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Trigeminal Neuralgia and Dental Work
Four professors from the Parker E. Mahan Facial Pain Center and the University of Florida College of Dentistry in Gainesville discussed the link between dental problems and Trigeminal Neuralgia.
Some TN patients are initially misdiagnosed by a dentist and have unnecessary root canals or extractions.
According to clinical assistant professor Brian D. Fuselier, D.D.S., dentists assume that if tapping a tooth produces severe pain, the tooth generally has pulpitis (inflammation of the pulp or nerve); the appropriate treatment is root canal. However, in rare cases the problem is not dental.
A dentist should take an extensive medical history, do a thorough examination, and ask detailed questions about the pain, said Dr. Parker E. Mahan, D.D.S., Ph.D., a distinguished Service Professor Emeritus at the pain center that bears his name.
To help in the diagnosis, Dr. Fuselier added, the dentist can test the health of the tooth with hot or cold; if that hurts, pulpitis is likely. A dentist uncertain about whether the pain truly is a dental problem can refer the patient to a pain-management specialist, such as a neurologist, who can prescribe Tegretol®.
Dr. Henry A. Gremillion, D.D.S., of the Mahan pain center, described a condition that appears to be a precursor to trigeminal neuralgia. The patient may report sporadic, stabbing pain like that of classic TN or, more typically, a dull ache that comes and goes or is constant. There is no specific trigger zone on the face, he said, but chewing, drinking hot or cold liquids, yawning, talking, or brushing teeth can bring on an attack.
To make a diagnosis, the dentist numbs the area with a long-acting local anesthetic. If the problem is dental, relief is short lived. If it’s a precursor to TN, the patient may remain pain-free after the anesthetic wears off. In some cases, a series of injections of local anesthetic can give relief lasting for months or even years.
Major dental work can increase the pain of TN or end a remission. Dr. Mahan noted that the surgical procedures used to treat TN often fail to produce permanent relief, and it probably doesn’t take much stimulation to trigger a breakthrough of pain. TN presents a paradox, he said.
On one hand, it’s of the utmost importance to maintain good dental health in order to avoid dental problems that worsen TN symptoms. On the other hand, because having major dental work can aggravate the tngeminal nerve, you should have only procedures that are truly necessary -- for instance, don’t agree to let your dentist replace a very large filling with a crown if the filling is still serviceable.
For someone who must have major work done, Dr. Mahan recommends preemptive anesthesia to prevent the pain of the dental procedure from “jazzing up” the transmission of pain signals from the trigeminal nerve to the brain. He suggested these steps:
- For a day or so before and after the procedure, increase the dose of any TN medications you’re taking.
- Ask your dentist to use Marcaine® without epinephrine for the local anesthetic. Marcaine is long-acting, so you’re less likely to need multiple injections -- each one producing pain signals. Epinephrine is a vasoconstrictor; it’s sometimes added to local anesthetics to prolong their numbing effect. However, epinephrine can trigger nerve pain, so you’re better off without it.
- Ask the dentist to inject the local anesthetic at a site as far as possible from the trigger point for the TN pain.
- Several hours before the procedure, take a pain-killing medication such as codeine. After the procedure, take it again. The goal is to have at least five hours afterwards during which you’re free of pain.
- If dental procedures make you very nervous, you might ask for laughing gas or IV anesthesia to reduce emotional trauma.
If tooth brushing is intolerably painful, Dr. Mahan said, ask your dentist to prescribe a topical anesthetic called viscous lidocaine to numb your mouth. If that fails, try a prescription mouth rinse called Peridex®. An oral antibiotic, it can leave a stain, so wipe off your teeth as best you can.
Drink only lukewarm fluids to avoid stimulating the nerves in your mouth. When the pain flare-up is over; remember that you should have your teeth cleaned by your dentist at least twice a year if you have TN, to forestall dental problems.
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