Brushing Technique

01:40 abrasion, bass, charter, circular, erosion, fones, rolls, scrub method., stillman, tooth brushing technique, tooth paste 33 Comments

TOOTH BRUSHING TECHNIQUES:- One of the major cause of tooth abrasion is the wrong brushing technique that many of the people use daily.some techniques are mentioned here to make people aware of the common techniques one should use.
The best technique is the "ROLL TECHNIQUE" TECHNIQUES for Children up to 9 years:Scrub technique advised .Normally the Scrubbing technique is advised for very young children; brush for at least 2 minutes; always use tooth brush with soft bristles and fluoridated, flavoured toothpaste. A tooth brush with hard bristles can cause gum recession(i.e. they will recede and move backward) and if used with an abrasive toothpaste, can cause tooth abrasion(loss of tooth substance)

Children 10-15 years: Bass Technique is advised-Directly push the filaments toward roots of teeth at 45 degree angle, press lightly but not enough to bend filaments of brush and gently, brush forward and backward in short vibratory movement, attempting to press into gums margin ; brush for at least 3 minutes; use soft toothbrush with fluoridated toothpaste Adults: Soft or medium toothbrush & fluoridated paste.

Several techniques can be used :
 Modified bass technique: add circular movement which will cover gum as well as tooth surface. It massages the gums .
Roll technique: Position your tooth brush as in bass technique , then roll downwards over tooth surface, away from gum margins. Lift the brush, position it and repeat.it is the most commonly used method, it is an easy method but it neglects the gum margins.
Stillman technique: Position your tooth brush as in bass technique, press the filaments of your tooth brush till the gum blanches, turn your wrist through an angle of 45 degree and proceed to vibrate and roll against each tooth. Wrist movement is required; it is an unpopular technique because it is difficult. Also the gum margin is often ignored.
Fones technique (circular method): Brush is placed perpendicular to teeth. Large circular motion of brush over clenched teeth to simultaneously cover both upper and lower teeth.A soft tooth brush is used.it was Previously popular but is not advised nowadays as it has proven to cause tooth abrasion Charter’s method: Brush is angled 45 degree downwards, with half the bristles of the brush over the gum and half over the crown. Vibratory movement along with a circular motion is done.
Modified Charter’s method: Modification is to include occlusal surfaces(i.e bitting surfaces). Both these are difficult to learn, hence unpopular

Read More

Extraction Socket Healing

01:27 bone, buccal walls, Extraction, healing, necrosis, oral; surgery, osteoblast, osteoclast, wound 12 Comments

Tissue taken from a socket 3 days after tooth extraction was comprised of a fibrin clot
partially infiltrated with inflammatory cells, which were loosely organized and very
fragile. In another sample, tissue taken from a 1-week-old extraction socket
was found to be composed of degenerating fibrin and early granulation tissue


fibrin clot----Granulation tissue----organize into----collagen plug[1 month]----plug increase in density---replaced from the apex and the periphery---by bone deposition



After the development of a fibrin clot, the tissue becomes granulation tissue, which
contains blood vessels, fibroblasts, and chronic inflammatory cells. The granulation
tissue eventually matures into a collagen plug. For example, the authors found that, after
1 month, tissue removed from the center of the extraction site was composed of fibrous
connective tissue and fibroblasts with some remaining inflammatory cells.The
buccal wall and alveolar crest was resorbing with associated gingival collapse and loss of
interdental papilla. The socket enlarged to the buccal, and bone on the buccal alveolar
surface, and alveolar crest resorbed in the area of the extraction site. In this
patient, tooth extraction precipitated a generalized resorptive response in the alveolar
bone.

In tissue samples of the periphery of the soft tissue removed from extraction sockets, new 

bone formation occurred on the old necrotic bone of the original socket wall. 

However, in the same socket, necrotic bone was set free from the underlying vital bone 

and was sloughed into the socket to be expelled as bone sequestra . The  bone of the original socket wall dies and is undermined by osteoclastic resorption. This necrotic bone can form a nidus for new bone growth, or the necrotic bone can be expelled from the socket as bone sequestra. A portion of the old socket wall will form new bone on its surfaces and will become incorporated into bone forming in the extraction socket. However, a significant portion of the old socket wall will be undermined, become 

necrotic, and be sloughed into the oral cavity through the extraction socket orifice.

If the first stage of extraction-socket healing is resorption and disposal of necrotic bone,
then this would explain why tooth extraction in patients on bisphosphonates occasionally
leads to osteonecrosis. The bisphosphonates prevent osteoclastic undermining and disposal of necrotic bone lining the socket wall. The inability of the alveolus to dispose of the necrotic bone lining the socket wall could then lead to progressive osteonecrosis

Even with modern antibiotics, osteomyelitis and osteonecrosis are major medical
challenges. To prevent osteomyelitis and osteonecrosis, bone mounts an inflammatory
response to protect the host.After extraction, a significant amount of bone is sacrificed
by the body, but the host survives.However, with proper treatment, our findings
indicate the resorptive, clotting, granulation, and collagen phases of healing can be
skipped, and the extraction socket can proceed directly from extraction to regeneration.


To skip the negative phases of extraction-socket healing, a biocompatible material must
be placed in the socket after extraction. However, to avoid the resorptive phase of
healing, the graft material should not require resorption before bone formation. The graft
material should be biocompatible, inhibit bone resorption, and stimulate osteogenesis.
Also, to limit bone resorption on the buccal, lingual, and crestal bone surfaces, gingival
flaps that expose this bone should not be raised during placement of the graft material.

The drug component in Socket Graft stimulates osteoblasts and inhibits osteoclasts and
phagocytes. As the calcium phosphate based component of the bone graft is replaced by
bone, the drug component enters the osteoblasts, stimulating osteogenesis. The drug
component is retained by the osteoblast and continues to stimulate osteogenesis after the
calcium phosphate portion of the graft material has been converted into bone

Read More

Diagnosis Of Pulpal Disease

21:52 irreversible pulpitis, necrosis, pain pulpal pain, pulp vitality, Pulpal disease, pulpitis, reversible, symptoms, thermal test 10 Comments

Classification of pulpal diseases
1) Within normal limit_asymptomatic or mild to moderate transient pain subside after the stimulus is removed.tooth is not tender on percussion.

2) Reversible pulpitis_quick, sharp, hypersensitive response to the stimulus.that subside after the removal of the stimulus.

3) Irreversible pulpitis_
a) asymptomatic- hyper plastic pulpit is /pulp polyp or internal resorption.

b) symptomatic- spontaneous, unprovoked, intermittent or continuous pain, lingering pain to thermal stimulus.
Radiographs can help in identifying the tooth involved or widening of PDL space in advance stages.

4) Pulpal  Necrosis-
a) partial necrosis-one or two canal is undergoing necrosis in a tooth with more than one canal. It can be symptomatic.
b) total necrosis- no symptoms , negative pulp vitality
It is a stage before it affects the periodontal ligament.

Read More

Preferred Periodontal Flaps

03:18 apically displaced, flaps, free gingival graft, laterally displlaced, periodontics 2 Comments

CONDITION	PREFERRED FLAP
·        For accessibility in anterior teeth segments ·        For reconstructive osseous surgery	Papillary preservation flap
·        For accessibility in non – esthetic zone	Modified widman flap
·        For osseous defect closure by bone recontouring ·        Decreased width of attached gingiva with thick pocket wall	Apically displaced flap
·        Long narrow gingival defect on single tooth	Laterally displaced flap
·        Absence of attached gingival with friable pocket wall or no pocket	Free gingival graft
·        Isolated recession on upper teeth	Tarnow’s semilunar coronally displaced flap

Read More

3D Tooth Atlas- Beyond Visualization

07:56 2 Comments

''Few things can be learn by actually seeing it''. The credit goes to who created it and who shared it on you tube.I am sharing this for educational purposes.

Read More

Dental Anatomy: Maxillary Molars

07:44 4 Comments

We must understand anatomy of tooth first then  invade those structures.

Read More

8 KEYS TO BEAUTIFUL ALGINATE IMPRESSIONS

13:18 5 Comments

Wow! very precise way of taking alginate impression. You can take really good impression with alginate provided you follow the guidelines appropriately.

Read More

Classification and components of removable partial dentures

08:37 classification, Dr Shotwell, major connector, minor connector, Removable partial denture, you tube 2 Comments

While going through the basics I came across to this valuable video which I accessed through you tube.Thanks to Dr Shotwell for making things easy to learn.

Read More

Design Principle For The Access Cavity

05:40 access opening, endodontics, molar RCT, multirooted teeth, pulpal floor 1 Comment

1] The access cavity should enable root canal instruments to be introduced into the canals to their                         apical constriction without undue bending and binding coronally.

2] The access cavity must be large enough to allow complete debridement of the pulp chamber otherwise it may lead to reinfection or crown discolouration.

The roof of the pulp chamber must be removed completely.If not removed completely, access to canals is difficult.Also, infected and necrotic material will be retained within the pulp chamber which may then be transferred to root canals through instumentation. Breakdown products from such remnants may responsible for the subsequent discolouration of the crown.

3] In multirooted teeth great care must be taken not to damage the floor of the pulp chamber.Not only is there a possibility of perforation but the contour of the floor is such that the openings to the root canal tend to be funnel shaped. If  this natural anatomy is destroyed, subsequent instrumentation is more difficult.

4] The access cavity should funnel into the canal orifices.In multirooted teeth the orifice of the root canals should be at the periphery of the base of the access cavity so that instruments may be slipped down the walls of the cavity and into the root canal.

5] The occlusal projection of the access cavity should be larger than the base, to allow better visualization of the floor of the pulp chamber, especially if an operating microscope is used.

6] As part of the access preparation, the unsupported cusps of posterior teeth must be reduced by trimming with a tapered fissure carbide or diamond stone until a definite clearance in occlusal and lateral movement is obtained.

7] The objective of entry is to give direct access to the apical foramina, not merely to the canal orifice.

8] The likely interior anatomy of the tooth under treatment must be determined.Each tooth has a typical length no. and configuration of roots and canals. Prior to starting of the access, radiographs taken from  atleast 2 different angles must be studied, knowing what combinations of interior anatomy are possible and having the information given by radiograph, the operators will be able to ascertain with great accuracy the canal system present in the tooth to be treated and the possible alternative configurations. This information gained prior to initiation of preparation will greatly facilitate the entry as well as urther treatment.

Read More

Composition Of Local Anaethesia

05:54 No Comments

1] LA agent - Lignocaine HCL-21.34 mg

2] Vasoconstrictor - adrenaline - 0.05 mg

3] Reducing agent - Sodium metabisulfite - 0.05 mg
                             prevents oxidation of vasoconstrictor in LA

4] Preservative- Methyl Paraben - 1 mg
                        maintain stability of solution and give shelf life of 2 years

5] Fungicide- Thymol

6] NaCl - 5-6 mg/ml

7] Vehicle - water - 1 ml

Read More

Components Of Dental Prescription

05:38 antibiotic, antiinflammatory, components of prescription, dental, stamp, treatment follow up No Comments

Doctor's details


                          Letter Head
                                                                        date:
MCO
Special instructions
Investigation




                      Name and age of the patient

                    -ANTIBIOTICS
                    -ANALGESIC/ANTINFLAMMATORY
                    -ANY OTHER [ IN ORDER]




Advice:


Follow up




                                                             sign and stamp

Read More

Principles Of Endodontic Therapy

06:24 case presentation, cementodentinal junction, debridement, diagnosis, electrolysis, endodontics, instrumentation, local anaesthesia, medicament, principles of RCT, restoration, rubber dam, surgery, treatment 41 Comments

1] Objective-The objective of endodontic therapy is restoration of the treated tooth to its proper form and function in the masticatory apparatus, in a healthy state.


2] Basic phases of therapy: three phases


first phase-diagnostic phase-in which the disease to be treated, is determined and treatment plan developed.


second phase-preparatory phase-when the contents of the root canal are removed and the canal prepared for the filling material.


third phase-involve filling or obliterating canal to gain hermetic seal with an inert material as close as possible to cementodentinal junction.




3] Importance of debridement
Endodontic is essentially a debridement procedure that require the removal of  the irritants of the canal and periapical tissue if success  is to be gained.


Debridement may be required in various ways:
1] instrumentation of the canal
2] placement of the medicament
3] irrigant
4] electrolysis
5] surgery


4] Use of rubber dam is mandatory


5] Great respect due the periapical tissue during treatment


6] Proper restoration the culmination of success


7] Postoperative observation necessary


8] Case presentation to set the stage

Read More

Movements Of Files

03:35 apex, apico coronal filing, balanced force, canals, movement of files in RCT, retreatment, root, Root Canal Treatment, stem winding 1 Comment

1] stem winding,watch winding or twiddling
the file is used with 45 degree rotational movement clockwise and anticlockwise with gentle apical force.The canal becomes enlarged and the file can be moved apically into the root canal.
use-useful when penetrating fine canals and in re-treatment cases.Files are usually precurve prior to use in this way


2] Quarter turn and pull
this causes more aggressive cutting than stem winding and tends to remove more material from the wall.


3]Apical-coronal filing
The file is applied to the wall of the root canal and moved in and out of the canal at an amplitude of 1-2mm. This movement is especially efficient with Hedstrom files.
To ensure that all the walls of the root canal are cut, circumferential filing is done.


4] Balanced force technique


The movement of the file is clockwise and anticlockise and its action is based upon Newton's third law .The file is placed into the canal till it first binds and then advanced further by clockwise rotation, usually through approximately 60 degree. The file cuts into the root canal wall and creates threads in the dentin as it moves apically.This is the powerphase.The anticlockwise rotation, through approx 120 degree is carried out with some apical pressure so that the file does not unscrew out of the canal..


During this movement the threads of the dentin formed during the power phase are cut from the wall.This is so called control phase.
Oten an audible click can be heard which resembles an instrument fracturing but is merely the dentin being cut from the wall. The file is then removed and the flutes cleaned of debris.If difficulty is encountered in removing the file then the small rotation clockwise, of about 30 degree,allows the file to be forced.In nearly all studies where this manipulations of the file has been compared with other methods.The balanced force technique has been shown to be superior in shaping the canal with less likelihood of iatrogenic damage.The reason for this is tha the file i tends to remain more centrally placed within the root canal which means that the canal can be prepared to a large size without compromising the structure of the root. This combination of a larger size and smooth, even flare follows the natural curvature of the canal probably results in a cleaner canal and certainly one that is easier to obturate with GP.

Read More

Ledges

22:37 endodontics, files, ledges, procedural accidents, RCT, reamers 16 Comments

Ledges are result of careless instrumentation
 caused by:
1] large instruments out of sequence and
2] insertion of instruments short of working length or
3]use of inflexible instruments in a curved root canal
4]poor design access cavity prevent direct access to apical third of root canal

The access curvature in the coronal part of canal may prevent negotiation of an instruments through the apical curvature in a fine, tortuous canal and may result in ledge formation
ledges and blocked canals are recognized when the instrument cannot be reinserted to its established working length.


How to remove ledge

• Locate its position by inserting an instrument until it is blocked, verify the depth by the radiograph
• Once ledge is located, irrigate within sequence with sodium hypochlorite and EDTA.
• Explore ledge-take a small file 10 or 15 in which a severe curvature has been made from the tip extending about 1 to 3mm up the blade.
• When the ledge is reached, the instrument is retracted slightly and rotated to allow the curved tip to bypass the ledge and the instrument is teased apically past the obstruction 
• Patiently try again if initial attempts are successful once the ledge is bypassed, do not remove the instrument rather start the circumferential filing of the canal to remove the ledge before witdrawing the instrument from the canal.
• Repeat the procedure with larger instrument and recapitulating with similar size until the ledge is filed away and desired enlargement at the established working length is made.
• If ledge cannot be bypassed, clean, shape and fill the RCto the level of obstruction.
• If the terminous of the filling is closed to the canal apex, monitor the toothfor healing and repair.
• If endo treatment is unsatisfactory consider an alternative treatment procedure such as retrograde amalgam surgery, hemisection or radisectomy, internal replantation or extraction.

Read More

RCT versus Endodontic Treatment

21:49 Endodontic treatment, RCT, Root Canal Treatment, supporting structures, tooth 34 Comments

Just before starting the Root Canal Treatment[RCT] educate your patient with the procedure through audio visual aids.It makes dentist job easy to explain the whole procedure in one go.
RCT deals with root canal treatment and if you are treating the tooth with its supporting structures [bone,periodontal ligament, gums]then we call it Endodontic treatment. So don't do RCT but Endodontic treatment for better prognosis.

This tooth needs to be treated with Endodontic Treatment 

Read More

Dentin Hypersensitivity

04:08 brushing technique, GIC, light cure, mouthrinses, tooth paste, Treatment options for dentin hypersensitivity 6 Comments

Treatment Options For Dentin Hypersensitivity

In office
1] GIC
2]Modified Ionomer that releases Fluoride, Calcium ,Phosphate
3]Extended Contact Varnish  [Vanish XT]
4]Light cure act a physical barrier.
5]Surgery-Connective tissue graft if DHS is because of recession alone [without bone loss]

Over the counter
1] Tooth paste or mouth rinses contains:
a] Strontium salts and fluoride-occlude dentinal tubules.
b] Formaldehyde-destroys vital element within tubules.
c] Potassium salts- Potassium nitrate, potassium chloride, Potassium citrate treats DHS by diffusing along dentinal tubules and decrease the excitability of interdental nerves by altering their membrane potential.

note: these mouthrinses additves must be able to perform in such a manner that they overcome hydrostatic pressure.

Advice patient:
1] How to brush-demonstrate the right brushing technique.
2] Use mouthrinse after the consumption of acidic food and juices but after 5-10 minutes.

Read More

Purposes of Obturation

03:42 apical periodontitis, Criteria for obturation, exudate, purulent discharge 3 Comments

Root canal obturation involves the three-dimensional filling of the entire root canal system and is a critical step in endodontic therapy. There are two purposes to obturation: the elimination of all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system; and the sealing within the root canal system of any irritants that remain after appropriate shaping and cleaning of the canals, thereby isolating these irritants. Pulpal demise and subsequent periradicular infection result from the presence of microorganisms, microbial toxins and metabolites, and the products of pulp tissue degradation. Failure to eliminate these etiologic factors and to prevent further irritation as a result of continued contamination of the root canal system are the prime reasons for failure of nonsurgical and surgical root canal therapy.Other factor that influence the ultimate success or failure of each case include the materials used and how they are used. 




Criteria for obturation:


1] Teeth with signs of apical periodontitis
e.g. those tenderness to apical palpation.


2] Teeth associated with radiographic signs of apical periodontitis.


3] Teeth with excessive exudate that cannot be stopped.


4]Teeth with a purulent discharge into the canal.


5] Teeth associated with aprocedural accident e.g.perforation.

Read More

Steps in Root Canal Treatment

03:22 anaesthesia, BMP, crown, dentist, endodontics, file x ray, pulp, steps in root canal TREATMENT tibiotics, treatments 259 Comments

1] Diagnosis- identify the tooth with the problem by taking proper  history.
    Diagnostic x- ray to evaluate the tooth[ root anatomy, extent of damage to the tooth, no. of canals, its           anatomy etc]and  status of surrounding bone if associated with periapical pathology.
vitality test- to detect the vitality of pulp.


2] prescribe an antibiotic or/and anti-inflammatory medicine for some days before starting the root canal procedure. The purpose is to control the infection and to ease the swelling which can make the anesthetic less effective. 


3] Anaesthesia may not be necessary, since the nerve is usually dead, but most dentists still use anesthesia to make the patient more relaxed. 


 4] Isolate the tooth, keep it dry and prevent the contamination of the tooth by saliva bacteria during the root canal procedure.


5]Access Opening of tooth-First, remove any decay from the crown of the tooth.Opening the dental pulp chamber relieves the pressure inside the tooth and can offer significant pain relief.


6] Pulp extirpation


7]  File X-ray to measure working length of the tooth.


8] The cleaning phase of a root canal procedure might need more than one appointment, especially in cases when the dentist suspects that the root canals are branched in a way that infected tissue and bacteria might be left in areas that the dentist can not see or the files can’t reach. In these cases, the dentist will put antimicrobial medication in the pulp and canal area to kill any remaining bacteria and will use a temporary filling to protect the tooth until the next visit. 


The dentist may decide to leave the tooth open for a few days to allow drainage of a periapical abscess and prescribe an antibiotic to stop the infection. If the infection is not controlled until the next appointment, the process is repeated.


9] When the dentist decides that it is safe, he will dry the interior of the root canals with paper points and start to fill them with a permanent root canal filling material. The material used for the filling is often a biocompatible rubber-like material called “gutta percha” in combination with an antibacterial cement (sealer). 


10]  If the tooth has suffered significant damage from tooth decay and it is unable to support a crown, the dentist will place a metal post in the pulp chamber to provide structural support for the crown restoration.


11]Final restoration prevents contamination of the tooth. Another problem is that the tooth remains weak until restored, and it will fracture easily if pressured. 


12] Endodontically treated teeth often become brittle with time after treatment. Crowning the tooth is usually safer, especially if molar is involved.

Read More

Oral Ulcers-Needs to eyeball them

04:33 dental problem, etiology, oral ulcers, treatment of oral ulcers 1 Comment

History of ulcers:-

Duration, onset, location, if pain is present,aggravation and remission, radiation, discharge-purulent?

On clinical examination:

How do they appear[Shape],tender?,soft base/hard-indurated

If the ulcer persists for longer duration then we call it chronic ulcer and in that case....duration,onset,content of the ulcer-slough/healing,no.,location,associated with other symptoms,chronic irritation from tooth,cause of ulcer-trauma-[mechanical,chemical, thermal changes], infection,medicinal side effect, post dental treatment or during dental treatment from caustic agents, neoplastic, immune disease, deficiencies, allergic response should be asked.

If the ulcer is painful it reveal that it could be traumatic,infectious[acute], aphthous ulcer minor[if more in no.] and if one single large,deep ulcer is present then it could be apthous major, herpetic or ulcer with viral etiology have a history of rupture of fluid filled vesicles that ruptured to form ulcers.

ulcer of neoplastic origin are often associated with history of tobacco/ chronic irritation from dentures[materialused in prosthesis might leach out and liberate free radical which are cancerous]

Any ulcer should not be left unnoticed as chronicity will increase with time.Any ulcer not healing within 2 weeks need to seek immediate attention of dentist.

Before starting the management of any disease ,the diagnosis is crucial for the prognosis, so thorough history, examination and investigation like culture [microbiological test], biopsy must be done as and when required.

Its better to be sure about the disease you are treating.

Read More

Salman Khan Conquered Trigemial Neuralgia?

04:26 Salman Khan, Trigeminal Neuralgia 1 Comment

Salman Khan’s ‘jaw pain’ returns-

''Jaw Pain'' that was diagnosed as Trigeminal Neuralgia. A very few people know about this disease.

What is Trigeminal Neuralgia?

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that causes extreme, sporadic, sudden burning or shock-like face pain.  The pain seldom lasts more than a few seconds or a minute or two per episode. The intensity of pain can be physically and mentally incapacitating. TN pain is typically felt on one side of the jaw or cheek. Episodes can last for days, weeks, or months at a time and then disappear for months or years.  In the days before an episode begins, some patients may experience a tingling or numbing sensation or a somewhat constant and aching pain.  The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.  The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind.  TN occurs most often in people over age 50, but it can occur at any age, and is more common in women than in men.  There is some evidence that the disorder runs in families, perhaps because of an inherited pattern of blood vessel formation. Although sometimes debilitating, the disorder is not life-threatening.

The presumed cause of TN is a blood vessel pressing on the trigeminal nerve in the head as it exits the brainstem. TN may be part of the normal aging process but in some cases it is the associated with another disorder, such as multiple sclerosis or other disorders characterized by damage to the myelin sheath that covers certain nerves.

 

The cause of trigeminal neuralgia is not always certain. Approximately five percent of patients have a tumor pressing on the trigeminal nerve where it leaves the brain, while other patients have a blood vessel that presses on the trigeminal nerve, close to the brain. In some patients the cause cannot be determined.

Approximately five percent of patients with trigeminal neuralgia have multiple sclerosis. Patients with TN and multiple sclerosis are generally younger, and tend to first experience TN symptoms while in their mid 40s. These patients are more likely to have pain on both sides of the face (bilateral trigeminal neuralgia) and often have other neurological abnormalities, such as weakness or numbness in the arms or legs, dizziness, unsteadiness and double vision. Most patients in their 40s and 50s who have trigeminal neuralgia do not have multiple sclerosis. Patients who have TN but not multiple sclerosis tend to first experience TN symptoms while in their mid 50s.

Nonsurgical Treatment

There are some patients who have very mild face pain that may subside and even disappear without treatment. For severe pain, medications, especially Tegretol, are often highly effective. Tegretol can cause many side effects including sleepiness, forgetfulness, confusion, drowsiness, dizziness and nausea. Tegretol can also cause more serious problems such as bone marrow suppression, which can lead to anemia or a decrease in the number of white blood cells. A low white blood cell count can predispose a patient to contracting an infection. Rarely, these problems are life threatening. Blood counts must be monitored in order to lessen the chance of these complications occurring. Tegretol can also harm many other parts of the body, so patients who take this medicine must be under careful medical supervision. Tegretol interacts with many medications, so patients must advise their doctor of all the medications they are taking. Elderly patients and those with multiple sclerosis are more likely to experience the side effects of Tegretol.

There are other medications that can be used either alone or in combination to control trigeminal neuralgia pain. These are usually less effective than Tegretol. They include Lioresal (baclofen), Dilantin (phenytoin), Klonopin (clonazepam), Neurontin (gabapentin), or Lamictal (lamotrigine). All of them, except baclofen, are also used to prevent seizures.

Surgical Treatment

A surgical procedure is recommended for patients who continue to experience severe pain or side effects from medications. In the past, patients with TN did not consider neurosurgical options until the pain or medicines became unbearable, because surgical procedures carried higher risks. Now that surgery is safer, and especially with GKRS, which is not only highly effective but safer than any of the other procedures, patients no longer have to wait to be in agony in order to undergo neurosurgical intervention.

There are five important neurosurgical procedures. Each is effective, but not always, and occasionally has to be repeated. These procedures are: Gamma Knife radiosurgery (GKRS), radiofrequency electrocoagulation (RFE), glycerol injection (GLY), balloon microcompression (BMC), and microvascular decompression (MVD). All of these procedures treat the trigeminal nerve at around the same place, close to where it leaves the brain.

Gamma Knife radiosurgery is the most recent and least invasive neurosurgical treatment for trigeminal neuralgia. Of all the surgical procedures, it is least likely to cause complications and uncomfortable new facial sensations (dysesthesias).

What is Gamma Knife Radiosurgery?

Gamma Knife radiosurgery is a method for treating certain problems in the brain without making an incision. Two hundred-one beams of cobalt-60 radiation are focused precisely on a specific region in the brain. In the case of TN, the target area is the trigeminal nerve, just where it leaves the brain. The treatment does not require general anesthesia, and the patient stays in the hospital for less than five hours.

Who is a candidate for Gamma Knife Radiosurgery?

Any patient with trigeminal neuralgia who has pain or has difficulty with the medicines used to relieve the pain is an excellent candidate for GKRS. The patient's age or medical condition does not affect the decision to have GKRS. Even the elderly or medically infirm can undergo this treatment. Patients who are receiving anticoagulants for other medical conditions do not have to stop or reverse the anticoagulation therapy prior to GKRS. Those who have had previous procedures for TN may also undergo GKRS. Patients who are concerned about the possibility of numbness are particularly good candidates for GKRS, because the chance of postoperative numbness occurring is very small. Patients who poorly tolerate medicines given for sedation and relief of pain during a procedure are also very suitable for GKRS because these medications are not necessary.

What results can be expected from GKRS?

Excellent or good pain relief occurs in approximately 85 to 90 percent of patients. Onset of pain relief may occur one day to four months after the procedure. About half of patients will experience pain relief within four weeks. Recurrent pain occurs within three years in 10 percent of patients. Patients with TN and multiple sclerosis are less likely to respond to GKRS than those without multiple sclerosis, although they also may be helped by the procedure. Gamma Knife radiosurgery can be repeated, but not until at least four months after the original procedure.

What are the complications from GKRS?

Major complications have not been reported. Additional numbness in the face or new facial sensations occur in less than 10 percent of patients. There are theoretical possibilities of delayed complications such as brain damage or brain tumor formation, but these are rare and have not been reported to occur in any patients treated for trigeminal neuralgia.

Gamma Knife radiosurgery was first performed in Sweden in the 1950s, but few patients were treated for TN. The Gamma Knife has been used in the United States since 1987, and most cases of TN have been treated during the past five years. Although there is not much information on long term effects, initial and medium range follow-up suggest that GKRS is not only effective but also very safe.

Linear Accelerator Radiosurgery

There is another form of radiosurgery, called LINAC (Linear Accelerator) radiosurgery. It uses high-energy X-rays delivered by a sequence of arcs, and is very different from GKRS. Only a few cases of TN have been treated with LINAC radiosurgery, and there are no reports on these cases in peer-reviewed journals. Unlike GKRS, LINAC radiosurgery has not been demonstrated to be an effective and safe treatment for trigeminal neuralgia.

Radiofrequency Electrocoagulation, Glycerol Injection and Balloon Microcompression

These procedures are performed through a needle that is inserted into the face and directed, under X-ray guidance, toward the trigeminal nerve. All of these procedures partially damage facial numbness, which is sometimes very painful. Major complications, such as bleeding or infection in the brain, are rare but can be devastating when they occur.

Microvascular Decompression

Microvascular decompression is a major neurosurgical procedure in which the skull is opened. During the operation, which requires general anesthesia, the surgeon sees the nerve. If he or she finds a blood vessel pressing on the trigeminal nerve, a soft piece of material will be placed between the blood vessel and the nerve, thus lifting the blood vessel away from the nerve. This operation carries greater risks than the other procedures do, and these risks, although infrequent, include possible death, stroke, bleeding, infection, inflammation of the surface of the brain, facial weakness, hearing loss, facial numbness and pain.

Summary

Gamma Knife radiosurgery is a major advance in the treatment of trigeminal neuralgia, an otherwise agonizing condition characterized by paroxysmal triggered face pain. Gamma Knife radiosurgery not only relieves the pain as well as the other neurosurgical forms of treatment, but it does so with fewer complications.

The Gamma Knife is the only radiosurgical machine for which positive results of trigeminal neuralgia treatment have been published in peer-reviewed journals.

Read More