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Alcoholic facial neuralgia: report of three cases
CLINICAL
REPORTS
Alcoholic facial neuralgia: report of three cases J a m e s T . M u lr y , M D J o s e p h C er b in , M D D a v id L. S p e n c e r , M D
He described steady, nontraum atic jaw pain, m ore intense in the area o f the m andible than the maxilla, and had numbness o f both hands. T h e patient had 14 cm hepatomegaly, trem or, and num bness to pinprick in the hands, b u t the jaw and face were norm al. Levels o f blood al cohol, venous amm onia, mean corpuscular vol um e (MCV), and serum glutamic pyruvic trans aminase (SGPT) were elevated. Results o f fast h ree cases o f n o n trau m atic facial ing blood glucose and a panoram ic radiograph pain associated with consum ption o f the jaw were norm al. Abstinence from al o f alcohol are p rese n ted . In two o f c o h o l a n d tr e a tm e n t w ith o x azep am a n d the cases, pain rem itted w ith abstinence thiam ine brought remission o f all symptoms in and re tu rn e d with relapse to alcohol inges 2 days. tion. We postulate th a t these cases involve D uring a second admission 3 months later, alcoholic n eu ralg ia in th e d istrib u tio n o f the patient adm itted that he had relapsed to the m ental a n d su p e rio r alveolar b ranches daily alcohol ingestion without other d ru g use o f the trigem inal nerve; possibly a m o n o for 6 weeks before admission. His mandible n eu ro p a th y o r a re fe rre d sym ptom from again had become num b and tender. Alcohol on the breath, agitation, and possible laryngeal irritation. lid lag were present. T h e blood pressure was 130/80. T h ere now was bilateral m andibular, Review of literature m ore than maxillary, numbness to pinprick as well as tenderness to touch. T h ere was 11 cm Facial pain in patients who have alcoholism clas hepatomegaly and epigastric tenderness, but no sically resu lts fro m a ltercatio n -a sso c iate d c lin ic a l e v id e n c e o f g o it e r , p e r i p h e r a l traum a. In reviews o f facial pain in the internal neuropathy, o r visible oral disease. T h e patient m edicine,1'3 family practice,4'6 psychiatric,7 had elevated levels of gamma glutamyl trans otolaryngological,8 dental,9 and neurological10 ferase (GGT), venous ammonia, blood alcohol, literature, no association o f facial pain with al and MCV, a lowered serum folate, and norm al coholism em erged beyond the expected m en levels o f thyroxin, serum B 1 2 , and fasting blood tion o f traum a,10 alcoholic aggravation o f clus glucose. H e im proved slightly after treatm ent ter m igraine,11 and the glossalgia/glossodynia w ith p a re n te ra l th iam in e, o ral o x azepam , o f alcohol-associated riboflavin (vitam in B fenoprofen calcium, lactulose, and pyridoxine. complex) deficiency.4 No previous reports o f On the sixth day, the oral problems persisted alco h o l-induced facial n eu ra lg ia o r facial and an oral-surgical consultant found no evi neuropathy exist.12,13 Reviews o f literature re dence o f dental, tem porom andibular (TM), or g a rd in g cases o f p a in fu l alcoholic n e u ro g in g i v a l/ p e r i o d o n ta l d is e a s e . A n o th e r pathy14' 16 contained no mention o f facial pain panoram ic radiograph was norm al. o r facial n e u ro p a th y in p a tie n ts w ith a l D uring the next 10 days, oral pain slowly coholism. rem itted and the patient completed an inpa tient alcoholism rehabilitation program . How ever, the patient was adm itted again 3 months Report of cases later for detoxification. At this time, the patient Case 1 . A 27-year-old male was adm itted to the stated that pain in the lower jaw had recurred 2 hospital for detoxification. H e fulfilled {DSM weeks after he had resum ed drinking. T h e ad III)17 criteria for alcohol intoxication and de m itting physician noted trem or, alcohol on the pendence. A history o f previous m arijuana, b reath , a blood pressure o f 160/100, and epigas am phetam ine, sedative, and narcotic abuse was tric tenderness but no lid lag o r hepatomegaly. obtained. T he patient did not have diabetes T h e blood alcohol and SGPT levels were ele mellitus, m alnutrition, o r exposure to heavy vated, with norm al levels o f MCV, venous am metals. He smoked one pack o f cigarettes daily. m o n ia , flu o re s c e n t tre p o n e m a l a n tib o d y
Three cases o f ja w p a in recu rren tly p r e c ip i ta te d by consum ption o f alcoh ol a re de scribed. A lcohol-induced neu ralgia is a d d e d to the d ifferen tia l diagn osis o f a ty p ic a l oro fa c ia l p a in .
T
(FTA), and blood glucose. All problems rem it ted after 4 days o f treatm ent with oral clorazepate and parenteral thiamine. T h e patient was referred to Alcoholics Anonymous but left the state and again relapsed. O n the patient’s final admission, 1 year later, he reported daily ingestion, d u rin g the past year, o f a fifth o f vodka, 60 mgm o f diazepam, and 4 to 6 oz o f a hydrocodone bitartrate, pseudoephedrine, guaifenesin antitussive. He again had dull, sometimes lancinating, jaw and chin pain but no odontalgia. He continued to smoke one pack o f cigarettes daily. Initially, the patient appeared to be norm al except for hepatomegaly and trem or, with no evidence o f dental disease or trigger points; GGT, SGPT, and venous amm onia levels were elevated. A toxicological screening was positive for diazepam, nordiazepam , alcohol, and aspi rin. An ear, nose, and th ro at consultant observed deviation o f the nasal septum with reduced air flow, m outh breathing, hyperem ia o f the left true vocal cord, and m andibular tenderness. Jaw pain was reduced by h alf after application o f to p ic a l a n e s th e tic (b e n z o c a in e 14% / tetracaine 2%) to the vocal cords. A neurologi cal consultant found norm al pain and touch sensation; m otor function and corneal reflexes also were norm al. U nfortunately, noninvasive electrodiagnostic studies o f the mental and al veolar nerves were unavailable. T h e facial pain partially improved after the patient gargled with viscous lidocaine (Xylocaine) and completely rem itted in 7 days with abstinence from alcohol, reduced smoking, and treatm ent with thiamine, multivitamins, and neomycin. A fter 4 m onths’ sobriety and partici pation in Alcoholics Anonymous, he retu rned for septoplasty. Case 2 . A 39-year-old male was referred for
medical evaluation after 2 years o f treatm ent by three dentists and two oral surgeons. T h e pa tient was concerned that serial extraction o f eight teeth had failed to relieve recu rren t jaw and tooth pain. H e related a p attern o f repeated visits to various oral clinicians, seeking relief. Only in retrospect were the problems linked to alcoholism. Each time, despite norm al radiographs and oral examination results, endodontic therapy
M ulry-Cerbin-Spencer : ALCOHOLIC FACIAL NEURALGIA ■ 847
CLINICAL REPORTS
was performed. The patient was given codeine and stopped drinking for a period, not wanting to mix alcohol with other drugs. During this alcohol-free time, the pain remitted. Each time, on depletion o f the codeine, the patient would resume drinking, the pain would recur, and the consultant would extract the tooth and represcribe codeine. Again tem porarily sober, the patient would be free of pain. But again, on depletion of the codeine, he would resume the cycle with new drinking, pain in another tooth, and the selection o f a new consultant. Examination confirmed the referring den tist’s impression o f a normal mouth and jaw, except for the extracted teeth. Despite a normal neurological examination, a 3-finger breadth of hepatomegaly, palmar erythema, and testicular atrophy indicated advanced alcoholism. GGT, triglyceride, and serum glutamic oxaloacter transaminase (SGOT) levels were elevated, with MCV, T4, and blood glucose normal. The patient was diagnosed as having al coholism with alcoholic neuralgia o f the jaw. He was unreceptive to both the diagnosis and re ferral to either Alcoholics Anonymous or an alcoholism treatment center, and subsequently was lost to follow-up.
o n ly w ith d ip h t h e r ia , d ia b e t e s , o r Guillain-Barre syndrom e.24 Nontraum a tic cases o f atypical facial neuralgia in a trigem inal distribution similar to these cases (excluding the ophthalmic branch) have been reported,25,26 but not with al cohol as an inciting agent. Facial pain from self-inflicted injury by a m alingerer seek ing narcotics has been reported, but gingi val lesions were present,27 whereas other so-called “psychiatric causes” o f facial pain6 often prove to be a painful trigem i nal neu rop ath y5 rather than the com m only sought classical trigeminal neural gia.28 A contributing m echanism in the fourth admission o f the patient in case 1 may have been referred laryngeal pain, as suggested by the partial im provem ent o f mandibular pain after topical laryngeal anesthesia. T h e interconnection o f the trigem inal nerve with the glossopharyngeal, vagus, and facial nerves provides an anatomic m echanism for referred pain.29 T h e clini cal observation that stim ulation o f the g lo ss o p h a r y n g e a l n erv e m ay trig g e r Case 3. A 46-year-old male with odontalgia was trigeminal neuralgia30 and the occasional referred by a dentist for evaluation after the experience o f referred odontalgia caused odor o f alcohol was noticed on the patient’s by laryngeal irritation30 support this addi breath. The patient had a history o f multiple tional mechanism. dental visits for mandibular pain. Despite nor mal dental examinations, endodontic therapy was attem pted twice w ithout relief. T h e panoramic and other radiographic examina tions in the dentist’s office were normal, and the patient was referred to the author. The interview showed that the patient satis fied the SDM I I I 17 criteria for alcohol abuse. As the diagnosis became obvious in the course o f the interview, the patient became anxious and refused examination, laboratory evaluation, or a follow-up appointment. He abruptly left the office and subsequently was lost to follow-up.
Conclusion
Atypical facial pain and odontalgia are re ported, associated with alcoholism. An alcohol-induced distal, trigeminal, atypi cal neuralgia, possibly a m ononeuropathy, explains the clinical findings. Referred laryngeal pain also was suggested as an a g g r a v a tin g fa cto r in th e fir st case. Awareness by the oral clinician o f this clin ical sign will facilitate diagnosis o f the un derlying alcoholism, a treatable disorder Discussion in m any patients. A bstinence from al cohol, as finally achieved in the first case, is A lcoholic neuropathy, an attractive ex the fundam ental treatm ent o f alcoholplanation for the clinical observations re induced atypical facial neuralgia. ported here, has been considered variably --------------------jm A --------------------a toxic,18 nutritional, or m ixed disease.19,20 The authors thank Robert E. Finch, MD, for his Although the disease usually affects the contributions to this paper. extrem ities, it also som etim es can affect Dr. Mulry is assistant professor; Dr. Cerbin is clinical the sympathetic nervous system.21 Painful instructor; and Dr. Spencer is professor and chairman, alcoholic neuropathy has been compared department of family practice, Southern Illinois Uni with diabetic neuropathy,22 which can af versity, School o f Medicine, 421 N Ninth, Springfield, fect the face, but facial pain with alcohol IL 62708. Address requests for reprints to Dr. Mulry. has not been described. Alcoholic cranial nerve palsies have been described,23 but all 1. Needham, C. W. Major cranial neuralgias and the were nonpainful. In the first case, electro surgical treatment o f headache. Med Clin North Am diagnostic studies, for technical reasons, 62(3):545-557, 1978. 2. Duane, D.D. Neurological analysis o f facial pain. could not confirm facial neuropathy in the Postgrad Med 76(2): 161-172, 1984. patient; therefore the diagnosis was al 3. Clark, J.L. An overview o f face pain. Postgrad coholic atypical facial neuralgia. Med 76(2):90-97, 1984. 4. Donlon, W.C., and Jacobson, A.L. Maxillofacial T oxic facial neuralgias are associated 848 ■ JADA, Vol. 112, June 1986
pain. Am Fam Phys 30(1): 151-163, 1984. 5. Gerschman, J.A., and Reade, P.C. Orofacial pain. Austr Fam Phys 13(1): 14-24, 1984. 6. Ebersold, M.J. Review o f face and head pain Fam Phys 20(7):480-489, 1985. 7. Seltzer, S., and others. The effects o f dietary tryptophan on chronic maxillofacial pain and experi mental pain tolerance. J Psychiatr Res 17(2): 181-186, 1983. 8. Carron, H. Control o f pain in the neck and head Otolaryngol Clin North Am 14(3):631-652, 1981. 9. Poswillo, D.E. Prevention and early recognition o f major orofacial disorders. Br Dent J 149:326-333, 1980. 10. Reik, L. Atypical odontalgia: a localized form oi atypical facial pain. Headache 24:222-224, 1983. 11. Pearson, B.W. ENT approach to face pain Postgrad Med 76(2): 133-145, 1984. 12. Geokas, M.C., ed. Symposium on ethyl alcohol and disease. Med Clin North Am 68(1): 1984. 13. Eckardt, M.J., and others. Health hazards as sociated with alcohol consumption. JAMA 246:648666, 1981. 14. Mayer, R.F., and Kurana, R.K. Peripheral anc autonomic nervous system, chap 13. In Pattison, E.M., and Kaufman, E., eds. The encyclopedia handbook ol alcoholism. New York, Gardner Press, 1982. 15. Mayer, R., and Garcia-Mullin, R. Peripheral nerve and m uscle disorders associated with al coholism, vol 2. In Kassin, B., and Begleiter, H., eds. The biology o f alcoholism. New York, Plenum Press, 1972. 16. Victor, M. Polyneuropathy due to nutritional deficiency and alcoholism. In Dyck, P.; Thomas, P.; and Lam bert, E., eds. Peripheral neuropathy. Philadelphia, W. B. Saunders Co, 1975. 17. American Psychiatric Association diagnostic and statistical manual o f mental disorders, ed 3. Wash ington, DC, American Psychiatric Association, 1980. 18. Mayer, R.F. Recent studies in man and animal o f peripheral nerve and muscle dysfunction associated with chronic alcoholism. Ann NY Acad Sci 215:370372, 1973. 19. Strauss, M.B. T he etiology o f “alcoholic” polyneuritis. Am J Med Sci 189:378-382, 1935. 20. Victor, M., and Adams, R.D. On the etiology of the alcoholic neurologic disease. Am J Clin Nutr 9(4):379-397, 1961. 21. Low, P.A., and others. The sympathetic ner vous system in alcoholic neuropathy. Brain 98:357364, 1975. 2 2. C o ers, C ., and H ild e b r a n d , J. L aten t neuropathy in diabetes and alcoholism. Neurology 15(1): 19-38, 1965. 23. Hornabrook, R.W. Alcoholic neuropathy. Am J Clin Nutr 9:398-403, 1961. 24. Merritt, H.H. Textbook o f neurology, ed 5. Philadelphia, Lea 8c Febiger, 1973, pp 264-644, 784802. 25. Gibilisco, J.A. Dental perspective on face pain. Postgrad Med 76(2): 121-132, 1984. 26. Goldstein, N.P.; Gibilisco, J.A.; and Rushton, J.G. Trigeminal neuropathy and neuritis: a study of etiology with emphasis on dental causes. JAMA 184:458-462, 1963. 27. Shiloah, J.; Lee, V.B.; and Binkley, J.H. Selfinflicted oral injury to secure narcotic drugs. JADA 108(6):977-978, 1984. 28. Gibilisco, J.A.; Goldstein, N.P.; and Rushton, J.G. Differential diagnosis o f atypical facial pain. Lan cet 85:450-454, 1965. 29. Crosby, E.C.; Humphrey, T.; and Lauer, E.W. Correladve anatomy o f the nervous system. New York, Macmillan, 1962. 3 0. P a p a r ella , M .M ., and S h u m rick , D .A . Otolaryngology, vol 1. Philadelphia, W. B. Saunders Co, 1973.
REPORTS
Alcoholic facial neuralgia: report of three cases J a m e s T . M u lr y , M D J o s e p h C er b in , M D D a v id L. S p e n c e r , M D
He described steady, nontraum atic jaw pain, m ore intense in the area o f the m andible than the maxilla, and had numbness o f both hands. T h e patient had 14 cm hepatomegaly, trem or, and num bness to pinprick in the hands, b u t the jaw and face were norm al. Levels o f blood al cohol, venous amm onia, mean corpuscular vol um e (MCV), and serum glutamic pyruvic trans aminase (SGPT) were elevated. Results o f fast h ree cases o f n o n trau m atic facial ing blood glucose and a panoram ic radiograph pain associated with consum ption o f the jaw were norm al. Abstinence from al o f alcohol are p rese n ted . In two o f c o h o l a n d tr e a tm e n t w ith o x azep am a n d the cases, pain rem itted w ith abstinence thiam ine brought remission o f all symptoms in and re tu rn e d with relapse to alcohol inges 2 days. tion. We postulate th a t these cases involve D uring a second admission 3 months later, alcoholic n eu ralg ia in th e d istrib u tio n o f the patient adm itted that he had relapsed to the m ental a n d su p e rio r alveolar b ranches daily alcohol ingestion without other d ru g use o f the trigem inal nerve; possibly a m o n o for 6 weeks before admission. His mandible n eu ro p a th y o r a re fe rre d sym ptom from again had become num b and tender. Alcohol on the breath, agitation, and possible laryngeal irritation. lid lag were present. T h e blood pressure was 130/80. T h ere now was bilateral m andibular, Review of literature m ore than maxillary, numbness to pinprick as well as tenderness to touch. T h ere was 11 cm Facial pain in patients who have alcoholism clas hepatomegaly and epigastric tenderness, but no sically resu lts fro m a ltercatio n -a sso c iate d c lin ic a l e v id e n c e o f g o it e r , p e r i p h e r a l traum a. In reviews o f facial pain in the internal neuropathy, o r visible oral disease. T h e patient m edicine,1'3 family practice,4'6 psychiatric,7 had elevated levels of gamma glutamyl trans otolaryngological,8 dental,9 and neurological10 ferase (GGT), venous ammonia, blood alcohol, literature, no association o f facial pain with al and MCV, a lowered serum folate, and norm al coholism em erged beyond the expected m en levels o f thyroxin, serum B 1 2 , and fasting blood tion o f traum a,10 alcoholic aggravation o f clus glucose. H e im proved slightly after treatm ent ter m igraine,11 and the glossalgia/glossodynia w ith p a re n te ra l th iam in e, o ral o x azepam , o f alcohol-associated riboflavin (vitam in B fenoprofen calcium, lactulose, and pyridoxine. complex) deficiency.4 No previous reports o f On the sixth day, the oral problems persisted alco h o l-induced facial n eu ra lg ia o r facial and an oral-surgical consultant found no evi neuropathy exist.12,13 Reviews o f literature re dence o f dental, tem porom andibular (TM), or g a rd in g cases o f p a in fu l alcoholic n e u ro g in g i v a l/ p e r i o d o n ta l d is e a s e . A n o th e r pathy14' 16 contained no mention o f facial pain panoram ic radiograph was norm al. o r facial n e u ro p a th y in p a tie n ts w ith a l D uring the next 10 days, oral pain slowly coholism. rem itted and the patient completed an inpa tient alcoholism rehabilitation program . How ever, the patient was adm itted again 3 months Report of cases later for detoxification. At this time, the patient Case 1 . A 27-year-old male was adm itted to the stated that pain in the lower jaw had recurred 2 hospital for detoxification. H e fulfilled {DSM weeks after he had resum ed drinking. T h e ad III)17 criteria for alcohol intoxication and de m itting physician noted trem or, alcohol on the pendence. A history o f previous m arijuana, b reath , a blood pressure o f 160/100, and epigas am phetam ine, sedative, and narcotic abuse was tric tenderness but no lid lag o r hepatomegaly. obtained. T he patient did not have diabetes T h e blood alcohol and SGPT levels were ele mellitus, m alnutrition, o r exposure to heavy vated, with norm al levels o f MCV, venous am metals. He smoked one pack o f cigarettes daily. m o n ia , flu o re s c e n t tre p o n e m a l a n tib o d y
Three cases o f ja w p a in recu rren tly p r e c ip i ta te d by consum ption o f alcoh ol a re de scribed. A lcohol-induced neu ralgia is a d d e d to the d ifferen tia l diagn osis o f a ty p ic a l oro fa c ia l p a in .
T
(FTA), and blood glucose. All problems rem it ted after 4 days o f treatm ent with oral clorazepate and parenteral thiamine. T h e patient was referred to Alcoholics Anonymous but left the state and again relapsed. O n the patient’s final admission, 1 year later, he reported daily ingestion, d u rin g the past year, o f a fifth o f vodka, 60 mgm o f diazepam, and 4 to 6 oz o f a hydrocodone bitartrate, pseudoephedrine, guaifenesin antitussive. He again had dull, sometimes lancinating, jaw and chin pain but no odontalgia. He continued to smoke one pack o f cigarettes daily. Initially, the patient appeared to be norm al except for hepatomegaly and trem or, with no evidence o f dental disease or trigger points; GGT, SGPT, and venous amm onia levels were elevated. A toxicological screening was positive for diazepam, nordiazepam , alcohol, and aspi rin. An ear, nose, and th ro at consultant observed deviation o f the nasal septum with reduced air flow, m outh breathing, hyperem ia o f the left true vocal cord, and m andibular tenderness. Jaw pain was reduced by h alf after application o f to p ic a l a n e s th e tic (b e n z o c a in e 14% / tetracaine 2%) to the vocal cords. A neurologi cal consultant found norm al pain and touch sensation; m otor function and corneal reflexes also were norm al. U nfortunately, noninvasive electrodiagnostic studies o f the mental and al veolar nerves were unavailable. T h e facial pain partially improved after the patient gargled with viscous lidocaine (Xylocaine) and completely rem itted in 7 days with abstinence from alcohol, reduced smoking, and treatm ent with thiamine, multivitamins, and neomycin. A fter 4 m onths’ sobriety and partici pation in Alcoholics Anonymous, he retu rned for septoplasty. Case 2 . A 39-year-old male was referred for
medical evaluation after 2 years o f treatm ent by three dentists and two oral surgeons. T h e pa tient was concerned that serial extraction o f eight teeth had failed to relieve recu rren t jaw and tooth pain. H e related a p attern o f repeated visits to various oral clinicians, seeking relief. Only in retrospect were the problems linked to alcoholism. Each time, despite norm al radiographs and oral examination results, endodontic therapy
M ulry-Cerbin-Spencer : ALCOHOLIC FACIAL NEURALGIA ■ 847
CLINICAL REPORTS
was performed. The patient was given codeine and stopped drinking for a period, not wanting to mix alcohol with other drugs. During this alcohol-free time, the pain remitted. Each time, on depletion o f the codeine, the patient would resume drinking, the pain would recur, and the consultant would extract the tooth and represcribe codeine. Again tem porarily sober, the patient would be free of pain. But again, on depletion of the codeine, he would resume the cycle with new drinking, pain in another tooth, and the selection o f a new consultant. Examination confirmed the referring den tist’s impression o f a normal mouth and jaw, except for the extracted teeth. Despite a normal neurological examination, a 3-finger breadth of hepatomegaly, palmar erythema, and testicular atrophy indicated advanced alcoholism. GGT, triglyceride, and serum glutamic oxaloacter transaminase (SGOT) levels were elevated, with MCV, T4, and blood glucose normal. The patient was diagnosed as having al coholism with alcoholic neuralgia o f the jaw. He was unreceptive to both the diagnosis and re ferral to either Alcoholics Anonymous or an alcoholism treatment center, and subsequently was lost to follow-up.
o n ly w ith d ip h t h e r ia , d ia b e t e s , o r Guillain-Barre syndrom e.24 Nontraum a tic cases o f atypical facial neuralgia in a trigem inal distribution similar to these cases (excluding the ophthalmic branch) have been reported,25,26 but not with al cohol as an inciting agent. Facial pain from self-inflicted injury by a m alingerer seek ing narcotics has been reported, but gingi val lesions were present,27 whereas other so-called “psychiatric causes” o f facial pain6 often prove to be a painful trigem i nal neu rop ath y5 rather than the com m only sought classical trigeminal neural gia.28 A contributing m echanism in the fourth admission o f the patient in case 1 may have been referred laryngeal pain, as suggested by the partial im provem ent o f mandibular pain after topical laryngeal anesthesia. T h e interconnection o f the trigem inal nerve with the glossopharyngeal, vagus, and facial nerves provides an anatomic m echanism for referred pain.29 T h e clini cal observation that stim ulation o f the g lo ss o p h a r y n g e a l n erv e m ay trig g e r Case 3. A 46-year-old male with odontalgia was trigeminal neuralgia30 and the occasional referred by a dentist for evaluation after the experience o f referred odontalgia caused odor o f alcohol was noticed on the patient’s by laryngeal irritation30 support this addi breath. The patient had a history o f multiple tional mechanism. dental visits for mandibular pain. Despite nor mal dental examinations, endodontic therapy was attem pted twice w ithout relief. T h e panoramic and other radiographic examina tions in the dentist’s office were normal, and the patient was referred to the author. The interview showed that the patient satis fied the SDM I I I 17 criteria for alcohol abuse. As the diagnosis became obvious in the course o f the interview, the patient became anxious and refused examination, laboratory evaluation, or a follow-up appointment. He abruptly left the office and subsequently was lost to follow-up.
Conclusion
Atypical facial pain and odontalgia are re ported, associated with alcoholism. An alcohol-induced distal, trigeminal, atypi cal neuralgia, possibly a m ononeuropathy, explains the clinical findings. Referred laryngeal pain also was suggested as an a g g r a v a tin g fa cto r in th e fir st case. Awareness by the oral clinician o f this clin ical sign will facilitate diagnosis o f the un derlying alcoholism, a treatable disorder Discussion in m any patients. A bstinence from al cohol, as finally achieved in the first case, is A lcoholic neuropathy, an attractive ex the fundam ental treatm ent o f alcoholplanation for the clinical observations re induced atypical facial neuralgia. ported here, has been considered variably --------------------jm A --------------------a toxic,18 nutritional, or m ixed disease.19,20 The authors thank Robert E. Finch, MD, for his Although the disease usually affects the contributions to this paper. extrem ities, it also som etim es can affect Dr. Mulry is assistant professor; Dr. Cerbin is clinical the sympathetic nervous system.21 Painful instructor; and Dr. Spencer is professor and chairman, alcoholic neuropathy has been compared department of family practice, Southern Illinois Uni with diabetic neuropathy,22 which can af versity, School o f Medicine, 421 N Ninth, Springfield, fect the face, but facial pain with alcohol IL 62708. Address requests for reprints to Dr. Mulry. has not been described. Alcoholic cranial nerve palsies have been described,23 but all 1. Needham, C. W. Major cranial neuralgias and the were nonpainful. In the first case, electro surgical treatment o f headache. Med Clin North Am diagnostic studies, for technical reasons, 62(3):545-557, 1978. 2. Duane, D.D. Neurological analysis o f facial pain. could not confirm facial neuropathy in the Postgrad Med 76(2): 161-172, 1984. patient; therefore the diagnosis was al 3. Clark, J.L. An overview o f face pain. Postgrad coholic atypical facial neuralgia. Med 76(2):90-97, 1984. 4. Donlon, W.C., and Jacobson, A.L. Maxillofacial T oxic facial neuralgias are associated 848 ■ JADA, Vol. 112, June 1986
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