Not a small number of the dental patients suffer from non-odontogenic chronic pain. However, the detailed suituation has not been unknown. We survey on the backgrounds of the patients, duration of initial illness and medical history of the non-odontogenic toothache.
Sixty-four patients with non-odontogenic toothache were enrolled in this study. We checked the medical records and medical interviews of these patients about their backgrounds, duration of initial incidence of non-odontogenic toothache, the times of medical and dental consultation, the history of medical and dental treatments. In addition, expected medical and dental expenses for their symptom were calculated.
The mean age of the patients was 55.0±13.8 years（male/female 11/53）. The mean of duration of initial illness was 49.6±60.9 months. These patients visited 3.71±1.94 medical and/or dental clinics. The patients received many kinds of dental treatments including endodontic treatments for 48 patients （75％） and tooth extraction for 29 patients （45.3％）. The mean decrease of their pain previous treatments was 11.3 ＋/－ 14.51 （％）. The mean of calculated medical expenses was ￥219,948±238,869.5. This evaluation revealed that most of patients with non-odontogenic toothache had visited some medical and/or dental clinics, and received dental examinations and treatments for initial illness. Medical cost of non-odontogenic toothache in Japan was estimated at least ￥596 billion, it was ￥144 billion per year. We should establish the diagnosis and treatment program for non-odontogenic toothache urgently.

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Purpose: Ketamine hydrochloride （ketamine） is one of the notable N-methyl-D-aspartate receptor blockers. The purpose of this study was to elucidate the effect of ketamine on changes in spontaneous pain and other signs and symptoms of trigeminal neuropathic pain.
Methods: Seven patients suffering from peripheral neuropathic pain in the trigeminal region were enrolled in this study. The study consisted of five sequential trials for two test drug mixtures, midazolam plus ketamine and midazolam plus saline in a randomized double-blinded crossover study. Patients received a five-day repeated administration of midazolam and ketamine followed by another repetition of midazolam and saline （Group A） and vice versa （Group B）. Intensity of pain （VAS）, area of allodynia/dysesthesia and electric detection threshold （EDT） were recorded at three points, before administration of agents, 10 and 120 minutes after administration.
Results: VAS showed a significant decrease in both （the Ketamine and the Saline） groups after administration of agents. VAS in the Ketamine group showed a more significant decrease than that in the Saline group. However, neither long-lasting nor accumulated analgesic effect was observed in both groups. There was a significant difference in the EDT when analyzed according to time course. Some patients reported alleviation of dysesthesia but not hypoesthesia with repeated ketamine treatment. There were no adverse effects observed during the observation period.
Conclusion: Ketamine had a transient analgesic effect with inhibition of innocuous input from the affected region in trigeminal neuropathic pain patients, although these effects were neither long lasting nor accumulative.

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Purpose: Administration of carbamazepine （CBZ） forms a part of the treatment for trigeminal neuralgia. However, administration is sometimes discontinued if patients suffer adverse effects or show drug resistance. We reviewed clinical data on trigeminal neuralgia patients to determine the best therapeutic intervention for this condition.
Methods: We collected data on the age, gender, involved site, head MRI findings, approach to treatment, and side effects in 48 patients at the Department of Dentistry and Oral Surgery at Tokyo Metropolitan Tama Medical Center to determine the current status of trigeminal neuralgia patients.
Results: The age distribution was from 29 to 96 years with the average age of 69.7 years. The patients comprised 11 men （22.9％） and 37 women （77.1％）. The most common involved site was the maxillary division of the trigeminal nerve （25 cases, 52.1％）. MRI findings （44 cases） revealed the involvement of 18 （40.9％） blood vessel, the most common being the superior cerebellar artery （9 cases or 50％）. Three cases of brain cancer were also detected （6.8％）, specifically, an acoustic nerve tumor, a meningioma, and an epidermoid tumor. Thirty-four of 45 patients received CBZ, which produced an instant effect. However, the remaining 11 cases required additional treatment. The peak response to CBZ was obtained most frequently at a dosage of 200mg. Fourteen （31.1％） side effects were recognized, the most common of which was wobbling （6 cases）.
Conclusion: We reviewed the clinical data of 48 trigeminal neuralgia patients at the Department of Dentistry and Oral Surgery at Tokyo Metropolitan Tama Medical Center. However, we were unable to find specific clinical features enabling identification of patients who experience adverse effects or resistance to CBZ.

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Purpose: Many types of onomatopoeia are used in the Japanese language. The aim of the present study was to clarify the use of onomatopoeia for evaluating neuropathic pain in the orofacial region.
　Materials and methods: Subjects comprised patients who were examined at Osaka Dental University Hospital between August 1, 2015 and July 31, 2016 and were diagnosed with neuropathic pain in the orofacial region before symptoms were alleviated or eliminated with medication. The investigation was conducted based on responses to “questions regarding sensation type” during medical examinations.
Results: The data of 23 patients were analyzed. The majority of subjects （22） were female, and only one subject was male. Ages ranged from 27 to 74 years, with a mean age of 50.4 years. Regarding sensations that were constantly experienced, the most common answer for the strongest onomatopoeia felt was jinjin （painful tingle, 22％）, followed by jiin （numbing pain） and hirihiri （stinging pain, 13％ for each）. Surface pain accounted for 22％ of onomatopoeia, deep pain for 52％, and sensations other than pain for 26％. Examination of all sensations that were constantly experienced demonstrated that piripiri （smarting pain, 52％） and jinjin （35％） were the most common. Onomatopoeic expressions used for pain that was difficult to bear were zukizuki （throbbing pain, 23％）, hirihiri （18％）, zuun （slow irradiating pain, 14％）, and zukinzukin （pounding pain, 14％）. Many onomatopoeic expressions for pain that was difficult to bear contained voiced consonants.
Conclusions: The results of the present study indicate that onomatopoeia expressed by patients with neuropathic pain may provide diagnostically useful information.

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Purpose: The aim of this study was to compare the subjective sleep influenced by duration of chronic pain with temporomandibular disorders （TMD）, burning mouth syndrome （BMS） and trigeminal neuralgia（TGN） patients.
Methods: Subjects in the Orofacial and Head Pain Clinic, Nihon University Hospital at Matsudo were selected according to the research Diagnostic Criteria for TMD （n＝1838）, International Association for the Study of Pain criteria for BMS （n＝396）, and the International Classification of Headache Disorders for TGN （n＝108）. In each disorder, subjects classified acute stage group （＜ 3 month）, middle stage group （from 3 month to 6 month）, and chronic stage group （＞ 6 month） according to lengthen chronic pain. Difficulty falling asleep （DFS）, arousal during sleep （AS）, and early-morning awakening （EA） scores were evaluated from questionnaire in each group from all disorders.
Results: DFS, AS, and EA at chronic stage group in TMD were significantly higher than at acute stage group and middle stage group （p＜0.01）. DFS, and AS at chronic stage group in BMS were significantly higher than at acute stage group and middle stage group （p＜0.05）. There were no significantly differences in DFS, AS, and EA between each group in TGN.
Conclusions: Our result suggests that quality of sleep in TMD and BMS patients influenced by their lengthen chronic pain.

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Patients: A 71-year-old Japanese woman was referred to dentistry & Oral surgery at Kawasaki hospital with symptoms of pain on right palatal mucosa. There were edematous erythema with partial ulcer and multiple vesicles on the right palatal mucosa. Because the patient had been diagnosed and treated with herpes zoster （HZ） by the Dermatology 3 year earlier, we diagnosed relapsing HZ. Although the edematous erythema and haphalgesia on right palatal mucosa was disappeared by taking antiviral drug, symptoms of persistent pain and right upper teeth were remained. The patient was referred to our clinic again because of pain increment by occlusion 4 months later. We diagnosed post herpetic neuralgia （PHN） on grounds of the allodynia of right palatal mucosa and absence of odontogenic source. Finally, pregabalin was prescribed for management of the PHN pain and her pain was completely disappeared.
Discussion: HZ was hardly ever supposed to relapse. However, since cell-mediated immunity has an important role for onset of HZ, it might relapse due to immunocompromised condition with aging. The patient was 71-year-woman. Thus, it could be considered that HZ had relapsed owing to low VZV specific cell-mediated immunity, and it led to postherpetic neuralgia with non-odontogenic toothache.
Conclusions: We experienced the rare case which is relapsing HZ and it led to PHN with non-odontogenic toothache.

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Patient: A 55-year-old man had experienced stabbing pain around the right periorbital area seven years ago. After visiting the Neurosurgery clinic, he was prescribed carbamazepine for trigeminal neuralgia, and his pain was relieved. Incision and drainage were performed for implantitis at a dental office. One week following the procedure, he presented to our orofacial pain clinic with intermittent right periorbital and temporal pain accompanied by autonomic symptoms, such as redness of eye or lacrimation. At the first visit, we diagnosed possible trigeminal neuralgia, and he was prescribed carbamazepine （100 mg/day）. Magnetic resonance imaging showed neurovascular decompression at the root entry zone of the right trigeminal nerve by the superior cerebellar artery. Subsequently, the attack frequency, duration, pain intensity and autonomic symptoms reduced, and then completely disappeared after two months. After administering for seven months, carbamazepine was withdrawn. As of five months since medication withdrawal, stabbing pain around the upper eyelid has recurred with a few attacks per day without autonomic symptoms. Carbamazepine （100 mg/day） was resumed, which provided complete relief of pain for fifteen months.
Discussion: It is clinically difficult to differentiate trigeminal neuralgia from SUNCT since patients with trigeminal neuralgia may present with mild autonomic symptoms such as lacrimation and/or redness of the eye. According to ICHD3β such patients should receive both diagnoses.
Conclusions: Trigeminal neuralgia with autonomic symptoms is rare. The dentist should carefully discriminate between the two diseases/cases since there are cases where patients have facial pain with autonomic symptoms, like TACs.

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We often experience refractory cases of orofacial pain, most of which are neuropathic pain. The pain persists despite treatment with nonsteroidal anti-inflammatory drugs in most cases. A combination of pregabalin, tramadol hydrochloride/acetaminophen （T/A） tablets, and powdered processed aconite roots （PA） was recently developed. Here we describe the cases of 3 patients （1 male, 2 females, mean age 65 years, range 50 – 81 years） with orofacial pain that was well-treated with the concomitant medication of pregabalin, T/A tablets, and PA. This medication remarkably relieved the orofacial pain: the patients’ visual analogue scale （VAS） scores representing pain intensity decreased after this medication. Significant adverse events did not occur in any of the cases. This combination medication may thus be useful for the treatment of orofacial pain.

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A 56-year-old woman with chief complaints of occlusal discomfort and jaw pain visited our dental clinic in December 2014. Bilateral temporomandibular disorder was diagnosed and treated. Her symptom of temporomandibular joint improved. However, she complained of pain in the right mandible. Computed tomography （CT） performed at Specialized medical institution indicated chronic sclerosing osteomyelitis was suspected. We were recommended a detailed examination for synovitis, acne, chronic pustulosis, hyperostosis, and osteitis （SAPHO） syndrome, and referred the patient to a university hospital Department of Rheumatology, where close inspection of the whole body was performed, and SAPHO syndrome was ruled out. Her symptoms are stable now, and we are continuing to follow up with giving dental treatment.
Discussion: When a temporomandibular disorder does not show typical findings on a medical examination, physical examination, primary care examination, or panoramic radiography, it is necessary to perform CT and magnetic resonance imaging （MRI） to arrive at a definitive diagnosis. These examinations may lead to the correct differential diagnosis or identification of comorbidities. However, when a patient is referred to a highly advanced medical institution, we should consider the subjective symptoms of the patient and visible symptom views particularly the image that even ourself did a reading shadow and talked with a specialist in image reading shadow.
Conclusions: We performed MRI and CT for a patient with chief complaints of occlusal discomfort and jaw pain at the Specialized medical institution. A detailed examination for SAPHO syndrome was performed in this case.
But the diagnosis was eventually ruled out.

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Patient: A 67-year-old woman presented with a 5-month history of pain in the right maxillary molar; the patient also reported having right occipital pain after boarding an airplane one month prior to the first visit to our hospital. Moreover, she had been experiencing headaches and discomfort since a traffic accident that had occurred 2 years ago. After visiting her family dentist, she received occlusal treatment, splint therapy, and instructions on avoiding tooth contact, but her pain did not improve. At the first visit, pressure pain in the right masseter muscle was induced with referred pain to the right occipital region and the right maxillary molar region. After receiving an explanation of her clinical condition, initial treatment by means of self-care, and information on lifestyle changes, the patient’s pain in the maxillary molar region disappeared, and the occipital pain improved. Goreisan and Zomig （a triptan） were prescribed for the patient’s edema and migraine, resulting in an even greater decrease in her pain level. However, the neuropathic pain was still present; therefore, low-dose pregabalin was prescribed, and her neuropathic pain improved subsequently.
Discussion: This patient presented with concurrent myofascial pain of the masticatory muscle, referred pain in the jaw and the occipital region, neurovascular pain, and neuropathic pain. Self-care, information on lifestyle changes, Goreisan, and low-dose pregabalin were effective in relieving pain in this complicated case.
Conclusion: In this case of complicated chronic pain, suitable treatments for each possible factor resulted in adequate pain control.

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Patient: The patient was a 49-year-old woman. In the year X-1, she got bruised her face and dislocated her front teeth in a traffic accident. Complaining of these teeth, and pharynx pain and numbness of hands, she was taken to a hospital by ambulance. After the reduction of the front teeth, a CT scan of the head was performed. It was confirmed that there was no problem. A month later, she underwent a pulpectomy of upper right central incisor at the oral surgery in a hospital, and then a pain was reduced. Soon after that, however, her pain was enhanced. She consulted doctors in the otorhinolaryngology besides the cranial nerve surgery. Also, there were no abnormalities in the head MRI examination. After six months, in the year X, she visited our department. The patient was diagnosed with chronic apical periodontitis and suspicion of neuropathic toothache of the upper right central incisor, and then comprehensive medicine using endodontic, kampo medicine, and logotherapy centered listening was carried out. When we practiced comprehensive medicine, we analyzed the patient’s problem using Patient evaluation grid and evaluated her with the passage of time. As a result, the pain was relieved after one year and two months from the first visit.
Discussion: The endodontic and kampo medicine were effective for physical treatment. The logotherapy centered listening was important for the treatment of psychological and social dimensions. It is considered that these methods were effective because it was the treatment after accurately extracting the problem in each dimensions.
Conclusions: Listening to patient, analyzing the state of a patient, setting of treatment goals and over time evaluations were important for the treatment of chronic pain.

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Patient: A 35-year-old woman visited the Center for Advanced Dental Health Care, Tokushima University Hospital, because of severe orofacial pain that was precipitated by chewing on food approximately 4 months ago. Two months after onset, she consulted a neighboring dental clinic and was diagnosed with temporomandibular disorders. Her severe pain did not improve with splint therapy. The pain was particularly more severe when eating sour foods. The pain episodes persisted for a few minutes. We considered her sudden, paroxysmal, brief pain to be glossopharyngeal neuralgia（GPN） because of the characteristic pain, and prescribed carbamazepine. Although the magnitude of her severe pain decreased with this medication, it did not completely disappear. Four months after her initial visit, the patient complained of abnormal sensation in her hands, and was advised to get a blood test, which revealed marked hyperglycemia. Accordingly, the patient was diagnosed with type 2 diabetes at the Endocrinology and Metabolism department of Internal Medicine. Subsequently, with appropriate glycemic control her neuropathic pain completely disappeared approximately 1 year later.
Discussion: A few studies of GPN caused by diabetes mellitus have been reported. Takahashi et al. reported that patients with GPN due to diabetes were younger than those with a general GPN, and developed bilaterally. Similarly, our present case showed such characteristics. In addition to such findings, because her neuropathic pain completely disappeared with appropriate glycemic control, a definitive diagnosis of paroxysmal neuralgia due to diabetic neuropathy was made.
Conclusions: We have described a rare case of GPN caused by diabetes mellitus and acknowledged the importance of careful medical interview of patients with characteristic orofacial pain.

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Patient: A 67-year-old woman suffering from dull pain in the left mandibular first molar visited our pain clinic. She complained of this symptom after root canal treatment. At her first visit, the pain was diagnosed as idiopathic odotalgia of the left mandibular first molar. However, further examination revealed palpable bands in her left masseter, sternocleidomastoid, and temporal muscles. Moreover, the trigger points were located in her left masseter muscle. Hence, trigger point injections were administered, and her toothache disappeared after the administration of the third injection. She received dental treatment for the left mandibuler first molar after the administration of the seventh injection and was able to complete dental treatment without the worsening of her toothache.
Discussion: This symptom was related to three factors; acute apical suppurative periodontitis，myofascial toothache and idiopathic odotalgia. Furthermore, a vicious cycle of reflexes might be formed due to these factors, and made myofascial toothache more serious. In this case, myofascial toothache was determined to be pain arising from trigger points in the masseter muscle. Hence, trigger point injections into the left masseter muscle could eliminate her toothache.
Conclusion: This report suggests that the myofascial toothache should be considered when a patient’s toothache dose not improve even after an appropriate dental treatment. In addition, trigger point injection is effective in managing myofascial toothache.

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Patient: A 43-year-old man experienced persistent pain at the maxillary right second molar and the right palate around the tooth. After visiting a dental clinic, diclofenac sodium was taken, but the pain was not relieved at all. Upon examination, no apparent caries or periodontitis was found. X-ray was taken, but there was no tooth fracture or other abnormalities. Allodynia was obsereved on mucosal surfaces around the tooth. Since the past history was herpes zoster of trigeminal second division two years ago, we diagnosed as postherpetic neuralgia （PHN）. The patient could not use tricyclic antidepressants or pregabalin due to the side effect. The pain is relieved dramatically by adenosine triphosphate （ATP） infusion and stellate ganglion block （SGB）. Therefore, we could control the pain appropriately by ATP infusion and SGB every 2 weeks. However, the sudden intense pain sometimes occurred with blister at same parts. We controlled　the　pain　by using antiviral drugs.
Discussion: PHN is one of refractory neuropathic pain. Both peripheral and central pathophysiological mechanisms contribute to PHN. There are some medication therapies for PHN. We experienced recurrence of acute pain to struggling in pain control. We considered recurrent infection of Varicella zoster virus （VZV）, and controlled the pain adding prescription antiviral drugs.
Conclusion: When the pain control became intractable difficult in PHN treatment like this case, it should consider recurrent infection of VZV.

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Patient: The patient was a 68-year-old woman who visited the surgical department of general hospital for a facial injury caused by a fall 5 years earlier. The woman was diagnosed with a bruise and received her final examination 1 month later. But allodynia and dysesthesia on the right middle face was not lightened, she visited the general hospital again to complain to her attending physician, who told her she was probably imagining her pain. The patient was also experiencing occlusal discomfort for which she visited her local dental clinic. However, when the patient’s symptoms failed to improve, she was referred to liaison outpatient clinic, dentists and psychiatrists have performed cooperative treatment based on dental/psychiatric diagnoses. The patient underwent a medical interview with a dentist and a psychiatrist, who noted spontaneous pain （visual analog scale ［VAS］ 50/100） in the maxillary right central incisor, lateral incisor and canine, allodynia and dysesthesia from the right wing of the nose to the lips. The patient was diagnosed with neuropathic pain based on local findings and her episode 5 years earlier. Althouh the patient had anxiety about her prolonged pain, mental disorders including depression could be ruled out by the psychiatrist.
Discussion: Use of pregabalin, one of the first-line drug for neuropathic pain, was proposed and the patient’s VAS score improved to 30/100. The patient was saved to hear that her pain was resulted from neural damage for the first time, which could also have contributed to improvement of her symptoms.
Conclusions: Facilities that offer liaison dental clinics with psychiatrists are scarce in Japan. Even in cases of chronic neuropathic pain, it is very important to coordinate with dental and psychiatric departments because validating patient’s distress, giving psychological support and choosing the appropriate pharmacological treatment are effective at alleviating symptoms.

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Patient: The patient was a 36-year-old female who visited a private dental clinic with the complaints of uncomfortable feeling in the gingival area of left maxillary molar region and itch sensation in the left side head, neck and shoulder regions. Since her uncomfortable feeling of the gingival area did not improve after the pulpectomy of the maxillary left side second molar, she visited our hospital. Root canal treatment of the left maxillary molars was carried out under the diagnosis of the periapical periodontitis based on the X-ray and cone beam CT findings. However, percussion pain of the concerned tooth and itch sensation of the left side maxillary molar region continued. She said that shoulder stiffness accompanied with the itch sensation of gingiva and simultaneously aggravated and continued for a couple of days. Additionally, she complained tenderness at left masseter, temporalis and sternocleidomastoid muscles and the itch sensation could be evoked by continuous press of those tender points, similarly with the refereed pain from myofascial trigger point.
From the above findings, the itch sensation was considered as a related symptom of her myofascial pain conditions. Thus, we instructed her physical therapies such as muscle massage and hot pack to alleviate myofascial pain. Furthermore, since she was aware of having nocturnal bruxism habit, she was also instructed to wear stabilization splint at night. As the results, her myofascial pain improved and consequently the percussion pain of left side second molar and the itch sensation of maxillary molar gingival region disappeared as well.
Discussion: In addition to the myofascial toothache, it was possible to consider that itch sensation appears at distant parts of body as a related symptom of myofascial pain conditions.
Conclusion: We experienced the patient case who complained itch sensation of gingiva likely appeared as a related symptom of myofascial pain.

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