Trigeminal Neuralgia: The Great Toothache Mimicry (Case Study #5)

Trigeminal Neuralgia: The Great Toothache Mimicry (Case Study #5)

Patient Complaint: Left Facial Pain for Month

Ms T, aged 50, came to me with intense stabbing pain on the right side of her lower jaw. There are many conditions that could be the cause; From a regular toothache, to a rare condition like Trigeminal Neuralgia.

 

It started as a dull, constant ache in the teeth, which progressed to widespread jaw pain. She described the pain as akin to ‘electric jolts’.

 

The pain was extreme and debilitating, and would strike whenever she moved her mouth. As a result, she had severe problems when she ate or talked. Over the months, this chronic pain led to a loss in appetite and thus, weight.

Endless Diagnoses & Misdiagnoses

The medical doctors and dentists she had visited were unable to diagnose the problem. One doctor even misdiagnosed her condition as Cranial Arteritis, an autoimmune condition.

 

A few of the dentists deduced that she was suffering from a bad toothache, and had suggested root canal treatment.

 

These vast differences in prognoses and diagnoses left Ms. T confused. Like any chronic pain patient, she wanted a definitive answer to her painful conundrum.

Visiting Our Clinic

She then sought help at our clinic, where I did a lengthy clinical examination which included the appropriate scans. It was rather clear to me that her chronic pain condition did not originate from the teeth, gums or surrounding musculoskeletal structures.

 

I suspected that she might be suffering from a nerve condition called Trigeminal Neuralgia. Thus, I ordered an MRI scan of her brain, which confirmed the diagnosis definitively. The scan showed that a blood vessel was compressing the nerve root at the right side of the brain.

What is Trigeminal Neuralgia?

According to the National Institute of Neurological Disorders and Stroke:

“Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the most widely distributed nerves in the head.”

It is classified as a form of neuropathic pain, which stems from a faulty or injured nervous system. Patients’ faces often twitch from the pain, which is where the term ‘tic douloureux’ comes from.

 

The fifth cranial nerve carries sensory information from the face to the brain, and also controls the muscles involved in chewing. Malfunction of this cranial nerve is also known to cause headaches.

The Two Types of Trigeminal Neuralgia

The classic form of Trigeminal Neuralgia is known as TN1 / Type 1. Some of the symptoms include:

  • Facial pain that comes in shocks.
  • Burning sensation in the face.
  • Pain near the lips, jaws, teeth, gums, eyes, forehead and more.
  • Pain that affects only one side of the face.
  • Tingling, numbing or aching sensation before an onset of an attack.
  • Pain that is triggered by touch or sound from regular activities, such as applying makeup, taking a shower, drinking a hot or cold beverage, feeling a light breeze and more.

These painful episodes can be traumatic as they strike suddenly. They can last anywhere from a few seconds to about two minutes.

 

TN2 / Type 2 is the atypical form of Trigeminal Neuralgia, where the pain may be less intense, but more constant.

 

It may be experienced as aching, burning or stabbing sensations. It is also possible for a patient to suffer from both types of Trigeminal Neuralgia at the same time.

Who Does Trigeminal Neuralgia Affect?

Trigeminal Neuralgia is a rare condition that affects about 12 out of 100,000 people per year. It has a predilection for elderly females aged 50 and above, although anyone can be affected by it, even infants. Young adults with Multiple Sclerosis also have a higher possibility of developing Trigeminal Neuralgia.

 

It is also the most common cause of facial pain in the U.S., with approximately 15,000 people diagnosed per year.

Other Disorders That Can Mimic Trigeminal Neuralgia

There are also other brain lesions or autoimmune disorders that can mimic the symptoms of Classical Trigeminal Neuralgia, such as: tumours, aneurysms, vascular malformations, Multiple Sclerosis and Connective Vascular Diseases.

 

Brain diseases and/or lesions can be life-threatening, and can manifest as jaw or teeth pain. It is imperative that the attending practitioner look beyond the mouth in search for answers, even though the primary complaint of pain is within that area.

 

Whilst Trigeminal Neuralgia may not be life-threatening, it is known to be one of the most painful chronic conditions that one can experience. The pain can take a severe toll on the patient and have a negative impact on their quality of life.

Treatment Options for Trigeminal Neuralgia

There are a few treatment and pain management options for Trigeminal Neuralgia. These include:

 

Medications.
Medications such as anticonvulsants or tricyclic antidepressants. The type of medication used is dependent on the type of Trigeminal Neuralgia a patient has as well. For example, anticonvulsants which are used to block nerves from firing, are more effective in TN1 than TN2.

 

The fact that Trigeminal Neuralgia is a progressive disorder needs to be taken into account as well, together with the intensity of the patient’s pain. This is because medication resistance can develop over time.

 

Surgery.
There are many factors to consider should a patient wish to undergo surgery to treat Trigeminal Neuralgia. Some of these factors include:

 

  • The patient’s current state of health
  • The distribution of trigeminal nerve involvement
  • Blood pressure
  • If they live with Multiple Sclerosis
  • And more

Other problems can result from surgery as well, such as hearing loss, balance problems and infections. Trigeminal Neuralgia often also returns despite initial success from surgical procedures.

 

There are a few different types of surgeries to choose from, such as: Balloon compression, Glycerol injection, Radiofrequency thermal lesioning (RF Ablation / RF Lesion), Stereotactic radiosurgery (gamma knife / cyber knife) and Microvascular decompression (MVD).

 

As these surgeries involve highly sensitive areas, it is best to discuss them in-depth with a trusted medical expert and/or surgeon in this field.

 

Complementary therapies such as low impact exercises, acupuncture, nutritional therapy and upper cervical chiropractic may work in tandem with medical treatment for Trigeminal Neuralgia. This is, once again, highly dependent on the patient’s preferences and state of health.

What This Case Study Highlights

After lengthy discussions on the diagnosis and treatment options for Trigeminal Neuralgia, Ms. T. chose to do a gamma knife surgery to rectify the brain lesion. I then referred her to a neurosurgeon for the procedure.

 

This case study highlights the importance of proper investigation when it comes to chronic pain, which is often ‘invisible’. In this incident, the patient appeared to have ‘only’ a toothache, when it was really a rare and debilitating condition.

 

A combination of knowledge, experience and skills are necessary to pinpoint such causes and treat them.

How Nourish Dental & TMJ Care Can Help

Here at Nourish Dental & TMJ Care we focus on diagnosing and treating orofacial pain, TMD, pain and sleep disorders. You can find out more about Dr. Eric Chionh and our dental practice on our About Page.