two-way ANOVA. RESULTS: Fifty-three adolescents were evaluated and a significant reduction was observed in the oxyhemoglobin level in the masseter muscle at rest (p = 0.04) and contraction (p = 0.02). A greater total hemoglobin level was found in the upper trapezius muscle at rest in DG (p = 0.03), with a significant difference in the tissue saturation index during contraction (p = 0.05) intergroup. Individuals in the DG were 4.523 times more likely to exhibit signs and symptoms of stress than in CG. CONCLUSION: Adolescents from DG showed reduced masseter oxyhemoglobin values at rest and during contraction and showed more signs and symptoms of stress than healthy controls. In the upper trapezius, DG showed higher values of total circulating hemoglobin, essential for greater blood flow and efficient maximum voluntary contraction. CLINICAL RELEVANCE: Changes in tissue oxygenation and stress in adolescents with TMD prompted the earlier treatment of this population to prevent disease progression into adulthood.

The effect of tooth cusp morphology and grinding direction on TMJ loading during bruxism.

Increased mechanical loading of the temporomandibular joint (TMJ) is often connected with the onset and progression of temporomandibular joint disorders (TMD). The potential role of occlusal factors and sleep bruxism in the onset of TMD are a highly debated topic in literature, but ethical considerations limit in vivo examinations of this problem. The study aims to use an innovative in silico modeling approach to thoroughly investigate the connection between morphological parameters, bruxing direction and TMJ stress. A forward-dynamics tracking approach was used to simulate laterotrusive and mediotrusive tooth grinding for 3 tooth positions, 5 lateral inclination angles, 5 sagittal tilt angles and 3 force levels, giving a total of 450 simulations. Muscle activation patterns, TMJ disc von Mises stress as well as correlations between mean muscle activations and TMJ disc stress are reported. Computed muscle activation patterns agree well with previous literature. The results suggest that tooth inclination and grinding position, to a smaller degree, have an effect on TMJ loading. Mediotrusive bruxing computed higher loads compared to laterotrusive simulations. The strongest correlation was found for TMJ stress and mean activation of the superficial masseter. Overall, our results provide in silico evidence that TMJ disc stress is related to tooth morphology.

Current Trends in the Management of Temporomandibular Joint Dysfunction: A Review.

The temporomandibular joint (TMJ) is a synovial bi-condylar joint with 3 degrees of freedom. One-third of the adult population reportedly suffers from temporomandibular joint dysfunction (TMD). Females are more commonly affected than males. Almost 50% of TMD patients do not require any intervention, and the symptoms are self-limiting within one year after the onset; however, 75-80% of adults suffering from TMD require medical intervention and it takes up to three years for the complete remission of the symptoms. The clinical features of TMD are clenching, clicking, and locking of the jaw, and occlusion due to faulty posture. Based on the diagnostic criteria for temporomandibular disorder (DC/TMD) criteria proposed in the year 2014, the classification of TMD is done based on axis I and axis II diagnoses. This review aims to provide an overview of TMD and examine available treatment strategies for TMD. Various conservative treatment methods have been proven to be effective, including self-care strategies, dental treatment strategies, pharmacological treatment, physical therapy modalities, manual mobilization, electrotherapy and dry needling, relaxation techniques, intra-articular injections, cognitive behavioral therapy, and surgical corrections.

The relationship of biochemical factors related to calcium metabolism with temporomandibular disorders.

OBJECTIVE: The aim of this study is to investigate the relationship between calcium metabolism-related biochemical factors (alkaline phosphatase, vitamin D, parathyroid hormone (PTH), calcium, phosphorus and magnesium), and temporomandibular joint (TMJ) disk displacement with reduction (DDWR). MATERIALS AND METHODS: This prospective observational study included patients with temporomandibular disorders (TMDs) (n = 50) and healthy controls (n = 50) of similar age and sex. The diagnosis of TMJ DDWR was made using the diagnostic criteria for temporomandibular joint disorders (DC/TMD). Both groups were compared in terms of serum alkaline phosphatase, 25 (OH) vitamin D, PTH, calcium, magnesium, and phosphorus levels. P<0.005 was accepted as a significant difference. RESULTS: There was no significant difference between the groups in terms of age, gender, and body mass index (BMI). Calcium levels of patients with TMD were statistically significantly lower than control patients (p<0.05). While there was no significant difference between the two groups in terms of mean VIT D, the number of people with severe Vit D deficiency (<10 ng) in the TMD group was significantly higher than in the control group (p<0.05). There was no statistically significant difference between the groups in terms of serum alkaline phosphatase, magnesium, phosphorus and PTH levels. CONCLUSION: The differences in serum calcium and vitamin D levels seen in the study indicate that biochemical factors related to calcium metabolism may be associated with TMJ DDWR. These results suggest that calcium and vitamin D deficiency should be evaluated and corrected in patients with TMD.

Evaluation of the relationship between temporomandibular joint disorders and tinnitus with computed tomography.

PURPOSE: This study aimed to radiographically determine tinnitus and joint disorders by evaluating glenoid fossa depth and the horizontal angle of the ramus mandible in patients with isolated temporomandibular joint disorder and temporomandibular joint disorder with tinnitus by computed tomography (CT). METHODS: In total, eighty two patients with temporomandibular disorders (TMDs) (forty two patients with tinnitus; forty patients without tinnitus) were evaluated using CT. CT images were analysed according to glenoid fossa depth and the horizontal angle of the ramus. RESULTS: A total of 82 cases 43 (52.4%) female and 39 (47.6%) male were included. The distribution of gender was not significantly different between the TMD patients and the TMD-tinnitus patients (p >0.05). The mean age of the patients with isolated TMD was 31.70 ± 9.68 years, and the mean age of the patients with TMD-tinnitus was 34.07 ± 11.72 years. Comparisons were made of the right and left glenoid fossa depths of the patients with TMD and TMD-tinnitus, respectively. There was a statistically significant difference between the right glenoid fossa depths (p = 0.016) also there was also a statistically significant difference between the left glenoid fossa depths (p = 0.049). CONCLUSION: Our study revealed that decreased glenoid fossa depth may be associated with an increased incidence of tinnitus in TMD patients by the way temporomandibular joint and ear can affect each other in diseases such as tinnitus due to their close anatomical relationship.

Algunas consideraciones sobre el tratamiento precoz en pacientes con bruxismo / Some considerations on the early treatment in patients with bruxism

El bruxismo es una disfunción neuromuscular considerada hoy día una parafunción, ya sea consciente (bruxismo en vigilia) o inconsciente (bruxismo del sueño). Debido al posible daño que puede ocasionar en las estructuras del aparato estomatognático, el tratamiento precoz resulta muy importante, de ahí la necesidad de un diagnóstico temprano para aplicar medidas preventivas y curativas. Teniendo en cuenta lo anterior, se realizó el presente estudio con el objetivo de fundamentar diferentes aspectos concernientes al tema en cuestión.

Bruxism is a neuromuscular dysfunction considered a parafunction nowadays, either conscious (awake bruxism) or unconscious (sleep bruxism). The early treatment is very important due to the possible damage that can cause in the structures of the stomatognathic system, hence the necessity of an early diagnosis to apply preventive and healing measures. Taking into acount the above-mentioned, the present study was carried out aimed at supporting different aspects concerning the topic in question.

Assessment of thickness of roof of the glenoid fossa in dentate, edentulous, and partially edentulous subjects using cone beam computed tomography (CBCT) - a retrospective study.

OBJECTIVES: Studies have inferred a direct association between Temporomandibular joint disorders (TMD) and the integrity of the structures associated with it such as the Glenoid fossa thereby necessitating the requirement to measure the thickness of this oft ignored entity. This study was carried out to assess the thickness of the glenoid fossa roof in dentulous, edentulous, and partially edentulous subjects using archival Cone beam computed tomography (CBCT) images. METHOD: Analysis of CBCT data of 120 joints from 60 adult subjects without signs and symptoms of TMD was carried out. The scans were grouped based on the dental status as dentulous, edentulous, and partially edentulous and additionally into two sets as those below and above 40 years of age. The distance between the superior and inferior cortices of the glenoid fossa was measured indicating the thickness of the roof of the glenoid fossa in the coronal and sagittal planes, by three independent observers. Analysis of Variance (ANOVA) and Tukey's post hoc test were used to compare the association between the mean thickness of the glenoid fossa and the dentition status. A p ≤ 0.05 was considered to be significant. RESULTS: There was no significant association between the mean thickness of the glenoid fossa and the dentition of the study participants of all three groups, when assessed by the three observers, except the mean thickness on the right side in the sagittal section as measured by one observer. A thicker fossa was observed in edentulous subjects when compared to dentulous participants, and the difference was statistically significant (p = 0.035). CONCLUSION: The thickness of the roof of the glenoid fossa demonstrated no association with the dental status of the study participants and no age or sex related differences were noted.

Quantitative analysis of the mouth opening movement of temporomandibular joint disorder patients according to disc position using computer vision: a pilot study.

Background: Temporomandibular joint disorder (TMD), which is a broad category encompassing disc displacement, is a common condition with an increasing prevalence. This study aimed to develop an automated movement tracing algorithm for mouth opening and closing videos, and to quantitatively analyze the relationship between the results obtained using this developed system and disc position on magnetic resonance imaging (MRI). Methods: Mouth opening and closing videos were obtained with a digital camera from 91 subjects, who underwent MRI. Before video acquisition, an 8.0-mm-diameter circular sticker was attached to the center of the subject's upper and lower lips. The automated mouth opening tracing system based on computer vision was developed in two parts: (I) automated landmark detection of the upper and lower lips in acquired videos, and (II) graphical presentation of the tracing results for detected landmarks and an automatically calculated graph height (mouth opening length) and width (sideways values). The graph paths were divided into three types: straight, sideways-skewed, and limited-straight line graphs. All traced results were evaluated according to disc position groups determined using MRI. Graph height and width were compared between groups using analysis of variance (SPSS version 25.0; IBM Corp., Armonk, NY, USA). Results: Subjects with a normal disc position predominantly (85.72%) showed straight line graphs. The other two types (sideways-skewed or limited-straight line graphs) were found in 85.0% and 89.47% in the anterior disc displacement with reduction group and in the anterior disc displacement without reduction group, respectively, reflecting a statistically significant correlation (χ2=38.113, P<0.001). A statistically significant difference in graph height was found between the normal group and the anterior disc displacement without reduction group, 44.90±9.61 and 35.78±10.24 mm, respectively (P<0.05). Conclusions: The developed mouth opening tracing system was reliable. It presented objective and quantitative information about different trajectories from those associated with a normal disc position in mouth opening and closing movements. This system will be helpful to clinicians when it is difficult to obtain information through MRI.

Occlusal splint therapy in patients with Ménière's disease and temporomandibular joint disorder.

OBJECTIVE: This retrospective study aimed to verify the outcomes of stabilising occlusal splint therapy prescribed to 22 patients with unilateral definite Ménière's disease and comorbid temporomandibular joint disorder. METHODS: The results of a battery of audiometric and vestibular tests were recorded before and after 6 months of treatment, as well as the scores of disease-specific questionnaires. RESULTS: The average hearing threshold in the affected ear and the acoustic immittance were unchanged. No spontaneous and positional nystagmus were recorded. Caloric hypo-responsiveness and vestibular myogenic evoked responses did not vary. No changes of stabilometric body sway parameters in eyes opened condition and with optokinetic stimulation delivered to the unaffected labyrinth were observed. A significant reduction was recorded in eyes closed condition and with the optokinetic stimulation toward the affected ear. The Tinnitus Handicap Inventory, the Situational Vertigo Questionnaire and the Numeric Pain Rating Scale scores improved. The number of vertigo attacks was reduced. CONCLUSIONS: Occlusal splint therapy is a favourable option to reduce aural symptoms of Ménière's disease and comorbid temporomandibular joint disorder, even if its pathophysiological mechanism remains elusive.

Thermal ultrasound, manipulation and exercise on pain and mouth opening in Chronic temporomandibular joint disorder.

BACKGROUND: A 60-year-old female patient reported with a chief complaint of pain in bilateral temporomandibular joints (TMJ) region since 11/2  years. The pain was initially reported to be insidious in onset, moderate in intensity, aggravated on chewing food and during excessive mouth opening. On examination her mouth opening was found to be less than 8 mm and standard head and neck examination showed grade 2 tenderness with swelling on bilateral TMJ and forward neck posture with rounded shoulders. The patient reported her pain to be 6 at rest in NPRS (with 0 being no pain and 10 being maximum) and 8 out of 10 on mouth opening. METHODOLOGY/MANAGEMENT: A 4-week Physiotherapy Intervention program, which consisted of Ultrasound Therapy at varying intensity, TMJ manipulation, Cervical Range of Motion Exercises and Manual Cervical traction was administered. Repeated evaluation of pain and other functional outcomes were done on a weekly basis. RESULTS: There was significant improvement in her mouth opening (41 mm), restoration of masticatory functions, complete resolution of pain and overall improvement in quality of life after the 4 weeks intervention program. CONCLUSION: A structured Physiotherapy intervention program consisting of Non-thermal Ultrasound, Manipulation and exercise targeting TMJ and Upper quarter, proved to be highly effective in increasing functions and reducing signs and symptoms in Chronic TMJ Dysfunction which can be highly disabling. The recovery observed in this patient, who was not on any standard treatment for almost 18 months, hence the severe limitations she encountered, is a testament to the need of designing individualized treatment protocols addressing the many facets of impairment in TMJ Disorders.

Treatment of temporomandibular joint disc displacement using arthrocentesis combined with injectable platelet rich fibrin versus arthrocentesis alone.

BACKGROUND/PURPOSE: Temporomandibular joint disc displacement is the most frequently reported temporomandibular disorder that may severely impair quality of life and can be challenging to treat. This study aimed to evaluate and compare the efficiency of intra-articular injection of injectable platelet rich fibrin (i-PRF) following arthrocentesis or arthrocentesis alone in treatment of patients with TMJ disc displacement with reduction. MATERIALS AND METHODS: Forty patients for a total of forty joints with reducible anterior disc displacement, as confirmed by Magnetic Resonance Imaging (MRI) were selected and divided into 2 equal groups. In group I (control group), arthrocentesis alone was performed with Ringer solution. In group II (study group), a combination of arthrocentesis and intra-articular injection with 1.5 ml i-PRF was performed. The outcome variables included pain intensity evaluated with a visual analogue scale, inter-incisal opening, lateral movement evaluated in millimeters, and clicking. Assessments were done pre-operatively, and 1 week, 3 months, and 6 months postoperatively. RESULTS: There was statistically significant reduction in pain intensity and clicking sound and increase in mouth opening and lateral movement in i-PRF group when compared to arthrocentesis group. In addition, the differences between preoperative and postoperative status in all the measured parameters were statistically significant within the study and the control group throughout the postoperative period. CONCLUSION: The combination of i-PRF with arthrocentesis is a safe and effective method in the treatment of TMJ disc displacement with reduction.

THE VOICE OF THE PATIENT IN OROFACIAL PAIN MANAGEMENT.

As pain cannot be measured objectively, the use of patient reported outcomes (PROs), and specifically dental PROs (dPROs), is essential for adequate assessment and management of the patient with orofacial pain. For orofacial pain conditions, some of the suitable PROs are specific to dentistry and hence can be labelled dPROs, whereas others are not. There is also a need to understand which outcomes and domains are most relevant to the patient with pain complaints within the context of the biopsychosocial model. Acute pain in the orofacial area is most often related to toothache, whereas the most common chronic orofacial pain are temporomandibular disorders. Other chronic pains in the orofacial area include neuropathic pain and unknown or idiopathic pain. PROs have been fundamental in the development of both screening procedures and diagnostic criteria in temporomandibular disorders. PROs are now often a prerequisite for the most common temporomandibular disorder pain diagnoses. Furthermore, PROs form the basis for decision-making with regard to treatment, prognostics, and referrals. Future areas of development include the standardized use of PROs in the screening and diagnostics of the less common orofacial pain conditions, together with development of core outcomes sets and standardized protocols for the use of PROs in evaluation of treatment including efficacy, compliance, adherence, and side-effects.