Trigeminal Neuralgia Support Group

Case Reviews in Pain

Toothache or Trigeminal Neuralgia: Treatment Dilemmas

Christopher J. Spencer, John K. Neubert, Henry Gremillion, Joanna M. Zakrzewska,

and Richard Ohrbach

Case Reviews in Pain

Toothache or Trigeminal Neuralgia: Treatment Dilemmas

Christopher J. Spencer, John K. Neubert, Henry Gremillion, Joanna M. Zakrzewska,

and Richard Ohrbach

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.

Many acute, chronic, and recurrent painful maladies

22% of the U.S. population have orofacial pain on more

than 1 occasion in a 6-month period. However, the etiology

of pain for countless patients who have chronic orofacial

pain disorders is unknown. In many instances,

these patients may not recognize an injury or serendipitously

report having a relatively minor dental procedure

(eg, restoration or root canal) completed at the time of

pain onset. Although pain involving the teeth and the periodontium

is the mostcommonpresenting concern in dental

practice, other nonodontogenic causes of orofacial pain

must be considered in the differential diagnostic process.

Neuropathic orofacial pain, which is pain initiated or

caused by a primary lesion or dysfunction in the nervous

system, is relatively common. It is diagnosed in approximately

25% to 30% of patients presenting in a tertiary

representative of neuropathic orofacial pain are postherpetic

neuralgia, trigeminal neuralgia, traumainduced

neuropathy, atypical odontalgia/nonodontogenic

toothache, idiopathic oral burning, and Complex Regional

Pain Syndrome (CRPS). In some instances, diagnosis

can be difficult, as neuropathic orofacial pain is associated

with significant interpatient variability regarding

presentation and response to treatment. Additionally,

neuropathic pain conditions are frequently associated

with qualities that the patient is not familiar, thus making

it difficult for the patient to communicate their pain

experience. Typical descriptors used by patients include

stabbing, burning, electric-like, and/or sharp, with

numbness or tingling projected to a cutaneous area.15,16

However, aching pain does not preclude the possibility

of a neuropathic basis for the patient’s pain.

The present case illustrates an interesting conundrum

whereby the practicing clinician must decide whether

Address correspondence to Judith A Paice, PhD, RN, Editor, Case Reviews

in Pain; Director, Cancer Pain Program, Northwestern University, Feinberg

1526-5900/$34.00

© 2008 by the American Pain Society

doi:10.1016/j.jpain.2008.07.001