Candidate Information
Theme: History
Patient demographics:
Name | Peter McKay |
Age | 16/11/1947 (72 years’ old) |
Gender | Male |
Employment | n/a |
Pertinent Social History | None |
Pertinent Medical History | None |
Pertinent Dental History | None |
Scenario
You have been asked to see this patient with jaw pain
Listen to the patient’s history and explain management options available.
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Trigeminal neuralgia (TN), also known as tic douloureux, is a debilitating condition characterised by intense facial pain. Dental practitioners hold a crucial role as the initial point of contact for patients, necessitating accurate diagnosis and effective management of TN. The review encompasses various aspects of TN, ranging from its presentation and classification to diagnosis and available treatment options.
TN is a neurological disorder distinguished by sudden, excruciating, and transient shock-like facial pain localised to the distribution of the trigeminal nerve. Classical TN (CTN) commonly exhibits pain triggers such as mastication, touch, tooth brushing, eating, talking, and exposure to cold wind, while hair combing typically does not elicit pain. Pain predominantly occurs along the Trigeminal V2 and V3 branches, and trigger zones manifest in over 90% of patients. Although pain may manifest on either side of the face, the right side is more frequently affected.
Classification: The classification of trigeminal neuralgia has undergone significant revisions in recent years. According to the third edition of the International Classification of Headache Disorders (ICHD-3), TN is now categorised into three distinct types: classical, secondary, and idiopathic.
Healthcare providers must differentiate between these TN types due to potential variations in management approaches.
Carbamazepine (CBZ) is the drug of choice. Additionally, alternative therapeutic interventions, such as local anaesthetic injections and botulinum toxin A injections can be utilised. Surgical options, including percutaneous procedures and microvascular decompression, are potential alternatives for patients unresponsive to or intolerant of medication.
Other disorders that can mimic TN symptoms, include painful trigeminal neuropathy, Herpes Zoster infestation, chronic paroxysmal hemicrania, Tolosa-Hunt syndrome, migraine, cluster headache, and glossopharyngeal neuralgia.
Diagnostic approaches for TN, include the patient’s history, thorough physical and neurological examination, and utilisation of neurophysiological tests and imaging techniques such as MRI/MRA.
Carbamazepine (CBZ), as the drug of choice for TN, alternative medications, such as oxcarbazepine (OXC), pregabalin, gabapentin, topiramate, levetiracetam, and valproic acid, for patients unresponsive to or intolerant of CBZ.
Non-pharmacological interventions, includes local anaesthetic injections (alcohol, glycerol, phenol, tetracaine, or bupivacaine) and botulinum toxin A injections, as potential options for pain relief.
Surgical procedures, include percutaneous trigeminal ganglion balloon compression rhizotomy, percutaneous radiofrequency gangliolysis, trigeminal ganglion compression, retrogasserian glycerol rhizolysis, microvascular decompression (MVD), stereotactic radiosurgery, and peripheral neurectomy, as alternative approaches for patients who do not respond to conservative management.
What distinguishes Trigeminal Neuralgia (TN) from other facial pain conditions?
Which type of TN is characterised by recurrent, unilateral facial pain along the trigeminal nerve’s distribution with pain-free intervals between episodes?
What is the main difference between CTN and STN?
Which medication is considered the drug of choice for TN?
In addition to Carbamazepine, which non-pharmacological intervention is used as a potential option for pain relief in TN?
Which condition is often mistaken for TN and may present with similar symptoms?
What is a key step in diagnosing TN?
What type of imaging technique is commonly used to aid in the diagnosis of TN?