Possible Lingual/Inferior Alveolar Nerve damage which has led to Trigeminal Neuralgia

[S3B]

Good afternoon everyone (I am from South Africa, so excuse the time difference for those experiencing it),

I am new to the forums, and you can call me Seb. I am just here to enquire about some recent dental issues I have encountered which has left me in a state of chronic pain. I will get into details a bit later, considering I first just want to get to the bottom of the situation.

I'm suspecting I might have sustained damage to my the Lingual/Inferior Alveolar Nerve on the right side of my face (my perspective) which might have led to a condition referred to as Trigemnal Neuralgia (TN), commonly known as "Suicide Disease". I'd like to enquire about the necessary steps I'm supposed to follow in case I had an injury to any of the nerves which might contribute to said condition. Who do I see to determine if this is in fact nerve damage; a Neurologist or Oral and Maxillofacial Surgeon? Are there tests they can run to ascertain 100% if I have indeed sustained a nerve injury? Would you be able to PHYSICALLY SEE this perhaps?

I have already gone back to the dentist, but she told me to wait 2 weeks and has put me on Celebrex 200 for the time being. Can this potentially heal over time, or am I screwed for life? I know in some cases, nerve damage can be permanent. My pain is EXCRUCIATING, and it doesn't stop (which has me worried, and is the main reason I came to this forum). It's like a stinging/aching pain, and it feels like it's in the back of my mouth behind the 3rd molar where the dentist injected me (x3 times, due to not anesthetizing easily). I don't think it's the tooth that had to get an inlay that's causing the problem (this tooth seems fine now). It almost feels like I'm still getting injected, or alternately, stabbed in the nerves in the back of my mouth.

PLEASE, if anyone can help me, it would be much appreciated, even if people can link me to other threads. I am in a state of constant chronic pain and I haven't been able to function normally. I have even cried a couple of times, up to the point where I am not even able to cry anymore. This is really a SERIOUS issue to me. Any help would be MUCH appreciated.

Thanks you in advance.

Regards,
Seb

P.S. A GP has also put me on Panafcort (Prednisone) 5 mg x 24. I was supposed to take 12 this past Thursday after I had just seen the GP, and then another 12 yesterday (Friday), 24 hours later. I haven't taken ANY thus far, considering I am doubtful when it comes to Prednisone and cortico-steroids (I have been on them before and suspect they might've contributed to my lower-immunology and persistent allergy (Chronic Idiopathic Urticaria). Is it a bad decision abstaining from what the doctor's recommended if I'm doubtful?

 

[Busybee]

I'm very sorry that you are in so much pain. I had transient Trigeminal neuralgia years ago. It was very distressing but in my case I'd get random shooting pain and I would not have any warning of when. It went after three or four months but I would panic if I didn't have painkillers with me. I think mine was caused by a too high nightguard and possibly also a whiplash injury a couple of years earlier. I was helped by nurofen codeine tablets. Cortico steroids do have side effects in some people. In my case they make me fall asleep. I've needed them for a severe allergy. It's good to know exactly what's happening before taking something so strong on a regular basis. Have you tried any regular painkillers?

What dental work did you have just before this started?

 

[MattKW]

If this pain started up after recent treatment, that is the logical place to start before getting into more obscure diagnoses like TN. "If you hear hoofbeats, think horses, not zebras." If your dentist can't define the pain, then go to an endodontist to rule out tooth pain. They will then guide you elsewhere if necessary.

 

[S3B]

Hi again,

Thanks so much for the feedback everyone, I really appreciate it.

I'm trying to keep this as short as possible for the time being, for the sake of brevity, and will get into the more finer details a bit later if necessary.

Just to some things up quickly: I recently had work done x2 on my 1st molar on the right hand side of my lower jaw (mandible) from my perspective. Both were inlays done by 2 different dentists. The 1st dentist's inlay I didn't like (my bite was screwed up), while the 2nd one did a good job, except for the pain I now have in my mandible close to where she injected me and worked on the tooth. This pain only came after I saw the 2nd dentist who did a good job with the 2nd inlay.

The 1st doctor who did a bad job gave me x2 injections, while the 2nd doctor who did a good job gave me x3 injections (both due to the fact that I don't anesthetize easily). Personally, I think I should wait a bit longer with regards to injections (maybe a bit longer than the average person actually), because my reaction time seems slow (i.e. maybe we can do away with 1 shot only, but we must just wait for long enough, or at least a little longer than average). Maybe I feel like we DIDN'T wait long enough, and possibly overdosed on injections.

What are the chances that I might have suffered needle injury due to having had TOO many dental injections in the same region in a short time-spain? Could this have damaged a nerve perhaps? Could the anesthetic have played a role? I also hear a weird clicking/crunching sound more or less where the pain is felt when I bite up and down properly. This doesn't sound like it's my jaw's bones, but more like it could be tissue (flesh) damage. Could this also potentially indicate nerve damage? This is what originally got me worried: the pain and the sound, originating from the same area.

The pain seems less now, but it's still there. It's lingering, and I feel it most of the time and it's hard NOT to focus on it. It's almost like a new permanent sensation my jaw has now. I am however still on the painkillers.

I'd like to find out what steps I should take in case of needle injury/trauma, stiff painful jaw and this weird sound I'm hearing when I'm biting up or down. Am I overreacting? I'm scared I ignore this/don't treat it right in time/don't see the right doctor in time and end up with permanent long term problems.

Is there anything I can do in the meantime at home to help with the recovery process (apart from drinking painkillers, trying to eat healthy and maintaining good oral hygiene).

Any help/tips would go a long way toward putting my mind (and hopefully pain) at ease.

Thank you.

 

[Busybee]

How long ago was the treatment?

 

[MattKW]

1. Nerve damage from routine injections does not match with your problems. At most, if the nerve has been pranged (unlikely), then you may have transient numbness for several days, just like bruising.It is actually quite difficult to directly hit the Inferior Alveolar Nerve (IAN) as it is tucked away behind a spur of bone. I might get it once every 3-6 months, and the patient gets an immediate electric shock to the lip.
   
2. Local anaesthetic is also extremely safe. There must be billions of LA injections every year in dental and medical situations. To overdose would take a huge amount, at least 30mL in a very short time, and I've heard of doses higher without ill effect. Most dental cartridges contain about 2 mL. The first signs will be agitation.
   
3. Every dental injection causes some muscle damage, and the occasional trismus afterwards can happen rarely. It will settle.
   
4. If you have your mouth open for a long time, this can upset the jaw function and give TMD symptoms. Resolution is aimed at palliative care by limiting your opening when eating or yawning. These things settle down in most cases. If you're going in for a long dental session, ask for a bite block.
5. Again, I would be looking at the tooth that was recently filled for the primary source of pain.

 

[S3B]

Dear MattKW,

Thanks so much for your input, it really means a lot. I'll try give it some time and be a bit more patient. It's just that I've never experienced lingering pain for so long, so it's got me all worried and upset. In the past when they'd worked on this tooth, it seemed fine within 2-3 days.

I have however done some research which has indicated that people can hit the lingual nerve (very rarely) when doing injections, but it is quite a rare incident (some also mention the inferior alveolar nerve being a potential target). People also react differently to the anesthetics used (e.g. Novacaine, Lidocaine etc.). Also, there was another article I skimped through which advised against injecting repeatedly. I'll link it when I have some more time.

I would however like to establish the following: if something went wrong during the injection, how can you exactly pick it up? I'm assuming it's not that easy finding out where the needle went, and what it might've hit? There aren't tests they can do to evaluate this? Like let's say for instance someone wants to take a look at their nerves and if they were in fact damaged/bruised, could you pick this up with any testing? Also, which doctor should you be consulting?

Lastly, if this was in fact just standard post-op needle bruising, is there anything I could do to speed up/improve/maximize recovery perhaps?

Please let me know if you've got any additional tips/recommendations.

 

[MattKW]

Quite the opposite. The lingual nerve is shallower than the IAN, and is easily struck; I probably hit it 1 in 5 injections, and this gives an electric shock feeling to the tongue. You just pull the needle back and reinsert slightly to the side.
People don't react differently to different LA solutions. The only difference is that most contain adrenaline to make it work better. This will often give people a few heart jitters because the injection, being close to a nerve, is also close to veins and arteries. If it really annoys people, I give them a plain solution. All dentists probably carry at least 1 LA without adrenaline.
The degree of damage is determined externally by testing the residual amount of numbness to the face. Simply from needle trauma, I've never had to do this because it will resolve within a few days. It is only in cases where there has been serious damage to the nerve like after surgical extraction of wisdom teeth where closer monitoring is required.
You can't change the rate of healing. Like any bruise, it can take up to 2 weeks.

 

[honestdoc]

Dr. MattKW is right. Nerve damage results in feeling numb afterwards. Your mouth recovers very quickly after injections. Like Dr. MattKW says, you can't change the rate of healing but you can try corticosteroids to minimize excessive inflammation (you had previously mentioned abstaining from). With the type of stabbing, stinging pain you are experiencing, hopefully a neurologist may be able to help or manage it.

 

[S3B]

I think a Oral and Maxillofacial Surgeon would be the better option if I'm REALLY worried about persistent pain, especially considering it's in my jaw (lower) where the pain is localized, and that's what they specialise in (apart from the fact that they've studied dentistry as well, unlike Neurologists). Wouldn't they be more qualified in dealing with LN and IAN injuries/problems resulting from dentistry, than say a Neurologist?

I know you guys think I'm over-reacting, but the pain comes up more stronger than usual every now and then (in fact, it just came back stronger just now (this afternoon) than it was this morning; maybe my painkillers have worn off). Also, the fact that I'm obsessing about it due to the level of pain and and it's persistence has me worried. I'm just scared it never goes away, and I need to figure out what the next steps I should take, would be. I was thinking this would be nerve pain if it wasn't general post-dental injection pain. Unless this is tooth-ache. But the type of pain is like stinging/biting/zapping/aching, so I'm scared it might be more than just regular post-dental healing pain. It's also hard to localize it exactly.

I'm going to wait till the end of this week and keep on taking my painkillers as described and then take things from there. I've found out about doctors in my local area specializing in these types of conditions.

 

[S3B]

How long ago was the treatment?

It took place on the 19th of October 2018, so I'm going on my 3rd week now actually. This is why I have become a tad worried...

 

[Busybee]

It took place on the 19th of October 2018, so I'm going on my 3rd week now actually. This is why I have become a tad worried...

After dental treatment I would give it three months before worrying. The worrying helps nobody and just makes you more anxious every time the pain happens. You've had one lot of treatment after another so it could just be your body reacting and your jaw trying to adjust to a different bite. It may be your nerve has been irritated but nerves tend to calm down over time. The time it takes varies with each individual.

I'd also suggest ibuprofen first. Corticosteroids are serious meds and should not be taken if you can find relief using alternative medication. You should not take them long term. I found relief using an ibuprofen codeine tablet. These can be highly addictive, but they have fewer side effects than Prednisolone. Either way you should protect your digestive system. It took three months for my shooting pains to go. In my experience pain can be at its worst just before it stops for good.

The neurologist will likely tell you that it should settle. There is little they can do other than try to diagnose and refer you for pain management. It's worth trying different things such as a biteguard to see whether you have pain relief when the jaw is relaxed,

 

[MattKW]

I DO wish that you would see an endodontist first to make sure you rule out a toothache-related pain. I've had a few patients who have gone to neurologists who were found later to have had a toothache. That's after they've usually been drugged with Lyrica and Tegretol in a simplistic bombarding to try and control the pain. If you do end up at a neurologist in the end, they're going to feel more secure knowing you've completely eliminated the dental possibilities. Your problems began after dental fillings; the injections have nothing to do with it as I've already detailed.

 

[MattKW]

Thank you, honestdoc. Apart from my joke about zebras, I also like to espouse the KISS principle, "Keep It Simple Stupid".

 

[S3B]

I DO wish that you would see an endodontist first to make sure you rule out a toothache-related pain. I've had a few patients who have gone to neurologists who were found later to have had a toothache. That's after they've usually been drugged with Lyrica and Tegretol in a simplistic bombarding to try and control the pain. If you do end up at a neurologist in the end, they're going to feel more secure knowing you've completely eliminated the dental possibilities. Your problems began after dental fillings; the injections have nothing to do with it as I've already detailed.

I'll consider this if the pain persists. Just keep in mind that I'm reacting like this because of unexpected long-duration pain after recent dentistry. I've never had pain for this long, which has led to my incessant worry.

Also, people can hit your your nerves with common injections during routine dental visits, with pretty bad consequences as well. I'm sure this doesn't happen too often, but unfortunately, it can:

I'm assuming dentists are VERY aware and VERY WELL COVERED regarding the aforementioned.

 

[S3B]

After dental treatment I would give it three months before worrying. The worrying helps nobody and just makes you more anxious every time the pain happens. You've had one lot of treatment after another so it could just be your body reacting and your jaw trying to adjust to a different bite. It may be your nerve has been irritated but nerves tend to calm down over time. The time it takes varies with each individual.

I'd also suggest ibuprofen first. Corticosteroids are serious meds and should not be taken if you can find relief using alternative medication. You should not take them long term. I found relief using an ibuprofen codeine tablet. These can be highly addictive, but they have fewer side effects than Prednisolone. Either way you should protect your digestive system. It took three months for my shooting pains to go. In my experience pain can be at its worst just before it stops for good.

The neurologist will likely tell you that it should settle. There is little they can do other than try to diagnose and refer you for pain management. It's worth trying different things such as a biteguard to see whether you have pain relief when the jaw is relaxed,

I'm giving it between 4-8 weeks (going on my third now). From what I can gather, if someone did in fact hit a nerve, this is the time-span it'll take to heal naturally by itself (unless there's been permanent damage). After this time-span I guess you can look at further investigation. I am still taking a Celebrex 200 during the morning and evenings (2 in total per day), but I've stopped with the Mypaid forte pills for now which are anti-inflammatory and pain relieving (containing 400 mg Ibuprofen and 325 mg Paracetamol). I've been told to not take this for too long a period, 'cause it's bad for your stomach apparently (is that why you mentioned the 'digestive system'?). Do you rate taking both these at the same time would be a bad idea?

Also, I already have a retainer/biteguard. I don't always know how much it helps with my grinding; I think this tooth of mine is pretty f*cked (excuse my language) from taking the brunt of the 'grind', so to speak. I'm considering looking at other alternatives. I have very bad anxiety, and I think it's only getting worse, which has contributed TOO negatively to my bruxism (grinding). I live a very stress-filled life at the moment I'm afraid.

 

[S3B]

Dr. MattKW is right. Nerve damage results in feeling numb afterwards. Your mouth recovers very quickly after injections. Like Dr. MattKW says, you can't change the rate of healing but you can try corticosteroids to minimize excessive inflammation (you had previously mentioned abstaining from). With the type of stabbing, stinging pain you are experiencing, hopefully a neurologist may be able to help or manage it.

Panafcort (Prednisone) 5 mg x 24 is what I've been prescribed, where I need to take 12 on one day, and then 24 hours later another 12 (which I haven't done as of yet). It's not a long duration for taking Prednisone, which they usually advise against (some people say long term use can have disastrous effects, especially once you try to get off of it again (I'm talking about people that have to take it regularly, as prescribed). I'm just paranoid about taking it because I'm scared said drug might've contributed to my dip in general health (I recently became very allergic and now suffer from Chronic Idiopathic Urticaria), and if I'm not mistaken, I had this drug along with penicillin round about the same time my allergies started. I am thus hesitant/dubious when it comes to taking Prednisone. Just look at all the bad rap people give it when you Google it.

I know it helps with inflammation however, but I also know it inhibits your immune system. I'm scared of doing that when I'm recovering from dental pain/injuries. I don't know how much I like the idea of HOLDING MY IMMUNE SYSTEM BACK in order to reduce inflammation. Isn't the inflammation a sign of healing/recovery? Why would you want to curb that? Isn't inflammation a 'natural sign of recovery' that should be left to sort itself out? I'm scared it leads to 'impaired' healing which might yield even longer term issues.

How often do they prescribe Prednisone in dentistry for post dental pain/injury/inflammation? Do you perhaps know?

 

[MattKW]

That video is so mixed up and misleading, I'm insulted by it. But,... that's the internet. Everyone gets a soapbox.

1. He talks that he was injected into the lingual nerve. No, we don't do that because we are passing BY the lingual nerve. We may skewer it on the way if we totally ignore the screaming patient. I don't think any patient would let me do that. We pull back and redirect.
   
2. He talks of prolonged anaesthesia of not just the lingual nerve but also the IAN (tongue, and lip). What, they were both skewered in the same injection? That IAN is hard to hit directly at the best of times.
   
3. We don't aim blindly. The lingual nerve is ~1cm deep, the IAN is ~2.5cm deep. We can't see them, but there are bony and tissue landmarks which guide us. There are a few techniques for aiming at the IAN, but they all have pros and cons.
   
4. He confuses 3% prilocaine with 4% articaine. It was articaine that raised some concern following a Danish study which has since been discredited. Usage of articaine here in Australia was behind that in Europe and USA, but has become very popular for certain reasons. There has been no increase in lingual nerve damage.
5. I have no idea what happened to this poor fellow, but LA is not matching up. There have been cases of dentists reusing empty dental cartridges for other solutions and getting them mixed up - can't imagine anyone being that idiotic anymore, but maybe....?
6. He makes it sound as if dentists have the lawyers on side. No, we can't be found negligent unless we have stepped outside the normal procedures (like reusing cartridges). Maybe this fellow should try dental treatment without LA in future. Or maybe just brush his teeth.

 

[honestdoc]

Panafcort (Prednisone) 5 mg x 24 is what I've been prescribed, where I need to take 12 on one day, and then 24 hours later another 12 (which I haven't done as of yet). It's not a long duration for taking Prednisone, which they usually advise against (some people say long term use can have disastrous effects, especially once you try to get off of it again (I'm talking about people that have to take it regularly, as prescribed). I'm just paranoid about taking it because I'm scared said drug might've contributed to my dip in general health (I recently became very allergic and now suffer from Chronic Idiopathic Urticaria), and if I'm not mistaken, I had this drug along with penicillin round about the same time my allergies started. I am thus hesitant/dubious when it comes to taking Prednisone. Just look at all the bad rap people give it when you Google it.

I know it helps with inflammation however, but I also know it inhibits your immune system. I'm scared of doing that when I'm recovering from dental pain/injuries. I don't know how much I like the idea of HOLDING MY IMMUNE SYSTEM BACK in order to reduce inflammation. Isn't the inflammation a sign of healing/recovery? Why would you want to curb that? Isn't inflammation a 'natural sign of recovery' that should be left to sort itself out? I'm scared it leads to 'impaired' healing which might yield even longer term issues.

How often do they prescribe Prednisone in dentistry for post dental pain/injury/inflammation? Do you perhaps know?

You are right to be concerned with corticosteroids like Prednisone. I don't prescribe it often and only as a Dose Pack for 7 days. It is more effective Anti-inflammatory agent than Non Steroids like Ibuprofen.

 

[Busybee]

Prenisolone does suppress the immune system S3B. They give it to me when I have an allergic reaction. I don't think my body would tolerate it on any regular basis. It is really strong and works great on reversing anaphylaxis but I'd never consider taking it for pain. I am sensitive to various meds and this is one of them. You really should get a proper diagnosis before taking prescription meds. You shouldn't take prednisolone and ibuprofen at the same time. The dose you mention is similar to what I've been given for allergic shock.

I've taken paracetamol at the same time as ibuprofen. It works but I cannot recommend it as I'm sure it's not great for your body to do that too often. I find codeine is a great painkiller but as mentioned there's a risk of addiction particularly if you have chronic pain.

You should always try to reduce inflammation to promote healing. For example I'm sure you've heard of RICE for sprain injuries. (rest, ice, compression, elevation), most of that relates to reducing inflammation. Inflammation may be a natural reaction to protect the area and promote healing in the first instance, but it also damages tissues over time, may cause scar tissue and causes pain.