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Trigeminal neuralgia or odontogenic pain

  • Joanna M. Zakrzewska
Published/Copyright: July 1, 2010
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 1 Issue 3

Aim

Appreciate the significance of a detailed history in patients with unilateral episodic trigeminal pain.

The commonest cause of pain in the trigeminal region is dental, followed by unilateral temporomandibular disorders and so patients with trigeminal neuralgia (TN) will often seek dental care first. Neurosurgeons have estimated that up to 60% of patients with TN will have undergone irreversible dental treatment and the average duration before referral is around 6 years. It must be noted that dental disease and TN can co exist.

Although the diagnostic criteria for classical TN as put forward by IASP and IHS are widely accepted they have not been validated [1]. In order to help improve diagnosis Drangsholt and Truelove [2] posed a question in the PICO format: “In patients with TN [Patient/problem], do specific questions in the history or specific examination findings [Intervention] do better than a standard dental history and physical examination [Comparison intervention] to increase the likelihood of a correct diagnosis [Outcomes]?”. They found the key features were: refractory period after stimulation of at least one minute, short electric-like stabbing or shooting pains that last under 2 min and unresponsiveness to opioids. Other features such as non-nociceptive triggering have lower validity whereas rapid onset, trigeminal distribution and severity provide no differential clues. Dental X-rays are helpful in identifying deep caries causing irreversible pulpitis [3].

Some patients who report atypical symptoms, such as a prolonged burning quality of their pain or pain triggered every few seconds over several hours have been labelled as having atypical TN or type 2 TN [4]. These patients are thought to be patients with a longer history of TN in which the trigeminal nerve had acquired atrophic features. However an epidemiological study (submitted) and recent neurophysiological studies [5] suggest these may be different entities and have more central causes. Other essential questions are to determine whether there are any autonomic symptoms, e.g. eye tearing, redness, oedema.

These patients may be suffering from SUNA (short neuralgiform headaches with autonomic symptoms) who do not respond to surgery and are more responsive to lamotrigine [6].

Correct diagnosis is essential as once branded certain treatments are instigated, which may not be correct.

Please read these three case histories: what is the diagnosis? Which are the differentiating diagnostic features?

Case 1 2 3
Age 50 30 57
Gender Female Male Male
Development of pain Began after difficult dental extraction 3 years ago and not getting worse Began slowly initially Intermittent pain, recent exacerbation which has not settled as usual, has not taken any medication for it as it was not “that bad”.  First episode of pain 3 years ago beginning suddenly. Lasted for several weeks and then no pain for 9 months. Several similar episodes but shorter periods of no pain. Present episode of pain began 8 months ago. 
Character/quality Words from McGill pain questionnaire Quivering, jumping, pricking, sharp, burning, stinging, aching, tender, tiring, wretched, annoying, piercing, numb, nagging Dull, aching, heavy, nagging sometimes sharp Quivering, shooting, stabbing, sharp, crushing, tingling, burning, aching, tender, tiring, terrifying, killing, blinding, unbearable
       
       
Site and radiation Right mandibular area only intraoral in area of dental extraction Local Right side of face principally pre-auricular and extends down the mandible intra-oral and extra oral and extends down the neck. Earchache Left nasolabial area is the trigger point pain radiates up along the whole of the left maxilla occasionally radiating to lower jaw Pain felt both intraorally and extraorally. 
       
Severity Visual analogue scale 0-10cm At its worse 6 cm, mean of 3 cm, pain never goes completely Average 3 cm, range 3-8 cm Worse 9 cm, average of 4 cm, times when there is no pain. 
       
       
Duration and periodicity Pain lasts for hours and may be followed by a milder period of pain Intermittent lasting several hours severe episodes last for few minutes Each pain episode lasts a few seconds but followed by a period of milder burning pain, then no pain, pains occur many times a day, maybe no pain for a week or two
Provoking factors Eating and brushing the teeth can make pain worse, touching the area can be painful Prolonged chewing, yawning, tiredness Eating, talking, shaving, washing face light touch
Relieving factors Drugs help slightly Massage No activities
Associated factors no other pain or disturbances Often has migraine, back pain, fatigue, poor concentration, bruxist. occasional locking Lost weight as cannot eat
Effect of pain on life style Unable to socialise as much as would like, no anxiety or depression Lost job recently, has had some impact on social life—going out to eat considerable effect on quality of life, took a week of work as telephonist, mild depression
Examination Very tender to touch in right mandibular alveolus area Fully dentate, two tender points on muscles of mastication, good mouth opening but clicks No cranial nerve abnormalities and fully dentate with no dental disease
Diagnosis      

References

[1] Zakrzewska JM. Diagnosis and differential diagnosis of trigeminal neuralgia. Clin J Pain 2002;18:14–21.Search in Google Scholar

[2] Drangsholt M, Truelove E. Trigeminal neuralgia mistaken as temporomandibular disorder. J Evid Base Dent Pract 2001:41–50.Search in Google Scholar

[3] Zakrzewska JM. Orofacial pain. Oxford: Oxford University Press; 2009.Search in Google Scholar

[4] Limonadi FM, McCartney S, Burchiel KJ. Design of an artificial neural network for diagnosis of facial pain syndromes. Stereotact Funct Neurosurg 2006;84:212–20.Search in Google Scholar

[5] Obermann M, Yoon MS, Ese D, et al. Impaired trigeminal nociceptive processing in patients with trigeminal neuralgia. Neurology 2007;69:835–41.Search in Google Scholar

[6] Cohen AS, Matharu MS, Goadsby PJ. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)—a prospective clinical study of SUNCT and SUNA. Brain 2006;129:2746–60.Search in Google Scholar
Published Online: 2010-07-01
Published in Print: 2010-07-01

© 2010 Scandinavian Association for the Study of Pain

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https://doi.org/10.1016/j.sjpain.2010.05.003

Articles in the same Issue

  1. Editorial comment
  2. Functional brain imaging of acute postoperative pain
  3. Clinical pain research
  4. Brain activation due to postoperative pain from the right hand measured with regional cerebral blood flow using positron emission tomography
  5. Editorial comment
  6. Long-term low-dose transdermal buprenorphine therapy for chronic noncancer pain
  7. Original experimental
  8. A 6-months, randomised, placebo-controlled evaluation of efficacy and tolerability of a low-dose 7-day buprenorphine transdermal patch in osteoarthritis patients naïve to potent opioids
  9. Editorial comment
  10. Repeated nociceptive stimulation for detecting drug effects
  11. Original experimental
  12. The effects of gabapentin in human experimental pain models
  13. Editorial comment
  14. Whether the weather influences pain: High prevalence of chronic pain in Iceland and Norway: Common genes? Or lack of sunshine and vitamin D?
  15. Observational studies
  16. A population based study of the prevalence of pain in Iceland
  17. Editorial comment
  18. Swedish nurses are prone to chronic shoulder and back pain because of miserable working conditions and poor leadership?
  19. Observational studies
  20. Predicting of pain, disability, and sick leave regarding a non-clinical sample among Swedish nurses
  21. Abstracts
  22. Trigeminal neuralgia or odontogenic pain
  23. Abstracts
  24. What’s wrong with animal models of pain?
  25. Abstracts
  26. Immunotherapy for neuroblastoma elicits a complement dependent whole body allodynia
  27. Abstracts
  28. Pain mechanisms in animal models of rheumatoid arthritis
  29. Abstracts
  30. Translating basic research to pharmacological treatment of neuropathic pain
  31. Abstracts
  32. Free Poster Presentations: Forearm heat pain does not inhibit electrically induced tibialis anterior muscle pain
  33. Abstracts
  34. Offset analgesia evoked by non-contact thermal stimulator
  35. Abstracts
  36. Inhibition of FAAH reverses spinal LTP
  37. Abstracts
  38. Hyperexcitable C-nociceptors in human paroxysmal pain
  39. Abstracts
  40. Pain sensitivity and experimentally induced sensitization in red haired women
  41. Abstracts
  42. How are opioids used in Norway? Persistent use, utilization of depot formulation and age profile in non-palliation patients
  43. Abstracts
  44. To which extent does incident and persistent use of weak opioids predict problematic opioid use?
  45. Abstracts
  46. Is transdermal buprenorphine for chronic non-malignant pain used long term without co-medication with other potentially addictive drugs?
  47. Abstracts
  48. Prostaglandin E2 production in synovial tissue and acute postoperative pain after knee arthroscopy
  49. Abstracts
  50. Girl presenting with oesophageal spasm pain after fundoplication
  51. Abstracts
  52. Epidemiology of persistent postoperative pain: Association of persistent pain and sensory abnormalities
  53. Abstracts
  54. Cost–benefit of a 13-week multidiciplinary rehabilitation course for chronic non-malignant pain patients
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  56. A novel and effective treatment modality for medically unexplained pain
  57. Abstracts
  58. Somatocognitive therapy in the management of chronic gynaecological pain. A review of current approach and historical background
  59. Abstract
  60. The Manual Intervention Trial (MINT)—The effect of various combinations of naprapathic manual therapy. The study protocol of a randomized controlled trial
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  62. The experience of chronic pain, loss and grief
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  65. Abstract
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  67. Abstracts
  68. Pigs in pain—Porcine behavioural responses towards mechanical nociceptive stimulation directed at the hind legs
  69. Abstracts
  70. A human experimental bone pain model
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