¶Guide to perform an OFP patient’s interview, diagnosis, and treatment plan
*Notes in italicare clues for diagnosis or management.
In general, a patient will complete forms related to medical history and review of systems prior to the clinical encounter. In some cases, that will include specific questionnaires or inventories, such as McGuill, Sleep scales, Depression or Anxiety scales, and others. If such forms are available, the clinician might review those prior to the medical interview and examination.
Posture (Standing, Walking, balance or involuntary movements, Lordosis or scoliosis). (Note: Looking for imbalance, vertigo, cervical or lumbar problems).
Oriented in time, place, and purpose; Communication ability. (Note: Looking for cognitive challenges and overdramatization).
Speech issues. (Note: Looking for oral conditions, neurological disorders, or dysarthria).
Travel. (Note: Related with specific diseases such as Lyme).
Nourishment. (Note: Looking for general health. Ask for recent weight gain or loss. Include recent fatigue).
Behavior. (Note: Secondary to guarding, severe pain, high anxiety, need for attention, somatization).
Legal Any litigation involved?
YOU CAN DO HPI OR PMH FIRST. HERE, PMH AND ROS IS INCLUDED FIRST.
Go over medical history, surgeries, hospitalization, medications, and allergies. A good trick is to put yourself in the patient's position and answer: What does a doctor need to know about me?
Do you have any current medical problems? If so, list them. (Note: consider asking for shingles).
Are you under treatment for those conditions?
Are you taking any medication (including OTC), or have done so in the last 6 months?
Prone to side effects or resistant to medications? (Note: Is this patient hesitant to take medications?)
Are you taking any vitamins or natural products for any medical condition? (Note: consider pharmacophobic patients)
Have you been hospitalized or seen in the emergency room for any reason?
Have you had any type of surgery? (ambulatory as well). (Note: Consider trauma from intubation).
Allergies. (Note: Special attention to any possible interaction or medication reaction).
Dental care
Note: If the chief complaint is related to dental pain, more details regarding past treatments is required. Specially important if the patient had pain previous to any procedure.
Do you have regular dental care? When was your last visit?
Recent dental treatments? If so, describe to the best of your knowledge.
Have you have any problems during a dental appointment, including bad reactions to anesthetics, jaw lock or pain, difficult to heal extractions, persistent pain)?
Psychosocial history
Note: Start with a general question such as: “Tell me about yourself” (job, daily activities, routine, stress management).
What do you do? What is your occupation and how a regular day looks like?
Have you taken time off recently?
Is the patient single, married, divorced, separated, or widowed? Children? Hobbies?
How much stress do you have, and what do you do to handle it.
What your social life looks like?
Have you been depressed or felt lonely? If so, how do you deal with that?
Anxiety or overwhelming feelings? If so, how do you deal with that?
Impact of disease or condition in mood and behavior.
Caffeine? Tobacco usage? Alcohol intake? Marijuana or other drugs? If so, how frequently.
Habits: nail-biting, clenching, lip biting (Note: if so, include in the treatment plan to encourage and support breaking those habits).
Do you have a support system (family, friends, groups, church)?
Do you see or have you seen a psychiatrist, psychologist, or social worker?
Family History
Any member of your immediate family with similar problems as yours?
Any conditions in your immediate family, such as diabetes, cancer, or any hereditary disease?
Anyone in your family with headaches or chronic pain?
If more than one chief complain needs the info on each one! A good mneumonic is OPQRSTU
Onset
Do you recall when did this started?
Can you identify a specific situation that triggered this?
Was the onset abrupt or evolved from a minor situation?
Have you had a similar situation in the past?
Can you identify any trauma in head or neck (direct or indirect, macro or micro).
Pattern, Provokes, Palliates
Is the pain continuous or episodic?
If episodic, how frequent it is? Per day, week, or month.
If episodic, how long does it last?
Duration
What makes the pain worse? (Note: if increases with head movement, consider cervical pain, sinusitis. If toothache increases with physical exertion consider cardiac problems).(Note: remember to ask what aggravates and what triggers the pain).
What makes the pain better?
Does the pain wake you up (Note: consider cervical pain)
Quality
Could you describe the pain using specific words (pressure, dull, achy, throbbing, burning). (Note: Use descriptors from McGuill inventory).
Have you noticed any other symptoms when you have the pain? (sensory, autonomic or motor).
Region / Radiation
Can you point to me where the pain is?
Can you show me the area of pain?
Is the pain extra and/or intraoral?
Is the pain always in the same area or moves around? (Note: is referred or radiated pain?).
Is the referred pain always from and to the same location?
Has the area of the pain increased or decreased in size?
Do you have pain (similar or not) in other parts of your body?
Severity
How severe the pain is from 0-10 (if the intensity fluctuated, give a range).
Is it more severe at any specific time during the day?
Treatments
Have you been treated by someone else? If so, what type of treatment did you receive.
Do you have any imaging for this problem?
Do you have any laboratory tests for this problem?
Have you been prescribed medications, if so, could you mention which ones and if possible, dosage and time of usage? Any of those showed efficacy at any given moment? Please comment on side effects as well.
Have you tried any physical therapy modality (in office or home-based). If so, did that help?
Have you tried alternative or complementary treatments? If so, did that help?
Understand impact
How much does this pain interfere with your daily activities?
How much does this pain interfere in your social relationships?
Affective descriptors which describe the pain
Headache History (more detailed if it is part of the chief complaint)
Do you have frequent headaches? If so, how frequent.
Note: Use the same OPQRSTU mneumonic, and include SNOOP to rule out red flags headaches.
Onset
Long time headache or new-onset
Change in the headache pattern (Note: consider circadian and circannual for CH).
Do you have any warning symptoms before the headache begins? (aura? PRODROME: tiredness, stiff neck, difficulty in concentration?)
Morning headaches (Note: related to reduced oxygenation, consider OSA).
SNOOP
Systemic. Fever chills, jaw claudication, malignancy, immunosuppression, or HIV
Does your pain get worse with physical activity? Or Valsalva maneuver? (Note: consider all exertional headaches, Chiari, aneurysm).
Does the pain reduce by laying down? (Note: might be related with CSF level)
Quality
Could you describe the pain using specific words (pressure, dull, achy, throbbing, burning)? Use descriptors from McGuill inventory.
Have you noticed any other symptoms when you have the pain? (sensory, autonomic, or motor).
Are there any associated symptoms during an attack (Autonomic): runny nose, nasal congestion, teary eyes, full sinuses, and swelling sensation?
Do you have sound or light sensitivity during the headaches (Note: unilateral will suggest TAC).
Do you have nausea and or vomiting with the headaches
What do you do during a headache?
Does the pain go away with rest or sleep?
Region / Radiation
Can you point to me where the pain is?
Can you show me the area of pain?
Is the pain always in the same area? (Unilateral or bilateral).
Severity
How severe the pain is from 0-10 (if the intensity fluctuated, give a range).
Is it more severe at any specific time during the day?
Treatments
What treatments have you tried for the headache?
Do you have any imaging for this problem? If so, which ones.
Do you have any laboratory tests for this problem?
Have you been prescribed medications, if so, could you mention which ones and if possible, dosage and time of usage? Any of those showed efficacy at any given moment? Please comment on side effects as well.
Have you tried any physical therapy modality (in office or home-based)? If so, did that help?
Have you tried alternative or complementary treatments? If so, did that help?
Understand impact
How much does this pain interfere with your daily activities?
How much does this pain interfere with your social relationships?
Affective descriptors which describe the pain
Sleep history (more detailed if it is a sleep-relatedcomplaint)
Do you sleep well? (Note: Try to identify sleep architecture - 4 stages).
Do you snore or gasp for air while sleeping? (Note: looking for Apnea).
Grinding or clenching (Note: careful considering a stabilization splint in OSA, since it will actually aggravate it).
Previous sleep studies. (Note:If available, ask for AHI, Oxygen saturation levels, and if the values are different in supine vs. non-supine positions).
Bed Partner questionnaires would be employed, are there any relevant findings?
Do you have morning stiffness (Note: consider systemic disorders).
Nasal passage and patency – speculum and light, cover nostrils one at a time. (Note: possible contact headache and confirm with image).
Maxillary and frontal sinus (tenderness at tapping).
Rhinoscopic — acute sinusitis, membrane contacts, or other pathology (you can use otoscope). (Note: consider sinus headache. Does pain increases with head movements?)
Neck range of motion (flexion, extension, rotation, side bend) (Note: if there is referred pain during neck movements, consider cervical nerve root impingement).
Neck circumference (Note: 17 inches or more might be related with OSA)
Problems relaxing the neck
Anterior
Thyroid Gland Inspection. (Note: is it centered? Is it enlarged? Is it symmetrical?, Is there a scar?)
Carotid artery auscultation. (Note: If the Carotid Sinus senses high blood pressure, it stimulates the corresponding brain center to slow the heart down. This is the carotid sinus reflex mediated by the glossopharyngeal nerve).
Vertebral artery test. This is to evaluate the lumen of the artery by moving the neck. Insufficiency might produce ischemic attacks and stroke. (Note: important to know about the test but not performed in a dental setting)
Lateral
SCM and trapezius
Stylohioid ligament (Note: Intra or extraoral palpation. Requires radiological finding).
Transverse process of the atlas.
Brachial plexus compression (Note: patient will have numbness in the arm and lower pulse rate, consider TOS).
Posterior
Neck muscles (post occipital and paracervical muscles) and Vertebrae palpation.
Cervical sounds during movement (Note: consider arthropathy).
Note: Use 0.5-4kg of pressure per cubic centimeter. Hold for 5-20 seconds to see if you have pain and Hold for 10-20 seconds for pain referral. Your fingernail usually blanches. (not universally accepted standard).
Techniques: flat (localized myalgia – local soreness), snapping (taut band), and pincer palpation (SCM).
Anterior, middle and posterior temporalis muscle palpation
Lateral TMJ capsule palpation (Note: Use 1kg, if painful, consider otitis media as well).
Dorsal TMJ capsule palpation (Note: if painful, consider otitis media as well).
TMJ clicking or crepitus palpation and auscultation
Early or late opening click (Note: consider elongation of ligaments)
Reciprocal click (Note: the condyle is positioned more posterior than the disk during closing)
A single click at wakening (Note: Consider sticky disc secondary to reduced lubrication).
Orthopedic maneuvers
Load testing or bite maneuvers: (Note: You can distract or contract the joint manually, or you can use a tongue blade to load individual joints).
Pain at compression (manually): inflammatory pain in the joint (Note: capsular pain or arthritic pain)
Pain with a separator in the contralateral side: inflammatory pain in the joint (Note: capsular pain or arthritic pain)
Pain with a separator in the ipsilateral side: local soreness (Note: muscle pain, identify the muscle by palpation. Consider superior belly of lateral pterygoid and medial pterygoid).
Pain in retrusion by manual manipulation: retrodiscitis. (Note: Pain reduces with biting in a separator [tongue blade]. In any trauma case, consider retrodiscal pain).
Joint sounds reduction with an anterior separator (tongue blade) (Note: might indicate that providing space in the upper articular space improves condylar translation. A similar situation is achieved by opening the mouth from a protrusive position).
Protrusive jaw motion assessment (Note: especially important if a MAD appliance is indicated).
Path of oral opening (deviation or deflection) (Note: understand joint dynamics, DDWR, and muscle co-contraction. DEVIATION: a wide deviation is most likely muscle, short deviation is most likely joint. DEFLECTION: Masseter deflects ipsilaterally, Medial Pterygoid deflects contralaterally).
Dental tests (Note: rule out odontogenic).(Note: consider neurovascular pain if there is throbbing quality, and in that case do a triptan test)
Dental midline assessment
Fremitus testing
ICP contact examination using mylar (Note: if bitting hard increases pain consider Inferior belly of lateral pterygoid).
Changes in occlusion. (*Note: you can have a stable malocclusion)(Note: If there are recent changes consider lateral pterygoid spasm, retrodiscitis, capsular pain, arthritic diseases).
1 Olfactory Coffee beans or by the report (does the patient has any problems smelling)
2 Optic Ask for visual acuity. Quadrants by confrontation (visual acuity and peripheral vision) Can you read the eye chart? I am going to shine a light into your eye Right side, do the pupils have an equal reaction? Follow my finger out to the peripheral, do I see any nystagmus, diplopia, ptosis
3, 4-6 Oculomotor Trochlear and Abducens Ocular movements. H-test, tracking, and accommodation (CNIII & CNIV, CNVI); (Note: SO4, LR6, EE3 Superior oblique 4, Lateral rectus 6, Everything else is controlled by oculomotor 3). Nystagmus/diplopia/ptosis. (Note: If movements are painful consider Tolosa Hunt syndrome).
5 Trigeminal Motor and sensory. Motor by clench, Sensory by light touch, and pin-prick in each dermatomal distribution.
7 Facial expressions and taste in the anterior third of the tongue. Motor facial expressions (raise eyebrows, smile, platysma, hyperacusis when testing, sensory for taste anterior 2/3 of the tongue, Sensory - Q-tip to the anterior wall of the middle ear. (Note: If you have not, ask for a history of rash [herpex] or travel [Lyme disease]. If there are lesions on the ear consider Ramsay Hunt syndrome (herpes zoster of nervus intermedius).
8 Vestibulocochelar Balance and hearing. Weber and Rinne tests. Bilateral finger rub, without visual bias, Weber – Conductive loss, centered on forehead Normal =, No Lateralization of sound, Abnormal = defective ear hears louder (256 Hz); Rinne— Neurosensory loss, Normal = mastoid process, air conduction is louder than bone conduction.
9, 10 Glossopharyngeal and vagus. Phonation with bilateral palatal rise, swallow, gag reflex by stroking posterior tongue with a tongue blade. (Note: If the patient has pain at swallowing, does the pain reduce using a bite block? If so, consider trigeminal pain and not glossopharyngeal). (Note: Uvula deviation might indicate dysfunction of vagus).
11Accesory shoulder movement and head turn.
12 Hypoglossus tongue movements and strength. Stick out tongue observe for deviation of tongue, atrophy, Fasciculation. (Fasciculation = Borreliosis, MS, UMN damage. If the damage is in hypoglossal, the tongue deviates to the side of the problem, but if is a weakness of the genioglossus muscle will deviate to the contralateral side).
Thermal (Warm) 50C - Thermal probe or disk (Neurologically affected sites have a reduced discrimination threshold which indicates that thermal test may help to grade neuropathy.)
Motor — Test grip strength (Note: this is done to evaluate upper body strength).
Coordination — Patient walks in a straight line. Finger-to-nose, look for tremor with intention (cerebellar) and without intention that stabilizes (basal ganglia)
Reflexes — Reflex hammer to radial tendon, biceps tendon, triceps tendon, patellar tendon, Achilles tendon, Mandibular reflex. (Note: look for Hyperreflexia, meaning a lesion above the level of the spinal reflex pathways).
Sensory — Stroke areas of hand (Thumbs are C6, Middle finger is C7, pinky is C8) and feet (L4 is inner portion of the lower leg, L5 is external portion of the lower leg, S1 is the posterior portion of the lower leg).
¶DIAGNOSTIC TESTS (Note: some tests are therapeutic as well).
Blood labs for Lymes, giant cell, rheumatological conditions, biopsy for giant cell, and oral pathology. (Note: consider existing reports).
Pregnancy test
Endocrine (thyroid, pituitary, hormones)
Vitamin levels (or order individually) (Note: For BMS and endocrine disorders)
Diagnostic studies
PSG (Sleep study lab or home) recommendation, not a prescription.
Dental tests
Comprehensive eval of dental condition and restorations
Crack tooth
Thermal tests
Percussion
Anesthetic test
Pharmacological tests
Indomethacin test, 75 mg PO (Note: Indo responsive headaches to be considered).
Sumatriptan test, 50mg (Repeat in 20 mins if no response). (Note: consider migraine).
Anesthetic test
Topical anesthetic
Nerve blocks (Note: never inject if there is infection).
Auriculotemporal nerve block (Note: 27 needle above the insertion of the tragus and ear lobe, depth 1cm until touching posterior aspect of the condyle, remember to aspirate. 3% mepi without vasoconstrictor or 2% lidocaine without vasoconstrictor - consider myotoxicity).
Autonomic block (Stellate ganglion).
Spray and Stretch. If I used ethyl chloride, does it reduce the pain, and by how much, increase of range of motion?
Trigger point 1 cc 1% lidocaine if indicated. Does it reduce or resolve the pain?
Consultations
¶Differential diagnosis (Use Okeson, AAOP, DC/TMD criteria, or ICOP). (Note: Do a quick mental overview of the following categories: Odontogenic, muscle, joint, neuropathic, neurovascular, psychological, and sleep-related conditions. If you are missing info, go back to questioning the patient)
My 1st diagnosis would be…
Another (or others) diagnosis includes a possible…
Understand the diagnosis and course of the disease
Avoid risk factors or pain activators
Reassurance
Promote treatment adherence
Give a pain diary if appropriate
Prefer monotherapy when possible
In all cases of chronic pain consider nonpharmacological approaches
In all cases include sleep hygiene (Cold room, the bed is only for sleep, don’t look for LED lights, avoid alcohol).
Address diet if appropriate.
Mucogingival pain: Identify cause and treat it (Trauma, allergies, infections, or systemic conditions). Be sure to do palpation of all intraoral tissues.
Dental pain: If there is a chance that the pain is odontogenic, be sure to address that.
Musculoskeletal conditions: Decrease pain, decrease loading, restore function and resume normal activities. A similar approach to all categories (Guarding or co-contraction, localized myalgia or muscle soreness, MFP, Spasm, Myositis, centrally mediated myalgia). TMJ pain (capsulitis or arthralgia, OA, Internal derangements) [Okesson].
Home-based therapy
Avoidance
Limit opening
Soft diet
Rest
Habit awareness and modification
N position
Posture
Home physical therapy
Thermal
Stretch (N stretch or passive stretch)
Range of motion exercises
Hinge axis (for TMJ lubrication)
Retruded hinge axis for Lateral pterygoid (with resistance)
Behavioral
Emotional stress reduction
Relaxation and self-regulation, meditation, yoga
Control habits
Referral for Biofeedback therapy
Pharmacologic (consider the need to monitor medications)
Analgesics
NSAIDs
Nabumetone 500 mg bid
Mobic 7.5 (once per day)
Myogenous
Muscle relaxants (only for trismus)
Cyclobenzaprine 10 gm hs (2 weeks)
Benzodiazepines
Diazepam 2-5mg hs (2 weeks)
TMJ
Steroids
Medrol dose pack (methylprednisone) - For capsulitis (Remember the justification for taper down the medication).
Topical medications: (for people with GERD or other conditions)
NSAIDs, capsaicin
DMARD prescription (prescribed by a rheumatologist)
Procedures
TMJ
Mobilization (if severe pain, block or refer for sedation)
TMJ injections
Steroid (Triamcinolone 20mg with 2%lidocaine)
Hyaluronic acid / PRP (evidence not strong).
Myogenous
Dry needle
Trigger point injections (Note: use 1-2% lidocaine – non epi)