| Facial Pain |
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| Getting Help/What to Expect |
Patients with neuropathic orofacial pain often visit many doctors and undergo many tests, all of which are negative. Even more frustrating and upsetting to the patients is that they undergo useless treatments. In the mouth, this may include gum surgery, root canal and even extraction, which often results in only temporary relief, no relief at all, or in many cases an increase in pain.
Persistent pain should be evaluated by a physician, usually a neurologist or anesthesiologist specially trained in pain management or, in the case of the head and neck, by an orofacial pain specialist. The doctor will perform a comprehensive evaluation, which may include a thorough history, examination, and diagnostics tests.
The history should include recording the exact nature of the pain and other symptoms you may have, the history leading up to the persistent pain, previous doctors seen, past treatments and their results, and list of medications taken with their effectiveness and/or side effects.
The examination should consist of touching different areas of the head, neck and inside the mouth, measurements and evaluation of the jaw, head and neck, and gentle provoking of the pain. This can be with light touch, cold or heat or heavier touch. The doctor may also perform some simple neurological tests.
After this, the doctor may decide to order diagnostic tests which could include magnetic resonance imaging (MRI), computer assisted tomography (CT) or other radiographs (X-rays). In addition your doctor may want to order blood tests, urinalysis, and other tests. These tests are used to make sure that there are no other factors that may be contributing to the neuropathic pain. To discover if the pain is peripheral or central (or both), the doctor may use a series of diagnostic injections, usually with a local anesthetic, similar to what might be done when you have a tooth filled. By "numbing" the nerves in the peripheral part of the nervous system and determining its effect on the pain, important information can be learned and may help in planning a more effective treatment. A battery of psychological tests may be appropriate since anxiety and depression often accompany persistent pain.
Depending on the complexity of the problem, the orofacial pain specialist will decide which of the diagnostic tests are appropriate. After piecing together the results of the history, examination, and diagnostic tests, the doctor will make a diagnosis and recommend a treatment strategy. Sometimes treatment is done on a trial basis and several treatments may be attempted before an effective approach is found. In addition your doctor may enlist the help of several professionals to provide what is called a "multidisciplinary approach". |
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| Pre-Trigeminal Neuralgia |
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Some patients will experience a vague, deep dull achy pain in the face or teeth. It may be constant or on and off. Local anesthesia often temporarily relieves the pain. This pain eventually develops into TN and is called "Pre-Trigeminal Neuralgia". This is treated with the same medications as TN. This pain can be difficult to diagnose but becomes evident as it presents itself in the classical form of TN
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| Atypical Odontalgia (Phantom Tooth Pain) |
As previously mentioned, some patients develop persistent tooth pain and go from dentist to dentist only to be told there is nothing wrong with their teeth. This pain often, but not always, follows a dental procedure such as a root canal or filling. Unfortunately, many patients undergo unnecessary root canal treatment, gum surgery, and even extraction in a vain attempt to treat their pain. The pain actually starts at the peripheral nerves that go to the teeth and in some cases can progress to changes in the central part of the nervous system that then senses tooth pain.
When the pain comes from the part of the nerve close to the teeth or gums, injections of local anesthetics and steroids may be effective. Some patients find relief by applying specially prepared creams with various combinations of medications mixed in them. In patients where the pain is central rather that peripheral, medication taken by mouth may be needed on a daily basis. These often include antidepressants and anti-seizure medications and in some cases even narcotics.
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| Chronic Regional Pain Syndrome |
Chronic Regional Pain Syndrome (CRPS) often results from peripheral nerve damage that causes changes in the peripheral and central parts of the nervous systems, similar to what is seen in atypical odontalgia. The difference with this kind of pain is that the sympathetic nervous system is involved. This is the part of the nervous system that, among many other things, controls blood flow. So, in addition to the pain, the patient often complains of a cold feeling because the blood vessels in the area narrow. The pain is often described as burning and is triggered by light touch or other stimulation. CRPS most often occurs in the arms and legs but can occur in the face.
Treatment usually consists of antidepressants, pain medication, and medications used to control blood pressure. Physical therapy aimed at restoring the affected area to normal function may be helpful. Sometimes a series of injections in certain of the main nerve intersections or "ganglia" are helpful, particularly in the early stages of the disorder.
When all else fails, there is a surgical procedure that treats specific nerves that surround the area. The procedure is called "sympathectomy". But, as with any surgery for chronic pain, proceed cautiously.
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