You have got  Facial Pain?……………..extreme, sporadic, sudden burning or shock-like pain in your  face that lasts from a few seconds to as long as 2 minutes per episode. It is almost always on  the same side of your face but it does move around.   The intensity of pain can be physically and mentally incapacitating.  Often they tell you it is all you your head.   “ Your crazy”   Your friends and loved ones remind you that  you have been to Doctor after Doctor and they all say your are just fine. There is nothing  there.  Get over it. Get on with your life.  Yah sure…………. but no one seems to understand your pain.  They think your are making it up to get attention or get out of doing some thing you are supposed to do. Episodes can last for days, weeks, or months at a time and then disappear for months or even years. But then they come back. It is view by your loved ones as a another sign of depression.  You are having a bad week.

The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.  The intense flashes of pain can be triggered by vibration or contact with the cheek such as when shaving, washing the face, or applying makeup, brushing teeth, eating, drinking, talking, or being exposed to the wind. Wow, This is getting serious.   Finally someone helps you come up with a name for this pain. Viola.  Sometimes they call it Trigeminal Neuralgia, or  TN  Sometimes they call tic douloureux. Ok so now maybe your are not alone.  You have companionship.  You gradually learn that if you have what you think it might be that there are only  1 in 25,000 people have this.  The reason the doctors couldn’t find your  problem is because  they only have maybe 5,000 patients. So how would they ever learn about this. .  Then you find that most likely your pain is cause by something messing with your Trigeminal nerve. That is the nerve leads from  3 part of your face on  either the left or the right side and goes directly to the brain.

TN occurs most often in people over age 50, but it can occur at any age, and is a little  more common in women than in men. But that doesn’t leave anyone off the hook including very small children or growing teenaages  There is some evidence that the disorder runs in families, perhaps because of an inherited pattern of blood vessel formation. Although sometimes debilitating, the disorder is not life-threatening.

The presumed cause of TN is a blood vessel pressing on the trigeminal nerve in the head as it exits the brainstem. TN could be part of the normal aging process but in some cases it is the associated with another disorder, such as multiple sclerosis, a tumor or other disorders characterized by damage to the myelin sheath that covers certain nerves.

Is there any hope? Yes of course there is hope. The problem is  you have to find exactly where in the head the source of the pain is coming from. Because there are a large number of conditions that can cause facial pain, TN can be difficult to diagnose.  But finding the cause of the pain is important as the treatments for different types of pain may differ.  Treatment options include medicines such as anticonvulsants and tricyclic antidepressants, surgery, and complementary approaches. Typical analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN.  If medication fails to relieve pain or produces intolerable side effects such as excess fatigue, surgical treatment may be recommended. Several neurosurgical procedures are available. Some are done on an outpatient basis, while others are more complex and require hospitalization. Some patients choose to manage TN using complementary techniques, usually in combination with drug treatment.  These techniques include acupuncture, biofeedback, vitamin therapy, nutritional therapy, and electrical stimulation of the nerves.

What is the prognosis?
The disorder is characterized by recurrences and remissions, and successive recurrences may be incapacitating.  It is very serious. Due to the intensity of the pain, even the fear of an impending attack may prevent activity. Trigeminal neuralgia is not fatal. Therefore it is not treated by the research community as if it were terminal. But the pain is there and unless you have had  sporadic facial pain you can’t really understand what a TN patient is going through. 

If you have just one more ray of hope or have found a friend here who has a similar pain problem who can understand how you feel then I feel. t Is there hope  in finding the cause of your pain.  Yes Yes.  It is not easy but the more we meet and discuss this the more  we learn on how to treat this.  There has been some  research which has helped discover  many things but the only way we can discover more to help everyone is  have a lot more research?  Research costs a lot of money. We are gradually getting there but it won’t come overnight.  One of our biggest problems is  that although TN is one of the most painful  medical disorders know it usually is not fatal.   Therefore the funds for research are few and far between. 

Let me give you some ideas on what are some of the things that are being done?  

• TNA Professional Outreach & Education Pilot Program
• TNA Regional Conference – Vanderbilt – May 2007
• Lifetime Achievement Dinner for Peter Jannetta, MD – Pittsburgh – April 2007
• TNA National Conference 2008 – Detroit?  (Not confirmed yet but looks like it will work out)
• TNA Support Groups
• TNA Telephone Support Contacts
• OHSU Diagnostic Questionnaire (you can view it at www.ohsu.edu and then type in TN questionnaire to find the questionnaire)
• University of Florida’s McKnight Brain Institute Facial Pain Research Program (which will include adult stem cell research)
• TNA Patient Registry
• Epidemiology Study (already in the works)
• NIH funding for facial pain research
• $100,000 Botox trial for TN patients (we haven’t gotten the money for this yet but have been told the check is coming)
• Voice America health talk on-line radio show
• Brian Nelson Houston, TX    77024  Click: E-mail me 713-467-3025  From Slide Script. 7-26-06

TN and Dental Problems

Dental problems loom large for anyone with TN because the trigeminal nerve goes to both face and teeth. Some people are initially misdiagnosed by a dentist and have unnecessary root canals and/or extractions. Later on, major dental work can make the pain of TN worse or it can end a remission.

Dentist Brian D. Fuselier: It's true that TN is often diagnosed only after the patient has had a number of unnecessary dental procedures. My colleagues and I are trying to educate dentists to consider TN when they're diagnosing facial pain.

Dentists assume that when prodding a tooth produces severe pain, it is usually caused by pulpitis (inflammation of the pulp or nerve of the tooth) and the appropriate treatment is a root canal. If that doesn't help, the dentist may do a second root canal on another tooth.  Eventually, the patient may have one or more teeth extracted. All this dental treatment may be unnecessary.

The first thing a dentist should do in diagnosing pain is to make sure the patient has a true dental problem. If the pain is not dental, it could be caused by a number of different conditions, including TN. To make a diagnosis, the dentist should ask questions about the quality of the pain - is it throbbing, stabbing, electrical, continuous, etc. - and about its intensity, duration and frequency, as well as its location.

Dentist Parker E. Mahan: Dentists differentiate between types of pain by taking an extensive medical history and examining the teeth, jaw muscles, salivary glands, blood vessels, mucus membranes, and temporomandibular joints. There are several facial pain syndromes that are sometimes confused with TN. They include:

Atypical odontalgia, or atypical toothache: It's atypical because X-rays show nothing wrong with the tooth but it hurts. This often occurs in 30- to 50-year-old women who are depressed. However, the pain is real.

There are a number of theories about the cause of it. Some suggest that the disorder originates in the blood vessels or the sympathetic nervous system. When patients take a tricyclic antidepressant like imipramine (Tofranil) for three-toeight weeks, half find that the pain goes away.

Myofascial pain dysfunction (MPD):  People who clench their teeth repeatedly while they sleep (a problem called bruxism) can develop pain in the muscles on the sides of the face. Hard knots appear within the muscles; squeezing a knot produces shooting pain. If a dentist injects a local anesthetic into these knots, they become soft. The injection disrupts the muscle, but it heals in three weeks. To prevent the pain from returning after that, it's necessary to prevent bruxism, perhaps with a bite splint worn at night.
   
Before doing a root canal, should a dentist use Tegretol to make sure the patient doesn't have TN? (If facial pain is relieved by Tegretol, that strongly suggests that it may be caused by TN.)

Dr. Fuselier: If a dentist is uncertain about whether the pain truly is a dental problem, it would be appropriate to refer the patient to a pain-management specialist, such as a neurologist, who has been trained in the use of Tegretol.

Neurosurgeon John M. Tew Jr: Sometimes patients demand that one or more teeth be extracted. If the dentist refuses them, they go looking for someone else who will agree to pull the teeth.

What is being done to educate dentists about TN?

Dr. Gremillion: At dental conferences there are presentations about facial pain, including TN, and dental schools have a growing interest in teaching their students about it. Currently there is strong pressure on the American Association of Dental Schools to make training in facial pain a mandatory part of a dentist's education.  

A Precursor to TN

Dr. Gremillion: Dentists sometimes see a pain problem that appears to be a precursor to trigeminal neuralgia. It can occur months or even decades before full-blown TN, and the procedure used to diagnose the  problem often produces a respite.

In this condition, the pain is sometimes sporadic, sharp, and stabbing, like classic TN, but more typically it's a dull ache or it can feel like sinus pain or a toothache. It may be constant or may come and go, lasting minutes or hours each time. There is no specific trigger zone on the face but chewing, drinking hot or cold liquids, yawning, talking, or brushing teeth can brin on the pain. It is often localized at first. Over time it may spread to involve a larger area or move to another site. To make a diagnosis, the dentist numbs the area with a long-acting local anesthetic. If the pain came from a tooth, it will soon return. If it was produced by TN, relief may continue after the anesthetic wears off. In some cases, a series of injections of local anesthetic can relieve pain for months or even years.

How to Prevent TN Flare-ups after Dental Work

Why does dental work often trigger a new attack of TN for someone who is in remission?  Why does it tend to make the problem worse for those who have their pain under control with medications? Is there any way to prevent these things from happening?

Dentist Parker E. Mahan: After all of the surgical procedures used to treat TN, some patients experience a breakthrough of pain. It probably doesn't take much stimulation to trigger that breakthrough.

TN presents a paradox. On one hand, it's of the utmost importance to maintain good dental health in order to avoid problems that might precipitate, an upsurge of pain. On the other hand, because major dental work can aggravate the Trigeminal nerve, you should have only procedures that are truly necessary - for instance, don't agree to let your dentist replace a very large filling with a crown if the filling is still serviceable.

If you must have major work done, I recommend pre-emptive anesthesia to prevent the pain of the dental procedure from "jazzing up" the transmission of pain signals from the trigeminal nerve to the brain.
 

• For a day or so before and after the procedure, increase the dose of any TN medications you're taking.

• Ask your dentist to use Marcaine without epinephrine for the local anesthetic. You may need to ask in advance because the average dentist doesn't keep this particular drug in stock. Marcaine is long-acting, so you're less likely to need multiple injections - each one producing pain signals. Epinephrine is a vasoconstrictor; added to a local anesthetic, it prevents blood flow from carrying away the anesthetic and thus prolongs its numbing effect. However, epinephrine can trigger nerve pain, so you're better off without it.
   
• Ask the dentist to inject the local anesthetic at a site as far as possible from the trigger point for the TN pain.
   
• Several hours before the procedure, take a pain-killing medication. Opioids such as codeine are good at preempting pain. After the procedure, take the painkiller again.  The goal is to have at least five hours afterwards during which you're free of pain.
   
• If dental procedures make you very nervous, consider foregoing local anesthesia. You can have laughing gas or IV anesthesia instead to reduce emotional trauma.

If you have TN, is it better to have a root canal or to have a problem tooth pulled?

Dr. Langan: Provided an extraction isn't contraindicated for some reason, I believe it is often a better solution than a root canal because the trauma is short-lived, minimizing painful stimulation of the central nervous system.

What can you do to maintain good dental hygiene when it hurts too much to brush your teeth?

Dr. Langan: Ask your dentist to prescribe a topical anesthetic called viscous lidocaine and use it to numb your mouth. If that doesn't help, try a prescription mouth rinse called Peridex, an oral antibiotic. It can sometimes stain the teeth, so wipe off your teeth as best you can. Drink only lukewarm fluids to keep from stimulating the nerves in your mouth. When the pain flare-up is over, remember that if you have TN, good dental hygiene means having your teeth cleaned by your dentist at least twice a year.