Nevralgia TRIGEMEN Tratament Laser

8/20/2019 Nevralgia TRIGEMEN Tratament Laser

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Y' Once again, there is a serious lack of controlled clinical experimentalmaterial. However, those who have atlempted to treat pharyngitiswith the laser have lil lie doubt as to its effectiveness. t is possible toeliminate p ain while swallowing in 9 o ut of 10 patients within 10minutes after laser treatment. In cases of severe tonsillitis, pain can be

reduced fora short period of time. '.'

Poin ts in the reddes t and most swollen areas near the palat ine archand the tonsils are treated with 2 J each. Additionally, 2 J are deliveredjust under the angulus mandibulae bilaterally. The total dosage is 14-

18J

I f j aw function i s reduced, th is will al so ~ normalised fhirtyquickly. ~

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Clinical laser tteafiftent, .' ~,jIj

neural aibnents

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This chapter willdiscussa group ofpain-Au;ing ailmentswhiJhare.'__.',. ;~i,.'>difficultto definein relation to other painful conditions. The

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characteristic of these ailments is thM they directly affect th peri:.

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pheral or central nervous system. ' .' .~o< '. (

The practicalteason fordiscussing theseailmentsseparatelyis that' ,,:ie,laser treatment and patient reaction to treatment differs ion that ' , . j, .

discussedin previouschapters in a numberof ways. IGenerally speaking, this is the group of ailments that is the mostt'difficult to treat with the laser.On the other hand, one can loftenachieve extremely positive results -particularly when one considers

the resistanceto treatment demonstrated by thesepatients. I

Therefore, i t i svery importan t to descr ibe the patien t's pain andsymptoms very accurately before the first treatment is administered.This isbecause patients havea tendency to forgethow much pain theyhad before therapy. Also, the pain and symptoms often change,char-

acterduring therapy I ~'~ ~, I

These pains can be grouped in different w:-ys. I

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Accordingto duration Acute(up to2 months), Subacute(2 -6 months)

',Chronic'(morethan 6 months)

According to origin

According to scope

Accurding to locntion

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Centrill

I Peripheral

Viscerally

Locally(at the source) i

Communicated (felt inan areaother. thanat the source) I

Radicular/projecting(painwhichshootsout in the innervationregionfor a root or peripheralnerve) I

Headache

Facialpain

BackpainPain in extrcmities,eiC.

The pain descriptionshould include the followingpoints:

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Locatiun

Pain rlmrarteristics

Pain intensityCourse amI duratiun

Proloking oraggra,'ating f:\ctors

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Pain-redu~ingf:\ctors iPrc,'ious trcatmcnt

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IFacial pain

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Radicular pain inthe extremities

})Caffcrcnl pain

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Provoked, gradual, or sudden appearance? typic l trigemill l neur lgi is charaderised byattacksof.pain which last longerand are lIequentlyaccompaniedby .

pain between attacks. .~

typical facial paillis characterised as non-neuralgic pain Wibe communicated or in rarer instances, radiated. Pain isone.in the profound facial structures and are frequently piercing.sive, throbbing or buming in character.

Where docs it hurt?

. I s the pain cons tan t or dOl 'S i t vary?

Is i t oppress ive, p iercing , throbbing , st inging , burning , Slabbing ,shooting, sharp? .

Compare with known pains.Always present?Variations?'Can the patient sleepat night?

Process The anamnesis is taken, with particular attention focused 4

scIiption of the pain/symptoms as described earlier in this c711(' objectil l examillation is performed by palpating the faoughly with both hands, start ing medially from the borderthe innervation of the two sides of the trigeminal branches.

Additionally, the oral region should be palpated.

It isimportant torecord the location ofallsignificant tenders)trigger zones, that is to say,areas where a light touch sets of)

Palpation tenderness is usually found in:

I. infraorbial foramen

Docs the pain becomcs worse in.certain physical posit ions or whilepcrfolluing particular movements/functions? Under stressful condi-tions? . .

Improvement while resting or sleeping? By changing positions?

Medical treatment, nerVe blocks (including alcohol blocks), surgic.'\I'\ treatment'l .

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,' We h :lvechosen to divide the relevant painful conditions into the

\:followingmain c.'\tcgorics: .~~ .

2. mental foramen

3. supraorbital foramen4. mandibular foramen

5. foramen platium major6. foramen incisivum

Typicaltrigeminal neuralgia

Atypical trigeminalneuralgia-.. ...

Atypical facial pain

'See Chapter 16.1 7. angulus mandibulae

8. hinge oftl1Caw

9. the tcmples

10. the points atwhichtheos nasale.processuslIontalismaxilthe os frontalemeet

11. at the fossacanina

Anaesthesia dolorosa

Phantom pains

Post-herpetic pains

Facial pain.' .Typical trigemillal lIeuralgia i s c ha ra ct er is ed b y:

R adj at ing. n eu ra lgi c p ai ns w hi ch oc cur dur in g a tt ac ks w hi ch l as t up t oseveralmimJtes. .

. , ~'The ppinradiatesout inone oCthebranchesof thetrigeminalnerve.Inrarcr instances, thc pain willoccur in twobranches.

The pain most often occursduring the day and can be triggeredbytalking, chcwing, brushing the teeth, or while eating and drinking.Many patients have an area of skin or mucous membrane which isscns,itivcto slight stimulations which set off the pains, a so-called

. triggerzone ,

Intraoral tender spots can be found at:

1.the sidc and under tl1etonguet2. in the medial and lateral pterygoideus

TIigger zones are also located

The points which h~ve been located are treated with an appJ1dosage from 0.5 - 4 / . Tlus will be discussed in more detailla



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II Dosages

Treatment reaction

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TI1prinriple, wcdo not dillhcntiate bctwecn thc various types offhcialpain.

On thc other hand, the objcctive examination as wellas the patient 'sreaction \\;11result in a difTerencein the way various types of f.'1cialpain are treated.

Thus, a typical case of trigeminal neuralgia will usually only rcquirctreatment ata few points, and with a lowcr dosage than that needed inthc trcatmcnt of an atypical c se

If, during the coursc ofthcrapy, positivc trcatment rcsponsc does not

occur, thc paticnt should bc recxamincu in order tu locate any,tcmJcrspots which may have been overlooked earlier. It is also important tonote any new tender spots which have appeared as a result of thechanges which have taken place during therapy.

With regard to trigeininal patients who have undergone a neurosurgi-ca l procedure or alcohol b locks, p lease refer to the sect ion on de-afTcrent pain.

Fig.t5.2

Chronic paticnts should not receive a total dosage which isin excess of20 -25J during the first treatment. Acute patients can toleratc slightlyhigher dosages. During intraoral treatment, acute patients will oftenexperience increased pain which later subsides. ,I f no t reatment react ion occurs fo llowing thc fi rst t rea tment, thedosagc should bcdoubled for thc next treatment. This can be repcatedif necessary.

The treatment reaction will typic;tly be quite pronounced.

Whcn treating acute conditions. an immediate improvement can bemade. In all other cases. it is imp0l1ant to prepare the patient for theintensified attacks of pain which will fotlow, This reaction usuallyoccurs dur ing the f irs t 24-hour period , but in some cases wi ll occurwithin a matt.er of minutes. The reaction can last (j'OInsevcral \toursup to an cntirc day. Ilowevcr, in some cases these intcnsified symp-toms can last for sevcl-aldays and in mre instances evcn longcr.I 'The basicprineiplc to remcmber is that the patient should hot betreated again before the previous. treatmcnt reaction has completclysubsided.

The typiCalcourseof therapy is iIIustratcdin Fig. 15.2.

This graph showsthe relationshipbetweentimc and pain Icvclin a.. ., .. ,' :--' --.:--.

Pain

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TimePain phase tntermediate phase Symptom.frbe

A schcmat ic rcpresental ion of the course of therapy overa per iod 00 -6 rhonths fora pat ient suffe ring f rom chronic t rigemina l neura lg ia . The pain curve i~mcant tosymbolise the fact that pain peaks become less and less intense as whll as lessfrequen\. The eonstant'pain also decreases.' , T he mo st im por tan t ph ys ic al s ig n whc n det er min ing t hc p at ient 's pr ogno si s i sdecreased palpa tion lenderness. ~ .Most patients will pass through a phase where there is limitcd pain. but pronouncedpalpa tion tenderness s ti ll exist s. In these cases ; the 'Pa in wil l return within 2 -3months. The dOlled line illustrates this course.Therefore. laser therapy treatmentsshould beadministered about every 4 weeks unt il palpa tion tenderness i sgone. The

long-termprognosis is good. . I

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,The first part ofthe course oftherapy iscalled the pain phase , whichnonnally lasts3 -6 weeks.

During this phase:

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I. pain peaks during attacks will become less intense.

2. Tile time interval between atlacks will become longer.

3. Th~ levclof the patient's basic pain , often described as aconstantthrobbing will decrea,se.

As shown in 'Fig. \5.2, the pat icn t' s palpat ion tcnderness wi ll al so, (Jecreascduring this phase.Thc intenncdiate phase begins whcn thc

pati':.nt no longer experiences attacks of pain. .. .Fig. i5.2 illustrates thc fact that palpation tcnderness will be prcsentduring thc entire intcrnlcdiatc phasc.

\ t i s impor tant to continue laser t reatment of tender spots unt il alltenderness isgone. In other words. even though the patient may not beexperiencing attacks of pain. therapy should continue, If therapy iscominued, the remaining tenderness willeventually disappear and the

First trcatment - dosagc PCI'point

Points/duration acutc subacute chronic

tcnder spots I J 1.5 J 2J

trigger points 0.5 J 0.5 - I J 0,5 - I J



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Temple

Jaw joint:.

Ramus

Angulus,

III.15.2Allhcsuproaorbitalfofamcn

At the ruotof the nose,near the eye iAt theinIl aorbitalforamcn

Ncar thecaninc tceth

Il l. 1 5. ] a nd 1 5. 2

A patienl with trigeminalneuralgia is usuall\ Irealeda lte nd er s po ts a t ih e h ing eof the jaw and the angulus .

At the baseof the foramenmcntalis Ill. 15.3

A s ch em al ic r ep re se nl ati on o f I he mo st c om mo n e xt ra or al P Oi nlS tr ca le d in co n-j un cli on w il h fa cia l p ain . Th e a ll ac hme nl o f s lc rn oc le id om asl oid eu s a s we ll a s a lv~r tebrae CI-C2 should be normally be t reated . 100 .\

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I I i s impor tani lO f ind and(real all intraoraltcndasputs. \\ hen Ireating thesespots. the patienl \\ illuftene~per iencc a per iod ofmore inlense pain IQllo\\cdb) a ~riod of relaxation.

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Nevralgia TRIGEMEN Tratament Laser