Bill Klaproth (host): This is OMS Voices, an AAOMS Podcast. I'm Bill Klaproth. And with me is Dr. Michael Miloro, who is here to discuss nerve repair, nonsurgical and surgical treatments. Dr. Miloro, thanks for being here.

Michael Miloro: Great to be here with you, Bill.

Bill Klaproth (host): Absolutely. So, we're going to talk about nonsurgical and surgical treatments of nerve repair. So, let's talk about the trigeminal nerve. What is that?

Michael Miloro: The trigeminal nerve is one of 12 cranial nerves that has a variety of functions. This nerve is important to oral and maxillofacial surgeons since the branches of this nerve are in the area that we operate, there can be many problems with this nerve. Something called trigeminal neuralgia can occur. This causes intense pain for patients. This nerve is one of the largest cranial nerves and its location in the oral cavity make it susceptible to injury. And it can be injured from a variety of factors, including trauma, facial fractures, tumors and infections. It can also be injured during surgical procedures that we've performed commonly, including wisdom teeth extractions, orthognathic surgery, fracture repairs, cancer, surgery and cosmetic facial surgery.

Bill Klaproth (host): So, Dr. Miloro, this is fascinating. So, this nerve has an important role in vision, hearing and controlling of the function of the facial muscles. So, this is a big guy, right?

Michael Miloro: Very important nerve.

Bill Klaproth (host): Yeah. So, what are the symptoms of trigeminal nerve pain?

Michael Miloro: The signs and symptoms of trigeminal nerve injury can vary significantly between patients and may be inconsistent from person to person. There are some potential signs of nerve injury, including numbness or decreased sensation of the face, including the tongue, the mouth, the lower lips and chin. There can be loss of taste because part of the function of one of the other nerves in the area is taste sensation. These patients can have significant facial pain that's triggered by simple things like speaking, eating, chewing, brushing their teeth or simply touching their face. Sometimes painful attacks occur, especially in trigeminal neuralgia. And these can increase in frequency over time.

Bill Klaproth (host): So, does this come and go, this pain? Is it constantly there? How does that work?

Michael Miloro: Yeah, kind of both. Depending on the patient, it can be constant or it can be intermittent.

Bill Klaproth (host): So, then what are the effects of trigeminal nerve pain?

Michael Miloro: Well, as a result of the broad functions of the nerve that we’ve been talking about, nerve injuries can have a significant impact on a patient's quality of life, affecting activities of daily living such as speaking, eating, toothbrushing, shaving, applying lipstick or merely smiling.

Bill Klaproth (host): So, where does an OMS come in then? How would an OMS diagnose and begin treatment of the trigeminal nerve?

Michael Miloro: First and foremost, the oral surgeon needs to see the patient to diagnose the injury. Based upon the patient's description of the symptoms and formal clinical neurosensory testing, which an OMS is an expert at doing, an oral surgeon may order an MRN. We call that a magnetic resonance neurography to determine if there's a specific site of nerve injury. And then treatment is based upon the specific clinical scenario initially. In an attempt to decrease swelling around a nerve that's newly injured, steroids are often prescribed to decrease that swelling. And we also use vitamin B12 in an attempt to heal the nerve. And then for painful nerve symptoms, treatment often begins with medications, including anticonvulsant medications, membrane stabilizing agents and a variety of other medications.

Bill Klaproth (host): So, the first form of treatment is nonsurgical.

Michael Miloro: Yes.

Bill Klaproth (host): And then if so then you try that and if that doesn't work then what are some of the other treatments used?

Michael Miloro: Exactly. Well, medication allows some patients to manage their trigeminal nerve pain or trigeminal neuralgia. Other treatment options may include a variety of surgical options, including microvascular decompression, gamma knife therapy or other forms of nerve destruction. For some patients with decreased sensation or numbness, micro neurosurgical repair remains a mainstay of treatment. Using a nerve graft if indicated and depending upon the time from injury to repair, a patient may or may not be a candidate for a micro neurosurgery.

Also, 3D computer planning can be used before nerve repair to estimate the length and diameter of the nerve graft and facilitate the actual surgical procedure, resulting in improved patient outcomes. And finally, really any patient with a trigeminal nerve injury should seek a consultation with an oral and maxillofacial surgeon in order to diagnose their specific injury and discuss the variety of treatment options.

Bill Klaproth (host): So, if someone does need micro nerve surgery, what is involved in that?

Michael Miloro: Again, as experts in this area, dealing with this nerve, oral surgeons can expose the nerve in the mouth. Expose the area of injury. Resect that area of injury, we call it a neuroma or a scar in the nerve. And typically that leaves a defect that will require a nerve graft. And now we have a nerve allograph that's available. In the past, we used to use a nerve from the patient's ankle or neck that left an area of loss of sensation in exchange for regaining sensation in the mouth, either the tongue or the lower lip and chin. And now we have a categoric allograft available that we can suture in to repair the defect from the resection of the neuroma.

Bill Klaproth (host): So, Dr. Miloro, after this type of surgery, how effective is it?

Michael Miloro: It really depends upon the individual patient. It depends upon the mechanism of injury. Most commonly, this occurs due to wisdom tooth extraction, and most commonly we're talking about the lingual nerve that supplies sensation to the tongue. It also depends upon the time, the time from the injury to the repair. We know that a repair done earlier results in improved outcomes. If we wait too long, surgery can become less effective.

Bill Klaproth (host): Interesting. So, if this happens because of someone having their wisdom teeth out, which people usually have in their teens and twenties, if someone needs micro surgical repair, does it lasts a whole lifetime, then once it's done generally?

Michael Miloro: Yeah, that's the expectation and the younger the patient, the more likely they are to recover. In fact, the majority of these injuries recover spontaneously without the need for micro neurosurgery or medication. But for those few patients that do have painful symptoms, medications are effective. And for those patients that have decreased sensation or complete numbness, micro neurosurgery is the best option.

Bill Klaproth (host): Absolutely. Well, this has been fascinating. So, as we wrap up talking about nerve repair, is there anything else you’d like to add?

Michael Miloro: This field has been evolving for the past few decades. And we’re at the point now where we’ve made significant progress in our ability to diagnose these injuries, again, using MRN, magnetic resonance neurography. Our clinical neurosensory testing have improved our ability to diagnose and then treatment plan these patients effectively. And I think the word around the dental and medical community is that the earlier the patient is referred to somebody who can manage that injury, an oral and maxillofacial surgeon, the better the outcome will be.

Bill Klaproth (host): I was just thinking that when you're thinking about the list of symptoms, facial pain, aching or burning, feelings that can evolve into spasm, like pain, pain in the cheek, jaws, gum teeth. There's so many other things that could cause that, it makes sense to go see an OMS to really clarify this and really understand what's happening. Is that right?

Michael Miloro: For sure. In the past, patients were left with really no option there. Their treating physician surgeon, dentist would say, there's nothing we could do. Let's wait. And likely you'll have return of sensation. And we know that that's not the current philosophy, and that earlier treatment is better in improving the outcome.

Bill Klaproth (host): Yeah, I think another takeaway is think of an OMS if you’re having these symptoms. Certainly can be beneficial and can give you the proper diagnosis and treatment then.

Michael Miloro: Right. Patients are more aware now with the internet. Many patients who come to see me are self-referred. Their dentist or surgeon had not referred them to an oral and maxillofacial surgeon. And they find me. They're very proactive now in their own treatment. So, they use the internet, they do a search, they find my email address, email me directly, and we get them in. And it's the ideal timing for these types of injuries.

Bill Klaproth (host): Absolutely, always good to be your best self-advocate, I guess. Well, Dr. Miloro, thank you so much for your time.

Michael Miloro: My pleasure, Bill.

Bill Klaproth (host): And once again, that's Dr. Miloro. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.