Trigeminal neuralgia, characterized by sudden, severe, recurring facial pain along the distribution of the trigeminal nerve, can arise from various causes including idiopathic, tumors, and vascular compression. The management of this condition involves a combination of medical therapies, primarily anticonvulsants, and surgical interventions if medical management is ineffective. Careful diagnosis and patient education are essential for effective treatment and management of trigeminal neuralgia.

1. TRIGEMINAL NEURALGIA
(Tic Douloureux)

2. International Association for the Study of
Pain defines pain as
"an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage."

3. "if it isn't unpleasant, it isn't pain."

4. categories:
Somatic from the noxious
stimulation of normal
structures that innervate the
affected area
Normal or Physiologic

5. Neuropathic
arises in the absence of any
noxious stimulation.
a functional or structural
abnormality within the
nervous system itself.
episodic (paroxysmal) and
continuous
Pathophysiologic

6. psychogenic
arises from psychological causes.
Neither elicited by noxious stimuli nor an
abnormality within the neural system

7. General characteristics of
neuropathic pain
Pain in the absence of obvious nociception
Pain that can be intense and out of
proportion to the degree of stimulation
Pain quality that is bright, stimulating and
burning
Pain that is relatively unresponsive to low
doses of narcotic analgesics.

8. TRIGEMINAL NEURALGIA
(Tic Douloureux)

9. HISTORY
John lock------------1677
(1st description)
Nicolous Andre-----1756
(Tic douloreux)
John Fother Gills---1773
(Full description)
Other Names----- (Prosopalgia,
Face Palsy, Suicide disease)

10. Trigeminal – Cranial nerve V
Neur – Nerve related
Algia - Pain

11. Definition;
Trigeminal neuralgia (TN) is defined as
sudden,usually unilateral, severe, brief,
stabbing, lancinating, recurring pain in the
distribution of one or more branches of 5th
cranial nerve.

12. Age
Average age of onset - typically sixth
decade
may present at any age.
Symptomatic or secondary trigeminal
neuralgia tends to occur in younger
patients.

13. Sex
F more than M
5.9 : 3.4
In 100000

14. KCD. 242 CASES in 3 years
(PODJ 25 (2) Dec 2005)
Mean age; 43.88 with peak inci.age.50 - 60
M:F----1.068:1
Rt—63.22%, Lt—35.95%,Bil; o.82% (2. F)
Branch; Max & Mand almost equal.40.08%
& 39.667%.Opth.2.08%(5 cases in combi.)

15. Relation with diet
A. Elite class with v luxurious socio economic
status.-----------------------NIL.
B. Good socio economic status.—2.49%
C. Moderate s e status-------------36.77%
D. V V poor Labor class---------60.74%

16. IT SHOWS THAT THERE MIGHT BE
SOME DEFICIENCY OF IMPORTANT
INGREDIENTS IN THE DIET.

19.  V3 commonly involved than V2.

20. Types of Trigeminal Neuralgia and Their Causes:
1. Typical Trigeminal Neuralgia (Tic Douloureux)
2. Atypical Trigeminal Neuralgia
3. Pre-Trigeminal Neuralgia
4. Multiple Sclerosis-Related Trigeminal Neuralgia
5. Secondary or Tumor Related Trigeminal Neuralgia
6. Trigeminal Neuropathy or Post-Traumatic Trigeminal
Neuralgia
TRIGEMINAL NEURALGIA

21. CAUSES:
 PRIMARY
 Idiopathic
 SECONDARY.
 TUMORS (acoustic neuroma,cerebellopontine
angle tumors, Schwanoma. Pituitary gland
tumor)

22. VASCULAR
 Pulsatile compression of adjacent artery .
INFLAMMATORY; multiple sclerosis
POST TRAUMATIC.
 Viral
 Accident
 Dental trauma
 Sinus trauma

24. Clinical Features
Sudden, Sharp, Shooting, lancinating, unilateral paroxysmal,
intermittent, shock like pain.
trigger zones ; V1;
V1 over the supraorbital ridge
V2; Skin of the upper lip, ala nasi , cheek,gums.
V3; lower lip,teeth, gums, tongue
Rarely crosses the midline.
short duration-seconds
During attack, hands over the affected side, stop activities, hold
or rub the face which may redden or the eyes water until the
attack subs.

25. Paroxysms----weeks / months cycles
Electric shock like –like electric light in rain
Bad oral hygiene
No attacks during sleep
History of extractions
Loss of weight
Depression

27. Trigeminal Neuralgia

28. Nature of pain
Tic douloureux - pain
attack is accompanied
by tic-like cramps or
involuntary spasms of
the facial muscles

30. DIAGNOSTIC CRITERIA(IHS)
 paroxysmal attacks of pain lasting a second to 2mins and
affect one or more division of trigeminal nerve .
 CHARACTERISTICS
 Sharp
 Intense
 Stabbing
 Superficial
 Precipitated by trigger zone
 Doesn’t cross the midline
No Neurological deficit's
 Attacks are stereotyped.

31. Differential Diagnosis:
1. Odontogenic
2. Sinusitis.
3. Atypical facial pain.
4. Cluster Headache (but last for 20-45 minutes) not along
course of nerve.
5. Post herpetic neuralgia.
6. Opthalmoparesis (Reader Syndrome).
7. TMJD. 8.Temporal arteritis.
9 Acoustic neurilemoma, Multiple sclerosis,
Post herpetic neuroma, post traumatic neuroma.

33. DIAGNOSIS
 History.
 Clinical Features.
 Local Anaesthesia
 Carbamazepine response
 Age less than 35 years, suspect space occupying
lesions or arteriovenous malformations
intracranially.
 MRI,CT SCAN

35. Management
3 aspects
1. Support and Education.
2. Medical.
3. Surgical.

36. Management
No treatment modality to permanently
eliminate
Managed initially with medication
Surgical if refractory to medical
management or develops serious side
effects

37. Support and Education:
Make patient aware that it is not life
threatening.
Realize the severity of condition.
Educate for:
Causes
Therapies
Reassurance and Follow up.

38. Medical Management

40. Medical Management
Do not respond to conventional analgesic drugs
Controlling drugs exert their effect by depressing
excitatory afferent transmission or through
facilitation of segmental inhibition
Although mechanisms not fully clear, treatment
for TN is still quite successful.
slowly discontinue the medications when the
patient is asymptomatic to see if the patient is in
a pain-free remission period.

41. ANTICONVULSANTS
– Carbamazepine
– Gabapentin Cap Xaar
(Pregabalin)
– Phenytoin
– Divalproex Sodium
– Lamotrigine
SKELETAL MUSCLE RELAXANTS
– Baclofen
ANTIANXIETY DRUGS
– Clonazepam

42. Carbamazepine
still the drug of choice for the initial
management
stabilization of neuronal membranes by
blocking sodium channels thus preventing
the generation of an action potential.
selective for hyperactive sodium channels.

44. Carbamazepine
Started with a dose of 100 mg twice daily.
increased by 100 mg/day until either a
decrease in pain is noted or signs of
toxicity appear.
suggested maximum dose is 1500 mg.
sustained-release form of carbamazepine
is also available for a more sustained
effect.
bioavailability can be assessed through
blood levels

45. Carbamazepine
Side Effects
most common side effects - rash, sedation,
vertigo, blurred vision, and ataxia.
Other reactions although low - aplastic anemia,
leukopenia and thrombocytopenia.
complete blood count (CBC) before prescribing
Also potential for inducing serious liver toxicity -
liver function tests.
Blood smear and liver function tests should be
repeated every few weeks at the start of therapy
and then once or twice a year thereafter.

47. Surgical Management

48. Neurosurgical interventions
when medical therapy proves ineffective in
controlling TN pain.
potential benefits as well as risks of
complications or long-term side effects.
None of the surgical interventions are
effective in every case.
no accurate way to predict.

49. SURGERY
Peripheral neurectomy
– Supraorbital
– Infraorbital
– lingual
– Inferior alveolar
– Long buccal neurectomy

52. Nerve Injury / Destructive Procedures
(Rhizotomies)
Non-nerve injury procedures

54. Rhizotomies
Peripheral Trigeminal Nerve Blocks,
Sectioning and Avulsions
Percutaneous Rhizotomies
Stereotactic Radiosurgery (Gamma
Knife)
Microsurgical Rhizotomy

55. Peripheral Trigeminal Nerve
Blocks, Sectioning and
Avulsions
Increased susceptibility to surgical
complications.
Very elderly, frail or medically unfit.
A relatively simple means to injure any
branch of the trigeminal nerve.

56. By injection of alcohol, cutting
(sectioning) or
avulsion of the nerve branch,
cryo surgery
Effective immediately
Also cause severe or complete
numbness at least temporarily.
Often recurs
Other interventions for long-
term disease control.

57. Rhizotomies

58. Percutaneous Rhizotomies
Percutaneous Glycerol Rhizotomy
Percutaneous Balloon Compression
Rhizotomy
Radiofrequency Rhizotomy

59. Percutaneous Glycerol Rhizotomy

60. Percutaneous Balloon
Compression Rhizotomy

61. Radiofrequency Rhizotomy

62. Stereotactic Radiosurgery
(Gamma Knife)
focused radiation to the
trigeminal nerve root
Frame applied to the
patient’s head and then
MRI
positioned in the Gamma
Knife (up to 201 focused
beams of cobalt radiation)
delayed injury & pain
reduction within a few
weeks

63. Microsurgical Rhizotomy

64. Nerve Decompression
alleviates neurovascular compression
by placing inert shredded Teflon® felt
implants between offending vessels and
the trigeminal nerve root

66. CONCLUSION
Proper diagnosis is the key
Peripheral neurectomy needs to be
encouraged
Psychological support.
Role of the Dentist
TN a Medical Dilemma

67. Patients who are fit for surgery now but
might not be in 10 years should be
referred now, not in 10 years when the
drugs no longer work and the surgery is
more likely to be dangerous.

68. SURGICAL MANAGEMENT
Peripheral procedure
Ganglion procedure
Open procedure

69. PERIPHERAL PROCEDURE
Neurectomy
Cryotherapy
Alcohol injection
Radiofrequency

70. GANGLION PROCEDURE
Radiofrequency thermocoagulation
(Temperature 60-80c)
Glycerol injection (glycerol rhizotomy, 16g
needle, 0.5-0.75ml)
Balloon compression (4 FG Catheter,
1minute)
Stereotactic Radiosurgery (70-90 grays)

71. OPEN OPERATIONS
Microvascular decompression (by
Retromastoid incision 5-6cm)
Trigeminal root sectioning (sensory
rhizotomy)