Persistent Oral Pain: Causes and Diagnostic Approaches

Oral issues?

Hello Dr.
Tseng, I have been experiencing oral symptoms for six months now.
Currently, I still have a burning pain on the left side of my oral mucosa, and there is slight discomfort in the occlusion of my teeth.
My tongue also has a mild abnormal taste sensation.
Occasionally, I feel a sharp pain in the area of the upper left gum where my last molar used to be; however, that tooth was extracted in January and another in May, and the extraction site still has a slight indentation.
I have consulted with dentists who said the extraction sites and oral mucosa appear fine.
Additionally, I have seen many other specialists, but none have been able to identify the underlying cause.
In May, I underwent a contrast-enhanced CT scan of the head and neck, and the doctor reported no abnormalities in the oral cavity or brain, nor did they find any lesions.
I also had an MRI of the brain done by a neurologist, which showed no abnormalities, along with a series of brainstem nerve examinations.
The doctor mentioned that the brainstem function indices were borderline, indicating potential degeneration affecting the sensory nerves of the oral cavity and tongue, but this was not definitively stated.

I have also consulted with a metabolic specialist who performed blood tests and a 24-hour urine test, as well as a contrast-enhanced MRI of the brain, all of which did not reveal any issues.
My menstrual cycle has been irregular over the past few months, and I wonder if this could be related to my oral symptoms.
However, the head and neck CT scan with contrast did not show any abnormalities in the oral cavity, and the brain MRI also showed no issues.
The only potential factor affecting my oral symptoms seems to be a neurological problem.
I am currently managing my symptoms with medication, but I truly hope to receive treatment and understand what illness I have.
The stress over the past six months has been overwhelming, and I still worry about the possibility of lesions or abnormalities in my gums and the floor of my mouth.

Could you please advise on any further examinations I should consider? Do I still need to undergo a CT scan or MRI specifically for the oral area? Should I return to the oral medicine department for further examination of the oral mucosa, or is there a possibility of performing a biopsy? After all these tests, can we rule out the presence of lesions or abnormalities in the gums? I apologize for the lengthy message, and I appreciate your patience in reading it.
Thank you for your kindness and compassion.

Miss Lin, 40~49 year old female. Ask Date: 2019/08/01

Dr. Zeng Guanghui reply Dentistry

If a CT scan and MRI of the head and neck have been performed and no abnormalities were found in the brain, but there is still a burning pain in the oral mucosa, it may be related to an autoimmune issue.
It is recommended to consult an immunologist for further evaluation.

Reply Date: 2019/08/01

More Info

Persistent oral pain can be a complex issue, often requiring a multifaceted approach to diagnosis and treatment. Your symptoms, which include burning sensations in the oral mucosa, mild pain at the bite position, altered taste sensations, and occasional sharp pain in the area where teeth have been extracted, suggest that there may be several underlying factors contributing to your discomfort.

Firstly, it’s important to consider the possibility of nerve-related issues. Given that you have undergone extensive imaging studies, including CT scans and MRIs, which have not revealed any abnormalities, it is plausible that your symptoms could be related to nerve irritation or dysfunction. Conditions such as trigeminal neuralgia or neuropathic pain can manifest as burning or sharp pain in the oral cavity, even in the absence of visible dental problems. The trigeminal nerve is responsible for sensation in the face and can sometimes become hypersensitive or damaged, leading to persistent pain.

Another potential cause of your symptoms could be post-extraction complications. After tooth extractions, especially if they were recent, the surrounding tissues can take time to heal. The presence of a dry socket or incomplete healing can lead to ongoing discomfort. Additionally, if the extraction sites are not healing properly, they may become sites of irritation or infection, even if they appear normal upon examination.

Oral mucosal conditions should also be considered. Conditions such as burning mouth syndrome (BMS) can cause a burning sensation in the mouth without any identifiable dental or medical cause. BMS is often associated with hormonal changes, nutritional deficiencies (such as vitamin B12 or iron), or psychological factors like anxiety and depression. Given your mention of irregular menstrual cycles, it may be worth exploring whether hormonal fluctuations could be contributing to your symptoms.

You also mentioned that you have seen various specialists, including neurologists and endocrinologists, which is a good approach to rule out systemic issues. However, if you have not yet consulted with an oral medicine specialist or an oral pathologist, it may be beneficial to do so. These specialists can perform a thorough examination of the oral mucosa and may recommend a biopsy if there are any suspicious lesions or if the symptoms persist without a clear diagnosis.

In terms of further diagnostic imaging, while your previous scans have not shown abnormalities, a cone-beam computed tomography (CBCT) scan specifically focused on the oral cavity may provide more detailed information about the bone structure and any potential issues that standard imaging might miss.
Finally, managing your symptoms with medications is important, but it’s equally crucial to address the underlying cause. If nerve involvement is suspected, medications such as anticonvulsants or antidepressants may be helpful. Additionally, topical treatments or oral rinses may provide symptomatic relief for mucosal pain.

In summary, your persistent oral pain could stem from a combination of nerve-related issues, post-extraction complications, or oral mucosal conditions. It is advisable to consult with an oral medicine specialist for a comprehensive evaluation, including the possibility of a biopsy if warranted. Continuing to monitor your symptoms and maintaining open communication with your healthcare providers will be key in finding an effective treatment plan.

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