Pre-trigeminal neuralgia.

Eighteen patients who subsequently developed typical trigeminal neuralgia experienced a prodromal pain termed "pre-trigeminal neuralgia." These patients described their prodromal pain as a toothache or sinusitis-like pain lasting up to several hours, sometimes triggered by jaw movements or by drinking hot or cold liquids. Typical trigeminal neuralgia developed a few days to 12 years later, and in all cases affected the same division of the trigeminal nerve. Six additional patients experiencing what appeared to be pre-trigeminal neuralgia became pain-free when taking carbamazepine or baclofen. Recognition of pretrigeminal neuralgia makes it possible to relieve the pain with appropriate medications and avoid unnecessary irreversible dental procedures.

Myofascial pain may present clinically as occipital neuralgia.

Three case presentations illustrate that the clinical signs and symptoms of occipital neuralgia may be produced by myofascial pain. Assessment of myofascial trigger points is needed before making a diagnosis of occipital neuralgia. Myofascial trigger points can be effectively treated with minimally invasive procedures, thereby avoiding irreversible surgical interventions.

Amitriptyline and fluphenazine in the treatment of postherpetic neuralgia.

BACKGROUND: Postherpetic neuralgia (PHN) is a vexing problem occurring in 10 to 20 percent of people with from herpes zoster (shingles). Anecdotal reports show that fluphenazine enhances the effects of amitriptyline for the treatment of PHN. The aim of this study was to determine, in a controlled manner, whether this was the case. METHODS: In a double-blind placebo-controlled study, 49 patients with PHN were randomly assigned to four treatment groups: Group 1, amitriptyline; Group 2, amitriptyline and fluphenazine; Group 3, fluphenazine; Group 4, a placebo. An active placebo was used to mimic the anticholinergic side effects of dry mouth. The study lasted 8 weeks, with weekly progress evaluations with use of visual analog scales (VAS), the McGill Pain Questionnaire (MPQ), and a side-effects scale. RESULTS: A statistically significant decrease was seen in pain in Groups 1 and 2, and no significant changes were seen in Groups 3 and 4. There was no significant difference when fluphenazine was added to amitriptyline. CONCLUSION: These data support the effectiveness of amitriptyline in treatment of PHN, but do not support the addition of fluphenazine.

Oromandibular disorders and headache. A critical appraisal.

Oromandibular disorders are functional disorders and associated pains in the anatomic region of the temporomandibular joint. Their diagnosis and treatment are controversial because of the lack of conformity concerning these disorders among health care providers. This article provides a clear classification of these disorders and critically reviews their evaluation and treatment.

Benign indomethacin-responsive headaches presenting in the orofacial region: eight case reports.

Indomethacin-responsive headaches can present in the orofacial region. According to the classification of headache by the International Headache Society, indomethacin-responsive headaches include chronic paroxysmal hemicrania, hemicrania continue, benign cough headache, benign exertional headache, and sharp, short-lived headache pain syndrome. The mechanism by which indomethacin produces its therapeutic effects in these headache disorders remains speculative. A review of indomethacin-responsive headaches and eight cases in which the presenting symptom was orofacial pain are reported. Because these headache disorders are rare but may present as facial pain, they should be considered in the differential diagnosis of orofacial pain. A comprehensive evaluation prior to performing irreversible treatments is essential when an idiopathic facial pain presents to the dental clinician.

Chronic paroxysmal hemicrania presenting as toothache.

Chronic paroxysmal hemicrania is an intermittent head-pain problem that is characterized by pain paroxysms lasting about 15 minutes. The attacks usually produce pain in the frontotemporal region and are responsive to indomethacin. A set of symptoms that defines chronic paroxysmal hemicrania is presented, and two cases in which the presenting symptom was toothache are reported. It is emphasized that clinicians should consider chronic paroxysmal hemicrania in the differential diagnosis of orofacial pain.

Traumatic dysesthesia of the trigeminal nerve.

Traumatic injury to the peripheral nerves often results in persistent discomfort. Substance P has been implicated as a mediator of pain, and depletion of this neurotransmitter has been shown to reduce pain. Subjects suffering from traumatic dysesthesia of the trigeminal nerve were treated with capsaicin, a substance P depleter with significant long-term effects. This form of therapy may be used individually or in combination with other pharmacologic interventions in the treatment of traumatic trigeminal dysesthesia.

Thermographic assessment of neuropathic facial pain.

Ongoing pain, intermittent sharp pain, or intermittent dull aching pain around the teeth can evoke the suspicion of tooth pathology. However, when no dental cause can be found clinically or radiographically, the differential diagnosis involving neuropathic pain and pulpal pathology is still a challenge. Neuropathic facial pains are still too often misdiagnosed as tooth pain of dental origin, resulting in unnecessary dental extraction or endodontic therapy. The purpose of this study was to determine if electronic thermography was able to differentiate neuropathic facial pains presenting as toothache from pulpal pathology. Electronic thermography was used to compare asymptomatic subjects and subjects with neuropathic facial pains. Asymptomatic subjects and subjects with trigeminal neuralgia, pre-trigeminal neuralgia, and pulpal pain without periapical pathology showed no thermographic difference in the territory of the pain complaint when compared to the opposite nonpainful side. Patients with sympathetically maintained traumatic trigeminal neuralgia (atypical odontalgia) and half of the group with sympathetically independent traumatic trigeminal neuralgia presented with "hot" thermograms. The other half of the patients with sympathetically independent traumatic trigeminal neuralgia displayed "cold" thermograms in the area of their pain complaints. Electronic thermography was the least selective test for the group showing "cold" thermogram patterns (80% agreement with the thermographic characterization criteria). These data suggest that electronic thermography may be helpful in differentiating neuropathic pains from pulpal pathology.

Trigeminal neuralgia: how to rule out the wrong treatment.

Toothache is difficult to diagnose and treat appropriately when traditional dental diagnostic test results are negative. This study looked at 61 patients who were treated for pretrigeminal or trigeminal neuralgia. Of these, 61 percent were incorrectly diagnosed and treated.

Headache problems that can present as toothache.

Toothache of nonodontogenic origin may be better differentiated with the use of differential diagnostic blockade. Table 9 reviews the expected outcome of somatic block at the site of pain and when the nerve division or the site of nociception is blocked. Although there is considerable overlap, this technique together with a careful history and detailed physical examination will prevent many unnecessary irreversible treatments. If no sign of periapical pathology can be determined (radiography is normal) and the dental examination is nonrevealing, at least a 4-month period should be allowed to elapse before considering any irreversible dental procedure. During this time pharmacologic trials may be attempted, bearing in mind the clinical presentation. Patients should be informed that it may take at least 4 months for the dental pathology to manifest and in the hope of preventing irreversible damage, careful observation accompanied by the pharmacologic trials will be carried out. The practicing clinician is encouraged to maintain a broad perspective of the differential diagnosis of toothache when the pathology is not obvious.

Orofacial pain - an overview.

Orofacial pain is a complex problem that requires careful assessment, understanding and appropriate therapy. This article reviews the function of the nervous system as it pertains to orofacial pain and introduces an organ based classification system that can be used to help differentiate the patient with orofacial pain. Current concepts in the pathogenous of each disorder and therapies are reviewed.

Melkersson-Rosenthal syndrome. A review of the literature and case report.

Melkersson-Rosenthal syndrome is an uncommon condition of obscure aetiology and uncertain pathogenesis. It is characterized by swelling of the lips or other parts of the face and mouth, Bell's palsy, and fissured tongue. Disturbances of salivary, lacrimal and nasal secretion, disorders of taste and vision, migraine, and febrile symptoms occasionally accompany the condition. Treatment is aimed at management of the facial paralysis and cosmetic reduction of established facial swelling.

Facial pain.

Facial pain is a debilitating disorder if left untreated. Too often patients are labelled as having psychopathology when face pain etiology is unclear. These patients are categorized as 'atypical', 'idiopathic' or 'psychogenic'. Idiopathic, when referring to a medical problem suggests that there is something unknown, and does not define the problem. The same applies to terms incorporating the word 'atypical'. It is postulated that the most commonly undiagnosed facial pain conditions include neuropathic and myofascial pains because their pathophysiologies are not well understood. Peripheral and central mechanisms associated with these disorders are used to provide an update of these frequently seen clinical conditions.

SUNCT syndrome responsive to gabapentin (Neurontin).

A 48-year-old male suffering with SUNCT (severe unilateral neuralgiform headache with conjunctival injection and tearing, rhinorrhea and sub-clinical sweating) presented in 1996 after a 10-year history of multiple failed therapies. The symptoms included strictly left-sided ocular, as well as facial and temple pain. The pain attacks were burning, sharp, shooting and occurred 25 times daily, lasting 2 to 3 minutes with tearing and conjunctival injection. There was no associated nausea or vomiting, but there was photophobia. No other autonomic changes were reported and the pain was not triggerable. Initially Indocin (indomethacin) was tried without significant benefit. Gabapentin (Neurontin) was then started with improvement at 1800 mg per day. The patient was then lost to follow-up for 3 years, as he moved from the Los Angeles area. He returned in 1999 having stopped the gabapentin after his prescription ran out in 1996, reporting the pain returned immediately. Again gabapentin was prescribed and at 900 mg three times daily he has been pain free for 12 months.

Regional myofascial pain syndrome and headache: principles of diagnosis and management.

Myofascial pain is frequently overlooked in dealing with headache pain. Myofascial pain is defined as pain and/or autonomic phenomena referred from active trigger points, with associated dysfunction. The trigger point is a focus of hyperirritability in the muscle, that when compressed, is locally tender, and if sensitized, gives rise to referred pain and tenderness. The therapy for myofascial pain requires enhancing central inhibition through pharmacology or behavioral techniques and simultaneously reducing peripheral inputs through physical therapies including exercises and trigger point-specific therapy.

A retrospective study of patients with cluster headaches.

Referred pain in the midface and teeth is a common clinical feature of the cluster headache and cluster headache-like disorders. It is not unusual therefore for patients with cluster headaches to go to the dentist. In this report, 33 cases of cluster headache, which met the International Headache Society classification criteria, and which were seen by us during a 2-year period, are reviewed. Fourteen (42%) of 33 patients who were seen by dental practitioners and who received some form of ineffective dental or pharmacologic treatment are described here. Since almost 50% of the cluster headache patients described here received inappropriate dental treatment, it is hoped that this review and retrospective assessment will make the dental practitioner aware of this disorder and provide a broader perspective in the treatment of pain in the orofacial region. Clinical presentation, pathogenesis, and treatment of cluster headaches are discussed.