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Trigiminal neuralgia and dental management 

Review literature Dent TU 3rd Round
0n 16/02/2012 ; 15:30-15:55 pm.
Revise and edit finish on 19/3/2012;13:05 pm.

 

 
 
Tags:  Trigiminal neuralgia  dental management 
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Published:  March 18, 2012
 
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Slide 1: Trigeminal neuralgia นศ.ทพ.อริยา สุนทรารักษ์ ชันปี ที่ ๖ ้ คณะทันตแพทยศาสตร ์ มหาวิทยาลัยธรรมศาสตร ์
Slide 2: Outlines • • • • • 16/2/2555 Definition Epidimiology Classification Diagnosis Management Trigeminal neuralgia
Slide 4: Definition of Trigeminal neuralgia “Unilateral disorder characterized by brief electric shock-like pains, abrupt in onset and termination, and limited to the distribution of one or more divisions of the trigeminal nerve” (International Headache Society, 2004) 16/2/2555 Trigeminal neuralgia
Slide 5: Epidimiology • 4.3 : 100,000 persons/year • Women > men (5:3) • Most common in middle and old age • Right side > left side • CN V2 and V3 are common affected (Obermann, 2010) • CN V1 alone is involved in less than 5% of cases (Galetta and Prasad, 2009) (Neville et el., 2009) 16/2/2555 Trigeminal neuralgia
Slide 6: Epidimiology • The pain characterized by sharp, shooting, “electric shocklike” pain sensation • Non-noxious stimuli (ex.lightly touched, brushing the teeth, applying facial cosmetics) may trigger intolerable pain (Dessy, 2010) 16/2/2555 Trigeminal neuralgia
Slide 7: Classification 1. Classic (Idiopathic/Essential) trigeminal neuralgia; CTN 2. Symptomatic trigeminal neuralgia; STN (International Headache Society, 2004) 16/2/2555 Trigeminal neuralgia
Slide 8: Classic trigeminal neuralgia; CTN • Clinical features – M/C type of TN – Without an established etiology as well as those with potential vascular compression of the trigeminal nerve (Lemos et al., 2011) – M/C: superior cerebellar artery (75%) or the anterior inferior cerebellar artery (10%) (Galetta and Prasad, 2009) 16/2/2555 Trigeminal neuralgia 7
Slide 9: Classic trigeminal neuralgia; CTN 16/2/2555 Trigeminal neuralgia
Slide 10: Classic trigeminal neuralgia; CTN 16/2/2555 Trigeminal neuralgia
Slide 11: Classic trigeminal neuralgia; CTN • Clinical features – Starts in the second or third divisions, affecting the cheek or the chin – Single attack generally lasts from less than a second to a few seconds, but it may present in clusters of variable intensity with up to 2 minutes duration (International Headache Society, 2004) 16/2/2555 Trigeminal neuralgia 10
Slide 12: Classic trigeminal neuralgia; CTN • Clinical features – > 50% episodic onset of TN pain (Tatli et al.,2008, Limonadi et al., 2006) 16/2/2555 Trigeminal neuralgia 11
Slide 13: Symptomatic trigeminal neuralgia; STN • Clinical features – Founded less than 2% of patients TN – Bilateral TN pain (Cruccu et al., 2008; Gronseth et al., 2008)  confirm with MRI/Trigeminal reflex testing (Obermann, 2010) 16/2/2555 Trigeminal neuralgia 12
Slide 14: Symptomatic trigeminal neuralgia; STN • Clinical features – >50% constant pain (Tatli et al.,2008, Limonadi et al., 2006) – Results secondarily to cases such as tumors (Cerebellopontine angle) or multiple sclerosis (Lemos et al., 2011) 16/2/2555 Trigeminal neuralgia 13
Slide 15: Diagnosis • History taking remains the essential tool for diagnosis of TN • The main objective of special diagnostic procedures is the differentiation of CTN from STN 16/2/2555 Trigeminal neuralgia
Slide 16: Diagnosis • Clinical presentation with bilateral TN as well as trigeminal sensory deficits are indicative of STN, but due to low specificity, their absence does not rule in out completely (Cruccu et al., 2008; Gronseth et al., 2008) 16/2/2555 Trigeminal neuralgia
Slide 17: 16/2/2555 Trigeminal neuralgia
Slide 18: Management 1. Pharmacological management 2. Surgical management 16/2/2555 Trigeminal neuralgia
Slide 19: Pharmacological management • First line drugs – Carbamazepine (CBZ; 2001200 mg/day) – Or Oxcarbazepine (OXC; 600-1800 mg/day) 16/2/2555 Trigeminal neuralgia
Slide 20: Pharmacological management • First line drugs – S/E of carbamazepine: drowsiness, nausea, dizziness, ataxia, constipation, leukopenia and liver dysfunction and also affects the metabolism of other drugs (notably warfarin) 2009) 16/2/2555 (Galetta and Prasad, Trigeminal neuralgia
Slide 21: Pharmacological management • Second line drugs – add-on or switch with lamotrigine (400 mg/day), baclofen (40-80 mg/day) – S/E of lamotrigine: dizziness, nausea, blurred vision and ataxia – S/E of balcofen: drowsiness, dizziness and gastrointestinal discomfort 16/2/2555 Trigeminal neuralgia
Slide 22: Pharmacological management • Alternative drugs  Gabapentin 900-3600 mg/day  Pregabalin (150-600 mg/day)  Topiramate (100-400 mg/day)  Tocainide (20 mg/day)  Valproate (600-2400 mg/day) 16/2/2555 Trigeminal neuralgia
Slide 24: Surgical management • “In patients with medically intractable pain or intolerable medication side effects, invasive therapeutic approaches are often necessary, and can provide excellent success.” (Galetta and Prasad, 2009) Trigeminal neuralgia 16/2/2555
Slide 25: Surgical management 1. Microvascular decompression (MVD) 2. Percutaneous procedures on the Gasserian ganglion 3. Gamma knife radiosurgery Trigeminal neuralgia 16/2/2555
Slide 26: Surgical management 1. Microvascular decompression (MVD) – Superior method of choice among neurosurgical procedures (Fariselli, Zeme, 2008) 16/2/2555 Trigeminal neuralgia
Slide 27: Surgical management 1. Microvascular decompression (MVD) • The most sustained pain relief with 90% of patients reporting initial pain relief and over 80% still pain free after 1 year, with 75% after 3 years and 73% after5 years remaining pain free 16/2/2555 Trigeminal neuralgia
Slide 28: Surgical management 1. Microvascular decompression (MVD) • The most common complications are aseptic meningitis (11%), sensory loss (7%) and hearing loss (10%) as long-term complications (Cruccu et al., 2008; Gronseth et al., 2008) 16/2/2555 Trigeminal neuralgia
Slide 29: Surgical management 2. Percutaneous procedures on the Gasserian ganglion • all destructive • include radiofrequency thermocoagulation (RFT), balloon compression (BC) and percutaneous glycerol rhizolysis (PGR) 16/2/2555 Trigeminal neuralgia
Slide 30: Surgical management 2. Percutaneous procedures on the Gasserian ganglion • 90% of patients report pain relief • After 1 year, 68-85% of patients are still pain free, after 3 years this is reduced to 54-64% and after 5 years only 50% of patients are stillTrigeminal neuralgia pain free 16/2/2555
Slide 31: Surgical management 2. Percutaneous procedures on the Gasserian ganglion • Most common side effects are sensory loss (50%), dysesthesias (6%), corneal numbness with risk of keratitis (4%) 16/2/2555 Trigeminal neuralgia
Slide 32: Surgical management 3. Gamma knife radiosurgery • Focused beam of radiation is aimed at the trigeminal root in the posterior fossa 16/2/2555 Trigeminal neuralgia
Slide 33: Surgical management 3. Gamma knife radiosurgery • 1 year F/U: 69% of patients are pain free without additional medication • 3 years F/U: 52% of patients are still pain free (Obermann, 2010) 16/2/2555 Trigeminal neuralgia
Slide 34: Surgical management 3. Gamma knife radiosurgery • Side effects are sensory complications in 6% that may develop with a delay of up to 6 months, facial numbness in 937% which improves over time and paresthesias in 6-13% 16/2/2555(Cruccu et al. 2008; Gronseth et al. 2008) Trigeminal neuralgia
Slide 36: References • • Dessy R Emril, Kok-Yuen Ho. Treatment of trigeminal neuralgia: role of radiofrequency ablation. Journal of Pain Research. 2010;3:249–54. Lemos et al. Pharmacological versus microvascular decompression approaches for the treatment of trigeminal neuralgia: clinical outcomes and direct costs. Journal of Pain Research. 2011;4:233–44. Neville et al. Oral and Maxillofacial pathology. 3rd ed.2009.861-3. Obermann M. Treatment options in trigeminal neuralgia. Therapeutic Advances in Neurological Disorders. 2010;3(2):107-15. Sashank Prasad, Steven Galetta. Trigeminal Neuralgia: Historical Notes and Current Concepts. The Neurologist. [REVIEW ARTICLE]. March 2009;15(2):8794. • • •

   
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