TRIGEMINAL NEURALGIA

Dr. DEEPTHI ATHULURU

First Year Post Graduate
Public Health Dentistry
CONTENTS
Introduction
Definition
Classification
Etiology and Pathogenesis
Clinical features
Diagnosis
Treatment and management
Public Health Importance
Conclusion
References
INTRODUCTION
Anatomy of Trigeminal nerve
=
DEFINITION

• Sudden, usually
unilateral, severe brief
stabbing pain in the
distribution of one of
more branches of the
V nerve.
 Other names

Tic douloureux – Nicholaus Andre

Fothergill’s disease – John Fothergill

CLASSIFICATION:

International Headache Society (IHS) classified

trigeminal neuralgia into two types:
 Classical /idiopathic/typical
 Symptomatic
Classical trigeminal
neuralgia is a unilateral
disorder characterized
by brief electric, shock-
like pains.
They are abrupt in
onset and termination
and limited to the
distribution of one or
more divisions of the
trigeminal nerve.
Symptomatic trigeminal neuralgia
Pain is similar to classical type
But it is caused by a demonstrable
structural lesion other than vascular
compression.
ETIOLOGY
Compression of the trigeminal nerve root
Primary demyelination disorders
Multiple sclerosis
Charcot-Marie-Tooth disease(hereditary
sensory motor neuropathy)
Infiltrative disorders of the trigeminal nerve
root, ganglion and nerve
Carcinomatous deposits
Perineural spread of head and neck cancer
Non-demyelinating lesions of the pons or
medulla
Familial trigeminal neuralgia
Compression of the Trigeminal Nerve Root
Compressive lesions
Tumor of cerebellar pontine angle
Posterior cranial fossa tumors
Schwannomas
Meningioma
Epidermoid cyst
Compression from osteoma or deformity
resulting from osteogenesis imperfecta
(rarely)
 PATHOGENESIS
Superior cerebellar artery pressing on or
grooving the root of the nerve causes pressure
which results in

focal demyelinization and hyperexcitability of

nerve fibres

which fire in response to light touch resulting in

brief episodes of intense pain.
CLINICAL FEATURES
Rare
Middle age
Female predilection (60%)
Maxillary division more commonly involved
Opthalmic division rarely involved
Shaving, showering, speaking, eating, or
exposure to wind triggers episodes
Contd…….
CLINICAL FEATURES……………….

Pain occurs in areas of the face where the

trigeminal nerve supplies normal sensation:
cheek, jaw, teeth, gums and lips, and
sometimes the eye or forehead
The pain is described as episodes of
intense feeling like –stabbing, electric
shocks, burning, crushing, exploding,
lancenating pain
Pain lasts for few
seconds to minutes
Unilateral
(predominantly right
side)
Precipitated by trigger
zones
Extreme cases ‘frozen
or mask like face’
Trigger zones
DIAGNOSIS

 History
 Clinical examination
 Diagnostic LA blocks
 CT scan
 MRI
Pain History

 Chief complaint
 History of present illness
 Current symptoms: Onset, Location, Quality,
Intensity, Frequency, Duration
 Aggravating and alleviating factors
 Past treatments
IHS diagnostic criteria for trigeminal
neuralgia
Classic trigeminal neuralgia
A. Paroxysmal attacks of facial or frontal pain
that last a few seconds to less than 2 minutes,
affecting one or more divisions of the
trigeminal nerve and fulfilling criteria B and
C.
B. Pain has at least one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2. Precipitated from trigger areas or by
trigger factors
3. The patient is entirely asymptomatic
between paroxysms.
C. Attacks are stereotyped in the individual
patient.
D. There is no clinically evident neurological
deficit.
E. Not attributed to another disorder.
Symptomatic trigeminal neuralgia
A. Paroxysmal attacks of pain lasting from a
fraction of a second to 2 minutes, with or
without persistence of aching between
paroxysms, affecting one or more divisions of
the trigeminal nerve and fulfilling criteria B.
B. Pain has at least one of the following
characteristics:
1. Intense, sharp, superficial or stabbing
2. Precipitated from trigger areas or by trigger
factors
3. Attacks are stereotyped in the individual
patient
4. A causative lesion, other than vascular
compression, has been demonstrated by
special investigations and/or posterior fossa
exploration.
Differential Diagnosis Of Classic
Trigeminal Neuralgia

1. Secondary trigeminal neuralgia

2. Pain of dental origin
3. Extracranial
4. Neuropathic
5. Neurovascular
6. Psychogenic
TREATMENT

Medical management

Surgical management
 Treatment of trigeminal neuralgia is broadly
divided into two categories:
1. Destructive treatment:
 Radiofrequency Rhizotomies
 Balloon Gangliolysis
 Stereotactic Radiosurgery (ie Gamma Knife)
The possible complication of destructive
treatment is facial numbness, neuroparalytic
keratitis, or the sever complication of anesthesia
dolorosa which is a more complex facial pain.
2. Non destructive treatment:
 Medical treatment (Tegretol, Baclofen,
Dilantin, etc.)
 Microvascular decompression (with initial
success rate of 85 to 95%)
The possible complication of non destructive
treatment is side effect of medication and risk of
surgery.
Medical management

CARBAMAZEPINE
 100 – 200mg, bd or tid
 Which provides benefit to more than 75% of
patients
 Common trade names: Tegretol, Tegretol XL,
Carbitrol
 Mode of action
 Side effects
 Other Medication

Oxcarbazepine Phenytoin
Gabapentin Clonazepam
Lamotrigine Felbamate
Baclofen Pimozide
Topiramate Zonisamide
Sodium valproate Pregabalin
 Surgical management
Surgical options have been reserved for those
patients
who have a clearly defined secondary cause
for the trigeminal neuralgia,
 who are unresponsive,
 who have severe, unremitting pain that
limits their ability to eat,
 for whom multiple medications are
intolerable or contraindicated
 Surgical options

Percutaneous glycerol rhizolysis

Percutaneous balloon compression
Radiofrequency trigeminal (retrogasserian)
rhizotomy
Gamma knife radiosurgery
Microvascular decompression
 Percutaneous Glycerol Rhizolysis

This procedure is used in

Arterial or venous compression of the
trigeminal nerve
Multiple sclerosis
Done with absolute alcohol or phenol or
phenol/glycerol mixture injected into the
trigeminal cistern
Hartel technique

 When the needle pierces the foramen ovale and enters

the trigeminal cistern there is usually a characteristic
jaw twitch and CSF returns through the needle.
 Lack of CSF return may be related to poor position of
the needle or to scarring within the cistern due to prior
surgery
Glycerol rhizolysis (GR)

 Test dose: 0.1-0.15 ml

 0.05~0.1 ml at 3~5 min. intervals
 Total dose: 0.1~0.4 ml
 Sensory changes: pain, burning or
paresthesia
Percutaneous balloon compression

0.5 - 1 ml of contrast
Pear-shape balloon
Compression time: 1- 7
min.
Radiofrequency thermo-coagulation

 The theory behind the use of radiofrequency to

lesion the trigeminal nerve is that it may
selectively injures/destroys the unmyelinated
or poorly myelinated nociceptive nerve fibers
and spares the (heavily) myelinated fibers
which serve touch, proprioception, and motor
function
A permanent lesion in the retrogasserian trigemianal
nerve is made by beginning at 10V and approximately
60mA for a duration of 30-40 sec and increasing to
approx. 20V and 100mA
(a) Thermal lesion of trigeminal nerve. (b) Mislocation of the electrode

(c) Expansion of thermal energy to neighboring neural structures.

Gamma knife radiosurgery
 The Gamma Knife is a
focused array of 201
intercepting beams of
gamma radiation, produced
by separate cobalt sources.
 The dose is 70–90 Gy.
 Pain relief is usually not
immediate.
 The mean time to pain relief
in two series was
approximately one month.
 Microvascular decompression

It is the only medical or surgical intervention

that directly addresses the presumed
underlying pathology of classic trigeminal
neuralgia.
Retrosigmoid craniectomy approach
Operative approach
Microvascular decompression(MVD)
 RFL for patients who are elderly or medically
frail.

Posterior fossa exploration and MVD for

younger healthier patients who can tolerate the
longer more invasive surgical procedure.

 GKR as an alternative to RFL in frail or elderly

patients. MVD or RFL remains the standard
for surgical treatment of younger patients who
have considerable life expectancy
Peripheral procedures
Peripheral
neurectomies
Cryotherapy
(cryonanlgesia)
Alcohol block
Streptomycin –
lidocaine injections
 OMFS….
Peripheral neurectomy
Supra orbital
Infra orbital
Mental
Inferior alveolar
Long buccal
Lingual (rarely)
Infraorbital neurectomy
SUPRAORBITAL NEURECTOMY
Inferior Alveolar Nerve
Neurectomy
 Trigeminal Neuralgia Diet

Low fat, high protein, high calorie

Easy chewable foods
Served lukewarm
Offered frequently

Trigeminal Neuralgia Association recommends

 avoidance of: extreme hot/cold, hot sauce,
chili, spicy salsa, mints, black pepper,
cinnamon, ginger, nutmeg
 PUBLIC HEALTH IMPORTANCE
 Trigeminal neuralgia has an incidence of 4–5 per
100,000 of the population.
 It is nearly twice as common in women,
 Incidence increases in age to around 1 in 1000
patients older than 75 years of age.
 Rarely, familial cases have been reported.
 It is reported that 150,000 people are diagnosed
with trigeminal neuralgia every year.
 The only indication about the prevalence of
TN comes from a study by Penman , who in
1969 reported rates of 107.5/1000000 in men
and 200.2/1000000 in women.
 TN is therefore a rare disease
 TN incidence progressively increases with
increasing age: from 17.5/100000/ between 60
and 69 years of age up to 25.6/100000/year
after 70.
 The female-to-male ratio was 1.74:1 in the
Katusic et al. study
 and 3:2 in another study by Ashkenazi and
Levin.
CONCLUSION

Population-based epidemiological studies

are essential to determine the spectrum of
TN symptoms in the population,
identifying individuals in whom symptoms
are mild enough that they do not seek
treatment. Potentially useful approaches in
studying the epidemiology of TN include
multi-site population-based studies
A concerted program of epidemiologic
studies is needed to identify these key
features of TN: prevalence and public
health impact, especially among women
and members of minority groups; risk
factors; comorbidity; prodromal symptoms;
and natural history.
REFERENCES:

Fonseca, Marciani, Turvey, Oral and

Maxillofacial surgery, 2nd edition, volumeII
,Saunders Elsevier, 2009.
Jafferey P. Okeson, Bells Orofacial pain, 6th
edition, Quintessence publishing co Inc,
2005.
Peterson, Ellis, Hupp, Tucker, Oral and
maxillofacial surgery, 4th edition, Elsevier,
2003.
 G.C. Manzoni , P. Torelli, Epidemiology of typical
and atypical craniofacial neuralgias, Neurol Sci
(2005) 26: S65–S67
 Abhishek singh nayyar, Mubeen Khan, Trigeminal
Neuralgia: Revisiting clinical characteristics in the
Indian scenario. A Journal of Medical science and
Technology. Volume I, Issue 2, August 2012; pages
9-17
 Cheryl A. Kitt et al., Topical review Trigeminal
neuralgia: opportunities for research and
treatment, International Association for the Study
of Pain, 2000.
THANK YOU