A rare case of vestibular schwannoma manifesting as trigeminal neuralgia.

BACKGROUND: In this case report, the authors reviewed a rare case of a vestibular schwannoma manifesting as trigeminal neuralgia (TN). Intracranial tumors can have a variety of orofacial pain symptoms. Among benign cerebellopontine angle tumors, vestibular schwannoma is the most common cause of a TN-like manifestation. Although the most common symptoms of a vestibular schwannoma are hearing loss and vestibulopathy, the unique feature of this case was the manifestation of symptoms consistent with TN. CASE DESCRIPTION: The patient had right-sided episodic facial pain that was short in duration and severe in intensity. The initial differential diagnoses included short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing and TN. As part of the routine evaluation, the patient was referred for brain magnetic resonance imaging, which revealed a right-sided vestibular schwannoma. The patient was prescribed 200 mg of gabapentin 3 times daily and was referred to neurosurgery for excision of the schwannoma. Surgical excision resulted in complete resolution of pain. PRACTICAL IMPLICATIONS: This case illustrates the importance of interdisciplinary treatment and how it can lead to an optimal outcome for a patient with complex orofacial pain symptoms.

Biomechanics and Derangements of the Temporomandibular Joint.

The human temporomandibular joint, is a ginglymo-arthrodial joint. The articular disk serves as a fibrous, viscoelastic structure that allows force distribution and smooth movement of the joint in its normal arrangement during mandibular movements. Most studies suggest that in the normal disk position the posterior band is located at the 12'o clock position within the glenoid fossa in the closed mouth posture. When the biomechanics of the joint is altered, the disk may be displaced creating an abnormal relationship between the disk, condyle, and the eminence that is often referred to as an internal derangement. This article reviews the various presentations of internal derangements.

Myofascial Temporomandibular Disorders at a Turning Point: Pragmatic or Evidence-Based Management?

Unvalidated theories have been proposed for the etiopathogenesis of masticatory myofascial temporomandibular disorders (mTMD). Modalities such as cone-beam computed tomography/computed tomography and MRI contributes little to the diagnosis of mTMD. Diagnosing mTMD is based on the recognition of "familiar pain" presentation in the masticatory myofascial tissue. This assessment tool contributes little our understanding of the underlying disease process. Thus, management of mTMD is empirical and arbitrary. Exploring emerging technologies to identify biomarkers and objectively assess myofascial tissue physiology in disease and health may be key in moving the diagnosis of mTMD from the pragmatic paradigm to an evidence-based paradigm.

Persistent Idiopathic Dentoalveolar Pain: Is It a Central Pain Disorder?

The International Classification of Orofacial Pain (ICOP) describes idiopathic pain as "unilateral or bilateral intraoral or facial pain in the distribution(s) of one or more branches of the trigeminal nerve(s) for which the etiology is unknown. Pain is usually persistent, of moderate intensity, poorly localized and described as dull, pressing or of burning character." Several diagnoses are included in the ICOP Idiopathic pain section, burning mouth syndrome and persistent idiopathic facial and dentoalveolar pain. This article, with a representative case presentation, briefly discusses common features that may lead to a common central cause for a variety of peripheral complaints.

Sensory Changes Related to Dental Implant Placement: A Scoping Review.

AIMS: To perform a scoping review of the literature to elucidate the occurrence of nerve damage related to dental implant placement and the factors causing the sensory changes. METHODS: An extensive electronic search was conducted using the Cochrane Library, Medline via Ovid, PubMed, Wiley Online, Science Direct, CINAHL, and the Google Scholar databases from the year 1950 to 2020. RESULTS: The search resulted in 1,067 articles, out of which 76 were selected for this review. The articles were categorized as literature review articles, retrospective studies, prospective studies, and case series/case reports. Altogether, 2,526 subjects were assessed retrospectively, with 5.27% transient and 1.39% persistent sensory changes, and a cohort of 2,750 subjects were followed prospectively, with 6.22% transient and 1.31% persistent sensory changes. A total of 336 subjects were enrolled in various case reports and case series, with 5.95% transient sensory changes and 84.52% persistent neurosensory changes. The articles included were not of high quality and have variations in their study designs and reporting procedures, with limited sensory change data to include in this study. CONCLUSION: After surgical placement of dental implants in 5,612 patients, the incidence of transient sensory changes was 5.63%, and the incidence of persistent sensory changes was 6.33%. Factors affecting the incidence were: mandibular location of the implant, with the inferior alveolar nerve as the most commonly affected nerve. The common symptoms reported were paresthesia and dysesthesia. Age and gender were among other factors, for which data were not available in all the articles.

Chronic orofacial pain.

While pain chronicity in general has been defined as pain lasting for more than 3 months, this definition is not useful in orofacial pain (OFP) and headache (HA). Instead, chronicity in OFP and HA is defined as pain occurring on more than 15 days per month and lasting for more than 4 h daily for at least the last 3 months. This definition excludes the periodic shortlasting pains that often recur in the face and head, but are not essentially chronic. Although the headache field has adopted this definition, chronic orofacial pain is still poorly defined. In this article, we discuss current thinking of chronicity in pain and examine the term 'chronic orofacial pain' (COFP). We discuss the entities that make up COFP and analyze the term's usefulness in clinical practice and epidemiology.

The twin block injection: an adjunctive clinical aid for the management of acute arthrogenous temporomandibular joint dysfunction.

BACKGROUND: The twin block Injection is a novel nerve block that has been shown previously to be efficacious in the management of masticatory myofascial pain. Little is known about its effectiveness for reducing pain from the temporomandibular joint (TMJ). CASE REPORT: A 19-year-old man presented with limited mouth opening with pain in the left side of his face. After a thorough history and examination was completed, the diagnosis was acute anterior disc displacement without reduction in the left TMJ and myalgia of the left side temporalis and masseter muscles. After receiving the twin block injection, the patient reported that the pain in his TMJ had reduced along with the concomitant myalgia. The twin block injection is efficacious for the management of both arthrogenous and myogenous sources of temporomandibular disorders.

The effect of the twin block compared with trigger point injections in patients with masticatory myofascial pain: a pilot study.

OBJECTIVE: The twin block, a novel nerve block that blocks the deep temporal and masseteric branches of the trigeminal nerve, has been shown to be effective in the short-term management of masticatory myofascial pain. However, little is known about its effectiveness in long-term management. The objective of this study was to assess the efficacy of the twin block in comparison with trigger point injections for the treatment of masticatory myofascial pain. STUDY DESIGN: Forty-eight patients age 18 to 89 years were randomly assigned to the twin block group (n = 23) or the trigger point injection group (n = 25). The final analysis was based on a total number of 40 patients. RESULTS: Mean numerical pain intensity at baseline was 6.54 ± 1.90 for the trigger point injection group and 6.47 ± 2.23 for the twin block group. At the 6th month visit, it was 1.85 ± 1.85 for the trigger point injection group and 1.85 ± 1.94 for the twin block group. There were no statistically significant differences in pain intensity between the 2 groups at baseline (P = .64) and at the 6th month follow-up (P = .45). CONCLUSIONS: The twin block is effective in the long-term management of masticatory myofascial pain compared with trigger point injections. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03870191.

Myofascial pain with referral from the anterior digastric muscle mimicking a toothache in the mandibular anterior teeth: a case report.

BACKGROUND: Non-odontogenic toothaches often present as a diagnostic dilemma to clinicians. Myofascial pain with referral from the trigger points in the masticatory muscles are one of the common causes of non-odontogenic toothaches. However, there are limited reports of myofascial pain from the anterior digastric muscle referring pain to the mandibular anterior teeth and mimicking odontogenic pain. CASE PRESENTATION: A case of non-odontogenic toothache in the mandibular anterior teeth due to myofascial pain with referral from trigger points in the anterior digastric muscle is presented. The patient had significant relief with a trigger point injection of the anterior digastric muscle. Amitriptyline 10 mg once daily was prescribed for 1 month. In addition, she was advised home care instructions to control predisposing, perpetuating, and precipitating factors, and given home care exercises, a hard joint stabilization splint, physiotherapy, and postural re-education. CONCLUSION: Non-odontogenic toothaches may be multifactorial. The case presented emphasizes the importance of a comprehensive evaluation to differentiate odontogenic pain from non-odontogenic pain. Irreversible dental procedures should be instituted after an accurate diagnosis and multidisciplinary management may be required in complex cases.

Minimally Invasive Trigeminal Ablation: Long Buccal Nerve.

AIMS: To describe a technique of minimally invasive trigeminal nerve ablation of the long buccal nerve that was performed at a tertiary care academic medical center. METHODS: This case describes a 44-year-old woman with refractory left long buccal nerve neuropathy following a dental procedure. After failing medical management, she was taken for nerve exploration, which revealed no nerve discontinuity or neuroma formation. She was therefore counseled regarding the risks and possible benefits of a novel minimally invasive trigeminal nerve thermoablation of the long buccal nerve technique. RESULTS: Postoperatively, the patient experienced mild anesthesia along the long buccal nerve division and no longer experiences any allodynia or hypersensitivity. Additionally, she no longer requires any additional medical therapy or interventions. CONCLUSION: Minimally invasive trigeminal nerve ablation of the long buccal nerve may be effective surgical intervention in treating refractory neuropathic pain in cases of no structural nerve defects. However, long-term well-designed studies are required to fully define its role.

Orbital pseudotumor presenting as a temporomandibular disorder: A case report and review of literature.

BACKGROUND AND OVERVIEW: Orofacial pain has multifactorial causes and is often a diagnostic challenge. Misdiagnosis can result in morbidity or mortality due to misdirected and inappropriate treatment. A delay of necessary treatment, in cases of ominous illnesses, may result in its perpetuation or progression. The authors present a case report that illustrates these possibilities. CASE DESCRIPTION: This case report describes a 36-year-old woman with the chief symptom of painless, limited mandibular movement. She also reported restricted movement of the left eye. She was previously diagnosed and treated for a traumatic right inferior alveolar nerve neuropathy, migraine, myofascial pain, and bilateral temporomandibular joint disk displacement with minimal benefit. Eventually she sought an orofacial pain evaluation, presuming her problems were related to a temporomandibular disorder. A complete history and comprehensive clinical evaluation including a cranial nerve screening evaluation, intraoral and extraoral examinations, an evaluation of the masticatory system, and dental radiographs were performed. The cranial nerve screening examination found painful, restricted eye movements. Magnetic resonance revealed a large, soft tissue mass in the inferolateral wall of the left orbit with soft tissue components in the infratemporal fossa and pterygoid space, involving the lateral pterygoid muscle and insertion of the temporalis muscle. The patient was referred to appropriate medical specialties and the diagnosis of orbital pseudotumor was confirmed and the patient was treated appropriately. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The case emphasizes the importance of a comprehensive evaluation of a patient with preexisting orofacial pain when new symptoms arise or if there is a change in existing symptoms.

Efficacy of the twin block, a peripheral nerve block for the management of chronic masticatory myofascial pain: A case series.

Masticatory myofascial pain is the one of the most common etiologies for nonodontogenic pain, often characterized by the presence of trigger points. Conventional management includes approaches such as jaw exercises, physical therapy, intraoral appliances, medications, and trigger point injections. Peripheral/regional nerve blocks have shown to be effective in managing myogenous pain conditions. The twin block is a nerve block that blocks both the masseteric and the anterior deep temporal nerves. The objective of this case series is to illustrate expeditious and sustained efficacy of the twin block in the management of chronic masticatory myofascial pain.

Continuous neuropathic pain secondary to endoscopic procedures: report of two cases and review of the literature.

Neuropathic pain encompasses a spectrum of conditions that can arise from a lesion or dysfunction of the central or the peripheral nervous system, and it may develop at variable intervals after nerve injury or inflammation. Nerve injuries arising from surgical procedures commonly occur secondary to the surgical trauma, and in rare instances they are a complication of intubation during general anesthesia or endoscopic procedures. A series of 2 cases of bilateral glossopharyngeal neuropathic pain subsequent to endoscopic procedures is presented with a review of the literature concerning the mechanisms of development of neuropathic pain after these procedures. The purpose of these case reports is to make dentists aware of the occurrence, the mechanisms of nerve injuries, and the treatment of neuropathic pain after endoscopic procedures. In the first case, the patient had relief of pain with a combination therapy of clonazepam 1.0 mg in divided doses twice daily and gabapentin 300 mg in divided doses 3 times daily. In the second case, the patient had significant relief of pain with a monotherapy of gabapentin 1200 mg in divided doses 3 times daily.

Efficacy of regional nerve block in management of myofascial pain of masseteric origin.

OBJECTIVE: To compare the efficacy of a regional masseteric nerve block (MNB) in the management of myofascial pain of masseteric origin, relative to trigger point injection (TrP-Inj) and intra-oral stabilization appliance (IOA). STUDY DESIGN: A retrospective chart review of 200 patients treated for myofascial pain of masseteric origin was performed. Sixty patients met the eligibility criteria and were grouped based on their treatment regimen; IOA, TrP-Inj or MNB. Pain scores recorded at pre-treatment (baseline), 30 minutes post-treatment, and 2 weeks post-treatment were analyzed. RESULTS: Treatment with MNB resulted in significant reduction in pain at 30 minutes and two weeks post-treatment compared to TrP-Inj and IOA. CONCLUSION: MNB provided an immediate and sustained therapeutic effect for the management of myofascial pain for at least up to two weeks. MNB is a simple and valuable tool in the management of myogenous pain, especially for the non-orofacial pain practitioner.

Burning mouth syndrome: Current concepts.

Burning mouth syndrome (BMS) is a chronic pain condition. It has been described by the International Headache Society as "an intra-oral burning or dysesthetic sensation, recurring daily for more than 2 h/day for more than 3 months, without clinically evident causative lesions." BMS is frequently seen in women in the peri-menopausal and menopausal age group in an average female/male ratio of 7:1. The site most commonly affected is the anterior two-thirds of the tongue. The patient may also report taste alterations and oral dryness along with the burning. The etiopathogenesis is complex and is not well-comprehended. The more accepted theories point toward a neuropathic etiology, but the gustatory system has also been implicated in this condition. BMS is frequently mismanaged, partly because it is not well-known among healthcare providers. Diagnosis of BMS is made after other local and systemic causes of burning have been ruled out as then; the oral burning is the disease itself. The management of BMS still remains a challenge. Benzodiazepines have been used in clinical practice as the first-line medication in the pharmacological management of BMS. Nonpharmacological management includes cognitive behavioral therapy and complementary and alternative medicine (CAM). The aim of this review is to familiarize healthcare providers with the diagnosis, pathogenesis, and general characteristics of primary BMS while updating them with the current treatment options to better manage this group of patients.

The role of sensory input of the chorda tympani nerve and the number of fungiform papillae in burning mouth syndrome.

OBJECTIVE: The aim of this study was to evaluate patients suffering from burning mouth syndrome (BMS) and control subjects by means of sensory testing and fungiform papillae count. STUDY DESIGN: The left and right anterior two-thirds of the tongue of of 25 BMS subjects and 20 healthy control subjects were evaluated for electric taste and electric detection threshold. The number of fungiform papillae/cm(2) was evaluated by using close-up digital photography. RESULTS: The electric taste/tingling detection threshold ratio was significantly higher in BMS compared with control subjects (P = .041). No difference was found between the number of fungiform papillae/cm(2) in the BMS compared with the control subjects (P = .277). Patients suffering from BMS for a prolonged period of time presented with a significantly elevated electric taste/tingling detection threshold ratio (P = .031). CONCLUSIONS: BMS may be a neurodegenerative process with chorda tympani nerve hypofunction potentially playing a role in the pathophysiology of this disorder.

Prolonged gingival cold allodynia: a novel finding in patients with atypical odontalgia.

OBJECTIVE: The aim of this study was to examine atypical odontalgia (AO) patients with extraoral quantitative sensory testing (EQST) and an intraoral mucosal cold test. STUDY DESIGN: Twenty-one subjects with AO and 18 control subjects underwent EQST for electrical and thermal pain and detection thresholds. Cold was applied to painful mucosal areas in AO patients and randomly in control subjects. RESULTS: Electrical pain thresholds were higher in AO patients than in control subjects in the same dermatome affected by the pain (P = .03), but no significant differences were observed in electrical detection thresholds and heat pain and detection thresholds at other sites. Cold application was painful in control and AO subjects, but duration of pain sensation was significantly longer in AO patients (P = .019 in contralateral side; P = .029 in affected side). CONCLUSIONS: The finding of extended painful aftersensation following cold application in AO patients supports the involvement of central mechanisms. The cold test is clinically easy to apply and of clinically significant value.

Use of topical medication in orofacial neuropathic pain: a retrospective study.

OBJECTIVE: The objective of this study was to evaluate the effect of topical medications as a single treatment or in combination with systemic medications in the treatment of orofacial neuropathic pain conditions. STUDY DESIGN: A retrospective chart review of 39 patients treated for orofacial neuropathic pain at the Orofacial Pain Clinic in the New Jersey Dental School was performed. In line with the treatment selection, the subjects were divided into 3 groups: topical medications only (n = 12), systemic medications only (n = 10), and a combination of both (n = 17). RESULTS: The starting pain level as expressed in pain Visual Analog Scale for the 3 groups was significantly different. The combined treatment group baseline pain level (7.5 +/- 0.403 SEM; P = .0015) and the systemic treatment only group pain level (8.6 +/- 0.611 SEM; P = .0375) was significantly elevated compared to the topical only group (6.1 +/- 0.716 SEM; P = .1057). Following treatment, pain level was significantly reduced in all 3 groups. The combined group had the highest pain relief (52.0 +/- 6.676 SEM % reduction; P < .0001) followed by the systemic-only group (40.6 +/- 9.727 SEM % reduction; P = .0029) and the topicals-only group (40.9 +/- 10.775 SEM% reduction; P = .0048). The time taken for the topical treatment only to act was significantly shorter (3 weeks +/- 0.479 SEM; P = .0015) when compared with the systemic-only (4 weeks +/- 0.772 SEM; P = .3629) and the combined group (5.5 weeks +/- 0.912 SEM; P = .1738). CONCLUSION: Topical medication as single treatment or in combination with systemic medications can reduce orofacial neuropathic pain severity. Further prospective research should be performed to validate this treatment option.