Orofacial Pain: Editorial

Scandinavian Journal of Pain

Objectives Patients with facial pain are sometimes referred for neurosurgical treatment with a poorly documented diagnosis of trigeminal neuralgia. In such cases, neurosurgery will usually not be helpful. We conducted a re-evaluation of the diagnosis in patients referred for neurosurgical treatment of presumed trigeminal neuralgia. Our objective was to find out why and how often misdiagnosis occurred. Methods A retrospective study was done in consecutive first-time patients referred for trigeminal neuralgia to our outpatient clinic in 2019. We used five ICHD-3-based clinical criteria to verify or exclude the diagnosis. In patients where trigeminal neuralgia was excluded, we established a diagnosis for their facial pain based upon medical history and a physical examination by a neurosurgeon – often supplemented with examination by an oral surgeon. Results Thirty-eight patients were referred for presumed trigeminal neuralgia. Only 17 of them fulfilled the five criteria and were diagno...

The Clinical Journal of Pain, 2002

Trigeminal neuralgia is a chronic facial pain classified as a neuropathic pain. There is widespread agreement regarding the International Association for the Study of Pain definition of classical idiopathic trigeminal neuralgia as "a sudden, usually unilateral, severe, brief, stabbing, recurrent pain in the distribution of one or more branches of the fifth cranial nerve." However, there are variations in presentation that are less easy to diagnose and an erroneous diagnosis of trigeminal neuralgia is occasionally made. In patients with tumors or multiple sclerosis, trigeminal neuralgia is termed secondary. Currently, clinical manifestations are the mainstay for diagnosis because there are no objective tests to validate the diagnosis. The sensitivity and specificity of these clinical manifestations is reviewed. Magnetic resonance imaging (MRI) and three-dimensional fast-inflow with steady-state precession MRI are performed to determine the presence of tumors or plaques of multiple sclerosis and to assess possible compressions and deformations of the trigeminal nerve. Their specificity and sensitivity regarding compressions found at the time of surgery is reviewed. Other differential diagnoses for chronic unilateral orofacial pain are discussed.

The Journal of Pain, 2008

A 61-year-old woman presented to her general dentist with a complaint of pain associated with the maxillary left first premolar. The patient described a sharp, lancinating pain that was triggered by stimulation of the tooth in question. She also reported 2 specific episodes in which she experienced severe, shooting electrical shock-like pain followed by a hot sensation in the same area. One of these episodes was triggered by a cool breeze on her face and the other occurred while washing her face. Examination and radiographic assessment revealed a periapical osseous lesion resulting in a diagnosis of acute apical periodontitis. Nonsurgical endodontics was completed with no undue effects. Approximately 2 months after the endodontic treatment, the patient began to have a recurrence of the paroxysmal sharp, shooting pain with a marked increase in the frequency of these episodes. The pain was triggered by light touch of the left cheek. Each episode lasted 1 to 2 seconds; however, she occasionally had 5 to 10 repetitive bursts. Clinical evaluation resulted in a diagnosis of trigeminal neuralgia of the left maxillary division. Initial treatment included 100 mg carbamazepine bid., which was gradually increased to a maximum dose of 600 mg bid. The patient derived modest benefit from the medication; unfortunately, cognitive changes necessitated a reduction in the dose. Gabapentin was introduced in a bedtime dosage regimen 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.

BMJ, 2014

Trigeminal neuralgia is a severe, unilateral, episodic pain of the face that is provoked by light touch; it should be differentiated from dental causes of pain Magnetic resonance imaging (MRI) can distinguish between patients having secondary trigeminal neuralgia related to tumours and that related to multiple sclerosis The first line drug for treatment is either carbamazepine or oxcarbazepine, and doses should be slowly escalated. Neurosurgical options should be discussed at an early stage, but surgery may not be required until quality of life is compromised Microvascular decompression is a major neurosurgical procedure that provides the longest period of pain relief and aims to preserve function of the nerve Percutaneous, palliative destructive procedures and stereotactic radiosurgery can provide temporary relief, but at the risk of facial numbness, which increases with repetition of the procedure Sources and selection criteria We used Medline and Embase and the search terms "trigeminal neuralgia" and "tic doloureux." One author (JZ) has done Cochrane reviews on both medical and surgical outcomes for trigeminal neuralgia, and the search strategy is shown in those publications. We searched the Cochrane Neuromuscular Disease Group specialised register, Cochrane Library, Medline, and Embase using the search terms "trigeminal neuralgia/facial neuralgia/tic douloureux," "tic doloureux," "tic doloreux," or "tic douloreux" with no language exclusion. Clinical knowledge summaries and international guidelines for trigeminal neuralgia were published in 2008, and the search strategy can be found on www.aan. com. We also used our own extensive archives of references.

European Journal of Neurology, 2008

Bmj British Medical Journal, 2007

The trigeminal nerve, fifth equal of cranial nerves, a mixed nerve is considered by possessing motor and sensitive components. The sensitive portion takes to the Nervous System Central somesthesics information from the skin and mucous membrane of great area of the face, being responsible also for a neural disease, known as the Trigeminal Neuralgia. The aim of this study was to review the literature on the main characteristics of Trigeminal Neuralgia, the relevant aspects for the diagnosis and treatment options for this pathology. This neuralgia is characterized by hard pains and sudden, similar to electric discharges, with duration between a few seconds to two minutes, in the trigeminal nerve sensorial distribution. The pain is unchained by light touches in specific points in the skin of the face or for movements of the facial muscles, it can be caused by traumatic sequels or physiologic processes degenerative associate the vascular compression. Prevails in the senior population, frequently in the woman. In a unilateral way it attacks more the maxillary and mandibular divisions, rarely happens in a simultaneous way in the three branches of trigeminal nerve three branches.

Neurology, 2008

Background: Trigeminal neuralgia (TN) is a common cause of facial pain. Purpose: To answer the following questions: 1) In patients with TN, how often does routine neuroimaging (CT, MRI) identify a cause? 2) Which features identify patients at increased risk for symptomatic TN (STN; i.e., a structural cause such as a tumor)? 3) Does high-resolution MRI accurately identify patients with neurovascular compression? 4) Which drugs effectively treat classic and symptomatic trigeminal neuralgia? 5) When should surgery be offered? 6) Which surgical technique gives the longest pain-free period with the fewest complications and good quality of life? Methods: Systematic review of the literature by a panel of experts. Conclusions: In patients with trigeminal neuralgia (TN), routine head imaging identifies structural causes in up to 15% of patients and may be considered useful (Level C). Trigeminal sensory deficits, bilateral involvement of the trigeminal nerve, and abnormal trigeminal reflexes are associated with an increased risk of symptomatic TN (STN) and should be considered useful in distinguishing STN from classic trigeminal neuralgia (Level B). There is insufficient evidence to support or refute the usefulness of MRI to identify neurovascular compression of the trigeminal nerve (Level U). Carbamazepine (Level A) or oxcarbazepine (Level B) should be offered for pain control while baclofen and lamotrigine (Level C) may be considered useful. For patients with TN refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife, and microvascular decompression may be considered (Level C). The role of surgery vs pharmacotherapy in the management of TN in patients with MS remains uncertain.

Stomatological Disease and Science, 2019

Trigeminal neuralgia (TN), also known as tic doloureaux, is a nerve disorder of the face and is considered to be one of the most painful human conditions. A 51-year-old male presented with severe intermittent pain on the left side of his face. Magnetic resonance image scan with contrast revealed a close association of the superior cerebella artery and the trigeminal nerve on the left side of the face. Oral medication is the first line of treatment for TN, because of its non-invasiveness, low cost and high effective rate. Surgical intervention for TN aims to relieve the pressure of the offending artery or vein that is compressing the trigeminal nerve or in other instances; surgery may stop the uncontrolled pain signals. An important criterion for clinical diagnosis is pain that cannot be attributed to another disorder and also the lack of evident neurologic disorder. TN is one of the most debilitating diseases an individual may suffer and an early astute diagnosis of TN will provide patients with relief from suffering, unnecessary dental and medical intervention. Appropriate and early diagnosis of TN is important to formulate an optimal management plan based on the patient's age and general condition. The aim of this case report is to describe a case of Classical TN, and subsequent successful surgical management with microvascular decompression.

ACTA CLINICA CROATICA, 2017

-Trigeminal neuralgia is one of the most common causes of facial pain. It implies short lasting episodes of unilateral electric shock-like pain with abrupt onset and termination, in the distribution of one or more divisions of the trigeminal nerve that are triggered by innocuous stimuli. Most cases of trigeminal neuralgia are caused by compression of the trigeminal nerve root. Depending on the etiology, trigeminal neuralgia can be classifi ed as classic trigeminal neuralgia or painful trigeminal neuropathy. It may be precipitated by some actions at trigger zones. Th e diagnosis of trigeminal neuralgia is based on diagnostic criteria for classic trigeminal neuralgia, neuroimaging and electrophysiologic trigeminal refl ex testing. Treatment of classic trigeminal neuralgia for most patients is pharmacological therapy, while surgical approach is reserved for patients that are refractory to medical therapy and in cases of painful trigeminal neuropathy.