Managing Continuous Orofacial Neuropathic Pain
March 1, 2019
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Dr. Thomas Shackleton is a general dentist in Calgary where he has been practicing for the past 20 years. He is a graduate of We sat down with Dr. Shackleton to discuss neuropathic patient pain including:
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Read/download the transcript of the conversation (PDF)
Dr. Shackelton
Thank you for your informative presentation.
Q1- Which comes first? (The chicken or the egg?) Are the treatments in the effected quadrant due to the misdiagnosis of neuropathic pain or are they the cause of the neuropathic pain? Have you encountered patients with neuropathic pain who have not had any major dental treatment?
regards
KA
Dr. Shackleton provided the following response:
Great question! Neuropathies will have a precipitating cause, be it trauma (common), surgical or otherwise; infection (e.g. shingles); or systemic disease (e.g. diabetes). Some presumed neuropathies, like burning mouth disorder, sometimes have no identifiable cause, but these are by far the exception. The cases we see as dentists will almost always have some sort of surgical procedure or other trauma that precedes the neuropathic pain. Root canal, periodontal surgery, extraction, etc. are all the usual suspects in these cases. A very common scenario is pain followed by root canal. This will often provide relief for 1-3 weeks, then the pain returns. Non-surgical retreatment, possible pain relief for 1-3 weeks, pain returns. Apical surgery. Pain relief for 1-3 weeks, pain returns. extraction. Pain relief, pain returns. The person insists it is the adjacent tooth. Root canal. pain. extraction. Next tooth and so it goes.
After the initial trauma, any succeeding surgical procedure may offer temporary relief, presumably because the afferent fibres have been “cut back” by the surgical intervention. Unfortunately, experience has shown that they will typically heal in the same, aberrant fashion, resulting in pain. This hypothesis explains why there is often 1-3 weeks of relief, followed by the return of the pain. Sometimes, each successive intervention worsens the pain, which is why we are hesitant to advise implants in an area that has been cleared – we worry about worsening the pain. Yes, function will be restored, but at what cost? That is a conversation we have with out patients and some elect to proceed with implant, most do not.
The problem we have with this condition is that it is a great imposter: it will present as a toothache, jaw pain and gingival pain and the person suffering will SWEAR it is the tooth and you will spend a great deal of time trying to convince them that the teeth are okay, which will often make you question your diagnosis. This is why it is important to rely on your colleagues (I sure do) to assist you. This is a diagnosis of exclusion and we always have to rule out dental pathology. However, once dental pathology has been ruled out, you have done some anesthetic testing with topical and even LA, proceed with managing as a neuropathic condition. Response to treatment is critical in confirming you diagnosis. If they do not respond to topical or systemic medication, perhaps re-visit dental pathology.
I hope I’ve answered the question. If you’d like more information, please let me know.
Dr. Tom Shackleton
How is the diagnosis for trigeminal neuralgia made?
Great question! Typically, we see this in older people (usually no younger than 40 and often older than 50), women more than men, and often has the following characteristics: brief, intense, sharp/electric/stabbing pain that lasts several seconds to 1-2 minutes. It always follows a defined nerve distribution, is most common in V1 & V2, sometimes both. We have to rule out dental pathology and TMD. So, diagnosis involves an interview with the patient (onset of pain, location, quality of pain, frequency, duration, intensity VAS 0-10, does anything make it better or worse) and any other associated symptoms. Then, perform your evaluation (palpation, endodontic testing, radiographs, etc.). When we suspect trigeminal neuralgia, we perform a trial with carbamazepine or oxcarbarbazepine and see how they respond. If you suspect TN and are not familiar with these medications, their physician will often administer the trial. The good news is that this is a rare condition but you likely will come across it. I hope this helps.
Tom
This was an excellent video. Thank you, Dr. Shackleton, for some very useful notes and takeaways. I appreciate the information sharing.
DT
Thank you for your kind comment. This can be a difficult condition to identify and sometimes even more difficult to manage, because it truly feels like a toothache to the patient and often presents as one to us. It underscores how we have to rely on our testing and when things don’t add up, pause. Maybe get another opinion (I am a big fan of second opinions).
Thanks again
fantastic presentation Tom! concise and to the point. thank you!
Fantastic presentation Tom! Relevant, concise and informative. thank you!