Chronic Pain

 

Dental/Oral Conditions seen frequently which can cause chronic pain:

Non-Dental conditions which can cause pain in the teeth or oral structures.

Infrequently seen painful conditions

Trigeminal Neuralgia

This very painful condition typically manifests itself as sharp, electric, lightning-bolt pain in the face, which can be triggered by touching the face, by a puff of wind, or it may come on spontaneously. It may be regular or very sporadic. True trigeminal neuraldia seems to be associated at times with pressure against the trigeminal nerve near its exit from the skull.

Atypical Facial Pain

This type of pain is more difficult to characterize, and depending upon the method of classification used may have several sub-categories, such as myofascial pain, idiopathic pain, and other types of rare pain. Idiopathic means that the cause is unknown.

Neuralgia Inducing Cavitational Osteonecrosis (NICO)

Also known as ischemic necrosis, and formerly referred to by some as non-suppurative osteomyelitis, this condition is becoming more well known and better understood, as ongoing research is conducted. NICO is described in Oral and Maxillofacial Pathology, by Neville, Damm, Allen, and Bouquot. This is the textbook most frequently used in dental schools in the United States.

Symptoms may include severe pain in the face, behind the eyes, or even around the top, sides, or back of the head. In the case of NICO, this pain is referred from some area in the jawbones, either upper (maxilla) or lower (mandible).

Ischemic necrosis of mandible from cadaver

The actual source of disease may be traced to abnormal bone, often where a tooth has been extracted earlier. Due to poor healing, pathogenic bacteria, suppressed immune system, clotting disorders, or a combination of these, the nerves in these areas can react in highly unusual ways, causing excruciating pain in areas seemingly unrelated to the source. For example, a NICO defect in the lower back jaw may cause a burning pain on the side or the top of the head. The clinical appearance of the diseased area may seem normal, and radiographs do not always show these pockets in the bone, due to the nature of density variations between inner and outer bone and the way in which radiographs are typically exposed. Certain tests may be performed to determine if an area of NICO exists and where it is located. Surgical exposure of the site of ischemic necrosis will reveal dead bone and poor healing, with seldom any trace of pus. Examination of the excised tissue from such sites shows a unique appearance under the microscope.

Many patients who are determined to have ischemic necrosis of the jawbones may receive some relief from the surgical debridement of the bony lesion, with subsequent re-evaluation and retreatment as necessary. Actual treatment modalities vary, as do results.

Frequently this disease is not identified until the patient has exhausted all other avenues of relief, with no discovery of the source of the problem, until eventually the patient is told the pain does not exist, or until they come upon someone familiar with this rare anomaly.

Dr. Getty first encountered NICO when his father was successfully treated for it in 1981. After graduating from dental school, Dr. Getty continued his interest in this malady. He has experience with treating numerous NICO/ischemic necrosis patients both locally and from as far away as New England, Florida, and even Brazil. He has given testimony as an expert witness before the Superior Court of Washington, DC.

If you have unexplained head or face pain, and have already been determined to be free from known dental disease, such as cavities or abscesses, sinusitis or TMJ, you need to be sure to rule out a central problem, such as a brain tumor or arterial pressure on a nerve inside the skull. This requres a referral to a neurologist and should be done prior to exploring for any NICO lesion(s). The neurologist will undoubtedly order an MRI and/or CAT scan. If this is negative, and no other source of pain can be identified, please feel free to contact our office for an evaluation. A full examination, necessary radiographs, and in-office tests can be performed. This usually takes about 1-2 hours. Treatment will vary on a case by case basis. If you have been seen by multiple practitioners in the past, it is good to bring a concise summary of all such previous evaluations and treatments, as is relates to the pain problems you have had.

NICO has been identified most often in areas of previous extraction(s), but has also been seen in areas of failed root canals or in sinus infections which perforate into the maxilla. Often the pain will not occur until years, even decades after the initial extraction or root canal. Antibiotic therapy alone may temporarily decrease pain but seldom alleviates the underlying cause.