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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 152-156

A baleful combination of trigeminal neuralgia and menopause: An epoch of cognizant


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, Crawley WA, Australia

Date of Submission02-Nov-2020
Date of Decision18-Apr-2021
Date of Acceptance04-May-2021
Date of Web Publication23-Jun-2021

Correspondence Address:
Dr. Vishal Mehrotra
503-Twin Tower, Near Gurudev Palace, Kanpur, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_233_20

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   Abstract 


Introduction: Menopause is found to be associated with several adverse changes in the oro-facial complex, which may affect neural mechanisms because of attribution of the estrogen imbalance. Aim: The present study was conducted on female patients suffering from trigeminal neuralgia and was either in the peri-menopausal or menopausal age groups. The aim of the present study was to find out the incidence of trigeminal neuralgia in peri-menopausal and menopausal females. Material and Methods: In 2 years period, a total of 169 women patients with clinically diagnosed trigeminal neuralgia were included in the study. Based on neuralgic symptoms and gynecologist confirmation, selected patients were subdivided into groups based on age which were further subdivided into perimenopause and menopause. Collected data was tabulated and calculations were made with SPSS v21 and Chi-square test. Results: In the present study, 70.4% of patients were of 46–55 years of age which was the maximum proportion. Trigeminal neuralgia was more common in the age group of 46–55 years (82.2%), and the incidence of neuralgic pain was more common in the lower jaws (75.1%) and the right side of the face. In the present study, the lower jaw (79.8) was commonly involved as compared to the upper jaws in both perimenopausal (67.2%) and menopausal women (85.9%). Conclusion: This study stated that trigeminal neuralgia affects more commonly the older age group with a high incidence in postmenopausal women as compared to the perimenopausal women, where the lower jaw is more commonly affected in older and postmenopausal females.

Keywords: Females, menopause, perimenopause, trigeminal neuralgia


How to cite this article:
Mehrotra V, Sachdev R, Garg K, Saxena S, Sambyal S. A baleful combination of trigeminal neuralgia and menopause: An epoch of cognizant. J Indian Acad Oral Med Radiol 2021;33:152-6

How to cite this URL:
Mehrotra V, Sachdev R, Garg K, Saxena S, Sambyal S. A baleful combination of trigeminal neuralgia and menopause: An epoch of cognizant. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Jul 29];33:152-6. Available from: https://www.jiaomr.in/text.asp?2021/33/2/152/319066




   Introduction Top


Menopause, defined as the complete cessation of menstrual periods which occur naturally in most women resulting from the gradual loss of ovarian follicles. With the aging of the worldwide population in the coming decades, it is estimated that 1.2 billion women worldwide will be menopausal or postmenopausal by the year 2030.[1] The term “Perimenopause” is defined as the years leading to menopause which usually occur to begin during 30s and 40s and is due to the result of fluctuations in secretion of estrogen by the ovaries.[2]

Menopause is found to be associated with significant adverse changes in the oro-facial complex, which are attributed to the estrogen, which affects oral mucosa directly or through the neural mechanism, thus altering the periodontal health in menopausal women.[3] Oral cavity problems may include a paucity of saliva leading to xerostomia, burning mouth syndrome, increase in the incidence of dental caries, dysesthesia, alterations in taste (dysgeusia) and breath, swallowing difficulties, facial or dental pain, atrophic gingivitis, periodontitis, and osteoporotic jaws.[4],[5]

Trigeminal neuralgia_(TN) is a sudden, severe, stabbing, recurrent, and usually unilateral pain in the distribution of one or more branches of the fifth cranial nerve. Some patients may have a background dull aching pain after the main attack. It is seen more in women than men and affects usually between the fifth and eighth decade of life.[6] The present study is a pioneer cross-sectional study carried on diagnosed cases of trigeminal neuralgia in women to find the incidence of trigeminal neuralgia in perimenopausal and menopausal women.


   Subjects and Methods Top


This was a cross-sectional, descriptive-analytic study carried out from August 2018 to January 2020 in Dental College, Kanpur. Ethical clearance was obtained from the Institutional Ethical Committee with the ethical clearance number RDC/ESIT/2018/1908 to undertake the study, and informed verbal consent was taken from the patients. The total numbers of study patients were taken from the patients reported in an outpatient department within the study period duration. Sample size estimation was based on formula n = Z2S2/d2, with a standard deviation of 2.5 with an acceptable error of 0.6 P value of 0.05 at Zα=1.96 at 5% level of significance; hence, a total of 169 women patients were included in the study with clinically diagnosed trigeminal neuralgia. These selected patients were divided into two groups based on their age; the first group consisted of patients aged between 35 and 45 years and the other group consisted of women in the age group of 46–55 years. These patients were further subdivided into perimenopause and menopause (based on the consultation and as confirmed by the gynecologist). The sample size was calculated based on the patients visiting the dental outpatient department with clinically diagnosed trigeminal neuralgia. Neuralgic pain criteria as specified in the classification on A.F. Kaufmann and M. Patel: Centre for cranial nerve disorders, Winnipeg, Manitoba, Canada (2001)[7] and International headache society guidelines for symptomatic trigeminal neuralgia were followed as diagnostic criteria for TN.[8]

Statistical analysis

Collected data were analyzed using IBM SPSS Statistics-version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Descriptive statistics included the calculation of percentages. Categorical data were compared using the Chi-square test. All values were considered statistically significant for a value of P < 0.05.


   Results Top


In the present study, all selected patients were divided into two groups depending on their age: 35–45 years and those in the range of 46–55 years. These patients were subdivided into perimenopause and menopause groups. The highest proportion of patients was between 46 and 55 years of age (70.4%), while 29.5% were aged between 35 and 45 years [Table 1], [Graph 1]. Out of the total number of trigeminal neuralgia patients with a positive history of attaining menopause (n = 169), it was found that trigeminal neuralgia was more common in the age group of 46–55 years (82.2%) as compared to 30 patients in the age group of 35–45 years (17.7%). It was also found that the incidence of neuralgic pain was more common in the lower jaws (75.1%) as compared to the upper jaws (24.8%) in both age groups with no significance for P value. There was no single case reported in which both the jaws were affected by trigeminal neuralgia in both the age groups [Table 2], [Graph 2].
Table 1: Demographic distribution of females (n=169)

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Table 2: Jaw wise distribution of patients (n=169)

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In the present study, [Table 3] [Graph 3] indicate that out of the total number of trigeminal neuralgia patients, the most common affected side of the face was the right side, a total of 27 (15.9%) cases in the age group of 35–45 years and 114 (67.4%) in the age group of 46–55 years about the right side of the face and P value came significant. In the present study, only those women patients were included who gave a positive history of trigeminal neuralgia and were either in a perimenopausal or menopausal state. It was reported that the lower jaw (79.8) was commonly involved as compared to the upper jaws in both perimenopausal (67.2%) and menopausal attained women (85.9%) [Table 4], [Graph 4]. It was found in the current study that trigeminal neuralgia affected 39 (70.9%) cases in perimenopausal and 95 (83.3%) in a menopausal group for the right side of the face with P value came as 0.0618 [Table 5], [Graph 5].
Table 3: Trigeminal neuralgia and involvement of the side of the face (n=169)

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Table 4: Jaw wise distribution of perimenopausal and menopausal females

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Table 5: Trigeminal neuralgia affecting the side of the face in perimenopausal and menopausal females

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   Discussion Top


Menopause means “without estrogen” and is, by definition, the time at which cyclic ovarian function, as manifested by menstruation, ceases. Menopause results in various physiologic changes and endocrinological alterations with atrophy of epithelial lining the vagina and the urinary tract. There is also a decrease in estrogen levels increasing the risk of developing heart disease and osteoporosis in menopausal and postmenopausal women.[3]

Menopause also affects oral and dental structures. Gingival tissues exhibit decreased epithelial keratinization of marginal gingiva and desquamation of gingival tissues. Postmenopausal women were found to have a higher risk of developing osteoporosis resulting in periodontal diseases and limitations of dental treatments.[3] As for saliva, the flow rate is decreased initiating a state of xerostomia, oral discomfort, burning mouth syndrome, and high DMFT (decayed, missing, and filled teeth) scores due to a decrease in the pH levels.[4] Bullon et al.[9] in 2007 stated that for all postmenopausal women, a thorough clinical investigation followed by detailed oral examination is essential; this includes the periodontal and dental status and salivary flow for both quality and quantity. The dental practitioner can play a pivotal role in the management of postmenopausal women by recognizing and treating the oral complications seen in association with menopause.[10]

Trigeminal neuralgia presents with sudden and severe lancinating pain that usually lasts few seconds to minutes, within the distribution of the trigeminal nerve, mostly the mandibular or maxillary branches. The diagnosis of trigeminal neuralgia is mostly based on the history and clinical findings. Pain is often evoked by trivial stimulation in the “trigger zones.”[11]

Diagnostic criteria for classic trigeminal neuralgia[11]

  • Sudden and severe lancinating pain which is paroxysmal
  • Pain lasts a fraction of a second to minutes that affect one or more divisions of the trigeminal nerve
  • Pain has at least one of the following characteristics intense, sharp, superficial, or stabbing precipitated from trigger areas or by trigger factors
  • Attacks are similar in individual patients
  • No neurological deficit is clinically evident
  • Not attributed to another disorder.


The years leading to menopause are called perimenopause. Beginning during the 30s and 40s, the amount of estrogen secreted by the ovaries starts to fluctuate. This results in changes in the menstrual cycles' duration and also the amount of flow. The cycles may become too long, too short, or may even skip and the amount of flow may range from lighter to heavier.[2] Menopause is the time in female life when there is a natural stop in having menstrual periods. The etiology behind this is the absence of production and secretion of estrogen by the ovaries. Menopause marks the end of the reproductive years.[2] Menopause in women is a physiological state that gives rise to adaptive changes at both systemic and oral levels.[3]

Various potential biological mechanisms have been stated in literature in context to the high prevalence of pain in women; these include chromosomal differences and sexual hormone involvement in sensory perception.[12],[13] Hormones such as estrogen and progesterone play an important role in neuromodulation, and fluctuations in their levels during the menstrual cycle are associated with the neurogenic inflammation of migraine.[14],[15]

Besides other chronic pain syndromes such as irritable colon syndrome, subtypes of TMJ disorders other primary headaches, and fibromyalgia are at least in part modulated by neural inflammatory mechanisms.[16] Estrogen receptors are present in the cardiovascular, immune, musculoskeletal, and neural systems, which include the spinal sensory ganglions, the trigeminal complex, and the sensory and limbic cortexes.[17] They can be down- or upregulated by several substances, including cytokines and inflammatory mediators such as IFNγ and neurotrophins, which are involved in chronic pain mechanisms, facilitating peripheral and central hyperalgesia by neuroplasticity mechanisms that spread the pain.[14] Apart from psychological issues, there is strong evidence supporting that the neurobiological factors involved in sensory sex differences and female hormones are pain and neuronal modulators with a neurotrophic role.[18]

It was found that trigeminal neuralgia was more common in the older age group of 46–55 years (70.4%) as compared to the younger age group of 35–45 years (29.5%) with significant P values. This signifies that the incidence of trigeminal neuralgia is more common in the elderly age group. This finding was consistent with the results obtained from the study conducted by Rehman A et al.[19] who reported that trigeminal neuralgia affects older individuals more commonly than the younger individuals with the peak age of onset is between the fifth and sixth decade of life.

There was an increased incidence of neuralgic pain in the lower jaws (75.1%) as compared to the upper jaws (24.8%) in both the age groups and not a single case of both the jaws were affected by trigeminal neuralgia in both the age groups. These results were similar to the one obtained in the studies conducted by Bangash T.H. and Shah et al.[20],[21] In the literature it has been stated that the right side of the face is more commonly affected than the left (ratio of 1. 5:1), possibly because of the narrower foramen rotundum and foramen ovale on the right side.[22],[23]

Similarly, a high incidence of lower jaw involvement was seen in women in perimenopausal and menopausal stages. With more incidence found in menopausal stage with a significant P value, substantiating the above finding that trigeminal neuralgia affects more commonly in the elderly age group was similar to the one found in the study conducted by Wardrop et al.[24] in postmenopausal women aged 30–63 years and receiving treatment for control of the symptoms. They stated that 33% of women in the postmenopausal state have various neurological symptoms including the burning mouth. The results were consistent with the results found in our study where the elderly age group (46–55 years) was more affected with trigeminal neuralgia than the younger age group (35–45 years). They further noted the prevalence of oral discomfort in postmenopausal women to be 46%, when compared to 6% for premenopausal women.[24] These results were also similar to the one in our study where postmenopausal women are more affected with trigeminal neuralgia than premenopausal women.

Limitations and future prospects

Although in the present study the sample size was small, thus in the future, further studies with a larger sample size and in collaboration with a gynecologist are required to find out the prevalence of trigeminal neuralgia in perimenopausal and menopausal women.


   Conclusion Top


To deliver high-quality care, dental practitioners need to be knowledgeable about menopause and its oral manifestations as a possible risk factor for increasing oral health problems. Current demographic trends in the Indian female population underscore this need. Dental practitioners can play a vital role in meeting the oral health needs of the menopausal patient by early diagnosis, treatment planning, and patient education. Further research is however indicated to corroborate the findings of this study, determine causes, and investigate to improve the knowledge levels to a further extent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors would like to thank all the patients and their families 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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World Health Technical Report Series. Research on the Menopause in the 1990's. Geneva, Switzerland: World Health Organization; 1996. Available from: https://apps.who.int/iris/handle/10665/41841 [Last accessed on 2020 Jan 20].  Back to cited text no. 1
    
2.
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Santosh P, Sinha N, Kaswan S, Rahman F, Bharati D, Ashok KP. Oral findings in postmenopausal women attending dental Hospital in Western part of India. J ClinExp Dent 2013;5:e8-12.  Back to cited text no. 3
    
4.
Cao M, Shu L, Li J, Su J, Zhang W, Wang Q, et al. The expression of estrogen receptors and the effects of estrogen on human periodontal ligament cells. Methods Find Exp Clin Pharmacol 2007;29:329-35.  Back to cited text no. 4
    
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Friedlander AH. The physiology, medical management and oral implications of menopause. J Am Dent Assoc 2002;133:73-81.  Back to cited text no. 5
    
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Goto F, Ishizaki K, Yoshikawa D, Obata H, Arii H, Terada M. The long lasting effects of peripheral nerve blocks for trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine. Pain 1999;79:101-3.  Back to cited text no. 6
    
7.
Kaufmann AM, Patel M. Your complete guide to trigeminal neuralgia (2001). Available from: http://www.umanitoba.ca/cranial_nerves/trigeminal_neuralgia/manuscript/. [Last accessed on 2020 Jan 20].  Back to cited text no. 7
    
8.
Headache Classification Committee of the International Headache Society (IHS). The International classification of headache disorders, 3rd edition (beta Version). Cephalalgia 2013;33:629-808.  Back to cited text no. 8
    
9.
Bullon P, Chandler L, Segura Egea JJ, Perez Cano R, Martinez Sahuquillo A. Osteocalcin in serum, saliva and gingival crevicular fluid: Their relation with periodontal treatment outcome in postmenopausal women. Med Oral Patol Oral Cir Bucal 2007;12:E193-7.  Back to cited text no. 9
    
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Hariri R, Alzoubi EE. Oral manifestations of menopause. J Dent Health Oral Disord Ther 2017;7:00247.  Back to cited text no. 10
    
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Sadat SMA, Sultana A, Rita SN, Khan MR. Trigeminal neuralgia: Report of a case and literature review. Med Today 2014;26:66-8.  Back to cited text no. 11
    
12.
Klatzkin RR, Mechlin B, Girdler SS. Menstrual cycle does not influence gender difference in experimental pain sensitivity. Eur J Pain 2010;14:77-82.  Back to cited text no. 12
    
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Greenspan JD, Craft RM, LeResche L, Arendt-Nielsen L, Berkley KJ, Fillingim RB, et al. Studying sex and gender difference in pain and analgesia: A consensus report. Pain 2007;132:26-45.  Back to cited text no. 13
    
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Tommaso M. Pain perception during menstrual cycle. Curr Pain Headache Rep 2011;155:400-06.  Back to cited text no. 14
    
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Hellstrom B, Anderberg UM. Pain perception across the menstrual cycle phases in women with chronic pain. Percept Mot Skills 2003;96:201-11.  Back to cited text no. 15
    
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Martin VT. Ovarian hormones and pain response: A review of clinical and basic science studies. Gend Med 2009;6:168-86.  Back to cited text no. 16
    
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Craft RM. Modulation of pain by estrogens. Pain 2007;132:s3-12.  Back to cited text no. 17
    
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Alves B, Ibuki F, Gonçalves AS, Teixeira MT, Tesseroli De Siqueira SRD. Influence of sexual hormones on neural orofacial perception. Pain Medi 2017;18:1549-56.  Back to cited text no. 18
    
19.
Rehman A, Abbas I, Ali Khan S, Ahmed E, Fatima F, Anwar SA. Spectrum of trigeminal neuralgia. J Ayub Med Coll Abbottabad 2013;25:168-71.  Back to cited text no. 19
    
20.
Shah SA, Murad N, Sallar A. Trigeminal neuralgia: Analysis of pain distribution. Pakistan Oral and Dent J 2008;28:37-41.  Back to cited text no. 20
    
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Bangash TH. Trigeminal neuralgia: Frequency of occurrence in different nerve branches. Anesth Pain Med 2011;1:70-2.  Back to cited text no. 21
    
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Rabinovich A, Fang J, Scrivani SJ. Diagnosis and management of trigeminal neuralgia. Editor Board 2000;5:4-7.  Back to cited text no. 22
    
23.
Cruccu G, Biasiotta A, Galeotti F. Diagnosis of trigeminal neuralgia: A new appraisal based on clinical and neurophysiological findings. In: Cruccu G, Hallett M, editors. Brainstem Function and Dysfunction. Amsterdam, the Netherlands: Elsevier; 2006. p. 171-86.  Back to cited text no. 23
    
24.
Wardrop RW, Hailes J, Burger H, Reade PC. Oral discomfort at 18 menopause. Oral Surg Oral Med Oral Pathol 1989;67:535-40.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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