From the Guidelines
Trigeminal neuralgia affecting the lower jawline that seems to originate from a molar is typically caused by dental issues, nerve compression, or inflammation, and the most recent evidence suggests that addressing the underlying cause, whether dental or non-dental, is crucial for effective management 1. The most common dental causes include:
- Tooth infections (abscesses)
- Cracked teeth
- Failed root canals
- Periodontal disease that irritates the mandibular branch of the trigeminal nerve Non-dental causes may include:
- Compression of the trigeminal nerve by blood vessels, tumors, or cysts near the nerve pathway
- Multiple sclerosis affecting the nerve's myelin sheath
- Trauma to the jaw or face Initial treatment often includes medications like carbamazepine (200-400mg twice daily) or oxcarbazepine (300-600mg twice daily) to reduce nerve pain, as recommended by international guidelines and Cochrane reviews 1. For dental-related causes, addressing the underlying dental problem is essential - this might require:
- Root canal therapy
- Extraction of infected teeth
- Treatment of periodontal disease If medication and dental interventions fail, surgical options like microvascular decompression or gamma knife radiosurgery might be considered, with microvascular decompression being the only non-ablative technique that provides the best rates of long-term complete pain relief and preservation of facial sensation 1. The connection between dental problems and trigeminal neuralgia occurs because the mandibular branch of the trigeminal nerve provides sensation to the lower teeth, gums, and jaw, making it susceptible to irritation from dental pathology that can trigger the characteristic shooting, electric-like pain of trigeminal neuralgia, and recent studies emphasize the importance of imaging the entire course of the trigeminal nerve to evaluate for a causative lesion 1.
From the Research
Causes of Trigeminal Neuralgia
- Trigeminal neuralgia (TN) is a disorder characterized by repetitive lancinating pain along one or more branches of the trigeminal nerve, commonly triggered by chewing and manipulation of the gums 2.
- The etiology of TN can be classified into idiopathic, classic, and secondary, with classic TN associated with neurovascular compression in the trigeminal root entry zone, leading to demyelination and dysregulation of voltage-gated sodium channel expression 3.
- Most cases of TN are caused by compression of the trigeminal nerve root, usually within a few millimeters of entry into the pons, while a few cases are caused by a primary demyelinating disorder 4.
- TN often presents in the lower trigeminal divisions, and dental causes need to be eliminated in the initial presentation, as it frequently presents with symptoms similar to dental issues 5.
- Neurovascular compromise is the most currently accepted theory of TN pathogenesis, with minimal stimulation caused by light touch, talking, or chewing leading to debilitating pain and incapacitation of the patient 6.
Triggers and Characteristics
- The pain description is characteristic of electric shock-like pain that is light-touch provoked, paroxysmal, and occurring daily, with the condition able to go into remission for weeks or months 5.
- TN is rare, affecting 4 to 13 people per 100,000, and is characterized by recurrent attacks of lancinating facial pain in the dermatomal distribution of the trigeminal nerve 6.
- Pain may occur sporadically, though is primarily unilateral in onset, and the diagnosis is typically determined clinically 6.
Relationship to the Lower Jawline and Molar Tooth
- The second and third divisions of the trigeminal nerve are most commonly affected, which includes the lower jawline and the area surrounding the molar teeth 2.
- Patients with TN may initially consult their dentist due to symptoms similar to dental issues, and may receive unnecessary dental treatment, including extractions, root canal treatments, and implants 2.