TMJ vs Trigeminal Neuralgia

A 32 year old female bank officer recently visited our clinic and reported an acute onset of severe facial pain extending from her right lower jaw region and temporomandibular joint region as well as numbness in the lower jaw, severe headache and intermittent right eye pain.

She described the pain as piercing and sharp and lasting up to 30 minutes of acute short-lived stabs. The onset of pain was sudden while sleeping 24 hours prior to her consultation. She could not recall a precipitating event but did some heavy lifting over the weekend and had her wisdom teeth removed four and two weeks previously which made it necessary to keep her mouth open for long periods. She had been treated in the past at our clinic for neck pain and cervicogenic headache. Her local doctor had prescribed analgesics for her pain and gave her time off work.

Sensorary distribution of the trigeminal nerve V1 opthalmic, V2 Maxillary, V3 Mandibular

On examination she was obviously distressed but had a good range of cervical movement. The temporomandibular joint was extremely tender on the right and she had restricted mouth opening with deviation of the lower jaw to the right. She also had increased tension in the masseter muscle and upper cervical stiffness on both sides with tension in the suboccipital muscles.

The analgesics had eased her pain by 40% at night but chewing and hot and cold foods increased her pain levels. The headache persisted but was eased by her medication. I treated the temporomandibular joint with gentle posterior anterior pressures, reduced tension in the masseter muscle and mobilised the upper cervical spine.

The pain continued and she went to the emergency department of a local hospital and a diagnosis of trigeminal neuralgia was made. The doctor prescribed Carbamazepame, which is an anti convulsant drug useful in treating neuralgia. The pain eased significantly but she still had signs of TMJ and upper cervical dysfunction. I asked her to call her dentist to discuss the impact of her recent surgery.

I contacted a colleague who specialises in dental surgery and TMJ dysfunction and asked about mechanical causes of trigeminal neuralgia. He explained that trigeminal neuralgia is a demyelination type disorder with compromised blood supply. The anti convulsant medication improves the blood supply to the nerve and decreases the irritability. He did not feel there was a link between mechanical pressure on the mandibular branch of the trigeminal nerve by the TMJ: rather the TMJ signs were coexisting rather than causal.

The importance of this case history suggests that the presentation of severe short lived lancinating pain in the region of the trigeminal nerve distribution is strongly suggestive of trigeminal neuralgia rather than mechanical, temporomandibular or upper cervical dysfunction.

The effectiveness of the prescribed medication is a confirmatory sign that the injury is due to the nerve primarily. If the symptoms are severe and acute the appropriate course of action is referral to the local doctor or emergency hospital department immediately. This condition can cause debilitating pain and needs to be addressed promptly.