Jim arrived in my office with a history of severe pain on the right side of his face following removal of his tonsils. Since his surgery he had not been able to eat or sleep regularly due to the pain which had lasted nearly a year. He had visited three other dentists whom all diagnosed his condition as Temporomandibular Joint Dysfunction or TMD, formerly termed “TMJ”. This was a logical diagnosis based upon his recent history of oral surgery. It was assumed that his jaw had been stretched open for a prolonged period during the procedure and had stretched and damaged the ligaments in the Temporomandibular Joint. Each dentist had made a night guard appliance to relieve the symptoms; however the appliances were not the correct design; so I made him a fourth appliance. None of the appliances including the one that I made offered complete relief. This emphasizes the fact that TMD often has multiple layers of causes for pain. He well may have had joint damage which lessened the pain with the appliances and medications. His continued symptoms were related to additional causes making his care more complex.
Trigeminal Neuralgia is a condition of the Trigeminal Nerve which is one of twelve pairs of nerves that come directly from the brain. Most nerves in the body branch off the spinal cord in the neck or back. The Trigeminal Nerve exits the brain through a tiny hole in the base of the skull and then branches into three separate nerves which go the upper and lower jaws and to the skin on the sides of the face. In Eric’s case the branch serving the right side of his face was involved. The cause of the pain is considered to be from a blood vessel that rests next to and applies pressure to the nerve which triggers impulses to the brain perceived as pain.
All the various methods of treatment for TMD produced limited relief; so he was referred to a neurologist for more advanced care. This care will begin with antidepressant drugs which have been shown to be quite beneficial in other patients. If this does not relieve his symptoms the neurologist will have to look for additional causes and treatments.
Common treatments include placing either a soft cushion around the nerve where it exits from the brain or inserting, using a needle technique, a balloon between the nerve and the blood vessel. These techniques have been met with instant relief. Unfortunately over the span of a few years the cushion or balloon can slip out of place requiring the repeat of the procedure.
In addition to treatment of Trigenimal Neuralgia the neurologist should also consider the possibility of Multiple Sclerosis (MS) as patients under the age of 50 develop this facial as one of the first symptoms of that disorder. Obviously facial pain can be quite complicated. In Eric’s case it took nearly a year before he was able to find someone who understood that facial pain can have multiple causes, and after treatment of the more obvious causes, if the pain does not subside, then other causes must be considered and treated. Then after addressing these other causes, if the pain still continues, then the patient must be referred to the next level of care which in this case was a neurologist.