Educational Methodologies

A Four-Tier Problem-Solving Scaffold to

Teach Pain Management in Dental School
Chris S. Ivanoff, D.D.S.; Timothy L. Hottel, D.D.S., M.S., M.B.A.
Abstract: Pain constitutes a major reason patients pursue dental treatment. This article presents a novel curriculum to provide
dental students comprehensive training in the management of pain. The curriculum’s four-tier scaffold combines traditional and
problem-based learning to improve students’ diagnostic, pharmacotherapeutic, and assessment skills to optimize decision making
when treating pain. Tier 1 provides underpinning knowledge of pain mechanisms with traditional and contextualized instruction
by integrating clinical correlations and studying worked cases that stimulate clinical thinking. Tier 2 develops critical decision
making skills through self-directed learning and actively solving problem-based cases. Tier 3 exposes students to management
approaches taken in allied health fields and cultivates interdisciplinary communication skills. Tier 4 provides a “knowledge and
experience synthesis” by rotating students through community pain clinics to practice their assessment skills. This combined
teaching approach aims to increase critical thinking and problem-solving skills to assist dental graduates in better management
of pain throughout their careers. Dental curricula that have moved to comprehensive care/private practice models are well-suited
for this educational approach. The goal of this article is to encourage dental schools to integrate pain management into their
curricula, to develop pain management curriculum resources for dental students, and to provide leadership for change in pain
management education.
Dr. Ivanoff is Associate Professor, Department of Bioscience Research, College of Dentistry, University of Tennessee Health
Science Center; and Dr. Hottel is Professor, Department of Prosthodontics, and Dean, College of Dentistry, University of Ten-
nessee Health Science Center. Direct correspondence and request for reprints to Dr. Chris S. Ivanoff, Department of Bioscience
Research, College of Dentistry, University of Tennessee Health Science Center, 875 Union Avenue, Memphis, TN 38163;
901-448-1770 phone; 901-448-2744 fax; civanoff@uthsc.edu.
Keywords: pain management, clinical curriculum, problem-solving, critical thinking, dental education, clinical education
Submitted for publication 2/26/12; accepted 8/28/12

P
ain is a major reason patients seek the services
of a dentist. Undertreatment of pain is poor
dental practice and can result in many adverse
effects. Unrelieved acute pain commonly elicits
pathophysiologic neural alterations that can evolve
into chronic pain syndromes.1 Chronic pain, in turn,
may lead to a constellation of maladaptive physical,
psychological, family, and social consequences, and
can be regarded as a disease entity by itself.1-5
The barriers of health care professionals to
pain relief have been outlined extensively in the
literature, including misconceptions about medica-
tions, especially opioids.6-10 Although opioids are
central to acute pain management, many clinicians
prescribe them incorrectly, resulting in inadequate
pain management and side effects.1,5-10 Poor opioid
prescribing practices include inadequate dosing,
failure to use nonsteroidal anti-inflammatory drugs
for additive effect, and failure to anticipate and treat
potential side effects of opioids.6-8 Among the rea-
sons cited for poor pain management practices are
outdated attitudes, a lack of knowledge about opioid
pharmacology, and concerns about addiction.6-15
Clinician opiophobia is further compounded by opi-
oignorance as a result of insufficient training in pain
management.1,6-15 Both dentists and dental students
are aware of these problems and reverberate in the
literature the need for more effective ways to teach
pain management, especially in regard to chronic
orofacial pain.11-15
As prescribers of 12 percent of immediate-
release opioids in the United States,10 both dental stu-
dents and clinicians have a responsibility for safe and
efficient pain management, which involves a complex
decision making process affected by many variables.
Traditional pain management classes, however, often
omit critical content and teaching strategies that may
improve the implementation of information and,
ultimately, the treatment of pain.5,7,12-21 Educational
plans that incorporate model-based instruction in
both cognitive and affective domains could more
effectively achieve positive changes in practitioner
behavior related to pain management than traditional
teaching approaches.12,14-20,22

June 2013  ■  Journal of Dental Education 723

 Adequate management of pain is critical in
today’s health care environment. When pain is man-
aged well, patients stay on critical paths and have
fewer complications.5 Despite this, only 3 percent
of the nation’s medical schools currently have a
separate course in pain management.23,24 Although
there are no data in the literature tracking pain man-
agement training in predoctoral dental curricula, it
has been speculated that most dental schools do not
provide adequate coverage in this area either.10,11,13
With respect to predoctoral curricula, the American
Dental Association has essentially acknowledged
these shortcomings by mandating, through the Com-
mission on Dental Accreditation, that postgraduate
orofacial programs be designed to provide advanced
knowledge and skills beyond those of the standard
curriculum.21,25 Among the topics mandated in the
curriculum are pharmacology and, specifically,
pharmacotherapeutics, which is essential for proper
treatment of pain that is often chronic, multifactorial,
and complex.25
Improved pain management education has
been mandated by several organizations.5 Although
studies have shown that pain management education
programs can change self-perceptions of knowledge,
skill, and comfort/confidence, as well as objective
knowledge, including knowledge about the appropri-
ate use of opioids,7,14,15,26-28 the current literature does
not yet offer a systematic way to improve clinician
practices and/or patient outcomes in pain manage-
ment.7,26,27 For this reason, the College of Dentistry
at the University of Tennessee Health Science Center
introduced a comprehensive teaching plan to teach
students pain management more effectively. This
plan is designed to deliver content while also chang-
ing behavior and to yield more positive results than
episodic teaching when painful problems are identi-
fied. The rationale is based on the premise that, if pain
management education in dental school cultivates
better clinical reasoning, better drug-prescribing
behavior and improved pain management skills will
follow.7,14-22 This, in turn, might enable students to
make optimal clinical decisions when managing pain,
particularly in cases that are mired in confusion and
uncertainty.
Pain management is central in the practice of
dentistry. When considering its relation to dental
education, we can either view it individually or
as an integral component of several subjects.19,20,22
Pain management can be taught as a set of facts, or
alternately, as part of a curricular philosophy that
aims to get students to think and act like clinicians.20
724
The curriculum model presented in this article is
structured upon a four-tier scaffold that combines tra-
ditional and problem-based learning (PBL) to teach
pain management in a comprehensive care-based
dental clinical curriculum. The model integrates
both worked and unsolved PBL case scenarios22 and
includes multidisciplinary participation to increase
critical thinking and problem-solving skills that
may assist dental graduates in managing pain better
throughout their careers.
Structure of the Pain
Management Teaching
Model
The teaching model we developed is a blend of
traditional and problem-based learning that aims to
increase knowledge in pain management while also
attempting to overcome the barriers to knowledge
transfer into practice.20,22 This is done by challenging
attitudes and encouraging students to explore their
clinical practice alongside theoretical concepts. The
model is carried out in four tiers.
Tier 1
A traditional lecture approach during students’
first and second years provides base knowledge about
basic health sciences as a backdrop to pain manage-
ment before advancing to the third and fourth years.
The scaffolding process begins by introducing and
integrating into the student’s knowledge base the
anatomical and physiologic principles of pain with
small-group discussions led by instructors in each
of the relevant basic science courses who help the
students work cases that correlate information to
clinical scenarios.22 This includes the neurological
and pharmacological basis of pain transmission
and modulation; how pain systems are developed;
discussions about ethical standards in pain manage-
ment; and current clinical research that provides
basic knowledge about experimental methodology
and contemporary evidence-based pain management
strategies.
Tier 2
A PBL pain management workshop is given
during summer orientation before entering the clinic
in the third year. This PBL experience is student-
centered learning in which small groups of students
Journal of Dental Education  ■  Volume 77, Number 6
are guided by preceptors (facilitators) to resolve
problems in pain management that form the basis for
organized focus and stimulus for learning and spur
the development and use of problem-solving skills.
New knowledge is acquired by self-directed learning.
Groups of six students are paired with a preceptor
and given case scenarios22 they have to work out to-
gether. While researching the literature, the students
begin to formulate strategies to resolve the cases.
Through active dialogue and group discussions led
by the preceptor, the students reflect on feedback and
gain new insights from the process of discovery as a
stimulus to continue constructing and integrating new
knowledge to further refine their strategies.
Building on basic science knowledge acquired
in Tier 1, the problems require the integration of
knowledge about drugs recently acquired in pharma-
cology. These problems are designed to simulate the
treatment of pain before the students enter the clinic.
Case scenarios guide the students toward a clinical
understanding of the differentiation among opioids,
antipyretic analgesics, anxiolytics, antidepressants
and anticonvulsants, etc., as well as how and when
they are used. As the case scenarios increase in diffi-
culty, the student is called upon to continuously refer
back to the knowledge acquired in Tier 1 in order to
rationalize and manage dental pain associated with
more complex medical profiles. The emphasis is on
orofacial pain, headache, cervical pain, and muscu-
loskeletal and myofascial pain.
Tier 3
A multidisciplinary problem-based pain man-
agement experience is ushered in as a series of weekly
workshops after students have completed pharmacol-
ogy near the beginning of the senior year. Groups of
three dental students are paired with three medical
students and one nursing or pharmacy student. The
student groups are then given case scenarios they
have to work out together. Students investigate ap-
propriate textbooks and references to jointly come
up with answers to problems in pain management
cases, while sensitizing and exposing each other to
the different pain management approaches that would
be taken by allied health fields.
The case scenarios require the students to dis-
tinguish the differences between acute and chronic
pain; the psychosocial and cultural aspects of pain;
sex and gender issues in pain; neuropathic pain due
to nerve damage; complex regional pain syndromes;
differentiating pain management strategies in infants,
June 2013  ■  Journal of Dental Education
children, adolescents, and the elderly; special cases
of individuals with limited ability to communicate
due to cognitive impairment; pain relief in substance
abusers; pain management in seriously ill patients
with cancer and AIDS; and complementary thera-
pies for pain management including nerve blocks,
psychological treatments, surgical pain management,
physical medicine, and rehabilitation.
Since dentists often have the opportunity to de-
tect, screen, and intercept serious medical conditions,
their role can be central to motivating and directing
patients to get accurate diagnosis and appropriate
treatment. Teaching dental students to interact with
other health professionals adds further value to the
students’ learning experience since the real-world
referral process for complex cases often requires
multidisciplinary treatment efforts. A PBL team built
of allied health students provides the dental graduate
with a basis of experience that can be transferred into
practice to assist in communication with specialists
in the future.
Tier 4
In this “knowledge and experience synthesis,”
groups from Tier 3 are activated in the field during
the second semester of the senior year. This is co-
ordinated with the medical, pharmacy, and nursing
schools in order to include the allied health students
in the experience. The exercise engages the students
outside of the school in underserved areas and com-
munity centers (such as nursing homes) as part of
a clinical rotation. The rotation includes additional
shadowing in a pain management center, as well as a
hospital emergency trauma center or similar clinical
setting. By transitioning from cases to actual experi-
ence, these multidisciplinary teams apply the PBL
experience in a tangible way that directly benefits
the community and will be ingrained in the students’
memory.
Assessment Tools, Report Cards,
Pain Management Index
During actual clinical encounters with patients
experiencing pain, the students use assessment tools,
report cards, and Pain Management Index (PMI)
scoring for accurate and comprehensive assessment
of pain management.5,29 Since patients are credible
judges of their pain, patient self-reports serve as the
basis for planned intervention5,30,31 by assessing pain
intensity, location, and characteristics as well as
725
 pain-related interference with activity. Using a nu-
merical pain rating scale of 0 (no pain) to 10 (worst
pain possible), pain ratings of 4 to 7 are regarded as
interfering with comfort and function, and ratings of
8 or higher adversely affecting quality of life.5
Report cards measure overall performance in
pain management by using nine indicators significant
to pain management to compare the desired target
set by clinicians to the actual findings reported by
the patients. The purpose of the tool is to collect
information needed for immediate course correc-
tion; help students identify where goals are not be-
ing met; and allow planning at the root cause level
to institute effective pain management processes.
The evaluation gives instant feedback about patient
satisfaction with pain management during the pain
experience, thus allowing closer monitoring and
earlier intervention.5,31,32
The PMI measures the adequacy of pain man-
agement, using the worst pain rating and the most
potent analgesic prescribed. In this methodology,
the 1-10 pain intensity scale is divided into three
categories: mild (1-3), moderate (4-7), and severe (8-
10). Analgesics are classified on a 1-3 scale (1=non-
opioid; 2=mild opioid; 3=strong opioid). The pain
intensity level is then subtracted from the analgesic
ranking to calculate the score. For example, if the
patient’s pain is a 3 after using a category 2 analgesic,
the pain management index is a -1, indicating that the
patient is undertreated for pain. The PMI provides the
students a quick way to assess adequate treatment,
while also improving their assessment skills.5,27,32
Discussion
Many acute, chronic, and recurrent painful
conditions occur in the orofacial region, including
temporomandibular disorder, neuropathic trigeminal
pain, burning mouth syndrome, and trigeminal neural-
gia.22 According to prevalence studies, 22 percent of
the U.S. population experiences significant orofacial
pain on more than one occasion within a six-month
period, while over 7 percent of the population or 13
million people have a chronic orofacial pain disorder
that requires treatment.33 Since only 3 million people
with chronic orofacial pain seek treatment per year,
the remaining 10 million patients go untreated. Stud-
ies suggest further that these patients are not being
treated adequately by general dentists or dental spe-
cialists and that there are not enough orofacial pain
dentists to deal with the problem. The percentage of
726
general dentists who treat any of these patients is low:
14 percent with less than 5 percent of their practice in
this area. Furthermore, studies have found that these
patients have seen at least five dentists before seeing
an orofacial pain dentist, while having lived with the
pain, on average, for at least four years.34
Although acute dental and periodontal pain is
the most common complaint in dental practice, other
nonodontogenic causes of orofacial pain must be
considered in a differential diagnosis. Neuropathic
orofacial pain is relatively common,35 and graduates,
at a minimum, should be able to provide a basic
diagnosis and palliative measures, with referral to a
specialist if they cannot provide further help. Early
intervention is important in these patients’ treatment,
and dental education must bridge the gap in students’
understanding to ensure a basic level of care.
The curriculum presented in this article is a
multidisciplinary pain curriculum, addressing top-
ics such as the ethical, behavioral, and sociocultural
aspects of pain, along with clinical issues and the
neurochemistry of pain. Multidisciplinary and
problem-based learning elements of the curriculum
are inspired by Tufts University School of Medi-
cine’s two-semester Capstone Project. This is “A
Knowledge and Experience Synthesis” experience
offering students the opportunity to integrate and
apply the knowledge and skills they have learned in
the classroom to comprehensively address clinical,
public health, and/or social problems pertaining to
pain.36 Since the ultimate goal of dental education
is improved patient care, this model may lead to
improved dental student knowledge, attitudes, and
self-perception (confidence/comfort/skill) that are
prerequisites for good prescribing practices and pain
management skills.14,15,27
Although better knowledge and self-perception
make improvements in clinical practice possible,
reinforcement of the principles taught in the class-
room also needs to occur in the clinical setting
for this change to be sustained. These principles
are reinforced by clinical preceptors in the private
practice comprehensive care model, who mentor the
students and conduct chart reviews to monitor their
progress and intervene preemptively when neces-
sary. This method has been shown to result in better
opioid prescribing practices of medical students.7
Other studies have found that good role models for
medical students and residents may be critical to the
process.37,38 It would be logical to assume, therefore,
that the preceptor in the private practice clinical
model would be critical in this process also.
Journal of Dental Education  ■  Volume 77, Number 6
 Chart reviews used to measure changes in the
prescribing practices of the dental students provide
an inexpensive way to monitor continuous quality
assurance efforts. Chart reviews are also used by the
preceptors to give positive feedback to their students
who improve their practices and to provide encour-
agement or further education to those who do not.
Feedback about practice patterns and quality of care
measures, when combined with education, has been
shown to change physician behaviors,7,38 as well as
to improve dental students’ confidence and skills.27
Pain management is central to emergency den-
tal treatment and can be taught by traditional means in
a pain management or emergency dental care course.
A pain management module could theoretically also
be incorporated into a private practice preceptor pro-
gram as a series of lectures given by the preceptors to
their group. Six to twelve hours of lectures devoted
to pain management, after pharmacology, concurrent
with the third- and fourth-year clinical experience
would perhaps be one model. Of course, the approach
would have to be standardized so that all preceptor
groups are exposed to the same learning experience.
It could also be taught as a constituent module as part
of one or several major health science courses such as
pathology, pharmacology, neurobiology, or physiolo-
gy during the preclinical years of dental education. If
taught as a separate dental emergency course during
the third or fourth year, all the information students
have learned in the basic health sciences will have a
chance to come together in a timely manner pertinent
to their concurrent clinical activities.
Traditional teaching requires students to learn a
large number of facts, and retention of information is
a potential problem.20 Often the set of facts students
are required to memorize are chosen by the instruc-
tor based on what he or she is familiar with and may
not be relevant to dental practice.13,14,20 Furthermore,
the student, a passive recipient in the traditional ap-
proach, may or may not learn the facts in a way that
is suitable or useful in future practice.14-22 Problem-
based learning, however, overcomes these challenges
by developing scientific thinking about patients’
problems and providing both basic science and clini-
cal information in a manner that promotes retention
and transfer to the real-life task of the clinician.20
Unlike traditional instruction, this model actively
engages the student in constructing knowledge about
pain management. The content learned is related to
the task of resolving problems and made useful to
the student by the active and ongoing integration of
information from many disciplines (neurobiology,
June 2013  ■  Journal of Dental Education
pharmacology, anatomy, etc.) all integrated in one
focused area.20,22 The principles the student learns
after solving early problems then help to transfer
skills and information to the student’s work with
subsequent problems.20,22
By learning about pain management in the
context of complex, multifaceted, and realistic
problems, the dental students develop flexible knowl-
edge, effective problem-solving skills, self-directed
learning, effective collaboration skills, and intrinsic
motivation.39 Working in groups, the students identify
what they already know, what they need to know, and
how to resolve the problem. The preceptor facilitates
their learning and provides appropriate scaffolding,
support, and modeling of the process,40 while also
stretching their understanding41 with problems that
can be solved in many different ways and have more
than one solution.42 The assigned problems are au-
thentic, meet the students’ level of prior knowledge,
engage the students in discussion, and are interest-
ing.40,43 The aim, of course, is to train practitioners
to become skillful in decision making for sustainable
and responsible development and, ultimately, to think
like clinicians.20
The rationale for presenting worked cases44
(Table 1) versus unsolved pain management prob-
lems35,45 (Table 2 and Table 3) during Tier 1 is that
active problem-solving is not as effective in early
learning due to cognitive load or a guidance-fading
effect.46 Processing a large amount of information
in a short amount of time is difficult for students.14,20
Thus, studying worked examples early in the learning
process followed by a gradual introduction into active
problem-solving is a more effective approach.45-49
In summation, PBL teaches students how to
analyze pain problems, identify relevant facts and
generate hypotheses, identify necessary informa-
tion/knowledge for solving the problems, and
make reasonable judgments about solving the prob-
lems.14,20,22,39-43,46 The PBL experience also helps stu-
dents build better communication, teamwork, respect,
and collaboration skills.20,39-43,47 By being exposed to
the interdisciplinary aspects of pain management as
members of a PBL team that consists of students from
multiple allied health fields, the dental students are
acquiring a broader and fuller approach to managing
pain.11,12 Thus, when they go into practice, they will
have a more comprehensive understanding of their
patients to more effectively manage the complex
medical profiles they will be treating.
Research has shown that many dental students
find PBL to be more effective than traditional teach-
727
 ing methods in learning and assimilating knowledge cological treatment and evaluation of treatment
associated with orofacial pain14 and that these topics outcome increase with PBL.14,15,26,27 They perceive
are better understood.15 In general, their confidence that patients are cared for more capably, as clinical
and perception of clinical competence in pharma- reasoning helps them to continually define and satisfy

Table 1. Sample worked case scenario for students

Case: Atypically Presenting Irreversible Pulpitis vs. Atypical Odontalgia

A 39-year-old woman had been given a tentative diagnosis of atypical odontalgia before presenting for a second opinion. The
patient described her pain as pounding, stabbing, radiating, and awful. Her dentist had previously removed two fillings (teeth 6
and 7) without any change in the pain. Standard radiographs did not disclose any pathology, and the pain could not be induced
by thermal tests or percussion. The pain worsened during the night and radiated to the temple and ear. The pain persisted for
several weeks, and at the time of examination, she was medicated extensively to control the pain. She took 4 g paracetamol,
1800 mg ibuprofen (non-steroid anti-inflammatory drug), 100 mg tramadol (opioid), 150 mg pregabalin (anticonvulsant), and
acetylic salicylic acid as a supplement. The pain was severe, and the patient was crying and asking for stronger analgesic drugs.
A clinical examination revealed myofascial TMD and a disc displacement in the right temporomandibular joint. These findings
were not thought to be responsible for the full pain problem. Intraorally, teeth 6 and 7 had temporary fillings but otherwise no
signs of pathology. Palpation of the right infraorbital foramen was painful. Because the pain worsened during the night, odonto-
genic pain was suspected and needed to be excluded. A 3D cone beam computed tomography was performed, which revealed
periapical periodontitis of tooth 3 and a mucoid retention cyst in the right maxillary sinus. As such a cyst is not usually painful,
treatment of tooth 3 was performed with no changes in the pain. A diagnostic analgesic block of tooth 7 reduced the pain to a
minimum, and therefore, a pulpectomy was performed with an immediate effect on the pain. She has been pain-free since then.
Diagnosis: The diagnosis was an atypically presenting irreversible pulpitis of tooth 7 and not AO. Usually, pulpitis pain can be
easily provoked by changes in temperature, but this was not the case for this patient.

Table 2. Sample unsolved pain management problem for students

Case: Trigeminal Neuralgia

A 52-year-old man presents with pain associated with the upper right canine (#6). Stimulation of the tooth elicits sharp-shoot-
ing, lancinating pain. Prior to being examined, he reports having experienced several episodes of severe, electrical shock-like
pain followed by a hot sensation in the same area. One of these episodes was triggered by a light touch on his face, and the
other occurred while shaving. Radiographic assessment revealed a periapical osseous lesion resulting in a diagnosis of acute
apical periodontitis. Root canal therapy was performed with no undue effects. Approximately two months later, the patient
began experiencing a relapse of paroxysmal sharp, shooting pain with a marked increase in frequency of these episodes. The
pain was triggered by light touch on the right cheek. Each episode lasted 1 to 2 seconds; however, he occasionally had 5 to 10
repetitive bursts. Clinical evaluation resulted in a diagnosis of trigeminal neuralgia of the right maxillary division.
Initial treatment included 100 mg carbamazepine bid, which was gradually increased to a maximum dose of 600 mg bid. Medi-
cation yielded modest relief; unfortunately, cognitive changes necessitated a reduction in the dose. Gabapentin was introduced
at a bedtime dosage of 100 mg. This provided a marked reduction in pain for approximately 1 week. A gradual titration of
gabapentin to 300 mg tid was efficacious for approximately 1 month. Neurosurgical consultation and MRI of the brain revealed
no intracranial pathology and confirmed a diagnosis of trigeminal neuralgia. Surgical intervention is being considered.
Challenge: This case presents a dilemma in which the dentist must decide whether the two pain complaints (tooth vs. neuro-
pathic pain) are related or merely coincidental. Such concurrent conditions may result in diagnostic confusion and perpetuate
the patient’s pain condition.
1) What factors must you consider in delineating the etiology and, ultimately, treatment recommendations in this case?
2) What are the mechanisms underlying trigeminal neuralgia as well as the pathophysiology of odontogenic pain?
3) Describe how bacteria-induced destruction of tooth structure can subsequently trigger the activation of tooth nociceptors.
4) Are coexistent sources of pain in this patient playing an additive role in the overall complaint of pain?
5) Can persistent peripheral noxious stimulus (i.e., tooth pain) sensitize trigeminal ganglion neurons in the brainstem (i.e., cen-
tral sensitization) to, in turn, influence the trigeminal neuropathic pain.
6) Identify all of the factors associated with the underlying pathology in this case.
7) How would you manage this case?
8) What pharmacotherapeutic strategies would you consider for management? Are ablative surgery or microvascular decom-
pression appropriate treatment options? If so, how would they impact pharmacotherapeutic treatment?
Clinical Impact: This case highlights that trigeminal neuropathic pain may exist in many forms and may easily be mistaken to
represent an odontogenic source. The pitfall for the practicing dentist is to focus on the odontogenic pain component while the
physician focuses on the trigeminal neuropathic pain component. Failure to identify the source of the patient’s entire problem
may lead to erroneous and ineffective treatment. Therefore, it is important to consider all sources of pain in trying to delineate
the etiology and ultimately recommend treatment.

728 Journal of Dental Education  ■  Volume 77, Number 6

their educational needs to keep their skills and infor-
mation contemporary and care properly for problems
they encounter.14,15,18,20,22,26,27
With respect to the traditional aspects of this
curriculum, clinical thinking begins as early as the
basic sciences by integrating clinical correlations
which, in turn, assist the students in learning about
pain management.50 Integrating biomedical science
and clinical teaching along with contextualized19,51
and interdisciplinary19 learning presents additional
opportunities for deeper levels of learning. Teach-
ing the diagnosis and management of acute dental
pain alongside the underpinning oral physiology has
been shown to help dental students understand the
topic better than teaching them acute dental pain as
a separate topic.51

Table 3. Additional unsolved pain management problems given to students

Students were instructed to read through the cases presented and answer the questions about each case.
Case 1: Temporomandibular Pain

A 40-year-old male presents with a two-year history of preauricular pain. The pain began gradually, but there have been periods
of weeks when the pain disappears. The rest of the time, the patient has pain which fluctuates in severity from mild to severe,
with an average score of 4. He describes the pain as piercing, pressing, annoying, and nagging. The pain begins preauricularly
and then radiates behind and into the ear as well as partially down the muscles of the face. It is bilateral but worse on the left
side. It is worse when eating hard things or biting into food and is helped by rest and analgesics. It is associated with some limi-
tation in opening, a clenching habit, and clicking of the left joint. He suffers from headaches, has occasional tinnitus and back
pain, and does not sleep well. He has a history of mild depression and anxiety. PMI assessment shows mild impact of the pain
on quality of life. He was recently divorced and is now bringing up a 16-year-old son on his own. His sister helps him out while
he goes out to work as a security guard. He thinks the pain is caused by a disease of the joint and would like some surgery for
it. On examination there is some limitation in opening and an audible click on opening wide is heard. The muscles of mastica-
tion are tender on palpation. Intraorally, there are signs of frictional keratosis (white lines) in the buccal mucosa in line with the
occlusal plane.
Case 2: Trigeminal Neuralgia

A 57-year-old male presents complaining of a sharp, shooting pain on the left side of his face. The pain began two months ago,
but he had a similar episode one and a half years ago when it lasted for six weeks and disappeared completely until recently.
Each bout of pain lasts for a few seconds, but the bouts seem to merge together and so it can seem like several minutes of pain.
He may be free of pain for several hours. The pain begins in the left nasolabial fold and then spreads across the whole cheek up
to the ear. He grades his pain an average 7/10 with PMI 4. He describes his pain as shooting, stabbing, sharp, stinging, tender,
exhausting, terrifying, gruelling, wretched, unbearable, and torturing. It appears to be made worse when eating, shaving, and
talking. He is terrified of brushing his teeth. He has lost weight and has stopped going out, as he cannot get through a meal.
Sleep brings him relief. He has a history of mild anxiety and severe depression. The patient has had time off work as he works
as an actuary. He is married and has three adult children. He thinks he has a nerve pain and wants his nerve cut. Examination
shows that touching the skin in the area of the infraorbital nerve provokes pain. There are no other abnormalities.
Case 3: Chronic Idiopathic Pain/Atypical Facial Pain

A 30-year-old female has had facial pain for two years. The pain began in her left maxillary teeth, and she had extensive dental
treatment leading to root canal therapy and finally extraction of her upper left molar (#14). She had limited pain relief after each
of the procedures. There have been periods of no pain after dental treatment, but since treatment was completed a year ago, the
pain has been continuous. She scores her pain 3 (mild-moderate) with an average of 4 out of 10. It does fluctuate in intensity,
and she may not be aware of it during the day, but it is worse in the evenings. She describes her pain as sharp, aching, miser-
able, and radiating. The pain is now located both externally and intraorally on the left maxilla and radiates as far as the forehead
and down to the neck. Nothing seems to help, and she has stopped using all analgesics as they do not relieve the pain. She
reports headaches and neck and back pains, as well as occasional pruritus. She shows pronounced anxiety, but no history of
depression. The quality of life assessment measures 5. She is married and has two children. She reported an unhappy childhood.
She had an authoritarian father who was an alcoholic. She dropped out of school, but later got her high school equivalency and
went on to college to become a school teacher. She enjoys her job but finds it stressful at times. The lack of diagnosis has been
very frustrating, and she is concerned that she may have a brain tumor. Examination reveals no abnormalities and cranial nerve
testing is normal.
Questions for each case:
1. What are the main characteristics of each of the pains?
2. What measurements and assessments have been presented, and how useful are they?
3. What other factors may help in the management of each case?
4. What is the differential diagnosis for each case?
5. Are there any diagnostic tests you could perform that would help?
6. What details in the history will help you determine the prognosis of treatment and patient compliance?
7. How would you start managing the patient?

June 2013  ■  Journal of Dental Education 729

 Since a good understanding of the differences
between musculoskeletal and neuropathic pain is
important for successful management of chronic,
complex, facial pain,52 teaching neuroscience with
this approach can also provide students with a bet-
ter understanding of how the nervous system works
in the care and management of dental pain.50 When
students acquire information that is both clinically
useful and relevant, the knowledge acquired early in
their anatomical, neurological, and pharmacological
studies is then further amplified and reinforced with
useful PBL correlations to enhance understanding
during the clinical years. Furthermore, pharmacology
alone is not always appropriate management and can
even be hazardous to patients. Chronic pain disorders
often require a multidisciplinary approach with a
strong focus on psychological factors.12,19 Teaching
behavioral sciences, including interpersonal and
communication skills, is therefore integrated with the
teaching of pharmacologic methods of pain control
to improve prescribing behavior, patient safety, and
control of pain.12,18,19,29,30
This curricular undertaking will raise a number
of issues that must be addressed in future studies,
including 1) the relationships between changes in
objective knowledge, self-perceptions, and attitudes
and changes in practice; 2) the specific components of
the curriculum (content, role modeling, instructional
strategies, etc.) that were most responsible for the
improved practice; and 3) whether and how improved
practice patterns translate into improved patient out-
comes.7 Research is needed to better understand the
relevant factors in how pain management practices
and patient outcomes can be improved.
Conclusion
The practice of dentistry is a lifelong learning
process that does not end in dental school. With
regard to the management of pain, an avalanche of
information in the way of new drugs and medical
knowledge will require graduates to continually en-
gage in cognitive learning throughout their careers.
The four-tier scaffolding learning model presented in
this article blends traditional teaching with a meth-
odology that can effectively develop critical thinking
skills to help students overcome the obstacles to life-
long learning, as well as the challenges of managing
pain. PBL is a tool that promotes an attitude towards
learning and a desire for self-study that can, subse-
quently, help students resolve problems effectively
throughout their careers.
730
As a key facilitator, the preceptor in the private
practice clinical model provides additional value to
the student’s learning experience. The preceptor pulls
together everything the student has learned during the
preclinical years, translating it in a way that is both
clinically pertinent and useable. The preceptor in this
model plays a critical role in cultivating cognitive
skills that will pass on logic, reason, and good judg-
ment to the students that will help them to manage
pain better and ultimately care for their patients more
humanely. Though the curriculum’s effectiveness is
not yet assessed, we speculate that, with continual
refinement, better management of pain will likely be
one of the positive outcomes.
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