uccessful management of patients who are seeking care for
orofacial pain requires the clinician to gain an understanding
of the problem and establish a proper diagnosis.
(or diagnoses, as there is rarely only one) cannot be based solely
on the patient’s description of pain; it must also involve taking a
detailed pain history, performing a comprehensive physical exami-
nation, and ordering and interpreting appropriate diagnostic tests.
The orofacial pain clinician must then synthesize the information to
determine pain etiology and establish a diagnosis utilizing accepted
Familiarity with orofacial pain disorders and
their classication is essential for targeted assessment and accurate
diagnosis. The immediate goal after establishing the diagnosis is to
initiate a treatment plan. As such, before commencing any treat-
ment, an evaluation of the patient’s overall health status, including
◊ The general assessment of the orofacial pain patient is
aimed at identifying the what, where, how, and why of the
◊ Diagnosis of orofacial pain requires taking a detailed his-
tory, completing a comprehensive clinical examination,
and ordering appropriate tests of established validity.
◊ All dental patients should be screened for temporoman-
dibular disorders (TMDs), and positive screening ndings
should prompt more comprehensive evaluation.
their medical and surgical, drug, and psychoso-
cial history is also required. Collaboration with
various specialists (eg, otolaryngology, neurol-
ogy, rheumatology, psychiatry) is often neces-
sary. The objective of general assessment is
to accurately identify the what, where, how,
and why of the patient’s complaint. This chap-
ter discusses the basic tests and techniques
for the assessment of an orofacial pain patient.
It has become integral to current practice that
all dental patients be screened for TMDs and
other orofacial pain disorders as part of their
initial and regular examinations. The results of
the screening should help the clinician deter-
mine whether a more comprehensive evalua-
tion is necessary.
The screening may consist
of a short questionnaire (Box 2-1), a brief his-
tory, and a limited examination. Although the
value of questionnaires may be challenged, a
questionnaire can facilitate the clinical exami-
nation by focusing on specic complaints.
TMD screener is a three-item questionnaire in-
cluding questions about duration and timing of
pain and aggravating and relieving factors. The
questionnaire has a sensitivity of 98% and a
specicity of 97% and has been shown to both
accurately identify painful TMDs and to discrim-
inate them from other conditions that present
with overlapping symptoms.
The high positive
predictive value (over 98) suggests that the
TMD screener can be used to identify patients
requiring a more comprehensive evaluation.
The TMD screening examination usually
consists of observation of the mandibular
range of motion, palpation of the temporo-
mandibular joints (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 can disclose un-
coordinated movements that may indicate
internal biomechanical problems.
should be observed when evaluating the re-
sults of the screening process because the
clinical ndings and the patient’s complaints
may not be consistent. Positive ndings on
the screening evaluation may prompt a more
comprehensive evaluation. An understanding
of the clinical signicance of positive ndings
is essential. For example, a clinical sign such
Box 2-1 Example of screening questions for TMDs*
• Do you have difficulty, pain, or both
when opening your mouth (eg, when
• Does your jaw get stuck, get locked, or
• Do you have difficulty, pain, or both when
chewing, talking, or using your jaws?
• Are you aware of noises in the jaw
• Do your jaws regularly feel stiff, tight,
• 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
*All dental patients should be screened for TMDs and other orofacial pain disorders. The decision to complete a
comprehensive history and clinical examination 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 sufcient to warrant a
comprehensive examination if it is of concern to the patient or viewed as clinically signicant.
General Assessment of the Orofacial Pain Patient
as a clicking TMJ may merely represent a sta-
ble, nonpainful condition that does not require
A comprehensive evaluation should be per-
formed when a patient’s complaints of pain are
not of dental origin or when a patient’s screen-
ing evaluation results are positive for an orofa-
cial 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 list of com-
plaints; if the clinician carefully analyzes the
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
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
ndings and the clinical signicance of each nding. Any
single positive nding may be sufcient to warrant a
components of each complaint, this can lead
to a differential diagnosis. A meticulous history
will often guide the clinician to the most likely
diagnoses and therefore aid in determining
what additional diagnostic procedures may be
appropriate, if any.
The interview, or history, is usually the rst
contact between the clinician and the patient,
and as such, an empathetic attitude by the cli-
nician can quickly create a bond critical to suc-
The patient must be allowed to comfortably
express the symptoms that prompted the con-
sultation, although the clinician must take con-
trol of the interview to gather information in
an organized manner. Adequate time is neces-
sary to allow the patient to fully describe each
of the complaints. The complaints are docu-
mented in the order of severity as indicated by
the patient, and details of each complaint are
elicited in a systematic manner.
History of chief complaints
A description of each chief complaint usually
includes its location, onset, quality, intensity,
frequency and duration; triggering, exacer-
bating and alleviating factors; and associated
symptoms. The combination of these features
often represents recognizable patterns that
can help the clinician to appropriately catego-
rize the complaint, resulting in well-directed
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 under-
stand the anatomy. Therefore, it is helpful to
have the patient identify the exact location of
the pain using a nger to either point to or cir-
Box 2-3 Comprehensive history format for orofacial pain patients*
1. Chief complaint(s) and history of
– Date and event of onset
– Remissions or change over time
– Modifying factors (alleviating,
precipitating, or aggravating)
– Previous treatment results
2. Medical history
– Current or preexisting relevant
physical disorders or disease
(specifically, systemic arthritides
or other musculoskeletal or
– Sleep disorders and sleep-related
– Previous treatments, surgeries, and/
– Trauma to the head and face
– Medications (prescription and
– Allergies to medications
– Alcohol and other substances of
3. Dental history
– Current or preexisting relevant
physical disorders or diseases
– Previous treatments, including the
patient’s attitude toward treatment
– History of trauma to the head and
neck (including iatrogenic trauma)
– Parafunctional history, both awake
4. Psychosocial history
– Social, behavioral, and psychologic
– Occupational, recreational, and
– Litigation, disability, or secondary
Table 2-1 Comprehensive orofacial pain physical examination procedures
Type of evaluation Reviewing sequence
General head and
1. Note scars; asymmetry; unusual size, shape, consistency, or posture; and
involuntary movement or tenderness.
Muscles, TMJ, and
1. Palpate the muscles of mastication and cervical muscles.
2. Palpate the TMJ preauricular.
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
Intraoral 1. Assess hard and soft tissue conditions or disease.
*All dental patients should be screened for TMDs and other orofacial pain disorders. The decision to complete a compre-
hensive history and clinical examination 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 sufcient to warrant a
comprehensive examination if it is of concern to the patient or viewed as clinically signicant.
General Assessment of the Orofacial Pain Patient
cumscribe the area of complaint. An 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, nding
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 cir-
cumstances that precipitated the pain, if any.
Trauma is a frequent cause of pain and should
be differentiated from pain secondary to sys-
temic disease or personal stressors. It is also
important to know how the pain begins with
each episode (ie, whether it arises gradually
or suddenly or is spontaneous). The temporal
component of pain, be it the time of day, week,
or month the pain occurs may also render im-
portant 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 be-
cause 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 specicity, although
not specically designed for orofacial pain, are
available to help clinicians distinguish between
neuropathic pain, nociceptive pain, and mixed
They include the Leeds Assessment of
Neuropathic Symptoms and Signs (LANSS)
and S-LANSS (short version), Douleur Neu-
ropathique (DN4), Neuropathic Pain Question-
PainDETECT, and ID-Pain.
LANSS and DN4 contain clinical items in addi-
tion to self-reported symptoms. The self-report
items of the DN4 can be used alone with good
sensitivity and specicity.
Table 2-2 Pain-quality descriptors and secondary symptoms associated with
dierent pain categories
Pain category Quality Secondary symptoms
Musculoskeletal • Dull
• Occasionally sharp
• Can refer to or be referred from distant sites
• Worse with function
Neurovascular • Throbbing
• Worsened by increasing intracranial pressure (eg, Valsalva,
bending over, physical activity)
• Sensitivity to light and/or sound
• Nausea, vomiting
Neuropathic • Shooting
• Electric shock–like
Psychogenic • Descriptive • Complaint patterns often do not match anatomical sensory
Intensity. The intensity of pain is subjective,
variable, and often inuenced by the psycho-
social status of the patient. It is important for
clinicians to understand the patient’s interpre-
tation 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); nu-
meric rating scale (ie, a number between 0 and
10, where 0 represents “no pain” and 10 rep-
resents 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”). Because intensity can
vary, it may be rated at the time of presenta-
tion in addition to the intensity at worst, best,
and average in the preceding week. Sensory
changes such as diminished or increased per-
ception of touch or pain can be similarly rated
and 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 peri-
ods of remission, or is constant. The duration
of pain may be recorded in seconds, minutes,
hours, days, weeks, or months. The daily dura-
tion of pain is rated as continuous or intermit-
tent. 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, aggravat-
ing, and alleviating factors yield important in-
formation. Seemingly minor details that may
not strike the patient as important may have
tremendous diagnostic value. Examples in-
clude precipitating factors such as light wind,
touch, or shaving initiating the pain and aggra-
vating factors such as having increased pain
during periods of personal stressors. Simi-
larly, discovering that jaw function does not
precipitate or aggravate an individual’s pain
is of equivalent diagnostic importance. In an
injured musculoskeletal system, symptoms
tend to aggravate when the system is used. If
the masticatory system is the source of pain,
then pain should worsen during jaw function. If
it does not worsen, the source of the pain may
be outside of the masticatory system.
Associated symptoms. Very often, a symp-
tom associated with the patient’s pain com-
plaint can help the clinician narrow his or her
diagnostic focus. Sensory and motor changes
as well as autonomic features may be re-
corded. For example, the presence of visual
and sensory changes or light or sound sensi-
tivity may be indicative of migraine with aura,
whereas drooping, redness, and/or tearing of
the eye may indicate a trigeminal autonomic
Prior medical and dental 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 alleviates the pain
complaint, the pain is likely not of neuropathic
origin. The patient’s recall of medications, dos-
ages, and length of medication trials should
also be recorded. This information helps the
clinician to evaluate whether previous thera-
pies have been adequately tried and titrated or
if they were discontinued due to side effects
or adverse events. This part of the interview
may also provide insight into patient compli-
ance with previously proposed therapies.
Medical and dental history
Past illnesses, surgeries, developmental or ge-
netic abnormalities, and any sequelae should
be documented. Long- and short-term use
of medications (including over-the-counter
medications and herbal, vitamin, and mineral
preparations) and their purpose should also be
documented, as they may inuence potential
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Key PointsSuccessful management of patients who are seeking care for orofacial pain requires the clinician to gain an understanding of the problem and establish a proper diagnosis.1 Diagnosis (or diagnoses, as there is rarely only one) cannot be based solely on the patient’s description of pain; it must also involve taking a detailed pain history, performing a comprehensive physical exami-nation, and ordering and interpreting appropriate diagnostic tests. The orofacial pain clinician must then synthesize the information to determine pain etiology and establish a diagnosis utilizing accepted classication systems.2 Familiarity with orofacial pain disorders and their classication is essential for targeted assessment and accurate diagnosis. The immediate goal after establishing the diagnosis is to initiate a treatment plan. As such, before commencing any treat-ment, an evaluation of the patient’s overall health status, including ◊ The general assessment of the orofacial pain patient is aimed at identifying the what, where, how, and why of the presenting complaint.◊ Diagnosis of orofacial pain requires taking a detailed his-tory, completing a comprehensive clinical examination, and ordering appropriate tests of established validity.◊ All dental patients should be screened for temporoman-dibular disorders (TMDs), and positive screening ndings should prompt more comprehensive evaluation.2General Assessment of the Orofacial Pain Patient 27Screening Evaluationtheir medical and surgical, drug, and psychoso-cial history is also required. Collaboration with various specialists (eg, otolaryngology, neurol-ogy, rheumatology, psychiatry) is often neces-sary. The objective of general assessment is to accurately identify the what, where, how, and why of the patient’s complaint. This chap-ter discusses the basic tests and techniques for the assessment of an orofacial pain patient.Screening EvaluationIt has become integral to current practice that all dental patients be screened for TMDs and other orofacial pain disorders as part of their initial and regular examinations. The results of the screening should help the clinician deter-mine whether a more comprehensive evalua-tion is necessary.3 The screening may consist of a short questionnaire (Box 2-1), a brief his-tory, and a limited examination. Although the value of questionnaires may be challenged, a questionnaire can facilitate the clinical exami-nation by focusing on specic complaints.4 The TMD screener is a three-item questionnaire in-cluding questions about duration and timing of pain and aggravating and relieving factors. The questionnaire has a sensitivity of 98% and a specicity of 97% and has been shown to both accurately identify painful TMDs and to discrim-inate them from other conditions that present with overlapping symptoms.5 The high positive predictive value (over 98) suggests that the TMD screener can be used to identify patients requiring a more comprehensive evaluation.The TMD screening examination usually consists of observation of the mandibular range of motion, palpation of the temporo-mandibular joints (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 can disclose un-coordinated movements that may indicate internal biomechanical problems.6 Caution should be observed when evaluating the re-sults of the screening process because the clinical ndings and the patient’s complaints may not be consistent. Positive ndings on the screening evaluation may prompt a more comprehensive evaluation. An understanding of the clinical signicance of positive ndings is essential. For example, a clinical sign such Box 2-1 Example of screening questions for TMDs*• Do you have difficulty, pain, or both when opening your mouth (eg, when yawning)?• Does your jaw get stuck, get 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 complete a comprehensive history and clinical examination 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 sufcient to warrant a comprehensive examination if it is of concern to the patient or viewed as clinically signicant. 28General Assessment of the Orofacial Pain Patient2as a clicking TMJ may merely represent a sta-ble, nonpainful condition that does not require treatment.Comprehensive EvaluationA comprehensive evaluation should be per-formed when a patient’s complaints of pain are not of dental origin or when a patient’s screen-ing evaluation results are positive for an orofa-cial 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 list of com-plaints; if the clinician carefully analyzes the 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 ndings and the clinical signicance of each nding. Any single positive nding may be sufcient to warrant a comprehensive examination.components of each complaint, this can lead to a differential diagnosis. A meticulous history will often guide the clinician to the most likely diagnoses and therefore aid in determining what additional diagnostic procedures may be appropriate, if any.History TakingThe interview, or history, is usually the rst contact between the clinician and the patient, and as such, an empathetic attitude by the cli-nician can quickly create a bond critical to suc-cessful communication.Chief complaintsThe patient must be allowed to comfortably express the symptoms that prompted the con-sultation, although the clinician must take con-trol of the interview to gather information in an organized manner. Adequate time is neces-sary to allow the patient to fully describe each of the complaints. The complaints are docu-mented in the order of severity as indicated by the patient, and details of each complaint are elicited in a systematic manner.History of chief complaints A description of each chief complaint usually includes its location, onset, quality, intensity, frequency and duration; triggering, exacer-bating and alleviating factors; and associated symptoms. The combination of these features often represents recognizable patterns that can help the clinician to appropriately catego-rize the complaint, resulting in well-directed interventions.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 under-stand the anatomy. Therefore, it is helpful to have the patient identify the exact location of the pain using a nger to either point to or cir- 29History TakingBox 2-3 Comprehensive history format for orofacial pain patients*1. Chief complaint(s) and history of present illness – Date and event of onset – Location – Quality – Intensity – Duration – Frequency – Remissions or change over time – Modifying factors (alleviating, precipitating, or aggravating) – Previous treatment results2. Medical history – Current or preexisting relevant physical disorders or disease (specifically, systemic arthritides or other musculoskeletal or rheumatologic conditions) – Sleep disorders and sleep-related breathing disorders – Previous treatments, surgeries, and/or hospitalizations – Trauma to the head and face – Medications (prescription and nonprescription) – Allergies to medications – Alcohol and other substances of abuse3. Dental history – Current or preexisting relevant physical disorders or diseases – Previous treatments, including the patient’s attitude toward treatment – History of trauma to the head and neck (including iatrogenic trauma) – Parafunctional history, both awake and asleep4. Psychosocial history – Social, behavioral, and psychologic issues – Occupational, recreational, and family status – Litigation, disability, or secondary gain issuesTable 2-1 Comprehensive orofacial pain physical examination proceduresType of evaluation Reviewing sequenceGeneral head and neck1. Note scars; asymmetry; unusual size, shape, consistency, or posture; and involuntary movement or tenderness.Muscles, TMJ, and cervical spine1. Palpate the muscles of mastication and cervical muscles.2. Palpate the TMJ preauricular.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.*All dental patients should be screened for TMDs and other orofacial pain disorders. The decision to complete a compre-hensive history and clinical examination 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 sufcient to warrant a comprehensive examination if it is of concern to the patient or viewed as clinically signicant. 30General Assessment of the Orofacial Pain Patient2cumscribe the area of complaint. An 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, nding 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 cir-cumstances that precipitated the pain, if any. Trauma is a frequent cause of pain and should be differentiated from pain secondary to sys-temic disease or personal stressors. It is also important to know how the pain begins with each episode (ie, whether it arises gradually or suddenly or is spontaneous). The temporal component of pain, be it the time of day, week, or month the pain occurs may also render im-portant 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 be-cause 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 specicity, although not specically designed for orofacial pain, are available to help clinicians distinguish between neuropathic pain, nociceptive pain, and mixed pain.7, 8 They include the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) and S-LANSS (short version), Douleur Neu-ropathique (DN4), Neuropathic Pain Question-naire (NPQ), PainDETECT, and ID-Pain.9–14 The LANSS and DN4 contain clinical items in addi-tion to self-reported symptoms. The self-report items of the DN4 can be used alone with good sensitivity and specicity.11Table 2-2 Pain-quality descriptors and secondary symptoms associated with dierent pain categoriesPain category Quality Secondary symptomsMusculoskeletal • Dull• Aching• Pressure• Depressing• Tight• Stiff• Occasionally sharp• Flushing• Hyperalgesia• Allodynia• Can refer to or be referred from distant sites• Worse with functionNeurovascular • Throbbing• Stabbing• Pounding• Rhythmic• Worsened by increasing intracranial pressure (eg, Valsalva, bending over, physical activity)• Sensitivity to light and/or sound• Nausea, vomitingNeuropathic • Shooting• Bright• Stimulating• Burning• Itchy• Electric shock–like• Cutting• Numbness• Hyperalgesia• Paresthesia• Allodynia• DysesthesiaPsychogenic • Descriptive • Complaint patterns often do not match anatomical sensory supply 31History TakingIntensity. The intensity of pain is subjective, variable, and often inuenced by the psycho-social status of the patient. It is important for clinicians to understand the patient’s interpre-tation 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); nu-meric rating scale (ie, a number between 0 and 10, where 0 represents “no pain” and 10 rep-resents 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”). Because intensity can vary, it may be rated at the time of presenta-tion in addition to the intensity at worst, best, and average in the preceding week. Sensory changes such as diminished or increased per-ception of touch or pain can be similarly rated and 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 peri-ods of remission, or is constant. The duration of pain may be recorded in seconds, minutes, hours, days, weeks, or months. The daily dura-tion of pain is rated as continuous or intermit-tent. 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, aggravat-ing, and alleviating factors yield important in-formation. Seemingly minor details that may not strike the patient as important may have tremendous diagnostic value. Examples in-clude precipitating factors such as light wind, touch, or shaving initiating the pain and aggra-vating factors such as having increased pain during periods of personal stressors. Simi-larly, discovering that jaw function does not precipitate or aggravate an individual’s pain is of equivalent diagnostic importance. In an injured musculoskeletal system, symptoms tend to aggravate when the system is used. If the masticatory system is the source of pain, then pain should worsen during jaw function. If it does not worsen, the source of the pain may be outside of the masticatory system.Associated symptoms. Very often, a symp-tom associated with the patient’s pain com-plaint can help the clinician narrow his or her diagnostic focus. Sensory and motor changes as well as autonomic features may be re-corded. For example, the presence of visual and sensory changes or light or sound sensi-tivity may be indicative of migraine with aura, whereas drooping, redness, and/or tearing of the eye may indicate a trigeminal autonomic cephalalgia.Previous treatmentsPrior medical and dental 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 alleviates the pain complaint, the pain is likely not of neuropathic origin. The patient’s recall of medications, dos-ages, and length of medication trials should also be recorded. This information helps the clinician to evaluate whether previous thera-pies have been adequately tried and titrated or if they were discontinued due to side effects or adverse events. This part of the interview may also provide insight into patient compli-ance with previously proposed therapies.Medical and dental historyPast illnesses, surgeries, developmental or ge-netic abnormalities, and any sequelae should be documented. Long- and short-term use of medications (including over-the-counter medications and herbal, vitamin, and mineral preparations) and their purpose should also be documented, as they may inuence potential 32General Assessment of the Orofacial Pain Patient2treatment options. Use of caffeine, tobacco, al-cohol, and recreational drugs should be noted, as well as past or present substance abuse. The patient should be questioned about trauma, both physical and emotional. A complete den-tal history should be obtained, particularly as it relates to the chief complaint, or as the patient believes it relates to the chief complaint. Com-plications of therapies are important to docu-ment, as are any behaviors such as clenching (while awake or during sleep), bruxism, and other parafunctional activities (eg, gum chew-ing, nail biting). Because the patient’s com-plaints may be a manifestation of systemic dis-ease, he or she should be questioned regarding any symptoms that might relate to systemic disorders, such as those affecting connective tissue, autoimmune disorders, thyroid or sali-vary glands, bromyalgia, diabetes, cardiac dis-orders, or Lyme disease, as this may inuence treatment options and/or prognosis.Patients must also be questioned about sleep habits and sleep disruptions. Orofacial pain is often associated with frequent awak-enings or inadequate sleep duration. Sleep disorders may exist as a medical comorbidity or may be directly caused by pain.2 Pain can disrupt sleep, and sleep loss can increase pain sensation.15 The orofacial pain clinician must be knowledgeable about normal sleep struc-ture and function and how pain or stressors may disrupt sleep.2 Psychometric instruments such as the Pittsburgh Sleep Quality Index are useful to assess sleep quality.16 The Epworth Sleepiness Scale is useful in assessing day-time sleepiness.17, 18 The relationship of pain patterns to the sleep/wake cycle as well as risk factors for sleep-related breathing dis-orders such as obstructive sleep apnea and sleep-related bruxism should be assessed.19 The STOP questionnaire, the STOP-Bang ques-tionnaire, the Berlin questionnaire, and the multivariable apnea prediction index (MAPI) are useful tools to assess for obstructive sleep apnea.20–22 Patients with a suspected sleep disorder should be referred to a sleep physi-cian for full evaluation and diagnosis. The diag-nosis of a sleep disorder, including obstructive sleep apnea and other sleep-related breathing disorders, must be made by a physician.23 The orofacial pain clinician can work with the sleep physician in the management of a patient with obstructive sleep apnea (see chapter 11).Psychosocial historyFor some patients, psychologic and behavioral issues may result in orofacial pain. For others, these problems may be the primary etiologic factor or may play a role in sustaining or am-plifying the pain. Therefore, it is advised that the history-gathering portion of the compre-hensive evaluation include an evaluation of be-havioral, social, emotional, and cognitive fac-tors 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 pres-ence of any psychologic overlay.An evaluation for the presence of stressors and the patient’s response to stress is impor-tant to the diagnostic process. Specic inqui-ries 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. It needs to be determined if the patient has depression, anxiety, or both, because these are often comorbid and compli-cating factors related to chronic pain. A brief screening tool to assess anxiety and depression is the four-item Patient Health Questionnaire (PHQ-4).24 A more elaborate questionnaire to evaluate anxiety and depression, among other disorders, is the 90-item Symptom Check List Revised (SCL-90-R).25 In depressed patients, it is especially important to assess and document the risk of suicidal ideation and understand that suicide risk may uctuate, for example, with in-creased life stressors.26 33Physical ExaminationBox 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 gainAn 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 in-terferes with his or her life (see chapter 12 for more details on psychologic disorders, psycho-metric questionnaires, and suicidal ideation).27 Referral is recommended when signicant fac-tors are identied.Physical ExaminationVital signsBaseline blood pressure and pulse rate are re-corded, 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 patients taking medications. Abnormal ndings should prompt a more thorough evaluation with pos-sible referral to a physician.Neurologic screeningOrofacial pain complaints may be the result of a neurologic problem. As part of the orofacial pain examination, a cranial nerve screening is performed, aimed at assessing the function (ie, strength, sensation) of the nerves on the right and left sides. Cranial nerve dysfunc-tion may manifest as changes in either motor or sensory function. Abnormal movement of muscles stimulated by one of the cranial nerves can indicate pathosis along the motor pathways. A patient reporting sensory altera-tions may be tested for anesthesia, paresthe-sia, dysesthesia, allodynia, and hyperalgesia. Topical and local anesthetic blocking may be part of the neurologic screening. Areas of al-tered sensation can be mapped at regular in-tervals, which may help to determine if the pa-tient’s condition is progressive or if treatment is effective. However, 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 ndings should prompt a more detailed neurologic eval-uation, and if indicated, the patient should be referred to an appropriate medical specialist. Other texts are recommended for a complete review of the components of a neurologic and cranial nerve examination.General inspectionGeneral inspection of the head and neck includes recording of overall appearance; masses and/or asymmetry of the face, jaws, neck, and thyroid; presence of scars, unusual or abnormal posture, and involuntary move- 34General Assessment of the Orofacial Pain Patient2ments; and respiration and breathing pattern. It may also be important to observe the overall gait of the individual. This can easily be done when the patient is entering or exiting the ex-amination area.PalpationMusclesThe muscles of mastication are palpated in an attempt to reproduce familiar pain or identify tenderness upon palpation and to elicit referral patterns. Familiar pain is pain that is described by the patient as being similar to their expe-rienced pain.28 Reproducing the familiar pain helps to differentiate it from incidental pain provoked by muscle palpation.The clinician may also palpate for myofascial trigger points, which are hyperirritable sites in taut bands of muscle and tendons that, when palpated, cause discomfort and may radiate or refer pain.29,30 The temporalis, deep and super-cial masseter, medial pterygoid, and suprahy-oid muscles are often examined. Familiar pain may also be reproduced by asking the patient to clench the teeth while the clinician palpates the patient’s masticatory muscles. The inferior lateral pterygoid muscle is difcult to palpate intraorally but can be evaluated by functional manipulation, by challenging the muscle to contract against resistance, or by observing symptom changes from stretching.31–34 Myal-gia may be exacerbated during this maneuver. Similar procedures of functional manipulation may be used for the superior lateral pterygoid and medial pterygoid muscles.33 Muscles and structures that can be palpated with an intra-oral approach include the medial pterygoid muscle, anterior digastric muscle, and the temporal tendon.Table 2-3 Overview of cranial nerves and tests to evaluate their functionsNo. Cranial nerve TestI Olfactory Sense of smell, tested with camphor, coffee, and vanillaII Optic Visual acuity/visual eld: pupillary light reexIII Oculomotor Pupillary light reexes/accommodation, eyelid elevation, most eye movementsIV Trochlear Downward gaze during adductionV Trigeminal Sensation of light touch to face in all three divisions; motor innervation of muscles of mastication (strength); corneal reexVI Abducens Lateral gaze (III, IV, and VI); tested by having the patient follow nger in an H pattern)VII Facial Facial expressions; corneal reex; taste to the anterior two-thirds of the tongueVIII Acoustic vestibulocochlearHearing (eg, ability to hear a watch tick); Weber and Rinne tests (tuning fork); observation for nystagmus on extraocular muscle testing; caloric testingIX Glossopharyngeal Gag reex; taste to posterior one-third of the tongueX Vagus Speech; palatal/uvular elevation; gag reexXI Accessory Function of sternocleidomastoid and trapezius muscles (press against resistance)XII Hypoglossal Tongue bulk, strength, and movement (protrude and wiggle, press against resistance) 35Physical ExaminationIt is common for orofacial pain complaints to be caused by, and referred from, primary pain sites among the cervical structures.34 There-fore, evaluation of the cervical range of motion and palpation of the cervical muscles, including the sternocleidomastoid, splenius capitis, tra-pezius, levator scapulae, and scalenes should be performed as part of the comprehensive orofacial pain evaluation. The recommended pressure when palpating head and neck mus-cles is between 0.5 and 4 kg/cm2, maintained for about 5 to 20 seconds, although there is no universally accepted reference standard for the diagnosis of trigger points.35–37JointsThe TMJs (lateral capsules) are palpated bilater-ally for tenderness, pain, swelling, and patterns of movement. Palpation and/or stethoscope auscultation during jaw movements is a com-mon method of detecting joint sounds. The presence and timing of early, middle, or late opening and/or closing sounds or noises (eg, clicking, popping, crepitus) and other interfer-ences with smooth jaw movement should be noted.38 Joint sounds can be signs of an intra-capsular abnormality, such as internal derange-ment, degenerative processes, or architectural defects of articulating surfaces. They may cor-relate with pain or pathologic conditions or may be due to functional adaptations not associated with pain or dysfunction. Joint sounds are com-mon in the general population and should be evaluated within the context of other present-ing signs and symptoms.39 While the predic-tive value of joint palpation is low in nonpatient populations, positive ndings may have clinical signicance in symptomatic patients.40–42Lymph nodesAs part of the head and neck examination, the clinician should palpate lymph nodes, includ-ing the submental, submandibular, supercial, and deep cervical chains. The latter group may be examined with relative ease by palpat-ing the relaxed sternocleidomastoid muscle. Disease states of the oral cavity are most often reected in changes of submental and submandibular lymph nodes.38 Lymph nodes in a healthy individual are soft, nonpalpable structures. Lymph nodes that are palpable, swollen, hard, painful, xed, or nodular are considered abnormal and potentially indica-tive of infection, inammation, or neoplasm. The cause of abnormal nodes requires further investigation.43ArteriesThe temporal arteries may be palpated for tenderness, consistency, and provocation of pain in patients over the age of 50 years who complain of headache. Pain on palpation of the temporal artery may be a sign of giant cell arte-ritis, particularly in elderly patients (see chapter 4). If giant cell arteritis is suspected, additional diagnostic tests are indicated in addition to im-mediate physician referral.Range of movementThe recording of mandibular range of move-ment in opening, lateral, and protrusive excur-sions with a millimeter ruler is a core exami-nation procedure for TMDs, and the recorded measurements may also serve as a treatment outcome measure. Normal mandibular open-ing ranges between 40 and 55 mm, whereas excursive movements of at least 7 mm are con-sidered normal.44 While these are the generally accepted ranges, individual measurements may vary depending on many factors such as stature, craniofacial form, and other vari-ables.45,46 The normal opening range or active range of motion is less in women than in men and decreases with increasing age.46 An inter-national collaborative effort of experts has led to scientically validated and reliable examination protocols and diagnostic criteria for the most common TMDs. The Diagnostic Criteria for Tem-poromandibular Disorders (DC/TMD) have been published and are highly recommended in both the clinical and research settings.28 36General Assessment of the Orofacial Pain Patient2Three interincisal mouth opening measure-ments may be utilized to obtain important information: maximum pain-free opening; maximum unassisted opening; and maximum assisted opening. Maximal pain-free opening is that which can be attained without pain. Maximum unassisted mouth opening, also called active range of motion, is the mouth opening measurement that can be achieved by the patient regardless of the presence of pain. Assisted mouth opening, also called pas-sive range of motion, is dened as the maxi-mal mouth opening that can be attained with gentle stretching by the examiner after the pa-tient has reached maximum unassisted mouth opening. The “jaw opening pattern” should be noted as either a straight line or deviated to the right, left, or both sides. A corrected devia-tion means that the mandible deviates away from the midline at rst but then returns to the midline, while an uncorrected deviation means the mandible does not return to the midline. The mandibular lateral and protrusive range of motion should also be measured and recorded as outlined in the DC/TMD.28 The location and severity of familiar pain elicited by these move-ments should be recorded. It is important to engage the patient’s perception of restricted movement or reduced quality of movement.46Cervical range of movement may also be recorded and includes rotation to the left and right (normal range of motion, 65 to 75 de-grees), lateral tilt (normal range of motion, 35 to 45 degrees), exion (normal range of mo-tion, 50 to 60 degrees), and extension (normal range of motion, 60 to 70 degrees). These normal ranges are for middle-aged individuals. The range of motion declines approximately 5 degrees for extension and 3 degrees for all other movements as one ages based upon a 10-year period.47Ear, nose, and throatPatients who present for assessment of oro-facial pain may be suffering from diseases or disorders of the ear, nose, and throat. Given the close and complex anatomical and func-tional relationship of these structures to the orofacial structures, otolaryngologic problems should be considered as potential causes of orofacial pain and dysfunction. For example, it is common for patients to report ear pain (otal-gia) when the pain is primarily due to a TMD. Maxillary tooth pain can be caused by maxil-lary sinus disease and vice versa. Although aural symptoms are very common in TMD patients, particularly ear fullness and otalgia, symptoms such as ear discharge, hearing loss, tinnitus, dysequilibrium, and vertigo should raise suspicion of possible otologic causes of orofacial pain that require further investiga-tion.48,49 To date, the cause and background of aural symptoms associated with TMD is not fully understood, and no cause-effect relation-ship has been identied.50,51 In a systematic review inquiring about the effectiveness of conservative TMD therapies on changes to otologic signs and symptoms in adult patients with a TMD and related otologic complaints, the authors concluded there to be insufcient evidence for or against the em-ployment of these interventions. Furthermore, it was suggested that further studies with a higher level of evidence and more representa-tive samples should be conducted to increase our understanding regarding the effect of TMD therapy on otologic complaints.52 Examination of the external ear, the exter-nal auditory canal, and the tympanic mem-brane is performed using an otoscope.53 The outer ear may be examined for redness or swelling, which could indicate an infection or inammatory process. The external audi-tory canal may be examined by pulling the ear upward and backward to straighten the canal for inspection. The canal is then observed for signs of infection, inammation, discharge, or blockage. The properly trained clinician can ob-serve the tympanic membrane (ie, eardrum) for any gross pathology that could explain the complaint of ear pain. If the clinician has 37Diagnostic Testsconcerns, then referral to an otolaryngologist would be warranted.When evaluating the nose and sinuses, the skin overlying the nose and maxilla is rst in-spected for abnormalities, such as unexplained ulcers, dark moles, or tissue growths. The skin over the maxillary and frontal sinuses is pal-pated and tenderness noted. The trained clini-cian may inspect the nostrils using adequate light and a nasal speculum, looking for swollen turbinates and deviated septa that may be as-sociated with breathing problems.All major salivary glands, including the pa-rotid, submandibular, and sublingual glands may be palpated. Salivary gland duct exits can be inspected intraorally to conrm salivary ow. If no spontaneous ow is observed after the area of the exit is dried, the gland can be massaged, with the clinician noting color and consistency of any discharged uid, if any. When indicated, a salivary ow test can be performed, and the saliva may be cultured.54The oropharynx is readily visualized by re-traction of the tongue with a tongue depres-sor or dental mirror. The tonsils and posterior pharyngeal walls should be visualized. Airway patency can be visualized and scored via the modied Mallampati or the Standardized Ton-sillar Hypertrophy scales.55,56Dental examinationDepending on the history, the patient may be provided with either a screening or a more thorough dental examination. Particularly where dental or oral mucosal pathosis is sus-pected as the source of orofacial pain, clinical examination of the oral hard and soft tissues is indicated, possibly in conjunction with radi-ography. It should always be remembered that the vast majority of orofacial pain is of odonto-genic origin or related to the associated struc-tures. Assessment for possible odontogenic pain requires careful inspection for dental caries, cracked teeth, and use of pulp vitality testing procedures. In addition to pulp vital-ity testing, the presence of periapical inam-mation can be assessed via tooth percussion and mobility testing, periodontal probing, and periapical radiography. Transillumination may be of assistance in detecting the presence of cracked teeth.Soft tissue or superficial pain may be caused by trauma, oral mucosal infections and disease, and neoplasia. The tongue, oor of the mouth, palate (hard and soft), gingival tissue, and buccal mucosa should be carefully inspected and palpated. The presence of oral ulceration, inammation, infections, and soft tissue ridging should be noted. Diagnostic an-esthesia, either topical and/or local, may assist in the diagnostic process of both odontogenic and soft tissue orofacial pain. The dental occlusion should be evaluated, when indicated, keeping in mind that occlusal variables are of limited use in the diagnosis of TMDs and may be the result of a TMD process rather than its cause.57,58 A number of occlusal variables have been associated with the pres-ence of various TMDs.59 Accordingly, extensive tooth wear patterns, anterior open bites, unilat-eral crossbites, and large slides between the jaw’s retruded and maximum intercuspation positions should be recorded. These baseline studies may be of importance in monitoring a progressive disease process.Diagnostic TestsThe gold standard for diagnosis of orofacial pain, including TMDs, is a thorough history, examination (Axis I), psychosocial assessment (Axis II), and appropriate imaging, when nec-essary.60 The clinical diagnostic criteria and examination protocol for the most common TMDs can be obtained via the DC/TMD, which is readily accessible on the website of the International Network for Orofacial Pain and Related Disorders Methodology (INfORM; previously known as the International RDC/TMD Consortium Network). Standardized and 38General Assessment of the Orofacial Pain Patient2validated psychometric tools for assessment of the patient’s psychosocial characteristics (Axis II) are also available. Adjunctive diag-nostic tests are not necessary in every case; however, there are tests and procedures that may contribute signicantly to the diagnostic process for the individual patient. A test should be performed only if it is deemed appropriate for the individual patient to either conrm or rule out a diagnosis and therefore potentially alter the treatment that is being considered.A selected diagnostic test should have es-tablished scientic merit. Reliability and validity are measures that reect how well a diagnos-tic test or procedure can measure what it pur-ports to assess. For such a test or procedure to become clinically useful, it must rst be proven to consistently, accurately, and reliably identify or measure the specic target. Reli-ability refers to the stability and consistency of measurements, whereas validity refers to the test’s ability to measure what it is sup-posed to measure. Additionally, if whatever is measured has no established diagnostic value, then the diagnostic test cannot be considered valid. Several other factors are important in determining the usefulness of certain instru-ments proposed for use in diagnosis. These include the sensitivity, specicity, and positive and negative predictive values. Sensitivity is a measure of how well a certain test is able to identify a disease when the disease is actually present, also called the true positive rate. If a highly sensitive test is negative, it rules out the disease. Specicity is a measure of how well a test, when negative, identies those who do not have the disorder, also called the true neg-ative rate. A test with high specicity, when positive, can rule in the disease. For appropri-ate diagnosis, both sensitivity and specicity of the test should be over 70%. The positive predictive value is a measure of the probability that a person has the disease, given a positive result. Likewise, the negative predictive value is the probability that a person does not have the disease, given a negative result. Many instruments meet the criteria for validity and reliability but demonstrate low sensitivity and specicity and therefore should not be used to establish a diagnosis.61–69 Relying on these instruments as diagnostic aids could lead to overtreatment and unnecessary increased medical costs.The lack of scientic validation of many diagnostic tests, especially use of certain technologic devices, may lead to many false positive diagnoses and some false negative diagnoses. Some of these devices are dis-cussed in the next section. There are imme-diate and implied future health and nancial costs related to treating false positives and delayed costs of not treating false negatives. Until well-controlled, double-blind clinical tri-als are performed on specic subgroups of orofacial pain patients and are compared with control groups, these tests should be consid-ered experimental and should not be used in routine clinical practice.Electrodiagnostic testingThere are many electronic devices on the market that claim to aid in the diagnosis and treatment of TMDs. Although many of these devices may have the potential to be clinically useful, their reliability, validity, safety, and ef-cacy have yet to be established.62,65–69Jaw-tracking devicesObserving and recording the range, direction, and quality of various jaw movements is an im-portant aspect of assessing TMDs. Jaw-tracking devices allow jaw movements to be visualized and recorded; however, the utility of these trac-ings for diagnostic purposes is still unclear.69–74 Mandibular movement measurements may be obtained by use of jaw-tracking devices; how-ever, there are no data to demonstrate that this technique is any more useful in measuring mandibular movements than a traditional mil-limeter ruler.62 With this in mind, cost efciency should be considered, and routine use of these 39Diagnostic Testsdevices for TMD diagnosis is currently not sup-ported by the scientic literature.62 Although these devices are cleared by the US Food and Drug Administration from a safety standpoint, a special notation was added that documentation for efcacy in diag-nosis has to be provided for each device.60,62 The usefulness of kinesiographic recordings of jaw movements to diagnose TMJ articular disc displacements compared with the use of the gold standard (ie, magnetic resonance imaging [MRI]) has been investigated. The specicity and positive predictive values for all kinesio-graph variables were found to be well below acceptable standards to recommend its use.75 Furthermore, the use of these devices in the diagnosis of myofascial pain as either a stand-alone measurement or an adjunct to clinical decisions fails to meet the standards of reli-ability and validity for their usage.76 A review of literature published since the last edition of the AAOP Guidelines failed to identify new ar-ticles supporting the use of jaw tracking as a diagnostic aid in TMDs. Therefore, at this time, jaw-tracking devices are not recommended as part of the orofacial pain evaluation.62ElectromyographyElectromyography (EMG) is a useful tool in measuring muscle activity and nerve conduc-tion and has been shown to be reliable.74–80 Although numerous publications have docu-mented the use of EMG testing to establish diagnoses of TMDs, a thorough review of the evidence-based literature concluded that limi-tations with regard to reliability, validity, sen-sitivity, and specicity render EMG testing of limited value for TMD diagnosis.62–69,76,81–83 Fur-thermore, increased EMG activity correlates poorly with masticatory muscle pain, and it is more likely that long-lasting, low-level con-tractions may be more relevant.84–86 A study investigating the diagnostic accuracy of sur-face EMG for myofascial pain concluded that EMG should not be used clinically to diagnose or monitor the course of TMDs in an individual patient because of the potential risk for overdi-agnosis and/or overtreatment.78 Similar conclu-sions as to the lack of utility on the use of EMG in diagnosing TMDs have also been described in several systematic reviews.85,86ThermographyThe use of thermography to diagnose painful neurologic and musculoskeletal conditions is based on the presence of thermal asymme-tries of the skin when comparing normal and abnormal sites. Thermographic assessments of TMDs and other orofacial pain disorders have been published with conicting results.87–95 A review from 2004 concluded that there is in-sufcient evidence to support thermography use in routine clinical practice.96 Two articles published in 2013 investigated the use of ther-mography in the diagnosis of TMJ arthralgia and myogenous TMDs, nding low diagnostic accuracy for both.97,98 To date, the use of ther-mography for the diagnosis of TMDs or other orofacial pains remains unproven. The avail-able evidence remains insufcient to conclude that thermography has a benecial impact on either diagnosis or treatment outcomes. Fur-thermore, standards for image evaluation and cutoff values that may allow clinical decision making have yet to be established.SonographyDoppler sonography data are similar to the data obtained with vibration analysis (see below) but with use of sound recordings in-stead of joint vibrations. Although Doppler so-nography has been suggested for diagnosing TMDs based on the detection of joint sounds, the clinical signicance and reproducibility of sounds emanating from the TMJs is not reli-able.82,99 Studies evaluating sonography for the diagnosis of articular disc displacement have found that both clinical and sonographic exami-nation had a high sensitivity but a low speci-city compared with MRI ndings.99–101 Since the last edition of the AAOP Guidelines was published, no new data has been published to 40General Assessment of the Orofacial Pain Patient2justify the use of sonography for detection of TMJ sounds and internal derangements in lieu of clinical palpation and auscultation. Hence, there is insufcient evidence to justify the use of sonography for the diagnosis of TMDs.Vibration analysisVibration analysis is similar to sonography in using joint sounds to assist in the diagnosis of TMDs with internal derangements.102–108 Sensi-tivity and specicity are less than desired, with many false negatives and false positives.107 A systematic review investigated the usefulness of joint vibration analysis in the diagnosis of TMD. The authors concluded that the litera-ture failed to establish reliability and validity and that the use of vibration analysis in TMD diagnosis was unconvincing.108Diagnostic imaging of the TMJThere are a number of diagnostic imaging modalities that may conrm the presence of suspected pathosis, rule out disease, and stage various diseases affecting the orofacial region.109–111 Imaging should not be done rou-tinely for every patient or as an initial diagnostic test. Appropriate imaging can gather additional information when the clinical diagnosis remains equivocal or unclear. Similarly, the presence of unusual signs and symptoms and the failure of conservative management strategies are indications for the use of appropriate imaging. The optimal type of imaging to be employed depends upon the presenting symptoms and clinical examination ndings of the individual patient.109 When abnormalities are suspected or identied that fall outside the scope of an individual’s training and experience, then ap-propriate referral should be made for medical specialist diagnosis and management.Panoramic radiography, also known as or-thopantography, is a type of tomography in which the maxilla and the mandible are de-picted on a single lm. The panoramic radio-graph is useful for screening for gross dental and periodontal pathology, as well as other maxillary and mandibular disorders and dis-eases. After intraoral dental radiographs, it re-mains the most common radiographic study performed in a dental ofce. However, as far as TMJ imaging is concerned, the projected image is inaccurate and cannot be used for diagnostic purposes.112 Conventional tomogra-phy, apart from the panoramic radiograph, has essentially been replaced by computed tomog-raphy (CT) procedures.CT is predominantly used where primary bony pathoses are suspected clinically. CT is particularly useful for evaluating degenerative and arthritic changes, fractures, bony cysts, in-fection, tumor invasion, and other pathology. The newer multidetector CT (MDCT) also has utility for soft tissues, and using appropriate protocols, the TMJ articular disc and pres-ence of intra-articular effusion can be demon-strated.113,114 Because soft tissue ndings can be critical, this is a signicant advantage over cone beam CT (CBCT). In general, however, it is considered that soft tissue lesions, the TMJ articular disc, and associated soft tissues are best evaluated with MRI. Relative advantages of CT over MRI include exquisite bone details and three-dimensional assessment of congeni-tal, traumatic, and postsurgical conditions.109CBCT for the maxillofacial region has be-come readily available and is increasingly used in dentistry.115,116 The advantages of CBCT over MDCT are lower cost, slightly higher resolu-tion, and lower radiation dose. However, with appropriate protocols, the radiation doses now delivered by modern MDCT scanners are com-parable to CBCT. CBCT is useful for evalua-tion of osseous abnormalities of the orofacial region. However, relative weaknesses include longer imaging times and related potential for motion artifact, low signal-to-noise ratios, beam hardening, and absence of soft tissue detail.MRI represents the current gold standard of diagnostic imaging technology for soft tis-sues.109 MRI does not use radiation and so is considered biologically safe. The high resolu- 41Diagnostic Teststion and great soft tissue contrast of MRI af-ford detailed evaluation of TMJ anatomy, as well as TMJ biomechanics, through open and closed mouth views. MRI enables a determi-nation of the position and morphology of the TMJ articular disc as well as condylar bone morphology. Inammatory changes such as intra-articular effusion and condylar bone mar-row edema are also demonstrated. In consid-eration of these factors, MRI is considered the imaging modality of choice for the diagnosis of TMJ internal derangements.117–121 In the com-prehensive assessment of orofacial pain, MRI can also be used to rule out intracranial causes of pain in patients with trigeminal neuropathic pain or headaches.Arthrography of the TMJ involves injection of radiopaque dye into the TMJ that outlines the articular disc under video uoroscopy. Ar-thrography is rarely used today, having been replaced by MRI, which noninvasively provides superior information of all the TMJ structures without exposing the patient to radiation.Nuclear medicine studies involve the intra-venous administration of a radioactive isotope (eg, technetium), the uptake of which enters into tissues and is measured via either a scin-tillation gamma camera or single-photon emis-sion CT (SPECT).111 These tests have particular utility in identifying fractures, malignancy, in-fections, and other diseases involving bone.109 Scintigraphy is useful to determine bone growth activity in hyperplastic TMJ condyles where TMJ surgery is being considered.122 Scintigraphy is a highly sensitive but very nonspecic test with regard to identifying a specic disease or disorder. A recent study concluded that cross-sectional SPECT is more sensitive than traditional planar scintigraphy in the diagnosis of condylar hyperplasia.122Ultrasonography (US) is generally not con-sidered a conclusive diagnostic tool for TMJ articular disc derangements.123 A systematic review concluded that US can exclude rather than confirm TMJ articular disc derange-ments.124 An evidence-based review of this study conrms these ndings.125 US may also be used for the image-guided injection of med-ications (eg, corticosteroids, hyaluronic acid, or platelet-rich plasma) into individual muscles and the lower joint space of the TMJ.126 US is also a very useful technique for evaluating the soft tissues of the head and neck region, espe-cially the salivary glands and masses of uncer-tain origin and nature on clinical examination. US and US-guided ne-needle aspiration cytol-ogy are also excellent diagnostic techniques when indicated.127Functional neuroimaging of orofacial pain and headache has been the focus of many studies over the last few years. Various meth-ods, including functional MRI, magnetoen-cephalography (MEG), positron emission to-mography (PET) and SPECT, record patterns of changes in voltage, current, magnetic elds, neurochemicals, and blood ow spatially in the brain. Magnetic resonance spectroscopy can noninvasively assess different metabolites and neurotransmitters in the brain. Near-infrared spectroscopy can detect changes in blood he-moglobin concentrations associated with neu-ral activity and has great potential in measur-ing effects of pain upon the brain. Functional neuroimaging studies of migraine, trigeminal neuropathic pain, TMDs, and toothache are furthering our understanding of the anatomi-cal and pathophysiologic mechanisms of these and other orofacial pain disorders.128Neurosensory testingNeuropathic pain is “caused by a lesion or disease of the somatosensory nervous sys-tem.”129 If the patient’s history indicates the possibility of a lesion or disease that can af-fect the peripheral or central somatosensory system, and the pain has a distinct neuroana-tomically plausible distribution, then painful neuropathy is likely. Painful neuropathy is char-acterized by its burning, prickling, electrical, and sharp nature. Painful neuropathy can be spontaneous or evoked with distinctive associ- 42General Assessment of the Orofacial Pain Patient2Table 2-4 Diagnostic anesthesiaType of anesthetic block Type of painDental block Odontogenic pain or neuropathic painTrigger point injections Myofascial pain and headacheTrigger zone inltration Trigeminal neuralgiaAuriculotemporal nerve blockIntracapsular TMJ painIntracapsular block Intracapsular TMJ painGreater and lesser occipital blockCervicogenic pain and headacheSphenopalatine block Neuropathic facial painNeurovascular painSympathetically maintained painStellate ganglion block Sympathetically maintained painated positive (ie, heightened sensation) signs (eg, spontaneous pain, allodynia and hyper-algesia) and/or negative (ie, sensory decit) signs. There is almost always an area of abnor-mal sensation. Neurosensory tests assessing changes in responsiveness to different types of somato-sensory stimuli have been adapted for use in the orofacial region and are an important part of the clinical examination. A quick and easy chair-side technique can be used, or the patient can be referred to a specialized university setting or pain clinic for comprehensive quantitative sensory testing (QST).130,131 This type of testing allows noninvasive assessment and quantica-tion of sensory nerve function in patients with suspected neurologic disease or neuropathy. Various mechanical, thermal, and electrical stimuli can be applied to the affected area, and the evoked responses can be measured. The responses can be compared with normal contralateral sites or established normal QST ranges. Alternatively, different stimuli can be applied to establish either pain or other sen-sory threshold levels. Specic QST modalities can be used to activate different types of sen-sory nerve bers, allowing insight as to patho-logic processes. At this time, the use of QST in the trigeminal system is undergoing research and development and is not yet considered as established for routine clinical practice.131Diagnostic anesthesiaNeural blockade, both somatic and sympathetic nerve blocks, and myoneural (trigger point) in-jections may be used as diagnostic tools (Table 2-4). Examples of somatic nerve blocks in the head and neck include trigeminal, supraorbital, infraorbital, greater occipital, sphenopalatine ganglion, and cervical plexus nerve blocks. So-matic neural blockade is not only used to deter-mine whether or not pain is emanating from a particular nerve, but it may also be used to de-termine whether the source of pain is proximal or distal to a particular site along the nerve.1 In addition to its diagnostic potential, somatic neural blockade may be useful as a therapeutic agent by providing pain relief to the affected area by breaking the cycle of pain.Lidocaine (1% to 2%, often with epi-nephrine) is recommended for diagnostic nerve blocks because it produces a prompt, long-lasting, and extensive anesthesia. Neural blockade is of particular prognostic value prior to neurolytic blockade or surgical sympathec-tomy (neurolysis). When prolonged anesthesia is desired for pain management, bupivacaine (0.25%) can be used.Primary musculoskeletal pain, meaning pain in an injured or painful muscle or joint that can be provoked, may be arrested by a local or regional anesthetic block. The TMJ can be anesthetized by a lateroposterior and slightly inferior intracapsular approach, a posterior me-atal intracapsular approach, or an extracapsu-lar block of the auriculotemporal nerve at the posterior aspect of the neck of the condyle.1 Myofascial pain may be eliminated only if the 43Diagnostic Testsanesthetic blocks the source or primary site of pain.1 Therefore, an equivocal diagnostic injec-tion of a myofascial trigger point suggests that the source of pain has not been discovered, while an effective injection can allow the clini-cian to be condent that the source of pain has been found.1 Lidocaine 2% (without epineph-rine) or mepivacaine 3% are suitable for this purpose. Bupivacaine appears to be relatively myotoxic and should be avoided for muscle injections.132 A number of studies have investi-gated the use of botulinum toxin injections for the treatment of myofascial TMD pain and/or bruxism.133–137 However, there are no data to suggest that botulinum toxin can be used in a diagnostic sense.If a regional block, such as a mandibular block, eliminates neuropathic pain distal to the site of injection, the source of pain is located in the region of the anesthetized area. An ineffec-tive diagnostic block suggests that the neuro-pathic pain is more proximal or central and so may indicate neuroplasticity or involvement of the central nervous system.Stellate ganglion blocks (sympathetic) and sphenopalatine blocks (parasympathetic) are used for diagnosis and treatment of orofacial pain when an autonomic component is sus-pected. Performing a stellate ganglion block re-quires special training and is usually done in an operating room by a trained anesthesiologist. Anesthetizing the sphenopalatine ganglion has been described for treatment of orofacial pain, particularly cluster headache. Conventionally, local anesthetic has been delivered to the area by injection into the pterygopalatine fossa under uoroscopic guidance, or transnasal application by cotton-tip applicators. Devices have recently been developed to facilitate the procedure that may see increased utility for this type of block.Diagnostic castsBecause malocclusion is not a common eti-ology for TMDs (see chapter 8), diagnostic casts have little value in diagnosis and evalu-ation in most cases. They are helpful in iden-tifying wear patterns and recording a baseline static occlusion for documentation of occlusal changes during treatment.138,139 Dental casts also have utility to help determine whether or not changes at the level of either the teeth or TMJ are responsible for the examination nd-ing of an open bite. If the dental casts are able to achieve maximum intercuspation, it is sug-gestive that skeletal (TMJ) changes are the cause rather than result of tooth movement. If the dental casts do not achieve maximum intercuspation, changes in the occlusion could be either due to dental movement, skeletal changes, or both. Occlusal analysis is often not accurate when the joints or muscles are tender or painful; therefore, any in-depth eval-uation of the occlusion should be performed only after the pain is under control.140 Even the most accurate casts will not provide enough information by themselves for an accurate di-agnosis of joint or muscle pathology.141Laboratory testingA comprehensive assessment may include selective serologic testing, but this should not be a routine part of the orofacial pain exami-nation.142,143 Blood chemical analysis can rule out hematologic, rheumatologic, metabolic, or other abnormalities suggestive of systemic dis-ease (Table 2-5). The most frequently employed hematologic investigations for orofacial pain are listed in Table 2-6. The clinician should know the appropriate serologic studies and be able to collect and interpret the data to establish a dif-ferential diagnosis. If it is established that com-plaints of orofacial pain are related to a systemic disease, referral to a physician is indicated.Pretreatment testing and patient monitoringSpecic tests are sometimes necessary before or during certain pharmacotherapeutic treat- 44General Assessment of the Orofacial Pain Patient2ments.142 For example, the use of antiepileptic drugs, such as carbamazepine, must be pre-ceded by a baseline complete blood count, a blood differential test, and liver function tests. Tricyclic antidepressant drugs may be preceded by a baseline electrocardiogram for assess-ment of arrhythmia, especially in older patients.Renal functionThe kidneys are responsible for regulating uid volume and acid-base balance of the plasma, excreting nitrogenous waste, and synthesiz-ing erythropoietin, hydroxycholecalciferol, and renin. End-stage renal disease occurs when the kidney loses the ability to perform these functions. The early phase of renal disease, which usually is asymptomatic except for some mild laboratory abnormalities, is called renal insufciency. If the proposed medication could exacerbate or initiate renal dysfunction, the patient should be pretested or referred for treatment.Hepatic functionSome medications can have signicant effects on liver function, so knowledge of the status of liver function may be benecial. In addition, the metabolism of most medications is de-pendent on liver function. When medications are prescribed that require monitoring of the liver for hepatocellular damage, a liver prole is recommended. Blood chemical analysis is often required prior to and periodically during pharmacologic therapy.Scheduled drug agreementOn occasion, the clinician may have no other option than to treat a patient with nonmalig-nant intractable pain with scheduled drugs such as opioids. If the clinician deems this the best course of treatment for the patient, it is recommended that the clinician perform a thorough evaluation of the patient’s mental health status and psychosocial situation. The Table 2-5 Laboratory testing for nonodontogenic orofacial pain or TMDsDisease TestsJuvenile rheumatoid arthritis• Rheumatoid factor• Antinuclear antibodies• Erythrocyte sedimentation rateSystemic lupus erythematosus• Antinuclear antibodies• Other autoantibodies• Complement• BiopsyLyme disease • Indirect uorescent antibody• Enzyme-linked immunosorbent assay• Immunoblotting• Polymerase chain reactionMultiple sclerosis• MRI• Evoked potential studies• Antinuclear antibodies• B12• Complete blood count• Erythrocyte sedimentation rate• Urinalysis• Elevated myelin levelsTable 2-6 Frequently used hematologic studiesSerologic study Suspicion ofFull blood count Predominantly anemiasHematinics: Ferritin, B12, folateDeciency states causing secondary burning mouth symptomsZinc levels Fe absorption abnormalitiesHypothyroidism Cause of headacheHBA1c Diabetes-related neuropathyExtractable nuclear antigensMixed connective tissue disorders and lupusAntinuclear antibody Various autoimmune and connective tissue disordersErythrocyte sedimentation rate or C-reactive proteinInammatory conditions 45Referencesclinician should discuss the additional risks associated with these drugs, such as physical and psychologic dependence. It is also recom-mended that the clinician engage in a sched-uled drug agreement, in which the responsi-bilities of both parties are documented. Such responsibilities could include statements that prescriptions should be taken as prescribed, that prescriptions will not be lled early, that the patient agrees not to receive additional similar medications from other health care pro-viders, that the patient is subject to random urine screens and pill counts, and so on. The agreement could restrict the patient to lling his or her prescription at a predetermined phar-macy and indicate that if the patient breaches the agreement, scheduled drugs will no longer be provided, but other forms of treatment will be offered. The goal of treatment is to reduce pain, to improve function, and to increase qual-ity of life. If these goals are not achieved with this type of treatment, the patient should be weaned off the medications and alternative treatments offered. 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