Research on Brian's Pain Management.

What Is Trigeminal Neuralgia?

Brian Nelson’s Report Pain on Left side of Head.
Document Initiated on 8-22-04  Last update 8-30-04 620am ..

Brian Nelson, 31 Gessner Rd. , Houston, TX  77024
bnelson@PartyTentCity.com  , 713-467-3025 .

This letter is for the record and to keep a PAIN JOURNAL of where the above stated title problem stands. 

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Here is an interesting MVD website about surgery successes. I am surprised it was on the net.   http://www.hfs-assn.org/surgery.htm 

GLOSSOPHARYNGEAL NEURALGIA
Conditions: Other Cranial Disorders

Disclaimer.

Glossopharyngeal Neuralgia is described as a deep stabbing pain in one side of the throat. The pain is near the tonsil area and can extend into the ear. Thomas J. Lovely, M.D. , Peter J. Jannetta, M.D. of the University of Pittsburgh have a brief discussion on their experiences treating this condition at: Glossopharyngeal Neuralgia.

Links:

Glossopharyngeal Neuralgia - Singapore Journal 1999

Medline on Glossopharyngeal Neuralgia

Merk Manual-- glossopharyngeal neuralgia

Glossopharyngeal neuralgia, CCND Winnipeg

Glossopharyngeal neuralgia University of Pittsburgh

Glossopharyngeal Neuralgia , B.Todd Troost

The following article goes into greater detail although it does not discuss microvascular decompression surgery as a possible treatment..

The following article is excerpted from:
 

THE MANAGEMENT OF PAIN,
VOL 1, Second Edition, 1990, Lea & Febiger, Philadelphia]
CRANIAL NEURALGIAS
John D. Loeser

This article is posted here in compliance with the FAIR USE DOCTRINE and is for educational purposes only, not for commercial use.

"Glossopharyngeal neuralgia is characterized by shock like pains in the territory of the glossopharyngeal nerve. It is in every way similar to tic douloureux except for the distribution of the pain and the customary site of the triggering stimulus.

Etiology

"The vast majority of patients with glossopharyngeal neuralgia are thought to have an artery compressing the nerve as it exits from the medulla and travels through the subarachnoid space to the jugular foramen. This syndrome can be seen in patients with multiple sclerosis, but it is rare.

Symptoms and Signs

"Glossopharyngeal neuralgia is characterized by excruciating shock-like-pain in the region of the tonsilar fossa, pharynx, or base of the tongue. It can radiate to the ear or the angle of the jaw or into the upper lateral neck. The trigger zone is often in the same area, and patients frequently report that swallowing, yawning, clearing the throat, or talking is the precipitating stimulus. The pain often appears to be spontaneous. Chewing or touching the face does not precipitate an attack. Glossopharyngeal neuralgia is much less common than tic douloureux---the incidence ratio is about 1:100.

Diagnosis

"The nature of the pain, its description by the patient, and the chronology of the attacks are identical to those of tic douloureux of the trigeminal nerve. Indeed, glossopharyngeal tic is sometimes mistaken for mandibular division trigeminal tic douloureux. Involvement of the glossopharyngeal nerve can be demonstrated by localizing the triggering stimulus to the pharyngeal structures that it innervates. Blocking the trigger area with local anesthetic can confirm the site of the trigger and nerve involvement. This is unsuccessful in some patients because the vagus nerve can contain the involved sensory fibers. The role of the glossopharyngeal nerve in the regulation of heart rate and blood pressure is thought to be why some patients with glossopharyngeal neuralgia have profound cardiac arrhythmia's and even asystole with the attack of pain. The presence of such phenomena guarantees that the pain syndrome involves this nerve. The diagnosis can be confirmed by the cessation of pain when this nerve is blocked at the jugular foramen or when topical anesthesia of the pharynx stops the pain.

Treatment

"The pharmacologic management is the same as that for tic douloureux of the trigeminal nerve. When medical management fails, suboccipital craniectomy with exploration of the glossopharyngeal nerve is indicated. If a compressing blood vessel is found it can be mobilized, and the pain usually stops without any loss of nerve function. When no structural pathology can be identified, the glossopharyngeal nerve should be Sectioned. In such a case it is wise to Section the upper fibers of the vagus nerve as well, because they can also be involved in the pain syndrome. When rhizotomy is unsuccessful, which happens rarely, the medial aspect of the descending tract of the trigeminal nerve can be Sectioned to produce loss of pain and temperature sensation in the pharynx.

"A percutaneous technique of glossopharyngeal neurolysis has been described, but it has not been widely used because of cardiovascular and laryngeal complications. "

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.

What causes bruxing to occur?
This is a very difficult question to answer. Some researchers say that if the occlusion (bite) of someone is not correct they will brux. Others say that it is a central nervous system disorder. Others say it is a multifaceted problem.

For all practical purposes……EVERYONE  bruxes. Therefore, the question is NOT whether a person does in fact brux. Rather, the better question is to what degree do they brux. There is not a scale of bruxing that exists, but, we could imagine that there is such a scale. This scale could run from a 1 indicating a very very slight habit to a 10+ which would indicate a severe bruxer. A person at level 1 would not show any signs of bruxing at all. On the other hand the  people in the higher end on the scale would show one or several signs. The pressure that can be generated across the teeth can range from 100 to 600psi (pounds per square inch) this is an incredible amount of force. The problems outlined below occur as a result of these forces being applied over many years -  slowly - and it can be difficult to recognize the cause/effect sequence.

Possible signs, complications or damage that may occur are:

1. Wearing of teeth.
   Wear occurs from the movement of the teeth harshly against one another. Although all teeth may show this type wear, it is especially noticeable when a person has front teeth that appear having the same length - as if they were filed down.
2. Breaking of teeth.
   As teeth wear, the edges of front teeth and the cusps or corners of back teeth will begin to show microfractures or cracks. These cracks can not be seen on x-rays. It takes magnified vision and/or an intraoral magnified image to diagnose them. Where this becomes especially important, is that teeth with these type of fractures will either eventually chip, break a corner, or yet require root canal therapy. The reason for root canal therapy is that the fracture begins on the surface of the tooth and eventually deepens until the crack enters the area of the nerve.
3. Sensitive teeth.
   Usually a generalized soreness and/or a cold sensitivity..
4. Receeding gums and/or teeth with gum line “notches”.
   Most people have been told or assume that receeding gums occur because of age, using a hard bristle brush or the occurence of gum (periodontal) disease. In fact none of these reasons are correct in a majority of the cases. These are  referred to as abrasion areas. When teeth grind hard against each other year after year, they flex at the gum line and the enamel (which ends thinly at the gum line) microfractures away. The end result is an area at the gum line that you can catch your fingernail in and may get extremely sensitive to touch and/or cold.
    

   In this picture, there is exposed root surface  and advanced abrasion areas.

5. Loose teeth
   Teeth loosen because of the "rocking" back forth that occurs. The best analogy is the example of getting a fence post out of the ground by rocking it back and forth.
6. Periodontal pockets (loss of supporting bone around the teeth).
   Sometimes instead of the tooth getting loose, there may be a generalized horizontal loss of supporting bone and/or localized areas of bone loss.
7. Bony ridges (tori)
   Instead of losing bone support - some people actually form "extra" bone to support the teeth (this appears as bony ridges that can be seen and felt on the jaw bones as a smooth raised area about at the level of the roots.

   This image is of the lower jaw showing extra bone in the "floor" of  the mouth by the tongue.

   This picture shows the cheeks pulled back and the ridge along   and above the upper back teeth.

8. Cheek irritation - A ridge or line of fibrosed (toughened) tissue on the inside of the cheek that corresponds to where the teeth come together. Sometimes a person will actually bite themselves along this line (especially in the most posterior molar area).
9. Sore muscles (especially in the cheek and temple area) When these two muscles are overused. They may get sore - just like when you over exercise, your other muscles get sore.

                                
    10. Headaches (especially upon waking in the same muscle areas mentioned above).
          Instead of soreness, the muscle aches will appear as a headache.
   11. TMJ problems (jaw joint pain / soreness / etc)
         The jaw joint may be over loaded and resulting problems occur.

       These signs take time (usually decades of years) to show themselves.

Does everyone show every problem? No they don't, we are all very different. Some of us will exhibit none of these problems (thank your genetic code for that), some of us will exhibit severe problems (curse your genetic code for that).  So any combination, or NO problems may exist for any one person.

So, what should anyone do about bruxism? Is there a cure?

This is a very difficult thing to answer. For a large number of people, the problem is that their bite is off - this triggers through a series of physiological signals, a dramatic increase in the amount of bruxing.

STRESS is a huge factor when it comes to bruxing. In fact the mouth can show stress before any other area of the body. The more stress, the more bruxing and the harder the bruxing.

NIGHTGUARD
It would be logical to think that an acrylic nightguard is simply a piece of plastic used to cover and prevent the teeth from coming together while sleeping at  night. This is true - BUT - most importantly, when in place it provides a correct bite so that muscles will relax and problems in a persons bite will not trigger the bruxing action.. The aspect of making and delivering a nightguard CORRECTLY is difficult to explain but you may see this process by clicking here. A point needs to be made that tooth wear still slowly occurs when using a nightguard. The reason for this is that a person (especially severe bruxers) will clench and very slightly grind during the day time when their guard is not being worn. 

A nightguard is NOT a solution, rather a method of greatly decreasing  the damage caused by bruxing. It is possible to alter a bite so that a guard may not be needed - the method varies from case to case.

What is Sleep Bruxism?

Sleep Bruxism is a sterotyped movement disorder characterized by grinding or clenching of the teeth during sleep.  The disorder has also been identified as nocturnal bruxism, nocturnal tooth-grinding and nocturnal tooth-clenching.

What are the Symptoms?

The symptoms of Sleep Bruxism are tooth-grinding or tooth-clenching during sleep that may cause:

• abnormal wear of the teeth
• sounds associated with bruxism (It's about as pleasant as fingernails on a chalkboard!)
• jaw muscle discomfort

How serious is the disorder?

Some people have episodes that occur less than nightly with no evidence of dental injury or impairment of psychosocial functioning. And others experience nightly episodes with evidence of mild impairment of psychosocial functioning. Yet others have nightly episodes with evidence of dental injury, tempomandibular (jaw) disorders, other physical injury or moderate or severe impairment of psychosocial functioning.

When someone with suspected sleep bruxism has a polysomnographic test there is evidence of jaw muscle activity during the sleep period and the absence of abnormal movement during sleep.  Other sleep disorders may be present at the same time, e.g., obstructive sleep apnea, restless legs syndrome.

Damage to the teeth needs to be stopped. Pain and injury to the jaw may require surgery.

How is it treated?

If the damage is not advanced, your dentist can make you a mouthguard that fits over your lower set of teeth and prevents the two sets of teeth from grinding against each other. See below for treatments using neurofeedback to reduce stress, etc

ATYPICAL FACIAL PAIN
Conditions:  Facial Neuralgias

DISCLAIMER.

| DESCRIPTION | POSSIBLE CAUSES | SYMPTOMS | DIAGNOSIS 
| TREATMENTS | ONLINE RESOURCES |

DESCRIPTION
Atypical Facial Pain (ATFP) is a syndrome encompassing a wide group of facial pain problems. ATFP can have many different causes but the symptoms are all similar. Facial pain, often described as burning, aching or cramping, occurs on one side of the face, often in the region of the trigeminal nerve and can extend into the upper neck or back of the scalp. Although rarely as severe as trigeminal neuralgia, facial pain is continuous for ATFP patients, with few, if any periods of remission. Recent studies propose that ATFP is an early form of trigeminal neuralgia. Indeed, some patients have components of both ATFP and TN symptoms.  Earlier literature has linked ATFP to "psychological pathology." Recent studies, however have shown no such link exists.

POSSIBLE CAUSES
ATFP has many possible causes. In some cases, infections of the sinuses or teeth appear to be involved. Some studies postulate a   low-grade infectious and inflammatory process occurring over a long period can result in nerve damage and be the triggering factor for ATFP pain. Some believe that vascular compression of the trigeminal nerve in the same area that is postulated to lead to trigeminal neuralgia is a cause of ATFP although studies have shown that microvascular decompression rarely leads to pain relief in ATFP patients. Dental or some sort of physical trauma is also linked to ATFP. Several somewhat controversial studies postulate that a condition known as NICO - Neuralgia Inducing Cavitational Osteonecrosis is the cause of the neuralgia-like symptoms of atypical facial pain.

SYMPTOMS
Facial pain, often described as burning, aching or cramping, pinching, pulling, occurs on one side of the face, often in the region of the trigeminal nerve and can extend into the upper neck or back of the scalp. Although rarely as severe as trigeminal neuralgia, facial pain is continuous for ATFP patients, with few, if any periods of remission.

DIAGNOSIS
Diagnosing atypical facial pain is not an easy task. It's not unusual for ATFP patients to have undergone numerous dental procedures, seen multiple doctors and undergone many medical tests before being successfully diagnosed and treated. A diagnosis of ATFP is usually a process of elimination. When a patient complains of constant facial pain restricted to one side of the face, the physician must first rule out any other conditions. Tests include roentgenograms of the skull, MRI and/ or CT scan with particular attention to the skull base, careful dental and otolaryngolgic evaluation, and thorough neurological examination. Only after tests rule out other factors can a diagnosis of ATFP be made.

TREATMENTS
Treatment of ATFP can be difficult and perplexing for both doctor and patient. Medication is usually the first course of treatment. Surgical procedures such as microvascular decompression generally are not successful with ATFP patients.

The following drugs are used to treat atypical facial pain:

Amitriptyline. (Triptyl, Elavil)
  Gabapentin. (Neurontin).
  Pamelor
  Capsaicin

Other pain relief strategies include:

Hot and cold compresses|
Acupuncture
  Biofeedback
Dental Splint

ONLINE RESOURCES
Professional Websites

Atypical Facial Pain
Excellent discussion of Atypical Facial Pain from emedicine.com

Source:  www.cymbalta.com/

Thanks to Tracy for the time she gives our association!

If you have anesthesia dolorosa and want to share your experience with other Texans suffering from with the same problem, please send an e-mail to Shelly Wilson at swilson@tna-support.org or send a written note to Shelly Wilson at 604 Aberdeen Way, Southlake, TX  76092.  Please state that it is OK for TNA to share your name, phone number, and e-mail address (if you have one) with other anesthesia dolorosa patients.

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