Evaluation of the dental patient who presents with jaw or  face pain of nonodontogenic origin is an important skill for the dentist to master. Obtaining an accurate history is the most important component of information gathering.For chronic headache disorders and many neuropathic disorders, such as TN, pre-TN, and other cranial neural–
.glas, as well as burning mouth syndrome~:generally no abnormality is found on physical examination; therefore  the clinician must rely on the verbal history to arrive at anaccurate diagnosis. Chronic headache disorders based on symptom description are presented in Table 29-3.
The pain history should include the chid complaint,  including the current description of pain quality (e.g.,aching! throbbing, burning, shocklike, paroxysmal, or some combination), intensity, when it occurs, how long
it lasts, if it changes in character over time, precipitating factors, and alleviating factors, The history of the present illness should include date of onset, circumstances surrounding onset, how the pain evolved over time, diagnostic tests undertaken, diagnoses rendered, what treatments were instituted in the _past, and the response to those treatments. Finally, a comprehensive medral and dental history should be taken. Most commonly a short differential diagnostic list can be made at this time.

BOX 29-3

Differential Diagnoses of Common Headaches

Differential Diagnoses of Common Headaches
Migraine _Cluster ——T-en-s-io-n——–
Onset —- A-cu-te-o-r ch-ronic ——- Acu-te – — — –Ac-u-te– —
Location. Localized Unila!~~1 (40%) Unilateral –
Associated Weight loss, polymyalgia, Nausea, vomiting, Rhinorrhea,
symptoms rheumatica, fever, photophobia, lacrimation of
decreased vision, jaw phonophobia ipsilateral side
claudi ion
Temporal Arteritis
Chronic – _—“”__ ••• _ 0.-
.–9lobal, unil~-:.r~~_
complaints (?)
Pain character Severe throbbing over Throbbing
— – —– area affected
_P!:i.9rHX (=)
Diagnostic test ESR(+)
PE Tender temporal arteries,
myalgias, fever
Sharp stabbing Aching
-“-3…:..0_m’-‘-in_-2-“–h-‘.0_-u:-‘Drs~y _
(+) (.±L _
None-history None-history
Unilateral, rhinorrhea, (-)
lacrimation, partial
_______ Prolonged
Nausea, vomiting,


physical examination will attempt to narrow this list to obtain a working diagnosis. The physical evaluation should Include all aspects of the
normal de ntal evaluation, including vital signs determina- -, tion, intraoral examination with oral cancer screening, and head and neck examination with an evaluation of the temporal and carotid arteries, lymph nodes, skin, head, and neck, as well as myofascial and temporomandibular joint (TMJ) examination. In addition, a cranial nerve screening examinati<J1_ should be performed. It is understood that most dentists would not include all aspects of the formal neurologic examination, such as fundoscopic examination and testing of ability to smell, in this screening. See Box
29-10 for cranial screening evaluation. This latter exarnina- .tion is frequently an attempt to detect areas of hyperesthesia or hyperalgesia, allodynia, a trigger zone for TN, or an area of decreased sensation. In addition, it is important to define whether the pain follows normal neuroanat mic boundaries and, if so, to define these areas. Diagnostic anesthetic testing, usually with a vasoconstrictor-free solution,
is appropricllte to help define whether a suspected neuropathic pain condition has a significant peripheral component perpetuating pain. .
When a peripheral component occurs, local anest esia may arrest the pain for the duration of anesthesia. Most  commonly local anesthesia is applied to increasingly largerneuroa natomic regions. For instance, with a pain in
the region of the mandibular canine, topical anesthesia in the anterior mandibular gingiva is applied. If pain is  not arrested, the response to infiltration anesthesja is assessed. If no response is seen, a mental block (sparing  he lingual nerve) is attempted and, finally, inferior alveolar
and lingual nerve block anesthesia is undertaken if pain has not yet been alleviated. At each test any alter- J:i,m in pain response i< .,,,,,:01
. Imaging is appropriate for many disorders to rule out . all odontogenic, sinus, or bony pathology, The orthopan to graph is helpful when supported by selected dental periapical

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