|Dentistry has long been recognized as a necessary part of medical science and is no longer restricted to management of dental disease.|
|The scope of practice of the clinician includes a comprehensive assessment and the responsibility for the well-being of the entire patient, not just the oral structures.|
|Clinicians, specifically those treating orofacial pain, must be trained in taking a complete history, assessing vital signs, performing various components of the physical examination, and ordering and interpreting imaging studies and laboratory testing results.|
|The clinician must be confident in the evaluation of the patient’s health status before embarking on any treatment procedures or pharmacologic regimen.|
|This chapter discusses the basic tests and techniques for the assessment of an orofacial pain patient.|
In his lectures, Weldon Bell would state, “When examining and managing orofacial pain patients, it is important to set goals to achieve an acceptable degree of success. The first goal is to establish a specific diagnosis.” This statement, made more than 20 years ago, remains true today. Diagnosis cannot be based solely on the patient’s description of pain; it depends on an accurate assessment of the details of the history combined with an appropriate clinical examination and radiographic and laboratory findings. Even when information from the history is pathognomonic of a disorder, physical examination at the least is necessary to rule out comorbid disorders. “Having missed the first goal, diagnosis, the treating doctor cannot logically establish the second, third, or fourth goals. The result is that all patients are treated the same and we are merely technicians or methodologists. When an accurate diagnosis is made, the correct treatment often becomes apparent.”
The expanding field of orofacial pain has increased the scope of practice of today’s clinician. Evaluation of orofacial pain must go beyond the oral cavity, teeth, temporomandibular joints (TMJs), and the muscles of mastication. Knowledge of orofacial pain disorders allows the clinician to obtain a complete history with targeted questions and thorough documentation, to perform appropriate examinations, and to obtain consultations and referral when appropriate. This chapter guides the informed clinician in history gathering, physical examination, and testing by using techniques that have achieved acceptable reliability.
It has become integral to current practice that all dental patients, as part of their initial and regular examinations, be screened for temporomandibular disorders (TMDs) and other orofacial pain disorders. The results of the screening should help the clinician determine whether a more comprehensive evaluation is necessary.1 The screening may consist of a short questionnaire (Box 2-1), a brief history, and a limited examination. Although the value of questionnaires may be challenged, a questionnaire can facilitate the clinical examination by focusing on specific complaints.2
|Box 2-1 Example of screening questions for TMDs*|
|• Do you have difficulty, pain, or both when opening your mouth, for instance, when yawning?
• Does your jaw “get stuck,” “locked,” or “go out”?
• Do you have difficulty, pain, or both when chewing, talking, or using your jaws?
• Are you aware of noises in the jaw joints?
• Do your jaws regularly feel stiff, tight, or tired?
• Do you have pain in or near the ears, temples, or cheeks?
• Do you have frequent headaches, neck aches, or toothaches?
• Have you had a recent injury to your head, neck, or jaw?
• Have you been aware of any recent changes in your bite?
• Have you been previously treated for unexplained facial pain or a jaw joint problem?
|*All dental patients should be screened for TMDs and other orofacial pain disorders. The decision to actually complete a comprehensive history and clinical examintation will depend on the number of positive responses and the apparent severity of the problem for the patient. It should be noted that a positive response to any question may be sufficient to warrant a comprehensive examination if it is of concern to the patient or viewed as clinically significant.|
The TMD screening examination usually consists of observation of the mandibular range of motion, palpation of the TMJs, and palpation of the masseter and temporalis muscles for pain or tenderness (Box 2-2). Palpation and/ or auscultation of the joints for sounds and observation of jaw function may disclose uncoordinated movements that may indicate internal biomechanical problems.3
|Box 2-2 Example of screening examination procedure for TMDs*|
|1. Measure range of motion of the mandible on opening and right and left lateral movements. (Note any incoordination, deflection, or deviation in the movements.)
2. Palpate for preauricular or intrameatal TMJ tenderness.
3. Auscultate and/or palpate for TMJ sounds (ie, clicking or crepitation).
4. Palpate for tenderness and radiating trigger points in the masseter, temporalis, and cervical muscles.
5. Note excessive occlusal wear, excessive tooth mobility, buccal mucosal ridging, or lateral tongue scalloping.
6.Inspect symmetry and alignment of the face, jaws, and dental arches.
|*All dental patients should be screened for TMDs and other orofacial pains using this or a similar, cursory clinical examination. The need for a comprehensive history and clinical examination will depend on the number of positive findings and the clinical significance of each finding. Any one positive finding may be sufficient to warrant a comprehensive examination.|
Caution should be observed when evaluating the results of the screening process, because the clinical findings and the patient’s complaints may not be consistent. The results of the screening evaluation should not be the only rationale to pursue a more comprehensive evaluation. Common sense must prevail, because a clinical sign, such as a clicking TMJ, may merely represent a stable, nonpainful condition that does not require treatment.
A comprehensive evaluation should be performed when a patient’s complaints of pain are not of dental origin or when a patient’s screening evaluation results are positive for an orofacial pain disorder. A comprehensive evaluation starts with a detailed history (Box 2-3). The examination process that follows may include some or all of the components listed in Table 2-1. Many patients present with a lengthy list of complaints that, when reviewed, can lead the astute clinician to a differential diagnosis, provided that he or she carefully analyzes the components of each complaint. A meticulous history will often guide the clinician to the most likely diagnoses and, therefore, aid in determining which, if any, additional diagnostic procedures may be appropriate.
|Box 2-3 Comprehensive history format for orofacial pain patients*|
|Chief complaint(s) and history of present illness
Date and event of onset
Remissions or change over time
Modifying factors (alleviating, precipitating, or aggravating)
Previous treatment results
|*The sequence of a comprehensive history should parallel the traditional medical history and review of systems format, including the patient’s chief complaint(s), the history of present illness, medical and dental histories, and a psychosocial history.|
|Table 2-1 Comprehensive orofacial pain physical examination procedures|
|Type of evaluation||Reviewing sequence|
|General head and neck||1. Note scars; asymmetry; unusual size, shape, consistency, or posture; and involuntary movement or tenderness.|
|Muscles, TMJ, and cervical spine||1. Palpate the muscles of mastication and cervical muscles.
2. Palpate the TMJ intrameatally and/or preauricularly.
3. Palpate cervical vertebrae.
4. Measure range of motion and its association with pain.
5. Auscultate and palpate for joint noises in all movements.
6. Guide mandibular movement, noting pain, end feel, and joint noise.
7. Note any tenderness, swelling, enlargement, or unusual texture.
|Neurologic||1. Perform cranial nerve screening and note signs and symptoms.
2. Note vascular compression of the temporal and carotid arteries.
|Ear, nose, and throat||1. Inspect the ears and nose.
2. Inspect the oropharynx and uvula (Mallampati score, Tonsillar Hypertrophy Grade).
|Intraoral||1. Assess hard and soft tissue conditions or disease.|
The interview, or history, is usually the first contact between the clinician and the patient, and, as such, a sympathetic attitude by the clinician can quickly create a bond critical to successful communication.
The patient must be allowed to express the symptoms that prompted the consultation, although the clinician must take control of the interview to gather information in an organized manner. Adequate time is necessary to allow the patient to fully describe each of the complaints. The complaints are documented in the order of severity as indicated by the patient, and details of each complaint are elicited in a systematic manner.
History of chief complaint(s). A description of each chief complaint usually includes its location, onset, quality, intensity, frequency and duration, triggering, exacerbating and alleviating factors, and associated symptoms. The combination of these features often represents recognizable patterns that can help the clinician to categorize the complaint.
Location. Very often the patient will complain of pain in a part of the face or head in terms consistent with how he or she may understand the anatomy. Therefore it is helpful to have the patient identify the exact location of the pain using one finger to either point to or circumscribe the area of complaint. A very important concept to keep in mind is that the location or site of the pain does not always correspond to the source of the pain. Therefore, finding the true source of pain is imperative for both a diagnosis and effective treatment. To assess the extent of pain, asking the patient to draw his or her pain(s) on a whole body mannequin may be useful.
Onset. It is important to understand the circumstances that precipitated the pain, if any. Trauma is a frequent cause of pain and should be differentiated from pain secondary to systemic disease or psychologic stressors. It is also important to know how the pain begins with each episode (ie, whether it arises gradually or suddenly). The time of day the pain occurs may also render important clues regarding diagnosis, contributing factors, and treatment.
Quality. Different diagnostic categories of pain may be distinguished based on the quality of pain (Table 2-2). However, the clinician must be cautious when categorizing pain quality, because pain related to certain musculoskeletal disorders can mimic neurovascular or neuro-pathic disorders, and the reverse may also be true. Several clinically validated screening tools with high sensitivity and specificity, although not designed for orofacial pain in particular, are available to help the clinician distinguish between neuropathic pain and nociceptive pain.4 They include the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)5 and S-LANSS,6 Douleur Neuropathique (DN4),7 the Neuropathic Pain Questionnaire (NPQ),8 and PainDETECT.9 The LANSS and DN4 contain clinical items in addition to self-reported symptoms. The self-report items of the DN4 can be used alone with good sensitivity and specificity.
|Table 2-2 Pain-quality descriptors and secondary symptoms associated with different pain categories*|
|Pain category||Quality||Secondary symptoms|
Can refer to or be referred from distant sites
Worse with function
|Worsened by increasing intracranial pressure (eg, Valsalva, bending over, physical activity)
Sensitivity to light and/or sound
|Psychogenic||Descriptive||Complaint patterns often do not match anatomical sensory supply|
|*The above table gives examples of pain qualities for the different pain categories. Although the descriptive qualities are different for each pain category, there is muc|
Intensity. The intensity of pain is subjective and very often is augmented by the emotional status of the patient. It is important for the clinician to understand the patient’s interpretation of the intensity of his or her pain so that treatment priorities can be established. The intensity of the pain can be rated on a verbal rating scale (ie, mild, moderate, or severe), numerical rating scale (ie, a number between 0 and 10, where 0 represents no pain and 10 represents the most extreme pain), or a visual analog scale (ie, a 10-cm line labeled at one end with “no pain” and at the other end with “most extreme pain”). Sensory changes such as diminished or increased perception of touch or pain may relate to neuropathic disorders or centrally mediated pain disorders.
Frequency and duration. The frequency of painful episodes yields information such as whether the pain comes in clusters, has periods of remission, or is continuous. The duration of pain may be recorded in minutes, hours, days, weeks, or months. The daily duration of pain is rated as continuous or intermittent. If intermittent, the pain can be rated as brief, momentary, or persisting for minutes or hours. The frequency and duration of periods of remission should also be recorded.
Modulating factors. Precipitating, aggravating, and alleviating factors yield important information. Seemingly minor details that may not impress the patient as important may have tremendous diagnostic value. Examples include precipitating factors such as light wind or touch or shaving setting off the pain and aggravating factors such as having increased pain during periods of emotional stress. Similarly, discovering that jaw function does not precipitate or aggravate an individual’s pain is of equivalent diagnostic importance.
Associated symptoms. Very often, a symptom associated with the patient’s pain complaint can help the clinician narrow his or her diagnostic focus. Sensory and motor changes as well as autonomic features may be recorded. For example, the presence of visual and sensory changes may be indicative of migraine with aura, whereas drooping, redness, and/or tearing of the eye may be indicative of a trigeminal autonomic cephalalgia.
Previous treatments. Prior medical and dental treatment interventions for each complaint should be listed, along with the patient’s perception of results. Results of prior treatment can offer insight into the nature of the complaint. For instance, if an anti-inflammatory drug helped the pain complaint, it is not likely that the cause is neuropathic.The patient’s recall of medications, dosages, and length of medication trials should also be recorded. This information prevents the clinician from proposing therapies that have been previously tried and have failed. In addition, the clinician might learn whether certain medications have been tried at an appropriate dosage and for an appropriate period of time. This part of the interview may also provide insight into patient compliance of previously proposed therapies.
Medical and dental histories
Past illnesses, surgeries, developmental or genetic abnormalities, and any sequelae should be documented. Long- and short-term use of medications (including over-the-counter medications and herbal preparations) and their purpose should also be documented, as they may influence potential treatment options. Use of tobacco, alcohol, and recreational drugs and caffeine consumption should be noted, as well as past or present substance abuse. The patient should be questioned about trauma, both physical and emotional. Because poor sleep and sleep disorders are often present in the chronic pain population, a discussion of sleep quality, quantity, snoring, and sleep-related breathing disorders, including sleep apnea and sleep position, is also important (see chapter 11 for more details). Tools such as the Pittsburgh Sleep Quality Index are useful to assess sleep quality.10 Tools for sleep-related breathing disorders, such as the Epworth Sleepiness Scale11,12 and the Stop-Bang questionnaire,13,14 may help the clinician discern between simple snoring and sleep apnea and may be helpful in assessing the severity of sleep apnea as well. However, it is not the role of the orofacial pain clinician to diagnose a sleep disorder. This can only be done through polysomnography by a board-certified sleep physician in a sleep laboratory. The orofacial pain clinician’s role is to determine the likelihood of a sleep disorder or sleep-related breathing disorder and refer the patient to a sleep physician for evaluation and diagnosis.
A complete dental history should be obtained, particularly as it relates to the chief complaint. Complications of therapies are important to document, as are any behaviors such as clenching (while awake or during sleep), bruxism, and other parafunctional activities (eg, gum chewing, nail biting).
Review of systems. Because the patient’s complaints may be a manifestation of systemic disease, he or she should be questioned regarding any symptoms that might relate to systemic disorders, such as those affecting connective tissue, autoimmune disorders, fibromyalgia, diabetes, cardiac disorders, or Lyme disease, as this may influence treatment options and/or prognosis.
Psychologic and behavioral issues may result in orofacial pain for some patients. For others, these problems may be the primary etiologic factor or may play a role in sustaining or amplifying the pain. Therefore, it is advised that the history-gathering portion of the comprehensive evaluation include an evaluation of behavioral, social, emotional, and cognitive factors that can possibly initiate, sustain, or result from the patient’s pain complaints (Box 2-4). The psychosocial history may provide insight into the patient’s mental status and coping skills, interactions with others, and the presence of any psychologic overlay.
|Box 2-4 Checklist of psychologic and behavioral factors|
|• Inconsistent, inappropriate, and/or vague reports of pain
• Symptoms incompatible with the innervation and function of anatomical structures
• Overdramatization of symptoms
• Symptoms that vary with life events
• Significant pain of greater than 6 months’ duration
• Repeated failures with conventional therapies
• Inconsistent response to medications
• History of other stress-related disorders
• Major life events (eg, new job, marriage, divorce, death of a family member or friend)
• Evidence of alcohol and drug abuse
• Clinically significant anxiety, depression, or suicidal or homicidal ideation
• Evidence of secondary gain
An evaluation for the presence of stressors and the patient’s response to stress is important to the diagnostic process. Whether the patient has depression and/or anxiety, which are often comorbid and complicating factors related to chronic pain, needs to be determined. A brief screening tool to assess anxiety and depression is the four-item Patient Health Questionnaire (PHQ-4).15 A more elaborate questionnaire to evaluate anxiety and depression, among other disorders, is the 90-item Symptom Check List Revised (SCL-90-R).16 In depressed patients, it is especially important to assess and document the risk of suicidal or homicidal ideation. Specific inquiries should be directed to disclose a history of traumatic life events, such as sexual abuse or domestic violence. Litigation, the expectation of monetary reward for disability, or secondary gain can also be complicating factors for the patient’s prognosis.
An appreciation of how pain affects the patient’s life can help direct treatment. The Graded Chronic Pain Scale (GCPS) is a brief questionnaire that may be helpful to assess the patient’s pain intensity and how the pain interferes with his or her life (see chapter 12 for more details on psychologic disorders, psychometric questionnaires, and suicidal ideation).17 Referral is recommended when significant factors are identified.
Baseline blood pressure and pulse rate are recorded, and other vital signs (eg, respiration rate, temperature, height, and weight) may be obtained. Evaluating and recording baseline vital signs may provide valuable information for medically compromised patients and those patients taking medications.
Orofacial pain complaints may be the result of a neurologic problem. If this is suspected, a cranial nerve screening should be performed, aimed at testing equal function (ie, strength, sensation) of the nerves on the right and left sides.
Cranial nerve dysfunction may manifest as changes in either motor or sensory function. Abnormal movement of muscles stimulated by one of the cranial nerves can indicate pathology along the motor pathways. A patient reporting sensory alterations may be tested for anesthesia, paresthesia, dysesthesia, allodynia, and hyperalgesia. Quantitative sensory testing for such negative and positive signs could help gain valuable insight into the underlying mechanisms of pain. Typical tests include mechanical and thermal sensitivity.4 Von Frey filaments or weighted needles may be used to evaluate mechanical detection and pain thresholds and could elicit pinprick allodynia. Thermal pain and detection thresholds can also be measured, but instruments used to do so are expensive. All these methods use ascending and descending stimuli to establish thresholds. A major problem with these methods remains the high interindividual variability, which precludes solid normative reference ranges, although a recent study has published validation data based on 180 healthy individuals.18
Topical and local anesthetic blocking may be part of the neurologic assessment. Areas of altered sensation can be mapped to demonstrate pathology, and mapping may help to determine if the patient’s condition is progressive or if treatment is effective. Altered sensations are not pathognomonic for neuropathic pain.
Table 2-3 lists the cranial nerves and the most common methods of screening these nerves for dysfunction. Abnormal findings should prompt a more detailed neurologic evaluation, and, if indicated, the patient should be referred to an appropriate specialist. Other texts are recommended for a complete review of the components of a neurologic and cranial nerve examination.
|Table 2-3 Overview of cranial nerves and tests to evaluate their functions|
|I||Olfactory||Sense of smell, tested with camphor, coffee, and vanilla|
|II||Optic||Visual acuity/visual field: pupillary light reflex|
|III||Oculomotor||Pupillary light reflexes/accommodation, eyelid elevation, most eye movements|
|IV||Trochlear||Downward gaze during adduction|
|V||Trigeminal||Sensation of light touch to face in all three divisions; motor innervation of muscles of mastication (strength); corneal reflex|
|VI||Abducens||Lateral gaze (III, IV, and VI); tested by having the patient follow finger in an H pattern)|
|VII||Facial||Facial expressions; corneal reflex; taste to the anterior two-thirds of the tongue|
|VIII||Acoustic vestibulocochlear||Hearing (eg, ability to hear a watch tick); Weber and Rinne tests (tuning fork); observation for nystagmus on extraocular muscle testing; caloric testing|
|IX||Glossopharyngeal||Gag reflex; taste to posterior one-third of the tongue|
|X||Vagus||Speech; palatal/uvular elevation; gag reflex|
|XI||Accessory||Function of sternocleidomastoid and trapezius muscles (press against resistance)|
|XII||Hypoglossal||Tongue bulk, strength, and movement (protrude and wiggle, press against resistance)|