First-line management of post-traumatic trigeminal neuropathic pain: objective consensus analysis reveals marked heterogeneity among international expert centers

Background: Post-traumatic trigeminal neuropathic pain (PTNP) lacks disease-specific treatment guidance, and how experienced clinicians select first-line management remains unclear. We aimed to quantitatively characterize real-world decision-making for first-line treatment of PTNP in patients meeting International Classification of Orofacial Pain criteria. Methods: Nineteen experts from dedicated secondary and tertiary care centers worldwide were invited; 13 provided detailed management strategies. Their responses were converted into anonymized decision trees and analyzed using the Objective Consensus Method, which compares recommendations across all possible combinations of predefined clinical parameters. Similar criteria and treatments were grouped into broader categories to enable cross-comparability. Results: Thirteen decision-criteria categories were identified. Comparison of all submitted strategies yielded 35 distinct clinical scenarios. Limited agreement (54%) was reached in only 6 scenarios, whereas no agreement was observed for the remaining scenarios. Topical treatment was favored in selected patients without imaging evidence of injury and with superficial, localized pain, whereas a slight majority of experts chose surgical intervention for selected patients after mandibular third molar surgery with imaging evidence of nerve injury and a positive diagnostic block. All experts agreed that patient education and access to psychological support are essential components of first-line care. Conclusions: Current first-line PTNP management shows substantial variability. Surgical evaluation is being applied in selected patients with confirmed nerve injury and positive blocks, while conservative approaches are favored in the majority of the scenarios. Patient education and psychological support should be integral to care. These findings represent expert opinion rather than outcome-validated evidence. Standardized, PTNP-specific guidelines, informed by prospective outcome data, are needed.