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Trigger Zones Of Orofacial Region In Trigeminal Neuralgia

Trigeminal neuralgia is a condition characterized by severe, sporadic facial pain caused by abnormal stimulation of the trigeminal nerve. The pain is usually triggered by light touch on specific "trigger zones" of the face and can feel like electric shocks. It most often affects the maxillary division of the trigeminal nerve unilaterally in older patients. While the exact cause is unknown, it is believed to be due to compression of the trigeminal nerve root by blood vessels. Treatment involves medications like carbamazepine or surgery to decompress the nerve. Differential diagnoses include migraine, cluster headaches, and other neurological disorders.

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KRISHNAA S III BDS DEPT OF ORAL AND MAXILLOFACIAL PATHOLOGY
DEFINITION • ACCORDING TO NEUROSCIENCE AND NEUROLOGY, A TRIGGER ZONE (DOLOROGENIC ZONE) IS AN AREA OF THE BODY / OF A CELL , IN WHICH A SPECIFIC TYPE OF STIMULATION TRIGGERS A SPECIFIC TYPE OF RESPONSE • THE TERM WAS INTRODUCED BY, A JAPANESE AUTHOR, HUGH T PATRICK IN 1914
TRIGGER ZONES OF OROFACIAL REGION
TRIGEMINAL NEURALGIA SPHENOPALATINE NEURALGIA BELL’S PALSY FREY’S SYNDROME GLOSSOPHARYNGEAL NEURALGIA DISEASES OF THE NERVES
TRIGEMINAL NEURALGIA TIC DOULOUREUX FOTHERGILL’S DISEASE TRIFACIAL NEURALGIA SUICIDE DISEASE
NEURALGIA PAIN ALONG THE PATHWAY OF THE NERVE JOHN FOTHERGILL ENGLISH PHYSICIAN [1773] SO ACCORDINGLY, TRIGEMINAL NEURALGIA PAIN ALONG THE DISTRIBUTION OF THE TRIGEMINAL NERVE
 FIFTH CRANIAL NERVE  RESPONSIBLE FOR SENSATION IN THE FACE + MOTOR FUNCTIONS  TRI THREE 1. OPHTHALMIC 2. MAXILLARY 3. MANDIBULAR TRIGEMINAL NERVE B R A N C H E S
DESCRIBED AS … • SUDDEN, SHARP, LANCINATING, ELECTRIC SHOCK –LIKE RECURRENT PAIN ALONG THE BRANCHES OF THE NERVE. • GIVES ‘THE MOST TERRIBLE TYPE OF PAIN KNOWN TO HUMANS’ • FACIAL MUSCLE SPASMS MAY ALSO ACCOMPANY THE PAIN ATTACK
CLINICAL FEATURES • AGE - 50-70 yrs • GENDER - Female predilection • Pain is usually unilateral(right side more affected ) • Pain attack is initiated by touching specific areas of the face called TRIGGER ZONES
 ALA OF THE NOSE  CHEEKS  VERMILLION BORDER OF THE LIPS  AROUND THE EYES  SKIN ON CHIN  FOREHEAD  MIDFACE  ALVEOLAR BONE  NASOLABIAL FOLDDISTRIBUTION OF TRIGGER ZONES
“TRIGGERS PRECIPITATE AN ATTACK” CHEWING / SWALLOWING TALKING BRUSHING TEETH FACE WASHING / SHAVING LIGHT TOUCH / VIBRATION COOL BREEZE ACROSS THE FACE
CLINICAL FEATURES (CONTD…) • MAXILLARY DIVISION MORE COMMONLY INVOLVED • EARLY PAIN IS TERMED AS PRE-TRIGEMINAL NEURALGIA DULL ACHING BURNING SEARING SHARP TOOTHACHE
THE VERY SAME TRIGEMINAL NEURALGIA
TYPES TRIGEMINAL NEURALGIA CLASSICAL TRIGEMINAL NEURALGIA SYMPTOMATIC TRIGEMINAL NEURALGIA ACCORDING TO THE INTERNATIONAL HEADACHE SOCIETY (IHS),
CLASSICAL TN (COMMON) SYMPTOMATIC TN i. IDIOPATHIC TN ii. BELIEVED TO BE CAUSED BY A BLOOD VESSEL COMPRESSING THE TRIGEMINAL NERVE AS IT EXIT FROM THE BRAINSTEM. iii. CONSTANT COMPRESSION CAUSES DEMYELINATION, WHICH RESULTS IN HYPEREXCITABILITY OF THE NERVE. i. NEURALGIA CAUSED SECONDARY TO AN UNDERLYING MEDICAL CONDITION ii. NOT RELATED TO VASCULAR COMPRESSION iii. CAUSES CAN BE MULTIPLE SCLEROSIS, LEUKODYSTROPHY, GUILLAN-BARRE SYNDROME OR A TUMOUR COMPRESSING THE NERVE etc… PATHOGENESIS
DIAGNOSIS • DETAILED PAIN HISTORY (ONSET, LOCATION, INTENSITY, AGGRAVATING FACTORS, ALLEVIATING FACTORS, FREQUENCY, DURATION) • CLINICAL EXAMINATION • MRI SCAN • CT SCAN
DIFFERENTIAL DIAGNOSIS • MIGRAINE • CLUSTER HEADACHE (SPHENOPALATINE NEURALGIA) • TEMPORAL ARTERITIS • MULTIPLE SCLEROSIS • MANDIBULAR OSTEOMYELITIS • POSTHERPETIC NEURALGIA • TROTTER’S SYNDROME
TREATMENT (A) MEDICATIONS CARBAMAZEPINE ANTICONVULSANTS PHENYTOIN OXOCARBAZEPINE BOTULINUM TOXIN •RECENT STUDIES SHOWS IT INHIBITS THE RELEASE OF NEUROTRANSMITTERS GABAPENTIN
(B) SURGICAL MICROVASCULAR DECOMPRESSION ALCOHOL INJECTIONS GASSERIAN GANGLION GLYCEOL INJECTONS PERIPHERAL NEURORECTOMY INTRACRANIAL PROCEDURES CRYOTHERAPY GAMMA KNIFE RADIOSURGERY
SPHENOPALATINE NEURALGIA / HISTAMINE HEADACHE / ALARM CLOCK HEADACHE / CLUSTER HEADACHE • EXTREMELY PAINFUL CONDITION • INITIATING FACTOR – ALCOHOL, HEAT, CERTAIN MEDICATIONS • EXACT ETIOLOGY IS UNKNOWN BUT IS BELIEVED THAT IT IS DUE TO THE ABNORMALITIES IN THE HYPOTHALAMUS • TWO TYPES: 1. Episodic 2. Chronic • TREATED BY NERVE BLOCKS AND S EVERAL NEUROSURGICAL PROCEDURES.
CONCLUSION • PROPER DIAGNOSIS AND TREATMENT PLAN PLAY A MAJOR ROLE IN THE SUCCESS OF ANY TREATMENT. • THE VARIOUS ADVANCES HELP IN UNDERSTANDING THE CONDITION AND PROVIDE BETTER PROGNOSIS.
REFERENCES • Shafer’s textbook of Oral Pathology (8TH edition) • National organization for rare disorders (NORD) (www.rarediseases.org) • www.pubmed.gov.in (Medline database) • Jafferey P Okeson, Bells orofacial pain, 6th edition, Quintessence publishing co Inc., 2005 • Cheryl A. Kitt et al., Topical review Trigeminal Neuralgia: opportunities for research and treatment, International Association for the study of Pain, 2000
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