Three Teeth Had Already Been Taken Out and the Pain Had Not Moved

Quick answer: Not all facial pain comes from teeth. Trigeminal neuralgia produces sudden electric-shock pains lasting seconds, triggered by light touch, wind or eating, with complete freedom between attacks. Toothache does not behave that way. Extracting healthy teeth for it is a common and irreversible mistake.

The call

She arrived asking for a fourth extraction and had already decided which tooth.

Leah, 63, from Old Beit Shemesh, had had an upper right premolar removed fourteen months earlier, an upper right molar eight months after that, and another molar three months before this appointment. Each extraction had given her a week or two of relief, which she attributed to the extraction, and then the pain had returned exactly as before.

She was articulate, entirely credible, and in genuine severe pain. Nothing about the story suggested exaggeration.

What we found

The examination found no dental cause. All remaining upper right teeth responded normally to cold, none were tender to percussion, none had decay, deep restorations or cracks under magnification. Radiographs, including views of the extraction sites, showed normal healing and no residual pathology.

Three teeth had been removed and the mouth was healthy.

The pain history is what nobody had taken in full, and it took fifteen minutes.

Character. Sudden, electric, shooting, like a shock. Not throbbing, not aching, not dull.

Duration. Seconds, sometimes up to a minute or two, in bursts. Then nothing.

Between attacks. Completely free of pain. She would go days without one, and had once gone six weeks.

Triggers. Touching a specific spot near the corner of her mouth. Cold wind. Brushing her teeth. Chewing. A long phone call. Once, applying face cream.

What did not trigger it. Hot or cold drinks, and biting hard on that side provided she avoided the trigger spot. She had noticed this herself and thought it strange.

Distribution. The right cheek, upper lip and side of the nose, stopping at the midline and never crossing it or going below the jawline.

Timing. Never woke her at night, which she volunteered.

That history is characteristic of trigeminal neuralgia and is not compatible with toothache.

The contrasts, laid out, because this is the whole diagnostic problem:

• Toothache from an inflamed nerve is spontaneous, throbbing, lasts minutes to hours, is provoked by hot and cold, is worse lying down, wakes people at night, and is often poorly localised.
• Toothache from an abscess is constant, worse on biting, localises precisely, and produces swelling.
• Trigeminal neuralgia is paroxysmal, lasts seconds, is triggered by light touch and movement rather than temperature, has complete remission between attacks, respects the nerve divisions, stops at the midline, and characteristically does not wake people from sleep.

Cold testing was the practical discriminator. Ice on her teeth produced an entirely normal brief response with no attack. Light touch on a spot of skin near the corner of her mouth produced an immediate attack. That contrast, demonstrated in front of her, was more persuasive than any explanation.

Why the extractions appeared to help. Post-extraction anaesthetic, then swelling and analgesics, then a natural remission period. Trigeminal neuralgia remits and relapses spontaneously, sometimes for weeks or months. Any intervention timed at the start of a remission will look effective. Three times over, that produced a compelling and completely false pattern.

What we did

Told her the truth: the pain was real, it was not coming from her teeth, no further extraction would help, and there was effective treatment for what she probably had — through a doctor rather than a dentist.

Being believed mattered as much as the diagnosis. Patients with facial pain of this kind are often made to feel they are imagining it, and that desperation is what drives requests for extractions.

Referred to neurology, with a letter setting out the full pain history, the negative dental examination, the radiographs, and the explicit statement that three teeth had been removed without benefit and no dental cause existed.

Nothing was extracted. That was the single most important decision at the appointment.

Neurology confirmed trigeminal neuralgia and started carbamazepine, the standard first-line treatment; a characteristic response to it supports the diagnosis. An MRI was arranged, as it usually is, to look for a blood vessel compressing the nerve root and to exclude other causes. Hers showed vascular contact.

The outcome

Her pain came under control within a fortnight of starting medication. She has had two relapses in four years, both managed by dose adjustment.

She has not had another extraction and does not need one.

Three healthy teeth were lost and cannot be recovered. Each removal looked reasonable at the time, made without the full pain history, and each was made more likely by the apparent success of the one before.

The lesson is a question, asked before any irreversible treatment for unexplained facial pain: does this pain behave like a tooth? Seconds rather than minutes, touch rather than temperature, complete freedom in between, and no night waking are the answers that should stop the drill.

What to do if this happens to you

1. Describe the pain precisely — how long each episode lasts, what sets it off, and whether you are pain-free in between.
2. Say if it lasts seconds rather than minutes. That single detail changes the diagnosis.
3. Say if light touch or wind triggers it, rather than hot or cold.
4. Say if it never wakes you at night. Most severe toothache does.
5. Do not agree to an extraction unless a specific tooth has been identified as the cause with tests, not by elimination.
6. Say clearly if a previous extraction did not resolve the pain. It is the most important sentence in the history.

Facial pain and nobody has found a cause? Book a full pain assessment at Ramat Beit Shemesh Urgent Dental Care before agreeing to an extraction. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.