Maxillo-facial surgery :: Neuralgia

The term neuralgia comes from the Greek word πόνος στα νεύρα /nerve-pain/. Neuralgia of the trigeminal nerve (Neuralgia Nervi trigemini) we know as "tic douloureux de la fase", a disease of Fothergill and Truscott. Fothergill first described this disease in 1779. Trigeminal neuralgia is a severe disease characterized by extremely severe and sudden paroxysmal, short-lived pain in the face. It starts at one point and spreads rapidly in the area innervated by some of the branches of the trigeminal nerve. It is also characteristic that the pain tends to progress in strength and in terms of frequency of attacks.


There are different classifications of trigeminal neuralgia. According to Sikard, the forms are 3:
Essential / true, primary, idiopathic / - in her, even in the most precise examination, no cause is found.
Secondary / symptomatic / - her pain is a symptom of various diseases in the maxillofacial area.

Facial neuralgismus
According to other authors, neuralgia we divide into typical and atypical. In the first group we include the so-called "painful tic of the face", and in the second - diseases of various kinds.
The Bulgarian Dental School accepts only one type of trigeminal neuralgia.
It is an independent unit of overlap and overlaps with the so-called "painful tic of the face."
There is no other type of neuralgia, and these are the symptoms of pulpitis, periodontitis, sinusitis and others diseases.

Etiology and pathogenesis
Science is still not entirely clear on this issue. According to Sikard, neuralgia is due to compression of the branches of the trigeminal nerve in the openings through which it leaves the skull. In support of this theory is the fact that neuralgia more often covers the second and third branches, and on the right, the openings of which are narrower anatomically, according to the author's own research. In addition, it covers older people. At them, these openings sclerosis and become narrow. The first branch comes out of a wide opening and it is almost not sick. Some authors, such as Sontag and Rosenthal, explain neuralgia with pathological changes in the central nervous system (mostly infections) in which the trigeminal center becomes hypersensitive and at the slightest external irritation, it reacts with inadequate pain. Others, Duplay, Temple, Fay, Pichler, consider neuralgia as an isolated disease of the peripheral branches / neuromas, neuritis /, in causal connection with pathological processes of dental origin. A third group of authors / Fermier, Pete, Kulenkampf, Stauder /, propose a theory according to which „vasa vasorum“ sympathetic disease develops on the peripheral branches of the nerve or on the ganglion / node / of the trigeminal nerve and oxygen starvation occurs as a result of vasomotor spasm, of the nerves, to which they react sharply with pain. The authors call it a "nerve call for blood." As predisposing factors for the appearance and development of neuralgia, most authors point to a number of common diseases: malaria, tuberculosis, syphilis, atherosclerosis, anemia, influenza, typhoid fever, rheumatism, as well as metal intoxications / lead /, nicotine, alcohol. Each of these theories suffers from one-sidedness. The human body is a complex unity between organs and systems, in which the central nervous system plays a leading role and we could not consider in this way. Such an explanation of diseases generally leads to diagnostic and treatment errors. Our dental school / Kolarov / accepts the following theory about the origin and development of neuralgia.  We assume that in the genesis of topic neuralgia plays a role a complex of factors of general and local nature: gender, age and typological features, infectious diseases and intoxications, various diseases and pathological conditions in the peripheral branches of the nerve or its way. Common factors alter reactivity and weaken the functional state of the central nervous system. Against the background of weakened cortical activity, impulses from the pathologically altered periphery begin to act in various stomatogenic, rhinogenic and ophthalmogenic diseases and conditions. As a result, at a certain point in the cerebral cortex, the balance between the process of excitation and retention is disturbed, and a weakness of the process of excitation occurs. Due to the exhaustion and weakness of the cortical cells in this focus, they begin to respond inadequately, paradoxically, with a maximum, explosively occurring pain response to the stimuli that reach them, regardless of their strength and nature. Due to the small reserves that these cells have and due to the rapid depletion, after the onset of the attack, they quickly go into a state of precautionary detention. At that way it is possible to explain the short duration of the attack and the occurrence immediately after it of the so-called "refractory phase", ie. a time during which provocative moments are unable to trigger an attack.


Based on a number of clinical observations, we can assume that sometimes neuralgic attacks can have a conditioned-reflex nature, ie to appear in connection with some indifferent stimuli / time, situation, etc. /.
Because of a complex of general and local factors in the central nervous system, a pathological pain dominant arises, which becomes a major link in the pathogenesis of neuralgia, determining all the phenomena we observe in this disease.

Diagnosis and diagnostic errors

  1. We diagnose and treat neuralgia as an odontogenic disease.
    We diagnose and treat a dental disease such as neuralgia

Causes of diagnostic errors
1. Objective
A / Methodological
- We put a very broad meaning in the term neuralgia.
- Pain in the course of a given sensory nerve - paroxysmal pain in the course of a given sensory nerve.
B / Classification:
- Primary / essential / according to Sikar
- Clinical / symptomatic /

2. Subjective
- Poor knowledge of the characteristics of neuralgia and those dental diseases that cause neuralgic pain.

Trigeminal neuralgia is a disease of adulthood and old age - from 40 to 60 and over 60 years. Women get sick more often than men; II and III branch of the nerve get sick more often on the right. Bilateral neuralgia is extremely rare.
Extremely severe pain is the main symptom of neuralgia. Characteristic of the pain is its accessibility / only during the day / and short duration / seconds to several minutes /. The attack occurs on an insignificant occasion: talking, touching a certain area of the face / etc. excitation zones - trigger zones, which most often coincide with the Vale points - the nerve outlets /, chewing, facial expressions, and sometimes for no apparent reason. The pain has a different nature: shooting, clicking, stabbing, tearing, burning, as if from an electric current, etc. It starts from one point and spreads along the course of the nerve. During an attack, the patient has a characteristic spasm of the facial muscles, sweating, tearing of the eyes, profuse salivation, and redness of the facial skin.
Blood pressure rises sharply. After the attack, the pain passes suddenly and the patient calms down. Characteristically, with the development of the disease, the attacks become more frequent and the pain becomes stronger. Eventually, it may occur at night or separate seizures may merge. In some cases, we also observe trophic disorders - hair loss, beard, increased keratinization of skin areas or pigmentation, conjunctivitis or shingles. In some patients the so-called geographical language on the side of the affected nerve.

Examination of the patient
First, we look for the excitation zones. We take an X-ray to look for hidden caries, pulpitis, periodontitis, denticles, retained teeth, lagging teeth, periodontal pockets, etc. We also take a picture of the sinuses and the skull (possibly a scanner) to see sinusitis or intracranial processes. We consult every patient with neuralgia with an otolaryngologist and a neurosurgeon. We do a test block to see if the attack disappears or to identify the affected branch.

Differential diagnosis

Trigeminal neuralgia or pharyngeal nerve neuralgia and Charlin's symptom - neuralgia of n. nasociliaryis
Trigeminal neuralgia and neuritis
Trigeminal neuralgia or acute pulpitis
Trigeminal neuralgia or acute sinusitis
Trigeminal neuralgia or migraine


Trigeminal neuralgia is difficult to treat and often recur. We know the following methods: 1. Rehabilitation of the oral cavity 2. Blockades - essentially anesthesia of the affected nerve. We apply 10 in one course of treatment. 3. Drug treatment - we prescribe bromine, vitamins B1, C, B12. The combination of calcium gluconate, sodium salicylate and vitamin gives a good effect. B1 - intravenously for 10 days. We also successfully use the preparations Tegretol and Stazepin according to the respective scheme. 4. Physiotherapy - diathermy, iontophoresis, ASB2, etc. Deep X-ray therapy of the Gasser ganglion. Sometimes physiotherapy has the opposite effect. 5. Alcoholization of the nerve - we inject 80% sterile alcohol intraneurally.

6. Surgical treatment. It is:

    • neurotomy - cutting the nerve
    • nervectomy - cutting a certain area of the nerve
    • nervexeresis - plucking of the nerve

There are other surgical methods that are not particularly important: filling the bone hole, placing a silver ring around the nerve, widening its canal, etc.

Nervexeresis has the longest effect, as it removes a larger area of the nerve. As it recovers by about 1 mm. per month we can even predict when seizures will resume after measuring the length of the plucked area.

7. Tissue therapy according to Filatov. It consists of subcutaneous implantation of animal tissues or own skin. In addition, injection of plant extracts from plants grown under adverse conditions (darkness or low temperature). Thus, the organism forms the so-called biological stimulants. Krause modified Filatov’s method. In this method, we implant a preserved placenta and make injections with Krause's solution, 10 to 15 injections a day. We must exclude diseases such as syphilis, diabetes, anemia, AIDS, which lead to low resistance of the body. Nivalina derivative - ampoules of 2 ml. for electrophoresis or blockades /, Semenchenko solution - blockades - 12 to 15 sessions.


Lidocaine 0.8
Pyramidon 0.8
Analgin 1.2
Ephedrine 0.1
Aqua dest. To 100.0

Sometimes we apply combined treatment - a strictly individual combination at the discretion of the attending physician between these methods. We must say that there is no sure method and eventually the neuralgia recurs. The goal of treatment is to achieve as long as remission as possible.

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