Management Issues of Neuropathic Trigeminal Pain From a Dental Perspective

Neuropathic trigeminal pain conditions are more common than is generally appreciated. Sites inside the mouth as well as involve-ment of extraoral tissues are common manifestations of these dis-orders. There is a general lack of recognition of the complex char-acteristics of neuropathic trigeminal pain that frequently lead to mischaracterization of the nature of the complaint. Dentists are in an excellent position to detect the presence of neuropathic trigemi-nal pain and help to provide a rational diagnosis. The high preva-lence of orofacial pain of dental origin and the dramatic similari-ties between neuropathic orofacial pain and odontogenic and other pathologic pains in the region frequently lead to incorrect diagnoses and, more importantly, inappropriate treatments that are frequently invasive and irreversible. The records of patients presenting with neuropathic pain at our university pain clinic were reviewed to gain insight into dental factors as they related to the etiology, presentation, diagnosis, and management of neuropathic pain of the trigeminal system. Relative to etiology, the records review revealed that most onsets were associated with a specific dental treatment or odontogenic symptom that resulted in a dental diagnosis or treatment. Initial treatment modalities that either caused the pain or were used to address painful symptoms com-monly included replacement of restorations, endodontic therapy, apicectomy, extraction, splint therapy, and occlusal equilibration. Correct diagnosis, and particularly early definitive diagnosis, of neuropathic trigeminal pain is crucial to avoid invasive and poten-tially more damaging forms of treatment.

diagnosis; orofacial pain

1. Drangsholt M, Truelove EL. Trigeminal neuralgia mis-taken as temporomandibular disorder. J Evidence-Based Dent Pract 2001;1:41–50.

2. Vickers ER, Cousins MJ, Walker S, Chisholm K. Analysis of 50 patients with atypical odontalgia: A preliminary report on pharmacological procedures for diagnosis and treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:24–32.

3. Truelove E. Orofacial pain. In: Millard H, Mason D (eds). Second World Workshop on Oral Medicine. Ann Arbor: University of Michigan Continuing Dental Education, 1995:187–266.

4. Woolf CJ, Mannion RJ. Neuropathic pain: Aetiology, symptoms, mechanisms, and management. Lancet 1999;353:1959–1964.

5. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: An update and effect related to mechanism of drug action. Pain 1999;83:389–400.

6. Chen LA, Truelove ET, Drangsholt MT, et al. Hormonal changes and other related changes in atypical facial pain [abstract]. J Dent Res 2001(suppl);80.

7. Bennett GJ. Neuropathic pain in the orofacial region: Clinical and research challenges. J Orofac Pain 2004;18:281–286.

8. Eliav E, Gracely RH, Nahlieli O, Benoliel R. Quantitative sensory testing in trigeminal nerve damage assessment. J Orofac Pain 2004;18:339–344.

9. Robinson PP, Boissonade FM, Loescher AR, et al. Peripheral mechanisms for the initiation of pain following trigeminal nerve injury. J Orofac Pain 2004;18:287–292.

10. Fudin J, Audette CM. Gabapentin vs amitriptyline for the treatment of peripheral neuropathy. Arch Intern Med 2000;160:1040–1041.

11. Forssell H, Jääskeläinen S, Tenovuo O, Hinkka S. Sensory dysfunction in burning mouth syndrome. Pain 2002; 99:41–47.

12. Bennett M. The LANSS Pain Scale: The Leeds assessment of neuropathic symptoms and signs. Pain 2001;92:147–157.

13. Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: The Neuropathic Pain Scale. Neurology 1997;48:332–338.

14. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–355.

15. Zuniga JR, Meyer RA, Gregg JM, Miloro M, Davis LF. The accuracy of clinical neurosensory testing for nerve injury diagnosis. J Oral Maxillofac Surg 1998;56:2–8.

16. Svensson P, Baad-Hansen L, Thygesen T, Juhl GI, Jensen TS. Overview on tools and methods to assess neuropathic trigeminal pain. J Orofac Pain 2004;18:332–338.

17. Zakrzewska JM. Classification issues related to neuropathic trigeminal pain. J Orofac Pain 2004;18:325–331.

18. Hancock P, Drangsholt M, Truelove EL. A 31-year-old woman with jaw deviation and pain. Part I. J Evidence-Based Dent Pract 2002;2:168–174.

19. Von Korff M, Dworkin SF, LeResche L. Graded chronic pain status: An epidemiologic evaluation. Pain 1990;40: 279–291.

20. Watson CPN. Management issues of neuropathic trigeminal pain from a medical perspective. J Orofac Pain 2004;18:366–373.

21. Sessle BJ. Acute and chronic craniofacial pain: Brainstem mechanisms of nociceptive transmission and neuroplasticity, and their clinical correlates. Crit Rev Oral Biol Med 2000;11:57–91.

22. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–149.

23. Melzack R. The McGill Pain Questionnaire: Major prop-erties and scoring methods. Pain 1975;1:277–299.

24. Derogatis LR, Cleary PA. Confirmation of the dimensional structure of the SCL-90: A study in construct vali-dation. J Clin Psychol 1997;33:981–989.