Clinical Presentation of Various Cases of Trigeminal Neuralgia in Tertiary Care Hospitals

Clinical Presentation of Various Cases of Trigeminal Neuralgia in Tertiary Care Hospitals
Jehan Alam1, Kashif Ali Channar2, Noor ulWahab3, Abdul Qadir Dal4, Riaz Ahmed warriach5, ZafarAli Khan6

How to CITE:

Alam J, Channar K A,Wahab N U, Dal A Q,Warriach R A, Khan ZA. Clinical presentation of various cases of trigeminal neuralgia. J Pak Dent Assoc 2012, 20 (02), 85 – 89


The objective of this studywas to evaluate themajor clinical findings of trigeminal neuralgia.


This was a Descriptive Case Series. The cases were selected from OPD of oral/maxillofacial surgery department Mayo hospital Lahore from 1st April 2006 to 30th July 2009, Jinnah Postgraduate edical Centre Karachi from 1stAugust 2009 to 30th January 2011, and Liaquat university ofMedical and Health Science Jamshoro from 1st February 2010 to 5th June 2011 after taking written approval fromMedical ethical board of the concerned hospitals. Patient with Age 20 years to 80 years, irrespective of gender and Trigeminal neuralgia involving mandibular andmaxillary branches of trigeminal nerve were the inclusion criteria and Exclusion criteria wereTrigeminal neuralgiawith secondary causes tumors,multiple sclerosis) and Patients having other neuralgia in associationwith trigeminal neuralgia


ATotal number of 180 patients of TN reported during the study period. The average age of patients was 64years ( 11.45). Themost common age group for TNwas 60-80 years in our study. Female tomale ratio was 1.6:1.Mandibular branch is involved in 63.3%cases andmaxillary branchwas involved in 36.7%cases.The ratio of mandibular nerve andmaxillary nerve involvedwithTNwas 1.72:1


From available data we conclude that TN is common in female patients above 60 years of age. The most frequently affected nerve was the mental nerve.Right side involvement was four times greater than left.


Trigeminal neuralgia,mental nerve, inferior alveolar nerve, infra-orbital nerve.


TrigeminalNeuralgia is themost painful conditions of trigeminal nerve . It is characterized by brief electric shock like unilateral pain lasting fromfew seconds to less than two minutes in the distribution of one or more divisions of the trigeminal nerve. TN can be diagnosed by history and clinical examination. Radiographic assessment is necessary to identify any intracranial pathology . Pain is evoked by certain stimuli like washing, shaving, talking, yawning, smoking and brushing the teeth, and/or may also occur spontaneously. The pain usually appears as sudden shooting or stabbing. The onset and termination of pain is abrupt and may remit for varying periods. Attacks may occur during the day or night but rarely during sleep. Frequency of attack also varies, sometimes it may be once a day, once a month and in some cases it may be several attacks in a day or a week .Theremay be no pain for a prolonged period of time. The pain is very cruciating and causes disturbance in daily routine . Pain is almost unilateral in 97% cases, affecting maxillary and mandibular branches, In few cases (<5%), ophthalmic division is affected . LocalAnesthetic block at different location of nerve distribution is usually used to identify specific nerve involvement The prevalence ofTrigeminalNeuralgia is 0.1-0.2 per thousand and over all incidence is about 4-5/100,000/year and after the age of 60 up-to 20/100,000/year. The female to male ratio is 3:2. The right side of the face is 5 times more commonly involved than the left. It is typically idiopathic but may be due to structural lesions. No racial risk factors have been reported The purpose of this study was to evaluate the major clinical features of a consecutive series of cases of TrigeminalNeuralgia


The cases were select ed from OPD of oral/maxillofacial surgery department Mayo hospital Lahore from 1st April 2006 to 30th July 2009, Jinnah Postgraduate Medical Centre Karachi from 1st August 2009 to 30th January 2011, and Liaquat university of Medical and Health Science Jamshoro from 1st February 2010 to 5th June 2011 after takingwritten approval from Ethical medical board of each hospital. Patient with Age 20 years to 80 years, irrespective of gender, patients suffering from TN involving mandibular and maxillary branches were included in the study, patients having TN due to any secondary causes or in association to other neuralgia were excluded. An informed written consent was obtained from patients for participation in this study. The demographic information like age, gender and address were obtained. 2% lidocaine was injected around the TN at different locations to localize the branch involved with neuralgia. Routine investigations and radiographs like OPG and P-A face were done preoperatively. Radiographic imaging was carried out to exclude local pathology. Patient’s record was entered in proforma.

The collected data was entered and analyzed by SPSS version 16. Descriptive statistics were calculated for Variables included demographics (age, gender), site of pain (Right or left) and distribution of nerve involvement. Mean and standard deviationwas calculated for age.


A total number of 180 patients of TN reported at Oral/Maxillofacial Surgery Department of Mayo hospital,Department of Dentistry JPMC,Karachi and Oral/Maxillofacial Surgery Department of Liaquat University of Medical & Health Sciences Jamshoro during the study period andwere treated for the same.

The patients were divided into three groups. 8.3% (n=15) Patients were recorded in 1st group (20-49 years). 38.3% (n=69) patients were recorded in 2nd group (50-59 years). 53.3% (n=96) patients were recorded in 3rd group (60-80 years).Average age of patients were 64 years SD = 11.45. The most common age group for TN was 60-80 years in this study (Table no I).

38.3% (n=69) were Male and 61.7 %. (111) were female patients .TN was common in female patients. Female to male ratiowas 1.6:1 (Figure no I).

Patientswere divided into three groups on the basis of nerve branch involved. Mental nerve was involved in 45 % (n=81). Infraorbital nerve was involved in 36.7% (n=66) and inferior alveolar nerve was involved in 18.3 %( n=33) patients. Thus mandibular branch (V-III) was involved in 63.3% cases and maxillary branch (V-II) was involved in 36.7% cases. The ratio of mandibular nerve and maxillary nerve involved with TN was 1.72:1(Figure no II).

TN affected right side in 78.3% (n= 141) patients and left side in 21.7 % (n=39) patients. The right to left side ratio is 3.61:1 (Table no 2).


Trigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterized by severe, paroxysmal pain in the face. Little is known about the process in treatment of TN, and management with ntiepileptic drugs or surgical procedures carries risks of side effects, recurrence and complications.

The predominant age group in our study was 60 to 80years with mean of 63.9 years. This age group relates to john Fothergill statement that TNis the disease of elders. Scrivani SJ et al in their study noted the average age was 61 years in patients having TN. Ali K et al in their study noted the average age was 58 years, which relates to our study. Warraich RA et al in their study noted that the majority of patients having TN were between 50 to 70 years age. Erdem and Alkan in their study noted that patients with TN were 61 to 70 years age. LIU Hong-bing et al in their study of 276 patients reported TN patient between 65 and 32 years of age. Niall M et al noted in their study, themedian age at diagnosiswas 63 years, with a range of 29 to 88 years. Lee ST and Chen JF in their study of 80 patients (33 males and 47 females) reported patients in the range of 45 to 86. In 2006, Gorgulho et al in their study; patients with TN having mean age; 64.4 years (29-84 years). Spatz .L.Aet al in their study of 56 patients, ranged from 25-85 years with a mean age of 62.02 years. All studies mentioned above and this study show that this disorder occurs in elderly group of patients.

It appears from this study that females are suffering more from TN as compared to male. The female to male ratio in this studywas 1.6:1which is similar/near to results observed in studies conducted by Rana ZA1,Merrison FA et al , Zakrzewska JM et al , Warraich RA et al , Gorgulho et al and Cheshire w. Niall M et al in their study of 67 patients, 30 (45%) were men and 37 (55%) women, giving a gender ratio of 1:1.19 (men:women) . Erdem and Alkan in their study of 157 patients 92(58.59%) were female and 65(41.40%) male patients with TN. The female to male ratio was 1.415:1.15. All these studies favourably support this study, that TN is more common in female.

Trigeminal neuralgia ismore common on right side as compared to the left side. Mason DA observed in his study that 71% patients affected with TN, were involving the right side. Apfelbaum RI reported in his tudy that Right sidewas involved in 61% patients, Left side in 37%, both in 2%. Erdem and Alkan reported in their study of 157 patients, 112 patients have right side involvement and 45 patients left side. White and Sweet reported rightsided pain in 61%, left-sided in 36%, and bilateral in 4% patients. In this study we also observed that right side involvement is higher as compared to left sidewith ratio of 3.61:1 Neto HS et al in their hypothesis stated, and confirmed by anatomical and radiographical findings that foramen ovale and foramen rotundum are narrower on the right side compared to the left cranial fossa.Additionally, vascular compression in asymptomatic patients and inTN patientswithout aberrant blood vessels has been reported, thereby arguing against the idea that vascular compression alone is responsible for TN. However this requires further work up, as the data regarding this is insufficient to prove this hypothesis.

MelahatO et al in their study of 47 patients observed that the maxillary branch of the trigeminal nerve was involved in 11 patients (23.4%), whereas mandibular branch involvement was observed in 20 patients (42.5%). Sixteen patients (34%) had pain in more than one branch of the trigeminal nerve. NiallMet al1 in their study of 67 patients also noted that mandibular branch was involved more in TN. In this study the mandibular branch was also involved more than the maxillary branch which supports the studies reported above.

In this study patients were divided into three groups according to the type of nerve branch involved. Mental nerve was involved in 81 (45%). Infra-orbital nerve was involved in 66(36.7%) and inferior alveolar nerve was involved in 33(18.3%) patients. The V-II branch was involved in 66 (36.7%) cases and V-III in 114(63.3%). LIU Hong-bing et al in their study have 276 patients, 73 had 2nd branch involvement and 68 had third branch, 3 had 1st branch, Warraich RA et al in reported equal distribution of cases with V-II and V-III nerve involvement, whereas Sohail et. al . also observed similar results In this study mandibular branch is involved more frequently which relates to other studies listed above. It might be true due to the pattern of presenting their complaints to the concerned specialists . It has been observed by Loh H. S in 1998 , that it is highly likely that patients with maxillary or other craniofacial pain would consult physicians or ENT surgeons, believing the nature of problem is to be medically related. The reverse is also true that any mandibular pain may be perceived to be dentally related and therefore those afflicted would consult a dental surgeon.

The only limitation of our study was elucidating the proper history of pain because of linguistic problemas the study was carried out in Lahore, Hyderabad and Karachi needed language translators Trigeminal neuralgia is the disease of clinical diagnosis; there are no definite investigations. In our study we only focused on the clinical presentation of trigeminal neuralgia in order to rule out the other causes of orofacial pain (the management of these cases will be presented in next article).

This study is helpful in early diagnosis of the patients having orofacial pain, mimicking trigeminal neuralgia to lessen the medicine load and improving the functional / social life of individuals havingTN.


From available data we can conclude that TN is more common in female patients above the age of 60 years. The most frequently affected nerve was the mental nerve. Right side involvement was greater than left side of the face.Our study concludes that TNhas typical presentation and can be easily diagnosed by interpreting the characteristic features.


1. Rana ZA, Malik AM, Rana IZ, Aggrevating and relieving factors in Trigeminal neuralgia: PIMS
Experience.Ann Pak InstMed Sci 2005; 1: 32-6.
2. Scrivani JS, Mthews SE, Maciewicz JR. Trigeminal neuralgia.Oral SurgOralMedOral PatholOral Radiol
Endod 2005; 100: 527-538.
3. Meaney JF, Watt JW, Eldridge PR, Whitehouse GH, Wells JC, Miles JB. Association between trigeminal
neuralgia and multiple sclerosis: role of magnetic resonance imaging. J Neurol Neurosurg Psychiatry
1995; 59: 25-39
4. Nurmikko TJ, Eldridge PR. Trigeminal neuralgiapathphysiology, diagnosis and current treatment. Br J
Anaesth 2001; 1: 117-132.
5. Cole CD, Liu JK, Apfelbaum RI. Historical perspectives on the diagnosis and treatment of
trigeminal neuralgia.Neurosurg Focus 2005; 18:E4.
6. KugelbergE, indblomU.Themechanismof the pain in trigeminal neuralgia. J Neurol Neurosurg Psychiatry
1959; 22: 36-44
7. Chapman N. Remarks on tic douloureux; with cases. AmJMed Sci 1834; 14: 289-301
8. Lehri IA, Baloch MR. Trigeminal neuralgiadistribution of pain and nerve involvement. Med
Channel 2004; 10: 21-23.
9. Tiffany LM. Intracranial operations for the cure of facial neuralgia.Ann Surg 1896; 19:47-58
10. Merrison FA, Fuller G, Treatment options for trigeminal neuralgia. BrMed J 2003; 327: 1360-1361.
11. Fothergill J.Of a painful affection of the face,Medical Obs. Soc. Phys.London; 1773.5:129-142.
12. Barnard D, Lloyd J, Evans J. Cryoanalgesia in the management of intractable facial pain. J Oral
Maxillofac Surg 1981; 9: 10-12.
13. Ali K, Rashid N, Yusaf H. Efficacy of glycerol injection in the management of idiopathic TN. Pak
OralDent J 99; 19:10-16
14. Warraich RA, Saeed M, Cheema SA. Intractable TN; Comparison of neurectomy with cryosurgery as a
treatment option.The Prof 2001;8: 257-262
15. Erdem E, Alkan A, Peripheral Glycerol Injections in the Treatment of Idiopathic Trigeminal Neuralgia: Retrospective Analysis of 157 Cases. J Oral Maxillofac Surg 2001; 59:1176-1179
16. Hong-bing LIU,YiMA, Jian-jun ZOU , Xin-gang LI; Percutaneous microballoon compression for
trigeminal neuralgia. ChinMed J 2007; 120:228-230
17. Niall MH, Patton DW, Southampton, Swansea. Peripheral alcohol injections in the management of
trigeminal Neuralgia. Oral Surg OralMed Oral Pathol Oral RadiolEndod 2007; 104: 411-415
18. Lee ST, and Chen JF Percutaneous Trigeminal Ganglion Balloon Compression for Treatment of
Trigeminal Neuralgia, Part II: Results Related to Compression Duration. Surg Neurol 2003; 60: 149-154
19. Gorgulho A, Antonio AF, Salles D, Arthur DM. Brainstem and trigeminal nerve changes after
radiosurgery for trigeminal pain. Surgical Neurology 2006; 66: 127-135
20. SpatzAL, Zakrzewska JM, Kay EJ. Decision analysis of medical and surgical treatments for trigeminal
neuralgia: How patient evaluations of benefits and risks affect the utility of treatment decisions; Pain 2007; 131: 302-310
21. Cheshire W. Trigeminal neuralgia: diagnosis and treatment. CurrNeurolNeurosci Rep.2005; 5:79-85.
22. Mason DA: Peripheral neurectomy in the treatment of trigeminal neuralgia of the second and third division. J Oral Surg 1997; 30:11-13
23. Apfelbaum R.I Comparison of the long-term results of microvascular decompression and percutaneous
trigeminal neurolysis for the treatment of trigeminal neuralgia. International Congress Series 2002; 1247: 62943 C, Sweet WH. Pain and the Neurosurgeon. Springfield, IL: CharlesC.Thomas; 196-199
25. Neto HS, Camilli JA, Maques MJ. Trigeminal neuralgia is caused by maxillary and mandibular nerve entrapment: Greater incidence of right-sided facial symptoms is due to the foramen rotundum and foramen ovale being narrower on the right side of the cranium; JMehy 2005; 65: 1179-1182.
26. Toller MO, Uzen E, Incesu L. Clinical and magnetic resonance imaging evaluation of facial pain.; Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97: 652-658
27. Hong-bing LIU, Yi MA , Jian-jun ZOU, Xin-gang LI. Percutaneous microballoon compression for
trigeminal neuralgia. ChinMed J 2007; 120: 228-230 28. Sohail A, Saeed M, Qazi SR. Efficacy of peripheral glycerol injection in the management of TN. Pak Oral Dent J 2006; 26: 93-96
29. Loh.HS.Ling SY.Zain R.Yeo JF.Trigeminal neuralgia. A retrospective survey of a sample of patients in Singapore and Malaysia. Australian Dental Journal 1998; 43;3: 188- 191