TRIGEMINAL-NEURALGIA

BY MRUNAL JADHAV
4TH YEAR BDS
CONTENT
 INTRODUCTION
 GENERAL CHARACTERISTICS
 CLINICAL FEATURES
 DIAGNOSIS
 TREATMENT
i. MEDICAL MANAGEMENT
ii. SURGICAL MANAGEMENT
INTRODUCTION
Definition:
Trigeminal neuralgia (TN) is defined as sudden
usually unilateral, severe, brief, stabbing,
lancinating, paroxysmal, recurring pain in the
distribution of one or more branches of 5th
cranial nerve.
• John Locke in 1677 gave the first full
description with its treatment.
• Nicholaus Andre in 1756, coined the term 'Tic
Douloureux’.
• John Fothergill in 1773, published detailed
description of TN, since then, it has been
referred to as 'Fothergill's disease'.
 Trigeminal neuralgia is unpredictable, cause
due to compression or damage of the nerve
resulting in pricking, sharp pain like electric
shocks.
 The facial pain cause by this nerve is called
trigeminal neuralgia (Tic Douloureux).
 The cheek, jaw, teeth, gums, and lips are most
commonly affected.
 People with trigeminal neuralgia may have
anxiety because they are uncertain when the
pain will return so they are also called suicidal
disease.
 It can affect any of the three branches.
TRIGGER FACTORS
 Hair brushing and cleaning of
teeth
 Tilting head and shaving
 Stress and tiredness
 Cold and hot weather
 Chewing and swallowing
 Touching and washing face
 Light breeze or wind on face etc.
 Etiology D/D
• Infections • Glossopharyngeal neuralgia
• Ratner’s jaw bone cavities • Post herpetic neuralgia
• Multiple sclerosis • Geniculate neuralgia (Hunt
• Petrous ridge compression neuralgia)
• Post traumatic neuralgia • TM joint pain
• Intracranial tumors • Cluster headache
• Intracranial vascular abnormality
• Viral etiology
 General Characteristics
 Incidence: It is a rare affliction, seen in about 4 in100,000
persons.
 Age of occurrence: Late middle age or later in life.
 Sex predilection: With female predisposition (58%).
 Affliction for sides :Predilection for the right side is noted
(60%).
 Division of trigeminal nerve involvement:
i. V3 is more commonly involved than V2division.
ii. Very rarely V1 ophthalmic division is involved in about
5 percent of cases (Only sensory division is affected).
Clinical features
 Pain is usually confined to one part of one division of trigeminal nerve-mandibular or
maxillary but may occasionally spread to an adjacent division or rarely involve all three
divisions.
 The pain is of short duration and lasts for a few seconds, but may recur with variable
frequency.
 The patient grimaces with pain, clutches his hands over the affected side of the face,
stopping all the activities and holds or rubs his face, which may redden or the eyes
water until the attack subsides. Male patients avoid shaving.
 In extreme cases, the patient will have a motionless face the frozen or mask like face.
 Presence of an intraoral or extraoral trigger points provocable by obvious stimuli is seen
in TN.
 Trigger points depends on which division of trigeminal nerve is
involved:
i. V2-points are located on the skin of the upper lip, ala nasi or cheek or on
the upper gums.
ii. V3- is the most frequently involved branch and Trigger points are seen
over the lower lip, teeth or gums of the lower jaw.
iii. V1 -the trigger zone usually lies over the supraorbital ridge of the affected
side.
Pathophysiology
 Nerve injury
 Central and peripheral demyelination
 Ectopic action potentials in the sensory nerve root
 Paroxysmal, lancinating attacks
DIAGNOSIS
 The White and Sweet criteria were incorporated into the official research by the
International Association for the Study of Pain-IASP and the International Head
ache Society-HIS.

Sweet diagnostic 5 major criteria for TN

1 The pain is paroxysmal
2 The pain may be provoked by light touch to the face (trigger zones)
3 The pain is confined to trigeminal distribution
4 The pain is unilateral
5 The clinical sensory examination is normal
TREATMENT
 Depending on the severity and types, the treatment can be with classified as :–
 Medical.
 Surgery.
Medications (non invasive)
 Anticonvulsant:
 Tab. Carbamazepine 100 mg three times a day.
Side effects: Visual blurring, dizziness, somnolence, skin rashes and ataxia and in
rare cases hepatic dysfunction, leukopenia, thrombocytopenia-aplastic anaemia.
 Tab. Clonazepam 1.5 mg once a day.
Side effects: Drowsiness, fatigue, lethargy.
 Tab. Phenytoin: Dose 100 mg three times a day.
Side effects: Slurred speech, abnormal movements, swelling of lymph glands,
gingival hypertrophy,7 hirsutism, folate deficiency.
 Tab. Oxcarbazepine-1200 mg/day.
Side effects: Hyponatremia, double vision.
 Tab. Valproic acid- 600mg / day.
Side effects: irritability, tremors, confusion, hepa- toxicity, weight gain.
 Mephenesin Carbamate (Tolceram)-5 to 15 ml/5 times a day to every 3 hours.

Skeletal muscle relaxant:

 Tab. Baclofen-10 mg 3 times a day.
Side effects: fatigue, vomiting.
Medical line
• First line • Second line
• Carbamazepine • Gabapentin
• Phenytoin • Oxcarbazepine
• Valproate • Lamotrigine
• Baclofen • Topiramate
• Amitryptiline • Zonisamide
• Nortryptiline • Levetiracetam
Drug Initial Dose Maintenance Dose
Gabapentin 300 mg TID 1800 mg
Baclofen 5 mg BID-TID 80 mg maximum dose
Clonazepam 0.5 mg TID 4 mg, maximum 20 mg
Lamotrigine 50 mg QD 300-500 mg
Oxcarbazepine 300 mg BID 1200 mg BID
Toprimate 50 mg QD 200 mg BID
Carbamazepine 100 mg BID 1200-2400 mg

Drug Therapy for TN

SURGERY INVASIVE
 Those patients who do not respond to medications and are physically fit can go
for invasive procedures.
 Peripheral Injections
 Longer acting anesthetic agents
 Agents like bupivacaine without adrenaline but with or without corticosteroids
are injected to the peripheral nerve end.
Alcohol injections
 0.5-2ml of 95% absolute alcohol is used for injection.
Side effects: local tissue toxicity, inflam- mation and
fibrosis .It can also cause a complication of burning
alcohol neuritis.
 It provides relief for a period of 6 to 12 months or
sometimes patient comes back with pain
immediately within short time span.
 Peripheral injections-infraorbital, mental, inferior
alveolar nerve blocks can be given depending on the
involvement.
Glycerol Injection In The Gasserian
Ganglion
 Injected behind the ganglion and destroy both small and large nerve fibers.
Peripheral Neurectomy
 Oldest and most effective
method.
 Mostly performed on the
infraorbital nerve, inferior
alveolar nerve, mental nerve
and rarely lingual nerve.
 To achieve better results, the
peripheral nerve is always
avulsed both from the bone as
well as from the soft tissues.
INFRAORBITAL NEURECTOMY
1. Intraoral conventional approach- A u-shaped Caldwell-Luc incision is made in
the upper buccal vestibule in the canine fossa region.
2. Braun's trans antral approach (1977)-It has got the potential to have sound
treatment for intractable V_{2} neuralgia, because of the direct access and
visualization it provides.
Inferior alveolar neurectomy

 Extraoral approach-through Risdon’s

incision.

 Intraoral approach-via Dr Ginwalla’s

incision.
Lingual
neurectomy
Cryotherapy
 Direct application of cryoprobe (temperature -60°) intraorally to the affected
nerve producing wallerian degeneration of the affected nerve.
 In this, the nerve is not sectioned but destroyed.
Open Or Intracranial
Procedures
 Incision given over the mastoid process
and release the nerve compression from
the pulsating artery.
 Separate the nerve and the artery by
placing Teflon between them.
Gamma Knife Radiosurgery
 Noninvasive, scalpels radiosurgery by delivering radiation to the targeted site.
CONCLUSION
 Trigeminal neuralgia has been an enigma since ages. Although the pain is
intense, progresses and worsens with time the condition is not life-threatening.
 Proper diagnosis and treatment plan still plays an important role in success of
the treatment.
 However, the various advances help in understanding the condition and
increase the success rate of the treatment.
 If not cure there is a way to reduce pain and improve the quality life of the
patients with trigeminal neuralgia.
THANK YOU