Pain Assessment

Assessment and Clinical diagnosis

Normally a patient with OFP will be seen by a clinician who has experience in one aspect of orofacial pain. Dentists will explore dental pain, ENT surgeon will assess for sinus and ear related pain etc. This website aims to dispel many myths around the complexity of these conditions but also aims to assist patients and clinicians gaining a clear understanding of your condition(s) enabling swift diagnosis and improved and more efficient treatment of these pain conditions.

A summary of OFP diagnosis is provided and several online available papers may assist those interested further in learning about OFP diagnosis here.

Managing patient’s expectations is paramount and often a cure is not possible but management is (LINK to Treatment Goal doc). Providing the patient with clear understanding of what is taking place (LINK to Patient orofacial pain diagnosis doc).

Communication skills underpin a successful consultation for chronic pain. Pain is invisible thus diagnosis is based upon what the patient can communicate to their clinician.

• The patient must be heard
• Careful listening and confirmation of what the patient is trying to convey will elucidate important features and facts about the patients experience
• Often a careful history is suffice in making a diagnosis

Pain History Recording

Pain history taking is often taught as using SOCRATES

• Site – Where is the pain? Or the maximal site of the pain.
• Onset – When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive.
• Character – What is the pain like? An ache? Stabbing?
• Radiation – Does the pain radiate anywhere?
• Associations – Any other signs or symptoms associated with the pain?
• Time course – Does the pain follow any pattern?
• Exacerbating/Relieving factors – Does anything change the pain?
• Severity – How bad is the pain?

Alternative pain assessments include;

The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A “brief HPI” constitutes one to three of these elements. An “extended HPI” includes four or more of these elements.

Also usable is SOCRATES. For chronic pain, the Stanford Five may be assessed to understand the pain experience from the patient’s primary belief system.

Fundamentally pain must be assessed holistically.

Stanford Five in pain management is an augmented set of medical history obtained by the clinician during the medical interview for patients with pain. Unlike the OPQRST of pain history designed to elicit aspects of the pain experience itself, the Stanford Five is designed to assess and present the pain experience as viewed from the patient’s primary belief system.

A cornerstone of interdisciplinary pain management, its creation is attributed to Dr. Sean Mackey of Stanford University.

The following are the components of the Stanford Five :

• Cause: What tissue abnormalities the patient believes to be the cause of the current problem.
• Meaning: The presence of any sinister beliefs related to the pain, in terms of tissue damages, that precludes activities
• Impact: What impact does the primary problem have on the patient’s life including interference on vocational, social, recreational activities, and in general the patient’s quality of life
• Goals: What the patient expects to achieve with further treatment
• Treatment: What the patient believes needs to be done now and in the future to help resolve the problem

Assessment of pain must include

• History (medical, social, dental and previous treatments for OFP condition)
• Examination
• Psychometrics
• Investigations
• Special investigations

The following sections are aimed at giving the reader an overview of the processes involved in formulating a differential diagnoses for patients presenting with OFP. They are not meant to be exhaustive and interested readers are referred to several excellent texts on the subject.

Pain History

A recent report on the differential diagnosis of OFP highlights some important strategies to help distinguish between OFP conditions and come to a diagnosis or differential diagnoses. History-taking remains of paramount importance in facilitating the diagnostic process. Blau suggested fifteen questions to facilitate the history taking process in OFP which cover the following aspects of the presenting pain:

1. Onset
2. Frequency
3. Duration
4. Provoking factors
5. Site of initiation of pain
6. Radiation and referral of pain
7. Is the pain deep or superficial
8. Aggravating or exacerbating factors
9. Relieving factors
10. Characteristics of the pain
11. Severity
12. Other associated features, for example lacrimation or other autonomic signs and symptoms
13. Previous management strategies attempted
14. Patient’s perceived cause(s) of pain

Several recent recommendations for the assessment of pain patients cover the necessity for a full medical, dental, and social history, following the history of the presenting complaint.

The examination of a patient with OFP should include the following as a bare minimum and more detailed examination of some tissues or systems may be added as the diagnostic process refines:

1. Inspection of the head and neck, skin, topographic anatomy, and swelling or other orofacial asymmetry
2. Palpation of the temporomandibular joint and masticatory muscles, tests for strength and provocation. With assessment and measurement of the range of mandibular movement
3. Palpation of soft tissue (including lymph nodes)
4. Palpation of cervical muscles and assessment of cervical range of motion
5. Cranial nerve examination
6. General inspection of the ears, nose, and oropharyngeal areas
7. Examination and palpation of intraoral soft tissue
8. Examination of the teeth and periodontium (including occlusion)

Systemic conditions that can be associated with OFP are detailed in Table 7. There are also some conditions and diseases that can mimic or masquerade as OFP and Table 8 summarises the salient details of their presentations. Conversely some OFP conditions may masquerade or be misdiagnosed or misinterpreted as toothache and these are outlined in Table 9.

The clinical data will also be uploaded live onto the database facilitating complex analysis of the patient and clinical dataset for comparative analysis of proposed and actual diagnosis with identification of the order and importance of specific questions leading to optimising the sensitivity and specificity in AI diagnosis of many of the OFP conditions. Some OFP conditions may elude this method and further research is likely to be required for the rarer OFP conditions.

Orofacial Disorders That May Be Confused with Toothache

• Trigeminal neuralgia
• Trigeminal neuropathy (due to trauma or tumor invasion of nerves)
• Atypical facial pain and atypical odontalgia (PDAP)
• Cluster headache
• Acute and chronic maxillary sinusitis
• TMDs

Investigations 

Investigations are needed to exclude some systemic diseases may exacerbate your orofacial pain and these must be excluded by history and blood tests.

Ongoing diseases that may worsen or initiate orofacial pain Systemic Diseases Associated with Headache and Orofacial Pain:

• Paget’s disease
• Metastatic disease
• Hyperthyroidism
• Multiple myeloma
• Hyperparathyroidism
• Vitamin B deficiencies
• Systemic lupus erythematosus
• Vincristine and other chemotherapy for cancer
• Folic acid and iron deficiency anaemias

The various tests may include;.

• Blood tests or other lab tests: A small sample of your blood is taken and then checked to see if you have an infection or other condition that could be causing your pain.
• Imaging Tests
  Imaging tests are also called radiological tests.  With these tests, the doctor uses different technologies to get a better picture of what’s going on in the body—with the bones, soft tissues, and organs.

Here are the most common imaging tests:

X-ray:  These show the doctor your bony structures so that he or she can look for any abnormalities.  For example, if the doctor suspects you have osteoarthritis in the knee, he or she may use x-ray to take a closer look at your joint.

CT scan:  A CT scan (which stands for computed tomography scan) is used to look at the soft tissues, as well as the bones.  On a CT scan, the doctor can see ligaments, for example.  For example, a CT scan can show a spinal herniated disc, which is a soft tissue.  Looking the CT, the doctor can see if the herniated disc is pushing on a spinal nerve or the spinal cord.

MRI:  Similar to a CT scan, an MRI (which stands for magnetic resonance imaging) shows the relationship between soft tissues and the bones.  Unlike CT scans, it doesn’t use radiation (x-rays) to do this; instead an MRI uses magnetic fields and computers to produce high-resolution images of your bones and soft tissues.

Other imaging tests are myelograms, bone scans, and ultrasounds.

• Electromyogram (EMG) and nerve conduction studies or other nerve tests: These tests measure muscle and nerve function to find out whether your chronic pain is related to muscle or nerve problems.
• Angiogram or other studies of your blood vessels: This test injects a dye and inserts a small tube into your arteries to trace the movement of blood within your body.
• Diagnostic nerve blocks: One example is an injection of a local anesthetic into or around a nerve to identify whether that nerve is causing the pain.

Blood tests

Haematology investigations:

The most frequently employed haematological investigations for OFP include:

• Full blood count – predominately looking for anaemias
• Haematinics: Ferritin,B12, Folate – looking for deficiency states causing secondary burning mouth syndrome
• Zinc levels
• Hypothyroidism – causing headache
• Diabetes (HBA1c)
• Antibody screen ENAs ANAs
• ESR or CRP if inflammatory condition suspected.

Imaging

• Plain dental radiography (Dental pantomogram DPT) to identify caries, infection, bone loss etc
• MRI exclude space occupying lesions, demyelination and vascular compromise of theTrigeminal nerve

Psychometrics

Pain is a multifaceted phenomenon

It incorporates the simple pain transmitting system and all of the emotional components of the brain (the process cannot be separated no matter how logical you think you are!)

We use several psychological and pain questionnaires. within the patient questionnaire there are links to the following general health questionnaires for all patients to complete:

• Euroquol
• GAD-7
• PHQ-9
• MSPSS
• OHIP-14
• PCL

Additional questionnaires to be completed by only those with pain:

• PSEQ
• CPAQ
• McGill (short form)
• PainDetect

See also Differential Diagnosis table.