Orofacial pain/ oral surgery courses

Orofacial Pain
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
www.indiandentalacademy.com

Contents-Part-I
The Nature of Pain
• Defination
• Neural anatomy of orofacial pain
• Neurophysiology of orofacial pain
• Central processing and Psychology of pain
Clinical considerations of pain
• Measurement of Pain and Disability
• History of Orofacial pain
• Orofacial Pain Clinical examination
• Establishing the pain category
• Confirmation of clinical diagnosis
Classification of orofacial painwww.indiandentalacademy.com

Part-II
• Clinical pain Syndromes
• General Considerations in Managing
Orofacial pains.

Introduction
Orofacial pain derives from a vast number of complex etiologies
and its successful treatment requires contributions from many
different specialties.
This pain is one of the most distressing of all painful syndromes and
warrants aggressive and appropriate treatment in a multidisciplinary
setting.
The assessment of head and neck pain requires a careful physical
examination of multiple structures and systems, a thorough history, and
the employment of auxiliary diagnostic studies.

The Nature Of Pain
• Defination proposed by the subcommittee on taxonomy
of the International Association for the study of pain.
“It is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.”

Levels of Pain processing
• Nociception-refers to noxious stimulus originating from
the sensory receptors.The information is carried to the
central nervous system by the primary afferent neurons.
• Pain-Is an unpleasant sensation perceived in the cortex
usually as a result of incoming nociceptive input.
• Suffering-refers to how the human reacts to the
perception of pain.
• Pain behaviour-refers to individual’s audible and visible
actions that communicate his or her suffering to others.

Neural pathways of pain
• Transduction-is the process by which noxious stimuli
lead to electrical activity in the appropriate sensory nerve
ending.
• Transmission-The neural events that carry the
nociceptive input into the central nervous system for
proper processing.
• Modulation –is the ability of the central nervous system
to control the pain transmitting neurons.
• Perception-If nociceptive input reaches the cortex,
perception occurs,which immediately initiates a complex
interaction of neurons between the higher centres of the
brain. www.indiandentalacademy.com

Functional Neuroanatomy
Sensory Receptors
• At the distal terminals of afferent (sensory) nerves are
specialized sensory receptors that respond to physical or
chemical stimuli. Once these receptors have been
adequately stimulated, an impulse is generated in the
primary afferent neuron that is carried centrally into the
CNS.

They are classified into three groups-
a)Exteroceptors- Provides information from skin
and mucosa
b) Proprioceptors- Provides information from
musculoskeletal structures concerning
presence,position and movement of the body.
c) Interoceptors- Provides information from
viscera.

The First-Order Neuron
• Each sensory receptor is attached to a first-order or
primary afferent neuron that carries the impulses to the
CNS.
• A general classification of neurons divides the larger
fibers from the smaller ones, calling the larger fibers A
fibers and the smaller fibers C fibers.

• The A fibers are further divided by diameter size into
alpha, beta, gamma, and delta.
• It appears that the fast conducting A-alpha, A-beta, and
A-gamma fibers carry impulses that induce tactile and
proprioceptive responses but not pain.
• It seems that pain is conducted by A-delta and C fibers,
but these are not specific for pain only. The pricking
sensation by A-delta, the burning sensation by C fibers.

Second-Order Neuron
• The primary afferent neuron carries impulses into the
CNS and synapses with the second-order neuron.
• This second-order neuron is sometimes called a
transmission neuron since it transfers the impulse on to
the higher centers.
• The synapse of the primary afferent and the second-
order neuron occurs in the dorsal horn of the spinal cord

There are three specific types of second-order neurons that
transfer impulses to the higher centers and are named
according to the type of impulses they predominantly carry.
1) Low-threshold mechanosensitive neurons (LTM)
-transfer information of light touch, pressure and
proprioception.
2) Nociceptive specific neurons (NS)- exclusively carry
impulses related to noxious stimulation.
3) Wide dynamic range neuron (WDR)- This neuron is
able to respond to a wide range of stimulus intensities
from non-noxious to noxious.

• Once the impulses have been transferred from the
primary afferents, most of the second-order neurons
cross to the opposite side of the spinal cord and enter
the antero-lateral spinothalamic tract, which ascends to
the higher centers.
• Some of the second-order neurons remain on the same
side of the dorsal column and ascend by way of the
lemniscal system.

Brain Stem and Brain
Once the impulses have been passed to the second-order
neurons, these neurons carry them to the higher centers
for interpretation and evaluation.

The higher centers of the central nervous system can be subdivided
into the following four regions from the most inferior to the most
superior:
• The brain stem made up of the medulla
oblongata, the pons, and the midbrain
(or mesencephalon).
• The cerebellum.
• The diencephalon is made up of the
thalamus and hypothalamus
• The cerebrum made up of the cerebral cortex, the basal ganglia,
and the limbic structures

Second order neurons
↓
Medulla(either enhances or inhibits impulses to the brain)
↓
Thalamus (Relay station-makes assessments and directs
the impulses to appropriate regions)
↓
Cortex (Perceives the pain)

Orofacial pain pathway

• A graphic depiction of the trigeminal nerve entering the
brain stem at the level of the pons.
• The primary afferent neuron (1st N) enters the brain
stem to synapse with a second-order neuron (2nd Nj in
the trigeminal spinal tract nucleus (STN of V).
• The spinal tract nucleus is divided into three regions; the
subnucleus oralis (nso), the subnucleus interpolaris (sni),
and the subnucleus caudalis (snc).

• The trigeminal brain stem complex is also composed of
the motor nucleus of V (MN of V) and the main sensory
nucleus of V (SN of V).
• The cell bodies of the trigeminal nerve are located in the
gasserian ganglion (GG).
• Once the second-order neuron receives the input it is
carried on to the thalamus (Th) for interpretation.

The relationship of the trigeminal nerve input and the spinal nerve input
as impulses ascend to the higher centers

Neurophysiology of orofacial pain

Generation of Action Potential:
a) Resting membrane potential (RMP) at -70mV. Na+ on
outside and K+ on inside of cell
b) As depolarization reaches threshold of -55mV, the
action potential is triggered and Na+ rushes into cell.
Membrane potential reaches +30mV on action potential
c) Propagation of the action potential at 100 m/sec
(which is 225 mph)
d) Repolarization occurs with K+ exiting the cell to return
to -70mV RMP
e) Return of ions (Na+ and K+) to their extracellular and
intracellular sites by the sodium potassium (Na+K+)
pump

SYNAPSES
• A synapse is the junction point between two neurons.
• A nerve impulse can also be transmitted from a sensory receptor
cell to a neuron, or from a neuron to a set of muscles to make them
contract, or from a neuron to an endocrine gland to make it secrete
a hormone. In these last two cases, the connection points are called
neuromuscular and neuroglandular junctions.
• In a chemical synapse between two neurons, the neuron from which
the nerve impulse arrives is called the presynaptic neuron. The
neuron to which the neurotransmitters (chemical messengers) bind
is called the postsynaptic neuron.
• The terminal button of the presynaptic neuron’s axon contains
mitochondria as well as microtubules that transport the
neurotransmitters from the cell body (where they are produced) to
the tip of the axon.
•

• This terminal button also contains spherical vesicles filled with
neurotransmitters. These neurotransmitters are secreted into the
synaptic gap by a process called exocytosis, in which the vesicles’
membranes fuse with that of the presynaptic button.
• The synaptic gap that the neurotransmitters have to cross is very
narrow–on the order of 0.02 micron.
• Across the gap, the neurotransmitters bind to membrane
receptors: large proteins anchored in the cell membrane of the
post-synaptic neuron.
• Any given neurotransmitter has receptors that are specific to it.
• It is the presence or absence of certain of these sub-types that
causes a cascade of specific chemical reactions in the postsynaptic
neuron. These reactions result in the excitation or inhibition of this
neuron.

Neurotransmitters are divided into 2 types-
• Small rapid acting molecules –
Acetylcholine,Norepinephrine,Glutamate,
Aspartate,Serotonin(excitatory)
GABA,Glycine,dopamine(Inhibitory)
• Larger slower acting molecules-
Substance P, Endorphins

Once the transmitter performs its function of transmitting
the impulse , it is rapidly removed by one of the three
methods:
• Diffusion
• Enzymatic Destruction
• Neurotransmitter reuptake

Central processing and psychology
of pain
• A) Primary pain and heterotopic pain
• The site of the pain is the location that the patient feels
the pain.
• The source of pain is that area of the body from which
the pain actually originates .
• When the site and source of the pain are in the same
location it is called primary pain.
• If the site and source of pain are different ,then it is called
heterotopic pain. www.indiandentalacademy.com

Referred pain
• Referred pain is a spontaneous heterotopic pain
that is felt in an area innervated by a different
nerve from the one that mediates primary pain.

• The pain originating from viscera is generally of slow,
aching type,which is difficult to localise.
• Frequently visceral pain may be referred to other parts
of the body supplied by the same spinal nerve (the
dermatomal rule) known as referred pain.
• When pain is referred to another part of the body, the
site of referral is usually a part of the body that develops
from the same embryological segment or dermatome, as
the affected source of the pain. The same peripheral
nerves supply these common regions of the body.

B) Modulation Concept
• Neural impulses are altered , changed or modulated as
they travel up the neuraxis to the higher centers.
• Excitatory or inhibitory influences bear on the impulses
at various levels in the CNS,which can accentuate the
pain experience.
• The process of increasing the impulse is facilitation and
decreasing inhibition.

C) Psychology of pain
• Nociception is not pain until it reaches and proceed by
higher centres.
• Once impulses reach the higher centres , patient makes
the judgement on pain experience according to at least
four factors or conditions.
 Level of arousal of brain stem
 Prior experiences
 Emotional state
 Certain behavioural traits.

Measurement of Pain and Disability
Pain is a subjective experience and therefore impossible to
Measure directly, but a quantitative estimation of pain can
be obtained. However, there are only few available tests to
quantify separate aspects of pain.

Visual Analogue Scale (VAS)
• VAS consists of 10cm line on which 0cm is no pain and
10cm is pain as bad as it could be. . Numeric scales (eg,
1 to 10) and descriptive rating scales (eg, no pain, mild,
moderate, severe pain) are also used.
• VASs are sensitive to treatment effects, can be
incorporated into pain diaries, and can be used with
children.
• The multidimensional aspects of pain are not well
measured by scales that rate intensity.

The McGill Pain Questionnaire (MPQ)
• It was created to measure the motivational-affective and
the cognitive-evaluative qualities of pain, in addition to
the sensory experience.
• The questionnaire enables patients to choose from 78
adjectives (arranged in 20 groups) that describe pain.

• The form is designed to assess the sensory (groups 1 to
10), affective (groups 11 to 15), and evaluative (group
16) dimensions of pain and to produce a pain-rating
index.
• There are also sections for the location and temporal
characteristics of pain and a rating for present pain
intensity.

Turk and Rudy have developed the Multiaxial
Assessment of Pain (MAP) classification
Their assessment included a 61-item questionnaire, the
West Haven Yale Multidimensional Pain Inventory
(WHYMPI), which measures adjustment to pain from a
cognitive-behavioral perspective.
The following three distinct profiles emerged:
• (1) Dysfunctional, characterized by patients who
perceived the severity of their pain to be high, reported
that pain inter-fered with much of their lives, reported a
higher degree of affective distress, and maintained low
levels of activity

• (2) Interpersonally distressed, characterized by a
common perception that 'significant others' were not very
understanding or supportive of the patient's problems;
and
• (3) Adaptive copers, patients with high levels of social
support, relatively low levels of pain perceived
interference, affective distress, and higher levels of
activity and perceived control.

Dworkin and LeResche have developed a method for
assessing dysfunctional chronic pain as part of a
classification system, the Research Diagnostic Criteria.
They used the –
• Graded Chronic Pain Severity scale
• Depression and vegetative-symptom scales from the
Symptom Checklist-90-Revised (SCL-90-R)
• Jaw disability checklist.

All three of these scales are based on questionnaires that
are completed by the patient.
• The Graded Chronic Pain Severity scale has four grades
of disability and pain intensity based on seven questions,
of which three are related to pain intensity and four are
related to disability.
• The SCL-90-R depression scales are used to identify
patients who may be experiencing significant
depression, a problem commonly associated with
chronic pain.

Quantitative sensory technique
• Quantitative Sensory Testing (QST) is a set of sensory
tests based on normal and non-normal responses to
various non-invasive stimuli.
• QST modalities (thermal, mechanical, electrical, etc.)
selectively activate different sensory nerve fibers.
• Thin non-myelinated C fibres-Activated by heat stimuli.
• An important subset of C-fibres-responds to chemical,
mechanical, and thermal nociceptive stimuli.

• A8(Delta) fibers have a thin myelinated sheath -
activated mainly by cold stimuli, fast-onset contact,
radiant (including laser) heat, and punctuate mechanical
stimulation, such as a pin.
• Aβ fibers have a thicker myelin coat -mediate touch and
vibratory sensations.
• Aα fibers - activated by pulsed electrical stimuli at the
threshold for detection.

Three major levels of sensation can describe the response
to external sensory stimuli:
• Detection threshold
• Pain threshold
• Pain tolerance.

• Employing QST as part of the routine OFP examination
can add to the sensory and pain evaluation.
• Hyperalgesia, for instance to heat stimulus, suggests
thin unmyelinated nerve fiber pathology, whereas tactile
hyperalgesia may suggest involvement of myelinated
fibers.

Orofacial Pain History

I. The Chief Complaint
A. Location of pain
B. Onset of Pain
1) Associated with other
factors
2) Progression
C. Characteristics of pain
1) Quality of pain
2) Behavior of pain
a. Temporal
b. Frequency
c. Duration
1) Intensity
2) Concomitant symptoms

D. Aggravating and alleviating factors
1) Physical modalities
2) Function and parafunction
3) Sleep disturbances
4) Medications
5) Emotional stress
E. Past consultation and/or treatments
F. Relationship to other complaints

II. Past medical history
III. Review of systems
IV. Psychologic assessment

A) Location of pain
• The patient's ability to locate the pain with accuracy is
diagnostic. It can be very helpful to provide the patient
with a drawing of the head and neck and ask him or her to
outline the location of the pain .

• This allows the patient to reflect in his or her own way
any and all of the pain sites.
• The patient can also draw arrows revealing any patterns
of pain referral.These drawings can give the clinician
significant insight regarding the location and even the
type of pain the patient is experiencing.

B) Onset of the Pain
• It is important to assess any circumstances that were
associated with the initial onset of the pain complaint.
• These circumstances can give great insight as to
etiology.

• The onset of some pain conditions are associated with
trauma,systemic illnesses, or jaw function, or may even
be wholly spontaneous.
• It is important that the patient present the circumstances
associated with the initial onset in chronologic order so
that proper relationships can be evaluated.

C) Characteristics of pain
1)Quality of the Pain.
• The quality of pain should be classified according to how
it makes the patient feel.
• This classification is usually termed
Bright –Stimulating and excitatory effect
Dull-Depressing effect
• Further evaluation of the quality of pain should be made
to classify it as –
pricking, itching, stinging, burning, aching, or pulsating.www.indiandentalacademy.com

2)Behavior of the Pain.
The behavior of the pain should be evaluated according to-
 a)Temporal behavior- reflects the frequency of the pain
as well as the periods between episodes of the pain. It
is classified as- Intermittent, Continuous and Recurrent
 b)Duration –
• Momentary- if expressed in seconds
• Long lasting- If expressed in minutes,hours or a day
• Protracted- pain that continues from one day to the
next is said to be protracted.

 c) Localizability-
• Localized pain-site of pain easily localised by patient
• Diffuse pain-less well defined and vague pain
• Radiating pain-rapidly changing pain
• Lancinating pain-momentary cutting exacerbation
• Spreading-more gradually changing pain
• Enlarging-progressively involves adjacent anatomic
areas
• Migrating-changes from one location to another

3) Intensity of the Pain.
The intensity of pain can be-
• Mild pain-it is associated with pain that is described by
the patient but there is no display of visible physical
reactions.
• Severe pain- are associated with significant reactions
of the patient to provocation of the painful area.
• One of the best methods of assessing the intensity of
the pain is with a visual analog scale.www.indiandentalacademy.com

4) Concomitant Symptoms.
• Sensations such as hyperesthesia, hypoesthesia,
anesthesia, paresthesia, or dysesthesia should be
mentioned.
• Any concomitant change in the special senses
affecting vision, hearing, smell, or taste should be
noted.
• Motor changes expressed as muscular weakness,
muscular contractions, or actual spasm should be
recognized.

5) Manner of Flow of Pain.
• Steady
• Paroxysmal

D) Aggravating and Alleviating Factors
 Effect of Functional Activities.-
• Trigerring pain- triggered by minor superficial stimulation
such as touch or movement of the skin, lips, face,
tongue, or throat.
• Induction pain- result of functioning of the joints and
muscles themselves.
• Can be differentiated by-Topical anaesthesia or a block-
Trigerring pain gets relieved while induction pain does
not.
• Parafunctional activities- bruxisism, clenching.www.indiandentalacademy.com

 Effect of Physical Modalities- Effectiveness of hot or
cold on the pain condition.
 Medications.
The patient should review all past and present
medications taken for the pain condition. Dosages
should be reported along with the frequency taken and
effectiveness in altering the chief complaint.

 Emotional Stress.
Emotional stress can be a major contributing factor to the
pain condition. Emotional stress may be a major factor or
an aggravating factor.
 Sleep Quality.
Patients who report poor-quality sleep should be
questioned regarding the Relationship of this finding with
the pain condition.Particular notice should taken when the
patient reports waking during the night in pain or when the
pain actually wakes the patient.

 Litigation.
Important to inquire if the patient is involved in any form of
ligation related to the pain complaint. This information may
help the clinician better appreciate all conditions
surrounding the pain.

E) Past Consultations and Treatments.
During the interview, all previous consultations and
treatments should be thoroughly discussed and reviewed.
This information is extremely important so that repetition of
tests and therapies is avoided.
F) Relationship to Other Pain Complaints

II) Medical history
III) Review of Systems
IV) Psychological assessment
As pain becomes more chronic, psychologic factors relating
to the pain complaint becomes more common. Routine
Psychologic evaluation may not be necessary with acute
pain;however with chronic pain it becomes essential.There
are a variety of measuring tools to that can be used to
assess the psycological status of the patient.

There are a number of psychologic conditions that can
contribute to or actual be responsible for the pain disorder.
For example-
• Somatiform disorders
• Conversion disorders
• Hypochondriasis
• Depression
• Anxiety disorders

Summary of History
Once the history has been obtained, the clinician
should be able to accurately and completely
describe the pain condition.

Clinical Examination
A. Vital signs
1) Blood pressure
2) Pulse rate
3) Respiration rate
4) Temperature
B. Cranial nerve evaluation
C.Eye evaluation
D.Ear evaluation
E. Cervical evaluation
F. Balance and coordination
I) General examination

A)Vital signs-
Certain headaches may be associated with hypertension.
Systemic infections are often associated with elevated
body temperature. Increased breathing rates are often
associated with an upregulation of the sympathetic
nervous system. Therefore, blood pressure, pulse rate,
respiration rate, and body temperature should be
assessed especially when the pain condition is obscure.

B) Cranial nerves evaluation

C) Eye Evaluation
• Pain felt in or around the eyes is noted as is whether or
not reading affects it.
• Reddening of the conjunctivae should be recorded along
with any tearing or swelling of the eyelids

D) Ear evaluation
Hearing should be checked as in the eighth cranial nerve
examination. Infection of the external auditory meatus
(otitis externa) can be identified by simply pushing inward
on the tragus. If this causes significant pain, there could be
an external ear infection

E) Cervical evaluation
• The mobility of the neck is examined for range and
symptoms.
• The patient is asked to look first to the right and then to
the left .
• There should be at least 70 degrees of rotation in each
direction.
• Next, the patient is asked to look up as far as possible
(extension) and then down as far as possible (flexion).

• The head should normally extend back about 60 degrees
and flex down 45 degrees.
• Finally, the patient is asked to bend the neck to the right
and left . This should be possible to approximately 40
degrees each way.
• Any pain is recorded and any limitation of movement
carefully investigated to determine whether its source is
a muscular or a vertebral problem.

F) Balance and coordination-
Tested by-
1) Touching nose with finger with eyes closed.
2) Walking along a straight line on the floor with the toe of
one shoe touching the heel of the other.
• Significant balancing problems can be quickly identified.
• The presence of a balance or coordination problem
should be assessed as to its relationship with the pain
disorder.

II. Muscle examination
A. Palpation
1)Pain and tenderness
2)Trigger points and pain referral

There is no pain associated with the normal function or
palpation of a healthy muscle. In contrast, a frequent
clinical sign of compromised muscle tissue is pain. The
degree and location of muscle pain and tenderness are
identified during direct palpation of the muscle.

A) Palpation
A widely accepted method of determining muscle
tenderness and pain is by digital palpation. A healthy
Muscle does not elicit sensations of tenderness or pain
when palpated. Deformation of compromised muscle tissue
by palpation can elicit pain.

To classify the degree of pain when a muscle is palpated, the patient's
response is placed in one of four categories.
• A zero (0) is recorded when the muscle is palpated and there is no
pain or tenderness reported by the patient.
• A number 1 is recorded if the patient responds that the palpation is
uncomfortable (tenderness or soreness).
• A number 2 is recorded if the patient experiences definite discomfort
or pain.
• A number 3 is recorded if the patient shows evasive action or eye
tearing or verbalizes a desire not to have the area palpated again.
A routine orofacial muscle examination includes palpation of the
following muscles or muscle groups:- temporalis, masseter,
sternocleidomastoid, and posterior cervical (eg, the splenius capitis
and trapezius).

Trigger Points
• Trigger points are clinically identified as specific
hypersensitive areas within the muscle tissue.
• Often a small firm tight band of muscle tissue can be felt.
• Active trigger points represent a source of deep pain and
can therefore produce referred pain.
• Anaesthetic blocking of trigger point often eliminates the
referred pain and thus becomes a helpful diagnostic tool.

III. Masticatory evaluation
A. Range of mandibular movement
1) Measurements
2) Pain
B. Temporomandibular joint evaluation
1) Pain
2) Dysfunction

C. Oral structures
1) The mucogingival tissues
2) The teeth
3) The periodontia
4) The occlusion

Masticatory Evaluation
An examination of masticatory muscles should include-
A) Range of mandibular movements-
• Normal interincisal opening-53-58mm.
• Maximum comfortable opening and maximum opening is
recorded. In absence of pain both the measurements are
same.
• Resticted mouth opening is anything less than 40mm.

The path taken by the midline of the mandible during
maximum opening should also be observed.
• Deviation-It is usually due to a disc derangement in one
or both joints and is a result of the condylar movement
necessary to get past the disc during translation. Once
The condyle has overcome this interference, the straight
midline path is resumed.

• Deflection-It is due to restricted movement in one joint.
Resticted movements of the mandible may be due to –
 Extracapsular(related to muscles)
 Intracapsular restrictions.(related to disc-condyle
function and the surrounding ligaments and thus are
usually related to a disc derangement disorder.)

Testing end feel-
It describes the characteristics of the joint when an attempt
is made to increase mouth opening passively by gently
Placing downward force on the lower incisors with the
fingers to increase the interincisal distance.
• Soft end feel (increased opening can be achieved)-
muscle induced restriction.
• Hard end feel (increased opening cannot be achieved)-
associated with intracapsular sources.

Temperomandibular joint evaluation
Pain or tenderness of the TMJs is determined by digital
palpation of the joints when the mandible is stationary and
during dynamic movement.

Oral Structures
• The gingiva and entire oral mucosa should be tested by
touch, pinprick, and manual palpation to identify areas of
abnormal sensibility.
• Visual inspection of the superficial mucogingival tissues
of the mouth and throat is done to identify hyperemia,
inflammation, abrasion, ulceration, neoplasm, or other
abnormality.

The teeth, especially on the side in question, should be
examined individually to obtain the following data:
1. Sensitivity or tenderness without provocation.
2. Sensitivity or tenderness due to occlusal function.
3. Sensitivity to touch, percussion, or probing with a dental
explorer.
4. Tenderness from pressure directed down the long axis of
the tooth.

5. Tenderness from pressure exerted laterally on the tooth.
6. Response to thermal shock (Warmth may be applied via
a heated instrument; chilling may be done by applying
ethyl chloride on a cotton applicator. The tooth should be
isolated with celluloid strips, especially when adjacent
metallic fillings are present or when covered with an
artificial dental crown.)

7. Response to electric pulp tester (Each tooth should be
isolated with celluloid strips, especially when adjacent
metallic fillings are present. Care should be taken to
differentiate between pulpal and gingival responses.
8. Radiographic evidence of pathologic change
9. Evidence of occlusal trauma
10. Evidence to justify direct exploration ofthe tooth

IV. Other diagnostic tests
A. Imaging
B. Laboratory tests
C. Psychologic provocation tests

A) Imaging-
• When painful symptoms arise from the orofacial
structures, radiographs of the teeth, sinuses, and
temporomandibular joints can be helpful.
• Radiographs of the TMJs will provide information
regarding the morphologic characteristics of the bony
components of the joint, and certain functional
relationships between the condyle and the fossa.

• Another type of image that may have some usefulness in
identifying sites of pain is thermography. The crystals
change color in response to temperature gradients,
presumably due to altered blood flow in superficial
structures.

B) Laboratory testing
• Medical laboratory testing may be needed to confirm a
diagnosis for some conditions such as rheumatoid
arthritis, psoriatic arthritis, and hyperuricemia.
• Blood studies may also be helpful in ruling out systemic
infections or other systemic conditions such as diabetes.

C) Psychologic Provocation Tests
• 1) attempt to induce pain purely by suggestion.
• 2) trial placebo therapy

Establishing the Pain Category
Once the history and examination have been completed,
the clinician should have a significant understanding of the
patient's pain complaint. The next step in diagnosis is
to place the pain complaint into the proper pain category.

Proper category can be reached at by
answering the following questions
• 1) Is the Pain acute or chronic
• 2) Is the Pain Neuropathic or somatic
• 3) Is the Pain Primary or secondary
• 4) Is the Pain Superficial or deep.
• 5) Is the Pain Musculoskeletal or visceral
• 6) Is the Pain inflammatorywww.indiandentalacademy.com

Confirmation of the Clinical Diagnosis
Before undertaking definitive therapy, confirmation of the
clinical diagnosis is advisable.
There are four methods that can help confirm the
diagnosis:
• Diagnostic analgesic blocking
• Utilization of diagnostic drugs
• Consultations
• Trial therapy.

Diagnostic analgesic blocking
• The value of local anesthetic injections and application of
topical anesthetics to identify and localize pain cannot be
overemphasized.
• It is essential when differentiating primary from
secondary pains.

Diagnostic Drugs
• Confirmation of pain due to myocardial ischemia is
usually accomplished by using a testing dose of
nitroglycerin beneath the tongue.
• Discomfort of vascular and neurovascular pain disorders
seems to derive from the dilation and amplitude of
pulsation of the blood vessels involved, the diagnostic
use of medications that temporarily constrict blood
vessels may help confirm the diagnosis. For this
purpose, ergotamine tartrate is used and administered
as 0.5 to 1 mg of drug injected intramuscularly.

Consultations
• There are occasions when pain problems require
medical, otolaryngologic, orthopedic, neurologic,
rheumatologic, or psychologic consultation for proper
identification of the pain disorder.
• It requires judgment, therefore, on the part of the
examiner to guide the patient through the examining
procedure that will arrive at a firm diagnosis in the most
direct, time-saving, and economic manner.
• Elaborate diagnostic and consultative procedures should
not be routine. Yet if the problem justifies it, every
avenue of exploration should be used to attain at a
confirmed working diagnosis.

Trial Therapy
A short period of trial therapy is a good means of
confirming a diagnosis, provided the examiner is familiar
with the effectiveness of placebo therapy.
For Example-Trial therapy for muscular pains is useful
to help confirm the diagnosis. This includes the use of
vapocoolants, analgesic blocking of painful muscles,
controlled physical therapy, and the use of muscle
relaxants. If definite benefit accrues from such therapy, a
firm diagnosis of muscle pain becomes justified.

Conclusion
Diagnosing a pain complaint consists essentially of three main steps-
• 1) Accurately identifying the location of the structure from which the
pain emanates.
• 2) Establishing the correct pain category that is represented in the
condition under investigation.This is a matter of recognizing the
clinical characteristics that are displayed.Establishing the proper
pain category is dependent on a good understanding of the genesis
and mechanisms of pain.
• 3) Choosing the particular pain disorder that correctly accounts for
the incidence and behaviour of the patient’s pain problem.this
requires familiarity with the clinical symptoms displayed by pain
disorders that occur in the orofacial region.

Classification of orofacial pain

• Trigger Points vs. Tender Points
• Trigger points Tender points
• Local tenderness, taut band, local Local tenderness
• twitch response, jump sign
• Singular or multiple Multiple
• May occur in any skeletal muscle Occur in specific
locations that are
• symmetrically located
• May cause a specific referred Do not cause referred
pain, but often cause
• pain pattern a total body increase in pain sensitivity

• Trigger Points: Diagnosis and
Management
• DAVID J. ALVAREZ, D.O., and PAMELA
G. ROCKWELL, D.O., University of
Michigan Medical School, Ann
Arbor,Michigan (Am Fam
Physician 2002;65:653-60. Copyright©
2002 American Academy of Family
Physicians.)

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