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NEUROLOGICAL DISORDERS
OF MAXILLOFACIAL REGION
INDIAN DENTAL ACADEMY
Leader in continuing den...
www.indiandentalacademy.com

INTRODUCTION
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POINTS OF DISCUSSION
What is a Neurological disorder
 What are the neurological disorders
 ...
www.indiandentalacademy.com

WHAT IS A NEUROLOGICAL DISORDER
Its an altered nerve physiology resulting
either in an unplea...
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WHY IT OCCURS
Infection
 Compression
 Neoplasia

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ETIOPATHOLOGY
Reversible lesions
 Degeneration
- Segmental
- Wallerian
 Neurotrophic effect...
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WHAT ARE THE NEUROLOGICAL DISORDERS


Neuralgias
- Idiopathic trigeminal neuralgia
- Vagoglo...
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

Posttraumatic Sensory Disorders
- Posttraumatic trigeminal neuropathy
- Causalgia
- Phanto...
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

Infectious disorders
- Postherpetic trigeminal neuralgia
- Infectious meningitis
- Leprous...
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

Maxillofacial neuropathies of systemic origin
- Connective tissue disease neuropathies
- T...
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

Headaches
- Migraine
- Temporal arteritis
- Coronary disease headache
- Myofascial pain dy...
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

Central disorders
- Syringobulbia
- Thalamic syndrome
- Psychalgia
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

Maxillofacial neuritis
- Bell’s palsy
- Other cranial motor neuritides
- Paranasal sinus n...
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HOW TO DIAGNOSE
Interpreting the symptoms and signs of
altered neurophysiology
 Determining ...
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www.indiandentalacademy.com

TRIGEMINAL NEURALGIA
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IDIOPATHIC TRIGEMINAL NEURALGIA
History
 Anatomy of TN
 Pathophysiology
 Diagnosis
 Treat...
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HISTORY
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ANATOMY OF TN
Intracranial course
 Extracranial course

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

Intracranial course
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

Extracranial course
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ETIOPATHOLOGY
White & Sweet criterias
 Ignition Hypothesis
 Gardner’s Hypothesis

www.indiandentalacademy.com



White & Sweet Criterias
1) Pain is paroxysmal.
2) Pain may be provoked by light touch to t...
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

Gardner’s Hypothesis.



Ignition Hypothesis.
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PATHOPHYSIOLOGY
Compression at
root exit zone
 Focal segmental
axonal demyelination
 Sponta...
www.indiandentalacademy.com

DIFFERENTIAL DIAGNOSIS












Vago-glossopharyngeal neuralgia
Multiple scleros...
www.indiandentalacademy.com

AIM OF TREATMENT
• Maximum freedom from
negative impact of pain
• Not freedom from
symptoms
•...
www.indiandentalacademy.com

MEDICAL MANAGEMENT
Gold Standard – 3 RCTs
Carbamazepine
Daily dose : 600-1200mg (max.)
also r...
www.indiandentalacademy.com

CARBAMAZEPINE (CBZ)
All patients will get side effects
• Drowsiness/tiredness
• Dizziness
• P...
www.indiandentalacademy.com

• Liver enzyme inducer
• May depress white cell count especially
initially
• Long term use ma...
www.indiandentalacademy.com

LAMOTRIGINE
• Doses 200 – 400mg daily
• RCT showed effectiveness as add on therapy
• Can be u...
www.indiandentalacademy.com

BACLOFEN
• Doses 40-80mg daily
• Can add to other AEDs
• Wide dosage range
• Frequent doses n...
www.indiandentalacademy.com

Prospective cohort study
• Oxcarbazepine
Case series
• Gabapentin
• Phenytoin
• Clonazepam
• ...
www.indiandentalacademy.com

OXCARBAZEPINE (OXC)
• Doses 300 -1200mg daily
• OXC 300mg = CBZ 200mg
• Effectiveness shown i...
www.indiandentalacademy.com

GABAPENTIN
• Doses 1200- 3600mg daily
• Effectiveness reported in 33 cases
• RCT in post- her...
www.indiandentalacademy.com

NEW DRUGS
• Dextromethorphan – 3 patients in RCT
• Topiramate – 3 patients in RCT
• Leviterac...
www.indiandentalacademy.com

WHEN TO HAVE SURGERY?
• Ineffective pain relief from
medication
• Intolerable side effects
• ...
www.indiandentalacademy.com

Which Surgery ?
Evidence

What
www.indiandentalacademy.com

SURGICAL TREATMENTS
Peripheral injections
- long acting anesthetic agents
- alcohol injection...
www.indiandentalacademy.com



Cryoneurolysis for peripheral nerves.



Peripheral radiofrequency neurolysis
(thermocoag...
www.indiandentalacademy.com

VAGOGLOSSPHARYNGEAL NEURALGIA
Clinical features
 Occurrences
 Histopathology
 Etiology
 D...
www.indiandentalacademy.com

CONCLUSION

Thank You
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Seminar neurological disorders of maxillofacial region /certified fixed orthodontic courses by Indian dental academy

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Seminar neurological disorders of maxillofacial region /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com NEUROLOGICAL DISORDERS OF MAXILLOFACIAL REGION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com INTRODUCTION
  3. 3. www.indiandentalacademy.com POINTS OF DISCUSSION What is a Neurological disorder  What are the neurological disorders  Why & How it occurs  How to diagnose a neurological disorder  What are the treatment modalities available 
  4. 4. www.indiandentalacademy.com WHAT IS A NEUROLOGICAL DISORDER Its an altered nerve physiology resulting either in an unpleasant noxious painful sensations or in complete or partial loss of sensations…
  5. 5. www.indiandentalacademy.com WHY IT OCCURS Infection  Compression  Neoplasia 
  6. 6. www.indiandentalacademy.com ETIOPATHOLOGY Reversible lesions  Degeneration - Segmental - Wallerian  Neurotrophic effects  Normal regeneration  Abnormal regeneration 
  7. 7. www.indiandentalacademy.com WHAT ARE THE NEUROLOGICAL DISORDERS  Neuralgias - Idiopathic trigeminal neuralgia - Vagoglosspharyngeal neuralgia - Intermedius (geniculate) neuralgia - periodic migrainous neuralgia - multiple sclerosis neuralgia
  8. 8. www.indiandentalacademy.com  Posttraumatic Sensory Disorders - Posttraumatic trigeminal neuropathy - Causalgia - Phantom facial pain - Anaesthesia dolorosa
  9. 9. www.indiandentalacademy.com  Infectious disorders - Postherpetic trigeminal neuralgia - Infectious meningitis - Leprous neuropathy - Diptheric neuropathy - Neurosyphylis & tabes dorsalis
  10. 10. www.indiandentalacademy.com  Maxillofacial neuropathies of systemic origin - Connective tissue disease neuropathies - Toxic & nutritional neuropathies
  11. 11. www.indiandentalacademy.com  Headaches - Migraine - Temporal arteritis - Coronary disease headache - Myofascial pain dysfunction
  12. 12. www.indiandentalacademy.com  Central disorders - Syringobulbia - Thalamic syndrome - Psychalgia
  13. 13. www.indiandentalacademy.com  Maxillofacial neuritis - Bell’s palsy - Other cranial motor neuritides - Paranasal sinus neuritis - Salivary gland & mucosal neuritis - Odontogenic neuritis
  14. 14. www.indiandentalacademy.com HOW TO DIAGNOSE Interpreting the symptoms and signs of altered neurophysiology  Determining the anatomical localization of the disease process  Understanding the basic pathological processes that exist  When possible, identifying the etiological or precipitating factors. 
  15. 15. www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com TRIGEMINAL NEURALGIA
  17. 17. www.indiandentalacademy.com IDIOPATHIC TRIGEMINAL NEURALGIA History  Anatomy of TN  Pathophysiology  Diagnosis  Treatment - medical - surgical 
  18. 18. www.indiandentalacademy.com HISTORY
  19. 19. www.indiandentalacademy.com ANATOMY OF TN Intracranial course  Extracranial course 
  20. 20. www.indiandentalacademy.com  Intracranial course
  21. 21. www.indiandentalacademy.com  Extracranial course
  22. 22. www.indiandentalacademy.com ETIOPATHOLOGY White & Sweet criterias  Ignition Hypothesis  Gardner’s Hypothesis 
  23. 23. www.indiandentalacademy.com  White & Sweet Criterias 1) Pain is paroxysmal. 2) Pain may be provoked by light touch to the trigger area. 3) Pain is confined to trigeminal nerve distribution. 4) Pain is unilateral. 5) Clinical sensory examination is normal.
  24. 24. www.indiandentalacademy.com  Gardner’s Hypothesis.  Ignition Hypothesis.
  25. 25. www.indiandentalacademy.com PATHOPHYSIOLOGY Compression at root exit zone  Focal segmental axonal demyelination  Spontaneous discharge 
  26. 26. www.indiandentalacademy.com DIFFERENTIAL DIAGNOSIS           Vago-glossopharyngeal neuralgia Multiple sclerosis Pre Migrainous Neuralgia /(CH)/(HC) Migraine Temporal arteritis Bell’s Palsy MPD Phantom facial pain Occipital neuralgia Atypical facial neuralgia
  27. 27. www.indiandentalacademy.com AIM OF TREATMENT • Maximum freedom from negative impact of pain • Not freedom from symptoms • Enable patient to regain control
  28. 28. www.indiandentalacademy.com MEDICAL MANAGEMENT Gold Standard – 3 RCTs Carbamazepine Daily dose : 600-1200mg (max.) also retard formulation • 70% of patients will respond • may fail to offer relief because of increased severity of pain.
  29. 29. www.indiandentalacademy.com CARBAMAZEPINE (CBZ) All patients will get side effects • Drowsiness/tiredness • Dizziness • Poor concentration • Diplopia • Ataxia • Allergy 7%
  30. 30. www.indiandentalacademy.com • Liver enzyme inducer • May depress white cell count especially initially • Long term use may get depletion of folic acid • Drug interactions – other antiepileptic drugs (AED) numerous others, warfarin
  31. 31. www.indiandentalacademy.com LAMOTRIGINE • Doses 200 – 400mg daily • RCT showed effectiveness as add on therapy • Can be used on twice daily regimen • Cannot raise dose rapidly due to rashes
  32. 32. www.indiandentalacademy.com BACLOFEN • Doses 40-80mg daily • Can add to other AEDs • Wide dosage range • Frequent doses needed • Slow withdrawal necessary
  33. 33. www.indiandentalacademy.com Prospective cohort study • Oxcarbazepine Case series • Gabapentin • Phenytoin • Clonazepam • Valproic acid
  34. 34. www.indiandentalacademy.com OXCARBAZEPINE (OXC) • Doses 300 -1200mg daily • OXC 300mg = CBZ 200mg • Effectiveness shown in 49 cases long term cohort studies • Hyponatraemia dose related
  35. 35. www.indiandentalacademy.com GABAPENTIN • Doses 1200- 3600mg daily • Effectiveness reported in 33 cases • RCT in post- herpetic neuralgia shows effectiveness
  36. 36. www.indiandentalacademy.com NEW DRUGS • Dextromethorphan – 3 patients in RCT • Topiramate – 3 patients in RCT • Leviteracetam (Keppra) • Pregabalin (Lyrica)
  37. 37. www.indiandentalacademy.com WHEN TO HAVE SURGERY? • Ineffective pain relief from medication • Intolerable side effects • Duration of symptoms • Presence of compression Decision analysis needed
  38. 38. www.indiandentalacademy.com Which Surgery ? Evidence What
  39. 39. www.indiandentalacademy.com SURGICAL TREATMENTS Peripheral injections - long acting anesthetic agents - alcohol injections  Peripheral neurectomy (nerve avulsion) - infraorbital neurectomy - inferior alveolar neurectomy - lingual neurectomy 
  40. 40. www.indiandentalacademy.com  Cryoneurolysis for peripheral nerves.  Peripheral radiofrequency neurolysis (thermocoagulation)  percutaneous stereotactic differential radiofrequency thermal rhizotomy (RTR)  posterior fossa exploration and microvascular decompression of the trigeminal root (MVD)  “gamma knife” radiation treatment (GKR).
  41. 41. www.indiandentalacademy.com VAGOGLOSSPHARYNGEAL NEURALGIA Clinical features  Occurrences  Histopathology  Etiology  Diagnosis  Treatment 
  42. 42. www.indiandentalacademy.com CONCLUSION Thank You

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