Prof. Dr. Mehmet Şenoğlu — Brain, Nerve and Spine Surgery
One of the most unsettling stories I have heard in my office is this:
A patient comes in. They open their mouth and show me their missing teeth. Then they say:
“Doctor, there was nothing wrong with any of these teeth. They were pulled out one by one because my pain wouldn’t go away.”
Sadly, this is not a single, isolated story. And it is precisely why this article exists.
Let me give you the most important sentence at the outset:
Not all pain felt in a tooth comes from the tooth. Some of it comes from the nerve that supplies the tooth — and in that case, no procedure performed on the tooth will relieve the pain.
That distinction may look small. But it can prevent unnecessary root canals, unnecessary extractions, and years of continued suffering.
Let me now explain what is what.
First, Let Us Get to Know the Nerve Map
The key to understanding this subject is the nerve that carries sensation from your face.
The trigeminal nerve is the main nerve carrying sensation from your face to your brain. Its name means “triplet,” because it divides into three branches:
First branch — forehead and around the eye
Second branch — cheekbone, upper lip, and the upper teeth
Third branch — lower jaw, chin, and the lower teeth
And here is the critical point: Sensation from your teeth is carried to the brain along the second and third branches of this nerve.
What that means is this: A problem arising anywhere along this nerve pathway can be interpreted by the brain as “toothache” — even when the tooth is entirely healthy.
Let me explain it with an analogy: If a cable in your home’s wiring is faulty, the bulb will not light. Changing the bulb does not solve the problem, because the fault is not in the bulb but in the cable. In neurological tooth pain, the situation is exactly this: the tooth is the bulb, the nerve is the cable.
The Most Common Cause: Trigeminal Neuralgia
Recognizing this condition is vitally important — because it can be treated, and with the right treatment most patients do very well.
What Kind of Pain Is It?
People who experience this pain always use similar words to describe it:
“Like an electric shock.”
“As if lightning is striking.”
“Like a knife going in.”
Its characteristic features are these:
It lasts a very short time. Seconds, at most a few minutes. Then it stops. Then a new attack comes.
It is extremely severe. Patients generally say “the worst pain of my life.”
It is one-sided. It is felt in one half of the face, and that side generally does not change.
It is triggered — and this is the most distinguishing feature.
Triggers: The Strongest Clue to the Diagnosis
I would ask you to read this section with particular care, because it can almost establish the diagnosis on its own.
In trigeminal neuralgia the pain is set off by very light stimuli:
- Touching the face lightly
- Brushing the teeth
- Shaving
- Going out into the wind — cold air is almost a classic trigger
- Talking
- Chewing or swallowing
- Putting on make-up, washing the face
And here is a very telling observation: These patients frequently avoid touching one side of their face. They stop shaving, they do not chew on that side, they cover their face when going outside.
What I say to my patients is this: “If the thing that sets off your pain is disproportionately gentle compared with the severity of the pain — a light touch, a breeze — then it is not coming from a tooth.”
How Is It Distinguished From Toothache?
This table is the most practical tool for making the distinction:
| Genuine toothache | Nerve-related pain | |
|---|---|---|
| Character | Throbbing, continuous | Like an electric shock, like lightning |
| Duration | Lasts for hours | Seconds — then it stops |
| Hot and cold | Marked sensitivity | Generally unaffected |
| Trigger | Eating, hot and cold | Touch, wind, talking, shaving |
| At night | Can wake you from sleep | Generally comfortable during sleep |
| Location | A specific tooth can be pointed to | Spreads; cannot say “exactly where” |
| Dental treatment | Helps | Does not help |
| Between attacks | The pain continues | There are completely pain-free periods |
The two most valuable rows in this table are the last two. Because:
If dental treatment has been carried out and the pain has not changed at all — the diagnosis should be questioned.
If you have completely pain-free periods between attacks — that does not fit the profile of toothache.
Why Does It Happen?
The most common cause of trigeminal neuralgia is this: at the point where the nerve emerges from the brainstem, a blood vessel touches the nerve and irritates it over time. The nerve’s insulation wears down and the nerve becomes over-sensitive.
You can compare this to an electrical cable whose insulation has worn away: the slightest contact produces a spark.
Less frequently, a mass pressing on the nerve, or conditions affecting the nerve’s insulation, can produce a similar picture. These possibilities relate to the warning signs in the next section.
⚠️ Warning Signs: Do Not Delay If These Are Present
Now we come to the second part of the title. This section covers the findings that must not be missed.
1. Numbness and Loss of Sensation — The Most Important
I emphasize this item in particular.
In classical trigeminal neuralgia there is no loss of sensation. There is pain, but sensation in the face is normal.
So: if there is numbness, tingling, or loss of feeling in your face, lip, chin, or tongue — this suggests a different situation and must be investigated.
Numbness can indicate that something is pressing on the nerve from outside, or that the nerve has been injured.
The rule: Pain + numbness = further assessment is needed.
2. Starting at a Young Age
This condition is generally seen in middle and later life. Its appearance in a young person requires that another underlying cause be investigated.
3. Being on Both Sides
In the classical picture the pain is one-sided. Its occurrence on both sides at once is a reason for further investigation.
4. The Pain Becoming Continuous
If, instead of short attacks, it is turning into an increasingly constant, dull pain; or if the pain-free intervals between attacks have disappeared.
5. Other Accompanying Findings
- Hearing loss or ringing in the ear
- Weakness of the face, being unable to close the eye
- Double vision
- Difficulty swallowing
- Loss of balance
- Weakness or wasting of the chewing muscles
These suggest that neighboring structures are also affected.
6. A Palpable Swelling or Sore in the Mouth
If there is a visible mass, a non-healing sore, or swelling at the source of the pain — this requires separate assessment.
7. Fever and Swelling
If there is rapidly increasing swelling and redness of the face along with fever, this suggests infection and is an emergency. Dental infections can spread rapidly.
❗ A Warning That Could Save a Life: Jaw Pain of Cardiac Origin
I regard writing this section as this article’s most important responsibility.
A heart attack does not always present with chest pain. In some patients the pain is referred to the jaw, the lower teeth, the neck, or the arm.
And in the medical literature there are reported cases of patients who received dental treatment — and even had teeth extracted — for toothache of cardiac origin.
Distinguishing Features
If the following features are present, do not regard this as toothache:
- The pain increases with exertion — climbing stairs, walking, going uphill
- It eases with rest
- Pressure or tightness in the chest accompanies it
- Shortness of breath
- Cold sweating
- Nausea
- Radiation to the left arm or the back
- The pain can be felt in both sides of the lower jaw
- Dental examination and X-ray are completely normal
⚠️ For jaw or lower-tooth pain that increases with exertion and comes with sweating and shortness of breath, GO TO THE EMERGENCY DEPARTMENT. Call the emergency number.
In people with diabetes in particular, a heart attack can occur without typical chest pain. In this group, vigilance matters even more.
Other Causes of Neurological Tooth Pain
Trigeminal neuralgia is the most common cause, but it is not the only one.
Nerve Pain Developing After a Dental Procedure
This is an important and little-known situation.
Sometimes, after a dental procedure — particularly wisdom tooth extraction or implant placement — the nerve in that area can be affected and a lasting pain can develop.
The typical picture: The procedure has healed, the X-ray is clean, but the pain does not go away. It is frequently accompanied by burning, tingling, and numbness.
The critical point: In this situation, extracting another tooth or performing a new procedure does not help — and may make the picture worse. This is a different condition requiring treatment aimed at nerve pain.
Pain Continuing in the Same Place After a Tooth Has Been Extracted
In some patients, a constant, dull pain continues in the area where the tooth was extracted — despite there no longer being a tooth there.
The most critical aspect of this picture is this: The patient says the pain is continuing, the neighboring tooth is also extracted, the pain continues, another tooth is extracted… and the chain goes on.
If the pain continues in a tooth that is no longer there — the problem is not in the tooth. Stop the chain.
Headache Conditions
Some types of headache can make the pain felt in the upper teeth.
For example, cluster headache can produce very severe pain around the eye together with pain spreading to the upper teeth. In this picture there is usually redness of the eye, watering, and a runny nose on the same side.
Migraine too can sometimes be felt in the face and tooth region.
Sinusitis
The roots of the upper back teeth lie next to the sinus cavity. In sinusitis, pain can be felt in these teeth.
A distinguishing clue: The pain increases on bending forward, is generally felt in more than one tooth, and is accompanied by nasal congestion and post-nasal drip.
Jaw Joint Problems
If there is pain in front of the jaw joint, a clicking sound when opening the mouth, jaw fatigue in the mornings, and a history of clenching at night — the source of the pain may be the joint and the surrounding muscles.
Pain Originating in the Neck
This is a situation that also concerns my own field. Problems arising in the upper neck region can refer pain to the face and jaw. It is generally related to neck movements, and there is tightness in the nape as well.
How Is the Diagnosis Made?
The diagnosis is made largely by listening to your history.
This surprises patients, but it is true: the character of the pain, its duration, and what triggers it are usually the most valuable information.
What Is Examined
Sensation in the face — whether there is numbness is checked in particular. Facial muscles, eye movements, chewing muscles, and where necessary, hearing.
Why Is Imaging Done?
MRI is performed not to diagnose trigeminal neuralgia but to investigate whether there is another cause. It is particularly necessary if any of the warning signs listed above is present.
The Response to Treatment Is Also a Clue
A marked response to the particular medications used in this condition is an important finding supporting the diagnosis. Conversely, no response at all requires the diagnosis to be reconsidered.
The Role of the Dentist
I want to say this plainly: Going to the dentist is not a waste of time — it is the necessary first step.
Because genuine dental problems are far more common and must be excluded first. Indeed, medical sources emphasize that dentists play a critical gatekeeping role in this process: excluding dental causes and referring the patient to the right specialist when needed.
The problem is not going to the dentist. The problem is continuing along the same path when the pain does not go away.
Treatment Options
The good news on this subject is: trigeminal neuralgia is a treatable condition.
Medication First
The medications used in this condition are not ordinary painkillers. They are medications that reduce the over-excitability of the nerve.
An important note: Ordinary painkillers generally do not work for this pain. This misleads patients — they think “painkillers aren’t helping, so it must be something serious.” In fact, the correct class of medication is a different one.
For correct use of the medication:
- The dose is generally increased gradually — this reduces side effects
- Do not stop it on your own
- If side effects occur, tell your doctor; do not change the dose yourself
If Medication Is Not Enough: Interventional Options
In patients for whom medication does not give sufficient relief, or who cannot take it because of side effects, interventional options come onto the agenda.
Microvascular decompression: A procedure in which the vessel pressing on the nerve is separated from it and a small cushion is placed in between. The nerve is not damaged — only the contact is removed. In suitable patients it can give long-lasting relief.
Radiosurgery (a radiation-based method): Requires no incision; focused radiation is used. Its effect generally appears not immediately but over weeks to months.
Percutaneous methods: Procedures performed by reaching the nerve with a fine needle through the skin. These may be preferred in patients whose general condition is not suitable for surgery.
Which method suits whom is determined according to your age, general health, MRI findings, and preferences. This is a decision to be made together.
Which Department Should I Go To?
This is one of the most frequently asked questions.
The sequence is this:
1. The dentist first. Dental causes must be excluded — this is the necessary first step.
2. If there is no dental problem, or the pain persists despite treatment: Neurology.
3. If interventional treatment comes onto the agenda: Neurosurgery.
4. Others that may be needed: ENT if sinus involvement is suspected; oral and maxillofacial surgery if a jaw joint problem is suspected; pain medicine for pain management.
And I emphasize again: For jaw/tooth pain that increases with exertion and comes with sweating and shortness of breath → the emergency department.
The Most Practical Thing You Will Take From This Article
If you remember one thing from this article, let it be this:
“I had a dental treatment, my pain didn’t go. I had a second one, it still didn’t go.”
That is exactly the point at which to stop and ask: “Could the problem be not in my tooth but in my nerve?”
That single question can save patients from years of unnecessary procedures.
Situations Requiring Emergency Care Without Losing Time
Call the emergency number or go to the emergency department:
- Jaw/tooth pain that increases with exertion + chest tightness, shortness of breath, cold sweating, nausea (this may be a heart attack)
- Rapidly increasing swelling and redness of the face + high fever (spreading infection)
- Being unable to open the mouth + swelling + fever
- Difficulty swallowing or breathing
- A suddenly starting, very severe headache
- Sudden difficulty speaking, the mouth drooping, loss of strength in an arm (signs of stroke)
- Sudden loss of vision or double vision
Make an Appointment Without Delay
- Numbness or loss of sensation in the face or mouth
- Pain that does not change at all despite dental treatment
- Electric-shock-like facial pain starting at a young age
- Two-sided facial pain
- If hearing loss, ringing in the ear, or facial weakness accompanies it
- Pain continuing in the same area even though the tooth has been extracted
- A non-healing sore or a palpable swelling in the mouth
Frequently Asked Questions
Below, I have gathered the most frequently asked questions on this subject along with brief answers. These answers are for general information; the information that applies to your specific situation is the one given by the doctor who examines you.
What does neurological tooth pain mean?
It is a situation in which the pain is felt in the tooth but does not originate from the tooth. The source is the trigeminal nerve, which carries sensation to the tooth. For this reason the pain is felt in the tooth even when the tooth is healthy — and procedures performed on the tooth do not relieve it.
How do I know whether my pain comes from the tooth or the nerve?
The three most distinguishing features: the character of the pain (if it is like an electric shock and lasts seconds, the nerve; if it is throbbing and lasts hours, the tooth), the trigger (light touch, wind, shaving, talking → nerve; hot and cold → tooth), and the response to dental treatment (if it does not help, the nerve should be considered).
I had dental treatment but my pain didn’t go away — what should I do?
Do not continue along the same path. This is the clearest sign that the diagnosis needs to be reassessed. Speak with your dentist and ask for a neurological assessment. If the pain has still not gone after a second procedure in particular, do not delay this step.
Which warning signs should I watch for?
The most important is numbness. In classical trigeminal neuralgia there is no loss of sensation; if there is numbness in your face, lip, or chin it must be investigated. Others: starting at a young age, being on both sides, the pain becoming continuous, hearing loss, facial weakness, and double vision.
Could my jaw pain be coming from my heart?
Yes — and this is the most critical warning in this article. A heart attack does not always present with chest pain; the pain can be referred to the jaw and the lower teeth. If the pain increases with exertion, eases with rest, and is accompanied by sweating, shortness of breath, or chest tightness — do not treat it as toothache, call the emergency number. Be especially careful if you have diabetes.
The pain continues in the same place even though the tooth was extracted — is that possible?
Yes, and this is a situation that needs to be recognized. If the pain persists even though the tooth is no longer there, the problem is not in the tooth. At this point a further extraction will not help — and may make things worse. Stop the chain and ask for a neurological assessment.
I had a wisdom tooth out and there is burning and numbness in that area
This may be a nerve pain condition that can develop after a dental procedure. Typically the wound has healed and the X-ray is clean, but burning, tingling, and numbness persist. In this situation what is needed is not another dental procedure but treatment aimed at nerve pain. It should be assessed without delay.
Painkillers aren’t helping — is that a bad sign?
No — on the contrary, it may be a clue. In this nerve-related pain, ordinary painkillers generally do not work. The medications used belong to a different group, one that reduces the over-excitability of the nerve. So “painkillers aren’t helping” does not mean “something serious is going on” — it may mean “the wrong class of medication.”
Is going to the dentist a waste of time?
Absolutely not — it is the necessary first step. Genuine dental problems are far more common and must be excluded first. The dentist plays a critical role in this process. The problem is not going to the dentist but continuing along the same path when the pain does not go away.
Which department should I go to?
The sequence is: the dentist first (dental causes must be excluded) → if there is no dental problem or the pain persists despite treatment, Neurology → if interventional treatment comes onto the agenda, Neurosurgery. In addition, ENT may be involved if sinus disease is suspected, and oral and maxillofacial surgery if a jaw joint problem is suspected.
Will this pain go away — is there a treatment?
Yes, it is a treatable condition. In most patients, appropriate medication provides marked relief. If medication is insufficient or cannot be used because of side effects, there are interventional options — separating the vessel pressing on the nerve, radiation-based methods, and procedures performed through the skin. Which method suits you is determined individually.
If I have surgery, will my face become numb?
It depends on the method. In the procedure that separates the vessel from the nerve, the nerve is not damaged — only the contact is removed, so loss of sensation is not an expected outcome. With the other methods there is some possibility of a change in sensation. This is a subject that must be discussed before surgery; ask your surgeon plainly.
Disclaimer (Legal Notice)
The information contained in this article has been prepared for general informational purposes only and in no way replaces a medical examination, diagnosis, or treatment. This article is not a treatment recommendation and cannot be used as a guide for determining the source of your pain on your own. Pain in the face and tooth region has many different causes; the correct diagnosis can only be made by the doctor who examines you. For dental complaints, see a dentist first; this article is not a reason to skip a dental examination. Do not start, stop, or change the dose of your medications on your own. Jaw or lower-tooth pain that increases with exertion and is accompanied by sweating, shortness of breath, or a sense of chest tightness may be of cardiac origin; in that situation call the emergency number without losing any time. In addition, in situations such as rapidly increasing facial swelling with fever, being unable to open the mouth, difficulty swallowing or breathing, sudden difficulty speaking, or sudden loss of vision, go to the nearest emergency department immediately.