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Trigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterised by severe, paroxysmal pains in the face. Little is known about the decision process in treatment of TN, and management with anti-epileptic drugs or surgical procedures carries risks of side effects, recurrence and complications. One hundred fifty-six previously diagnosed TN patients completed an adapted time-trade-off utility measurement questionnaire to ascertain how they valued the potential outcomes from various surgical and medical treatments. The decision analysis revealed that microvascular decompression surgery (MVD) offered the best chance of improved quality of life or highest maximum expected utility (MEU). MVD (MEU = 16.08 out of a possible 20) was closely followed by balloon compression (MEU = 15.97), percutaneous glycerol rhizolysis (MEU = 15.61) and then radiofrequency thermocoagulation (MEU = 14.93). Medication offered the least optimal chance of improved quality of life (MEU = 14.61). The difference between the highest (MVD) and lowest scoring treatments (medication) was 7.3% (1.46/20). These results were sensitive to some utility values, meaning the preferred treatment is changed by the values patients assign to outcomes. As surgical techniques narrowly offer the highest chance of maximising patient quality of life, all patients with TN should consider surgery. However, surgery is not right for everyone, and patients should be informed about their full range of choices. Treatment decisions must take place after careful consideration of the values patients place on benefits and risks of treatment. (C) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

To estimate the prevalence of orofacial pain (OFP) by specific diagnostic subgroups in the general population. Cross-sectional population study. General medical practice in South East Cheshire, UK. Participants of baseline investigation who completed the full postal questionnaire (1510, adjusted study participation rate 81%). Clinical examination was attended by 126 (43%) of all the participants who reported OFP in the questionnaire. These individuals were classified as musculoligamentous/soft tissue type, dentoalveolar or neurological/vascular. OFP duration, location, descriptors and statements on OFP were predictors of classification group. The estimated prevalence in the general population of musculoligamentous/soft tissue type of OFP was 7%, dentoalveolar 7% and neurological/vascular 6%. This study has derived a statistical model to classify participants with OFP into three broad groups (musculoligamentous/soft tissue, dentoalveolar and neurological/vascular) based on questionnaire information about OFP (OFP chronicity, location and verbal descriptors of pain). It is potentially useful in large population studies of OFP, where a clinical examination is not possible, however, further validation of its performance in large populations are necessary.

Lamotrigine is a chemically novel antiepileptic drug which has not been adequately assessed for its antineuralgic properties. It was used in a double-blind placebo controlled crossover trial in 14 patients with refractory trigeminal neuralgia. Patients continued to take a steady dose of carbamazepine or phenytoin throughout the trial over a 31-day period. Each arm of the trial lasted 2 weeks with an intervening 3-day washout period. The maintenance dose of lamotrigine was 400 mg. Lamotrigine was superior to placebo (P = 0.011) based on analysis of a composite efficacy index which compared the numbers of patients assigned greater efficacy on lamotrigine with those assigned greater efficacy on placebo. Efficacy for one treatment over another was determined according to a hierarchy of: (i) use of escape medication; (ii) total pain scores; or (iii) global evaluations. Eleven of the 13 patients eligible for inclusion in the composite efficacy index showed better efficacy on lamotrigine compared with placebo. Global evaluations further suggested that patients did better on lamotrigine than placebo (P = 0.025). The adverse reactions with both lamotrigine and placebo were predominantly dose-dependent effects on the central nervous system. A 14th patient withdrew from the study due to severe pain during the placebo arm of the trial. It would appear that lamotrigine has antineuralgic properties.

The patient who presents with a burning mouth is a challenge to all clinicians both medical and dental as too little carefully controlled research both on aetiological factors and management has been carried out.