measured in millimeters and used for comparison against previous or subsequent assessments. ● The NRS asks patients to verbally rate their pain by giving a number on a scale from 0, meaning “no pain,” to 10, meaning “worst pain imaginable.” ● The VRS asks patients to choose from a list of words describing current pain intensity (e.g., Mild, Moderate, Severe, Excruciating). ● For children, a scale with different degrees of sad and happy faces can be used (Wong-Baker FACES Pain Rating Scale). ● For patients with cognitive problems such as Alzheimer’s disease or another form of dementia, a colored analogue scale appears to be best understood. In general, individuals with pain are able to characterize their pain intensity quickly and easily by using a numeric rating (e.g., on a scale of 0 to 10, with 0 being “no pain” and 10 being “the worst pain imaginable”). Pain quality Pain quality refers to the descriptive sensation of pain – whether it is cramping, sharp, dull, stabbing, burning, aching, throbbing, or intermittent, for example. A thorough evaluation of pain quality can help with proper diagnosis and treatment. For instance, a migraine is typically described as throbbing or pulsating, whereas a tension-type headache is more likely described as tight, pressing, or vice-like. The typical sensation of trigeminal neuralgia is described as electric shock-like, whereas a continuous neuropathic pain is described as gnawing, aching, and burning. Musculoskeletal pain can be described as a dull aching (often muscle pain) or sharp and throbbing (often joint pain). The patient should be asked to describe the pain. If the patient does not understand the question, the provider could list pain descriptors without emphasizing one or another. Sometimes a patient will describe his or her pain in terms of emotional concepts (e.g., punishing, overwhelming, aggravating). A useful tool to help a patient describe pain is the McGill Pain Questionnaire, which contains a thorough list of pain descriptors. Pain frequency and duration It is important to know how long an episode of pain lasts. For instance, one type of neuropathic pain is short-lasting, whereas other types are continuous. Even the short-lasting pains may be frequent and intense and have a major impact on a patient’s quality of life. The duration of pain can be recorded in seconds, minutes, hours, or even days. The dental practitioner should also ask whether there are periods of remission and, if so, for how long (e.g., hours, days, or months). Pain modulating factors It is important for the clinician to know what brings the pain on, what makes it worse, and what makes it better. Some excruciating pain conditions are brought on by the light touch involved in such activities as shaving or putting on makeup. This characteristic is a classical feature of trigeminal neuralgia. If jaw function, such as chewing or opening the mouth wide, worsens the pain in a patient who complains of jaw pain, a temporomandibular disorder may be the cause. Conversely, if jaw function does not aggravate the pain of a patient reporting jaw pain, the source of the pain is not likely to be the masticatory muscles or the temporomandibular joints. Discovering aggravating factors such as eating crunchy or chewy foods, stress, clenching the teeth, or poor posture may also lead to helpful treatment avenues. Failure to elicit information on the presence of such factors may contribute to treatment failure. Associated symptoms Patients may be asked about symptoms often associated with migraines, namely nausea, vomiting, and sensitivity to light or noises. Symptoms such as redness, drooping, or tearing of the eye may be indicative of a group of rare headaches called trigeminal autonomic cephalalgias . Patients may complain of sensory changes, such as (unexplained) numbness, loss of hearing, vision disturbances, and alterations in the ability to smell or taste. Such symptoms are red flags for cranial nerve
pathologies, and patients presenting with such symptoms should be referred to a neurologist for further evaluation. Sleep history Pain and sleep disturbances often occur together. Pain can cause sleep disturbances, and lack of sleep can cause or aggravate pain (Nijs, et al, 2018). For a comprehensive treatment plan, it is therefore important to identify sleep disturbances and have them addressed by the appropriate healthcare professional. Psychosocial history It is also important to consider the psychosocial history of the patient because chronic pain is often associated with depression and anxiety. Several studies have shown that patients with temporomandibular disorders have higher rates of psychosocial problems than the general population, especially those with masticatory muscle pain or those with combined temporomandibular disorders (Florjanski and Orzeszek, 2021; Yadav, et al, 2020; Jung et al., 2020). The prevalence of posttraumatic stress disorder is also higher in chronic pain populations than in the general population (Conversano, 2019; Ravn and Andersen, 2020). Questions about traumatic life events are therefore prudent. Patients who present with chronic pain should also be assessed for suicidal or homicidal ideation. Pain interference refers to the degree to which pain has created limitations in social, occupational, and physical functioning. For example, an individual with pain may limit his or her socializing or may have trouble focusing at work. Measures of pain interference tend to be highly correlated with measures of pain affect since interference tends to lead to negative mood states. A good question to ask would be, “What has the pain stopped you from doing?” As discussed earlier in the course, pain behaviors are the behaviors that people exhibit when in pain, either to alleviate their distress or to communicate to others that they are experiencing pain or suffering. Some of these behaviors may be under individual control (e.g., verbal reports, holding or rubbing an affected area), whereas others are often involuntary (e.g., wincing). Pain coping refers to an individual’s attempts to manage his or her pain or suffering. Coping may include a broad range of behaviors, ranging from coping efforts generally believed to be positive or helpful (physical exercise, seeking social support) to those believed to be unhelpful or detrimental (social avoidance, helplessness behaviors, alcohol consumption, inactivity, social isolation). Pain cognitions refer to an individual’s core beliefs about his or her pain. As previously described, these cognitions may include the belief that pain represents damage, that pain is unmanageable or catastrophic, or that there is a medical cure for the pain. Catastrophizing, which involves engaging in thoughts and statements that exaggerate the threat or negative consequences of pain, has been associated with higher levels of pain intensity and dysfunction in numerous pain populations (Petrini and Arendt- Nielsen, 2020). Conversely, belief in one’s ability to maintain control over pain has been shown to predict better psychological and physical function and a decreased perception of pain. (Vanhaudenhuyse, et al., 2018). The goal of assessing these key elements is to identify recognizable patterns in order to categorize the pain complaint and assess the emotional impact the pain has on the patient’s life. Identifying aggravating and alleviating factors also helps in developing a treatment plan. The following history highlights effective assessment of the key elements: An elderly lady describes a pain that started three weeks ago without a precipitating event [onset] as electric-shock-like pain [quality] of excruciating intensity [intensity], brought on by light touch [modulating factors], occurring at least 20 times a day [frequency] and lasting less than a minute [duration], not influenced by pain medication [modulating factors], and without any other associated symptoms. The
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