Identifying and managing trigeminal neuralgia in the dental office

Dental hygienists receive extensive education in common systemic diseases, oral pathology, and infectious diseases. Every hygienist will surely encounter some patients with a health condition that is unfamiliar to them, and trigeminal neuralgia (TN) may well be the case. This rare disease is twice as common in women than men and is often undiagnosed, misdiagnosed or underdiagnosed.

Also the author… Best Practices in Waterline Management of Dental Units

What is trigeminal neuralgia?

The trigeminal nerve sends important facial sensations and messages to the brain. When patients experience TN, some describe it as the most excruciating pain known to man. The severe pain is reported to be like an electric shock and is usually felt only on one side of the face.1 Trigeminal neuralgia affects approximately 150,000 people each year and can be triggered by simple daily tasks such as:

  • Brushing/flossing
  • Smile
  • a light touch
  • eat
  • open and close mouth
  • drink

Initially, pain caused by TN can last for several seconds. But as the condition continues, the electric shock may last for several minutes or even longer.2 The onset of TN usually occurs in women aged 50 years or older; if symptoms occur in women under 40 years of age, it is recommended that they also undergo multiple sclerosis evaluation.

More about trigeminal neuralgia… Trigeminal Neuralgia: A Suicidal Disease

The trigeminal nerve is often called the fifth cranial nerve. There are two trigeminal nerves, located on either side of the head. From there, the trigeminal nerve extends to branches and roots. Although the specific cause of TN is unknown, two types have been identified: primary trigeminal neuralgia and secondary trigeminal neuralgia. Primary trigeminal neuralgia is associated with compression of blood vessels on the trigeminal nerve near the junction of the brain and spinal cord. Secondary trigeminal neuralgia is caused by stress from secondary sources such as tumors, multiple sclerosis, injury, or trauma.3

Because TN is a rare neurological disease, it can be difficult to find a doctor familiar with its diagnosis and treatment. Patients often must see multiple healthcare providers from various disciplines before a diagnosis of TN is confirmed.

Treatment options for trigeminal neuralgia

In the past, TN was called a “suicidal disease” due to its psychological impact on patients.4 Patients report prolonged depression, anxiety, delayed diagnosis, and sleep disturbances. Dental complications of TN include dental anxiety, fear of toothache and/or dental treatment, which may precipitate recurrence of TN. The psychological effects of long-term exposure to TN may lead to suicidal ideation in some patients. Timely and accurate diagnosis can minimize the psychological impact of TN. However, if any mental health concerns are present, appropriate mental or behavioral health referral is recommended.

Treatment options for patients diagnosed with TN are limited, and there is still no cure. Symptom management and palliative care are important lifelines. Currently, treatments include non-surgical options using anticonvulsant medications such as gabapentin, oxcarbazepine, or carbamazepine. Surgery may be an option when the medication is no longer effective, the side effects of the medication are no longer tolerable, or the pain caused by TN is no longer controllable.

Trigeminal Neuralgia and Dental Patients

Dental professionals play an important role in identifying and referring patients with TN. Patients experiencing TN experience extreme facial pain, which may be related to toothache. Dental clinicians are often the first providers patients turn to for relief from unknown facial pain. A thorough intraoral and extraoral examination, including X-rays and examination of lymph nodes, temporomandibular joints, and salivary glands, should be performed to rule out any pathological problems.

An article was published in dental decision making 2021 discusses the involuntary muscle spasms around the eyes and mouth often observed in patients with TN at rest.5 If the cause of facial pain is unknown and TN is suspected, the patient should be referred to an appropriate specialist. It is estimated that “more than one-third of patients with undiagnosed TN who present to a dental office may undergo unwise surgery or delayed treatment.”5

2020, international neurosurgery published a retrospective study of patients with TN. This study assessed how many participants had visited a dentist for examination and/or treatment before a diagnosis of TN. Results showed that approximately 66% of participants initially sought dental care for pain, with 42% continuing to receive potentially unnecessary dental treatment.6

Knowing how best to make effective dental appointments and minimize TN pain can be a challenge. An initial discussion of where the patient is in treatment and in the pain cycle is key. The dentist should update the patient's health history at each appointment and document the location of TN pain, the cause of the pain, and the intensity of the pain. Accurate records help better understand common pain trends, patterns and triggers.

Adjust dental appointment

TN patients typically have heavier plaque buildup and/or calculus, increased inflammation, higher rates of dental caries, xerostomia, and poor oral hygiene. The dental hygienist should be prepared to adjust appointments to meet the patient's current needs and minimize any TN trigger areas.5

Due to facial neuropathy, the “simple” tasks of a dental care appointment may not be completed in these cases, including flossing, polishing, and fluoride application. In these cases, communicate with the patient, listen to what is causing their facial pain, and make personalized recommendations.

Subtle adjustments for dental hygiene appointments:

  • Use a post-surgery toothbrush to polish your teeth.
  • Apply fluoride with your post-operative toothbrush.
  • Use topical medications after scaling and scaling.
  • Use other interproximal aids instead of traditional floss.

Oral Hygiene Adaptations:

  • Use a post-operative toothbrush containing chlorhexidine gluconate.
  • Dip a sponge into chlorhexidine gluconate.
  • Use a prescription toothpaste with 5,000 ppm fluoride.
  • Use xylitol products and products to combat dry mouth.

Successful treatment of patients with trigeminal neuralgia

This is challenging when patients present with an uncommon condition and have many symptoms that can be attributed to other common conditions. This is why TN patients often believe that the pain they experience is caused by toothache. A comprehensive examination must be completed, complete documentation obtained, and appropriate referrals provided as needed.

Successful management of TN is based on teamwork between the dental provider and the neurological team. Dental hygienists are an important role on the dental team because they can adjust dental appointments to meet the patient's needs, providing a more positive experience. Patients benefit when hygienists provide appropriate oral hygiene advice and can easily implement it at home to manage TN.

Editor’s note: This article appeared in the November/December 2023 print edition RDH Magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.

refer to

  1. Trigeminal nerve. Cleveland Clinic. Updated June 14, 2021.
  2. Trigeminal neuralgia. Johns Hopkins Medicine. Date viewed: July 3, 2023.
  3. Pilitsis JG, Khazen O. Trigeminal neuralgia. American Association of Neurological Surgeons. Date viewed: July 13, 2023.
  4. Why trigeminal neuralgia is considered a suicidal disease. Arizona Pain. Updated September 26, 2021.
  5. McKinney S, Whittington KD, Collins SK. Care strategies for patients with trigeminal neuralgia. Dental Decisions. June 15, 2021.
  6. Tripathi M, Sadashiva N, Gupta A, et al. Please spare my teeth! Dental surgery and trigeminal neuralgia. Surg Neurol International. 2020;11:455. doi:10.25259/SNI_729_2020

Melissa Van Witzberg, MS, RDH, I have been engaged in dental hygiene for 20 years. She continues to pursue her passion by educating the geriatric population on oral health and systems connection. Melissa has also practiced clinically in periodontal clinics in the Chicago area and is a key opinion leader for HuFriedyGroup. Contact her: [email protected].

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