Atypical odontalgia and trigeminal neuralgia: psychological, behavioural and psychopharmacologic approach – an overview of the pathologies related to the challenging differential diagnosis in orofacial pain

Orofacial pain represents a challenge for dentists, especially if with a non-odontogenic basis. Orofacial neuropathic pain is chronic, arduous to localize and develops without obvious pathology. Comorbid psychiatric disorders, such as anxiety and depression, coexist and negatively affect the condition. This article presents one case of atypical odontalgia and one of trigeminal neuralgia treated with psychological and psychopharmacologic tailored and adapted therapies, after conventional medications had failed. In addition, an overview of the pathologies related to the challenging differential diagnosis in orofacial pain is given, since current data are insufficient. A 68-year-old male complained of chronic throbbing, burning pain in a maxillary tooth, worsening upon digital pressure. Symptoms did not abate after conventional amitriptyline therapy; psychological intervention and antianxiety drug were supplemented and antidepressant agent dosage incremented; the patient revealed improvement and satisfaction with the multidisciplinary approach to his pathology. A 72-year-old male lamented chronic stabbing, intermittent, sharp, shooting and electric shock-like pain in an upper tooth, radiating and following the distribution of the trigeminal nerve. Pain did not recur after psychological intervention and a prescription of antidepressant and antianxiety agents, while conventional carbamazepine therapy had not been sufficient to control pain. Due to concern with comorbid psychiatric disorders, we adopted a patient-centered, tailored and balanced therapy, favourably changing the clinical outcome. Comorbid psychiatric disorders have a negative impact on orofacial pain and dentists should consider adopting tailored therapies, such as psychological counselling and behavioural and psychopharmacologic strategies, besides conventional treatments. They also need to be familiar with the signs and symptoms of orofacial pain, recollecting a comprehensive view of the pathologies concerning the differential diagnosis. A prompt diagnosis prevents pain chronicity, avoiding an increase in complexity and a shift to orofacial neuropathic pain and legal claims.

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Atypical odontalgia and trigeminal neuralgia: psychological, behavioural and psychopharmacologic approach – an overview of the pathologies related to the challenging differential diagnosis in orofacial pain

F1000Research ◽

10.12688/f1000research.51845.1 ◽

2021 ◽

Vol 10 ◽

pp. 317

Author(s):

Riccardo Tizzoni ◽

Marta Tizzoni ◽

Carlo Alfredo Clerici

Keyword(s):

Neuropathic Pain ◽

Differential Diagnosis ◽

Trigeminal Neuralgia ◽

Psychiatric Disorders ◽

Orofacial Pain ◽

Negative Impact ◽

Psychological Intervention ◽

Current Data ◽

Atypical Odontalgia ◽

Comorbid Psychiatric Disorders

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Neuralgias of the Trigeminal Nerve

Pain Research and Management ◽

10.1155/2000/517683 ◽

2000 ◽

Vol 5 (1) ◽

pp. 107-113 ◽

Cited By ~ 2

Author(s):

Allan S Gordon

Keyword(s):

Neuropathic Pain ◽

Differential Diagnosis ◽

Trigeminal Neuralgia ◽

Clinical Features ◽

Trigeminal Nerve ◽

Postherpetic Neuralgia ◽

Facial Pain ◽

The Other ◽

Atypical Facial Pain ◽

Trigeminal Neuropathic Pain

Practitioners are often presented with patients who complain bitterly of facial pain. The trigeminal nerve is involved in four conditions that are sometimes mixed up. The four conditions - trigeminal neuralgia, trigeminal neuropathic pain, postherpetic neuralgia and atypical facial pain - are discussed under the headings of clinical features, differential diagnosis, cause and treatment. This article should help practitioners to differentiate one from the other and to manage their care.

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Cranial neuralgias and persistent idiopathic facial pain

Oxford Textbook of Headache Syndromes ◽

10.1093/med/9780198724322.003.0027 ◽

2020 ◽

pp. 237-247

Author(s):

Aydin Gozalov ◽

Messoud Ashina ◽

Joanna M. Zakrzewska

Keyword(s):

Neuropathic Pain ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Orofacial Pain ◽

Treatment Modalities ◽

Management Approach ◽

Trigeminal Neuropathy ◽

Facial Region ◽

Persistent Idiopathic Facial Pain ◽

Chronic Orofacial Pain

Orofacial pain is a complex problem and affects up to 7% of the population. Although trigeminal neuralgia has been considered the prime neuralgic condition in the facial region, other forms of neuropathic pain are now being more frequently recognized and require recognition and a different management approach. Many patients with chronic orofacial pain report numerous comorbidities, such as psychiatric or personality disorders, which significantly affect management. Various pain conditions present in the facial region. Some of them rarely present extra-orally (unless as radiating pain) such as atypical odontalgia or persistent dento-alveolar pain disorder and burning mouth syndrome, whereas others will present in both areas such as classical trigeminal neuralgia, post-traumatic trigeminal neuropathy, trigeminal neuropathy attributed to multiple sclerosis, and persistent idiopathic facial pain. Myofascial pain syndrome related to the muscles of mastication is very common and may also be associated with temporomandibular joint problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are similar in quality and characteristics with specific treatment modalities, but differ in pain location. Trigeminal neuropathic pain is caused most frequently by trauma. If no other diagnostic criteria are fulfilled, a diagnosis of persistent idiopathic facial pain is made. It is crucial for these patients to be managed by multidisciplinary teams.

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Peripheral neuromodulation for the treatment of refractory trigeminal neuralgia

Pain Research and Management ◽

10.1155/2015/482652 ◽

2015 ◽

Vol 20 (2) ◽

pp. 63-66 ◽

Cited By ~ 10

Author(s):

Naum Shaparin ◽

Karina Gritsenko ◽

Diego Fernandez Garcia-Roves ◽

Ushma Shah ◽

Todd Schultz ◽

...

Keyword(s):

United States ◽

Neuropathic Pain ◽

Trigeminal Neuralgia ◽

Chronic Headache ◽

Orofacial Pain ◽

The United States ◽

Headache Disorders ◽

Affected Patient ◽

Present Case Report ◽

The Face

Trigeminal neuralgia is a type of orofacial pain that is diagnosed in 150,000 individuals each year, with an incidence of 12.6 per 100,000 person-years and a prevalence of 155 cases per 1,000,000 in the United States. Trigeminal neuralgia pain is characterized by sudden, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve, which can cause significant suffering for the affected patient population.In many patients, a combination of medication and interventional treatments can be therapeutic, but is not always successful. Peripheral nerve stimulation has gained popularity as a simple and effective neuromodulation technique for the treatment of many pain conditions, including chronic headache disorders. Specifically in trigeminal neuralgia, neurostimulation of the supraorbital and infraorbital nerves may serve to provide relief of neuropathic pain by targeting the distal nerves that supply sensation to the areas of the face where the pain attacks occur, producing a field of paresthesia within the peripheral distribution of pain through the creation of an electric field in the vicinity of the leads.The purpose of the present case report is to introduce a new, less-invasive interventional technique, and to describe the authors’ first experience with supraorbital and infraorbital neurostimulation therapy for the treatment of trigeminal neuralgia in a patient who had failed previous conservative management.

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Chronic neuropathic facial pain associated with cranial nerves damage: clinical picture, diagnosis, treatment

Practical medicine ◽

10.32000/2072-1757-2020-5-42-45 ◽

2020 ◽

Vol 18 (5) ◽

pp. 42-45

Author(s):

T. G. SAKOVETS ◽

◽

E. I. BOGDANOV ◽

Keyword(s):

Neuropathic Pain ◽

Herpes Zoster ◽

Trigeminal Neuralgia ◽

Facial Pain ◽

Orofacial Pain ◽

Cranial Nerves ◽

Ear Canal ◽

Short Term ◽

Adequate Treatment ◽

Hunt Syndrome

The purpose — to study of the features of chronic neuropathic facial pain associated with cranial nerve damage. Material and methods. We studied the modern works on the features of the clinic, diagnosis and treatment of chronic orofacial pain caused the cranial nerves damage. Special attention was paid to the methods of diagnosing neuropathic facial pain of various etiologies, and identifying clinical variants of their course. Results. The best known and most common variant of neuropathic orofacial pain is trigeminal neuralgia. There are classic trigeminal neuralgia that occurs as a result of vaso-neural conflict, secondary trigeminal neuralgia (in multiple sclerosis, voluminous brain neoplasm, etc.), and idiopathic trigeminal neuralgia. Patients have short-term (from fractions of a second to 2 minutes) unilateral paroxysmal facial pain in classic trigeminal neuralgia. In case of secondary trigeminal neuralgia, mainly bilateral neuropathic pain is detected. Painful trigeminal neuropathy (trigeminal neuropathic pain other than trigeminal neuralgia) is caused by trauma and herpes zoster with acute neuropathic pain. After 3 months, painful manifestations after the herpes zoster are qualified as trigeminal postherpetic neuralgia. Post-traumatic neuropathic trigeminal pain is the result of external trauma or iatrogenic damage resulting from dental treatment or neuroablation procedures. Both classical and secondary, idiopathic neuralgia of the glossopharyngeal nerve is characterized by unilateral short-term stabbing pain in the ear, base of the tongue, tonsil region, posterior part of the pharynx; it is less common, in contrast to trigeminal neuralgia. Intermediate nerve neuralgia was first described in 1907 by Hunt; it is rare, manifests itself as unilateral, shooting, paroxysmal pain in the ear canal and temporal areas. Painful neuropathy of the intermediate nerve (Ramsey — Hunt syndrome) with herpes zoster is characterized by dull, persistent pain that occurs inside the ear canal, auricle or mastoid. Rarely, tumors of the face can be the cause of Ramsey — Hunt syndrome. Conclusion. Thus, chronic neuropathic facial pain associated with facial nerves damage has a varied etiology, which requires careful differential diagnosis and selection of adequate treatment tactics.

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Pontine Infarct Presenting with Atypical Dental Pain: A Case Report

The Open Dentistry Journal ◽

10.2174/1874210601509010337 ◽

2015 ◽

Vol 9 (1) ◽

pp. 337-339 ◽

Cited By ~ 4

Author(s):

Rajat Goel ◽

Sanjeev Kumar ◽

Ajay Panwar ◽

Abhishek B Singh

Keyword(s):

Trigeminal Neuralgia ◽

Orofacial Pain ◽

Neurological Diseases ◽

Case Reports ◽

Tension Headache ◽

Dental Pain ◽

Acute Onset ◽

Trigeminal Neuropathy ◽

Atypical Odontalgia ◽

Pontine Infarct

Orofacial pain’ most commonly occurs due to dental causes like caries, gingivitis or periodontitis. Other common causes of ‘orofacial pain’ are sinusitis, temporomandibular joint(TMJ) dysfunction, otitis externa, tension headache and migraine. In some patients, the etiology of ‘orofacial pain’ remains undetected despite optimal evaluation. A few patients in the practice of clinical dentistry presents with dental pain without any identifiable dental etiology. Such patients are classified under the category of ‘atypical odontalgia’. ‘Atypical odontalgia’ is reported to be prevalent in 2.1% of the individuals. ‘Atypical orofacial pain’ and ‘atypical odontalgia’ can result from the neurological diseases like multiple sclerosis, trigeminal neuralgia and herpes infection. Trigeminal neuralgia has been frequently documented as a cause of ‘atypical orofacial pain’ and ‘atypical odontalgia’. There are a few isolated case reports of acute pontine stroke resulting in ‘atypical orofacial pain’ and ‘atypical odontalgia’. However, pontine stroke as a cause of atypical odontalgia is limited to only a few cases, hence prevalence is not established. This case is one, where a patient presented with acute onset atypical dental pain with no identifiable dental etiology, further diagnosed as an acute pontine infarct on neuroimaging. A 40 years old male presented with acute onset, diffuse teeth pain on right side. Dental examination was normal. Magnetic resonance imaging(MRI) of the brain had an acute infarct in right pons near the trigeminal root entry zone(REZ). Pontine infarct presenting with dental pain as a manifestation of trigeminal neuropathy, has rarely been reported previously. This stresses on the importance of neuroradiology in evaluation of atypical cases of dental pain.

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