history and a list of medications the patient is currently taking. The medical history could provide clues for the diagnosis (e.g., general osteoarthritis, fibromyalgia, other systemic or autoimmune disease) or could reveal conditions that might impact the treatment plan (e.g., presence of ulcers, diabetes, or asthma). Obtaining a complete list of medications is important because of the many drug interactions among medications typically prescribed for chronic pain conditions. Sleep history A simple screening might suffice to determine poor, non- restorative sleep, and could include questions about total sleep time, how long it takes a person to fall asleep, frequent awakenings, presence of snoring or sleep apnea (i.e., waking up gasping for air), presence of daytime sleepiness, and presence of poor sleep hygiene habits (e.g., playing computer games in bed, watching exciting movies or disturbing news programs in bed). Sleep disturbances can be identified by the use of validated questionnaires such as the Pittsburgh Sleep Quality Index (Contained in: Nijs, et al., 2018). Screening tools for sleep- disordered breathing include the Epworth Sleepiness Scale (Hirotsu, et al, 2019) and the STOP-Bang questionnaire (Waseem, et al., 2021). If sleep-disordered breathing is suspected, the dental practitioner should refer the patient for more in-depth assessment. Psychosocial history A short questionnaire that the dental practitioner could use to screen for depression and anxiety and the need for appropriate referral is the four-item Patient Health Questionnaire (Ghaheri, et al., 2020). The four items ask the patient to rate on a 0 to 3 scale, where 0 means “not at all” and 3 means “nearly every day,” how much he or she has been bothered over the past 2 weeks by feelings of nervousness, worry, loss of interest, and depression/hopelessness. Another instrument used to assess the degree to which pain interferes with a patient’s life is the Chronic Pain Graded Scale (Von Korf, et al., 2020). The Chronic Pain Graded Scale is an eight-item scale that asks questions about pain severity and requests that the patient rate the degree to which the pain has interfered over the past 30 days with his or her ability to perform various activities, ranging from usual (work, school, housework) activities to recreational and family activities, on an 11-point numeric rating scale. The scale provides a grade of pain intensity and pain disability. The Posttraumatic Stress Disorder Checklist is a 20-item questionnaire that screens for posttraumatic stress disorder (United States Department of Veterans Affairs, 2021). This checklist has recently been updated to incorporate changes in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5, 2013).When use of this tool indicates possible posttraumatic stress disorder, appropriate referral for more in- depth assessment should be made. These instruments are freely available and easy to score. Several other instruments exist to assess for psychometric variables, but fall outside the scope of dental practice. If significant psychopathology is suspected, the patient should be referred to a mental health professional. signs should also be recorded, and these could include blood pressure, heart and respiration rate, temperature, height, and weight. A cranial nerve screening also is appropriate for patients experiencing chronic pain (Table 2). The screening should focus on equal function between right and left structures and sides.
patient states that the pain does not keep her from sleeping [sleep history], but does prevent her from drinking and eating and even brushing her teeth on the affected side [pain interference]. The patient is grabbing her face when the pain attacks [pain behavior]. The patient reports that she cannot live with this kind of pain, but denies suicidal ideation [psychosocial stressors]. In addition to the above elements pertaining to the pain history, the dental practitioner should of course also obtain a medical Self-report instruments So many validated self-report instruments to assess pain and its impact are available that the real challenge is deciding which measures are the most useful within a given practice setting. Some measures are comprehensive, assessing all aspects of the pain experience, whereas others are designed to measure only particular pain dimensions. Some measures are short enough to be included in a routine clinic screening; others are lengthy research instruments requiring the interviewee to respond to hundreds of questions about his or her pain. Some are freely available for use, while others carry per-use fees or require subscriptions for scoring. Various measures are described below based on evidence of their validity and reliability and anecdotal experience of the utility and practicality of each measure. History In some cases, when the history of the chief complaint is not clear or when the patient has not identified precipitating or aggravating factors, a pain diary can be employed as a way of assessing recent pain history. These diaries ask individuals to rate certain pain qualities (e.g., intensity, duration, location) as well as certain coping efforts, multiple times each day, over a specified period (e.g., 1 week or 1 month). Although traditionally pain diaries have used pen and paper, more recent efforts have employed smartphones to collect pain diary information (Sundararaman, et al., 2017; Zhao, et al., 2019). There is no standardized format for pain diaries, and the assessing clinician can include whatever pain-related information will be most useful for treatment planning. Alternatively, the clinician could refer the patient to one of numerous cost-free pain diary apps available for electronic devices (e.g., Chronic Pain Tracker Lite, Headache Diary, My Migraine Triggers, CatchMyPain, My Pain Diary Lite, and Stop Headaches). Pain location and quality The McGill Pain Questionnaire was developed by Dr. Ronald Melzack and Dr.Warren Torerson of McGill University in 1975 and is still one of the most widely used means to use a numerical scale which provides a quantitative measurement of pain. It includes a good assessment of pain quality as well as a body diagram on which people with chronic pain can indicate where their pain is located (Siemann, 2017). Importantly, this measure is suitable only for use with English speakers because attempts to translate words from the McGill Pain Questionnaire into other languages have been problematic (Flor & Turk, 2011).
Techniques for clinical assessment General inspection
A general inspection involves an overall assessment of the patient and could include items such as gait, posture, general appearance, and signs of distress, as well as asymmetry, scars, lumps, and bumps in the head, neck, and face region. Vital
Table 2: Cranial Nerve Screening Nerve Number Nerve Name
Function
Screening Test
Olfactory a
I
Smell.
Have patient detect differences between odors such as peppermint, coffee, and vanilla.
Optic a
II
Vision. Detection of light.
Check visual field; check gross vision.
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