Pain is the most common reason individuals seek healthcare services. Patients’ pain experiences provide insight into the underlying neurophysiologic and genetic mechanisms for pain. However, patients’ reports of their pain experiences and healthcare teams’ interpretations are the result of the complex interplay of biologic, psychologic, behavioral, environmental and societal factors.
Your patient reports jaw clicking with and without pain, and frequent headaches for 3 months.
How do we assess patients’ jaw pain?
How do patient’s experience this phenomenon as pain?
During this visit, you will learn to obtain key characteristics of pain and how to conduct a focused physical examination to elucidate the underlying neurophysiologic mechanisms of Oral and Facial pain. The neurophysiology of Oral and Facial pain will be outlined to enrich your knowledge of these mechanisms and their implications for obtaining a diagnosis and developing a multimodal treatment plan.
Oral and Facial Pain Assessment
Precheck
The patient reports jaw clicking with and without pain and frequent headaches for 3 months. What would you ask the patient about their pain to obtain a complete assessment?
Assessment of Pain
Location:
Recommended question: "Where does it hurt?"
Not recommended:
- "Point to where it hurts."
- "Does it hurt here?"
- Please draw a circle around where it hurts."
- "Is the pain localized or diffuse?"
Does the patient point to the site of pain with one finger, as when describing pain of dental causes or trigeminal neuralgia, or is it more diffuse or even radiate across the midline in atypical facial pain?
Almost 95% of orofacial pain is related to dentition. TMD is the second most common cause of orofacial pain, and all other diagnoses are rare.)
Intensity
Recommended question: "On a scale of 0 to 10, with 0 representing no pain, and 10 the worst possible pain, how would you rate how much you hurt?"
Not recommended:
- "How much does it hurt?"
- "What number would you rate your pain?"
- "On a scale of 1 to 10, what would you rate how much you hurt?"
Quality
Recommended question: "What does the pain feel like?"
Not recommended:
- Please describe the sensation?
- Is it a stabbing, throbbing, or burning pain?
- Is your pain bothersome?
- Is it pain or just discomfort?
Timing
Recommended question: "Tell me about the timing of your pain. Is the pain constant or does it come and go?"
Not recommended:
- Do you hurt right now?
- When does it hurt?
- When does your jaw hurt?
- Does your pain hurt more when you eat or talk?)
Duration
Recommended question: "When did this pain start?"
Not recommended:
- Have you had this pain for long?
- How long does the pain last?
- How many days a week do you have this pain?
Pain from exposed dentine is fairly transient (lasting only seconds). Trigeminal neuralgia is a brief lancinating pain lasting up to about five seconds, although some patients report a persistent, less severe background pain – more of a dull ache, while atypical facial pain is usually persistent.
Determine whether the pain occurs at specific times or related to specific events. Temporomandibular pain dysfunction syndrome may be more severe on waking if it is associated with nocturnal parafunctional activity such as clenching or tooth grinding. Sinusitis pain is often aggravated by lying down.)
Aggravating
Recommended question: "What makes your pain worse?"
Not recommended:
- When does your jaw hurt?
- Does your pain hurt more when you eat or talk?
- Does your pain aggravate you?
It may be necessary to ask leading questions to determine if temperature, biting, or posture affect the pain. Heat often aggravates dental pain; touching a trigger zone may precipitate trigeminal neuralgia attacks; stress may worsen atypical facial pain, and alcohol may induce episodes of migrainous neuralgia.)
Alleviating
Recommended question: "What makes your pain better?"
Not recommended:
- Does your pain ever go away? When?
- Do medications relieve your pain?
- Does your pain keep you from sleeping?
Associated Symptoms
What else do you need to know about your patient’s experience of pain?
Some types of pain may be associated with other features which are helpful diagnostically, such as the swollen face in dental abscess, nausea and vomiting in migraine, or nasal stuffiness or lacrimation in migrainous neuralgia.)
Other questions you may want to ask:
- How does your pain impair your functioning?
- What is your goal for pain management?
