TRIGEMINAL NEURALGIA

TRIGEMINAL NEURALGIA( TIC DOLOREAUX)

The neuralgic pain or facial pain occurring in the territory of a trigeminal nerve is termed as Trigeminal neuralgia.

• Mostly idiopathic, but in some cases, an aberrant loop or artery may press on the rootlets of trigeminal nerve as they emerge from the pons.
• Commonly in middle aged or elderly people.

CLINICAL FEATURES:-

• Pain is the characteristic symptom, sharp or lancinating and radiates to the territory of one or more sensory division of a Trigeminal nerve.
• Pain is triggered by touching, washing of face, shaving, teeth cleaning, cold breeze, eating, talking and applications of lotions and cosmetics.
• Paroxysms of Pain last only for a few minutes but disturb the concentration of the patient.
• If sensory loss or motor symptoms or signs accompany trigeminal neuralgia, then it is considered secondary to certain neurological diseases such as multiple sclerosis and meningioma of a trigeminal nerve.

MANAGEMENT:-

1. Medical
2. Surgical

MEDICAL:-

• Carbamazepine :- initial 100mg once or twice daily for a few days followed by 200-400mg 8 hourly for 2-4 weeks
•    Phenotypic  Averagedose is 300mg(150-500mg) daily for 2-4 weeks
•  Clonazepam 0.5-2.0mg 8 hourly may be effective as an alternative for 2-3 weeks.
• Antidepressants such as Amitriptyline have also been found effective.

SURGICAL:-

Surgical intervention is needed only when drug therapy has either failed or has produced undesirable side-effects.

Procedures are:-

• Injection of phenol or alcohol into a trigeminal ganglion.
• Radiofrequency coagulation of a branch of trigeminal ganglion.
• Sectioning of sensory root of Trigeminal ganglion inside the cranium.
• Microvascular decompression.

TRIVIA

Maxillary sinusitis is commonly accompanied with toothache.Why?

Since the mucosa of maxillary sinus and maxillary teeth,both are supplied by the same nerves,i.e. superior alveolar nerves derived from maxillary nerve.The inflammation of the mucosa of the sinus is frequently accompanied by the toothache.

ATTRITION

Attrition is a constant form of retrogressive change in teeth,characterized by wear of tooth substance or restoration as a result of tooth-to-tooth contact during mastication or parafunction.
It is an age related process and older individuals often exhibit more attrition in their teeth as compared to the young.
The rate and severity of attrition depends upon several factors such as

• Diet quality
• Dentition
• Force of the masticatory muscles
• Chewing habits etc.

Types of Attrition

1. Physiological attrition
2. Pathological attrition.

Physiological Attrition

• The tooth loss in physiological attrition is fairly constant and is appropriate to the age of the individual.
• Physiological attrition begins with the wearing of the install incisal edge of incisors.; it is followed by the palatal cusp of maxillary molars and buccal cusp of mandibular molars.
• Attrition also occurs in the proximal surfaces of teeth in the contact point areas.

Pathological Attrition

• Pathological attrition occurs due to certain abnormalities in occlusion, chewing pattern or due to some structural defects in the teeth.
• The tooth wear in this type of attrition does not maintain a consistent pattern.
• The amount of tooth loss is not proportionate to the age of the individuals.

Causes of Pathological Attrition

• Abnormal occlusion. May be developmental, may be acquired.
• Abnormal chewing habits :- Parafunctional chewing habits e.g.. Bruxism acc chronic persistent chewing of coarse and abrasive foods or other substance,e.g. Tobacco and betel nut etc.
• Structural defects in teeth

1. Amelogenesis imperfecta
2. Dentinogenesis imperfecta.

Clinical features of Attrition

• Clinically manifested by the formation of well-polished facets on the tip of the cursors, incisal edges and on the proximal contact areas of the teeth.
• Attrition may lead to severe reduction in the cuspal height with complete wearing of enamel and flattening of the occlusal surface.
• When dentin becomes exposed it generally becomes discolored brown.
• When the enamel is lost on the occlusal surface, the dentin becomes attrited at a faster rate.
• Men shows more severe attrition of teeth than women.
• In some cases, attrition may even result in pulp exposure.
• Attrition may also occur on the restorations of teeth.
• Possibly lead to fracture of the cusps of the teeth or restorations.

Treatment

Treatment of attrition is difficult, however certain things can be done to reduce further tooth wear.

• Correction of developmental abnormalities causing traumatic occlusion.
• Correction of para-functional chewing habits.
• Protection of tooth by metal or metal-ceramic crowns where structural defects(e.g. Amelogenesis or Dentinogenesis imperfecta) exit.
• Construction of occlusal guard if Bruxism habit is persisting.

Medical Trivia

Syringing of the  Ear for removal of ear wax or a foreign body sometimes results in persistent cough.Why? 

The auricular branch of vagus supplies the skin of the auricle,the external acoustic meatus,and the tympanic membrane.

The syringing of the ear may cause irritation of the auricular branch of the vagus nerve.This results in persistent cough and rarely even death due to sudden cardiac arrest by vagal stimulation.

ABSCESS

An abscess is a localised collection of pus.

Classification:

1. Pyogenic Abscess.It is the commonest form of an abscess,subcutaneous,deep,or it can occur within the viscera such as liver or kidney,etc.
2. Pyaemic Abscess occurs due to circulation of pyaemic emboli in the blood.(pyaemia)
3. Cold Abscess. Usually refers to tubercular abscess either due to involvement of lymph node or involvement of spine.

Dental Questions.

Infection of the pulp of a tooth causes severe pain.Why?

Tooth is made up of Dentin covered by enamel,over the crown and cementum over the remaning part.The cavity within the dentin contains connective tissues,blood vessels and nerves,which forms the pulp of the tooth.
Infection of the pulp occurs usually due to the invasion of pulp cavity by a deep carious lesion of the tooth causing inflammatory swelling of the pulp.
Since the pulp cavity is a rigid space,the swollen pulpal tissue causes severe pain in tooth(TOOTHACHE)

CELLULITIS

Cellulitis is a  spreading subcutaneous inflammation caused by haemolytic streptococcus .Streptococcal infection produces diffuse inflammation because of hyaluronidase and streptokinase.Net result is that the inflammatory exudate spreads in the sub-cutaneous and facial planes resulting in a gross swelling in the affected part.Wherever there is a loose sub-cutaneous tissue as in scrotum or loose connective tissue and interstitial tissue as in face,forearm,it spreads fast.

Sources of Infection:

• Injuries--Major or minor
• Graze or scratch
• Snake bite,scorpion bite,etc.

Precipitating Factors:

• Diabetes
• Low resistance of an individual

Common Sites:

• Lower limb
• Face
• Scrotum

Clinical Features:

• Inflammation such as redness.
• Itching followed by diffuse swelling.
• Skin is stretched and shiny.
• Pain
• Fever
• Toxemia

If untreated:

• Suppuration 
• Sloughing
• Gangrene can occur.

Treatment:

• Bed rest with legs elevated .Reduces Oedema of leg as in cellulitis of leg.
• Glycerine Mg2SO4 dressing which reduces oedema of the part by osmotic effect.
• Diabetes ,if present ,is treated with injection Crystalline Insulin given subcutaneously.
• Appropriate Antibiotics:

1. Injection Crystalline Penicillin 10 lakh units, Intramuscular(I.M) or Intravenous (I.V)  6 hourly for 5-7 days
2. Ciprofloxacin 500mg twice a day can be given .

• Anti -snake Venom is given in snake bites cases.

Complication :

• Cellulitis can turn into an abscess which needs to be drained.
• Gangrene of the skin and subcutaneous tissue can occur.It is treated by debridement and skin grafting later.
• Toxemia and septicemia.
• Cellulitis can precipitate Ketoacidosis in a patient who has diabetes.

Leukoplakia And Hyperkeratosis

Hyperkeratosis refers to increase in kertin layers.It occurs when there is definite aetiological causes and it is reversible.

E.g. Smokers hyperkaratosis of the palate and lips. Once the aetiological agent is withdrawn ,the lesion returns back to normal.

Leukoplakia appears clinically as a white patch in the mouth and cannot be scraped off.It is irreversible and occurs due to various aetiological factors.

Common causes of leukoplakia

• Smoking results in hyperkeratosis. Nicotine in the form of cigarettes,chewing tobacco,powdered snuff produces premalignant changes in the oral cavity.
• Spices
• Spirits have synergistic action with smoking.
• Sharp tooth,sepsis,poor oral hygiene.
• Sunlight-Actinic rays
• Syphilis causes endartiritis obliterans and results in chronic superficial glossitis of the tongue which is precancerous conditions(Rare now a days)
• Susceptibility of a person.

Betel nut,slake lime with betel leaf and tobacco(Pan) is eaten and usually kept inside the cheek for many hours.Overs the years,it brings about chronic irritation of mucosa of the cheek and causes leukoplakia.Tobacco contains multiple carcinogens including aromatic hydrocarbons.

Stages in the development of leukoplakia:

1. Keratosis appears as milky blush on the surface.
2. Acanthosis refers to elongation of rete pegs.This apears as a smooth,white,dry patch.
3. Dyskeratosis means the formation of keratin cells/layers in the deeper aspect of epidermis,before they reach the surface.
4. Speckled leukoplakia appear as multiple,small white patches.
5. Carcinoma in situ.

Erythroplakia is a red lesion with more incidence of malignancy.

TREATMENT OF LUEKOPLAKIA:

• About 10% of leukoplakia patients develop oral cancer.Hence,superficial excision of the lesion followed by skin grafting should be done.