Tips on assessing patients with orofacial pain and temporomandibular disorders

This summary is based on the article published in the Dental Clinics of North America: Clinical assessment of patients with orofacial pain and temporomandibular disorders (October 2013)

Key points

• Accurate diagnosis of chronic pain disorders of the mouth, jaws, and face is frequently complex because there are multiple structures localized in 1 small anatomic region that can be a source of painful sensations. Pain can originate from multiple structures including teeth, sinus, eye, nerves, blood vessels, temporomandibular joint, and masticatory muscle sources.
• 
  It is common for patients with chronic orofacial pain to consult multiple clinicians and receive an incorrect diagnosis and receive ineffective treatment before a correct diagnosis is reached. This problem is a significant public health concern when a serious or life threatening disease is overlooked or a patient has chronic pain when effective therapy is available for the undiagnosed painful condition.
• 
  Improved education in accurate diagnosis of orofacial disorders would not only decrease the number of patients with chronic pain but decrease the expense of unnecessary diagnostic tests and incorrect therapy.
• 
  A clinician treating a patient with chronic orofacial pain can minimize error by starting the diagnostic procedure with the well-established method of a careful, accurate history and thorough head and neck examination followed by a thoughtfully constructed differential diagnosis.
• A careful, knowledgeable clinician minimizes incorrect diagnoses, unnecessary laboratory studies, and ineffective therapy. The possibility that the patient has symptoms or signs of a life-threatening underlying disease rather than the more common dental, sinus, or temporomandibular disorder must always be considered.

Pain History

• Chronology of onset
• Location of pain/symptoms as pointed by patient
• Quality of pain/symptoms: aching, dull, pressure pain most often represents musculoskeletal category, whereas throbbing, stabbing, pounding
• pain is neurovascular and burning, itching, electric shock–like pain describes neuropathic pain (some degree of overlap may occur)
• Timing, frequency, and duration (constant vs intermittent)
• Pain intensity can be measured by verbal rating (mild/moderate/sever), numeric rating (0–10), or VAS (10-cm line starting at 0 5 no pain and ends at 10 5 pain as bad as could be)
• Factors that aggravate or alleviate pain (e.g., chewing, light touch, emotional stress)
• Associated symptoms (e.g., tearing; nasal congestion; nausea; vomiting; sensitivity to light, sounds, or motions; paresthesia; otalgia; headache)

Medical and Dental History

• Comorbid systemic disorders (e.g., musculoskeletal, rheumatologic, and arthritic conditions)
• History of trauma to head and neck
• Parafunctional history: clenching, grinding
• History of previous treatments, and outcomes. Obtain information about medication dosage and length of treatment to avoid retreatment and determine whether previous treatment given was for the appropriate time and dose

Psychological and Social History

• Stressors and response to stress (social and occupational)
• Depression and anxiety are often comorbid factors
• Litigation, disability, and second gain
• Activity level and expectations

Musculoskeletal Evaluation

General Appraisal

Asymmetry, swelling, tremors, posture
Palpation of extraoral soft tissues, such as lymph nodes and salivary glands

Examples of Related Disease

• Neoplastic disease
• Dyskinesia
• Cervical spine disorders
• Multiple sclerosis

Musculoskeletal Evaluation

• Palpation of cervical and muscles of mastication.
• Palpation (and auscultation) of the TMJs for joint noises and their time of occurrence, tenderness, and swelling
• Measuring mandibular range of vertical and lateral movements.
• Inspect for corrected and uncorrected deviations, maximum opening with comfort, with pain, and passive range of motion (assisted opening) and signs of
• parafunction

Examples of Related Disease

• Primary or secondary myalgia
• Myofacial pain
• Chronic widespread pain
• Localized arthritis
• Rheumatoid osteoarthritis
• Polyjoint osteoarthritis
• Disc displacement with or without reduction

Neurologic Evaluation

• Cranial nerve screening

Examples of Related Disease

• CNS neoplasia
• Multiple sclerosis
• Secondary trigeminal neuralgia
• Chronic daily headaches
• Acute trigeminal neuritis

Vascular Evaluation

• Compression of temporal and carotid arteries

Examples of Related Disease

• Temporal arteritis
• Trigeminal neuralgia caused by vascular compression

Ear, Nose, and Throat

• Ear discharge, external lesions, swelling of parotid, external auditory canal examination by trained clinician, palpation of the maxillary and frontal sinuses, and visualization of oropharynx

Examples of Related Disease

• Sinusitis
• Acute otitis media
• Neoplastic disease
• Parotid disease

Intraoral Evaluation

• Dental and periodontal examination
• Soft tissue condition (ulceration, mass, and infection)
• Stability of maxillomandibular relationship, and signs of parafunction

Examples of Related Disease

• Vesiculobullous and ulcerative disease
• Dental disorders
• Periodontal disease

Pain Assessment Methods

• Self-assessment instruments for pain measurement
• Visual analogue scale (VAS)
• Numerical Rating Scale (NRS)
• Verbal Rating Scale (VRS)
• McGill Pain Questionnaire (MPQ)

Diagnostic Tests

• Diagnostic Imaging
• Diagnostic Nerve Block
• Laboratory testing
  • Temporal arteritis
    • ESR
    • Temporal artery biopsy
  • Rheumatoid arthritis
    • Complete blood cell count
    • Rheumatoid Factor (RF)
    • Cyclic Citrullinated Peptide Antibody (CCP)
    • Antinuclear Antibody (ANA)
    • Erythrocyte Sedimentation Rate (ESR)
    • C-reactive protein test (CRP)
  • Systemic lupus erythematous
    • Complete blood cell count
    • Antinuclear Antibody (ANA)
    • Anti-dsDNA antibody
    • Anti-Sm antibody
    • Rheumatoid Factor (RF)
    • Anti-SSA
    • Anti-SSB
    • Urinalysis
    • ESR
    • CRP test
    • Serum complements
    • Biopsy