Why the diagnosis matters

Toothache, stabbing sensations, burning, pressure, numbness and aching can overlap in the way people describe them. Their causes, however, may be very different. The pattern of pain, duration of attacks, findings on examination and any changes in sensation all matter.

Trigeminal neuralgia (TN) typically produces abrupt, severe, electric shock-like attacks, often triggered by light touch or ordinary activities such as eating or washing. Some people also have a more continuous background pain. A dentist or doctor must still consider dental disease and other diagnoses when the symptoms do not fit.

Clinical expertise and patient experience

Professor Fedele’s clinical and research work encompasses oral medicine and chronic facial pain. Aneeta brought the perspective of someone living with bilateral trigeminal neuralgia, as well as her experience leading a national patient charity and working to improve awareness and support.

Different causes of persistent facial pain

1. Pain in a tooth that may not come from the tooth

Persistent idiopathic dentoalveolar pain can be experienced as continuing pain in a tooth, an extraction socket or the surrounding area when appropriate examination and investigations find no identifiable local cause.

Painful post-traumatic trigeminal neuropathy is a different condition, associated with nerve injury and clinical evidence of altered sensation or trigeminal nerve dysfunction. Persistent pain after root canal treatment or extraction does not by itself prove nerve injury. These distinctions need professional assessment.

2. Persistent idiopathic facial pain

Persistent idiopathic facial pain (PIFP) is typically ongoing and poorly localised, and does not follow the precise path of a peripheral nerve. Dental causes and other possible explanations need to be assessed appropriately. Pain is no less real because imaging is normal or no visible injury is found.

3. Burning mouth syndrome

Burning mouth syndrome can cause burning, scalding or stinging sensations affecting the tongue or elsewhere in the mouth, despite a normal-looking oral lining. Other causes of oral burning — such as infection, dryness, medicines, nutritional deficiencies or systemic illness — should be considered before diagnosing primary burning mouth syndrome.

Researchers are investigating changes to small sensory nerve fibres and pain processing in some patients. These ideas are still developing; there is no single diagnostic test or universally effective treatment.

4. Temporomandibular disorders and muscle pain

Temporomandibular disorders (TMD) and myofascial pain may produce discomfort around the jaw, temples and ear, sometimes worse when chewing or moving the jaw. Assessment should consider muscles, joints and other possible causes. Clenching or grinding may be relevant, but cannot explain every case. Treatment is often conservative and individualised.

5. Other possibilities

Headache disorders, sinus or oral disease, nerve-related pain, and less common conditions can sometimes be confused with TN or toothache. A clinician may need to involve oral medicine, dental specialists, neurology or other services. Ongoing symptoms should not automatically be assigned to a single diagnosis without adequate investigation.

Questions to take to your appointment

• What clinical features support the suggested diagnosis?
• If the pain is felt in a tooth, what evidence shows that the tooth itself is responsible?
• Do I have short attacks, continuous pain or both — and why is that relevant?
• What other explanations have been considered, and are any tests needed?
• Would referral to oral medicine, neurology or a specialist facial pain service help?
• What are the expected benefits and risks of the treatment being suggested?

Psychological support or pain management strategies can be useful alongside physical assessment and treatment. That does not mean the pain is imagined.