A Rise In Cases at Nourish TMJ Care, For Idiopathic Trigeminal Neuralgia After Dental Work

A Rise in Cases for Idiopathic Trigeminal Neuralgia After Dental Work

We have been seeing an increase in cases at Nourish Dental Sleep & TMJ Care for Idiopathic Trigeminal Neuralgia after dental work. These patients’ pain only started after some sort of dental-related treatment, ranging from minor to invasive procedures. As no obvious anomalies could be found on blood tests or scans, they are often misdiagnosed, or disbelieved by doctors or dentists.

Patients visit our clinic with complaints of orofacial pain after dental work such as root canals, tooth extractions, placement of dental implants, endodontic treatments, dental surgeries, injections used in the oral cavity, and more.

According to Agbaje et al. (2016):

“Damage to branches of the trigeminal nerve following maxillofacial surgery and dental treatment is unfortunately common, in most cases the symptoms are transient and patients fully recover sensation over time. Persistent nerve damage results in severe complications such as neuropathic pain and trigeminal neuralgias.”

*Disclaimer: As of March 30, 2020, the ADA (American Dental Association) has officially recognised Orofacial Pain as its 12th dental speciality. Any reference to ‘specialisation’ is made in the context of the United States of America and not Singare. Please visit our Disclaimers and FAQ pages for more information.

Where is the Trigeminal Nerve & What are Its Functions?

The trigeminal nerve is part of the nervous system, and is the largest sensory cortex representation in the brain. Its purpose is to send pain signals and other sensations, such as temperature changes, from the face to the brain. The mandibular nerve is the only branch of the trigeminal nerve with a motor function, which aids facial muscles to chew and move. It covers the lower portion of the face, including the jaws, gums and lower lip.

The other two branches of the trigeminal nerve are the ophthalmic and maxillary nerves. The ophthalmic nerve is responsible for sensations in the upper part of the face, from the scalp to the eye areas. The maxillary nerve is involved with the middle part of your face, which spans from your lower eyelids, down to the upper lips and gums.

As you can see, the trigeminal nerve is a complex nerve that spans across many parts of the head and face, in connection with the brain. Pain sensations can be felt anywhere within the orofacial region and beyond, since the brain is a major organ that regulates many processes in the body.

What is Trigeminal Neuralgia Pain Like?

As per The International Classification of Headache Disorders (ICHD-3), there are three classifications of Trigeminal Neuralgia – Classical, Secondary, and Idiopathic Trigeminal Neuralgia. Classical Trigeminal Neuralgia is generally due to neurovascular compression of the trigeminal root in the skull. Symptoms
include: “electric-shock” like pain, burning, tingling, shooting, pulsating, aching and/or numbing sensations in the face.

Secondary Trigeminal Neuralgia is generally triggered by an underlying disease, such as Multiple Sclerosis, connective tissue disorders such as Lupus and Sjögren’s Disease, tumors or vascular malformations. Sensory changes can be seen on clinical examinations. The pain is more of a chronic, continuous nature.

You can also read more about Type 1 and Type 2 Trigeminal Neuralgia in one of our case studies here.

How is Idiopathic Trigeminal Neuralgia Different from Classical & Secondary Trigeminal Neuralgia?

Idiopathic Trigeminal Neuralgia is rarer and much harder to diagnose, as it can mimic myriad other orofacial pain disorders. It affects approximately 4 out of 100,000 patients, and pain triggers can be from mundane activities such as laughing, chewing or brushing teeth. Unfortunately, many patients with Trigeminal Neuralgia undergo unnecessary tooth extractions or other dental procedures in a bid to resolve the pain to no avail, as there is nothing wrong with the teeth to begin with (von Eckardstein et al., 2015).

The pain from Idiopathic Trigeminal Neuralgia can be acute or continuous. Unlike Classical and Secondary Trigeminal Neuralgia, no abnormalities can be seen on MRI or electrophysiological tests either (Maarbjerg and Benoliel, 2021). The orofacial pain specialist needs to consider many factors before a diagnosis can be made. (You can read a case study of Idiopathic Trigeminal Neuralgia that we treated at our clinic in Singapore here.)

Pain from any type of Trigeminal Neuralgia is known to be one of the worst pains a person can experience, and gaslighting from medical professionals can add injury to insult. Many patients sink into depression and start to catastrophize their pain, which ultimately wears away at their coping abilities and resolve.

Can Pain from Trigeminal Neuralgia Cause Pain Elsewhere?

The head, neck, jaw, mouth and face contain many fine nerves, joints and structures. They work together to help you perform essential everyday functions such as eating, drinking, chewing, and talking. Loss of these basic yet important functions can reduce an individual’s quality of life drastically. This psychosocial burden needs to be acknowledged in addition to the physical pain, as they can feed off each other in a vicious cycle.

It is also now recognised that pain can occur throughout the entire trigeminal system, which includes the mid and lower face. This can present as persistent idiopathic facial pain (PIFP) (Benoliel and Gaul, 2017) or unilateral neuralgiform headache attacks (SUNHA) in its chronic form, which can further confuse doctors or dentists (Benoliel et al., 2017).

The trigeminal nerve is also in close proximity to the ears, and supplies innervation for blood vessels in the inner ear. Disruption to the trigeminal nerve can cause neuralgia (ear pain) and contribute to tinnitus as well (Cheng et al., 2020).

Risk Factors & Choice of Dentist or Surgeon

There are certain groups of people that are more susceptible to developing chronic pain after dental work. Factors include: genetics, what type of pain and problem existed prior to dental work, psychosocial factors, age (older patients are at a higher risk), sex (more prevalent in females), and the technique used for the surgical procedure (Renton, 2011).

It is also essential for the orofacial pain specialist or dentist to understand the patient’s lifestyle, medical history, details of how the episodes started, the pain and sensations experienced, and to assess other factors that may play a role. Your choice of dentist or surgeon matters, as inexperience can play a role in nerve injuries or lead to unnecessary complications, some of which may become long-lasting.

Possible Causes for Idiopathic Trigeminal Neuralgia After Dental Work

Sometimes, the patient is no longer sure whether the pain was worse before their dental work, or after, and how they differ. Pain sensations can differ depending on which part of the orofacial region or trigeminal nerve was impacted. It is also important to note that at times, the area where the pain is felt does not always correlate to where the root of the problem lies.

According to Neal and Zuniga (2022):

“The branches of the trigeminal nerve usually affected are the inferior alveolar nerve (IAN) and the lingual nerve (LN). These injuries are most commonly caused by third molar extraction, followed by orthognathic surgery, mandibular trauma, dental implant placement, local anesthesia injection, endodontic therapy, and pathology resection. The reported incidence of IAN or LN injury following these procedures is wide ranging at 0.6 to 90%.”

This list is merely meant to give you a rough idea of dental procedures that can lead to trigeminal nerve injuries. Whilst these are common causes, not all of them are idiopathic in nature. Thus, it is important to visit an orofacial pain specialist in order to obtain a proper diagnosis. Apart from a physical examination, clinical tests may be necessary.

Trigeminal Nerve Injuries from Injections and Anaesthesia

Trigeminal nerve injuries can occur from multiple factors whilst undergoing any sort of dental work, no matter how minor it may seem at the outset. Injections, such as from local anaesthesia, can lead to trigeminal nerve injury for a number of reasons. Some of these include: the type of anaesthesia used, how much is injected, and the location of the injection. General anaesthesia can be a greater risk factor as compared to local anaesthesia as well (Nguyen et al., 2014).

Nerve Damage from Facial or Mandibular Trauma After Surgery

Nerve damage can also happen during manipulation during surgeries to correct maxillomandibular deformities, or removal of tumours in the oral region. Besides pain, this can also result in nerve deformation, infections, ischemia (where blood flow is restricted), and transient oedema (water retention) (Agbaje et al., 2016).

Nerve Injuries from Dental Implants

Improper dental implant placements can also lead to nerve damage or injuries. Implant-related inferior alveolar nerve injury (a branch of the trigeminal nerve) varies from 0 – 40%, with some recent studies showing persistent neuropathic pain as a result of dental implants (Renton, 2021).

Third Molar Tooth Extraction

Third molar tooth extraction is also known colloquially as “wisdom tooth extraction”, and is the most common dental surgical procedure. It has also been implicated in more than 50% of nerve damage incidences (Agbaje et al., 2016). Wisdom teeth are located very close to branches of the trigeminal nerve, so extra precaution must be taken in order to prevent injury.

Orthognathic Surgery

Orthognathic surgery, also known as jaw surgery, is done to realign the jaws and teeth, and/or correct irregularities of the jaw bones. It is a common cause of nerve damage, due to the manipulation of nerve bundles and structures during the surgery. A study also showed that only 50% of patients in this category fully recover (Agbaje et al., 2016).

The Importance of Differentiating Idiopathic Trigeminal Neuralgia from Other Orofacial Pain Disorders

As per the American Academy of Orofacial Pain’s (AAOP) website:

“OFP associated disorders include but are not limited to temporomandibular muscle and joint (TMJ) disorders, jaw movement disorders, neuropathic and neurovascular pain disorders, headache, and sleep disorders.”

Orofacial pain disorders are complex and can be multifactorial. They range from the nerves, to muscles, vascular system and more. In addition to that, orofacial pain disorders can often be mistaken for toothaches, yet nothing is wrong with the teeth. There are also many other ‘invisible’ or idiopathic types of orofacial pain that exist, that could be mistaken for Idiopathic Trigeminal Neuralgia, such as PIFP, atypical facial pain, or myofascial pain.

Many patients undergo unnecessary treatments in a bid to relieve their pain, which can be costly at ‘best’, or cause permanent damage at worst. It is also important to treat any sort of nerve injury as soon as possible, so as to prevent further damage, or halt its progression into a chronic problem.

A trained orofacial pain specialist can help to determine the cause of your pain, and work together with you to formulate a treatment plan that is suited to your specific pain issues and needs.

Treatment for Idiopathic Trigeminal Neuralgia After Dental Work

There are a number of treatments that are available for Idiopathic Trigeminal Neuralgia. Medications are often the first line of treatment for pain management from Trigeminal Neuralgia, but it also depends on many other factors such as the type of TN, the type of pain the patient is experiencing, genetics, allergies and more.

Surgery may be needed for a subset of patients, but this is best avoided unless absolutely necessary. Once again, we have seen too many patients at our clinic who have undergone unnecessary, painful and costly procedures, with some of them experiencing even more problems after.

Complementary and physical therapies can also be included in the pain management regime, and we also offer such therapeutic approaches at our clinic. However, a proper diagnosis by a trained orofacial specialist should first be made, so as not to cause further injury.

How Nourish Dental Sleep & TMJ Care Can Help With Idiopathic Trigeminal Neuralgia After Dental Work (and Other Orofacial Pain Disorders)

At Nourish Dental Sleep & TMJ Care, Singapore, we encounter many patients who suffer from a wide range of orofacial pain disorders, including Idiopathic Trigeminal Neuralgia after dental work. Our clinic focuses on these disorders, as well as dental pain management, TMJ disorder treatment, jaw pain treatment, and sleep apnoea issues.

Dr. Eric Chionh runs the clinic together with a competent team, and believes in working together with his patients. He is formally trained in Oral Medicine and Orofacial Pain, and holds a Singapore Dental Council approved qualification in these areas. His additional training in Oral Medicine also means that he is more familiar with medically complex patients, as well as medically-related disorders or conditions that may affect the oral and maxillofacial region. This additional knowledge grants him more insight into both causes and treatments for orofacial pain disorders.

Dr. Chionh has a special interest in pain management, with over 20 years of hands-on experience. It brings him joy when his patients’ quality of life improves, and when their pain recedes and is well managed. You can learn more about Dr. Eric Chionh’s qualifications and our dental practice here. Visit Our Services page to view all dental and pain management services we provide.

References:

  • Agbaje, J. O., Van de Casteele, E., Hiel, M., Verbaanderd, C., Lambrichts, I., & Politis, C. (2016). Neuropathy of trigeminal nerve branches after oral and maxillofacial treatment. Journal of maxillofacial and oral surgery, 15, 321-327. https://doi.org/10.1007/s12663-015-0843-9
  • Benoliel, R., & Gaul, C. (2017). Persistent idiopathic facial pain. Cephalalgia, 37(7), 680-691. https://doi.org/10.1177/0333102417706349
  • Benoliel, R., Sharav, Y., Haviv, Y., & Almoznino, G. (2017). Tic, triggering, and tearing: from CTN to SUNHA. Headache: The Journal of Head and Face Pain, 57(6), 997-1009.
  • Cheng, Y. F., Xirasagar, S., Yang, T. H., Wu, C. S., Kao, Y. W., Shia, B. C., & Lin, H. C. (2020). Increased risk of tinnitus following a trigeminal neuralgia diagnosis: A one-year follow-up study. The journal of headache and pain, 21, 1-7. https://doi.org/10.1186/s10194-020-01121-6
  • Maarbjerg, S., & Benoliel, R. (2021). The changing face of trigeminal neuralgia—A narrative review. Headache: The Journal of Head and Face Pain, 61(6), 817-837. https://doi.org/10.1111/head.14144
  • Neal, T. W., & Zuniga, J. R. (2022). Post-traumatic trigeminal neuropathic pain: factors affecting surgical treatment outcomes. Frontiers in Oral Health, 3, 904785.
  • Nguyen, E., Grubor, D., & Chandu, A. (2014). Risk factors for permanent injury of inferior alveolar and lingual nerves during third molar surgery. Journal of Oral and Maxillofacial Surgery, 72(12), 2394-2401. https://doi.org/10.1016/j.joms.2014.06.451
  • Renton, T. (2021). Trigeminal nerve injuries. Oral and Maxillofacial Surgery for the Clinician, 515-529. https://doi.org/10.1007/978-981-15-1346-6_25
  • Renton T. (2011). https://doi.org/10.3389/froh.2022.904785 Persistent Pain after Dental Surgery. Reviews in pain, 5(1), 8–17. https://doi.org/10.1177/204946371100500103
  • von Eckardstein, K. L., Keil, M., & Rohde, V. (2015). Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurgical Review, 38, 355-360. https://doi.org/10.1007/s10143-014-0591-1

One Comment

Dr. Susan Marinovich
May 19, 2024 4:02 am

Interesting. As a dentist myself with new trigeminal neuralgia that was not induced by dentistry ,I know first hand that it can start out of nowhere without warning , predictability or dental cause. I have several patients with TN, and a I would say it is the most debilitating of all conditions to be afflicted with. My episodes last for several hours and days straight . Only Carbemazepine and Percocet make my bedridden days livable. I’ve never missed a day out of 34 years of work for illness, I don’t complain and I never cry. Until this. I’m sure you’ve seen the worst of it. What I wanted to tell you is that I was enjoying your article until I found out you were in Singapore. Here in Canada, land of the Used To Be Free, there is a 2 year waiting list to be seen at the Mt Sinai Hospital Facial Pain Clinic. . Our health care is terrible. Now our federal govt. wants to ruin privatized dentistry. I’m at my wits end from many angles. I’m retiring in September. Good luck with your endeavours, you are a Godsend to many people I’m sure

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