38

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.

BRITISH MEDICAL JOURNAL

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-

Department of Dental Prosthetics, Dental School, Belfast BT12 6BA

G. A. S. BLAIR, M.D.S., F.F.D., Senior Lecturer and Consultant
Department of Neurosurgery, Royal Victoria Hospital, Belfast
BT12 6BA
D. S. GORDON, M.CH., F.R.C.S., Consultant

ner3 thought that deficient insulation between touch and

pain fibres in the preganglionic root of the trigeminal nerve
would allow the development of a short-circuiting mechanism. On the rare occasions when an identifiable lesion is
present, it lies in the cerebellopontine angle-for example,
acoustic neurinoma.
The relation between dental malocclusions and paroxysmal craniofacial pain was first described by Costen.4 Henderson5 pointed out that a trigger point in a masticatory
muscle may be the single precipitating factor. The muscle is
often tender.
The classical treatment of trigeminal neuralgia was alcohol
injection of the Gasserian ganglion and its branches or operative section of the preganglionic root of the trigeminal nerve.
More recent treatment includes carbamazepine (Tegretol) and
phenoliophendylate injections. Injection or operation may be
complicated by painful numbness, (anaesthesia dolorosa);
prolonged carbamazepine therapy can have side effects.
A favourable short-term response to dental treatment in
patients with trigeminal neuralgia was reported by Lindsay.6
Adjustment of dental malocclusion can benefit various forms
of craniofacial pain; migraine and trigeminal neuralgia have
responded to the elimination of occlusal dysharmonies.7
This paper describes dental abnormalities, chiefly malocclusions, found in patients with trigeminal neuralgia. The
value of dental treatment is discussed.

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

Clinical Data on Patients Treated

Case No.

Sex and Age

.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.

FIG. 1-Acrylic plate to separate teeth.

Edentulous Patients
The
some

remaining 32 patients
had a few remaining

had complete upper dentures;

teeth in the mandible, others a

complete lower denture.

Dentures should provide the same occlusal face height as
in the natural dentition (fig. 2); the inclined planes of the
opposing teeth should establish a harmonious functional relation between the upper and lower dentures. If the inclined

FIG. 3-Artificial teeth separated by acrylic splint.

planes are incorrectly arranged a locked functional occlusion

results which may lead to facial pain or dysfunction or both.
If the occlusal face height of the dentures was too great
grinding the occlusal surfaces of the artificial teeth restored
it to normal. If the occlusal face height was below normal
a splint fitted to the lower denture (fig. 3) increased it. Occlusal dysharmonies were eliminated by grinding the occlusal
surfaces of the teeth to obtain a free-sliding interface. New
dentures were later constructed to restore the correct facial
dimensions and occlusal function.

40

The six consecutive short-term patients (see table) had

complete upper and lower dentures. In three the dentures
propped the jaws too far apart and they were advised not
to wear their lower dentures. A splint was fitted to the lower
denture for two patients whose jaws were overclosed; the
remaining patient, with a locked occlusion, had the surfaces of
the teeth altered to give a free-sliding, balanced occlusion.

Results
DENTATE PATIENTS

Only one of the seven dentate patients responded to occlusal

adjustment. This was a woman aged 60 (case 8, see table)
who had developed attacks of trigeminal neuralgia 11 years
previously. The pain was bilateral, affecting the upper lip
and nose; it was induced by sudden head movement, a cold
wind, or eating. Three years after onset the condition became more severe but was successfully controlled by carbamazepine. Four years later carbamazepine ceased to give
benefit, the attacks were frequent and severe, and her weight
fell from 10 to 84 st. (63 5 to 54 kg). The triggers included
walking, talking, touch, cold wind, and she could take only
liquid food through a straw. After dental treatment with an
upper canine guidance plate her condition improved rapidly and within one week she was free of symptoms. Subsequently she had to take carbamazepine on two occasions
for four days each. The alternative treatment of nerve injection or operation would have been difficult in a patient with
bilateral pain.

EDENTULOUS PATIENTS

Long-term.-Of the 32 edentulous patients treated, seven had

complete remission from pain for over three years (see
table). All had been suffering frequent daily attacks of pain
for many months. If dental treatment had failed they would
have been offered either injection or surgery, as carbamazepine had ceased to be effective or had caused an adverse reaction. All seven reported complete and almost
immediate relief from pain after treatment. Case 7 later had
occasional attacks of pain which were less severe and were
controlled by small doses of carbamazepine.
Short-term.-The swift remission of symptoms achieved
by simply removing the lower denture is shown in the table.
This was effective in type A patients, who had excessive
occlusal face height (cases 9-11). Patients with a reduced
occlusal face height (type B) benefited from the immediate
provision of a splint on the full lower denture (cases 13 and
14). An unusual but important exception was case 12, where
the occlusal face height was correct but marked dysharmony
was present in the occlusal relation between the upper and
lower dentures. This man, aged 72, had many trigger factors, which included touching the face, eating, talking, and
walking; he had unremitting pain for one year despite large
daily doses of carbamazepine. Like many patients with
trigeminal neuralgia he had considerable weight loss. His

BRITISH MEDICAL JOURNAL

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.

3Gardner, W. J., Transactions of the American Neurological Association,

1963, 78, 168.
4Costen, J. B., Journal of the American Medical Association, 1936, 107, 252
5 Henderson, W. R., British Medical Journal, 1967, 1, 7.
6 Lindsay, B., Australian Dental3Journal, 1969, 14, 361.
7Blair, G. A. S., and Gordon, D. S., Background to Migraine: Proceedings
of V Symposium of Migraine Trust, Oct. 1972. London, Heinemann.
In press.