References
IGale, E. F., Cundliffe, E., Reynolds, P. E., Richmond, M. H., and Waring,
M., Molecular Basis of Antibiotic Action. London, Wiley, 1972.
2 Woods, D. D., British Journal of Experimental Pathology, 1940, 21, 74.
3 Hitchings, G. H., in Drugs, Parasites and Hosts, ed. L. G. Goodwin, and
R. H., Nimmo-Smith, p. 196. London, Churchill, 1962.
4 Hitchings, G. H., Postgraduate Medical Journal, 1969, 45, (Nov.) Suppl.,
p. 7.
5 Lampen, J. O., Symposium of Society of General Microbiology, 1966, 16,
111.
6 OCTOBER 1973
Gale, E. F. In preparation.
7Mechlinski, W., and Schaffner, C. P., Jrournal of Antibiotics, 1972, 25,
255, 259, 261.
8 Weber, M. M., and Kinsky, S. C., Journal of Bacteriology, 1965, 89, 306.
9 Schaffner, C. P., Proceedings of the International Fermintation Symposium,
1973. In press.
10 Verkleij, A. J., et al., Biochimica et Biophysica Acta, 1973, 291, 577.
1 Cass, A., Finkelstein, A., and Krespi, V.,
Journal of General Physiology,
1970, 56, 100.
12 Holz, R., and Finkelstein, A.,J'ournal of General Physiology, 1970, 56, 125.
Hospital Topics
Trigeminal Neuralgia and Dental Malocclusions
G. A. S. BLAIR, D. S. GORDON
British Medical J1ournal, 1973, 4, 38-40
Summary
Out of 39 patients with intractable trigeminal neuralgia seven
have had continuing relief for over three years after dental
treatment. Five out of six recent consecutive edentulous
patients had immediate improvement. More radical treatment,
such as ganglion injection or nerve root section, has been at
least postponed.
Introduction
Trigeminal neuralgia is a severe paroxysmal pain occurring in
one or more divisions of the trigeminal nerve. The patient
describes a stabbing or electric shock sensation lasting usually
less than one minute. Initially the attacks are relatively mild
and remissions of some months are common. Later, remissions become shorter and the pain becomes more severe until
attacks occur daily for many months.
Pain is precipitated or "triggered" by a variety of stimuli
including eating, talking, tongue and lip movements, yawning,
touching the skin of the face, draughts, sudden movements
of the head, and, occasionally, walking, loud noise, or bright
light. It affects women more often than men; the onset is
usually after the 45th year.
As its fundamental cause remains unknown the condition
is usually referred to as idiopathic trigeminal neuralgia. A
few cases have been attributed to multiple sclerosis. Harris'
noted that the pain sometimes starts after dental extraction
or sepsis. Dott2 suggested that the basic mechanism is the
conversion of innocuous stimuli into intense paroxysmal pain
by a short-circuiting mechanism in the brain stem. Gard-
Patients
Thirty-nine patients (30 women and 9 men) referred to the
Royal Victoria Hospital Belfast, in 1969 and 1970 with trigeminal neuralgia were given various forms of dental treatment. They have been followed up at regular intervals for
three to four years (see table). The short-term response to
dental treatment of six consecutive patients seen recently is
also described (Cases 9-14, see table). Each patient fulfilled
all the diagnostic criteria for trigeminal neuralgia; these included the identification of the character of the pain, its
duration, its distribution, onset, periods and patterns of remission, and the triggering factors. A complete neurological
examination was carried out in the department of neurology or neurosurgery to eliminate primary disorders like multiple sclerosis or intracranial tumour.
BRITISH MEDICAL
6 OCTOBER 1973
JOURNAL
39
.M.
.F.
.F.
.F.
.F.
.F.
.F.
.F.
9 .M.
10 .F.
11 .F.
12 .M.
13 .M.
1
2
3
4
5
6
7
8
14*
57
71
36
40
54
55
70
60
63
38
57
72
55
.M. 52
Duration
(Years)
1
8
1
6/12
1
2
8
11
23
4/12
2
1
4
10
Division
(Vth Nerve)
L.V1-V2
L.V2-3
R.V3
L.V1-2
L.V1
L.V1-2
R.V3
L.V2-3
L.V1
R.V2
R.V3
L.V3
R.V1-2
R.V3
Carbamazepine
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Dental State
Interval to Response
(Days)
F/F B
F/F B
F/F B
F/F B
F/F A
F/F B
F/F B
3
6
3
6
3
14
F/F A
F/F A
F/F A
F/F C
F/F B
F/F B
2
6
0
1
3
2
5
3
Follow-up
No. of Years
3
3
3
3
3
3
3
4
Short-term
No response
Symptom-free
Symptom-free
Occasional twinge
Occasional twinge
Occasional twinge
Wheelchair case with multiple sclerosis. In 1965 patient had preganglionic fractional section L.V2-3.
F/F = Complete upper and lower denture. A = Excessive occlusal face height. B = Inadequate occlusal face height. C = Occlusal dysharmony of dentures. D = Occlusa
dysharmony of natural teeth.
Cases 9-11 were treated by leaving out -/F at all times.
*
DENTAL TREATMENT
Dentate Patients
Seven of the patients had most of their natural teeth; two,
with periodontal disease, required extraction of their remaining teeth followed by insertion of complete upper and lower
dentures. The remaining five patients had no dental abnormalities. Each had a canine guidance plate fitted behind
the upper canine teeth; it made contact with the incisal
edges of the lower canine teeth (fig. 1).
The effects of this plate are (1) to separate all the natural
teeth except the lower canines, (2) to allow the mandible
to assume its physiological position in relation to the maxilla,
(3) to inhibit reflex grinding and clenching of the teeth, and
(4) to encourage restoration of normal muscle tone.
FIG. 2-Facial height determined by dental bite gauge.
Edentulous Patients
The
some
remaining 32 patients
had a few remaining
40
Results
DENTATE PATIENTS
EDENTULOUS PATIENTS
6 OCTOBER 1973
dentures were altered to achieve a balanced free-sliding occlusion. Within 28 hours he reported almost complete relief
from pain and in the next three months retumed to his
normal weight. He has not since required medication.
It is too early to say if the remission in these short-term
patients will be maintained.
Discussion
The aetiology of trigeminal neuralgia remains unknown in
most patients. The neuralgic pain results from a bombardment by many relatively minor stimuli along a nerve with
a conductive abnormality. Dental factors clearly play a more
important part in precipitating paroxysmal facial pain than
has been previously realized. The pragmatic approach
recommended in this investigation depends on the reduction
of trigeminal input below threshold level. Probably the correction of dental abnormalities reduces the sensory inflow
from masticatory muscles which were malfunctioning because of abnormal occlusal face height or incorrect occlusal relationship. Dental correction leads to the abolition of
intraoral triggers and, somewhat unexpectedly, extraoral triggers as well.
The results of the present investigation indicate that a
dentist should examine all patients suffering from trigeminal
neuralgia and correct any dental abnormality. Most patients
have wom dentures for some years before the onset of trigeminal neuralgia. Often the dentures did not preserve the
correct relationships between the upper and lower jaws. Indeed, a long period of wearing incorrect dentures may alter
the state of the masticatory muscles and establish conditions favouring the development of trigeminal neuralgia.
Perhaps patients with trigeminal neuralgia have a neuralgic
diathesis, comparable to an epileptic or migrainous diathesis,
in which certain exciting factors are required to induce
clinical manifestations of the condition.
It was chiefly denture-wearing patients who benefited
from treatment of occlusal dysharmonies; the results of
treating dentate patients were disappointing. This approach
is empirical, but it does not involve any irreversible change
of the tissues and has the advantage over other forms of
treatment of being both diagnostic and therapeutic.
Further studies of the relation of masticatory dysfunction
to trigeminal neuralgia are needed and will be the subject
of a later report.
We are indebted to our neurological and neurosurgical colleagues.
in particular Mr. C. A. Gleadhill, for their interest and support.
References
1 Harris, W., Brain, 1940, 63, 209.
2 Dott, N. M., Proceedings of the Royal Society of Medicine, 1951, 44, 1034.