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    Diagnosing Dental and Orofacial Pain: A Clinical Manual
    Diagnosing Dental and Orofacial Pain: A Clinical Manual
    Diagnosing Dental and Orofacial Pain: A Clinical Manual
    Ebook565 pages4 hours

    Diagnosing Dental and Orofacial Pain: A Clinical Manual

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    About this ebook

    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
    LanguageEnglish
    PublisherWiley
    Release dateSep 27, 2016
    ISBN9781118924983
    Diagnosing Dental and Orofacial Pain: A Clinical Manual

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      Book preview

      Diagnosing Dental and Orofacial Pain - Alex J. Moule

      Chapter 1

      Introduction

      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 on the 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 the facts 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).

      Photo of a patient's mandibular teeth presenting multiple restorations and endodontic procedures.

      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 2

      The 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 This clinician–patient partnership should be built on a relationship of trust. It requires that the clinician be comforting, caring and encouraging, asking and answering questions, offering clear explanations, and listening and checking understanding.² Most patients who have orofacial pain seek advice first from a dentist. It is especially important with these patients to establish trust and develop good dentist–patient communication, which has been described as one that is purposeful: creating a good interpersonal relationship, exchanging information and deciding on the best course of treatment.³ Not surprisingly, most of the focus in studies of dentist–patient communication has centered on dentists, with little attention to the communication needs of patients themselves. A national survey, for example, which asked dentists about their communication strategies⁴ determined that good strategies that can be used include interpersonal communication, the teach-back method, patient-friendly materials and aids, the offering of assistance, and a patient-friendly practice. These communication techniques are what the dentist should say and/or do in interactions with patients.

      However, since communication is a keystone of good patient care, it can be helpful to look more broadly at dentist–patient communication, not as dentist-centered, but as listening-centered. As the research stresses, communicating clinicians not only should utilize effective speaking skills, but also must engage in careful listening. Good clinical practice requires that you listen with your ears and your eyes to assess what you and the patient need to know, and what the patient already knows and wants to know.⁵ It is important to start any interaction with good listening.⁶ It is important to your diagnosis to know what the patient is experiencing and, to explore this, consider beginning your interaction with small talk that can help to establish a basic level of communication comfort. This often overlooked step is important for your patient to feel as much at ease as is possible in their interaction with you. This is challenging, of course, because if the patient has a significant orofacial pain problem, they will undoubtedly be apprehensive about what is wrong and what you will need to do to resolve the problem.

      Beginning your interaction with small talk is time well spent, however, because you can learn a great deal about a patient’s issue by listening perceptively to them in the beginning. Consider not starting out with the traditional "How are you? greeting as a patient, understandably, cannot return the standard Fine, thanks response – thinking rather, I’m here for you to determine how I am! Instead, starting out with answerable questions such as: What is the temperature outside today? or How is the traffic out there? or You must be a Nationals fan?" can help you establish rapport and in the process reduce your patient’s

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