Science + Tech

The dentist’s role in managing trigeminal neuralgia

Trigeminal neuralgia is a chronic pain condition that can result in inexplicable and spontaneous pain in the areas innervated by all three branches of the trigeminal nerve. Oftentimes, patients with trigeminal neuralgia will approach a dentist with complaints of pain in their mouth with no obvious cause. It is important for dental providers to distinguish trigeminal neuralgia from the usual suspects of dental pain in order to best treat the patient and avoid unnecessary harm.  

Misdiagnosing trigeminal neuralgia in a dental office could lead to a patient receiving procedures such as restorations, endodontic therapy or untimely extractions of vital dentition — procedures that, ultimately, may not resolve the patient’s pain. Dentists are trained to recognize many causes of pain in the mouth and face, all of which are supplied by the trigeminal nerve. This familiarity with the anatomy of the head and neck is also what allows a dentist to play a pivotal role in recognizing a trigeminal-associated pathology. In the scenario where it is difficult to reach a logical, dentition-associated diagnosis of the origin of dental pain, one must consider the differentials of orofacial pain. 

Typical symptoms of trigeminal neuralgia include bouts of spontaneous, stabbing pain or a more chronic, burning feeling limited to areas of trigeminal nerve distribution. These painful episodes are usually followed by asymptomatic periods. In addition, most all patients will have stimuli or cutaneous triggers for pain. One study reports that the most common trigger of pain for trigeminal neuralgia is gentle touching on the face in 79% of patients observed, and other triggers include chewing, tooth brushing and even talking. It is not unlikely, then, that many of the chairside tests that dentists conduct to determine tooth vitality may also trigger these symptoms directly or indirectly. In this instance, it is especially important to recognize false positive test results and avoid tunnel vision that may rush treatment. The following are some cues in questioning that may aid a dentist or dental student in diagnosing trigeminal neuralgia: 

  • Obtain the patient’s medical history. Rule out differentials such as post-herpetic neuralgia, cluster headaches, temporomandibular joint disorder and oral pathologies.
  • Ask the patient to specify their pain sensation, looking out for the qualities described earlier. If they report numbness, constant pain, bilateral pain or an absence of triggers, it may not be trigeminal neuralgia.
  • Some patients may have tried over-the-counter pain relief medications with no success.

When the diagnosis of trigeminal neuralgia has been established or even suspected, it may be appropriate to refer the patient to a specialist. This could be an orofacial pain medicine doctor, a neurologist, a psychologist or a sleep medicine specialist, to name a few. The NIH reports that treatments for trigeminal neuralgia range from non-invasive medication regimens to a multitude of surgeries. The interdisciplinary knowledge to refer is invaluable for a patient who may need further imaging such as an MRI or treatments only capable in a hospital setting.

When a patient complains of pain in the mouth with no easily identifiable origin, a dentist should think of atypical conditions such as trigeminal neuralgia. It is a dentist’s responsibility to not only recognize the pain for what it is, but most importantly, recognize it for what it is not.

~Denise Miresmaili, Los Angeles ’22

Denise Miresmaili

Denise Miresmaili is a fourth-year student at UCLA School of Dentistry and is planning to attend a GPR at the Salt Lake City Veterans Affairs Medical Center in Utah after graduation. She plans to subsequently pursue private practice.

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