Neuropathic Facial Pain or Dental Pain

What is the cause of my pain? 

Neuropathic pain is a chronic pain condition, and refers to all pain initiated or caused by a lesion or dysfunction in the nervous system. Trigeminal neuralgia, atypical odontalgia (phantom tooth pain), burning mouth syndrome, traumatic neuropathies, postherpetic neuralgias, and complex regional pain syndrome are neuropathic pain conditions in the orofacial region. When you first experience pain in your face, it makes sense that you or your doctor will suspect a dental issue to be the cause of the pain. In order to get a correct diagnosis quickly, it is imperative to determine if you have a dental issue or neuropathic facial pain.

Classical trigeminal neuralgia is attributable to pathological blood vessel-nerve contact in the trigeminal nerve root entry zone to the brain stem. The typical pain symptoms are characterized by sudden stabbing pain attacks.  Atypical odontalgia, also known as phantom tooth pain, or neuropathic orofacial pain, is characterized by chronic pain in a tooth or teeth, or in a site where teeth have been extracted or following endodontic treatment, without an identifiable cause. Over time, the pain may spread to involve wider areas of the face or jaws. 

The pain is called “atypical” because it is a different type of pain than that of a typical toothache. Typical toothache comes and goes and is aggravated by exposure of the tooth to hot or cold food or drink, and/or by chewing or biting on the affected tooth. There is an identifiable cause, such as decay, periodontal disease, or injury to the tooth and the pain is predictably relieved by treatment of the affected tooth.  

Atypical odontalgia

With atypical odontalgia, the pain is described as a constant throbbing or aching in a tooth, teeth, or extraction site that is persistent and unremitting, and which is not significantly affected by exposure to hot or cold food or drink, or by chewing or biting. The pain may or may not be relieved by the injection of local anesthetic.  The intensity of the pain can vary from very mild to very severe. 

There is typically no identifiable cause to explain the pain and it often follows or is associated with a history of some type of dental procedure such as having a root canal or tooth extraction. On occasion, the pain can occur without any reason. The pain is felt in a tooth or teeth and persists in spite of treatment aimed to relieve the pain such as a filling, a root canal, or even an extraction. This often presents a frustrating and confusing situation for both the patient and the dentist, and can lead to more and more dental treatment, none of which is effective at relieving the pain. 

The diagnosis of atypical odontalgia is made after a thorough history, clinical examination, and radiographic assessment fail to identify a cause for the pain. Once the diagnosis is made, medications can be used in an effort to reduce the level of pain. 

What causes atypical odontalgia? 

The cause of atypical odontalgia is not known, and therefore, some clinicians refer to the pain as “idiopathic”. In all likelihood, it is probably due to a variety of factors which may include genetic predisposition, age, and sex. It is more common in women than in men, and is found most often in the middle-aged to older age group. Some studies have found an association between atypical odontalgia and depression and anxiety, however, the significance of this association is unclear. The actual pathologic mechanism seems to be dysfunction or “short-circuiting” of the nerves that carry pain sensations from the teeth and jaws that is triggered by some type of dental or oral manipulation. Areas of the brain that process pain signals appear to undergo molecular and biochemical changes that result in a persistent sensation of pain in the absence of an identifiable cause of the pain. 

Atypical odontalgia is treated by using a variety of medications. Many different medications have been used to treat this condition; however, the tricyclic antidepressants are used most frequently. In addition to the tricyclics, other drugs used to treat chronic pain conditions, such as gabapentin, baclofen, and duloxetine may be prescribed. Generally, treatment is successful in reducing the pain but not eliminating it completely. 

Since the exact cause of this problem is not known, it is difficult to say whether this is a permanent condition. There are cases in which the pain goes away spontaneously as well as cases in which the pain gradually subsides and disappears after prolonged treatment with medications. There are many cases however, that persist and require the continued use of medications. Diagnosis and treatment are best done by a dentist with advanced training and familiarity with the problem, such as a specialist in oral medicine or orofacial pain. 

Neuropathic causes of mouth pain

Glossopharyngeal neuralgia (GPN or GN) is a relatively rare condition, occurring in less than one person in 100,000. The glossopharyngeal nerve is the 9th cranial nerve. It is responsible for feeling in the tongue and throat and movements such as swallowing and the gag reflex, along with others. “Glosso-” means related to the tongue; “pharyngeal” means related to the pharynx, or throat. The pain of GPN is typically severe, brief, sudden, and recurrent pain in the ear, base of the tongue, tonsils or beneath the angle of the jaw. Read more

Trigeminal neuralgia episodes may start as short, mild attacks and progress and cause longer, more-frequent bouts of searing pain. TN pain is described as sudden, intense, “stabbing” or “shock-like”. This pain can occur almost anywhere between the jaw and forehead, including inside the mouth. This pain is usually only on one side of the face, and can include facial twitching (hence, the term ‘tic’). A constant aching, burning feeling that may also occur before evolving into the spasm-like pain. Many people report that their TN attacks become more intense and frequent over time, sometimes with pain-free periods in between. TN is often confused with dental pain. Read more

Burning mouth syndrome (BMS), also known as glossodynia, is a relatively rare condition that causes a burning sensation in your mouth with no obvious cause. This feeling is often compared to taking a large gulp of hot soup or coffee; it may also feel boiling, scorching, dry, tingling, rough/sandy, or stinging. Read more

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