Hindawi Publishing Corporation

BioMed Research International

Volume 2014, Article ID 563786, 7 pages
http://dx.doi.org/10.1155/2014/563786

Review Article
Differential Diagnostics of Pain in the Course of Trigeminal
Neuralgia and Temporomandibular Joint Dysfunction

M. Pihut,1 M. Szuta,2 E. Ferendiuk,1 and D. ZeNczak-Wiwckiewicz3

1
Department of Dental Prosthetics, Consulting Room of Temporomandibular Joint Dysfunctions,
Medical College, Jagiellonian University, 4 Montelupich Street, 31-155 Krakow, Poland
2
Cranio-Maxillofacial Surgery, Medical College, Jagiellonian University, 1 Zlotej Jesieni Street, 31-826 Krakow, Poland
3
Department of Dental Surgery, Wroclaw Medical University, 26 Krakowska Street, 50-425 Wroclaw, Poland

Correspondence should be addressed to M. Pihut; pihut [email protected]

Received 29 March 2014; Accepted 20 May 2014; Published 4 June 2014

Academic Editor: Mieszko Wieckiewicz

Copyright © 2014 M. Pihut et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Chronic oral and facial pain syndromes are an indication for intervention of physicians of numerous medical specialties, while
the complex nature of these complaints warrants interdisciplinary diagnostic and therapeutic approach. Oftentimes, lack of proper
differentiation of pain associated with pathological changes of the surrounding tissues, neurogenic pain, vascular pain, or radiating
pain from idiopathic facial pain leads to improper treatment. The objective of the paper is to provide detailed characterization of
pain developing in the natural history of trigeminal neuralgia and temporomandibular joint dysfunction, with particular focus on
similarities accounting for the difficulties in diagnosis and treatment as well as on differences between both types of pain. It might
seem that trigeminal neuralgia can be easily differentiated from temporomandibular joint dysfunction due to the acute, piercing,
and stabbing nature of neuralgic pain occurring at a single facial location to spread along the course of the nerve on one side,
sometimes a dozen or so times a day, without forewarning periods. Both forms differ significantly in the character and intensity of
pain. The exact analysis of the nature, intensity, and duration of pain may be crucial for the differential diagnostics of the disorders
of our interest.

1. Introduction sensations. Nociceptor excitability depends on physical stim-

uli, physiochemical milieu, and the quantities of endogenous
According to the definition provided by the International pain substances being secreted [2–6]. Factors such as micro-
Association for the Study of Pain, pain is a subjectively circulation, dysregulation of the sympathetic nervous system,
unpleasant and negative sensory and emotional experience and excessive muscle tone affect the activity of pain receptors.
occurring following activation of nociceptive stimuli that The process of the development of pain sensation is known as
damage the tissue. The character of pain depends on its nociception and consists of four stages: transduction, trans-
location, type of dysfunction of the particular region, and mission, modulation, and perception. Nociceptive stimuli are
stage of the disease. It is also an observation made during transmitted by the neuronal route of the posterior spinal horn
mental interpretation of associated phenomena. Although and by the spinothalamic routes to cortical centers where
pain is associated with unpleasant sensations, it also plays a perception of pain sensations occurs [1, 2].
positive forewarning and protective role. Pain is an extremely The objective of the paper is to provide detailed character-
complex neurophysiological process [1–12]. It appears as ization of pain developing in the natural history of trigeminal
the result of a damaging stimulus and the effect of tissue neuralgia and temporomandibular joint dysfunction, with
hormones (serotonin, bradykinin, histamine, leukotriene, particular focus on similarities accounting for the difficulties
and accumulation of hydrogen ions) on nociceptors, that is, in diagnosis and treatment as well as on differences between
receptors specialized in the reception of pain and discomfort both types of pain.
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2 BioMed Research International

2. Craniofacial Pain organs differ in their natural frequencies (8–12 Hz for the
head). The nerve is immersed in the cerebrospinal fluid that
Chronic oral and facial pain syndromes are an indication for transmits the vibrations of the surrounding structures [5, 9].
intervention of physicians of numerous medical specialties, The increase in the amplitude of vibrations damages the
while the complex nature of these complaints warrants permeability of ion channels, leading to nerve injury. The
interdisciplinary diagnostic and therapeutic approach. The disorder is characterized by recurrent, paroxysmal attacks of
incidence of oral and facial pains is estimated at 10% in sudden, intense, and piercing pain within the region supplied
adults and 50% in elderly patients. Oftentimes, lack of by the trigeminal nerve, comparable to an electric shock [5–
proper differentiation of pain associated with pathological 7, 9–19, 30].
changes of the surrounding tissues, neurogenic pain, vascular It might seem that trigeminal neuralgia can be easily
pain, or radiating pain from idiopathic facial pain leads to differentiated from temporomandibular joint dysfunction
improper treatment. Diseases that involve significant pain, due to the acute, piercing, and stabbing nature of neuralgic
when inappropriately treated, lead to the reduction in the pain. It should be mentioned that neuralgia may be of either
quality of life and to the development of depressive disorders spontaneous (primary) or symptomatic (secondary) form.
[2–14]. Both forms differ significantly in the character and intensity
Of the important data provided in medical interviews, of pain. Unexplained etiology of spontaneous neuralgias
particular attention should be drawn to the time of the onset of the second and third branch of the trigeminal nerve
of pain, pain location and characteristic, intensity, frequency is a cause of significant therapeutic problems [1–8, 10–15].
and factors that enhance or reduce the intensity of pain. Also Both branches may also be affected at the same time. The
important is the radiation of pain to the surrounding organs incidence is 1 in 15,000 cases. The acute, paroxysmal, and
of anatomical structures [1–15]. piercing pain occurs at a single facial location to spread
Pain within the craniofacial area is one of the most along the course of the nerve on one side, sometimes a
important reasons why patients present at the dentist’s office dozen or so times a day, without forewarning periods. Pain
[2–11]. Odontitis, periodontopathies, alveolar osteitis, nerve episodes may last several seconds to several minutes. As the
injuries, atypical facial pains, neoplastic lesions, elongated disease progresses, the number of episodes increases and the
styloid process syndrome (Eagle’s) syndrome, and reflex sym- remission periods become shorter. The pain is intensified
pathetic dystrophy of the face should be taken into account. during facial muscle and mandibular movements. Primary
Common causes of pain include trigeminal neuralgia (most neuralgia is often accompanied by facial muscle contractures
commonly of the third branch of the trigeminal nerve, (tic douloureux), increased salivation, lachrymation, running
nose, and skin redness. Stimuli that most commonly cause
i.e., the mandibular nerve) and temporomandibular joint
the pain are trivial and everyday causes such as wind gusts,
dysfunction. In the differential diagnostics of facial pains,
sudden changes in air temperature, bright light, sharp sounds,
disease duration of several months or several years required
or delicate touch (e.g., shaving in males). A typical feature of
unified diagnostic criteria with consideration of nontypical these disorders is the unilateral occurrence of pain and lack
cases. In the therapy, we use various methods of treatment of complaints during the night’s sleep [3, 5, 7, 9–13, 15].
such as medication, surgery, dental prosthetic, physiotherapy,
In contrast to the spontaneous neuralgia, its symptomatic
and psychological support [2–36].
(secondary) form is associated with pain that increases grad-
ually, has different nature, and persists with no interruptions.
The pain becomes intensified in heat. It may be a result of
3. Trigeminal Neuralgia numerous local or generalized causes (odontitis, cysts, sharp
socket edges, tumors within the mouth, and the maxillo-
Neuralgia is a symptom of nerve dysfunction present within ethmoidal massif, disorders of the maxillary sinuses or the
the brain stem or within the nerve segment running to the middle ear). Neuralgia of this type may be a symptom of
trigeminal ganglion located within the base of the middle numerous diseases within the region of the posterior cranial
cranial fossa. The disorder is most common in patients fossa, such as basal tumors or cerebellopontine angle tumors.
over 60 years of age and more common in women. Main This type of neuralgia may also be observed in alcohol,
etiological factors responsible for neuralgia include vascu- mercury, or nicotine intoxication [8–13, 15, 18, 30].
loneural conflict consisting in compression of the nerve by
Symptomatic neuralgia should be differentiated from
blood vessels at the site of neural connection to the brain
causalgia which may be due to the traumatic injury of nerve,
stem, within the region of the superior cerebellar artery, the
particularly maxillary nerve, or mandibular nerve within the
basilar artery, the vertebral artery, and the petrosal vein.
In addition, neuralgia may be a result of head injuries facial region. Causalgia may develop as a result of contusion,
or inflammation of nerve within the myelin sheath. The fracture, or surgical intervention in this region. As shown by
disorder may also be associated with other diseases such as the characteristic of pain, primary neuralgia is substantially
multiple sclerosis (formation of demyelinating plaque in the different from the secondary form. Therefore, the pain asso-
brain) or tumors that compress the nerve and disturb its ciated with the temporomandibular joint dysfunction may
function [4, 8–17, 23]. According to the most recent theory have a characteristic that is similar to the secondary neuralgia
of magnetic bioresonance, trigeminal nerve starts oscillating and may pose significant difficulties in differential diagnostics
at amplitudes that exceed its natural frequency. The human [4, 5, 8–10, 13, 14].
 2738, 2014, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2014/563786 by INASP/HINARI - PAKISTAN, Wiley Online Library on [07/12/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BioMed Research International 3

Table 1: Differential characteristics of pain in the course of trigeminal neuralgia and temporomandibular joint dysfunction.

Common features of pain in trigeminal Differential characteristics of pain in the course of trigeminal neuralgia and
neuralgia and temporomandibular joint temporomandibular joint dysfunction
dysfunctions Trigeminal neuralgia Temporomandibular joint dysfunctions
Increase in pain as a result of activity of
Unilateral location of pain (97%) Bilateral pain
facial or masticatory muscles
Possibility of pain being located on one Characteristics of pain: acute and Characteristics of pain: continuous and
side of the face stabbing dull
Remission of the neuralgic pain during
Possibility of otolaryngological symptoms Pain may still be present during the nights
nights
Significant reduction in patients’ quality The duration of pain: very short, lasting
The duration of pain: long-lasting
of life and the development of depressive several seconds to several minutes with
(several hours) with short intermissions
disorders long periods of remission during the day
Pain accompanied by facial muscle
Pain being radiated into the neighboring
convulsions (tics), skin redness, Lack of such symptoms
regions
lachrymation

4. Temporomandibular Joint Dysfunction the soft tissue. Lack of coordination of mandibular head and
disc is manifested by acoustic symptoms within the tem-
According to WHO report, temporomandibular joint dys- poromandibular joints, such as popping and cracking sounds
function is the third stomatological disorder to be considered upon mandibular movements. At advanced stages of disc
a populational disease, after dental caries and periodontal translocation and blockade, acoustic symptoms disappear to
diseases. Temporomandibular joint dysfunction consists in be replaced by chronic pain and significant restriction of jaw
a spectrum of changes disturbing the morphological and opening range, complicated by tilting the mandible towards
physiological balance within the musculoskeletal system. The the affected side upon abduction. Temporomandibular pains
nature of these changes is determined by psychoemotional, may also be the result of prolonged overload of articu-
environmental, and genetic factors. The changes include lar structures of high intensity, exceeding the adaptational
abnormalities in the relationship between opposing teeth, capabilities of the collagen fibers within the posterior disc
and the function of the muscles of the frontal and medial ligament, which are commonly subject to fragmentation.
part of the skull and neck, working in a symmetrical manner The nature of the pain observed in temporomandibular
in physiological conditions of the temporomandibular joints. joint dysfunction is similar to that in the symptomatic form
Increasing stress levels lead to intensification of adverse of neuralgia and significantly different from that in the
motion habits within the stomatognathic system and the spontaneous neuralgia [2, 15–28].
rapid increase in the number of patients observed in recent
years is associated with the drop in the age of patients with 5. Common Features of Both Types of Pain
dysfunctions manifested with pain symptoms [14, 15, 17, 18].
Functional disorders of the masticatory organ are Pains sensations experienced in trigeminal neuralgia and
pathologies of diverse etiology [2]. The incidence of the temporomandibular joint dysfunction have both common
painful form of the disorders is estimated at about 30% of all features and significant differences (Table 1). Common fea-
cases. Most commonly, pain is located within the temporo- tures include pain being radiated into the neighboring
mandibular joint region or, less commonly, the masticatory regions, and even to distant structures, possibility of pain
muscles (myalgia). It may range from slight tenderness to a being located on one side of the face, increase in pain as a
very strong discomfort. The pain is either acute and stab- result of increased activity of facial or masticatory muscles
bing or chronic, diffuse and radiating into the neighboring and the possibility of otolaryngological symptoms (earache
structures, that is, eyes, ears, temples, and occiput. It is not and hearing impairment) [16]. In addition, the diffuse pain
associated with inflammation; the intensity of muscle pain that lasts for many months in both cases may lead to
is closely related to excessive functional activity of particular significant reduction in patients’ quality of life and to the
muscle groups during occlusal parafunctions. Overburdened development of depressive disorders. Compared to primary
muscles are characterized by hypoxia and ischemia and thus neuralgia, pain experienced in secondary neuralgia is much
with the release of allogeneic substances that determine the more similar to that observed in functional disorders [2, 15,
resultant pain, such as bradykinin or prostaglandins. Muscle 17–20].
tenderness is a source of deep pain and may lead to protective
contractures [2–5, 18, 19]. 6. Differences in the Characteristics of Pain
The articular pain is a result of damage to articular sur-
faces, degeneration, injuries of articular capsule, or damage Features differentiating both nosocomial entities include
of retrodiscal tissue. Arthralgia may develop only as a result unilateral location of pain in neuralgia (97%) and bilateral
of impulsation originating from nociceptors located within pain in myalgia. Also the nature of pain is different, being
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4 BioMed Research International

Medical anamnesis and examination

MRI

Classical trigeminal neuralgia Symptomatic trigeminal neuralgia

Pharmacological treatment Surgical treatment

Surgical treatment

Microsurgical Ablative surgery

decompression:
1st choice treatment

Figure 1: Diagnostic and therapeutic management of patients suffering from trigeminal neuralgia.

acute and stabbing in neuralgia and continuous, dull in means of neural blockades of the terminal trigeminal nerve
temporomandibular joint dysfunction. Night’s rest is a period branches using lidocaine or bupivacaine solutions (Figure 1).
of remission of the neuralgic pain, while temporomandibular The next step consists in surgical treatment; however, the use
joint pain may still be present in this period in case of of surgical methods, even in the form of minor procedures
functional disorders [13–16]. The duration of pain is also such as neurotomy or exeresis, requires that the patient
different: the neuralgic pain is very short (lasting several should be qualified for the surgery by both internal medicine
seconds to several minutes), with long periods of remission specialist and anesthesiologist which constitutes a major
during the day, while the dysfunctional pain is long-lasting problem, considering the commonly elderly age of patients
(several hours) with short intermissions. Pain episodes in combined with significant burden of concomitant diseases
spontaneous neuralgia are induced by triggering stimuli [10, 36–39, 42].
which are usually the same in particular patient. Patients tend The latest method is stereotactic surgery/gamma knife,
to avoid these stimuli and are afraid of them. If neuralgia making use of electromagnetic gamma radiation from cobalt
episodes are induced by chewing, patients fast deliberately, 60
Co isotope sources, corpuscular radiation of protons of
which leads to secondary and multiplanar somatic disorders. heavy carbon ions, or electromagnetic X radiation gener-
Neuralgic pains are often accompanied by facial muscle ated by linear accelerators. The method was developed by
convulsions (tics), skin redness, lachrymation, which are professor Lars Leksel and has been known since 1967. The
not observed in temporomandibular joint dysfunction. In method consists in precise delivery of radiation from 192
neuralgia, pain is intensified by heat, while being alleviated collimator sources into intracranial pathological lesions using
in myalgia [2–5, 9–35]. stereotactic techniques. The first stage of the procedure is
Thanks to the development of neurophysiological exam- the placement of stereotactic frame on patient’s head using
inations, magnetic resonance imaging, cerebral angiography, special screws in local anesthesia. The patient is placed
and clinical symptoms, trigeminal neuralgia may be correctly within a gamma knife apparatus, where the irradiation spot
diagnosed while excluding other causes for paroxysmal facial location and dose magnitude is determined on the basis
pains. The exact analysis of the nature of pain may be crucial of magnetic resonance scan results and the location of the
for the differential diagnostics of the disorders of our interest lesion. The usual dose is 90 Gy and is absolutely safe for
[3, 10, 22, 36–48]. tissues permeated by radiation. Irradiation lasts about 30
Despite similarities of pain symptoms in both types of minutes. Factors taken into consideration when qualifying
pathologies, therapeutic management is different in both patients for the treatment include the type, size, and location
cases. In trigeminal neuralgia, treatment involves conserva- of lesions. Radiosurgery techniques have witnessed an enor-
tive and more or less invasive methods. Usually, the treatment mous technological progress. At the same time, a model of
is commenced carbamazepine (100 to 1000 mg/day) phar- multidisciplinary teams of oncologists, radiotherapists, neu-
macotherapy, in some cases combined with anticonvulsants rosurgeons, and other medical specialties has been developed
(phenytoin, clonazepam). One should also keep in mind the for the radiosurgery purposes. The efficacy of stereotactic
ability to achieve long-term remission of neuralgic pains by radiosurgery is estimated at 80–90%. Due to the minimum
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BioMed Research International 5

invasiveness of the procedure, it is the method of choice in interdisciplinary diagnostic and therapeutic approach. The
elderly patients or patients with high concomitant disease precise analysis of characteristic features of pain, its intensity,
load [42, 49]. and duration may be crucial for the differential diagnostics
Due to the poor availability of this treatment in Poland, of trigeminal neuralgia and functional disorders of the
microvascular decompression (MVD) technique is still in masticatory apparatus [2–4, 8, 13–15, 19, 50–53].
use, consisting of craniotomy followed by elimination of the
vasculoneural conflict by means of separating the problem- Conflict of Interests
atic artery or vain from the nerve using autogenic (muscle
fragment) or alloplastic (teflon, goretex) material [5, 8, 10, 14, The authors declare that there is no conflict of interests
32]. regarding the publication of this paper.
The natural history of temporomandibular joint dysfunc-
tion most commonly involves changes in the biomechanics of
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