March 1, 2014
by Tom Shackelton, DDS
When people experience orofacial pain, their first call is often to their dentist. Many different conditions will present with similar symptoms, making it difficult for a dentist to arrive at an accurate diagnosis. Without a correct diagnosis, it is virtually impossible to provide the care necessary to alleviate a person’s pain. The goal of this paper is to help dentists recognize common orofacial pain conditions, which should then assist them in making appropriate decisions regarding treatment, whether that be by referral or not.
Dentists see patients for pain almost every day. We see them for both transient pain conditions and chronic pain conditions.1 Our responsibility is to diagnose (if possible) and prescribe a course of treatment (when appropriate). Many patients we can treat ourselves, but there are times when we must recognize our own limitations and employ a multidisciplinary approach. To understand what we know and what we don’t isn’t a sign of weakness, but the simple recognition that none of us can do everything.
As dentists, we should be equipped with the diagnostic skill to differentiate many different types of pain. Broadly, we can categorize pain as dentoalveolar, musculoskeletal and neurogenic.2 Many of the symptoms in each category and those between categories can overlap, making diagnosis difficult. A systematic approach to all cases will assist in the correct diagnosis and triage of our pain patients. By triage, I mean the clinical decision to either treat or refer. And if referral is indicated, then to whom do we refer? It is important to recognize that correctly diagnosing a patient’s pain takes time. With experience, everyone will become more proficient, but there are certain steps that should always be followed.
INTERVIEW & EXAMINATION
• Thorough medical history, including updates of all medical & dental conditions, hospitalizations, medications and allergies. Family and specialist physicians should be recorded in the patient chart
• History of the present illness:
When did symptoms begin?
Location of the pain?
Is the pain daily or episodic? Is the pain worsening over time? What time of day are the symptoms present (e.g. worse in the morning? Or does it worsen as the day progresses?)
What is the nature of the pain? Dull ache, sharp, pressure, pulsatile, electric, burning, etc.
Is there a “trigger” for the pain? For example: touch, temperature, biting, postural, certain foods (spicy or acidic), etc.
What is the intensity of the pain on a Visual Analog Scale (VAS)? 0 is no pain, 10 is the worst pain imaginable
What makes the pain better? Worse?
Have you seen anyone else for the pain? This is important for possible consultation and reporting purposes
Do you suffer from headaches? Frequency? Duration? Location? Triggers? Associated symptoms? Treatments?
Anything else the patient wishes to report
• Extraoral examination:
Lymph node palpation
TMJ examination: tenderness to palpation, noises (crepitus or clicking)
Muscle examination: tenderness to palpation, taut bands or pain referral in the masseter, temporalis, sternocleidomastoid, or medial pterygoid (also palpated on the intraoral exam)
• Intraoral examination:
Maximum pain free opening (i.e. have them open until they feel pain)
Maximum unassisted opening (which may cause pain)
Maximum assisted opening (with very gentle pressure)
R/L lateral movement
Mucosa (normal, ulcerated, swollen, inflamed, white, etc.)
Gingiva (normal, recessed, swollen, presence of draining sinus tract, etc.)
Tongue/floor of mouth (normal, ulcerated, red/white lesions, etc.)
Teeth (wear, decay, restorations, hygiene, fractures, etc.)
Percussion, biting, thermal testing affected areas
• Radiographic examination: Bitewing, selected periapical, panoramic, CBCT, MRI as indicated. Always be mindful of ALARA, but do not hesitate to obtain whatever radiograph may be required to arrive at a correct diagnosis3
Armed with the above information, you should be able to diagnose most orofacial pain conditions. It should be emphasized that the following categories are not comprehensive, but that they comprise most conditions we commonly see in our day-to-day practices. Please note that diagnosis is an art based on science and if you are unsure of a diagnosis, consultation with or referral to the appropriate specialist is indicated.
While we are performing our examinations, we should understand the difference between signs and symptoms: Symptoms are subjective evidence of a disease that a patient will report (e.g. “It hurts when I eat”). Signs are objective evidence of disease that we can evaluate (e.g. gingival swelling with purulent discharge as a sign of infection).
The most common disease we see is dentoalveolar pain.4 As dentists, we should be absolutely proficient in diagnosing dentoalveolar disease. This does not mean we must be absolutely proficient in the treatment of all these diseases – that is not practical or even possible. But we should be able to understand pain of dentoalveolar origin and triage it appropriately.
Many patients will present with pain that has no apparent dental etiology. This underscores the necessity of a thorough interview. Often we can begin to piece together clues and start working toward a diagnosis based solely on the interview. It should be noted, however, that the interview does not replace a thorough extraoral/intraoral/radiographic examination, but provides a jumping off point for the investigation. Also, many patients want to be heard, so the interview should be seen as an opportunity to establish a mutually trusting relationship.
After dentoalveolar pain, musculoskeletal pain is the most common pain phenomenon we will see. As with other conditions, we should become comfortable identifying these conditions, even if we aren’t comfortable treating them. And while various treatments of TMD’s can be controversial, most agree that conservative, reversible treatments should be performed first and only if they fail should more aggressive, irreversible treatments be considered.
Depending on the demographics of our patient population, neurogenic pain may be more or less common in one practice versus another. For instance, in a practice that is made up of medically complex or older patients, these conditions will likely be seen with greater frequency than in a practice made up of healthy, younger individuals. That said, one should be ever vigilant when evaluating pain and consider all probable causes before arriving at definitive diagnosis
The diagnosis of many of these conditions is a process of exclusion. All other sources of pain should first be investigated and only when they have been shown to not be the source of a patient’s chief complaint, should we consider neurogenic pain. Also, some of these conditions may have co-morbidities (e.g. post-herpetic neuralgia) or a history of trauma (e.g. iatrogenic11 or otherwise), which again encourages a comprehensive history during the interview.
RCES OF PAIN
Autoimmune disorders,16 neoplasias,17 systemic causes18 (e.g. RA, MS, psychogenic disorders, diabetic neuropathy, HIV neuropathy, Bechet’s) have all been associated with orofacial pain. It is important to recognize that when someone presents with pain of an unidentifiable origin, consultation with or referral to colleagues is always in our patients’ best interest. Additionally, headaches9 (TTH, Migraine, TAC’s) often accompany orofacial pain and these may or may not be related to their orofacial pain condition. Obtaining a headache history as part of your interview and suggesting referral if they are not managing their headaches is part of responsible care.
As dentists, we live in a tooth-centered universe. That’s natural – most of what we see and treat is made up of enamel, dentin and pulp. When diagnosing, it is advisable to first focus on the person attached to the tooth before diving into their mouth. Information gathering (interview, EO/IO exams, radiographs) may take a few minutes or it may take several visits. A comprehensive, stepwise approach will enable to you correctly diagnose and triage patients effectively. Whether triage results in treatment in our own office or referral to an appropriate colleague will depend on our own experience and training, but ultimately, it is the provision of the highest quality of care for our patients is what counts.
CBCT = Cone Beam Computed Tomography; MRI = Magnetic Resonance Imaging; ALARA = As Low As Reasonably Achievable; TMD = Temporomandibular disorder; OFPOM = Orofacial Pain/Oral Medicine Provider; OMFS = Oral & Maxillofacial Surgeon; MD = Medical Doctor; RA = Rheumatoid Arthritis; MS = Multiple Sclerosis; TTH = Tension Type Headache; TAC = Trigeminal Autonomic Cephalgias. OH
Dr. Tom Shackleton is a General Dentist in Calgary, AB with a practice limited to Endodontics. He is currently working on a 3 year Masters’ degree in Orofacial Pain & Oral Medicine through the University of Southern California. Dr. Shackelton can be reached at firstname.lastname@example.org or www.drshackleton.com.
Oral Health welcomes this original article.
1. De Rossi SS Orofacial pain: a primer. Dent Clin North Am. 2013 Jul;57(3):383-92. doi: 10.1016/j.cden.2013.04.001. Epub 2013 Jun 4.
2. Hapak L, Gordon A, Locker D, Shandling M, Mock D, Tenenbaum HC. Differentiation between musculoligamentous, dentoalveolar, and neurologically based craniofacial pain with a diagnostic questionnaire.J Orofac Pain. 1994 Fall;8(4):357-68.
3. Hunter A, Kalathingal S. Diagnostic imaging for temporomandibular disorders and orofacial pain. Dent Clin North Am. 2013 Jul;57(3):405-18. doi: 10.1016/j.cden.2013.04.008. Epub 2013 Jun 5.
4. Canavan D. Dental perspectives on neuropathic origin. J Ir Dent Assoc. 2005 Spring;51(1):33, 35-7.
5. Pradeep AR, Agarwal E, Naik SB, Bajaj P, Kalra N. Comparison of efficacy of three commercially available dentifrices [corrected] on dentinal hypersensitivity: a randomized clinical trial. Aust Dent J. 2012 Dec;57(4):429-34. doi: 10.1111/j.1834-7819.2012.01726.x. Epub 2012 Sep 11.
6. Setzer FC, Kataoka SH, Natrielli F, Gondim-Junior E, Caldeira CL. Clinical diagnosis of pulp inflammation based on pulp oxygenation rates measured by pulse oximetry. J Endod. 2012 Jul;38(7):880-3. doi: 10.1016/j.joen.2012.03.027. Epub 2012 May 18.
7. Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013 May;31(2):465-80. doi: 10.1016/j.emc.2013.01.007. Epub 2013 Feb 13.
8. Marquez IC. How do I manage a patient with periodontal abscess? J Can Dent Assoc. 2013;79:d8.
9. Shephard MK, Macgregor EA, Zakrzewska JM. Orofacial Pain: A Guide for the Headache Physician. Headache. 2013 Nov 21. doi: 10.1111/head.12272. [Epub ahead of print]
10. Liu F, Steinkeler A. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dent Clin North Am. 2013 Jul;57(3):465-79. doi: 10.1016/j.cden.2013.04.006.
11. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency of nonodontogenic pain after endodontic therapy: a systematic review and meta-analysis. J Endod. 2010 Sep;36(9):1494-8. doi: 10.1016/j.joen.2010.06.020.
12. Klasser GD, Pinto A, Czyscon JM, Cramer CK, Epstein J. Defining and diagnosing burning mouth syndrome: Perceptions of directors of North American postgraduate oral medicine and orofacial pain programs. J Am Dent Assoc. 2013 Oct;144(10):1135-42.
13. Zakrzewska JM. Multi-dimensionality of chronic pain of the oral cavity and face. J Headache Pain. 2013 Apr 25;14(1):37. doi: 10.1186/1129-2377-14-37.
14. Wilcox SL, Gustin SM, Eykman EN, Fowler G, Peck CC, Murray GM, Henderson LA. Trigeminal nerve anatomy in neuropathic and non-neuropathic orofacial pain patients. J Pain. 2013 Aug;14(8):865-72. doi: 10.1016/j.jpain.2013.02.014. Epub 2013 May 17.
15. Pigg M. Chronic intraoral pain—assessment of diagnostic methods and prognosis. Swed Dent J Suppl. 2011;(220):7-91.
16. Kim SK, Chang M, Merrill R. Case report: an orofacial pain patient with spots on the brain-multiple sclerosis versus central systemic lupus erythematosus. J Orofac Pain. 2012 Summer;26(3):240-3.
17. Cook RJ, Sharif I, Escudier M. Meningioma as a cause of chronic orofacial pain: case reports. Br J Oral Maxillofac Surg. 2008 Sep;46(6):487-9. doi: 10.1016/j.bjoms.2007.11.020. Epub 2008 Mar 4.
18. Resende RG, de Fátima Correia-Silva J, Arão TC, Brito JA, Bittencourt H, Gomez RS, Abreu MH. Oral cGVHD screening tests in the diagnosis of systemic chronic graft-versus-host disease. Clin Oral Investig. 2012 Apr;16(2):565-70. doi: 10.1007/s00784-011-0529-8. Epub 2011 Mar 3.