A case presentation on Trigeminal Neuralgia of left

Mandibular Division

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Name- Balbir SinghOPD NO. -215937AGE/ Gender-63Y / MAddress- FarukhnagarOccupation-Retired teacher

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Chief complaint

Patient complaint of pain in lower left face region since last 4-5 years.

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History of present illness• Patient was apparently well 4 years back when he

experienced bouts of pain on left lower region of the jaw with 10-12 episodes of pain per day.

• Pain was sudden in onset. And was sharp, stabbing in nature • Pain was confined to the lower region of the face between the

angle of the mouth & the angle of the mandible.• Pain is initiated on washing face, shaving etc & relieved on its

own after 10-20 seconds. • Patient has also consulted neurologist for the same & taking

medication for the same since last 4 years. • After which the the pain episodes reduced to 3- 4 episodes of

the pain /day.• Recently about 20 days back, patient noticed a constant pain

in the same region, which he thought to be the severe form of the same condition. The pain aggravated on chewing food.

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PAST MEDICAL HISTORY

Patient gives history of taking medication since last 4 years- oxcarbamazepine OD (600mg).

PAST DENTAL HISTORY

No relevant past dental history

FAMILY HISTORY

No significant history was given by the patient

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PERSONAL HISTORY

• Patient is married.

• Has two children.

• He is a vegetarian by diet.

• He brushes his teeth with a brush and a toothpaste once daily.

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EXTRAORAL EXAMINATION

Examination of TMJ: TMJ movements were well co-ordinated and bilaterally symmetrical.

Muscles of mastication: normal, non tender

Lymph node Examination:leftsubmandibular lymph node was single, firm, mobile and tender.

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HARD TISSUE • Dental formula- 8 6 5 4 3 2 1 1 2 3 4 5 6 8

• 8 76 5 4 3 2 1 1 2 3 4 5 7 8

• Occlusion : molar relation class 1

• Number of teeth present : 30

• Decayed: 36, 47

• Tenderness present wrt 36

• Root stumps wrt 18, 23

• Missing: 17, 27

• Generalised attrition present

• Cervical abration wrt 34, 35

• Extrinsic stains+ ,

• Generalised calculus deposits

were found.8

SOFT TISSUE EXAMINATION

Normal on inspection and palpation.

BUCCAL MUCOSA:

Buccal mucosa is found normal

FLOOR OF MOUTH:

Floor of mouth is normal

OROPHARYNX AND VESTIBULE:

Normal

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GINGIVA:O/I –• Color- reddish pink• Size- gingiva is enlarged • Consistency- soft & edematous.• Position- Generalized Gingival recession is presentO/P-Bleeding on probing present

Generalized pocket were present10

Provisional diagnosis

• Trigeminal Neuralgia on Left side of the face involving mandibular division of the nerve.

• Apical periodontitis wrt 36

• Dental caries wrt 37

• Partially edentulous span wrt 17, 27

• Root stumps wrt 18, 23

• Chronic generalized periodontitis

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Differential diagnosis

1. Crack tooth syndrome2. Zoster sine herpete

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Previous investigations

• MRI has been done-normal

• There was no compression at the CV junction

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Investigations

• Advised IOPA wrt 36

• Liver function tests.

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Radiographic Interpretation

This is an intraoral periapicalradiograph of left mandibularposterior region, showing 36, 37 completely & 35 and 38 partially taken by using bisecting angle technique.36- ill-defined radiolucency is seen on the coronal portion of the tooth wrt 36 involving enamel dentin and pulp along with PDL space widening.Horizontal bone loss is seen wrt 35, 36, 37 by approximately 3-4 mm.

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Diagnosis

• Trigeminal Neuralgia on Left side of the face involving mandibular division of the trigeminal nerve .

• Chronic Apical periodontitis wrt 36

• Dental caries wrt 37

• Partially edentulous span wrt 17, 27

• Root stumps wrt 18, 23

• Chronic generalized periodontitis

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Treatment

Odontogenic origin of the pain was ruled out and the patient was sent for root canal treatment wrt 36

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Pharmacotherapy • Since 4 years- oxcarbamazepine 600mg 1 OD• First appointment-

Rxoxcarbamazepine 600mg 1 ODBaclofen 25mg 1OD X 15 days

pt was recalled after 15 days.• Second appointment-

Rxoxcarbamazepine 300mg TDS

• Third appointment-Rx

Oxcarbamazepine 600mg BDNeurobione forte 1 OD

• Forth appointment-RxOxcarbamazepine 600mg BDNeurobiome forte 1 OD

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Discussion

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Trigeminal Neuralgia

• It is defined as sudden, usually unilateral, severe, brief,

stabbing, lancinating, recurring pain in the distribution of one or more branches of fifth cranial nerve

• TN, also called Tic Doloureux , is most common of cranial neuralgias and chiefly affects individuals older than 50 years of age.

• IASP definition- Sudden, unusually unilateral, severe brief stabbing recurrent pains in the distribution of one or more branches of the Vth cranial nerve.

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• IHS Definition:Painful unilateral affliction of the face, characterized

by brief electric shock like pain limited to the distribution of one or more divisions of the trigeminal nerve.

Pain is commonly evoked by trivial stimuli washing, shaving, smoking, talking and brushing the teeth, but may also occur spontaneously. The pain is abrupt in onset and termination and may remit for varying periods.

• Types:1. Classic trigeminal neuralgia2. Symptomatic trigeminal neuralgia

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Etiology for Classic TN

Compression of Trigeminal Nerve Root:It is the commonest cause of Trigeminal Neur algia,

characterised by focal compression of Trigeminal Nerve Root, close to its point entry into the Pons.

Thought to account for 80-90 percent of the cases.Other compressive lesions include vestibular

Schwannomas, meningiomas, epideremoid cysts.PathologyOn ultrastructural observations, focal loss of myelin and

close apposition of demyelinated axons. There were few residual oligodendrocytes and no imflammatorycells.

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1. Primary demyelinating disorders-TN is a well recognised complication of multiple

sclerosis. Rarely patients with peripheral nerve demyelination due to Charcot- Marie- Tooth disease develop Trigeminal neuralgia.

PathologyOn examination of Trigeminal Rhizotomy specimens

variable numbers of thinly myelinated fibers, both within and immediately adjacent to the regions of demyelination were seen.

Etiology of Symptomatic TN

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2. Infiltrative disorders of the Trigeminal nerve root, Gasserian ganglion and nerve

The principal infiltrative causes of trigeminal neuralgia are carcinomatous deposits within the nerve root, gasserian ganglion and nerve.

Pathology

Depend on nature of infiltrative process like, infiltration by carcinoma, infiltration by amyloidmay be very extensive, involving the trigeminal nerve, asserion ganglion and both the distal and proximal parts of the nerve root.

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3. Non demyelinating lesions of the pons or medulla-

Small number of patients have been reported in whom trigeminal neuralgia was associated with a small infarct or angioma in the brainstem.

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Pathogenesis of Trigeminal Neuralgia

• Abnomal generation of sensory impulses.

• And their spread from fibers subserving light touch to pathways involved in the perception of pain in regions of the face.

• Exprimental evidences are present for the fact that ectopic impulses can arise from demyelinated axons.

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PHARMACOTHERAPY

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SURGICAL INTERVENTION

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1. Long acting anesthetic agents-: Without adrenalin bupivacaine can be given. But still the pain free period will be very short lived. The injection can be repeated when the pain recurs.

2. Alcohol injections- 95% alcohol- 0.5-2 ml. this produces anesthesia of the region supplied by the branch.

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3. Peripheral neurectomy- It acts by interrupting a significant number of afferent impulses to central trigeminal apparatus.

4. Cryotherapy- Direct application of cryotherapyprobe at temp. colder than -60°C are known to produce degeneration without destroying the nerve sheath itself.

5. Peripheral Radiofrequency Neurolysis- it involves lesioning of the peripheral nerves. The radiofrequency electrode that has the capacity to definitely destroy the pain fibres is used in this procedure. 80% pain remission is observed.

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6. Radiofrequency Gangliolysis- In this selective partial lesioning of the affected ganglion or the retrogasserion root is performed.

7. Glycerol gangliolysis- sterile anhydrous glycerol 0.1-0.4 ml is injected, to bring about the desired results.

8. Microvascular Decompression- the decompression of the trigeminal root from the offending vessel is done, aiming to thwelimination of the basic cause of the paroxismal pain.

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9. Balloon Compression- Balloon compression is performed to decompress the nerve root. Needle is inserted into the foramen ovale & balloon is inflated slowly with 0.5-1.0 ml of the contrast dye until it occupies the cave, ensuring adequate compression.

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COMPLICATIONS TO THE THERAPY

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References• Jorns T.P., Zakrewska J.M., Evidence- based approach to the medical

management of trigeminal neuralgia, British journal of Neurosurgery, june2007;21(3): 253-261

• P. Rajesh, J. Vishal, Trigeminal neuralgia: An insight into the current treatment modalities, Journal of Oral Biology and Craniofacial Research 2012 September- December volume 2, Number 3; pp. 188-197

• Sabalys G., Juodzbalys G.,Wang H.L.,Aetiology and Pathogenesis of Trigeminal Neuralgia: a comprehensive review, Journal of Oral and Maxillofacial Research

• Joffroy A., Levivier M., Massager N., Trigeminal Neuralgia Pathophysiologyand treatment, Acta neurol. Belg., 2001, 101; 20-25

• Nurmikko T.J., Elridge P.R., Trigeminal neuralgia- pathophysiology, diagnosis and current treatment, British journal of anaesthesia 87(1): 117-32 (2001)

• Love S., Coakham H.B., Trigeminal neuralgia Pathology and pathogenesis, Brain(2001), 124, 2347-2360

• Kasahara et al, A case of Zoster Sine Herpete of the Trigeminal Bull Tokyo Dent Coll(2011) 52(1): 47-51

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THANK YOU

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