This case presentation summarizes a 63-year-old male patient who presented with left trigeminal neuralgia involving the mandibular division of the trigeminal nerve for the past 4-5 years. The patient experienced sudden, sharp stabbing pains 10-12 times per day initially that were triggered by activities like washing his face and shaving. While medication had reduced the pain episodes to 3-4 times daily, he recently developed constant pain in the same region aggravated by chewing. Examination and investigations ruled out any odontogenic cause, and treatment focused on continued pharmacotherapy and management of other dental issues like chronic periodontitis.

1. A case presentation on
Trigeminal Neuralgia of left
Mandibular Division
1

2. Name- Balbir Singh
OPD NO. -215937
AGE/ Gender-63Y / M
Address- Farukhnagar
Occupation-Retired teacher
2

3. Chief complaint
Patient complaint of pain in lower left face
region since last 4-5 years.
3

4. 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.
4

5. 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
5

6. 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.
6

7. EXTRAORAL EXAMINATION
Examination of TMJ: TMJ movements
were well co-ordinated and bilaterally
symmetrical.
Muscles of mastication: normal, non
tender
Lymph node Examination:left
submandibular lymph node was single,
firm, mobile and tender.
7

8. 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

9. 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
9

10. GINGIVA:
O/I –
• Color- reddish pink
• Size- gingiva is enlarged
• Consistency- soft & edematous.
• Position- Generalized Gingival recession is present
O/P-Bleeding on probing present
Generalized pocket were present
10

11. 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
11

12. Differential diagnosis
1. Crack tooth syndrome
2. Zoster sine herpete
12

13. Previous investigations
• MRI has been done-
normal
• There was no
compression at the CV
junction
13

14. Investigations
• Advised IOPA wrt 36
• Liver function tests.
14

15. Radiographic Interpretation
This is an intraoral periapical
radiograph of left mandibular
posterior 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.
15

16. 16

17. 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
17

18. Treatment
Odontogenic origin of the pain was ruled out and the patient
was sent for root canal treatment wrt 36
18

19. Pharmacotherapy
• Since 4 years- oxcarbamazepine 600mg 1 OD
• First appointment-
Rx
oxcarbamazepine 600mg 1 OD
Baclofen 25mg 1OD X 15 days
pt was recalled after 15 days.
• Second appointment-
Rx
oxcarbamazepine 300mg TDS
• Third appointment-
Rx
Oxcarbamazepine 600mg BD
Neurobione forte 1 OD
• Forth appointment-
Rx
Oxcarbamazepine 600mg BD
Neurobiome forte 1 OD
19

20. Discussion
20

21. 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.
21

22. • 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 neuralgia
2. Symptomatic trigeminal neuralgia
22

23. 23

24. 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.
Pathology
On ultrastructural observations, focal loss of myelin and
close apposition of demyelinated axons. There were
few residual oligodendrocytes and no imflammatory
cells.
24

25. 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.
Pathology
On 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
25

26. 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 amyloid
may be very extensive, involving the trigeminal
nerve, asserion ganglion and both the distal and
proximal parts of the nerve root.
26

27. 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.
27

28. 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.
28

29. 29

30. PHARMACOTHERAPY
30

31. 31

32. 32

33. SURGICAL INTERVENTION
33

34. 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.
34

35. 3. Peripheral neurectomy- It acts by interrupting a
significant number of afferent impulses to
central trigeminal apparatus.
4. Cryotherapy- Direct application of cryotherapy
probe 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.
35

36. 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 thw
elimination of the basic cause of the
paroxismal pain.
36

37. 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.
37

38. COMPLICATIONS TO THE THERAPY
38

39. 39

40. References
• Jorns T.P., Zakrewska J.M., Evidence- based approach to the medical
management of trigeminal neuralgia, British journal of Neurosurgery, june
2007;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 Pathophysiology
and 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
40

41. THANK YOU
41