Bill Klaproth: This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth, and with me is Dr. Gary Bouloux, who is here to discuss the quality of life for a patient diagnosed with trigeminal neuralgia. Dr. Bouloux, thank you so much for being here.

Dr. Gary Bouloux: Well, thank you, Bill. It’s a great opportunity. Looking forward to having a great conversation.

Bill Klaproth: I am, too. So, let’s start with this: What is the trigeminal nerve?

Dr. Gary Bouloux: The trigeminal nerve is one of the cranial nerves, a particularly large nerve, and it subserves sensation and some motor function for the entirety of the face.

Bill Klaproth: So, trigeminal neuralgia then is when there’s an issue with the trigeminal nerve causing pain?

Dr. Gary Bouloux: Exactly. Some of the issues with the trigeminal nerve can relate to trigeminal neuralgia, which is a disease unto itself, but there are also other situations where you can have trigeminal pain, not trigeminal neuralgia, still related to the same nerve.

Bill Klaproth: Okay. So where do we sense trigeminal pain? Where does a patient feel that?

Dr. Gary Bouloux: Tri meaning three, the trigeminal nerve innervates the forehead, innervates the mid-face, and then the lower part of the jaw. Those are the three branches which sort of define the trigeminal nerve. So, you can perceive pain anywhere in the head and neck.

Bill Klaproth: That’s all related to the trigeminal nerve then.

Dr. Gary Bouloux: In many cases, it is.

Bill Klaproth: So that’s where an OMS would come in to diagnose this, I would imagine that it is misdiagnosed, people with forehead pain or general face pain, until they come to an OMS, because this is your specialty. Is that when generally a real diagnosis can happen?

Dr. Gary Bouloux: I think that’s an excellent point. An OMS has the ability to evaluate the head and neck region and really is probably the most comfortable individual to manage pain and pathology related to the trigeminal nerve.

Bill Klaproth: And how common is this?

Dr. Gary Bouloux: Exceedingly. If you think of the average individual and the perception of pain, particularly around the mouth and the head and neck, often it’s related to the trigeminal nerve for multiple reasons, whether it be tooth decay, whether it be gum disease, whether it be osteoarthritis of the jaw joint, whether it be other potential sources.

Bill Klaproth: I was just going to ask you, what are the risk factors or the causes of trigeminal pain?

Dr. Gary Bouloux: From an OMS perspective, I think probably the two greatest areas of concern for the trigeminal nerve and its presentation are trigeminal neuralgia, a disease unto itself as said previously, but then there are areas of surgical procedures like wisdom teeth removal, implant placement, trauma with fractures of the facial skeleton, pathology with tumors, and reconstruction. All of those, by necessity, involve surgery in and around the trigeminal nerve that can lead to persistent pain.

Bill Klaproth: Absolutely. So then how can an OMS help with trigeminal nerve pain?

Dr. Gary Bouloux: The first thing is to make the appropriate diagnosis. Therein lies the challenge of having a really good history supported by a good physical examination. And those two things unto themselves really put the OMS in a great place to be able to make the correct diagnosis. Once the diagnosis is made, then it’s a simple case of beginning to manage that pain. In some situations, that can be relatively straightforward, and others can be complicated. Managing can involve a non-surgical approach, which is usually medication-driven, of course, or it can involve surgery depending on the nature of the pathology and where it exists.

Bill Klaproth: So, how do you generally diagnose this then?

Dr. Gary Bouloux: The best way to make the initial diagnosis is based on the history. Because if you ask the right questions about what exacerbates the pain, what makes it worse, what makes it better, then often you can begin to determine what the source of the pain may be. Following that, the physical examination obviously examines the multiple branches of the trigeminal nerve to see if you can stimulate the pain or if you can alleviate it. Occasionally, using local anesthesia to numb or block a particular nerve can be helpful in determining if that branch of the nerve is the source of the pain. Then of course, there’s some advanced imaging which is important for many patients that present with trigeminal pain to ensure there’s no additional pathology that can be more serious.

Bill Klaproth: Are most people able to manage trigeminal nerve main and trigeminal neuralgia?

Dr. Gary Bouloux: If we think of trigeminal neuralgia, it is challenging to manage. It’s typically done medically, and there are several medications or classes of medications that are advantageous. Some patients respond exceedingly well, some patients have a more moderate response, and unfortunately, some individuals do not do well despite a multitude of medications.

Bill Klaproth: It sounds like it’s really painful. Is this a conditions that affects quality of life?

Dr. Gary Bouloux: It is probably one of those conditions that has the propensity to affect quality of life in the most significant and profound ways. It is an exceedingly painful disease and disorder that can really be debilitating to a patient on multiple levels, both physically and psychosocially.

Bill Klaproth: It does sound painful, absolutely. Are there any other treatment methods that you use? I know you’ve mentioned some of them. What is the efficacy of those treatment methods?

Dr. Gary Bouloux: Medication is probably the initial choice for the majority of patients, as long as imaging does not suggest the presence of a tumor or multiple sclerosis or other conditions that can lead to trigeminal neuralgia. The medications are typically antiseizure or anticonvulsants, sometimes muscle relaxants and occasionally botulinum toxin. The efficacy of the anticonvulsants is reasonably good, but there are side effects related to those doses. Some of the antispasmodics are a little kinder from a systemic point of view and have less side effects, but maybe not quite as beneficial as the anticonvulsants. And Botox has limited evidence to support it, but it still has some.

Bill Klaproth: So, when is it time to see an OMS? I know most times OMSs are being referred by a general practitioner. When should someone go directly to an OMS if they’re not getting answers to this pain they’re feeling?

Dr. Gary Bouloux: I think the sooner the better. The more active you are in beginning to control the trigeminal neuralgia or trigeminal pain in general, the better the outcome is going to be for the patient. Not only from a quality-of-life point of view, but the longer the chronicity of the pain, the more the neuroplasticity of the brain plays a role in perpetuating the pain despite attempts to alleviate it. So, early intervention I think is important.

Bill Klaproth: Okay, well that’s good to know. And Dr. Bouloux, anything else you want to add as we’re talking about trigeminal nerve pain and trigeminal neuralgia?

Dr. Gary Bouloux: Just that there are some surgical procedures which are very beneficial, and your OMS certainly can perform several of those procedures related to peripheral causes of trigeminal neuralgia and trigeminal pain, and we often work in close concert with neurology and neurosurgeons to manage more centrally driven trigeminal neuralgia pain including microvascular decompression, Gamma Knife and of course rhizotomy. But there are treatments and medications that can make life substantially better if it’s recognized early.

Bill Klaproth: Well, that is the good news. Well, Dr. Bouloux, thank you so much for your time.

Dr. Gary Bouloux: I appreciate it. Thanks for the opportunity.

Bill Klaproth: Once again, that is Dr. Bouloux, and for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels, and don’t forget to subscribe. Thanks for listening.