Trigeminal neuralgia: diagnosis delay and unnecessary dental procedures in the brazilian public health system

Abstract

Trigeminal neuralgia (TN) is a debilitating neuropathic pain condition characterized by brief, recurrent paroxysms of intense, electric shock-like pain, triggered by light stimuli within the distribution of the trigeminal nerve. Although the symptoms are distinctive, TN is frequently misinterpreted as odontogenic pain, leading to inappropriate dental interventions before the correct diagnosis is made.

Aim  to identify the first healthcare professional consulted by patients with TN, evaluate the number of unnecessary dental procedures performed, and determine the time elapsed between symptom onset and correct diagnosis among patients referred to a tertiary public university center.

Methods  Seventy-eight patients fulfilling clinical criteria for TN were included. Data were collected using a standardized questionnaire administered during consultation.

Results  The mean patient age was 66 ± 10.9 years. The maxillary (V2) and/or mandibular (V3) branches were affected in 82% of cases, with dentists being the first professionals consulted. In contrast, when the ophthalmic (V1) or combined V1–V2 branches were involved, patients more frequently sought physicians. This difference was statistically significant (p=0.019). Overall, 52 patients (87%) underwent unnecessary dental treatments, mainly extractions. A positive correlation was observed between diagnostic delay and the number of extractions performed (r=0.309; p=0.040). No significant associations were found between diagnostic timing and age, sex, pain characteristics, or first professional consulted. Nevertheless, patients diagnosed within 12 months were 80% less likely to have undergone dental extractions.

Conclusions  These results highlight the persistent underdiagnosis of TN and the urgent need for ongoing education and awareness among dental and primary healthcare professionals.

Keywords
Trigeminal neuralgia; Facial pain; Treatment outcome; Humans

Introduction

Trigeminal neuralgia (TN) is a serious health problem characterized by severe paroxysms of electric, shock-like pain limited to one or more divisions of the trigeminal nerve. It is commonly evoked by trivial stimuli such as chewing, talking, wind, cold, and light touch, but it frequently occurs spontaneously¹. Spontaneous remission lasting months or years occurs in most patients.

The pathophysiology of TN remains a matter of debate. Currently, there is considerable evidence demonstrating that classical TN is caused by focal demyelination of the trigeminal sensory fibers within the nerve root or, less commonly, the brainstem. Demyelination mostly involves the trigeminal root-entry zone due to chronic compression by an overlying artery or vein. Such segmental demyelination leads to the generation of abnormal impulse transmission (ephaptic transmission) in which non-noxious stimuli abnormally activate the neighboring pain fibers². Occasionally, however, TN is caused by an underlying disease (secondary TN) such as tumors, multiple sclerosis, or arteriovenous malformation.

Although the identification of TN patients is based on well-defined criteria, the diagnosis is based entirely on the patient’s history. In some cases, there are difficulties in establishing the proper diagnosis, especially due to the scarcity of objective diagnostic tests and the wide range of facial pain syndromes. With TN showing a prevalence rate of 0.3%³ in earlier studies and an incidence varying from 4-29 patients for every 100,000 inhabitants in more recent studies⁴,⁵, individual practitioners in medicine and dentistry may encounter very few cases of TN in their careers. The rarity of the cases contributes to the high rates of misdiagnosis and inappropriate treatment⁶. Patients approach several healthcare professionals prior to referral to a specialist clinic, and many of them experience pain for several years before receiving an accurate diagnosis. TN is often misdiagnosed, being commonly confused with toothache or temporomandibular disorders, with reports of patients undergoing unnecessary, aggressive, and irreversible dental treatments before being diagnosed correctly⁷-⁹. However, the rates of misdiagnosis and inappropriate treatments have been analyzed in few publications over time, especially concerning the Brazilian population where data are scarce¹⁰-¹⁴.

This study aimed to evaluate the first healthcare professional sought by the patients, the number of unnecessary dental procedures performed, and the time elapsed between the onset of TN and the correct diagnosis and treatment, in patients referred to a tertiary public university center. Clinical characteristics of this cohort were also analyzed.

Material and Methods

We included all consecutive patients visiting the neurosurgical division of Pedro Ernesto University Hospital with the diagnosis of TN, confirmed by two independent specialists, according to the ICHD-3 criteria¹, from April 2018 to December 2020. All patients had an MRI to exclude a symptomatic cause and identify potential neurovascular compression, some of which had been done prior to referral¹⁵. The exclusion criteria were psychiatric illnesses, inability to provide reliable information, and secondary TN. The number of patients in the study period determined the sample size. During the consultations, a standard questionnaire was used to collect information regarding the (i) clinical characteristics; (ii) age of onset of symptoms and time elapsed until the diagnosis and characterization of pain; (iii) type of professional sought initially and the type and number of unnecessary dental procedures performed until confirmed diagnosis; and (iv) treatments performed after diagnosis and medication. All dental procedures performed after the onset of typical TN symptoms that did not result in any improvement of TN pain were considered unnecessary. This study was approved by the Institutional Review Board (Protocol Number 1.813.961).

Statistical Analyses

Continuous data, such as age, were summarized using descriptive statistics. Categorical variables were presented as frequency distributions (n, %). The frequency was analyzed using the Fisher’s exact test. Spearman’s correlation was used to examine the relationship between the time elapsed between the first symptom and the TN diagnosis and the number of teeth extracted per patient. Time-to-diagnosis analyses were conducted to identify factors associated with diagnostic delay in trigeminal neuralgia. The cumulative probability of remaining undiagnosed over time was estimated using Kaplan–Meier curves, and differences between groups were compared using the log-rank test.

To identify independent predictors of diagnostic timing, a multivariable Cox proportional hazards regression model was fitted employing the Efron method for ties. The event of interest was receiving a diagnosis; therefore, hazard ratios (HR) greater than 1 indicated a shorter time to diagnosis, whereas HR values below 1 reflected a longer diagnostic delay. The mediation model incorporated age, sex, presence of paroxysmal pain, involvement of the V1 region, and the first professional consulted (dentist versus physician).

As a sensitivity analysis, the diagnostic interval was dichotomized (≤12 months versus >12 months after symptom onset) based on the Kaplan–Meier distribution. Subsequently, a multivariate logistic regression model was applied to examine whether early diagnosis was associated with a reduced likelihood of unnecessary tooth extraction, adjusting for the same covariates Figure 1. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated, and statistical significance was established at p < 0.05.

Figure 1
Relationship between the pain location and the first healthcare provider consulted by patients with trigeminal neuralgia (TN, trigeminal neuralgia; V1, ophthalmic branch of the trigeminal nerve; V2, maxillary branch of the trigeminal nerve; V3, mandibular branch of the trigeminal nerve).

The Stata Statistical Software Version 17 /2021 (Stata Corporation. College Station, TX) was used for statistical analyses.

Results

This study included 78 patients (54 females and 24 males, ratio 2.2:1) with a mean age of 66 years (range, 39-84 years). TN affected the maxillary (V2) and/or mandibular branch (V3) of the trigeminal nerve in 82% of cases. The right side was affected in 42 patients (53.8%). Without treatment, TN was considered the worst pain the patients had felt and the intensity was scored as 10/10. TN was best described as shock-like pain in 71 patients (91%). It was purely paroxismal in 68 patients (87%) and with concomitant continuous pain in 10 (13%). The majority of the patients (98%) reported TN triggering factors, the most frequent were chewing, touch, talking, shaving and brushing teeth. Forty-nine patients (63%) had extra-oral cutaneous trigger zones and 9 patients(12%) had intraoral trigger zones. Autonomic symptoms such as conjunctival injection, tearing, and nasal congestion were reported in 9 patients and only occurred after several consecutive TN paroxysms. The patient demographics are summarized in Table 1.

Table 1
Characteristics of patients

Age, (range)	66.2 (39-84)
Sex, n (%)
Female	54 (69.2%)
Male	24 (30.8 %)
Pain Characteristic , n (%)
Purely paroxysmal	68 (87%)
Paroxysmal + continuous pain	10 (13%)
Trigeminal Branches, n (%)
V1	1 (1.2%)
V1+V2	4 (5.1%)
V1+V2+V3	9 (11.5%)
V2	17(21.7%)
V2+V3	29 (37%)
V3	18(23%)
Best descriptor, n(%)
Shock-like pain	71(91%)
Sharp pain	5 (6.4%)
Stabbing pain	2 (2.5%)
Triggering factors n(%)
Chewing	59 (78%)
Touch	58 (77%)
Talking	53(70%)
Shaving	42(56%)
Brushing teeth	38(50%)
Wind	36(48%)
Extra-oral cutaneous trigger zones n (%)	49 (63%)
Nasolabial fold	26 (33%)
Jaw	26 (33%)
Continue
Continuation
Nasal wing	13 (17%)
Lower lip	11 (14%)
Intraoral trigger zones n (%)	9 (12%)
Alveolar gingiva	7 (8.9%)
Tongue	2 (2.5%)
Autonomic symptoms	9 (11.5%)

• TN, trigeminal neuralgia; V1, ophthalmic branch of the trigeminal nerve; V2, maxillary branch of the trigeminal nerve; V3, mandibular branch of the trigeminal nerve.

The average age of TN onset was 62 years, ranging from 37-81 years. The time elapsed between the first symptom of TN and the diagnosis ranged from weeks to 22 years (mean 4.5 years). Of the 78 patients, 60 initially consulted a dentist (77%), and the TN diagnosis was established in 7; 18 patients (23%) consulted a physician and 6 were diagnosed with TN. Dentists were the first health professionals sought by patients when TN affected branches V2 and/or V3. In contrast, physicians were sought when TN affected V1 or V1-V2 branches. This difference was statistically significant (p=0.019 Fisher’s exact test ) Figure 1.

Moreover, 52 patients underwent invasive dental treatments, such as tooth extraction, root canal treatment, surgical scraping, and restoration, because of misdiagnosis Figure 2.

Figure 2
Distribution of invasive dental treatments performed in 52 patients (raw counts) due to misdiagnosis of trigeminal neuralgia. Note that many patients underwent more than one invasive dental treatment.

In 43 patients undergoing tooth extraction, the number of teeth extracted ranged from one to 28 teeth (mean 4 ± 6.6). The median time to diagnosis was 36 [7–114] months for patients without tooth extraction and 60 [36–156] months for those who had dental extractions. We observed that the longer the time elapsed to obtain a correct diagnosis, the greater was the number of teeth extracted per patient. This positive correlation is statistically significantly (r=0.309 p=0.040). Figura 3.

Figure 3
Significant and positive relationship between the time elapsed until diagnosis and the number of teeth extracted (rho=0.309; p<0.041).

The Kaplan–Meier curve (Figure 4) illustrates the cumulative proportion of patients remaining undiagnosed over time. Patients who experienced unnecessary dental extractions tended to have longer diagnostic delays, as evidenced by the divergence of the survival curves, although this difference did not reach statistical significance in the log-rank test (p=0.364).

Figure 4
Kaplan–Meier curves demonstrating the time to diagnosis (measured in months) among patients diagnosed with trigeminal neuralgia, stratified according to prior history of tooth extraction. Although all participants ultimately received the correct diagnosis (with no censored observations), the curve suggests a possible trend towards a longer diagnostic delay in individuals who underwent tooth extraction. Nonetheless, the difference between the groups did not achieve statistical significance (p=0.364).

In the multivariable Cox regression model (Figure 5), none of the variables demonstrated a statistically significant association with the duration until diagnosis (likelihood-ratio χ²(5)=3.93, p=0.56) (Table 2). Female gender (HR=0.70; 95% CI: 0.43–1.15) exhibited a non-significant trend toward prolonged diagnostic delay, whereas initial consultation with a dentist (HR=1.20; 95% CI: 0.67–2.15) was not associated with a shorter time to diagnosis. Age, the presence of paroxysmal pain, and involvement of V1 similarly showed no statistically significant effect.

Figure 5
A Directed Acyclic Graph (DAG) illustrating the hypothesized causal pathway between diagnostic delay and tooth extraction in patients with trigeminal neuralgia. The mediation model presumes that an extended diagnostic delay elevates the likelihood of tooth extraction. The pain territory, presence of paroxysmal pain, and the initial professional consultation (dentist or physician) may influence both the diagnostic delay and the probability of extraction. Sex and age are incorporated as potential confounders.

Table 2
Multivariate Cox analysis of the factors influencing the timing of diagnosis for trigeminal neuralgia

Variable	HR	SE	Z	P	95% CI
Age	1.007	0.014	0.54	0.591	0.980-1.036
Sex (female)	0.698	0.194	-1.29	0.198	0.404-1.206
Presence of paroxysmal pain	1.354	0.381	1.08	0.281	0.780-2.352
Presence of pain at the V1 region	1.043	0.381	0.15	0.882	0.592-1.838
First professional consulted: dentist	1.196	0.310	0.69	0.490	0.718-1.991

• Note. HR: hazard ratio; SE: standard error; CI: confidence interval.

In the sensitivity analysis using logistic regression (Table 3), early diagnosis (within 12 months) was significantly associated with a lower likelihood of unnecessary tooth extraction (OR = 0.20; 95% CI = 0.06–0.65; p = 0.007), corresponding to an approximately 80% reduction in the odds of undergoing an unnecessary extraction. This finding underscores the clinical relevance of timely diagnostic recognition in trigeminal neuralgia.

Table 3
Odds Ratio and 95% Confidence Interval for Unnecessary Tooth Extraction in Patients Diagnosed with Trigeminal Neuralgia Within 12 Months of Symptom Onset Compared to Those Diagnosed After More Than 12 Months.

Variable	OR(95% CI)	p
Diagnosed TN within 12 months	0.20 (0.06-0.65)	0.007
Age	0.98 (0.94-1.03)	0.609
Sex (female)	1.00 (0.32-3.15)	0.990
Presence of paroxysmal pain	3.02 (0.64-14.22)	0.161
Presence of pain at the V1 region	0.69 (0.16-2.86)	0.614
First professional consulted: dentist	2.33 (0.67-8.12)	0.182

• Note. OR: Odds Ratio; CI: Confidence Interval; TN: Trigeminal Neuralgia.

After TN diagnosis, 59 (75.6%) patients were treated with carbamazepine in monotherapy, 5 (6.4%) with oxycarbazepine, 5 (6.4%) with gabapentin, and 7 (8.9%) with carbamazepine along with other drugs. Three patients were in remission at the time of consultation. Thirty-one patients (39.7%) underwent 37 surgical procedures, including microvascular decompression (n = 13) , percutaneous radiofrequency rhizotomy (n = 21), and percutaneous balloon compression (n = 3).

Discussion

Our study confirms that TN continues to be misdiagnosed in the Brazilian public health system and that the dentist is the first professional sought by patients when neuralgia affects the branches of the trigeminal nerve V2 and V3. Furthermore, more than half of these misdiagnosed patients undergo unnecessary dental treatments. The longer the time elapsed to obtain a correct diagnosis, the greater was the number of teeth extracted per patient. However, patients who were diagnosed with TN within 12 months had an 80% higher chance of not undergoing tooth extraction. This article focuses on this rare condition and aims to gather information to help dentists and clinicians diagnose it at an earlier stage.

The diagnosis of TN is primarily clinical and based on well-defined criteria; however, it still poses a challenge for clinicians and dentists. Both the location and presentation can be confused with other painful conditions, such as other neuropathic or nociceptive syndromes, dental pathologies, persistent idiopathic facial pain, headaches, post-herpetic neuralgia, and temporomandibular disorders¹⁶.

In our cohort, the majority of patients (83%) did not receive an early diagnosis, and 66% underwent unnecessary invasive dental procedures. Among these, tooth extraction was the most frequent, performed in 82,7% of cases. Comparable findings have been consistently reported in different populations over the past decades. An Austrian study in 1983 reported that 73% of patients with TN initially sought a dentist, and 48% of them had at least one tooth removed¹¹. Similarly, a Brazilian study in 2004 reported that 66% of patients underwent extraction of at least one tooth, in addition to other dental interventions¹⁰. In Germany (2015), dentists were the first professionals consulted, and 53% of patients received invasive treatment, including extractions, root canal therapy, and implants. More recent studies confirm the persistence of this pattern: in India (2020), 65.8% of patients first consulted a dentist, and 41.8% underwent extractions; in Pakistan (2021), 47.1% had unnecessary extractions before the correct diagnosis was established¹²-¹⁴. Thus, it seems that the problem of incorrect diagnosis has persisted over the years in different countries, despite greater access to information among patients and healthcare professionals.

We found a positive relationship between the time taken for a correct diagnosis and the number of extractions. This correlation was also evidenced by Siqueira et al.¹⁰ who evaluating the number of dental procedures performed and the duration of the disease, showing that 44.4% of patients had undergone some type of dental procedure in the first year of the disease and that 100% of them had undergone some type of dental intervention after 10 years of pain. Therefore, it is essential that the diagnosis be made early. We observed that patients who were diagnosed with TN within 12 months had an 80% higher chance of not undergoing tooth extraction.

In this cohort, TN affected the maxillary and/or mandibular branch of the trigeminal nerve in 82% of cases, which is consistent with other previously published series¹⁰,¹⁷. The higher involvement of V2 and V3 can be explained by the somatotopic distribution of sensory fibers in the trigeminal root and the site of vascular compression. It was observed that when TN affected V2 or V3, the conflicting vessel was found in a superior-lateral or inferior position relative to the circumference of the nerve root¹⁸. We observed that 81% of patients with involvement of V2 and/or V3 initially sought a dentist, compared to 57% of patients in whom V1 was also affected. Therefore, it is essential to differentiate TN pain from dental pain, as they can commonly be confused.

Some vital clues that may help recognize TN:

• The pain is not constant. TN is characterized by sudden pain that has been described as an electric shock by 91% of our patients. Other descriptors used by patients and those reported in the literature include sharp or stabbing pain¹⁷ which is completely different from the conventional throbbing of dental pain. TN is characterized by intense and short-lasting episodes of pain (typically each one may last from 2 seconds to 2 minutes) with abrupt onset and cessation occurring in multiple paroxysms up to 10 or even 20 times per day. On the other hand, odontogenic pain is generally more prolonged and continuous.

• The pain is evoked. TN is triggered by light touch or movement, especially chewing, speaking, touching the face, shaving, or brushing teeth; even a light breeze can trigger it. These triggering factors were present in 98% of our patients. Extraoral trigger zones were present in 63% of our patients and were often located in the nasolabial fold, jaw, nasal wing, and lower lip, in agreement with previous studies that observed that trigger zones were most frequently located in the nasal and perioral regions¹⁹. Intraoral trigger zones were reported in only 12% of our patients in the alveolar gingiva and/or tongue.

• TN pain cannot be localized to a specific tooth. Even in the presence of an intraoral trigger zone, findings from clinical and radiological examinations do not correspond to the intensity of the pain.

• TN is it is more common in the elderly. Age is considered an important factor in the diagnosis of TN since its incidence is proportional to it (17.5–25.6 per 100,000 inhabitants in the seventh and eighth decades of life)⁴. The average age of patients in our study was 66 years, in accordance with other reports¹⁰,²⁰,²¹. In contrast, some studies, including those conducted in the Brazilian population, have observed that dental pain is more prevalent in younger individuals than in older ones. This peculiarity is likely due to the greater number of teeth present in younger individuals, making them more susceptible to cavities and, consequently, dental pain²¹-²³.

• TN pain does not respond to analgesics and anti-inflammatories. In odontogenic pain, the relief can be achieved with the use of analgesics and nonsteroidal anti-inflammatory drugs, whereas sodium channel blockers have proven effective in treating TN. Antiepileptic drugs, such as carbamazepine and oxcarbazepine, are the first-choice medications for the long-term treatment of TN¹⁵.

Misdiagnosis adds incalculable morbidity as well as unnecessary costs to the healthcare system. A retrospective study conducted between 2003 and 2013 demonstrated that the annual cost of TN treatment exceeded 94 million dollars²⁴. This figure is underestimated if we consider all the tests, consultations, and unnecessary procedures performed over the years before these patients receive a proper diagnosis and appropriate treatment.

Our findings indicate the need for continuous education and awareness regarding TN, particularly among dental health professionals and primary care physicians. Considering the aging of the Brazilian population and the fact that TN typically affects the elderly, many patients with TN may undergo various unnecessary dental procedures over time due to misdiagnosis, leading to increased morbidity, financial costs, and reduced quality of life.

One of the limitations of this study is that patients were referred to a tertiary hospital for specialized treatment, selecting only cases that were refractory to conventional treatment. Additionally, the results were based on patient-reported information, which may not have been entirely accurate since a long time had elapsed since the onset of TN. Another limitation is the inability to verify radiographic exams and/or evaluation records of patients who underwent dental procedures and extractions. Therefore, it cannot be ruled out that dental management and treatment may have been justified due to the presence of concomitant dental disease. However, all procedures were performed after the onset of typical TN pain and none of them brought any relief from these symptoms.

TN remains underdiagnosed and that dentists are the first professional sought by the patient when neuralgia affects the V2 and V3 branches of the trigeminal nerve. Furthermore, more than half of these patients undergo unnecessary dental treatments. Our findings indicate the need for ongoing education and awareness regarding TN, particularly among dental healthcare professionals and primary care physicians.

Acknowledgments

This research did not receive any grant from funding agencies in the public, commercial or nor-for-profit sectors.

References

• ¹ Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. doi: 10.1177/0333102417738202.
  » https://doi.org/10.1177/0333102417738202
• ² Devor M, Amir R, Rappaport ZH. Pathophysiology of trigeminal neuralgia: the ignition hypothesis. Clin J Pain. 2002 Jan-Feb;18(1):4-13. doi: 10.1097/00002508-200201000-00002.
  » https://doi.org/10.1097/00002508-200201000-00002
• ³ Mueller D, Obermann M, Yoon MS, Poitz F, Hansen N, Slomke MA, et al. Prevalence of trigeminal neuralgia and persistent idiopathic facial pain: a population-based study. Cephalalgia. 2011 Nov;31(15):1542-8. doi: 10.1177/0333102411424619.
  » https://doi.org/10.1177/0333102411424619
• ⁴ Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol. 1990 Jan;27(1):89-95. doi: 10.1002/ana.410270114.
  » https://doi.org/10.1002/ana.410270114
• ⁵ Dieleman JP, Kerklaan J, Huygen FJPM, Bouma PAD, Sturkenboom MCJM. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain. 2008 Jul;137(3):681-8. doi: 10.1016/j.pain.2008.03.002.
  » https://doi.org/10.1016/j.pain.2008.03.002
• ⁶ Casey KF. Role of patient history and physical examination in the diagnosis of trigeminal neuralgia. Neurosurg Focus. 2005 May;18(5):E1. doi: 10.3171/foc.2005.18.5.2.
  » https://doi.org/10.3171/foc.2005.18.5.2
• ⁷ Graff-Radford SB. Headache problems that can present as toothache. Dent Clin North Am. 1991 Jan;35(1):155-70.
• ⁸ Goddard G. Case report of trigeminal neuralgia presenting as odontalgia. Cranio. 1992 Jul;10(3):245-7. doi: 10.1080/08869634.1992.11677917.
  » https://doi.org/10.1080/08869634.1992.11677917
• ⁹ Truelove E. Management issues of neuropathic trigeminal pain from a dental perspective. J Orofac Pain. 2004 Fall;18(4):374-80.
• ¹⁰ Siqueira SR, Nóbrega JC, Valle LB, Teixeira MJ, Siqueira JT. Idiopathic trigeminal neuralgia: clinical aspects and dental procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Sep;98(3):311-5. doi: 10.1016/S1079210404003191.
  » https://doi.org/10.1016/S1079210404003191
• ¹¹ Garvan NJ, Siegfried J. Trigeminal neuralgia--earlier referral for surgery. Postgrad Med J. 1983 Jul;59(693):435-7. doi: 10.1136/pgmj.59.693.435.
  » https://doi.org/10.1136/pgmj.59.693.435
• ¹² Tripathi M, Sadashiva N, Gupta A, Jani P, Pulickal SJ, Deora H, et al. Please spare my teeth! Dental procedures and trigeminal neuralgia. Surg Neurol Int. 2020 Dec 22;11:455. doi: 10.25259/SNI_729_2020.
  » https://doi.org/10.25259/SNI_729_2020
• ¹³ Rehman A, Abbas I; Alamgir; Ghous SM, Ahmad N, Ahmad A. Association between trigeminal neuralgia and unnecessary tooth extraction. J Ayub Med Coll Abbottabad. 2021 Jan-Mar;33(1):116-9.
• ¹⁴ von Eckardstein KL, Keil M, Rohde V. Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurg Rev. 2015 Apr;38(2):355-60; discussion 360. doi: 10.1007/s10143-014-0591-1. Epub 2014 Nov 25.
  » https://doi.org/10.1007/s10143-014-0591-1
• ¹⁵ Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A, et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019 Jun;26(6):831-49. doi: 10.1111/ene.13950.
  » https://doi.org/10.1111/ene.13950
• ¹⁶ Zakrzewska JM, Wu J, Mon-Williams M, Phillips N, Pavitt SH. Evaluating the impact of trigeminal neuralgia. Pain. 2017 Jun;158(6):1166-74. doi: 10.1097/j.pain.0000000000000853.
  » https://doi.org/10.1097/j.pain.0000000000000853
• ¹⁷ Lazar ML, Greenlee RG Jr, Naarden AL. Facial pain of neurologic origin mimicking oral pathologic conditions: some current concepts and treatment. J Am Dent Assoc. 1980 Jun;100(6):884-8. doi: 10.14219/jada.archive.1980.0267.
  » https://doi.org/10.14219/jada.archive.1980.0267
• ¹⁸ Sindou M, Howeidy T, Acevedo G. Anatomical observations during microvascular decompression for idiopathic trigeminal neuralgia (with correlations between topography of pain and site of the neurovascular conflict). Prospective study in a series of 579 patients. Acta Neurochir (Wien). 2002 Jan;144(1):1-12; discussion 12-3. doi: 10.1007/s701-002-8269-4.
  » https://doi.org/10.1007/s701-002-8269-4
• ¹⁹ Di Stefano G, Maarbjerg S, Nurmikko T, Truini A, Cruccu G. Triggering trigeminal neuralgia. Cephalalgia. 2018 May;38(6):1049-56. doi: 10.1177/0333102417721677. Epub 2017 Jul 14.
  » https://doi.org/10.1177/0333102417721677
• ²⁰ Maarbjerg S, Gozalov A, Olesen J, Bendtsen L. Trigeminal neuralgia--a prospective systematic study of clinical characteristics in 158 patients. Headache. 2014 Nov-Dec;54(10):1574-82. doi: 10.1111/head.12441.
  » https://doi.org/10.1111/head.12441
• ²¹ Vargas CM, Macek MD, Marcus SE. Sociodemographic correlates of tooth pain among adults: United states, 1989. Pain. 2000 Mar;85(1-2):87-92. doi: 10.1016/s0304-3959(99)00250-x.
  » https://doi.org/10.1016/s0304-3959(99)00250-x
• ²² Locker D, Grushka M. Prevalence of oral and facial pain and discomfort: preliminary results of a mail survey. Community Dent Oral Epidemiol. 1987 Jun;15(3):169-72. doi: 10.1111/j.1600-0528.1987.tb00508.x.
  » https://doi.org/10.1111/j.1600-0528.1987.tb00508.x
• ²³ Bastos JL, Gigante DP, Peres KG. Toothache prevalence and associated factors: a population based study in southern Brazil. Oral Dis. 2008 May;14(4):320-6. doi: 10.1111/j.1601-0825.2007.01379.x.
  » https://doi.org/10.1111/j.1601-0825.2007.01379.x
• ²⁴ Holland M, Noeller J, Buatti J, He W, Shivapour ET, Hitchon PW. The cost-effectiveness of surgery for trigeminal neuralgia in surgically naïve patients: a retrospective study. Clin Neurol Neurosurg. 2015 Oct;137:34-7. doi: 10.1016/j.clineuro.2015.06.011.
  » https://doi.org/10.1016/j.clineuro.2015.06.011

• Ethics Statement:
  The research was ethically conducted based on the Helsinki Declaration, and the study was approved by the Pedro Ernesto University Hospital Review Board (Protocol Number 1.813.961).
• Data availability:
  Datasets related to this article will be available to the corresponding author upon request.
• Artificial intelligence use disclosure:
  Artificial intelligence was not used in this research.

Edited by

• Editor:
  Dr. Altair A. Del Bel Cury

Data availability

Datasets related to this article will be available to the corresponding author upon request.

Publication Dates

• Publication in this collection
  24 July 2026
• Date of issue
  2026

History

• Received
  02 Apr 2025
• Accepted
  26 Oct 2025