Pain Assessment
Pain Assessment Tools
Use the link immediately following the name of each pain assessment tool to learn more. Note than tools listed may be subject to individual copyright protections. They are listed here for informational purposes only.
Unidimensional Pain Assessment Tools
- numeric pain rating scale: http://www.rehabmeasures.org/PDF%20Library/Numeric%20Pain%20Rating%20Scale%20Instructions.pdf
- faces scale: http://wongbakerfaces.org/
- visual analog scale: https://pami.emergency.med.jax.ufl.edu/files/2015/03/Visual-Analog-Scale-VAS-in-depth.pdf
- verbal pain intensity scale: https://www.jiaphd.org/viewimage.asp?img=JIndianAssocPublicHealthDent_2015_13_4_486_171205_f1.jpg
Multidimensional Pain Assessment Tools
- Brief pain inventory: http://www.npcrc.org/files/news/briefpain_short.pdf
- McGill pain questionnaire: https://www.sralab.org/sites/default/files/2017-07/McGill%20Pain%20Questionnaire%20%281%29.pdf
- PADT: https://www.drugabuse.gov/sites/default/files/PainAssessmentDocumentationTool.pdf
- West Haven-Yale MPI: http://www.va.gov/PAINMANAGEMENT/docs/WHYMPI.pdf
Beverly’s Pain Assessment
Beverly’s information includes her first and last name, Beverly Martin, age 46, MRN# 001343, height sixty four inches, weight one hundred forty pounds, with no known allergies. Her insurance company is CMS.
Beverly reports the severity of her pain as follows:
- now: 4/10
- average: 6/10
- least: 1/10
- worst: 8/10
She reports no relief with current modalities.
Beverly rates how much pain interferes with daily activities as follows:
- activity: 5/10
- mood: 10/10
- walking: 0/10
- relations: 7/10
- concentration: 8/10
- sleep: 1/10
- enjoyment: 10/10
- appetite: 3/10
- work: 3/10
Beverly describes her pain characteristics as follows:
- onset: approximately one year ago
- duration: intensity/severity changes throughout the day with some location changes
- alleviating: some relief while eating
- aggravating: spicy foods
Psychosocial/Psychological Assessment and Evaluation
Beverly’s Psychosocial Assessment
Beverly’s information includes her first and last name, Beverly Martin, age 46, MRN# 001343, height sixty four inches, weight one hundred forty pounds, with no known allergies. Her insurance company is CMS.
Beverly reports the distress relating to her pain as follows:
- Patient Health Questionnaire (PHQ-9): 14
- Hamilton Anxiety Rating Scale (HAMA): 18
- Beck Anxiety Inventory (BAI): 23
Beverly shows the following scores on her pain disability index:
- family/home responsibilities: 7
- recreation: 4
- social activity: 8
- occupation: 7
- sexual behavior: 7
- self-care: 3
- life supporting activities: 4
The following describes the scores for Beverly on the pain catastrophizing scale:
- I worry all the time about whether the pain will end: 1
- I feel I can’t go on: 2
- It’s terrible and I think it’s never going to get any better: 1
- It’s awful and I feel it overwhelms me: 2
- I feel I can’t stand it anymore: 3
- I become afraid that the pain may get worse: 4
- I think of other painful experiences: 2
- I anxiously want the pain to go away: 2
- I can’t seem to keep it out of my mind: 3
- I keep thinking about how much it hurts: 4
- I keep thinking about how badly I want the pain to stop: 2
- There is nothing I can do to reduce the intensity of the pain: 3
- I wonder whether something serious may happen: 4
Note: the Pain Catastrophizing Scale is under copyright protection. Please seek permission before using.
Beverly’s Psychological Evaluation
How Pain Affects Beverly’s Life
Beverly describes how her pain affects her life.
Worst Pain Rating
Beverly describes her worst pain rating.
Least Pain Rating
Beverly describes her pain at its best.
Average Pain Rating
Beverly describes her pain on average.
Pain and Mood
Beverly describes how her pain affects her mood.
Daily Change in Pain
Beverly describes how her pain changes throughout the day.
Diagnosis
Differential Diagnosis
Read through each of the following differential diagnosis for the listed orofacial pain disorders to learn more about their presentation.
Primary Burning Mouth Syndrome
Primary Burning Mouth Syndrome is a disease of exclusion without an obvious cause. Diagnosis follows:
- Oral screenings for cancer and candidiasis (poor oral hygiene, underlying medical condition, immunosuppression, a poorly fitting prosthesis, etc.)
- Medication reconciliation (reaction to new medication?)
- Allergy assessment (allergic reaction to a new toothpaste, home care product, or food?)
- Examining specific triggers (spicy foods, tomato sauce, cinnamon, mint, etc)
- Assessment of other medical conditions/life stressors that contribute psychosomatically
See “Secondary Burning Mouth Syndrome” for symptoms and location shared between both diagnoses.
Secondary Burning Mouth Syndrome
Symptoms
Tingling, moderate to severe burning, numbness, xerostoma, dysgeusia, scalding, perceptions of foreign body in mouth.
Location
Symmetrical / bilateral in most occurrences. Usually confined to the anterior 2/3 of the tongue dorsum, gingiva, lateral borders of the tongue, and the anterior hard palate.
Course
Average time to diagnosis is 6 years. Typically spontaneous onset of symptoms with daily intensity varying depending on Type.
Types
- pain free upon awakening with worsening pain throughout the day.
- continuous pain throughout the day, but absence of symptoms at night.
- intermittent symptoms with pain-free days.
Glossopharyngeal Neuralgia
Symptoms
Paroxysmal (abrupt, short attacks), stabbing, sharp, and/or shooting pain.
Location
Posterior tongue, pharynx, lower jaw angle, ear, tonsillar fossa, and typically with unilateral distribution.
Course
Paroxysms last seconds and are frequently trigger dependent. Symptoms are clustered for weeks to months, followed by periods of remission.
Trigeminal Neuralgia
Symptoms
Abrupt, severe, stabbing, electric or “shock-like” pain.
Location
Unilateral, confined to cranial nerve V (trigeminal nerve) and its three branches (opthalmic, maxillary, and mandibular).
Course
Symptoms typically brief and quickly arise and resolve (paroxysms) with some triggers and trigger zones described.
Post-Herpetic Neuralgia
Symptoms
Burning, sharp, stabbing pain that is constant or intermittent. May be associated with allodynia and sensory deficits.
Location
Unilateral, confined to affected dermatome(s), most commonly trigeminal, cervical, or thoracic.
Course
May present as continued pain from original zoster rash or as long as months to years following a zoster episode.
Temporomandibular Disorder
Symptoms
Dull, constant, aching, radiating pain associated with ear stiffness, pain, or fullness.
Location
Unilateral with origin at the mandibular angle. Can radiate to the ear, eyes, and even posterior neck.
Course
Waxes and wanes, with exacerbation following eating in most instances.
Test Your Knowledge: Diagnosis Review
Review the following description of an orofacial pain disorder as described by a woman in her thirties and select the corresponding diagnosis.
“I’ve been having this awful pain that feels that something is, or someone is stabbing me at the back of my throat, and even the tongue on one side. Sometimes it feels as if it’s occurring in my ear. It seems like when I cough a lot I experience some of the pain. I think I’ve probably gone days and sometimes weeks without having any of the pain, but it will come back for really no rhyme or reason. When it does come back, it’s there anywhere from three to five times each day. It’s really bad and nothing that I have actually ever tried over the counter has really helped.”
Review the following description of an orofacial pain disorder as described by a man in his mid-forties and select the corresponding diagnosis.
“The pain is on the left side of my face and mouth. It feels like I’m being burned almost constantly. But sometimes it feels like I’m being stabbed. Some areas of my mouth are numb, but even a light touch on my cheek can really hurt. So this all started a couple months after I had the shingles.”
Review the following description of an orofacial pain disorder as described by a man in his early forties and select the corresponding diagnosis.
“I’ve been dealing with this pain for years. It’s more on the right side of my face than the left. It really hurts most right around where my jaw seems to be, especially when I eat. It’s really there almost constantly though. When it’s really bad, it seems like it even moves. I think I’m crazy, but sometimes I feel it behind my eye, and even sometimes behind my ear, like there’s something in there. If I to describe the pain, I would definitely say it’s achy and bothersome.”
Review the following description of an orofacial pain disorder as described by a woman in her late twenties and select the corresponding diagnosis.
“I’ve been dealing with this pain for almost six months. It feels like my entire mouth has been scalded, like I drank something that’s way too hot. It really burns. And it seems to get worse throughout the entire day. Sometimes it feels like its numb, or tingly. And the front part of my tongue and the roof of my mouth has the worst pain.”
Beverly's Diagnosis
How would you diagnose Beverly?
Treatment
Pharmacotherapy
Burning Mouth Syndrome
Burning Mouth Syndrome pharmacotherapies as follows:
Clonazepam
- Available as Klonopin®.
- long-acting benzodiazepine
- numerous FDA-approved indications, none pain related
- Efficacy for Burning Mouth Syndrome: open-label studies assessing topical clonazepam as a mouth wash (full text: http://painmedicine.oxfordjournals.org/content/painmedicine/15/12/2164.full.pdf) and oral tablet (abstract: https://www.ncbi.nlm.nih.gov/pubmed/22344742)
- Side effects: addiction, withdrawal related seizures, sedation, and cognitive impairment.
Clonazepam is classified by the Drug Enforcement Agency as a controlled substance, abusable by patients.
Gabapentin
- Available as Neurontin®, Gralise®, Horizont®, generic.
- Anticonvulsant in the gabapentin class that selectively inhibitsa2d calcium channels.
- FDA-approved for numerous pain-related conditions not including Burning Mouth Syndrome.
- Efficacy supported by one randomized, controlled study at doses of 300 mg daily (full text: http://www.medicinaoral.com/pubmed/medoralv16_i5_p635.pdf)
- Side effects: weight gain, ataxia, sedation. Must be renally dosed.
Paroxetine
- Available as generic.
- Anti-depressant medication. Exhibits selective serotonin reuptake inhibition.
- FDA indicated for numerous anxiety-related disorders, but nothing pain-related.
- Efficacy for Burning Mouth Syndrome supported by one, 12-week, open label study at doses of 10 - 20mg daily (abstract: https://www.ncbi.nlm.nih.gov/pubmed/18996028).
- Side effects: suicidal ideation, weight gain, sedation, sexual dysfunction, and hyponatremia.
Milnacipran
- Milnacipran (Savella®): FDA approved for the treatment of Fibromyalgia. Uses outside of this indication are considered off-label.
- Milnacipran is pharmacologically a serotonin & norepinephrine reuptake inhibitor.
- Efficacy for Burning Mouth Syndrome is supported by one open label study (abstract: https://www.ncbi.nlm.nih.gov/pubmed/21738023). Doses studied began at 30mg of milnacipran daily.
- Side effects: nausea, headache, weight gain, and sexual dysfunction.
Glossopharyngeal Neuralgia and Trigeminal Neuralgia
Both Glossopharyngeal Neuralgia and Trigeminal Neuralgia are treated similarly. The following pharmacotherapies can be used for both:
Carbamazepine
- Carbamazepine (CBZ): anticonvulsant with potent sodium channel inhibition.
- FDA-approved to treat Trigeminal Neuralgia. (Trigeminal/Glossopharyngeal Neuralgia essentially treated identically.)
- CBZ is considered the treatment of choice for both conditions with guidelines supporting its use and reviewing numerous controlled studies (abstract: https://www.ncbi.nlm.nih.gov/pubmed/18716236).
- Numerous toxicities and side effects for CBZ exist.
Baclofen
- Baclofen: skeletal muscle relaxer with effects at the spinal cord level of primary afferent nerve terminals.
- FDA approved for spasticity due to multiple sclerosis or spinal cord injury.
- Efficacy for trigeminal neuralgia supported by a small, double-blinded cross-over study in doses up to 80mg daily (abstract: https://www.ncbi.nlm.nih.gov/pubmed?term=6372646).
- Side effects: headache, drowsiness, hypotension, and a severe sudden withdrawal syndrome.
Oxcarbazepine
- Oxcarbazepine (Trileptal®): anticonvulsant pharmacologically similar to carbamazepine as a potent sodium channel antagonist.
- Several randomized controlled studies exist to support similar efficacy of oxcarbazepine to carbamazepine for the treatment of trigeminal neuralgia (guidelines: http://www.neurology.org/content/71/15/1183.full.pdf+html).
- Side effects: similar with hyponatremia, drug rash, and aplastic anemia continuing to be of concern. Overall, fewer significant drug interactions exist with oxcarbazepine.
Lamotrigine
- Lamotrigine (Lamictal®): anticonvulsant. Actions include sodium channel antagonism and glutamate release inhibition.
- FDA approved for only bipolar disorder and certain epilepsies.
- Efficacy for trigeminal neuralgia supported by a small double-blind study (https://www.ncbi.nlm.nih.gov/pubmed?term=9415509) for adjunctive use and an open label study (https://www.uptodate.com/contents/trigeminal-neuralgia/abstract/46?utdPopup=true) for monotherapy.
- Side effects: increased liver enzymes and drug rash when titrated quickly. Significant drug interactions exist.
Post-Herpetic Neuralgia
Amitriptyline
- Amitriptyline: tricyclic antidepressant with pharmacologic properties of serotonin and norepinephrine reuptake inhibition.
- Frequently used to treat neuropathic pain syndromes. Not FDA approved for this use.
- Amitriptyline efficacy for post-herpetic neuralgia supported by several randomized controlled studies (review: http://www.nejm.org/doi/pdf/10.1056/NEJMcp1403062).
- Side effects: dry mouth, sedation, urinary retention, and QTc prolongation.
Gabapentin
- Gabapentin (Neurontin®, Gralise®, Horizont®, generic): anticonvulsant in the gabapentinoid class that selectively inhibits a2d calcium channels.
- FDA-approved for post-herpetic neuralgia.
- Efficacy supported by four randomized, controlled study at doses of 300mg daily (systematic review abstract: https://www.ncbi.nlm.nih.gov/pubmed?term=24771480).
- Side effects: weight gain, ataxia, sedation. Must be renally dosed.
Topical Lidocaine
- Topical lidocaine: available commercially in numerous preparations, including an FDA approved 5% patch to treat post-herpetic neuralgia.
- Lidocaine: antiarrhythmic. Pharmacologically acts as a potent sodium channel antagonist.
- 5% topical lidocaine patch may be worn over the site of zoster infection for 12 hours, with a 12 hour lidocaine-free period. Up to 3 patches may be worn concurrently.
- Side effects: generally limited to site reactions.
Pregabalin
- Pregabalin (Lyrica®): a gabapentinoid similar to gabapentin. Inhibits specific subtypes of the presynaptic calcium channel.
- FDA approved for numerous chronic pain conditions including post-herpetic neuralgia.
- Efficacy for post-herpetic neuralgia may be found in this review article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3915349/.
- Side effects: similar to gabapentin and include weight gain, edema, somnolence, and ataxia.
- Pregabalin must be renally dosed.
Temporomandibular Disorder
Few pharmacologic interventions have proven effective in well-controlled studies for chronic temporomandibular joint disorder.
Amitriptyline, naproxen, and cyclobenzaprine may provide limited benefit.
(Cochrane Review abstract: https://www.ncbi.nlm.nih.gov/pubmed?term=20927737).
Pharmacotherapy Review Questions
Which pharmacotherapy can be best used to treat Burning Mouth Syndrome?
Which pharmacotherapy can be best used to treat Trigeminal Neuralgia?
Which pharmacotherapy can be best used to treat Post-Herpetic Neuralgia?
Which pharmacotherapy can be best used to treat Temporomandibular Disorder?
Dental Interventions
For Burning Mouth Syndrome
- tongue protectors
- correction of parafunctional habits (repeated muscle movements)
- treatment of potential underlying causes (e.g., oral candidiasis or salivary dysfunction)
- correction of poorly fitting prosthesis
Counseling
For Orofacial Pain Syndromes
- individual or group education
- instruction on self-management therapies
- problem solving skills
- relaxation and biofeedback
- team conferences
- risk and adherence assessment
Complementary and Alternative Therapy
For Burning Mouth Syndrome
acupuncture (abstract: https://www.ncbi.nlm.nih.gov/pubmed/25987645)
lycopene enriched olive oil (abstract: https://www.ncbi.nlm.nih.gov/pubmed/24612248)
alpha lipoic acid (in combination with gabapentin; full text: https://www.ncbi.nlm.nih.gov/pubmed/27302545)
capsicum (capsaicin; full text review: https://www.ncbi.nlm.nih.gov/pubmed/21743415)
hypericum perforatum (full text review: https://www.ncbi.nlm.nih.gov/pubmed/18331283)
