Diseases of nerves, Oral and maxillofacial pathology

1. DR PK MUHAMMAD WASIM

2. An unpleasant sensory & emotional experience associated with
actual or potential tissue damage or described in terms of such
damages.

3. •Trigeminal Neuralgia (Tic douloureux, trifacial neuralgia,
Fothergill's disease)
•Paratrigeminal Syndrome (Raeder's syndrome,
paratrigeminal neuralgia)
•Sphenopalatine Neuralgia (cluster headache, periodic
migrainous neuralgia)
•Burning Mouth Syndrome
•Orolingual Paresthesia (Glossodynia or painful
tongue, glossopyrosis or ‘trigger zone’ tongue)
•Auriculotemporal Syndrome (Frey's syndrome,
gustatory sweating)

4. •Bell’s palsy (Seventh nerve paralysis,
facial paralysis)
•Glossopharyngeal neuralgia

5. •Motor System Disease (Motor neuron disease,
amyotrophies)
•Multiple Sclerosis (Disseminated sclerosis)
•Orofacial Dyskinesia
•Migraine (Migraine syndrome)
•Temporal/Giant Cell Arteritis
•Complex Regional Pain Syndrome (Causalgia, reflex
sympathetic dystrophy syndrome)
•Atypical Facial Pain (Atypical facial neuralgia, facial
causalgia)
•Marcus Gunn Jaw-winking Syndrome
(Trigemino-oculomotor synkinesis)

6. •follows the anatomical distribution of the fifth cranial nerve
•mainly affects the second and third divisions
•trigger zone, stimulation of which initiates paroxysm of pain
•accompanied by a brief facial spasm or tic
•Pain distribution is unilateral and lasts for a few seconds to a
minute.

7. Mystery ? Controversial?
•Earlier- teeth was considered-the extraction of
countless teeth in an effort to cure the disease - failed
•Most cases are idiopathic
•Peripheral injury or disease of the trigeminal nerve may be causative
or failure of central inhibitory mechanisms
•compression of the trigeminal roots by tumors or vascular anomalies
•Abnormal vessels, aneurysms, tumors, chronic
meningeal inflammation, or other lesions may irritate
trigeminal nerve roots along the pons
•an area of demyelination, occur with multiple sclerosis,
may be the precipitant

8. The most accepted theory is atherosclerosis
of superior cerebellar artery resulting in
pressing & grooving the root of trigeminal
nerve

9. •Older adults >50 yrs
•Females are more commonly affected (3:2)
•Right side of the face is affected more 1.7:1
•The pain is of a searing, stabbing, or lancinating type
• Trigger zone -which precipitate an attack when touched,
are common on the vermilion border of the lips, the alae of
the nose, the cheeks, and around the eyes
•Tic douloureux -spasmodic contractions of the facial muscles
•Pre trigeminal neuralgia-dull, aching or burning or resembling a sharp
toothache

10. •excruciating pain persists for few seconds to several
minutes
•disappears promptly
•avoid touching the skin over the trigger area and frequently
goes unwashed or unshaven
•exposure to a strong breeze or simply the act of eating or
smiling may precipitate it
•Any portion of the face may be involved
•mandibular and maxillary divisions
•two divisions may be simultaneously affected
•unilateral in nearly all cases

11. Migraine or migrainous neuralgia
period of hours, and has no ‘trigger zone’, bilateral
Sinusitis radical sinus operations have been performed
Costen’s syndrome- TMJ pain
Trotter's syndrome Tumors of the nasopharynx can produce a
similar type of pain, generally manifested in the lower jaw, tongue
and sideof the head with an associated middle ear deafness. As
the tumor progresses, trismus of the internal pterygoid muscle
develops, and the patient is unable to open his/her mouth.
Postherpetic neuralgia ophthalmic division of the fifth cranial
nerve, regresses within two to three weeks. may persist, in elderly
patients. The history of skin lesions aids in the diagnosis.
Split tooth or an interradicular periodontal abscess

12. MRI
To exclude an uncommon space occupying lesion or aberrant
vessel compression on the nerve roots.

13. none is successful in all cases
•Peripheral neurectomy—sectioning of the nerve at the mental
foramen, or at the supraorbital or infraorbital foramen
•Injection of alcohol either into a peripheral nerve area or centrally
into the gasserian ganglion
•Injection of boiling water into the gasserian ganglion
•Surgical sectioning of the trigeminal sensory root
•Phenytoin (dilantin)
•Carbamazepine
•Microsurgical decompression of the trigeminal root-One of the
newest procedures
•Gamma knife radio surgery- 200 tiny beams of radiations are
focused

14. •Sphenopalatine neuralgia is a pain syndrome or
described by Sluder as a symptom complex
referable to the nasal ganglion.
•an idiopathic syndrome consisting of
recurrent brief attacks of sudden, severe,
unilateral periorbital pain.

16. •The pathophysiology of sphenopalatine neuralgia is not
understood entirely.
•hypothalamic hormonal influences
•Pain is thought to be generated at the level of the pericarotid/
cavernous sinus complex.
•genetic predisposition.

17. • unilateral paroxysms of intense pain in the region of the eyes,
the maxilla, the ear and mastoid, base of the nose, and beneath
the zygoma. Sometimes the pain extends into the occipital areas
as well.
•rapid onset, persist for about 15 minutes to several hours, and
then disappear as rapidly as they began.
•no ‘trigger zone’.
• the attacks develop regularly, usually at least once a day, over a
prolonged period of time. Interestingly, in some patients the
onset of the paroxysm occurs at exactly the same time of day,
and for this reason, the disease has been referred to as alarm
clock headache

18. •Sneezing, swelling of the nasal mucosa and severe nasal
discharge often appear simultaneously with the painful
attacks,
•epiphora, or watering of the eyes, and bloodshot eyes.
•Paresthetic sensations of the skin over the lower half of the
face
•precipitated in some patients by either emotional stress or
•injudicious intake of alcohol.
•Men are affected more commonly than women (5:1)
•first manifestations of the disease before the age of 40 years.

19. •cocainization of the sphenopalatine ganglion or
•alcohol injection of this structure.
•Resection of the ganglion
•surgical correction of septal defects.
•ergotamine will often produce immediate and complete relief of
symptoms.
•In those cases where it is not totally effective, combining it with
methysergide, an antiserotonin agent, appears to produce a
synergistic action usually providing total relief..
•Invasive nerve blocks and ablative neurosurgical procedures all have
been implemented successfully in refractory cases.

20. •Burning mouth syndrome (BMS) is a burning or stinging of the
mucosa, lips, and/or tongue, in the absence of visible mucosal
lesions.
• There is a strong female predilection, with most female
patients being postmenopausal
•age of onset being approximately 50 years.
•The causes of BMS are multifactorial and remain poorly
understood.

21. •The burning sensation may be felt either as a continuous or
intermittent discomfort which most frequently affects the tongue, and
sometimes the lips or palate.
• Onsetof the symptoms may be sudden or gradual over months, and
•it has been suggested that psychosomatic factors are associated with
the onset of BMS.
•No oral mucosal lesions will be detected on examination.
•Up to 50% of patients with BMS report an associated sensation of dry
mouth.
•increased thirst.
•altered taste sensation either with reduction in taste perception
•or the presence of a persistent unusual taste, most frequently bitter or
metallic.
•Drinking or eating may temporarily reduce the severity of symptoms.
Patients may have associated anxiety or depression.

22. Local causes
•
Dry mouth (xerostomia)
•
Mucosal disorders—geographic tongue (erythema migrans),
lichen planus, etc.
•
Trauma to oral mucosa (e.g. poorly fitting dentures)
•
Repetitive oral habits •
Gastroesophageal reflux disease
•
Sensory nerve damage (e.g. due to trauma)

23. Systemic medical causes
•
Vitamin B12, folate, iron deficiencies
•
Medication (e.g. angiotensin converting enzyme [ACE]
inhibitors such as captopril)
•
Immunologically-mediated diseases (e.g. Sjögren's syndrome)
•
Psychogenic disorders (e.g. depression, anxiety, fear of
cancer)
•
Psychosocial stresses (e.g. stressful life events )
•
Diabetes mellitus
Menopause

24. •antidepressants,
•vitamins or dietary supplements such as alpha lipoic acid;
•analgesic sprays or mouthwashes such as benzydamine
hydrochloride,
•postmenopausal female patients, hormone replacement or
•topical estrogen applied to the oral mucosa.
•Where a dry mouth is a prominent symptom then saliva
substitutes.

25. • It is an abrupt, isolated,
unilateral, peripheral facial nerve
paralysis without detectable causes.
•Idiopathic facial paralysis was first
described more than a century ago by
Sir Charles Bell.

27. •Bell's palsy is considered an idiopathic facial paralysis;
•Herpes simplex virus (HSV) has been isolated in many patients with
Bell's palsy and is most likely the infectious agent.
•A popular theory proposes that the inflammation of
the facial nerve with resultant edema causes nerve
compression while it passes through the temporal bone.
•Various inflammatory, demyelinating, ischemic, or
compressive processes may impair neural conduction at this
unique anatomic site.

28. •Bell's palsy begins abruptly as a paralysis
of the facial musculature, usually
unilaterally.
•Familial occurrence
•Hereditary factors may play a role.
•Women are affected more
•middle-aged are most susceptible.
•arises more frequently in the spring and fall.
•It may develop within a few hours or be present when the
patient awakens in the morning.
•In some cases it is preceded by pain on the side of the face
which is involved, particularly within the ear, in the temple
or mastoid areas, or at the angle of the jaw

29. •The muscular paralysis manifests itself by the drooping of
the corner of the mouth, from which saliva may run,
•the watering of the eye, and the inability to close or wink
the eye, which may lead to infection.
•When the patient smiles, the paralysis becomes obvious,
since the corner of the mouth does not rise nor does the
skin of the forehead wrinkle or the eyebrow raise.
•typical mask like or expressionless appearance.
•Speech and eating usually become difficult, and
occasionally the taste sensation on the anterior portion of
the tongue is lost or altered.
•In many cases of a mild nature, the disease regresses
spontaneously within several weeks to a month. Any
residualmanifestation of the disease which persists for
over one year is apt to represent a permanent alteration.

31. •Recurrent attacks of facial paralysis, identical with Bell's
palsy, associated with multiple episodes of nonpitting,
noninflammatory painless edema of the face, cheilitis
granulomatosa, and fissured tongue or lingua plicata is known
as the Melkersson-Rosenthal syndrome.
•The facial edema resembles angioneurotic edema and
involves the upper lip, occasionally the lower, and sometimes
the nose, tongue or maxillary alveolar process.

32. •There is no specific treatment for Bell's palsy, since the etiology
of the disease is unknown.
•The use of vasodilator drugs, e.g. histamine, has proved
beneficial in some cases.
•Administration of physiologic flushing doses of nicotinic acid
has produced excellent results when treatment was instituted
within a week after onset of the disease.
•In permanent paralysis surgical anastomosis of nerves has been
carried out with some success.
•An attempt should be made to prevent infection of
the involved eye.

33. Pain similar to that of trigeminal neuralgia may arise from the
glossopharyngeal nerve. This condition is not as common as
trigeminal neuralgia, but when it occurs, the pain may be as
severe and excruciating.

34. •No gender predilection
•in middle-aged or older persons
•manifests itself as a sharp, shooting pain in the ear, the pharynx, the
nasopharynx, the tonsil or the posterior portion of the tongue.
• unilateral, rapidly subsiding type of pain characteristic of trigeminal
neuralgia is also a feature here.
•Numerous mild attacks may be interspersed by occasional severe
ones.
• ‘trigger zone’ in the posterior oropharynx or tonsillar fossa. These
zones are difficult to localize but can be found by careful
probing. Because of the location of these trigger zones,
certain actions are recognized as inciting the episodes of pain.
These include such simple acts as swallowing, talking,
yawning or coughing.

35. •The etiology of glossopharyngeal neuralgia is unknown.
•Neural ischemia has been suggested,but without conclusive
evidence.

36. •resection of the extracranial portion of the nerve or intracranial
section.
•The injection of alcohol into the glossopharyngeal nerve has
not been as widely accepted
•Periods of remission with subsequent recurrence are common
in this disease.

37. •Causalgia is a term applied to severe pain which arises after
injury to or sectioning of a peripheral sensory nerve.
•Although few reports of this condition exist in the dental
literature, cases do occur after the extraction of teeth.
•It has readily identifiable signs and symptoms and is treatable
if recognized early; however, the syndrome may become
disabling if unrecognized.

38. development of causalgia requires the following triad of
conditions:
an injury,
an abnormal
sympathetic response,
and a predisposing personality.
Others, however, dispute the need for an underlying personality
disorder.

39. • in patients of any age.
•It usually follows extraction of a multirooted tooth,
particularly when the extraction is difficult or traumatic.
•The pain arises within a few days to several weeks after the
extraction and has atypical burning quality from which the
condition derives its name.
•The pain itself develops locally at the site of the injury
and is evoked by contact or by application of heat or cold.
•by actual touch stimulation
•By emotional disturbances.
•By ingestion of alcohol,
•during the menstrual periods,
•or at times when the patient became frustrated or upset.

40. •Causalgia should be differentiated from local pain due to
simple traumatic injury to soft tissue or bone during the
extraction procedure.
• subacute thyroiditis. Since patients may seek dental
treatment for relief of their symptoms, the possibility of the
thyroid condition must be remembered. Treatment of the
thyroiditis almost invariably results in subsidence of the jaw
pain.

41. •The treatment of intraoral causalgia is indeed a difficult one.
•The injections of procaine, alcohol nerve block, phenol
cauterization and surgical curettement of the bone in the
involved area have generally proved ineffective.
•In some instances resection of the nerves in the retrogasserian
region has afforded relief.

42. •Atypical facial pain constitutes a group of conditions in which
there is a vague, deep, poorly localized pain in the regions
supplied by the fifth and ninth cranial nerves and the second
and third cervical nerves.
•The pain is not associated with trigeminal neuralgia,
glossopharyngeal neuralgia, postherpetic neuralgia, or with
diseases of the teeth, throat, nose, sinuses, eyes or ears.
•The distribution of this pain is unanatomic, since
it involves portions of the sensory supply of two or more
nerves and may cross the midline.
•This pain, which lacks a trigger zone, is constant and persists
for weeks, months or even years

43. • usually without a specific cause.
• injury of any peripheral or proximal branch of the trigeminal
nerve due to facial trauma or basal skull fracture
•psychogenic with regard to possible origin of the
neuralgia.

44. • Eagle's syndrome. This syndrome consists of either
elongation of the styloid process or ossification of the
stylohyoid ligament causing dysphagia, sore throat, otalgia,
glossodynia, headache, vague orofacial pain or pain along the
distribution of the internal and external carotid
arteries.Probably the most consistent symptom is pharyngeal
pain.
•It is common for the difficulty to arise following tonsillectomy,
presumably from fibrous tissue that forms and is stretched
and rubbed over the elongated styloid process.
• the carotid artery syndrome, in which pressure exerted by
either a deviant styloid process or an ossified ligament causes
impingement on the internal or external carotid arteries
between which the styloid process normally lies.

45. •Medical treatment of atypical facial pain is less satisfactory
than that of trigeminal neuralgia.
•Of the nonnarcotic drugs, tricyclic antidepressants give best
results; phenytoin is of intermediate effectiveness, and
carbamazepine is least effective.