Jawahar L Mehta*
Medicine and Physiology and Biophysics, UAMS, USA
Received date: December 30, 2014; Accepted date: January 30, 2015; Published date: February 05, 2015
Citation: Mehta JL (2015) Pain in My Head, or was It?. J Forensic Res 6:270. doi: 10.4172/2157-7145.1000270
Copyright: © 2015 Mehta JL. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Journal of Forensic Research
For 2 years- I had been experiencing headache- starting in my right temple- off and on. Initially the pain occurred once or twice a week and would be relieved with non-steroidal anti-inflammatory agents (NSAIDs) like aspirin and ibuprofen, but then it became more frequent occurring every day. The pain that initially was only modest became excruciating, lasting almost all day. The pain was at times throbbing. I could not sleep or perform my work normally. There were no specific precipitating or relieving factors. I saw my internist who ordered various tests- complete blood counts, and tests of my kidney and liver functions. All tests were normal. The headaches continued – requiring frequent intake of NSAIDs.
I decided to see a neurologist who after a brief examination found no neurologic deficit, and ordered tests to check for auto-immune disease, a CT and MRI- which were all normal. The headaches persisted despite use of NSAIDs, and the neurologist thought the pain might well be functional and referred me to a psychologist. Well- I began to believe some of it, because I was going through my mid-late years.
After a year of suffering chronic headaches, I began experiencing mild toothache on the lower right side and visited my dentist Dr. Peterson. Without much examination, he casually said that my right lower molar was the culprit and should be removed as per American Dental Association recommendations. Without much delay, he proceeded to take the tooth out. Unfortunately, the tooth broke in the middle of the procedure, and a 20 minute procedure turned into a 2 hour long nightmare. Under repeated local anesthesia, Dr. Peterson removed about 10-15 mm of mandibular bone to get the tooth out. The procedure resulted in severe piece bleeding. Dr. Peterson talked about the importance of clot retention which is essential for healing of the bone underneath. Lo and behold, the clot come out 2 hours later.
Dr. Peterson must have known that something was not right since he called me at home to see how I was feeling. This is not a usual procedure for him. I told him about the severe pain and that the clot had come off. He suggested continued use of opiates. Two days later- when I called him for help, he corroded the bone site under anesthesia and kept a gauze pad to facilitate clot formation. As luck would have it, the gauze and the clot came out on my way home. Two days later, for the third time he disrupted and corroded the bony surface to make a clot, again under anesthesia! I continued to experience excruciating pain, now radiating to the jaw and to the right side of my face.
My wife was seeing an oral surgeon Dr. Ackerman for her own tooth problem. I requested Dr. Ackerman to look at my tooth. He was very nice, got some x-rays- and said that all appeared fine and that I should continue NSAIDs since there was extensive trauma to the bone. Ten days later as the jaw pain continued, I saw the very courteous Dr. Ackerman again. This time he suggested a course of steroids for osteitis.
Now I was experiencing almost continuous pain that would start in the mandibular region, and radiate along the right side of the face, and then gradually around the right eye and all over the head. I returned to the neurologist and narrated my agony. He appeared to be frustrated, prescribed carbamzepine and gabapentin, and referred me to a prominent ENT specialist Dr. Sanders.
I was able a get a quick appointment with the ENT specialist Dr. Sanders whose specialty is trigeminal neuralgia. On my first visit, without much history or physical examination, he diagnosed my condition as classic atypical trigeminal neuralgia, and proceeded to administer lidocaine and steroid injections along the course of the trigeminal nerve, under the skin of my face and some inside the mouth. He continued to tell me how many patients like me he had treated, many of them writhing with pain. In any case, my pain was gone, but only for 3-5 hours, and then returned with vengeance. A week later when I told him about the short duration of pain relief, he repeated the injections and told me that some patients need multiple injections.
He also recommended that I have an MRI and an MRA to see if I had a tumor or blood vessel was compressing the trigeminal nerve. Both these tests turned out to be normal.
Now this was almost 2 months since I had dental extraction, and the pain was getting worse. I was frustrated with no proper diagnosis and relief in sight. My wife reminded me that I had developed good rapport with Dr. Ackerman and should see him. Unfortunately, Dr. Ackerman did not want me as a patient because my dentist Dr. Peterson had not referred him any patient in several months, and he did not want to inherit a patient who had had been messed up by Dr. Peterson.
We looked for an oral surgeon who could “fix” my mandible with a grape-size gap , and got an early appointment with Dr. Kohn who without much fanfare or bothering about the history ordered panoramic x-rays of my mouth in his fancy office. Right away he scheduled me for removal of the dead and infected root of the tooth next day. He pointed to the underlying trigeminal nerve and told me that he may have to remove adjacent part of the mandibular bone to get to the bottom of the tooth.
I was nervous, came home thinking less about my pain and more about a couple of lines in the sheet given by his office. The lines- “Contact your general dentist for any post-operative complication and follow-up care”. Wow, so I will be seeing the expert surgeon only for surgery who will not be interested in knowing about any post-operative problem. I canceled the surgery, and kept thinking that it must be trigeminal neuralgia which is hard to treat anyway.
My daughter suggested that I needed a good internist who will put it all together. So I made an appointment with my internist. This time he listened patiently and soon diagnosed my malady as autoimmune Giant Cell Arteritis, and ordered more blood tests. A couple of days later I received a letter had from him telling him that the tests were somewhat abnormal, and I needed to get temporal artery biopsy by a surgeon and to see a rheumatologist too!!! I decided against these recommendations.
But my pain was unrelenting and beginning to affect my life-style. My friends suggested that I should have oral surgery since the pain might well be due to some infection or abscess in the base of the extracted tooth.
I talked with my brother-in-law, a general dentist in the army, who shared my dental x-rays with his colleagues. They all thought that the pit from wisdom tooth removal was not the problem, but it was the adjacent 2nd molar that was hazy at the bottom and I should see an endodontist. So I called an endodontist Dr. Western who agreed to see me on an urgent basis. He indeed listened to my history, took more x-rays, and explained the findings. My wife and I are both physicians, but did not understand the findings. Nonetheless, he proceeded to perform the “root canal” work on the 2nd molar. After multiple lidocaine injections, root canal cleanings, x-rays and a $1000 check, I returned home. The pain reoccurred a few hours later, except that this time there was no radiation to the temporal area.
I decided to wait till the morning to see what to do next. I was beginning to feel that I am indeed a neurotic.
With intake of so much NSAIDs, my blood pressure was going up – from 120 to 160 mmHg systolic and 70 to 105 mmHg diastolic. A diuretic, thank goodness, helped. Discontinuation of ibuprofen also helped control my blood pressure.
Two days after root canal work, my pain began to subside, and a week later- it was almost all gone. The mandibular pain also began to subside. A few days later Dr. Kohn’s secretary sent me a significant bill for the panoramic x-rays and office visit- which was not covered by my insurance.
My headache was finally gone. I canceled my visits with my internist who diagnosed me with Giant Cell arteritis, my ENT surgeon who had diagnosed me with Atypical Trigeminal Neuralgia and my neurologist who all along thought that my headaches were functional.
What did I learn from this experience?
My headaches were probably caused by mild infection in my second molar which impacts the trigeminal nerve resulting in pain radiating along the course of the nerve, the ear, the temporal area and around the eye spreading all over my head. None of the dentists, physicians and surgeons I saw listened to my history carefully. The general dentist proceeded to remove the wisdom tooth just because the American Dental Association recommends that wisdom teeth are unnecessary and should be removed. When the complication did occur and the procedure had to be repeated 3 times, Dr. Peterson would not tell me that something had gone astray.
Being a physician, I was able to get access to specialists quickly. Many specialists tend to diagnose only what they know. The highly trained specialists depend on costly tests like CT and MRI, and then jump to perform the highly complex procedures without much thought of benefits and risks.
It appears that many internists and family physicians are not used to putting multiple maladies together. Beyond treating minor day-to-day problems, they begin to think of complex name disease like Giant Cell Arteritis. Further, they tend to refer patients to specialists as if referral would absolve them of any further responsibility. Importantly, brief time slots given to physicians limits their ability to spend time with the patients and think about the patients’ problems in a holistic fashion.
PS. The names of the physicians and dentists have been changed intentionally to protect their identity.
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals