How would you treat a patient with neuropathic orofacial pain?
This summary is based on the article published in the Journal of the American Dental Association: Dental treatment for patients with neuropathic orofacial pain (September 2013)
Clinical Case
A 56-year-old woman visited a dental office with acute dental pain in the left mandibular molar area. The treating dentist established a diagnosis of trigeminal neuralgia (TN) related to the left V3 branch, for which the patient was treated with nerve membrane–stabilizing anticonvulsants. The patient’s medical history included mild hypertension, hypothyroidism and intermittent low back pain for which she was being treated adequately by her physician.
The clinical examination revealed the left mandibular permanent first molar (tooth no. 19) had a large defective restoration. The dentist determined that placement of a full metal crown would be the treatment of choice for the restoration of tooth no. 19.
The dentist now faces the dilemma of bringing in the potential risk of reactivating the initial pain or exacerbating the patient’s ongoing condition.
Clinical Implications
Patients with current or controlled TN may be reluctant to participate in any activity or undergo any dental procedure (preventive or restorative) that involves manipulation to these hypersensitive areas. This may lead to progressive dental disease.
On the other hand, effective oral health maintenance may reduce the need for invasive dental treatments, with the added benefit of reducing the patient’s risk of developing complications associated with neuropathic orofacial pain (NOP).
It is very important for the dental team to recognize these issues and consider the following:
- Patient scheduling
- The use of local anesthetic and preemptive analgesia
- The implementation of preventive and hygiene procedures
- The adoption of the least invasive approach
Key Messages
- Dentists need to recognize and understand the concepts of NOP to provide appropriate treatment for patients.
- To provide the highest quality dental care for this unique patient population, they must incorporate into the final treatment plan factors such as communication among all health care practitioners and the patient, appreciation of and respect for the patient who is experiencing NOP and understanding the patient’s tolerance for potentially painful procedures.
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I read the entire original article. and find there are big gaps in the “pertinent history”. Although this may be true TN, the specific trigger sites and specific stimulation causes are not given in the article. No x-ray or photo of the 36 is provided, nor how long the TN was treated pharmaceutically prior to this assessment re crown, so questions come to my mind.
Mandibular TN is much less common than maxillary, and when it is left mandible, one thinks of cardiac angina etc triggers. Were these possibilities investigated? As far as 36 is concerned, cold reactive, with a defective filling could well indicate a slowly-dying pulp, which in turn could well act like TN. If 36 were anaesthetized with ligamentary or narrow infiltration, would the triggers fail to create the TN? I have seen maxillary TN being treated by drugs really caused by a pulp. RCT ended the need for drugs, with no TN recurrence. There is no mention of occlusion assessment – a centric slide or excursion clip affecting 36 could trigger “TN” and be still there but less despite medication. (I have seen this in maxillary, and the TN disappeared upon bite correction, no RCT.)
Much more info is needed, and I hope will be provided in the next 2 articles. I have requested them as per the link.
I COMMEND the Oasis project for these “MAKE ME THINK” case studies. Best way to become a wider assessor and better diagnostician.
I agree with Ron Kellen’s comments completely. The diagnosis of TN is too easy to make and I have, over my 30 years of practice in a group, seen many cases of TN diagnosed patients whose symptoms disappear once the pulp is treated, or tooth extracted.
I have only seen two cases in this time where I would agree that the diagnosis was TN. I believe that with the extremely high incidence of unusual symptoms that pulp disease can exhibit, it is critical that an exhaustive testing program be carried out, ideally with the help of an endodontist, before the mention of TN is made.
Patients who are given the TN diagnosis are placed in a very unfortunate category of, usually, chronic disease.
Let’s keep thinking!