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Diagnosis and Treatment of Oral Neuralgic Pains
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A National Health Problem. (Editorial.) Dent. Digest of frac., 2:158, November 1941. 6. B o y d , J. D . ; D r ain , C. L., and N elson , M.: Dietary Control of Dental Caries. Am. J. Dis. Child.., 38:721, October 1929. 7. B oyd , J. D.: Rôle of Diet in Control of Dentinal Caries. J.A.D.A., 27:750, May 1940. 8. H o w e , P. R .; W hite , R. L., and R abin e , M .: Retardation of Dental Caries in Outpatients of Dental Infirmary. Am. ]. Dis. Child., 46:1045, November 1933. 9. H o w e , P. R . ; W h ite , R u t h L., and E l l io t t , M. D.: Influence of Nutritional Supervision on Dental Caries. J.A.D.A., 29 : 38, January 1942. 10. B ro d sk y , R . H . ; S c h ic k , B ., and V o l l m e r , H.: Prevention of Dental Caries by Massive Doses of Vitamin D. Am. J. Dis. Child., 62:1183, December 1941. 11. M c B eath , E. C., and V erlin , W . A.: Further Studies in Rôle of Vitamin D in Nu
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tritional Control of Dental Caries in Children. J.A.D.A., 29:1393, August 1942. 12. B o yd , J. D . : Nutrition as It Affects Tooth Decay. J. Am. Diet. A., 18 :21 1, April 1942. 13. K lein , H en r y , and P alm er , C. E.: Studies on Dental Caries: I. Dental Status and Dental Needs of Elementary School Chil dren. Pub. Health Rep., 53:751, May 13,
1938. 14. Idem: Prevalence and Incidence of Dental Caries Experience, Dental Care, and Carious Defects Requiring Treatment in High School Children. Pub. Health Rep., 55:1258, July 12, 1940. 15. B r au er , J. C.: Unpublished data. 16. Iowa State Planning Board, Mineral Analysis of Underground Waters of Iowa. Des Moines: State Printing Office. 17. D ean , H. T., and J a y , P h i l i p : D o mestic Water and Dental Caries. Pub. Health Rep., 56:761, April 11, 1941.
DIAGNOSIS AND TREATMENT OF ORAL NEURALGIC PAINS M
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H E dentist today is often called upon to deal with pains which originate in the jaws, and which cannot always be attributed to the teeth. In some cases, these pains are present in the edentulous m outh; in others, they originate at the site of recent extractions. O ften, the trouble begins around a par ticular tooth, the extraction of which does not alleviate the condition. Again, it m ay center around certain teeth that show no pathosis. In the cases under consideration, ex amination of the jaws clinically and by means of roentgenograms reveals no un erupted or retained teeth or roots or other conditions that could cause these
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D.D .S., Buffalo, N. Y . disturbances. Likewise I am not re ferring to the numerous cases in which dental pain is caused by impacted teeth, pulp stones, putrescent pulps, salivary calculi in ducts or cysts of the jaw. The> literature is replete with reports of re lief obtained from the elimination of these causes. In all types of cases to be discussed, the patient suffers from many degrees of pain. Sometimes, the trouble is mild, but annoying. M ore often, the pain is more severe and disturbing. In other cases, it is so intense that it upsets the patient’s routine of living. T h e last con dition should not be confused with that form of pain known as trigeminal neural gia or other m ajor neuralgias. Most of the conditions are to be de scribed as neuralgia and, in the main, such a classification m ay be true. However,
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it has been stated on good authority1 that all true neuralgia is central in origin and that all other types of pain found in and around the oral cavity are forms of neuritis. M echanical injury is one cause of neuritis, and this condition is often found in the mouth. It is a controversial point, as the symptoms in many of the cases I examine seem to agree with the definitions of both neuralgia and neu ritis. Webster defines neuralgia as an acute pain, constant or intermittent, radiating along the course of a nerve and its branches; also the morbid condition characterized by such pain. Neuritis is defined as an inflammation of a nerve characterized by pain, sensory disturb ances and reflex abnormality or other signs of nervous disability in the part affected. It can readily be seen that the only way to prove the category into which a condition fits is to resect the tissues. If an inflamed nerve is found, neuritis is present; if not, neuralgia.
A check of the tabulated cases will show that the most numerous types are the various forms of neuralgia. R e ferred pain and thermal pain are often called neuralgia or neuritis before a diag nosis is made. T h ey are often found in combination. However, after a careful examination, their true status is easily revealed. It is in these divisions of cases that we have teeth as the exciting cause.
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There were twelve cases of thermal pain. In these cases, one or more teeth react to varying degrees of either hot or cold, or both. Exam ination shows no valid reason for such reactions. The trouble starts spontaneously and it is not the pain originating under new fillings. Occlusal trauma is not present, but there m ay be old deep fillings or pulp stones. There is no soreness on percussion. C on tact with* cold drinks, ice cream or cold air m ay start the pain.. In other cases, contact with cold or heat, or both, starts the trouble. In fewer cases, only heat is the irritant. I exclude the type of cases asso ciated with a degenerating pulp. In all these cases, there is a positive response to the vitality tester, especially in teeth reacting to cold. In those responding to heat only, there is a lesser response to the tester. T o determine the cause of this condi tion is difficult. It m ay be some form of
A survey of 180 recorded cases of per sistent pain gave, roughly, the accom panying classification. T h e reason for keeping a record is that most o f the cases respond to similar forms of treatment. Some cases m ay overlap from one type of pain to another at various times. Then again, simple pains may develop into more severe and persistent types if left untreated. Also, I observe some forms o f pain the diagnosis of which can be placed under several headings. Survey
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Type of Pain Number of Cases Referred pain ......................................... 13 Thermal pain ..........................................12 Mild and severe neuralgia.................... 62 Postoperative neuralgia ........................ 66 Atypical neuralgia types.........................20 Bursitis of temporomandibular joint. . 4 Antrum pains ........................................ 3
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There were thirteen cases of referred pain. In each one, the pain was re ferred from a tooth or part of the jaw to another tooth or some distant part o f the jaw or face. V ery little has been written regarding the etiology of referred pain in or about the jaw . It is probably caused by irrita tion of the nerves, of the teeth or the jaws referred fe* the gasserian ganglion. This stimulates other parts o f the gan glion and the pain is referred to other branches of nerves emanating from it. THERMAL PAIN
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arterial hyperemia and, occasionally, some types m ay be related to a venous form of hyperemia. It is also possible that there is a disturbance of the auto nomic sympathetic nervous system. A ccording to Cahn,2 the preganglionic seventh, ninth and tenth cranial nerves travel from the spinal cord and neck to the salivary glands and make their w ay into the tooth pulps. H e says, There are also some that probably fol low the same course but have their origin in the upper thoracic segments of the spinal cord. These come out from the ganglia arranged along the side of the cord, un doubtedly the stellate ganglia. T h ey control contraction and dilation o f the pulp and m ay be responsible for some of the conditions known as atypical neuralgia. I treat these cases successfully by the application of quartz light therapy with out opening the pulp chamber. Cahn believes that the actinic rays m ay cause a vasodilation that is beneficial. n e u r a l g ia
I have recorded sixty-two cases of mild and severe neuralgia. Although they both come under the general definition of neuralgia, I classify them according to differences in the degree of pain and as to whether these symptoms are simple or complex. A long-standing neuralgia could be called severe even though the pain were not so great. T h e reason for this is that a long-continuing pain, al though not extreme, tends to undermine the resistance. Pain can further be dis tinguished by referring to it as a mandib ular or a maxillary neuralgia. T h e etiology is obscure, but may be somewhat similar to that described in re ferred pain. It is possible that m any of the long-standing cases that w e describe as neuralgia could be classified as neuri tis. Sometimes, the symptoms fit the defi nition of neuritis, but they have been classified as one type to prevent confu sion.
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T h e pain m ay be dull or very sharp, constant or intermittent. It m ay be con fined to the jaws only or m ay include the face. Periodontoclasia may be present. M andibular and m axillary neuralgia is not related to the painful symptoms associated with ear conditions caused by reduction o f the vertical overbite. These symptoms are supposed to be caused by the erosion o f the bone of the glenoid fossa. T h e rocking movements of the temporomandibular joint cause pressure on the auriculotemporal nerve and the chorda tym pani nerve. Block and H ar ris3 have recently published a compre hensive paper on temporomandibular joint problems. T h ey show that diagnosis of the symptoms of this condition re quires much study and thought. Also, a fundamental knowledge of anatomy, physiology and pathology is necessary, aided by roentgenographic and clinical examination. Th ey show that the three vital factors to be considered in every mouth condition a r e : ( i ) centric rela tion, (2) vertical dimension and (3) bal anced occlusion. Rebuilding o f the jaws according to these specifications is the solution, and these authors claim a high percentage o f success in so treating these types of cases. M axillary and m andibular neuralgia are very often confused w ith spheno palatine ganglion neuralgia. This pain is often seen first by the dentist, and it is important to diagnose it because, in the hands o f an otolargyngologist, it can be quickly relieved. According to W att W . Eagle,4 it is a unilateral facial pain and not a head ache. It never extends above the level of the ear. He says, The pain is usually lancinating and con tinuous; it may last from a period of a few minutes up to several days at a time, re curring after no special interval and always more or less repeating the previous episode. There are usually two main points of maxi mum pain, one in the region of the orbit and the root of the nose and the other in
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the region just posterior to the mastoid proc ess in the temporal bone. In some patients, only one of these points of maximum tender ness is present, that more likely being the region the orbit and the root of the nose. If both points of intense pain are present, the pain seems to originate in the root of the nose and to involve the orbit, causing extreme soreness in the eyeball, and extend back through the eye into the region of the ear, frequently causing earache and a sen sation of fulness of the ear and tinnitus. T o establish the diagnosis, the spheno palatine ganglion is cocainized through the nose and, if the pain disappears in a few minutes, the diagnosis is considered correct. Sometimes, the ganglion is in jected with a small amount of alcohol. p o s t o p e r a t iv e n e u r a l g ia
I have listed sixty-six cases of post operative neuralgia, the most common classification in my records. T h e pain syndrome, which is occasionally seen by dentists, involves either the mandible or the maxilla, following extraction or other surgical measures. Postoperative neural gia differs from the usual traumatic pain in that it is not localized. It is generally unilateral and affects the jaw bones, face, fieck and ears. It m ay be accom panied by inflammation. T h e pain is usually a dull and continuous type, with no remissions. In some cases, the pain is sharp in the beginning, later becoming dull. Occasionally, postoperative neural gia takes on the characteristics o f re ferred pain, because the pain is trans mitted to other parts of the jaw , face and neck in addition to the region of the original disturbance. The patient usually gives a history of single or multiple extractions from one to ten days earlier. In most cases, several days pass before the full force of the pain is felt. O ther cases report the pain to have started after the effect of the local anesthesia wore off. In a few cases, the complete syndrome of pain was felt be fore the extraction. T he patients com
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plain of a dull continuous pain persist ing since the extraction and get relief only from continuous use of bromides or other sedatives. M any patients have the condition er roneously known as dry socket, sometimes in a severe form, but generally mild. T h e clot m ay be missing from the socket with no perceptible infection present. Often, there appears to be a normal clot. In some extreme conditions, the patient has been suffering from neuralgia for more than a week, during which the socket has completely healed. Thereafter, the pain will eventually disappear, but the patient is left debilitated and in a nervous con dition. A t other times, the pain persists long after the healing has taken place. T h e most common site of this neuralgia is the socket of the lower third molar, especially if the tooth has been im pacted. N ext in order of frequency is the sockets of the lower first molar, lower bicuspid and upper first molar. However, the symptoms m ay follow extraction of any tooth in the mouth. T h e diagnosis of postoperative neural gia is assumed in these cases. It appears that the contiguous nerve supplying the tooth becomes inflamed through trauma or infection, or both. The temporary re lief that sedative dressings give is prob ably due to seeping of the anesthetic m a terial through the bone into the nerve fibers. From this description, one could classify the condition as postoperative. ATYPICAL NEURALGIA TYPES
Cases of atypical neuralgia are often classified as trigeminal neuralgia. M y records show twenty cases. T o clarify these types of pain, I shall briefly add definitions of m ajor neuralgia and atypical neuralgia. Herman Chor writes,1 True neuralgia is characterized by its paroxysmal nature, whereby “ explosions” or “ bursts” of severe, sharp lancinating pain strike the patient. Such attacks of pain last
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only a few seconds, rarely longer than .half a minute. This short duration is a cardinal feature of true neuralgia. If the pain lasts longer, that is, for several minutes or half hour or more, it cannot be diagnosed as neuralgia. H e also mentions that, in neuralgia, the pain follows the course of a nerve and is not disturbed over the area be yond that supplied by a particular nerve. In trigeminal neuralgia, the m ain point in diagnosis is the presence of a trigger zone. O nly a slight touch in these areas starts the pain. There m ay be remissions of pain in some cases of true neuralgia. Reported cures following extraction or other dental operations m ay be due to this fact. O ther types of true neuralgia are glossopharyngeal and superior laryn geal neuralgia. L. B. Bender says,5 Atypical neuralgia is a type of pain about the face and head which does not fall into classification of true trigeminal neuralgia. It is usually very difficult to treat. Pain persists in these cases even after the gasserian ganglion has been removed. The at tacks are chronic and usually bilateral in character, dull, deep aching pain in the eye, molar region about the ear and face and worse at night. Glaser6 describes atypical neuralgia as of unknown etiology, with failures to respond to clinical relief. Certain types o f atypical neuralgia appear to simulate trifacial neuralgia in some of the later phases. It can be noted that there appears to be a close relation ship between some forms of atypical neu ralgia and various forms of neuritis. V ery little has been written regarding the etiology of atypical neuralgia. It is believed that the autonomic systems play a role in the etiology o f some cases. H ow ever, L . J. Pollack and L. Davis7 have the following to s a y : Painful impulses may be conducted along the sympathetic nerve fibers or the viscero motor or other reflex activities may pro
duce conditions which in turn are respon sible for conscious pain. On the other hand, both mechanisms may be present. Long-standing cases of neuralgia can be classified as the atypical type, because the definitions describing these conditions are rather variable and vague. Bursitis and antrum pains are distinct entities and will not be discussed in this paper although both respond to the form of treatment herein described. treatm ent
T h e principal form of treatment em ployed in attacking all these previously described forms of pain is physiotherapy, including use of the infrared lamp, the m ercury quartz lamp and short wave dia thermy. T h e quartz lamp that I use for this work is one of the more powerful types, developing 28 per cent ultraviolet light. In some cases, I manipulate the tissues in the area about the affected parts, paying especial attention to ter minal nerves of the infra-orbital and m en tal regions. This action is a combination of massage and stretching. These m odali ties are in addition to the routine treat ment such as irrigation and dressing of wounds in postoperative neuralgia. Prostigmine methylsulfate 1 :2,000 and prostigmine bromide have been used suc cessfully in treating neuritis of the face and neck region. Thiam ine chloride is of- value in the treatment of neuralgia. Occlusal trauma should be relieved whenever encountered. T h e exception to these forms, of treat ment is the handling of referred pain. In this condition, the cause must be as certained and removed. It may lie in an inflamed pulp, an obscure abscess or an infected antrum. Therm al pain is treated specifically by the quartz lamp as previously mentioned. I use a powerful water-cooled lam p and apply the light by means of quartz rods, using a round applicator one-half inch in diameter or a larger rod with a square
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face measuring about three-fourths inch across. T h e gums surrounding the sus pected teeth and the teeth adjacent are radiated over all the labial, buccal and lingual surfaces involved to a height of one-half to three-fourths inch. A t the initial exposure, ten seconds is given to each place of application, and this is in creased by two or three seconds at each successive treatment. A slight amount of pressure is employed to dehematize the tissues in using the quartz rods. This is the basic technic for most quartz light applications intra-orally. T h e teeth should also be exposed to the light. In mild and severe neuralgia, the infrared lamp is employed for twenty minutes at 18 inches. This generally gives some degree o f relief, but if it does not, its use is discontinued in this particu lar case. Either ultraviolet irradiation intra-orally and extra-oral or short wave diathermy follows, according to the ex perience and judgm ent of the operator. O ften, both agents are used, especially in severe cases. W hen the pain is centered around the mental or infra-orbital fora men, I employ also manipulation of the facial tissues about these areas. T h e quartz lam p is used with the tech nic previously described intra-orally and extra-orally, with the direct face of the lam p against the seat of complaint at about 4 inches for ten seconds. This ex tra-oral exposure is increased two or three seconds at each subsequent treat ment. A brunet w ill tolerate more ir radiation at eath sitting than a blonde. T h e short wave is applied by rubber pads well covered by two or three layers, of turkish toweling, one on each side of the face. T h e heat is applied from seven to ten minutes at 2,000 to 4,000 milliamperes, the m illiamperage depending on the amount of warm th tolerable to the patient. Most cases o f postoperative pain fol lowing extraction or surgical procedure will respond to the newer type of drugs
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now used for dressing wounds, and can be kept under control by frequent re placements. It is the exceptional case that does not respond to this orthodox treatment with which I am concerned. In these cases, the operative site is first cleaned up and a sedative dressing placed. Next, the patient is given twenty minutes’ exposure under the infrared lam p at 18 inches, and, in nearly every case, relief is obtained. Next, the entire intra-oral area about this part is exposed to the quartz lam p by means of a large quartz applicator, described in the pre ceding paragraph. Next, the extra-oral parts are exposed to the direct rays of the lamp. T h e next day, the patient usu ally reports that he has had hours of relief, and then a recurrence. I then re peat the treatment, but increase the dos age of light. Recently, I have employed the short w ave diathermy in addition to the foregoing treatment, and I find that it shortens the course considerably. F re quently, one application of the short wave will terminate the pain. Atypical neuralgia responds to the treatment described under m ild and se vere neuralgia. I have mentioned bursitis and antrum pains because of the success often at tained in seeking relief from these com plaints. In bursitis, I depend on very heavy doses of ultraviolet light. In antrum pains, I employ all three modalities. r epo r t o f cases
C a s e i.— Referred Pain.— Mrs. W. B., aged 25, complained of intermittent pain in the right infra-orbital region accompanied b y . twitching of the muscles. The muscles around the nose were contracted during the spasm. Examination showed a subacute abscess of the lower right first bicuspid. Ex traction revealed • a distended granuloma containing pus (staphylococcus). All symp toms immediately disappeared. C a s e 2.— Thermal Pain.— Mrs. F. M., aged 30, in the ninth month of pregnancy, gave a facial reaction to hot and cold
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especially affecting the upper left bicuspids and molars and the left side of the face. The pain had persisted for four days and the patient was unable to sleep. The teeth re sponded to electric and thermal vitality tests. A slight occlusal trauma was adjusted, with negative results. At the next visit, a quartz lamp was applied to the teeth, jaws and face, with complete relief the next day, and no recurrence. C a s e 3.— Thermal Pain.— Mrs. K., aged 31, had a vital lower left cuspid that reacted to heat. A quartz lamp was applied to the teeth and jaws around this area and to the face and, one week later, the patient re ported that she could drink hot liquid with out discomfort: Three months later, there had been no recurrence. Case 4.— Neuralgia.— Mrs. M., aged 51, complained of a pain resembling toothache, in the lower right jaw and cheek, of several weeks’ duration. She felt as if ,she had a toothache in the lower right second bicuspid and first molar areas although these teeth had been extracted three months previously. Ultraviolet light was applied to the right jaw and cheek arid the tissues about the mental foramen w6ie ¡stretched. Three days later, the patient reported that she was en tirely free from pain.' There has been no recurrence in threft-years. Case 5.— Neuralgia.— Mr: J. O., aged 43, early in November 1940 had a very sharp pain affecting the left side of the tongue, in creased when he was eating. November 22, he had the lower left impacted molar re moved. He had ha relief until the second week in December, when the pain suddenly disappeared. January 25, 1941, he came under my care.. He had had a recurrence of the pain and could obtain relief only through constant use of codeine. The pain traveled along the course of the lingual nerve from the third molar region forward. The teeth were not sensitive to percussion. X-ray examination revealed two roots of the extracted third molar remaining in the socket, one of them lying in the mandibular canal. The infra red lamp was applied to the left side of the face for twenty minutes at about 18 inches. This was followed by diathermy for seven minutes, and next the ultraviolet rays were applied* to the local affected parts through a quartz rod, as previously described. The
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tissues around the lingual nerve were lightly manipulated. It was decided that if no re lief was obtained in a few treatments, the remaining roots in the lower left third molar socket would be removed. February 5, after a period of complete relief, the pain recurred. The patient was in a city 90 miles away and the pain re turned while he was brushing his teeth. He, immediately came back to my office and had the treatment repeated. February 6, he reported taking one co deine tablet, to “play safe.” At breakfast, he was slightly bothered, but could eat. The treatment was repeated, but in larger doses. February 19, the patient reported three mornings of p^in lasting from one to one and a half hours. The treatment was re peated. May 1, the patient reported no recurrence of pain to date. C a s e 6.— Postoperative Neuralgia.— Mr. R. G., aged 25, had a lower left impacted molar removed April 23. The extraction was followed by dull, but occasionally sharp pains in the wound, face, temple region and head. April 24., the area was washed out and a sedative inserted, but with no relief. April 25, the patient first came to see me, with a history of having had no sleep or relief from pain. Infrared, ultraviolet and diathermy, given as heretofore de scribed, afforded some relief. April 26, the patient reported almost com plete relief. The treatment was repeated. April 27, relief was complete and the patient was discharged. C a s e 7.— Postoperative Neuralgia.— Mrs. G. C ., aged 30, had a lower left second bicuspid with an acute abscess extracted and three hours later developed a severe pain. Her dentist treated her for three days, ap plying powerful analgesics to the socket, but the ‘ treatment helped for only a short time. The patient took boxes of sedative pills during this time. . She was referred to me and I applied infrared, and ultraviolet light, using the basic technic described. The patient felt better that night, but the pain returned in the morning. The treat ment was repeated, with complete relief. C a s e 8.— Postoperative Neuralgia.— Miss W., aged 31, had had the upper teeth ex tracted by her dentist three weeks before.
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She later developed severe pain over the left infra-orbital region. Great quantities of sedative pills were consumed, with no results. The patient was very irritable and practically exhausted physically. Infrared and ultraviolet radiation were given as pre viously described and, four days later, great improvement was reported. The treatment was repeated. Three days later, there had been no recurrence and the patient was dis charged. C a s e 9.— A t y p ic a l Neuralgia.— Mr. F. W., aged 33, seen November 30, 1936, re ported a continuous dull pain present for the past seven years and affecting the lower left jaw from the third molar region to the mental foramen. A t times, the pain became sharp. There was a constant roaring in the Left ear. A n impacted third molar and de vitalized second molar were removed, with no results. Five treatments were given with the infrared light for twenty minutes at 18 inches. The ultraviolet light was applied with a quartz rod for ten seconds at each point and the face exposed to the direct rays. The tissues around the mental foramen were manipulated. The result was a com plete recovery. In December 1939, the patient reported that, three weeks before, thè pain had grad ually returned. It was especially severe while he was chewing. The roaring re turned to the ear. Five treatments with the infrared and ultraviolet lamps, as previously described, were given, with the addition of diathermy 3,000 milliamperes for ten min utes. The symptoms cleared up and the patient was discharged. C a s e 10.— Atypical Neuralgia.— Mrs. D. C ., aged 40, had had pain in the right an trum and infra-orbital region for the past four years. Tw o years previously, she had had an abcessed tooth in the upper right jaw removed with some relief for one month. A year previously she had had all of the upper teeth extracted to relieve the pain. She felt better for about a month, but the
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pain recurred. Three infrared and ultra violet treatments were given, to the jaw and face on the affected side according to the described technic. The tissues about the infra-orbital region were massaged and stretched. The patient was entirely relieved and was discharged. c o n c l u s io n
I have attempted to classify the various neuralgic pains which the dentist oc casionally encounters, and which do not respond to drug therapy or the usual armamentarium found in his office. Sev eral forms of physiotherapy have been mentioned that m ay be used with success in alleviating these conditions. A search of the dental literature gives little or no information regarding the treatment of these cases. There may be better and shorter methods of handling them which the publication of this paper may bring to light. BIBLIOGRAPHY
1. C hor , H e r m a n : Neurologic Aspects of Temporomandibular Disorders. J.A.D.A., 2 5 : 1033-1036, July 1938. 2. C a h n , L. R .: Personal communication to the author. 3. B l o c k , L. S., and H a r r i s , E l a m : Ap proach to Rational Study and Treatment of Temporomandibular Joint Problems. J.A.D.A., 29 :349-358, March 1942. 4. E agle , W. W . : Sphenopalatine Ganglion Neuralgia. Arch. Otolaryn., 35:66-84, Janu ary 1942. 5. B e n d e r , I. B . : Atypical Facial Neuralgia. D. Cosmos, 78:475 May 1936. 6. G laser , M. A.: Facial Neuralgia in Relation to Dentistry. J.A.D.A., 19:1537, September 1932. 7. P o l l a c k , L. J., and D a v is , L o y a l : Neurological Surgery. Philadelphia: Lea & Febiger, 1936. 131 Linwood Avenue.
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A National Health Problem. (Editorial.) Dent. Digest of frac., 2:158, November 1941. 6. B o y d , J. D . ; D r ain , C. L., and N elson , M.: Dietary Control of Dental Caries. Am. J. Dis. Child.., 38:721, October 1929. 7. B oyd , J. D.: Rôle of Diet in Control of Dentinal Caries. J.A.D.A., 27:750, May 1940. 8. H o w e , P. R .; W hite , R. L., and R abin e , M .: Retardation of Dental Caries in Outpatients of Dental Infirmary. Am. ]. Dis. Child., 46:1045, November 1933. 9. H o w e , P. R . ; W h ite , R u t h L., and E l l io t t , M. D.: Influence of Nutritional Supervision on Dental Caries. J.A.D.A., 29 : 38, January 1942. 10. B ro d sk y , R . H . ; S c h ic k , B ., and V o l l m e r , H.: Prevention of Dental Caries by Massive Doses of Vitamin D. Am. J. Dis. Child., 62:1183, December 1941. 11. M c B eath , E. C., and V erlin , W . A.: Further Studies in Rôle of Vitamin D in Nu
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tritional Control of Dental Caries in Children. J.A.D.A., 29:1393, August 1942. 12. B o yd , J. D . : Nutrition as It Affects Tooth Decay. J. Am. Diet. A., 18 :21 1, April 1942. 13. K lein , H en r y , and P alm er , C. E.: Studies on Dental Caries: I. Dental Status and Dental Needs of Elementary School Chil dren. Pub. Health Rep., 53:751, May 13,
1938. 14. Idem: Prevalence and Incidence of Dental Caries Experience, Dental Care, and Carious Defects Requiring Treatment in High School Children. Pub. Health Rep., 55:1258, July 12, 1940. 15. B r au er , J. C.: Unpublished data. 16. Iowa State Planning Board, Mineral Analysis of Underground Waters of Iowa. Des Moines: State Printing Office. 17. D ean , H. T., and J a y , P h i l i p : D o mestic Water and Dental Caries. Pub. Health Rep., 56:761, April 11, 1941.
DIAGNOSIS AND TREATMENT OF ORAL NEURALGIC PAINS M
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H E dentist today is often called upon to deal with pains which originate in the jaws, and which cannot always be attributed to the teeth. In some cases, these pains are present in the edentulous m outh; in others, they originate at the site of recent extractions. O ften, the trouble begins around a par ticular tooth, the extraction of which does not alleviate the condition. Again, it m ay center around certain teeth that show no pathosis. In the cases under consideration, ex amination of the jaws clinically and by means of roentgenograms reveals no un erupted or retained teeth or roots or other conditions that could cause these
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Prepared for the Section on Histology, Physiology, Pathology, Bacteriology and Chemistry (Research) of the American Den tal Association, 1942. Jour. A .D .A ., Vol. 30, M ay 1, 1943
D.D .S., Buffalo, N. Y . disturbances. Likewise I am not re ferring to the numerous cases in which dental pain is caused by impacted teeth, pulp stones, putrescent pulps, salivary calculi in ducts or cysts of the jaw. The> literature is replete with reports of re lief obtained from the elimination of these causes. In all types of cases to be discussed, the patient suffers from many degrees of pain. Sometimes, the trouble is mild, but annoying. M ore often, the pain is more severe and disturbing. In other cases, it is so intense that it upsets the patient’s routine of living. T h e last con dition should not be confused with that form of pain known as trigeminal neural gia or other m ajor neuralgias. Most of the conditions are to be de scribed as neuralgia and, in the main, such a classification m ay be true. However,
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it has been stated on good authority1 that all true neuralgia is central in origin and that all other types of pain found in and around the oral cavity are forms of neuritis. M echanical injury is one cause of neuritis, and this condition is often found in the mouth. It is a controversial point, as the symptoms in many of the cases I examine seem to agree with the definitions of both neuralgia and neu ritis. Webster defines neuralgia as an acute pain, constant or intermittent, radiating along the course of a nerve and its branches; also the morbid condition characterized by such pain. Neuritis is defined as an inflammation of a nerve characterized by pain, sensory disturb ances and reflex abnormality or other signs of nervous disability in the part affected. It can readily be seen that the only way to prove the category into which a condition fits is to resect the tissues. If an inflamed nerve is found, neuritis is present; if not, neuralgia.
A check of the tabulated cases will show that the most numerous types are the various forms of neuralgia. R e ferred pain and thermal pain are often called neuralgia or neuritis before a diag nosis is made. T h ey are often found in combination. However, after a careful examination, their true status is easily revealed. It is in these divisions of cases that we have teeth as the exciting cause.
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There were twelve cases of thermal pain. In these cases, one or more teeth react to varying degrees of either hot or cold, or both. Exam ination shows no valid reason for such reactions. The trouble starts spontaneously and it is not the pain originating under new fillings. Occlusal trauma is not present, but there m ay be old deep fillings or pulp stones. There is no soreness on percussion. C on tact with* cold drinks, ice cream or cold air m ay start the pain.. In other cases, contact with cold or heat, or both, starts the trouble. In fewer cases, only heat is the irritant. I exclude the type of cases asso ciated with a degenerating pulp. In all these cases, there is a positive response to the vitality tester, especially in teeth reacting to cold. In those responding to heat only, there is a lesser response to the tester. T o determine the cause of this condi tion is difficult. It m ay be some form of
A survey of 180 recorded cases of per sistent pain gave, roughly, the accom panying classification. T h e reason for keeping a record is that most o f the cases respond to similar forms of treatment. Some cases m ay overlap from one type of pain to another at various times. Then again, simple pains may develop into more severe and persistent types if left untreated. Also, I observe some forms o f pain the diagnosis of which can be placed under several headings. Survey
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Type of Pain Number of Cases Referred pain ......................................... 13 Thermal pain ..........................................12 Mild and severe neuralgia.................... 62 Postoperative neuralgia ........................ 66 Atypical neuralgia types.........................20 Bursitis of temporomandibular joint. . 4 Antrum pains ........................................ 3
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There were thirteen cases of referred pain. In each one, the pain was re ferred from a tooth or part of the jaw to another tooth or some distant part o f the jaw or face. V ery little has been written regarding the etiology of referred pain in or about the jaw . It is probably caused by irrita tion of the nerves, of the teeth or the jaws referred fe* the gasserian ganglion. This stimulates other parts o f the gan glion and the pain is referred to other branches of nerves emanating from it. THERMAL PAIN
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arterial hyperemia and, occasionally, some types m ay be related to a venous form of hyperemia. It is also possible that there is a disturbance of the auto nomic sympathetic nervous system. A ccording to Cahn,2 the preganglionic seventh, ninth and tenth cranial nerves travel from the spinal cord and neck to the salivary glands and make their w ay into the tooth pulps. H e says, There are also some that probably fol low the same course but have their origin in the upper thoracic segments of the spinal cord. These come out from the ganglia arranged along the side of the cord, un doubtedly the stellate ganglia. T h ey control contraction and dilation o f the pulp and m ay be responsible for some of the conditions known as atypical neuralgia. I treat these cases successfully by the application of quartz light therapy with out opening the pulp chamber. Cahn believes that the actinic rays m ay cause a vasodilation that is beneficial. n e u r a l g ia
I have recorded sixty-two cases of mild and severe neuralgia. Although they both come under the general definition of neuralgia, I classify them according to differences in the degree of pain and as to whether these symptoms are simple or complex. A long-standing neuralgia could be called severe even though the pain were not so great. T h e reason for this is that a long-continuing pain, al though not extreme, tends to undermine the resistance. Pain can further be dis tinguished by referring to it as a mandib ular or a maxillary neuralgia. T h e etiology is obscure, but may be somewhat similar to that described in re ferred pain. It is possible that m any of the long-standing cases that w e describe as neuralgia could be classified as neuri tis. Sometimes, the symptoms fit the defi nition of neuritis, but they have been classified as one type to prevent confu sion.
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T h e pain m ay be dull or very sharp, constant or intermittent. It m ay be con fined to the jaws only or m ay include the face. Periodontoclasia may be present. M andibular and m axillary neuralgia is not related to the painful symptoms associated with ear conditions caused by reduction o f the vertical overbite. These symptoms are supposed to be caused by the erosion o f the bone of the glenoid fossa. T h e rocking movements of the temporomandibular joint cause pressure on the auriculotemporal nerve and the chorda tym pani nerve. Block and H ar ris3 have recently published a compre hensive paper on temporomandibular joint problems. T h ey show that diagnosis of the symptoms of this condition re quires much study and thought. Also, a fundamental knowledge of anatomy, physiology and pathology is necessary, aided by roentgenographic and clinical examination. Th ey show that the three vital factors to be considered in every mouth condition a r e : ( i ) centric rela tion, (2) vertical dimension and (3) bal anced occlusion. Rebuilding o f the jaws according to these specifications is the solution, and these authors claim a high percentage o f success in so treating these types of cases. M axillary and m andibular neuralgia are very often confused w ith spheno palatine ganglion neuralgia. This pain is often seen first by the dentist, and it is important to diagnose it because, in the hands o f an otolargyngologist, it can be quickly relieved. According to W att W . Eagle,4 it is a unilateral facial pain and not a head ache. It never extends above the level of the ear. He says, The pain is usually lancinating and con tinuous; it may last from a period of a few minutes up to several days at a time, re curring after no special interval and always more or less repeating the previous episode. There are usually two main points of maxi mum pain, one in the region of the orbit and the root of the nose and the other in
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the region just posterior to the mastoid proc ess in the temporal bone. In some patients, only one of these points of maximum tender ness is present, that more likely being the region the orbit and the root of the nose. If both points of intense pain are present, the pain seems to originate in the root of the nose and to involve the orbit, causing extreme soreness in the eyeball, and extend back through the eye into the region of the ear, frequently causing earache and a sen sation of fulness of the ear and tinnitus. T o establish the diagnosis, the spheno palatine ganglion is cocainized through the nose and, if the pain disappears in a few minutes, the diagnosis is considered correct. Sometimes, the ganglion is in jected with a small amount of alcohol. p o s t o p e r a t iv e n e u r a l g ia
I have listed sixty-six cases of post operative neuralgia, the most common classification in my records. T h e pain syndrome, which is occasionally seen by dentists, involves either the mandible or the maxilla, following extraction or other surgical measures. Postoperative neural gia differs from the usual traumatic pain in that it is not localized. It is generally unilateral and affects the jaw bones, face, fieck and ears. It m ay be accom panied by inflammation. T h e pain is usually a dull and continuous type, with no remissions. In some cases, the pain is sharp in the beginning, later becoming dull. Occasionally, postoperative neural gia takes on the characteristics o f re ferred pain, because the pain is trans mitted to other parts of the jaw , face and neck in addition to the region of the original disturbance. The patient usually gives a history of single or multiple extractions from one to ten days earlier. In most cases, several days pass before the full force of the pain is felt. O ther cases report the pain to have started after the effect of the local anesthesia wore off. In a few cases, the complete syndrome of pain was felt be fore the extraction. T he patients com
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plain of a dull continuous pain persist ing since the extraction and get relief only from continuous use of bromides or other sedatives. M any patients have the condition er roneously known as dry socket, sometimes in a severe form, but generally mild. T h e clot m ay be missing from the socket with no perceptible infection present. Often, there appears to be a normal clot. In some extreme conditions, the patient has been suffering from neuralgia for more than a week, during which the socket has completely healed. Thereafter, the pain will eventually disappear, but the patient is left debilitated and in a nervous con dition. A t other times, the pain persists long after the healing has taken place. T h e most common site of this neuralgia is the socket of the lower third molar, especially if the tooth has been im pacted. N ext in order of frequency is the sockets of the lower first molar, lower bicuspid and upper first molar. However, the symptoms m ay follow extraction of any tooth in the mouth. T h e diagnosis of postoperative neural gia is assumed in these cases. It appears that the contiguous nerve supplying the tooth becomes inflamed through trauma or infection, or both. The temporary re lief that sedative dressings give is prob ably due to seeping of the anesthetic m a terial through the bone into the nerve fibers. From this description, one could classify the condition as postoperative. ATYPICAL NEURALGIA TYPES
Cases of atypical neuralgia are often classified as trigeminal neuralgia. M y records show twenty cases. T o clarify these types of pain, I shall briefly add definitions of m ajor neuralgia and atypical neuralgia. Herman Chor writes,1 True neuralgia is characterized by its paroxysmal nature, whereby “ explosions” or “ bursts” of severe, sharp lancinating pain strike the patient. Such attacks of pain last
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only a few seconds, rarely longer than .half a minute. This short duration is a cardinal feature of true neuralgia. If the pain lasts longer, that is, for several minutes or half hour or more, it cannot be diagnosed as neuralgia. H e also mentions that, in neuralgia, the pain follows the course of a nerve and is not disturbed over the area be yond that supplied by a particular nerve. In trigeminal neuralgia, the m ain point in diagnosis is the presence of a trigger zone. O nly a slight touch in these areas starts the pain. There m ay be remissions of pain in some cases of true neuralgia. Reported cures following extraction or other dental operations m ay be due to this fact. O ther types of true neuralgia are glossopharyngeal and superior laryn geal neuralgia. L. B. Bender says,5 Atypical neuralgia is a type of pain about the face and head which does not fall into classification of true trigeminal neuralgia. It is usually very difficult to treat. Pain persists in these cases even after the gasserian ganglion has been removed. The at tacks are chronic and usually bilateral in character, dull, deep aching pain in the eye, molar region about the ear and face and worse at night. Glaser6 describes atypical neuralgia as of unknown etiology, with failures to respond to clinical relief. Certain types o f atypical neuralgia appear to simulate trifacial neuralgia in some of the later phases. It can be noted that there appears to be a close relation ship between some forms of atypical neu ralgia and various forms of neuritis. V ery little has been written regarding the etiology of atypical neuralgia. It is believed that the autonomic systems play a role in the etiology o f some cases. H ow ever, L . J. Pollack and L. Davis7 have the following to s a y : Painful impulses may be conducted along the sympathetic nerve fibers or the viscero motor or other reflex activities may pro
duce conditions which in turn are respon sible for conscious pain. On the other hand, both mechanisms may be present. Long-standing cases of neuralgia can be classified as the atypical type, because the definitions describing these conditions are rather variable and vague. Bursitis and antrum pains are distinct entities and will not be discussed in this paper although both respond to the form of treatment herein described. treatm ent
T h e principal form of treatment em ployed in attacking all these previously described forms of pain is physiotherapy, including use of the infrared lamp, the m ercury quartz lamp and short wave dia thermy. T h e quartz lamp that I use for this work is one of the more powerful types, developing 28 per cent ultraviolet light. In some cases, I manipulate the tissues in the area about the affected parts, paying especial attention to ter minal nerves of the infra-orbital and m en tal regions. This action is a combination of massage and stretching. These m odali ties are in addition to the routine treat ment such as irrigation and dressing of wounds in postoperative neuralgia. Prostigmine methylsulfate 1 :2,000 and prostigmine bromide have been used suc cessfully in treating neuritis of the face and neck region. Thiam ine chloride is of- value in the treatment of neuralgia. Occlusal trauma should be relieved whenever encountered. T h e exception to these forms, of treat ment is the handling of referred pain. In this condition, the cause must be as certained and removed. It may lie in an inflamed pulp, an obscure abscess or an infected antrum. Therm al pain is treated specifically by the quartz lamp as previously mentioned. I use a powerful water-cooled lam p and apply the light by means of quartz rods, using a round applicator one-half inch in diameter or a larger rod with a square
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face measuring about three-fourths inch across. T h e gums surrounding the sus pected teeth and the teeth adjacent are radiated over all the labial, buccal and lingual surfaces involved to a height of one-half to three-fourths inch. A t the initial exposure, ten seconds is given to each place of application, and this is in creased by two or three seconds at each successive treatment. A slight amount of pressure is employed to dehematize the tissues in using the quartz rods. This is the basic technic for most quartz light applications intra-orally. T h e teeth should also be exposed to the light. In mild and severe neuralgia, the infrared lamp is employed for twenty minutes at 18 inches. This generally gives some degree o f relief, but if it does not, its use is discontinued in this particu lar case. Either ultraviolet irradiation intra-orally and extra-oral or short wave diathermy follows, according to the ex perience and judgm ent of the operator. O ften, both agents are used, especially in severe cases. W hen the pain is centered around the mental or infra-orbital fora men, I employ also manipulation of the facial tissues about these areas. T h e quartz lam p is used with the tech nic previously described intra-orally and extra-orally, with the direct face of the lam p against the seat of complaint at about 4 inches for ten seconds. This ex tra-oral exposure is increased two or three seconds at each subsequent treat ment. A brunet w ill tolerate more ir radiation at eath sitting than a blonde. T h e short wave is applied by rubber pads well covered by two or three layers, of turkish toweling, one on each side of the face. T h e heat is applied from seven to ten minutes at 2,000 to 4,000 milliamperes, the m illiamperage depending on the amount of warm th tolerable to the patient. Most cases o f postoperative pain fol lowing extraction or surgical procedure will respond to the newer type of drugs
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now used for dressing wounds, and can be kept under control by frequent re placements. It is the exceptional case that does not respond to this orthodox treatment with which I am concerned. In these cases, the operative site is first cleaned up and a sedative dressing placed. Next, the patient is given twenty minutes’ exposure under the infrared lam p at 18 inches, and, in nearly every case, relief is obtained. Next, the entire intra-oral area about this part is exposed to the quartz lam p by means of a large quartz applicator, described in the pre ceding paragraph. Next, the extra-oral parts are exposed to the direct rays of the lamp. T h e next day, the patient usu ally reports that he has had hours of relief, and then a recurrence. I then re peat the treatment, but increase the dos age of light. Recently, I have employed the short w ave diathermy in addition to the foregoing treatment, and I find that it shortens the course considerably. F re quently, one application of the short wave will terminate the pain. Atypical neuralgia responds to the treatment described under m ild and se vere neuralgia. I have mentioned bursitis and antrum pains because of the success often at tained in seeking relief from these com plaints. In bursitis, I depend on very heavy doses of ultraviolet light. In antrum pains, I employ all three modalities. r epo r t o f cases
C a s e i.— Referred Pain.— Mrs. W. B., aged 25, complained of intermittent pain in the right infra-orbital region accompanied b y . twitching of the muscles. The muscles around the nose were contracted during the spasm. Examination showed a subacute abscess of the lower right first bicuspid. Ex traction revealed • a distended granuloma containing pus (staphylococcus). All symp toms immediately disappeared. C a s e 2.— Thermal Pain.— Mrs. F. M., aged 30, in the ninth month of pregnancy, gave a facial reaction to hot and cold
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especially affecting the upper left bicuspids and molars and the left side of the face. The pain had persisted for four days and the patient was unable to sleep. The teeth re sponded to electric and thermal vitality tests. A slight occlusal trauma was adjusted, with negative results. At the next visit, a quartz lamp was applied to the teeth, jaws and face, with complete relief the next day, and no recurrence. C a s e 3.— Thermal Pain.— Mrs. K., aged 31, had a vital lower left cuspid that reacted to heat. A quartz lamp was applied to the teeth and jaws around this area and to the face and, one week later, the patient re ported that she could drink hot liquid with out discomfort: Three months later, there had been no recurrence. Case 4.— Neuralgia.— Mrs. M., aged 51, complained of a pain resembling toothache, in the lower right jaw and cheek, of several weeks’ duration. She felt as if ,she had a toothache in the lower right second bicuspid and first molar areas although these teeth had been extracted three months previously. Ultraviolet light was applied to the right jaw and cheek arid the tissues about the mental foramen w6ie ¡stretched. Three days later, the patient reported that she was en tirely free from pain.' There has been no recurrence in threft-years. Case 5.— Neuralgia.— Mr: J. O., aged 43, early in November 1940 had a very sharp pain affecting the left side of the tongue, in creased when he was eating. November 22, he had the lower left impacted molar re moved. He had ha relief until the second week in December, when the pain suddenly disappeared. January 25, 1941, he came under my care.. He had had a recurrence of the pain and could obtain relief only through constant use of codeine. The pain traveled along the course of the lingual nerve from the third molar region forward. The teeth were not sensitive to percussion. X-ray examination revealed two roots of the extracted third molar remaining in the socket, one of them lying in the mandibular canal. The infra red lamp was applied to the left side of the face for twenty minutes at about 18 inches. This was followed by diathermy for seven minutes, and next the ultraviolet rays were applied* to the local affected parts through a quartz rod, as previously described. The
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tissues around the lingual nerve were lightly manipulated. It was decided that if no re lief was obtained in a few treatments, the remaining roots in the lower left third molar socket would be removed. February 5, after a period of complete relief, the pain recurred. The patient was in a city 90 miles away and the pain re turned while he was brushing his teeth. He, immediately came back to my office and had the treatment repeated. February 6, he reported taking one co deine tablet, to “play safe.” At breakfast, he was slightly bothered, but could eat. The treatment was repeated, but in larger doses. February 19, the patient reported three mornings of p^in lasting from one to one and a half hours. The treatment was re peated. May 1, the patient reported no recurrence of pain to date. C a s e 6.— Postoperative Neuralgia.— Mr. R. G., aged 25, had a lower left impacted molar removed April 23. The extraction was followed by dull, but occasionally sharp pains in the wound, face, temple region and head. April 24., the area was washed out and a sedative inserted, but with no relief. April 25, the patient first came to see me, with a history of having had no sleep or relief from pain. Infrared, ultraviolet and diathermy, given as heretofore de scribed, afforded some relief. April 26, the patient reported almost com plete relief. The treatment was repeated. April 27, relief was complete and the patient was discharged. C a s e 7.— Postoperative Neuralgia.— Mrs. G. C ., aged 30, had a lower left second bicuspid with an acute abscess extracted and three hours later developed a severe pain. Her dentist treated her for three days, ap plying powerful analgesics to the socket, but the ‘ treatment helped for only a short time. The patient took boxes of sedative pills during this time. . She was referred to me and I applied infrared, and ultraviolet light, using the basic technic described. The patient felt better that night, but the pain returned in the morning. The treat ment was repeated, with complete relief. C a s e 8.— Postoperative Neuralgia.— Miss W., aged 31, had had the upper teeth ex tracted by her dentist three weeks before.
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She later developed severe pain over the left infra-orbital region. Great quantities of sedative pills were consumed, with no results. The patient was very irritable and practically exhausted physically. Infrared and ultraviolet radiation were given as pre viously described and, four days later, great improvement was reported. The treatment was repeated. Three days later, there had been no recurrence and the patient was dis charged. C a s e 9.— A t y p ic a l Neuralgia.— Mr. F. W., aged 33, seen November 30, 1936, re ported a continuous dull pain present for the past seven years and affecting the lower left jaw from the third molar region to the mental foramen. A t times, the pain became sharp. There was a constant roaring in the Left ear. A n impacted third molar and de vitalized second molar were removed, with no results. Five treatments were given with the infrared light for twenty minutes at 18 inches. The ultraviolet light was applied with a quartz rod for ten seconds at each point and the face exposed to the direct rays. The tissues around the mental foramen were manipulated. The result was a com plete recovery. In December 1939, the patient reported that, three weeks before, thè pain had grad ually returned. It was especially severe while he was chewing. The roaring re turned to the ear. Five treatments with the infrared and ultraviolet lamps, as previously described, were given, with the addition of diathermy 3,000 milliamperes for ten min utes. The symptoms cleared up and the patient was discharged. C a s e 10.— Atypical Neuralgia.— Mrs. D. C ., aged 40, had had pain in the right an trum and infra-orbital region for the past four years. Tw o years previously, she had had an abcessed tooth in the upper right jaw removed with some relief for one month. A year previously she had had all of the upper teeth extracted to relieve the pain. She felt better for about a month, but the
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pain recurred. Three infrared and ultra violet treatments were given, to the jaw and face on the affected side according to the described technic. The tissues about the infra-orbital region were massaged and stretched. The patient was entirely relieved and was discharged. c o n c l u s io n
I have attempted to classify the various neuralgic pains which the dentist oc casionally encounters, and which do not respond to drug therapy or the usual armamentarium found in his office. Sev eral forms of physiotherapy have been mentioned that m ay be used with success in alleviating these conditions. A search of the dental literature gives little or no information regarding the treatment of these cases. There may be better and shorter methods of handling them which the publication of this paper may bring to light. BIBLIOGRAPHY
1. C hor , H e r m a n : Neurologic Aspects of Temporomandibular Disorders. J.A.D.A., 2 5 : 1033-1036, July 1938. 2. C a h n , L. R .: Personal communication to the author. 3. B l o c k , L. S., and H a r r i s , E l a m : Ap proach to Rational Study and Treatment of Temporomandibular Joint Problems. J.A.D.A., 29 :349-358, March 1942. 4. E agle , W. W . : Sphenopalatine Ganglion Neuralgia. Arch. Otolaryn., 35:66-84, Janu ary 1942. 5. B e n d e r , I. B . : Atypical Facial Neuralgia. D. Cosmos, 78:475 May 1936. 6. G laser , M. A.: Facial Neuralgia in Relation to Dentistry. J.A.D.A., 19:1537, September 1932. 7. P o l l a c k , L. J., and D a v is , L o y a l : Neurological Surgery. Philadelphia: Lea & Febiger, 1936. 131 Linwood Avenue.