Chapter 2

Assessment of the Patient with Orofacial Pain

Aim

The aim of this chapter is to provide an insight into the manner of assessing the patient with orofacial pain (the OFP patient).

Outcome

Having read this chapter, the practitioner should be able to:

• differentiate dental and non-dental pain

• perform a structured OFP assessment

• appreciate the complexity and importance of history taking in the OFP patient.

Case Presentation

• Complaint. A 34-year-old, fit and healthy female teacher presented to her dentist complaining of left-sided facial pain. She gave a history of a vague episodic dull “achy” pain that originated in the maxillary left molar teeth. It tended to radiate locally into the left preauricular region and left ear. At times, the patient complained of left-sided earache. She attended her medical practitioner for this complaint, only to be told that otoscopic and sinus examinations were normal. She reported that the pain was absent in the morning on waking but increased as the day progressed. The pain was partially relieved by consuming analgesics and aggravated by chewing. Consequently, she tended to avoid the left side when chewing.

• Clinical examination. A thorough evaluation of the patient’s dental and periodontal structures failed to reveal any abnormalities or conditions. The patient had excellent oral hygiene. Her past dental history consisted of routine six-monthly check-ups with a scale and polish. Vitality testing of the maxillary and mandibular left molar and premolar teeth was normal. Tooth Slooth evaluation and mobility testing of these teeth was normal also. However, percussion testing revealed tenderness associated with multiple maxillary and mandibular molar teeth.

• Investigations. Radiographic examination of these teeth revealed uniform periodontal ligament spaces and intact lamina dura.

• Further clinical consultation. The patient became anxious and frustrated with her ongoing pain. Her sister had recently been treated for breast cancer and her mother died from cancer at a relatively young age. As her anxiety levels increased, her sleep became fragmented and her work suffered during the day. She decided to seek a second dental opinion, eventually persuading the dentist to whom she was referred to extract the maxillary first molar tooth. Following the extraction, the pain subsided for a few days, before increasing in intensity. She was then treated on multiple occasions for a dry socket. Eventually, she discontinued work on disability grounds, based on ongoing chronic pain.

Background

It is not uncommon for a dentist to face such a scenario. Traditionally, such complaints would have been classified as “atypical facial pain” and the patient prescribed a tricyclic antidepressant. Very often such patients become disillusioned to the extent that they often question the validity of their own pain. The prescription of an antidepressant stigmatises the condition further. Commonly such patients are labelled psychosomatic.

The purpose of this chapter is to provide a structured approach to managing a diagnostic dilemma of the type described above. It is important to remember that no irreversible treatment should be performed until a definitive diagnosis is made: No Diagnosis – No Treatment!

When assessing the OFP patient, dental and periodontal causes must first be excluded. If no definitive diagnosis is made, then the examination must move on to assess the non-dental pain possibilities. A similar approach is followed irrespective of the origins of the pain. This approach consists of three main components:

1. history

2. examination

3. investigation.

History

It is important to ask the appropriate questions, analyse the answers given and synthesise a working diagnosis. The working diagnosis can be confirmed during the latter stages of the patient assessment, thus evolving into a definitive diagnosis. The history is the most important part of patient assessment as it can provide at least 80% of the information required to make a definitive diagnosis. A good dentist is a good listener. Listening should be an active process. Make a mental note of the most important parts of the history and clarify these later. Ideally, the patient should be given every opportunity to talk freely at the start of the consultation, with minimal interruption. Common mistakes are to intervene too early, too often or to rush the patient. If the patient is a poor historian, they can be gently nudged along by asking further questions. History taking is an art. It requires compassion, experience and patience. It is imperative that the patient is made to feel that the dentist is listening carefully and has a genuine concern for their problems. This is especially true for the patient who has already seen a number of healthcare providers for the same complaint. It is common for patients with OFP to question the validity of their own complaints. The clinician should never question this. In contrast, the clinician should validate the presence of the problem whenever possible. The experienced practitioner will often pick up common themes and descriptors in the pain history. The compassionate dentist will feel more at ease discussing the psychosocial history. This may often reveal the triggering and perpetuating factors of the pain.

A systematic approach is followed. The history can be broadly fragmented into the components listed in Table 2-1.

The pain history is most important when interviewing a patient with OFP. The history starts with the principal complaint. If there are several such complaints, these should be prioritised and assessed separately. The principal complaint is assessed by means of the following variables

• location

• duration

• intensity

• temporal pattern

• speed of onset

• quality

• periodicity

• aggravating factors

• relieving factors

• pain radiation

• associated factors.

• Location of pain. It is important to ask the patient to pinpoint the location of their pain with a finger. It can also be helpful to allow the patient to trace the location of their pain on a diagrammatic representation of the head and neck. In early pulpitis, the patient often cannot localise the pain to a particular tooth or jaw because the pulp does not contain any proprioceptive nerve endings. As the pulpitis develops and the periapical tissues become involved, the tooth will become tender and the periodontal proprioceptive nerve fibres will be stimulated.

• Duration of pain. Certain OFP complaints are episodic and will last for seconds (trigeminal neuralgia); others are episodic and last for hours (cluster headache). Some OFP patients will complain of continuous pain that may be steady and unvaried, while others will complain of a continuous but variable pain.

• Intensity. It is important to assess the intensity of the pain complaint. A simple way of achieving this is to use a visual or verbal analogue scale: “can you grade your pain on a 0 to 10 scale, where 0 represents no pain and 10 represents the worst pain imaginable?”.

• Temporal pattern. Some patients with a temporomandibular disorder (TMD) will wake in the morning with increased pain, while others will complain of increasing pain as the day progresses. Increased morning pain may suggest nocturnal parafunctional behaviour, whereas a daytime clenching behaviour may present as increasing pain as the day progresses.

• Speed of onset. The pain of trigeminal neuralgia can often be paroxysmal in nature, stopping a patient in their tracks when it occurs. Other episodic OFPs are often slow in their build-up.

• Quality of pain. A facial migraine is often described as a throbbing, pulsating pain. A cluster headache is usually steady and boring; neuralgic pain is typically sharp and shooting. Conversely, muscle pain is dull, aching, heavy and pressing. Similarly, a patient with a tension-type headache may describe a band or vice-like gripping pain or pressure sensation. The adjective used by the patient may shed significant light on the nature of their complaint.

• Periodicity of pain. Always ask the patient if they have had a similar episode of pain before. Certain conditions such as trigeminal neuralgia and cluster headache will often have a distinctive recurring pattern. Periods of remission of varying time intervals separate each attack. Other conditions such as facial migraine may have a distinctive monthly presentation. This is often related to the menstrual cycle in female patients.

• Aggravating factors. When a patient complains of facial pain triggered by heat, a dental cause must be excluded. This can often be a diagnostic dilemma, in particular if a cracked tooth is suspected. Isolating individual teeth with a rubber dam and selectively applying hot water using a syringe may shed light on the offending tooth. Pain triggered by jaw function may suggest a variety of potential sources such as trigeminal neuralgia, irreversible pulpitis, temporomandibular joint (TMJ) capsulitis, myofascial pain or temporal arthritis. It is, therefore, essential not to jump to conclusions, but to gather as much information as possible.

• Relieving factors. If a patient reports that their pain can be reduced by swirling cold water around their mouth, a dental source must be eliminated.

• Pain radiation. The pattern of radiation gives clues to the aetiology. Patients with an acute TMJ inflammation may often complain of referred otalgia and attend their medical practitioner complaining of recurrent earaches. On questioning such patients as to the precise location of their pain, they often point to the preauricular region.

• Associated factors. Pain rarely occurs in isolation. If a patient complains of photophobia, phonophobia, ptosis, or profuse lacrimation, a neurovascular OFP should be suspected.

The history of the present illness describes the progression of the pain complaint from its onset to the time of presentation. When assessing the history of the present illness, a number of variables need to be considered:

• time of onset

• precipitating factors

• subsequent time course

• previous treatments

• effects of treatments.

• Time of onset. If at all possible, try and obtain the exact time and date of the onset of the pain. The onset of the pain in close proximity to a stressful time may suggest a musculoskeletal origin.

• Precipitating factors. Ascertain exactly what the patient was doing at the time of the onset of the pain. If the pain started immediately following a dental appointment that involved multiple inferior dental blocks and mandibular hypomobility, a musculoskeletal component must be considered.

• Subsequent time course. It is important to map out the time course and associated symptoms over the period since the onset of the pain.

• Previous treatments. A list of all previous treatments should be documented.

• Effects of treatments. The outcome of all previous treatments should also be recorded.

Examination: The Assessment of Odontogenic Pain

“We see what we look for and we look for what we know.”

When assessing a complaint of OFP, it is important to differentiate between the site of the pain and the source of the pain. When these locations coincide, there should be relatively little difficulty in establishing a definitive diagnosis; as clinical inspection will often reveal the problem. For instance, if a patient pinpoints the mandibular right first molar tooth as the site of pain, and clinical inspection reveals a large cavity in the tooth, it is a reasonable assumption that the tooth is the cause of the problem. If this is the source of the patient’s complaint, a right inferior dental block should eliminate the pain. It is not uncommon, however, for the site and source of the pain to differ. This is explained by the convergence theory of pain referral. There are many accounts in the literature of patients complaining of a dental abscess (source of pain) but pinpointing the preauricular region as the site of pain. Similarly, the patient with acute maxillary sinusitis may complain of dental sensitivity and tenderness on biting their teeth together. These common presentations were explained by elegant neurophysiological studies carried out by Dr Barry Sessle, who showed that a single neuron in the trigeminal nucleus caudalis receives input from sensory neurons innervating the maxillary skin, cornea, the mandibular canine, the mandibular premolar and the maxillary premolar.

The most common cause of treatment failure is an incorrect diagnosis. Guidelines that may assist in differentiating pain of dental and non-dental complaints are set out in Table 2-2. Sometimes it is not enough to identify a non-vital tooth and consider this to be the sole cause of the patient’s complaint. A comprehensive intraoral and extraoral examination should be performed, with special attention being paid to the TMD screening examination. Neurological and psychosocial considerations must also be pursued. Diagnostic (anaesthesia) blocking should be performed in select cases to facilitate a definitive diagnosis. It is imperative to consider the clinical findings together, not in isolation.

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