Detecting Trigeminal Neuralgia in the Dental Clinic
Dentists should be well-informed about Trigeminal neuralgia because patients with the condition will first complain of intense oro-facial pain similar to a pain due to an abscess or cracked tooth. Dentists should be able to recognize the condition for early referral and management and to avoid unnecessary treatments. Many patients underwent unnecessary root canal treatment due to misdiagnosis of Trigeminal neuralgia. If there is an obvious dental pathology, then dentists should proceed with treatment; however, if there is no clear pathology, then dentists should proceed with caution and maybe seek a second opinion on diagnosis first.
The diagnosis of Trigeminal neuralgia is mainly based on the patient's report of symptoms. The features to watch out for are:
1. Patients generally affected are women in their 6th to 8th decade of life.
2. The primary symptom is an episode of intense shooting or stabbing pain (electric shock quality) lasting a few seconds to a maximum of two minutes, which can be recurring.
3. Pain occurs unilaterally, with predilection to the right side of the face.
4. Pain is precipitated by a light touch on a trigger zone present on the skin or mucosa innervated by the trigeminal nerve. Triggers include brushing teeth, blowing the nose, shaving, hot or cold beverage, putting make-up, washing the face, smiling, talking, and encountering a light breeze.
5. During remission period, pain is not triggered even when stimulus is applied on trigger zones.
6. Pain attacks often stimulate other responses such as salivation, facial flushing, lacrimation, and rhinorrhea.
7. During pain attacks, there is intense contraction of muscles of mastication.
8. Pain does not occur during sleep.
9. Pain causes inability to perform daily activities, leading in some cases to depression and even suicide.
Other diagnostic aids include CT Scan and, better, MRI. However, these are mostly recommended for younger patients that exhibit signs of Trigeminal neuralgia, because occurrence of the disease in younger patients is usually due to an underlying pathology. Some points that may help dentists in diagnosing Trigeminal neuralgia versus tooth pain include:
1. Trigeminal neuralgia pain is triggered by light touch on the face while dental pain is triggered by direct percussion and palpation of the tooth.
2. Carbamazepine eliminates Trigeminal neuralgia pain within 45-60 minutes but does not relieve dental pain.
3. Local anesthetics may help but are not as reliable as Carbamazepine because they may relieve other kinds of pain, too.
Handling Patients with Trigeminal Neuralgia
Most medical professionals do not believe that there is a connection between dental treatments and the occurrence of Trigeminal neuralgia. It is more likely that the patient already had the disease and the dental treatment was only a trigger for it. Hence, in treating patients known to have Trigeminal neuralgia, dentists may use the following guidelines:
1. Have the patient come for treatment when there is no pain or it is in remission.
2. Have the patient be well-medicated during the treatment. The dentist may opt to increase the dosage before and after treatments and to schedule the treatment when the medicine is at its peak effect, approximately 1 hour after intake.
3. Apply topical anesthesia as needed to avoid occurrence of pain during simple procedures, such as oral prophylaxis.
4. In using local anesthesia, choose one without a vasoconstrictor. Use Mepivacaine or Carbocaine instead of Lidocaine that contains Epinephrine.
5. If there is need to inject anesthesia, choose a needle entry point as far as possible from any known trigger points of Trigeminal neuralgia.
6. Work on the sensitive area last.
If nothing works and dental treatment is necessary during periods of pain, then general anesthesia may be considered.
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