Mistaking Neuralgia for a Toothache

A patient felt a sharp pain in her upper right jaw and went to a dentist  who carefully examined her but could not find anything wrong.

After the pain continued for 10 weeks, the dentist diagnosed the problem as an infection laden soft tissue at an upper molar and persuaded her to undergo root canal surgery. But the pain did not go away, and they went to a specialist -- an endodontist -- who performed a second root canal.

Again the problem persisted, and the patient developed an excruciating pain in her cheek and upper lip.

Novocaine did not help. Nor did the removal of the tooth and massive amounts of codeine, to which the patient became addicted.

"I went to 11 dentists and doctors before getting the proper treatment," said the patient. "The pain lasted three years."

The proper treatment, it turned out, was surgery to relieve pressure on an irritated trigeminal nerve, the major pathway between the face and brain, said Dr. Steven Graff-Radford, associate director of the Pain Management Center at the University of California at Los Angeles, who made the correct diagnosis. Like a small, but significant number of toothache sufferers, he said, the patient had absolutely nothing wrong with her teeth.

An endodontist, a dentist who specializes in root canals, probably sees one to 10 such patients each year. But endodontists are not trained to diagnose pain unrelated to the teeth and gums. Because the pain can look like a regular toothache, dentists do what they are trained to do: operate. Again and again.

"We call this domino dentistry," said Dr. William Solberg, a dentist who directs the U.C.L.A. Pain Management Center. "They do root canal after root canal." They might do a tooth extraction and when the problem doesn't improve, he said, they move on to the next tooth."

"It's not that dentists are stupid," Dr. Solberg said. "Chronic facial pain is a perplexing problem that we are becoming more aware of. We are still learning that not all toothaches are caused by the teeth."

In a study published earlier in The Journal of the American Dental Association, Dr. Steven Graff-Radford and Dr. Robert Merrill, a U.C.L.A. lecturer on orofacial pain and occlusion, studied 61 patients who complained of shooting or dull pains in their teeth and lower face.

Two-thirds of the patients had received incorrect diagnoses of dental problems, Dr. Graff-Radford said. The group had undergone 101 unnecessary dental procedures, he said, including root canals, extractions, and splints applied to the jaw. Only one person had had a dental problem -- a cracked tooth. All had experienced pain for six or seven years.

The real problem lay in the trigeminal nerve, which arises in the brain stem, enters the face and divides into three major branches, Dr. Graff-Radford said. When the trigeminal nerve becomes irritated or is squeezed by a blood vessel, pain is felt in the distant nerve endings -- a condition called neuralgia, he said.

In classical trigeminal neuralgia, the pain strikes like lightning, lasting for a few seconds or minutes. Victims describe an electric shock sensation that is triggered by simple acts like washing, shaving, talking or brushing teeth and say the pain comes and goes without warning. The pain is so intense that patients wince, giving it the name "tic douloureux," meaning painful twitch in French.

"Every dentist who graduates from school learns there is a disease called trigeminal neuralgia," Dr Solberg said "But the problem doesn't always present itself in the classic fashion."

"Pretrigeminal neuralgia, an early stage of trigeminal neuralgia, is characterized by intermittent, aching pains that last minutes to hours and perfectly mimic toothache or temporomandibular joint disorder  (TMJ)," Graff-Radford said. This pain confuses patients and dentists alike.

"The patient comes in complaining of a toothache," Dr. Solberg said, "He does not wince or blink. The teeth look normal. Results of the neurological examination are normal. The dentist is perplexed."

At this point, Dr. Solberg said, patients may beg the dentist to try something, anything to kill the pain. "They complain that you missed something, that you don't know what you're doing," he said.

"A damaged tooth would show signs of inflammation," Dr. Solberg said. It would change over days and weeks, getting better or worse. Healthy teeth would look normal. But the dentist, prodded by the patient, thinks, "Gee, maybe I missed something," Dr. Solberg said. "He loses confidence and operates."

Sometimes the patient gets worse pain, Dr. Solberg said. Other patients seem to get better for a while, but then the pain comes back with a new trigger point.

Patients and dentists need to take more time to evaluate facial pain before doing invasive procedures, Dr. Graff-Radford said. The source of the problem can often be traced by injecting anesthetics into various parts of the nerve, he said, and can be treated with anticonvulsant drugs or surgery on the nerve.

Remember, only a dentist can diagnose your dental problems and offer the right treatment plan for you. If you need a dentist, call us at 1-866-970-0441 to be connected with one today.