CC
A 52-year-old White female is referred by her physician for evaluation of an 11-month history of intermittent severe, stabbing pain and dull throbbing pain in the right maxillary zygomatic buttress area. (Trigeminal neuralgia [TN] is more common in females than in males by a ratio of 3 to 2. The condition usually affects middle-aged or older adults; however, young adults and children can also be affected.)
HPI
The patient reports the pain over her right cheek area as stabbing and at times shocklike, superimposed on a dull background pain of varying duration (95% of the time, TN is located in the lower face or malar region). She rates her pain severity as a 9 on a 0 to 10 visual analog scale (VAS). (Most patients with TN rate their pain as 9 or 10 on a VAS.) These episodes last about 10 to 35 seconds and are triggered by chewing, washing her face, or brushing her teeth. (Triggering stimuli may include talking [76%], chewing [74%], touch [65%], cold temperature [48%], wind, applying makeup, and shaving. Intraoral TN triggers are associated with the gingiva.) Between attacks, the individual has periods of temporary remission, called refractory periods, when it is impossible or extremely difficult to trigger pain. (Trigger zones characteristic of TN are not clinically identifiable in 40%–50% of cases.) The pain does not wake her from sleep unless she has slept on her right side. (Pain occurs on the right side over the left by a ratio of 3 to 2; it is typically unilateral, with bilateral pain reported in 1%–4% of cases.)
PMHX/PDHX/medications/allergies/SH/FH
The patient’s medical history is unremarkable. (The presence of hypertension increases the risk of TN 2.1 times in females and 1.5 times in males; multiple sclerosis [MS] increases the risk by a factor of 20.) Her dental history indicates that she saw a dentist shortly after her symptoms began. She had received two root canals on her upper right first and second molars. Her symptoms did not resolve, and both teeth were subsequently extracted. (Because of its location and paroxysmal nature, TN has often been confused with dental pathology, leading to unnecessary dental treatment in 33%–65% of cases.) She still experiences bouts of pain that are triggered by eating, and she was treated for a temporomandibular disorder (TMD) with oral appliance therapy. (Pain with chewing is consistent with TMD.) She is anxious, depressed, and fearful of recurring attacks. (Quality of life is severely impaired with TN; depression is common, and suicides have been reported.) She is married and has two young children. At present, she does not work because of her symptoms. (Talking provokes attacks in 74% of patients.)
Examination
The patient is anxious; she appears well developed and well nourished. (Some patients limit their diet and thus exhibit signs of undernourishment.) There is no extraoral swelling or asymmetry. On palpation, there is tenderness of the temporalis and masseter on her right side. She is very resistant to any palpation over her zygomatic area and to opening her mouth for fear of eliciting sharp, shooting pain. Her opening is 42 mm with lateral excursions of 11 mm bilaterally and protrusive movement of 6 mm. Cranial nerve examination is noncontributory, and sensory testing results are normal. (This potentially differentiates between symptomatic and idiopathic TN.) Oral hygiene is poor, with significant plaque buildup on the buccal surfaces of her right premolar area. No evidence of dental caries is noted. Percussion and palpation over her premolars were negative. Gingival tissue is inflamed, primarily because of plaque buildup.
The physical examination in patients with TN is generally normal. Diagnosis of TN is largely based on an accurate clinical history (sudden onset of severe, unilateral facial pain lasting seconds) and necessary imaging (magnetic resonance imaging [MRI] with contrast or computed tomography [CT] scan) to differentiate between symptomatic and idiopathic TN, regardless of age. Ruling out ear, mucosal, sinus, teeth, and temporomandibular joint pathologies is necessary because problems in these areas may cause facial pain (see Table 20.3 for differential diagnoses).
| Diagnosis | Location | Quality | Intensity | Duration | Triggers | Other Characteristics |
|---|---|---|---|---|---|---|
| Trigeminal neuralgia | Second and third divisions of trigeminal nerve; unilateral Rarely, first division |
Stabbing, sharp, shooting; electric shock–like | Severe | Seconds | Touching or washing the face, eating, chewing, smiling, talking, brushing teeth, shaving | No sensory or motor paralysis in idiopathic cases |
| Postherpetic neuralgia | Usually ophthalmic or maxillary branch of fifth cranial nerve; unilateral | Burning, tingling, shooting | Severe | Continuous | Touch, movement | Allodynia, hyperalgesia, altered sensation |
| Glossopharyngeal neuralgia | Ear, tonsils, neck, posterior tongue | Sharp, shooting, stabbing | Severe | Seconds | Swallowing, chewing, yawning, coughing, touch |
|
| Atypical facial pain | One side of face, nasolabial fold or side, chin, jaw, neck; poorly localized | Aching, burning, often stabbing | Mild to severe | Constant | Depressive and anxiety states | |
| TMD | Jaw, mandible, preauricular region, masticatory muscles | Dull, aching, throbbing, sharp, stabbing | Mild to moderate | Minutes to hours | Prolonged chewing, talking, opening wide | Clicking, crepitus, limited opening, deviation of mandible on opening, ear pain or fullness, tinnitus |
| Tolosa-Hunt syndrome | Mainly retro-orbital; unilateral | Aching | Severe | Constant | Ophthalmoplegia, sensory loss over forehead, ptosis | |
| Carotidynia | Face, ear, jaws, teeth, upper neck; unilateral | Throbbing | Moderate | Constant | Compression of common carotid artery | Compression of common carotid at or below bifurcation reproduces pain in some |
| Temporal arteritis | Temporal region; unilateral or bilateral | Throbbing, dull, aching, tender | Moderate to severe | Constant | Pressure over temporal artery |
|
| Alveolar osteitis (dry socket) | Affected bone | Sharp, aching, throbbing | Moderate to severe | Continuous 4–5 days postextraction | Open socket | Loss of clot, exposed bone, halitosis |
| Mucosal pathology | Affected mucosa | Sharp, burning, tingling | Mild to severe | Intermittent | Touch | Erosive or ulcerative lesions, redness |
| Pulpitis | Teeth | Intermittent, throbbing | Mild to severe | Minutes to hours | Mechanical, cold, heat, lying supine | Deep caries, extensive restoration |
| Maxillary sinusitis | Over affected sinus; unilateral or bilateral | Dull, aching | Mild to moderate | Constant | Touch, bending | History of URTI, nasal discharge, fullness over cheek with or without erythema over cheek |
| Burning mouth syndrome | Tongue, palate, lips, pharynx | Burning, tingling, tender | Mild to moderate | Constant | Stress; spicy, acidic foods; vitamin and iron deficiency; candidiasis | Altered taste, xerostomia |
| Cluster headache | Orbital, suborbital, and/or temporal; unilateral | Boring, throbbing | Severe | Minutes to hours | Alcohol, smoking, stress, heat, cold, REM sleep | Autonomic symptoms |
| Tension-type headache | Frontotemporal and/or parietal; bilateral | Pressure, tight | Mild to moderate | Minutes to days | Stress | Not aggravated by routine physical activity |
| Migraine | Frontotemporal, orbital; usually unilateral | Pulsating, throbbing | Moderate to severe | Hours | Physical activity, stress, foods, odors, estrogen, alcohol, lack of sleep, barometric pressure |
|
| Paroxysmal hemicrania | Periorbital, temple; unilateral | Boring | Moderate to severe | Paroxysmal: 1–40 attacks/day lasting 2–30 min | Neck movement | Autonomic features |
| SUNCT or SUNA | First and second divisions of trigeminal nerve; unilateral | Stabbing | Moderate to severe | Recurring: 1–200 attacks/day, 10–250 seconds each | Cutaneous triggers | Tearing, conjunctival injection |
| Orofacial tumors | Variable | Variable (atypical) | Severe | Jaw movement | Frequently neurologic signs, WBC abnormalities |
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