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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 4  |  Page : 303-306

Prevalence of post traumatic trigeminal neuralgia (PTTN): Observational study at dental college, Kanpur


1 Department of Oral Medicine and Radiology, Rama Dental College, Kanpur, Uttar Pradesh, India
2 UWA School of Population and Global Health, University of Western Australia, Nedlands, WA, Australia
3 Department of Pedodontics, Rama Dental College, Kanpur, Uttar Pradesh, India

Date of Submission08-Aug-2019
Date of Acceptance20-Dec-2019
Date of Web Publication03-Mar-2020

Correspondence Address:
Dr. Kriti Garg
117/K-68 Sarvodaya Nagar, Kanpur, Uttar Pradesh - 208 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_146_19

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   Abstract 


Context: The trigeminal nerve is a mixed nerve performing both sensory and motor functions and supplies the orbit, the maxilla and the mandible, any trauma whether accidental or iatrogenic are the common cause of trigeminal neuropathy. Most cases of posttraumatic trigeminal neuralgia (PTTN) occur due to extraction of tooth, root canal treatment, and any kind of jaw fracture affecting the crown -root of a tooth. Aims: The aims of this study are to know the prevalence of PTTN in dental outpatient department (OPD) and to know the relation between traumatic dental extraction of teeth and occurrence of PTTN. Settings and Design: An institutional observational study. Methods and Material: The study was conducted during November 2018 to May 2019 and patients from dental OPD were selected based on the criteria of inclusion and exclusion factors. Statistical Analysis Used: Data collected were analyzed using the Statistical Package for Social Sciences (SPSS) software version 17 using descriptive frequency method. Results are represented as frequency and percentages. Results: The total new cases reported to the dental OPD were 8280 patients, out of those 129 patients of PTTN were recorded. In this study, the prevalence of PTTN patients was 1.55% and the males were more affected than female. Conclusions: PTTN is most often secondary to iatrogenic trauma during dental extractions and other orodental surgical procedures performed in oral cavity with localized sensory defects to inferior alveolar nerve, lingual nerve, and branches of maxillary nerves.

Keywords: Dental extraction, jaw, pain, posttraumatic trigeminal neuralgia


How to cite this article:
Garg K, Sachdev R, Mehrota V, Singh G, Mukherjee S, Ishrat S. Prevalence of post traumatic trigeminal neuralgia (PTTN): Observational study at dental college, Kanpur. J Indian Acad Oral Med Radiol 2019;31:303-6

How to cite this URL:
Garg K, Sachdev R, Mehrota V, Singh G, Mukherjee S, Ishrat S. Prevalence of post traumatic trigeminal neuralgia (PTTN): Observational study at dental college, Kanpur. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Apr 7];31:303-6. Available from: http://www.jiaomr.in/text.asp?2019/31/4/303/279851




   Introduction Top


The word “Trigeminal” is derived from the Latin word “tria,” which means three, and “geminus,” which means twin. The trigeminal nerve is the fifth of cranial nerves in the head. It is this nerve responsible for providing sensation to the face. One branch of trigeminal nerve runs to the right side of the head, whereas the other runs to the left side.[1] Trigeminal neuralgia (TN), also known as “tic douloureux,“is basically described as the most excruciating pain known to humans. The pain mainly involves the lower side of face and jaw; although sometimes it affects the area around the nose and above the eye.[1] The International association for the study of pain defines the TN as sudden, recurrent, intense pain along one or more branches of the fifth cranial nerve.[2] The International headache society defines TN as painful unilateral affliction of the face, characterized by brief electric shock like pain limited to the distribution of one or more divisions of the trigeminal nerve.[3],[4] Many theories have been profounded for etiology of TN, yet the most common factor considered is the compression of the nerve root.[5]

Traumatic injuries, traumatic extractions, and various viral infections, foci of dental abscess and bone resorption can compress the nerve in maxilla and mandible and results in neuralgia of nerve.[6] The pain of classic TN is sporadic in nature, described as electric shock like pain and attack lasts only for few seconds.[7]

Trigger points of pain on face may be located near to lips, side of the jaws, underneath the eyes and eyelids. Various activities, such as shaving, applying makeup drinking cold water may worsen the pain episodes.[8] The disorder is more common in women and patients older than 50 years of age. TN affects only one side of the face and the right side is affected more frequently than the left.[9] As per literature available on posttraumatic trigeminal neuralgia (PTTN) [PubMed central from 2010 to 2019 only two study reported]; thus, this observational study was conducted to evaluate the prevalence rate of PTTN in the patients visiting the dental OPD at a dental institution in Kanpur city.


   Subjects and Methods Top


In this observational study (November 2018 to May 2019), total 8280 new patients from the dental OPD were screened and data of 129 PTTN cases following dental extraction were taken from the past dental records. These 129 PTTN patients were selected based on the clinical diagnosis mentioned in the dental records which stated that these PTTN patients who were included for this observation study had a history of brief, demographic data of patient along with, site of the jaw involved was included. Patients were selected as per inclusion and exclusion criteria given below:

Inclusion criteria

  • The patients had given the history of extraction between past 8 months.
  • The patients who reported with the history of paroxysmal pain which triggered off following the dental extraction procedure.
  • Paroxysmal attacks of pain (electric/pricking type in nature) lasting from a fraction of a second to two minutes, affecting one or more divisions of the trigeminal nerve.
  • Neuralgic pain criteria based on the classification on A.F Kaufmann and M. Patel: Centre for cranial nerve disorders, Winnipeg, Manitoba, Canada (2001),[10] and diagnostic grading for Practice and Research for TN given by Cruccu et al.[11] for signs and symptoms were followed in patient's selection which describes TN as a paroxysmal, brief, sudden, stabbing, electric shock like and severe pain attacks. The examining physician/dentist must ascertain that the pain does not extend to the posterior third of the scalp, the back of the ear, or the angle of the mandible as these territories are innervated by cervical nerves.


Exclusion criteria

  • Patient with known history of TN.
  • Patient doesnot give sign and symptoms criteria as laid down by A. F Kaufman criteria and International headache society.[10]
  • The subjects below 20 years of age were not considered.
  • The pain ensues in the subjects before eight months of extraction were not included.
  • Severely ill patients and atypical features of pain suggesting symptomatic TN or an alternative diagnosis.


Ethical statement and informed consent

Institutional Ethics Committee approval was taken for the study. All patients were explained about the study and a verbal consent was taken from the patients willing to participate in the study.

Data collection and Statistical analysis

The data collected were tabulated, analyzed using the Statistical Package for Social Sciences (SPSS) software version 17 using descriptive frequency method. Results are represented as frequency and percentages.


   Results Top


In this 7 months observational study, total 8280 new patients from the dental OPD were screened, out of that total of 129 PTTN cases recorded. In the present study, the prevalence of PTTN is 1.55%. In this study, males were more in number 60.4% as compared to females 39.5%. Most of the cases were reported in the age group of 41–60 years 58.1% followed by 25–40 years 21.7% [Table 1], [Graph 1].
Table 1: Demographic distribution of patients (n = 129)

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Out of the total number of the patients with PTTN (n = 129) it was observed that there was more involvement of lower jaw, i.e., 103 PTTN patients (79.8%), in comparison to upper jaw where only 21 (16.2%) cases were involved, whereas only5 (3.8%) cases were involving both the jaws [Table 2], [Graph 2].
Table 2: Jaw-wise distribution of patients (n = 129)

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In 87 patients (67.4%) right side of quadrant (upper/lower) was affected, in comparison to left side, i.e.,42 patients (32.5%) [Table 3], [Graph 3]. Thus, the right quadrant (upper/lower) of the jaw was most commonly affected in all age groups of patients.
Table 3: Quadrants (upper/lower) wise distribution of patients (n = 129)

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All the patients who were diagnosed with PTTN were further treated with a combined effort by the Department of Oral Medicine and Department of Neurology.


   Discussion Top


TN has been referred to in the literature from decades. Unilateral facial pain causing facial spasms can be seen in the words of Aretaeus of Cappodocia in the 2nd century A.D.20 and those of the Arab physician Jujani in the 11th century A.D.[4] John Fothergill, in 1773, fully described the typical features of TN, including its paroxysmal nature and association with triggering factors, such as eating, speaking, or touching the face.[12] TN is a characteristic disorder of older life and has been well known for a long period of time.[13] PTTN with incidence of 40% of all cases is most often secondary to trauma; the most common cause is tooth extraction, with localized sensory defects to inferior alveolar nerve, lingual nerve, and branches of maxillary nerve.[14],[15]

This study aims to highlight the PTTN, i.e. one of the variant of TN and at the same time its association with iatrogenic damage to the nerve.[9],[10] The available literature shows very poor prevalence rate of cases of PTTN. In the present study, prevalence of PTTN cases was found 1.55%; lesser to the study done by Kumar et al., where prevalence rate of PTTN was 2.11%.[16] Various reasons have been mentioned in literature regarding the etiology behind PTTN, these include the poor surgical protocols performed during teeth extraction and also may be attributed to poor local anesthetic technique followed during injecting local anesthetic solution.[17]

In the present observational study sensory impairment in relation to PTTNwas more in males 60.4% as compare to females 39.5% in the age group of 41–60 years and 25–40 years and it is rare to best of our knowledge, only study done by Rai et al.male were more 55% in comparison to females 45% in 40–60 years of age group which was similar to our study.[18] In the literature available studies done by Kumar et al., Loh et al., and Katusic et al., confirmed the female dominance in age group of 40–60 years, which is found contradicting the present study.[14],[16],[19] Although most of the patients of both sex and in all age groups shows occurrence of PTTN cases 103, i.e. (79.2%) in lower jaw in comparison to upper jaw 21 cases of PTTN, i.e., (16.2%) reason may be due to lower impacted molars and in close proximity to lower nerves, like lingual nerve, inferior alveolar nerve, and branches of mandibular nerve. In the study done by Kumar et al. 96 (85.7%) of PTTN cases were present in lower jaw, data similar to the present study.[16] Most of the PTTN cases are detected in the right side quadrant of the jaw than in left quadrant of the jaw, anatomical reasons may be due to small foramen presents in the right side of the skull through which branches of mandibular nerve passes.[20] The present study states more involvement of right quadrant (upper/lower) of jaw 67.4% in comparison to left quadrant 32.5%, similar to the study done by Kumar et al., where right quadrant involvement was 57.1%.[16] The reported data of the present observational study suggested that may be poor surgical procedures were followed for dental extractions andpatients may have underwent surgical procedures by unqualified person (quack) for treatment due to lowsocio-economic background. This study also suggested the unilateral site of involvement rather than the bilateral jaw. In the present study, there is more predilections for male sex than female which is rare occurrence and lower jaw are more affected in both the sex despite of all age groups than the upper jaw.


   Conclusion Top


PTTN is most commonly occurring secondary to trauma mainly due to dental extractions with localized sensory defects of trigeminal nerve and its branches. Limitations of this study were small sample size and unicentric approach. Dental clinicians should do further research with large sample size and multicentric approach for poor surgical protocols followed in dental extraction which may lead to PTTN and also new medicinal regimes to alleviate the pain of TN that severely affect the quality of life of sufferingpatients. This multicentric approach can only be achieved by following proper standard surgical techniques and an aseptic environment during the dental extraction or any other orodental surgical procedure. This study also emphasizes on a healthy collaboration with Department of Neurology, Oral Medicine and Oral Maxillofacial Surgery for treating PTTN patients.

Acknowledgements

The authors would like to thank the study participants for their participation and kind cooperation throughout the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
Prasad S, Galetta S. Trigeminal neuralgia historical notes and current concept. Neurologist 2009;15:87-94.  Back to cited text no. 2
    
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Miles J, Eldrindge P. Trigeminal neuralgia. Br J Neurosurg 1998;12:288-9.  Back to cited text no. 4
    
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Siddiqui MN, Siddiqui S, Ranasinghe JS, Furgang FA. Pain management: Trigeminal neurlgia. Hosp Physician 2003:64-70. 64-70  Back to cited text no. 6
    
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Gupta A, Singh SK, Sahu R. Trigeminal neuralgia-A review. Available from: http://www.journalofdentofacialsciences.com2012;1:27-31. [Last accessed on 2019 Jun 04].  Back to cited text no. 7
    
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Ecker AD. The cause of trigeminal neuralgia. Med Hypotheses 2004;62:1023.  Back to cited text no. 8
    
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Bagheri SC, Farhidvash F, Perciaccante VJ. Diagnosis and treatment of patients with trigeminal neuralgia. J Am Dent Assoc 2004;135:1713-7.  Back to cited text no. 9
    
10.
Kaufmann AF, Patel M. Centre for cranial nerve disorders, Winnipeg, Manitoba, Canada. 2001. Available from: http://www.umanitoba.ca/cranial_nerves/trigeminal_neuralgia/manuscript/.  Back to cited text no. 10
    
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Cruccu G, Finnerup NB, Jensen TS, Scholz J, Sindou M, Svensson P, et al. Trigeminal neuralgia. New classification and diagnostic grading for practice and research. Neurology 2016;87:220-8.  Back to cited text no. 11
    
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Shahrokh CB, Farhidvash F, Perciaccante VJ. Diagnosis and treatment of patients with trigeminal neuralgia. JADA 2004;135:1713-7.  Back to cited text no. 12
    
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Sandstedt P, Sörensen S. Neurosensory disturbances of the trigeminal nerve: A long-term follow-up of traumatic injuries. J Oral Maxillofac Surg 1995;53:498-505.  Back to cited text no. 13
    
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Loh HS, Ling SY, Shanmuhasuntharam P, Zain R, Yeo JF, Khoo SP. Trigeminal neuralgia: A retrospective survey of a sample of patients in Singapore and Malaysia. Aust DentJ 1998;43:188-91.  Back to cited text no. 14
    
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Blackburn CW. A method of assessment in cases of lingual nerve injury. Br JOralMaxillofac Surg1990;28:238-45.  Back to cited text no. 15
    
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Kumar S, Kumar A, Rani V, Biswas NR, Kumar S, Sharma AK. Prevalence of post-traumatic trigeminal neuralgia (PTTN) in Dental OPD at tertiary care center, Bihar: A retrospective cross-sectional epidemiological study. Sch J App Med Sci 2017;5:626-31.  Back to cited text no. 16
    
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Peñarrocha M, Peñarrocha D, Bagán JV, Peñarrocha M. Post-traumatic trigeminal neuropathy. A study of 63 cases. Med Oral Patol Oral Cir Bucal 2012;17:e297-300.  Back to cited text no. 17
    
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Rai A, Kumar A, Chandra A, Naikmasur V, Abraham L. Clinical profile of patients with trigeminal neuralgia visiting a dental hospital: A prospective study. Indian J Pain 2017;31:94-9.  Back to cited text no. 18
  [Full text]  
19.
Katusic S, Beard M, Bergstralh E, Durland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol 1990;27:89-95.  Back to cited text no. 19
    
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Ahmed SS, Bey A, Hashmi SH. Trigeminal neuralgia-A neuropathic pain. Curr Neurobiol2011;2:75-9.  Back to cited text no. 20
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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