When Idiopathic Trigeminal Neuralgia Pain is Mistaken for Something Else

When Idiopathic Trigeminal Neuralgia is Mistaken for Something Else (Case Study #9)

We have covered Type 1 and Type 2 Trigeminal Neuralgia in a previous case study here. This case study examines a third type of Trigeminal Neuralgia – Idiopathic Trigeminal Neuralgia (ITN), which is even more difficult to diagnose. We have also been seeing a rise in cases of Idiopathic Trigeminal Neuralgia after dental work at our clinic.

*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.

Patient Profile & Pain Experienced

Mrs. D. is a 60 year-old female who came to Nourish Dental Sleep & TMJ Care in distress. She complained of a debilitating and painful toothache, as well as facial pain on the right mid facial area.

Mundane activities such as talking, putting on makeup, eating, brushing her teeth and every light touch came at the cost of extreme pain. Even trying to rest was nearly impossible, as lying on her affected side was painful as well. Her quality of life was reduced drastically, as her regular routines, activities and appetite were curtailed. The pain was so excruciating that she lost weight, became socially reclusive and sank into depression.

Finally Diagnosed with Idiopathic Trigeminal Neuralgia at Our Clinic

Mrs. D. had visited various medical specialists before coming to our clinic. Antidepressants prescribed by her psychiatrist helped the pain a little, but did not bring significant relief. Numerous dental practitioners she went to insisted that her pain was not a dental issue, yet neurologists she visited insisted that it was. Radiologists she consulted could not find anything on the scans that could explain her symptoms.

This, unfortunately, is a common scenario for many patients who experience invisible, chronic pain, which can go undiagnosed or misdiagnosed for years on end.

Classical Trigeminal Neuralgia is the most ‘common’, followed by Secondary Trigeminal Neuralgia, and finally Idiopathic Trigeminal Neuralgia, which accounts for approximately 10% of patients (Lambru and Zakrzewska, 2021). Yet, even the more ‘common’ types of Trigeminal Neuralgia are often misdiagnosed, so what more about Idiopathic Trigeminal Neuralgia?

Why Trigeminal Neuralgia is Difficult to Diagnose

In general, Trigeminal Neuralgia can be tricky to diagnose as it can mimic myriad other orofacial pain conditions. The head, jaw, oral cavity, face and neck are all within close proximity, and contain many fine nerves and structures. Pain in one area can easily affect other surrounding structures, which might not appear on scans. At times, the root cause of the pain does not correlate with the area where the pain is felt.

For example, we had a patient who was really suffering from Facial Migraine, and another from Myofascial Pain, yet both thought that they had toothaches.

Types of Trigeminal Neuralgia

Trigeminal Neuralgia is divided into three subtypes, based on the ICHD-3 (International Classification of Headache Disorders) – Classical, Secondary and Idiopathic.

For Idiopathic Trigeminal Neuralgia, no abnormalities can be seen on MRI or electrophysiological tests (Kikkeri and Nagalli, 2024). Unlike Classical or Secondary Trigeminal Neuralgia, no neurovascular compression or any other brain lesions can be attributed to the pain, which makes it even trickier to diagnose.

Diagnosing Idiopathic Trigeminal Neuralgia

Apart from a clinical evaluation, many other factors need to be taken into account on an individual basis, such as age, gender and lifestyle.

‘Pain’ in itself is not just a general descriptor either. The medical or dental practitioner needs to know crucial information, such as:

  • The circumstances of the first onset of pain
  • How the pain presents itself (is it shocking, sharp, dull, etc?)
  • How frequently the pain occurs and recurs, and how long the episodes last
  • What the patient’s individual pain triggers are
  • If there are any existing comorbidities that might play a part in the pain experience

Every detail matters, such that an experienced medical or dental practitioner is able to determine the next steps to take, in search of the correct diagnosis and treatment options.

At Nourish Dental Sleep & TMJ Care, we listened to Mrs. D.’s complaints of pain, and took note of her medical history, and what she had and hadn’t tried for pain relief. We conducted a thorough patient examination and used the appropriate tests, in order to rule out other possible diagnoses. At the end of it, we concluded that she was suffering from the enigmatic and notoriously difficult to diagnose condition, Idiopathic Trigeminal Neuralgia.

Idiopathic Trigeminal Neuralgia Treatment at Our Clinic

Mrs. D.’s pain eventually relented as it responded to treatment at our clinic, and she was placed on long-term maintenance therapy.

There are a number of treatment options for Trigeminal Neuralgia, from pharmacological to surgical. Once again, treatment should be selected based on the symptoms, existing medical conditions and patient profile.

Dental practitioners may come across toothaches or jaw pain of vague origins on occasion. It is even more crucial under such circumstances not to administer treatments in haste. Mrs. D. underwent numerous unnecessary teeth extractions and root canal treatments.

Such treatments are futile as they do not address the root cause, and are also expensive and painful. Irreversible dental procedures should not be carried out in vain hope of quelling the affliction, without even knowing if the pain will subside, or if it will return – with a vengeance, perhaps.

How Nourish Dental Sleep & TMJ Care Can Help with Idiopathic Trigeminal Neuralgia & Other Orofacial Pain Disorders

At Nourish Dental Sleep & TMJ Care, we encounter many patients who suffer from a wide range of orofacial pain disorders. Sometimes, a patient may be suffering from a few different pain conditions concurrently as well. Our clinic focuses on these disorders, and also on dental pain management and TMJ Disorder treatment.

Dr. Eric Chionh runs the clinic, together with a competent team. He is formally trained in Oral Medicine and Orofacial Pain, and holds a Singapore Dental Council approved qualification in these areas. He is passionate about pain management, and has had a lot of hands-on experience over the years. 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 at Nourish Dental Sleep & TMJ Care, Singapore.

References:

  • Kikkeri, N. S., & Nagalli, S. (2024). Trigeminal neuralgia. In StatPearls [Internet]. StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK554486/