Diagnosing Dental and Orofacial Pain E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 429

Veröffentlichungsjahr: 2016

Beschreibung

Diagnosing Dental and Orofacial Pain: A Clinical Manual approaches a complex topic in a uniquely practical way. This text offers valuable advice on ways to observe and communicate effectively with patients in pain, how to analyze a patients’ pain descriptions, and how to provide a proper diagnosis of orofacial pain problems that can arise from a myriad of sources—anywhere from teeth, joint and muscle pain, and paranasal sinuses to cluster headaches, neuralgias, neuropathic pain and viral infections.

• Helps the student and practitioner understand the diagnostic process by addressing the exact questions that need to be asked and then analyzing verbal and non-verbal responses to these
• Edited by experts with decades of clinical and teaching experience, and with contributions from international specialists
• Companion website provides additional learning materials including videos, case studies and further practical tips for examination and diagnosis
• Includes numerous color photographs and illustrations throughout to enhance text clarity

Leseprobe

Table of Contents

Cover

Title Page

Contributors

Acknowledgments

About the Companion Website

Chapter 1: Introduction

Introduction

Chapter 2: The Art of Listening – Communicating Effectively with a Patient in Pain

Introduction

Chapter 3: Causes of Pain in the Orofacial Region

Introduction

Causes of orofacial pain

Summary

Chapter 4: Gathering Information for an Accurate Pain Diagnosis

Introduction

Screening questions

Basic information gathering

Further basic information gathering

Chapter 5: Analyzing Patients in Pain – Describing Pain and the Importance of Descriptors

What sort of pain are you having?

Chapter 6: Analyzing Patients in Pain – Observing Patients in Pain

Introduction

Bilateral pain

Complaining of altered sensation

Describing pain in and around the eye

Chapter 7: Analyzing Patients in Pain – Associations with Cold and Heat

Introduction

Temperature sensitivity

Chapter 8: Analyzing Pain Descriptions – Pain on Biting or Eating and Other Considerations

Introduction

Other descriptions

Chapter 9: Analyzing Pain Descriptions – Time Analysis and the Diagnosis of Orofacial Pain

Introduction

Pain that occurs at a specific time each day

Pain on waking in the morning

Pain in the afternoon or evening

Chapter 10: Analyzing Pain Descriptions – Factors Influencing the Pain

Relief of pain

Chapter 11: Tests and Testing

Pulp sensibility (vitality) tests

Chapter 12: Diagnosing Dental Pain

Introduction

Clinical progression of pulpal disease

Confirmatory tests for dental pain

Treatment considerations

Some useful questions if a dental cause is suspected

Referral of dental pain

Confirmatory tests and findings

Questions to ask if referred pain is suspected

Chapter 13: Diagnosing Cracked (Crown Fractured) Teeth

Cracked (crown fractured) teeth

Management of cracked teeth

1. Tooth identification

2. Crack confirmation

3. Crack investigation

4. Treatment planning

Questions to ask when considering a cracked tooth

Chapter 14: Diagnosing Joint and Muscle Pains

Introduction

Temporomandibular disorder

Temporomandibular disorders associated with pain

Masticatory muscle pain

Arthralgia

Headaches associated with TMD

Chapter 15: Diagnosing Pain Referral from Neck and Shoulders

Pain referral from neck and shoulders

Pain referral from muscles

Cervicogenic disorders

Common cervical spine disorders likely to present in a dental setting

Examination of cervicogenic disorders

Useful questions if pain referral from neck and shoulder is suspected

Chapter 16: Diagnosing Pain from the Sinuses

Introduction

Classification of sinus pain

Treatment considerations

Helpful questions to ask if you suspect a patient has pain from maxillary sinusitis

Chapter 17: Diagnosing Tension Headaches and Migraine

Introduction

Tension-type headache

Useful question to ask if tension headache is suspected

Migraine headache

Useful questions to ask if migraine headache is suspected

Chapter 18: Diagnosing Cluster Headaches

Introduction

Associated autonomic symptoms

Useful questions to ask if cluster headache is suspected

Confirmatory tests

Treatment considerations

Chapter 19: Diagnosing Trigeminal Neuralgia

Trigeminal neuralgia

Pre-trigeminal neuralgia

Glossopharyngeal neuralgia

Useful questions to ask if trigeminal neuralgia is suspected

Confirmation tests for trigeminal neuralgia (TN)

Treatment options

Chapter 20: Viruses as a Cause of Orofacial Pain

Viral infection as an etiologic source of orofacial pain

Useful questions to ask the patient for facial herpes zoster (shingles) of CN V

Ramsay Hunt syndrome

Post-herpetic neuralgia

Chapter 21: Vascular Causes of Headaches

Giant cell arteritis

Cranial (carotid) artery dissection

Chapter 22: Diagnosing Neuropathic Orofacial Pain

Types of neuropathic orofacial pain

Clinical presentation of neuropathic orofacial pain

Diagnosing the pain problem

Psychosocial and behavioral factors

Questions to ask if trigeminal neuropathic facial pain is suspected

Presentation and confirmation tests

Treatment considerations

Chapter 23: Referral Strategies for Orofacial Pain Cases

Introduction

Coordinating with the general medical practitioner

Indications of urgent referral

Referral for pain diagnosis and management

Useful questions to consider when assessing whether to refer a patient

References

Index

End User License Agreement

List of Tables

Chapter 15

Table 15-1 Direction of movements and expected ranges for flexion, extension, rotation and lateral extension. These measurements are used as a guide only, as range of movement varies greatly among individuals.

Chapter 17

Table 17-1 Simplified classification of types of headaches (modified from

The International Classification of Headache Disorders

, International Headache Society, 2013).

165,171

Chapter 18

Table 18-1 Criteria necessary for a diagnosis of cluster headache (adapted from International Classification of Headache Disorders).

165

List of Illustrations

Chapter 01

Fig. 1-1 A patient with non-dental pain who had multiple restorations and endodontic procedures in an unsuccessful attempt to relieve orofacial pain.

Chapter 03

Fig. 3-1 (A) The major muscles of mastication: masseter (M), temporalis (T) and pterygoid (P). (B) The lateral (LP) and medial (MP) pterygoid muscles.

Fig. 3-2 Diagram showing (red) the anterior (left) and posterior (right) bellies of the digastric muscle which depress the mandible.

Fig. 3-3 Diagram of a section through the temporomandibular joint. In closed position (A) with the condylar head (C) positioned in the glenoid fossa with the articular disc (green) situated above and anterior to it. In open position (B) where the condylar head and the disc (green) have moved forward and are positioned over the temporal bone (T).

Fig. 3-4 Diagram of back of the neck showing the structures of the cervical spine and occipital bone (yellow). Damage to the cervical vertebrae or the discs can cause localized pain and referral to the orofacial region.

Fig. 3-5 The relative position of the paranasal sinuses: maxillary (yellow), frontal (purple), ethmoid (blue) and sphenoid (red).

Fig. 3-6 Representation of the trigeminal nerve (CN V), the largest of the cranial nerves. (A) The course of the nerve and (B) the areas of sensory innervation of the three divisions: mandibular (ochre), maxillary (green) and ophthalmic (blue).

Fig. 3-7 The facial nerve (A) showing the course of the nerve and (B) the sensory innervation of its five divisions: temporal (ochre), buccal (purple), zygomatic (blue), mandibular (orange) and cervical (green).

Fig. 3-8 Diagram of the course (orange) of the glossopharyngeal nerve. The nerve supplies sensory fibers to the pharynx, middle ear and posterior one-third of the tongue (including taste).

Fig. 3-9 Course (yellow) of the superior laryngeal nerve, a branch of the vagus nerve (CN X). The nerve innervates the cricothyroid muscle. Adapted from: https://www.google.com.kw/search?q=superior+laryngeal+nerve&biw=1325&bih=794&source=lnms&tbm=isch&sa=X&ved=0CAYQ_AUoAWoVChMIkO6xyOqYxwIVhbUUCh2eDQ1I#imgrc=W7t_Hu6om6ZQqM%3A (accessed 8 August 2015).

Fig. 3-10 Sagittal view of the face showing the relative position of the major salivary glands: parotid (orange), submandibular (green) and sublingual (blue). The parotid gland is situated superficially in front of the ear on the side of the face. The other glands are situated sublingually medial to the inner surface of the horizontal ramus of the mandible.

Fig. 3-11 Blood supply to the face with main branches highlighted: maxillary (M), facial (F) and superficial temporal (ST).

Fig. 3-12 Biopsychosocial model for chronic pain.

44,45

Chapter 04

Fig. 4-1 Diagnosis of orofacial pain can be made easier if clinicians use directed

questioning

and a

diagnostic tree

, where responses to a series of

general screening questions

, a descriptor or a test result directs questioning towards

screening questions for specific disease states.

Fig. 4-2 Be wary of patients with chronic pain who give a long explanation of a problem, who are particularly critical of past treatment and other practitioners and who attend for consultation with dossiers containing a comprehensive array of past reports and records. Many need psychological assessment as well as any physical treatment.

Chapter 05

Fig. 5-1 The use of a simple visual analogue scale allows a patient to describe the intensity of their personal present and past pain experiences. It is a useful means of recording the current pain intensity, as well as changes in intensity that occur over time with treatment.

Fig. 5-2 Representation of patterns of a patient’s pain experience. Pattern and intensity recorded in relation to a linear time line. The height of the line indicates intensity, and the shape of the line indicates the pattern of the pain experienced.

Figs 5-3 A and B. Representation of patterns of a patient’s pain experience. Time detail can be entered in more detail below a diagram. If stimulated, the point of stimulation (x) is marked as the start point. In the first diagram (A), pain experience is delayed for some minutes after stimulation but then builds in intensity and lasts for hours before slow dissipation. In the second diagram (B), the patient described constant dull pain that has lasted for days.

Fig. 5-4 Representation of patterns of a patient’s pain experience. Pain patterns can be specific for a specific pain condition.

Fig. 5-5 (A and B) Representation of patterns of a patient’s pain experience. Time detail has been entered below the diagram. In diagram (A), the patient describes severe recurrent and unstimulated pain, building in intensity and lasting for 3–4 hours before quickly dissipating (suggestive of migraine). In the second diagram (B), the patient describes e.g. severe pain that only lasts for a few seconds and is precipitated by touch, suggestive of trigeminal neuralgia.

Chapter 06

Fig. 6-1 (A) Diagram of the head and neck on which the clinician or patient can draw the location of pain. (B) Diagram of a body on which a clinician or patient can draw the location of pain. (C) Diagram of teeth and intra-oral structures illustrating the palate, the dorsal and the undersurface of the tongue on which a clinician or patient can draw the location of pain.

Fig. 6-2 Distribution of pain commonly seen in various conditions.

Fig. 6-3 Patient demonstrating the site of pain by placing a fingernail vertically between two teeth.

Fig. 6-4 Patient demonstrating their pain by scratching on the tooth close to the gingival margin with a fingernail.

Fig. 6-5 Patient demonstrating their pain by pressing over a tooth apex.

Fig. 6-6 Patient demonstrating their pain by pressing on the gingival margin.

Fig. 6-7 Patient demonstrating their pain by holding and moving an individual tooth.

Fig. 6-8 Patient demonstrating their pain by movement of several teeth together or independently.

Fig. 6-9 Fractures in the facial plate of bone result in sensitivity to percussion of anterior teeth after impact trauma. In (A), there were multiple alveolar fractures (arrow) involving the entire buccal plate of bone. In (B), there appeared to be a single fracture running across the maxillary incisors and involving the canine tooth. Endodontic treatment did not relieve the pain and was contraindicated.

Fig. 6-10 Profile view of patient illustrating the four positions described below: (A) tenderness beside the nose; (B) tenderness immediately under the eye; (C) tenderness on the lateral border of the zygomatic arch just above the second premolar; (D) tenderness in front of the ear.

Fig. 6-11 Patient demonstrating tenderness or pain (A) beside the nose, (B) immediately under the eye, (C) on the lateral border of the zygomatic arch just above the maxillary second premolar and (D) in the temporomandibular joint area. Patients often use two fingers to demonstrate joint pain.

Fig. 6-12 Patient demonstrating pain by pressing several fingers on the body of the masseter.

Fig. 6-13 Patient demonstrating pain by pressing on the body of the mandible. Muscle pain is most likely if the fingers are in motion, palpating the area.

Fig. 6-14 Patient demonstrating pain by moving fingers in line under the mandible.

Fig. 6-15 Patient describing a painful lymph node by pointing at the node with a single finger.

Fig. 6-16 Patient describing their pain by running a finger back and forth across the midline below the mandibular incisor tooth crowns.

Fig. 6-17 Patient demonstrating masseter muscle pain by using two hands unilaterally.

Fig. 6-18 Ways that symmetrical bilateral pain in the head and neck can be demonstrated: (a) bilateral pain in the temple, most likely from the temporalis muscles; (b) bilateral pain in the mandible, probably from the masseter muscle; (c) bilateral pain in the maxilla, from maxillary sinusitis; (d) bilateral pain centered in the posterior neck musculature.

Fig. 6-19 Assessing the response to percussion. Determine the comparative response to a percussive blow on adjacent teeth. Always retest the teeth in a different order if any positive response is reported.

Fig. 6-20 Patient demonstrating the location of their pain by holding or cradling the side of the face.

Fig. 6-21 Demonstration of a trigger point by lightly touching an area.

Fig. 6-22 Example of an area of altered sensation mapped on a patient’s face and photographed.

Fig. 6-23 Demonstration of orofacial pain in and around the eye. Note whether the patient is describing general pain that includes the eye or whether the pain is in or behind the eye.

Fig. 6-24 Patient describing pain centered between the eyes. Frontal or ethmoid sinusitis and referred muscle pain are common causes.

Fig. 6-25 Note whether the hand or fingers stray from the distribution of the trigeminal nerve. If they do, a dental cause is unlikely. If the pain is bilateral, it is not dental pain.

Fig. 6-26 Patient with severe orofacial pain who has demonstrated the pain by constantly rubbing the area directly over the TMJ joint (arrow). Screening questions and testing will establish whether the pain is from the joint or referred from another site.

Chapter 07

Fig. 7-1 Patients who present in dental pain, and who report that the pain is relieved by cold water or ice, are describing acute pulpitis.

Fig. 7-2 Radiograph of a patient who presented with a history of severe but delayed pain when drinking hot beverages. The mandibular right second molar and then the first molar tooth were tested with hot water under rubber dam isolation. Severe pain resulted, but as both teeth had been tested before the pain started, the identity of the tooth in question was not clear. Testing with cold spray produced a very slight response on the first molar but immediately relieved the pain on the second molar. The first molar was then re-tested separately, first with heat and then immediately with cold spray to relieve the pain. The tooth was then endodontically treated.

Fig. 7-3 Periapical radiograph of an acutely temperature-sensitive calcified tooth (A). A post was recently placed, and the tooth restored with an acrylic temporary crown. The post was exposed to the oral environment (arrow) (B), leading to transfer of thermal stimuli to a vital pulp in the calcified root canal.

Chapter 10

Fig. 10-1 Most dental pain can be controlled to some extent by regular analgesics. Patients who do not obtain relief and who do not have obvious signs of dental pathology may not be suffering pain of dental origin.

Fig. 10-2 A patient’s response to recently prescribed antibiotics can assist in determining the cause of their discomfort.

Chapter 11

Fig. 11-1 Yellowish discoloration of maxillary left central incisor suggestive of pulp canal obliteration (calcific metamorphosis) (A). Sagittal cone beam computed tomography (CBCT) image of the maxillary left central (B) incisor shows calcification of the coronal pulp (arrow).

Fig. 11-2 An electric pulp test is also a useful means of assessing the sensibility of a pulp in a tooth, particularly when the pulps are calcified. Calcified teeth often do not respond to cold testing due to the bulk of dentin between the stimulus and the pulp.

Fig. 11-3 Bathing individual teeth in hot or cold water under rubber dam isolation will quickly disclose the identity of a temperature-sensitive tooth. Each tooth is isolated individually and bathed for a few seconds. Where a delayed response to heat is reported, the teeth should be bathed in hot water, with adequate time to react to this stimulus, before the next tooth is tested.

Fig. 11-4 Testing the lingual surface of mandibular molars often gives a more reliable testing result.

Fig. 11-5 Assessing the response to percussion. Determine the comparative response to a percussive blow on adjacent teeth. Once a response has been observed, retest the teeth in a different order to confirm the identity of the percussion-sensitive tooth.

Fig. 11-6 CBCT imaging showing a fenestration of the root apex (arrowed) in an endodontically treated first premolar tooth with sensitivity to palpation over the buccal cortex near the root apex (A). The fenestration is not visible on the periapical radiograph (B). Radiographic changes are not apparent on the periapical radiograph as the inflammatory reaction is external to the confines of the surrounding bone.

Fig. 11-7 A maxillary first premolar tooth with an isolated deep probing pocket on the distal marginal ridge in an otherwise healthy periodontium. This is an indication that a vertical root fracture is present. Note normal probing depth on the buccal.

Fig. 11-8 An OPG is a good screening radiograph. It provides a good overview of the dentition, the supporting structures and the temporomandibular joints.

Fig. 11-9 OPG of a 37-year-old male complaining of persistent pain in his upper central incisor region. Note the lack of definition of the periapical regions of the maxillary and mandibular anterior teeth in OPG due to superimposition of other anatomic structures and the presence of an impacted maxillary canine (arrow), but the cause of the discomfort is not obvious. This became apparent with CBCT imaging (Fig. 11-10).

Fig. 11-10 An example how CBCT imaging can assist with diagnosis and show the full extent of a lesion.

Fig. 11-11 Systematically placing a propriety device between the teeth on individual cusps and testing for biting pain can help identify a cracked tooth or cusp.

Fig. 11-12 Transillumination with a bright light is a useful mechanism for viewing cracked or discolored tooth structure. A cracked cusp (arrow) can be easily identified using transillumination.

Fig. 11-13 Visualization of a tooth without magnification (A) may not show the cracked tooth structure that is evident on the distal marginal ridge under an operating microscope (arrow) (B).

Chapter 12

Fig. 12-1 Illustration of convergence of different neurons onto the same second-order neurons of the trigeminothalamic tract.

Fig. 12-2 The laminated pattern of representation of orofacial structures in the trigeminal spinal nucleus. Note the cephalic position of the structures close to midline and caudal position of lateral structures.

Chapter 13

Fig. 13-1 Diagram showing the relative susceptibility to fracture of the cusps in maxillary and mandibular premolar and molar teeth. Red cusps are the most susceptible, followed by orange and blue. Green dots indicate low risk areas, and yellow very low.

Fig. 13-2 Sequential isolation of individual teeth under rubber dam and testing with cold water will rapidly identify a cold-sensitive cracked tooth. Allow the water to pool over the whole tooth surface.

Fig. 13-3 A mandibular premolar tooth (A) exhibiting a crack running horizontally from the floor of the box from across the buccal cusp (arrowed). A mandibular first molar (B) with cracks emanating from corners of a cavity preparation (horizontal arrows) and a crack in the buccal groove, signs that the buccal cusp is completely cracked.

Fig. 13-4 A mandibular premolar with a notched vertical crack (arrow) indicating that the tooth is severely fractured.

Fig. 13-5 A mandibular tooth exhibiting a stained crack running across the mesial marginal ridge and a vertical crack running between the two lingual cusps (arrows).

Fig. 13-6 When a mesiodistal crack is seen in a endodontic access closure, it is confirmation that the tooth structure is cracked. In (A), the access closure is cracked in a number of places. While unsupported temporary filling material can crack, the mesiodistal crack (arrow) is a sign that the underlying tooth is cracked. In (B), (arrows) an obvious mesiodistal crack across the access closure is a sign that the underlying tooth structure is cracked.

Fig. 13-7 (A) Mandibular second molar with a cracked mesiolingual cusp (arrow). This cusp appears whiter and more opaque than the other cusps. Note the crack across the mesial marginal ridge. (B) Cracked distolingual cusp in a lower molar in shadow appears darker than other cusps. (C) A maxillary first premolar tooth with a cracked palatal cusp. Note the dark color of this cusp compared with the buccal cusp. The adjacent premolar (not arrowed) is root-canal filled and stained.

Fig. 13-8 (A) A mandibular first molar with two cracked lingual cusps. Note the loss of marginal definition and a frosty margin between the cusps and the amalgam restoration (arrow). (B) Maxillary molar tooth with a fractured palatal cusp. Note the frosted appearance of the crack line on the mesiopalatal and adjacent to the amalgam restoration.

Fig. 13-9 A cracked cusp is clearly visible when a bright (fiber-optic) light is held up against it.

Fig. 13-10 Proprietary products (e.g. Tooth Slooth® or Fractfinder®) are useful for detecting cracks. A folded piece of wet gauze or piece of hard paper card can be useful in diagnostically difficult cases.

Fig. 13-11 Selective percussion involves tapping on individual cusps with an instrument (e.g. a mirror handle). The direction of the blow must be in a direction that activates the crack.

Fig. 13-12 A sustained and controlled wedging force allows individual cusps to be loaded. If rapid release of the force results in

rebound pain

, it is indicative of a crack in the tooth.

Fig. 13-13 The use of dyes (e.g. Methylene Blue or vegetable dyes) can help to identify the presence of an otherwise difficult-to-see crack. While a crack is barely visible in the distal marginal ridge of this premolar (A) it is much easier to see when the crack is stained with Methylene Blue dye (B).

Fig. 13-14 (A) A symptomatic, unrestored maxillary molar tooth with acute pulpitis. A vertical crack is evident on the periapical radiograph (arrow). (B) A minimally restored symptomatic mandibular first molar tooth. The smaller the restoration and the greater distance between the restoration and the pulp (double arrow), the greater the chance the tooth has a deep mesiodistal crack.

Fig. 13-15 Example of cracks in teeth. (A) A cracked cusp. Note the change in color of the tooth structure at the pulpo-axial line angle (arrow) and the crack across the distal marginal ridge. (B) A cracked tooth. Note the stained line extending mesiodistally across the pulpal floor (arrows).

Fig. 13-16 Cracks involving the two lingual cusps of a second molar are clearly seen when the cavity preparation is filled with water; light refraction makes the cracks easier to see.

Fig. 13-17 Favorable (cuspal) crack. Note in the preoperative image (A) the difference in color between the buccal cusps and the mesiopalatal cusp, which is cracked. Staining shows the presence of a crack across the mesial marginal ridge (arrow). Removal of the restoration (B) reveals that the mesiopalatal cusp is cracked (arrows).

Fig. 13-18 A favorable (cuspal) fracture which has involved the pulp.

Fig. 13-19 Unfavorable cracks pass deeply into tooth structure. In (A), an unfavorable mesiodistal crack in an unrestored lower molar has been stained with Methylene Blue. In (B), an unfavorable crack can be seen passing into the pulp chamber.

Fig. 13-20 A symptomatic tooth with two cracked lingual cusps. When the cusps were removed, a bucco-lingual unfavorable crack was also apparent.

Fig. 13-21 A split tooth. A mesiodistal fracture has resulted in a complete separation of a lingual crown-root segment from the rest of the tooth.

Fig. 13-22 A maxillary second premolar with a cracked palatal cusp. Examination of the occlusion is an important part of treatment planning for such a cracked tooth.

Chapter 14

Fig. 14-1 The masseter muscle can refer pain (red) to the head and orofacial region, principally to the posterior teeth and infraorbital areas. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-2 The temporalis muscle can refer pain (red) to the head and orofacial region, principally to the maxillary teeth and temporal areas. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-3 The digastric muscle can refer pain (red) to the head and orofacial region, principally to the lower anterior teeth and posterior auricular areas. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-4 The sternocleidomastoid muscle can refer pain (red) to the head and orofacial region, principally to the posterior auricular and peri-orbital regions. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-5 Referral patterns for the medial pterygoid are illustrated in red. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-6 Referral patterns for the lateral pterygoid are illustrated in red. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-7 Referral patterns for the trapezius muscle are illustrated in red. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 14-8 Magnetic resonance imaging (MRI) images of the temporomandibular joint. (A) In the normal closed position, the disc (arrow) is positioned between the condyle and the articular eminence. (B) In the normal open position, the disc remains between the condyle and the eminence. (C) In the DDWR closed position, the disc is anteriorly displaced. (D) In the DDWR open position, the disc reduces into position between the condyle and the eminence. (E) In the DDWOR closed position, the disc is displaced anteriorly. (F) In the DDRWOD opening position, the disc remains displaced anteriorly throughout the range of movement. DDWR, disc displacement with reduction; DDWOR, disc displacement without reduction.

Fig. 14-9 CBCT imaging – cross-sections through condylar heads showing some morphological and radiological variations that can occur during remodeling, degenerative changes and disease processes.

Chapter 15

Fig. 15-1 The upper trapezius can refer pain to the angle and lower border of the mandible and into the temporal as well as suboccipitally. Trigger points are marked as X. Referral pattern from the trigger point is dotted.

Fig. 15-2 The SCM can refer pain (red) to the head and orofacial region, principally to the ear, TMJ, supraorbital and suboccipital. Trigger points are marked with an X. Referral pattern from the trigger point is dotted.

Fig. 15-3 Observe the patient’s forward head and elevated, rounded shoulder positions to help brace and protect inflamed structures.(A) In good posture the patient has a good upright position.(B) In poor posture the patient has a head-forward position and rounded shoulders. He has weak abdominal muscles and a sway back.(C) In poor posture the patient has a head forward position and rounded shoulders. He also has a relatively flat back and compensates for this by bending his knees forwards.

Fig. 15-4 Scalloping on the sides of the tongue due to the tongue being thrust laterally against the mandibular teeth as a postural prop to help stabilize the neck.

Fig. 15-5 Posterior view of the cervical spine and the occipital bone. The suboccipital region is drawn over the diagram in dark blue. Sensitivity to palpation of the upper cervical spine in this area is a strong indicator of a regional problem – occipital bone (ocher) and vertebrae (light blue).

Fig. 15-6 Assessment of cervical spine rotation. In (A), the chin in alignment with the shoulder at a full 80-degree rotation range to the right, while (B) shows a restriction of movement to the left with the chin forward of the shoulder at end of available range.

Fig. 15-7 Assessment of rotation in forward flexion, indicative of C0–2 segmental range of motion, which accounts for approximately 50% of the whole neck range. In (A), there is little restriction of movement as indicated by the chin alignment half-way across the clavicle. C0–2 segmental restriction is evident in (B), where chin alignment is only one-quarter across the clavicle.

Chapter 16

Fig. 16-1 The relative positions of the maxillary (beige), frontal (purple), ethmoid (blue) and sphenoid (red) sinuses are shown.

Fig. 16-2 Stimulation of the turbinates (a) can cause referred pain to all maxillary teeth. Stimulation of the ostium (b) can cause referred pain to maxillary molars

Fig. 16-3 Stimulation of the turbinates (a) can cause referred pain on the medial aspect of eyes and cheek. Stimulation of ostium (b) causes pain to be referred to the infraorbital and temporal regions

Fig. 16-4 Patient presented in acute pain of two weeks’ duration. The maxillary second and third molars were vital, mobile and very tender to percussion. The patient was in severe pain. A diagnosis of acute maxillary sinusitis was made based on radiographic diagnosis.

Fig. 16-5 Cone beam computed tomography (CBCT) images of lesion of endodontic origin from the non-vital maxillary first molar resulting in sinus mucositis, which is seen as a non-corticated thickening (arrows) of the sinus mucosa.

Fig. 16-6 An antral halo effect (arrows) due to the presence of a periapical lesion of endodontic origin on the maxillary right second molar showing a characteristic radiopaque outline.

Fig. 16-7 Periapical radiograph of a patient who had persistent rhinosinusitis for 12 years, which resolved after the separated K-file was removed from the mesiobuccal canal during endodontic retreatment.

Fig. 16-8 CBCT images of the patient in figure 16-6. (A). The circumferential lesion of endodontic origin (arrows) expanding into the maxillary sinus can be seen. Note the corticated border around the halo and that the maxillary sinus is otherwise clear. The association of the lesion with the maxillary second molar can be seen. (B) Close examination of sagittal slices revealed a two-rooted molar with under-filled mesiobuccal root canals.

Fig. 16-9 A panoramic radiograph (OPG) showing radio-opaque foreign (endodontic filling material from a previously treated tooth that was extracted) material in the right maxillary sinus with sinus opacity (arrow). The maxillary sinus on the left is clear, while the one on the right is completely obstructed by the filling material and the mucositis associated with it. The maxillary right first molar was non-vital and may have contributed to the ongoing problems (see below).

Fig. 16-10 Sagittal CBCT section (A) through the palatal root of the maxillary right first molar in Fig. 16-8A, showing a break in continuity of the palatal cortex at the root apex (arrow c) and the communication with maxillary sinus. Caries is seen as a radiolucency under the palatal margin of the crown (arrow a). The extruded filling material from extracted, previously endodontically treated teeth (arrow b) is clearly visible. Note the limited information provided by periapical radiograph (B) of the caries and the break in the continuity of the lamina dura.

Fig. 16-11 A space-filling maxillary sinus carcinoma which presented for diagnosis as orofacial pain.

Fig. 16-12 Maxillary sinus carcinoma. The clinical and radiographic appearance mimicked an endodontic lesion. The irregular outline of the lesion and lack of healing after endodontic treatment should arouse suspicion of a non-dental cause.

Chapter 18

Fig. 18-1 A patient with cluster headache. Note the unilateral nature of the pain, Horner’s syndrome, redness of the eye, redness on the cheek and nasal discharge.

Fig. 18-2 Diagrammatic representation of a patient with cluster headache exhibiting Horner’s syndrome. Note the unilateral drooping (ptosis) of the eyelid and constricted pupil (miosis) as well as the tearing and the sub-conjunctival injection (red eye).

Chapter 19

Fig. 19-1 Distribution and course of the three divisions of the trigeminal nerve. The ophthalmic branch (V1) (blue) conducts sensation from the scalp, forehead, front of nose and eye. The maxillary branch (V2) (lavender) conducts sensation from the cheek, upper jaw, top lip, gingiva and alveolar mucosa, maxillary teeth and the side of nose. The mandibular branch (V3) (ocher) conducts sensation from the lower jaw, mandibular teeth, lower lip, gingiva and alveolar mucosa.

Fig. 19-2 Axial image of an MRI brain scan showing a left-side lesion (arrow) in the pons within the brainstem.

Fig. 19-3 Sagittal MRI brain image showing a typical deep cerebral white matter lesion (arrow) seen in a multiple sclerosis patient. TN is often associated with multiple sclerosis.

Fig. 19-4 Axial MRI showing the anterior superior cerebellar artery compressing the trigeminal nerve close to where the nerve arises from the pons in the brainstem.

Fig. 19-5 Microvascular decompression surgery in which a Teflon® pad (blue) has been placed between the trigeminal nerve (TN) and an aberrant artery (red) close to where the nerve arises from the brainstem (adapted from: https: http://neurosurgery.ufl.edu/patient-care/diseases-conditions/trigeminal-neuralgia/Accessed 29 July 2015).

Chapter 20

Fig. 20-1 Photograph of a patient suffering from VZV infection two days after the first vesicles were noticed. The patient suffered severe local pain, altered sensation and allodynia along the distribution of the thoracic nerve trunk.

Fig. 20-2 Patient with severe headache above the right eye and in the temple area prior to vesicles appearing. A diagnosis of HZ was made when vesicles appeared several days later. Note: Vesicles are confined unilaterally to the distribution of the ophthalmic division (V1) of the nerve.

Fig. 20-3 Patient with HZ (V2) of CN V who presented with severe headache above the eye and in the temple area prior to vesicles appearing. Vesicles then appeared several days later. Note: Vesicles are confined to the distribution of the maxillary division.

Chapter 21

Fig. 21-1 Tender and prominent temporal artery (arrows) in a 65-year-old man who experienced sudden loss of vision in his right eye. Blood tests revealed an elevated erythrocyte sedimentation rate (ESR) and biopsy showed evidence of GCA.

Fig. 21-2 Retinal photograph depicting normal eye (A) and the swollen optic disc associated with anterior ischemic optic neuropathy (B).

Fig. 21-3 Ischemic complication involving lingual ischemia and infarction (from N. Mumoli, M. Cei, J. Vitale, F. Dentali (2015)

Tongue Necrosis in Giant-cell Arteritis

. DOI:

10.1093/qjmed/hcv099

. First published online: 15 May 2015).

Fig. 21-4 Ischemic complication involving the extra-cranial vertebral arteries resulting in occipital ischemia and infarction.

Fig. 21-5 (A) Photomicrograph of temporal artery showing transmural inflammation (original magnification 40×). (B) Obliteration of the arterial lumen by thrombosis and inflammatory tissue (original magnification 200×).

Fig. 21-6 Distribution of pain in patients suffering from a carotid dissection.

Fig. 21-7 Horner’s syndrome, a sign of carotid dissection, involves ptosis (drooping of the lower eyelid) and miosis (constriction of the pupil) on the same side.

Fig. 21-8 MRI/MRA of brain (A) revealing the signature intramural arterial hematoma (arrow). A bright crescentic signal change within the carotid artery wall can be seen on this fat-suppressed T1-weighted image. (B) Digital subtraction angiography showing narrowing of the dissected carotid artery (images courtesy of Dr N. Trost).

Chapter 22

Fig. 22-1 Pain qualities and location of the orofacial pain of a 68-year-old female with a 10-month history of pain after dental treatment in the right maxilla. Pain intensity was described as 8–9/10 (VAS). A diagnosis was made of primary neuropathic pain and secondary onset of temporomandibular disorder myofascial pain (from

Short-form McGill Pain Questionnaire

and excerpt from

Clinical Pain Inventory

in Vickers, R.D. Harris, H. Boocock and M.K. Nicholas (2006)

Orofacial Pain Problem Based Learning

. Sydney University Press 2005 Vickers (ed.), pp. 30–50).

Fig. 22-2 Intra-oral pain map of the above patient. Pain was initially in the right mandible and then spread to the tongue and left orofacial region. Pain intensity 8/10 (VAS). A diagnosis of primary neuropathic pain was made. The expansion of the pain field to other teeth and across the midline illustrates CNS maladaptive neuroplasticity.

Fig. 22-3 Intraoral pain map of a patient diagnosed with trigeminal neuropathic orofacial pain demonstrating maladaptive neuroplasticity of all quadrants and bilateral borders of the tongue.

Fig. 22-4 Extra-oral pain map of patient illustrated in Figs 22-1 and 22-2 showing spread of pain to extra-oral sites in the extremities, neck and back. The patient was also previously diagnosed with fibromyalgia. The multiple pain sites as represented in this figure of both neuropathy and fibromyalgia have central sensitization phenomena.

Fig. 22-5 Upregulation of the sympathetic nervous system. Note swelling and redness in the left cheek (arrows) in a patient with trigeminal neuropathic orofacial pain that developed after root canal treatment root canal therapy (RCT) of her maxillary left canine tooth.

Fig. 22-6 Secondary development of bilateral myofascial pain involving the masseter, temporalis and supraspinal muscle groups. A patient has marked the right cheek (black) as the initial source of neuropathic pain following trauma to the right infra-orbital nerve. The other red areas are insertions of muscle groups.

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Dedication

To Judy-Ann and LisaFor patience and understanding.

Diagnosing Dental and Orofacial Pain: A Clinical Manual

Edited by

Alex J. MouleM. Lamar Hicks

This edition first published 2017 © 2017 by John Wiley & Sons, Ltd

Registered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Names: Moule, A. J. (Alex J.), editor. | Hicks, M. Lamar, editor.Title: Diagnosing dental and orofacial pain : a clinical manual / edited by Alex J. Moule, M. Lamar Hicks.Description: Chichester, West Sussex, UK ; Ames, Iowa : John Wiley & Sons, Inc., 2017. | Includes bibliographical references and index.Identifiers: LCCN 2016022484 (print) | LCCN 2016023021 (ebook) | ISBN 9781118925003 (pbk.) | ISBN 9781118924990 (pdf) | ISBN 9781118924983 (epub)Subjects: | MESH: Facial Pain–diagnosis | Toothache–diagnosisClassification: LCC RK322 (print) | LCC RK322 (ebook) | NLM WU 140 | DDC 617.5/2–dc23LC record available at https://lccn.loc.gov/2016022484

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Contributors

Vishal R. AggarwalClinical Associate Professor in Acute Dental Care and Chronic PainSchool of Dentistry, Faculty of Medicine and HealthUniversity of LeedsLeeds, UK

Tareq Al AliFaculty of DentistryKuwait UniversityKuwait

Michael J. ApicellaRohde Dental ClinicFort Bragg, NC, USA

Scott CookDirector The Headache, Neck and Jaw Clinic(formerly Body Mechanics Physiotherapy)Brisbane, QLD, Australia

Dr Kerryn GreenConsultant NeurologistRoyal Brisbane and Women’s HospitalSenior Lecturer University of QueenslandBrisbane, QLD, Australia

M. Lamar HicksEndodontics DivisionUniversity of Maryland Dental SchoolBaltimore, MD, USA

Iven KlinebergProfessor and Head of ProsthodonticsUniversity of SydneyJaw Function and Orofacial Pain Research UnitWestmead Hospital Centre of Oral HealthWestmead, NSW, Australia

Unni KrishnanSchool of DentistryUniversity of QueenslandBrisbane, Australia

David MockProfessor and Dean EmeritusOral Medicine/Oral PathologyUniversity of TorontoToronto, ON, Canada

Alex J. MouleSchool of DentistryUniversity of QueenslandBrisbane, QLD, Australia

Chris MouleProsthodontistPrivate PracticeClinical EducatorFaculty of DentistryUniversity of SydneySydney, NSW, Australia

Mark PaineConsultant Neurologist/Neuro-ophthalmologistAlexandra NeurologyBrisbane, QLD, Australia

E. Russell VickersOral and Maxillofacial SurgeonUniversity of Sydney Medical SchoolSydney, NSW, Australia

Andrew D. WolvinDepartment of CommunicationUniversity of MarylandCollege Park, MD, USA

ILLUSTRATIONSJerry LiuJerry Liu Design and PhotographyBrisbane, QLD, Australia

Acknowledgments

I must acknowledge the many clinicians, colleagues, authors and lecturers who have assisted with this manual over so many years. It has been over twenty years in the making. Much of the information in it has been gleaned from over forty years of clinical practice treating patients presenting with orofacial pain. The source of information is often clouded by time, and my thanks must go to the countless colleagues with whom I have discussed the management of patients.

My thanks also to the many authors who have contributed to this project, without whom this manual would never had been written, and to many friends and family who willed it to completion. I thank my colleagues at the Faculty of Dentistry, Kuwait University, for their support and friendship as I worked on this manuscript.

Thank you Jerry Liu for the illustrations, and a heartfelt thanks to my co-editor, Lamar Hicks, who reviewed chapter after chapter and brought them all to life. My love and thanks to my wife, Judy-Ann, and my sons and daughter who have all travelled this long editorial journey with me.

Alex J. Moule

About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/moule/dental_and_orofacial_pain

The website includes:

Case studies that serve as examples for several chapters

22 videos that are cited throughout the book

Clinical Pain Inventory Form

Personal Pain Plan by the Australian Pain Management Association (APMA).

Chapter 1Introduction

Alex J. Moule and M. Lamar Hicks

Introduction

Clinicians are called upon to diagnose orofacial pain on a daily basis. For the most part, diagnosis is a routine procedure which is accomplished without too much difficulty. Most painful conditions follow certain predictable patterns and exhibit specific signs and symptoms which, when observed, make diagnosis a relatively easy task to perform. Patients do present, however, where diagnosis is especially difficult and where pain patterns do not follow recognized norms. Many of these difficult cases can have unsatisfactory outcomes for both patients and practitioners.

There are numerous textbooks that deal with pain diagnosis. Most of these provide a comprehensive review of the signs, symptoms and pathology associated with the various conditions that can cause facial pain. Few deal with the actual process of diagnosing orofacial pain, and even fewer deal in any detail with the specific questions and tests that are required to establish a diagnosis for each condition.

This manual addresses some of the difficulties in assessing patients with orofacial pain by focusing onthe questions that need to be asked and analyzing responses of patients to these questions. This is in contrast to just describing the various painful conditions. Particular attention is paid to the meaning of descriptors patients use when describing pain.

From a practical point of view, the initial task for a practitioner in assessing a patient with orofacial pain is a reasonably simple process: to establish whether the patient has a dental pain problem, a treatable non-dental pain problem, or a pain problem that requires referral to a dental or medical specialist. Once this broad sorting is carried out, more specific diagnosis and treatment planning can take place for each condition. To place the patient into one of these categories is often relatively uncomplicated. Nevertheless, mistakes often occur because practitioners jump to conclusions before assessing all of the facts, and because insufficient information is gathered before a diagnosis is made. Thus, when diagnosing pain, history is more important than testing. Indeed, it is the history that dictates the tests to perform. History is obtained by asking appropriate questions. Diagnosis is based on:

Observing the patient (“

What should I look for

?”)

Knowing the questions to ask (“

What should I ask

?”)

Analyzing the answers received (“

What does this answer mean?” “What else do I need to know?

”)

Performing appropriate tests

Applying all this information to the task of identifying the problem.

When diagnosing pain, there are two broad categories of questions that the clinician must be able to use. The first category is a series of general sorting or screening questions that elicit a broad picture of the pain profile. These form the basis for asking the second category of questions, which are specific screening questions used for a particular pain state (e.g. dental pain, muscle pain, trigeminal neuralgia, cluster headache). Unless a practitioner is aware of the specific questions that relate to the different pain states, an accurate diagnosis of challenging pain cases is difficult or impossible to make.

Mistakes in diagnosis are often made when clinicians approach the diagnosis too quickly without first analyzing the patient’s responses to questions, and when attempts are made to make thefacts fit a diagnosis rather than make the diagnosis fit the facts.

When confronted with any diagnostic situation it is helpful to remember a “golden rule”:

If it doesn’t add up, it doesn’t add up.

When confronted with any diagnostic situation that does not add up, it is helpful to remember a second “golden rule”:

If it doesn’t add up, then review it again or refer.

Similarly, if confronted with any diagnostic situation that does not add up and does not respond to initial treatment, it is helpful to remember a third important rule:

Do not “walk” along teeth.

When confronted with a patient with a complex pain problem, great care should be taken not to keep trying to find a dental cause by treating one tooth after another in an attempt to relieve pain that may or may not be dental in origin. Before treatment is initiated, an accurate diagnosis must be established (Fig. 1-1).

Fig. 1-1 A patient with non-dental pain who had multiple restorations and endodontic procedures in an unsuccessful attempt to relieve orofacial pain.

In the following chapters, the causes of orofacial pain will be identified and explained and the diagnostic processes that are necessary to arrive at an accurate diagnosis will be discussed. Particular attention is placed on:

How to record a pain profile

How to listen to and observe a patient in pain

How to analyze responses to questions

How to formulate questions.

Specific screening questions are described for each pain condition. Short and long case reports are presented in the accompanying e-web material.

Chapter 2The Art of Listening – Communicating Effectively with a Patient in Pain

Andrew D. Wolvin

Introduction

Good health care is a partnership between the patient and the clinician – and with the rest of a clinical team. The center of this partnership is effective communication. Research reinforces that “communication between clinicians and patients has been recognized as an integral part of providing optimum patient care.”1