"--

~
~,.
.'

'--'--------

',J

reduced for a short period of time.

15.

"".

~'

r,~. . f'~~

'"

'"

" .;

". ",

";:

/$,,;:,.'

Clinical laser tteafiftent

of neural aibnents
,

.'"

~',jIj

~"';

'

11\

'.'

This chapter willdiscuss a group of pain-Au;ing ailments whiJh are.'__.',. ;~i,.'>

difficult to define in relation to other painful conditions. The main '.,. . ;, "Ii

Points in the reddest and most swollen areas near the palatine arch
and the tonsils are treated with 2 J each. Additionally, 2 J are delivered
just under the angulus mandibulae bilaterally. The total dosage is 1418 J. If jaw function is reduced, this will also ~ normalised fhirty

quickly.

,.

, '~

::

",",

,.,

~" "

'"
Once again, there is a serious lack of controlled clinical experimental
material. However, those who have atlempted to treat pharyngitis
with the laser have lillie doubt as to its effectiveness.!t is possible to
eliminate pain while swallowing in 9 out of 10 patients within 10
minutes after laser treatment. In cases of severe tonsillitis, pain can be

--.,

... ~,C

.i.
"I'g~
Y'

~'n~ilis

.,.

..-

--

," "',~~

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

pheral or central nervous

system.

'"

"

.'

.~o<

'.

1
The practical teason for discussing these ailments separatelyis that' ",,:ie,
laser treatment and patient reaction to treatment differs !ion! that'
,.j,.
,

discussed
previousthis
chapters
a number
of ways.that is the mostt'
Generallyin
speaking,
is theingroup
of ailments
difficult to treat with the laser. On the other hand, one can loften
I

achieve extremely positive results

.I

-particularly when one considers

the resistance to treatment demonstrated by these patients.

Therefore, it is very important to describe the patient's pain and

symptoms very accurately before the first treatment is administered.
This is because patients have a tendency to forget how much pain they
had before therapy. Also, the pain and symptoms often change,char-

acter during therapy

Accordingto duration

~,

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

1

Acute (up to 2 months)

, Subacute (2 6 months)
',Chronic '(more than 6 months)

"'-'""

.~

Centrill

According to origin

{,

Accurding to locntion
~

II

",

I
i

~\,

Peripheral
Viscerally

According to scope

'~

"

Locally(at the source)

Communicated (felt in an area other.than at the source)

Radicular/projecting(pain whichshootsout in the innervation region

for a root or peripheralnerve)
I
Headache

'i

Facialpain
Back pain
Pain in extrcmities,eiC.
The pain description should include the followingpoints:

\,.

-~~~i@:;,;.j.,';,;;'

I'

- -

Start

".

neuralgia is charaderised by attacks of.

pain which last longerand are lIequently accompanied by .

Provoked, gradual, or sudden appearance?

Atypical trigemillal

Where docs it hurt?

pain between attacks.

"1'

Locatiun
Pain rlmrarteristics

Atypical facial paillis characterised as non-neuralgic pain Wi

be communicated or in rarer instances, radiated. Pain is one.
in the profound facial structures and are frequently piercing.
sive, throbbing or buming in character.

. Is the pain constant or dOl'S it vary?

Is it oppressive, piercing, throbbing, stinging, burning, Slabbing,
shooting, sharp?
.

Process

Pain intensity

Compare with known pains.

Course amI duratiun

Always present? Variations?'Can the patient sleep at night?

Proloking or
aggra,'ating f:\ctors

Docs the pain becomcs worse in .certain physical positions or while

pcrfolluing particular movements/functions? Under stressful condi-

Pain-redu~ing
f:\ctors
Prc,'ious trcatmcnt

Improvement

,'
'\ ~

.
i

I
Facial pain
j

tions?

".

The anamnesis is taken, with particular attention focused 4

scIiption of the pain/symptoms as described earlier in this c
711('objectil'l' examillation is performed by palpating the fa
oughly with both hands, starting medially from the border
the innervation of the two sides of the trigeminal branches.
Additionally, the oral region should be palpated.

It is important to record the location of all significant tenders)

trigger zones, that is to say, areas where a light touch sets of)

while resting or sleeping? By changing positions?

Palpation tenderness is usually found in:

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

treatment'l
.
.
.

I. infraorbial foramen

We h!:lvechosen to divide the relevant painful conditions into the

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

.~

2. mental foramen
3. supraorbital foramen
4. mandibular foramen

Typical trigeminal neuralgia

Atypical
trigeminal neuralgia
...
Atypical facial pain

5. foramen platium major

6. foramen incisivum

Radicular!pain in
the extremities

'See Chapter 16.1

7. angulus mandibulae

})Caffcrcnl pain

Anaesthesia dolorosa

8. hinge of tl1Cjaw
9. the tcmples

-..

10. the points at whichtheos nasale.processuslIontalismaxil

the os frontale meet

Phantom pains
Post-herpetic pains

11. at the fossa canina

Intraoral tender spots can be found at:

Facial
. pain

.'

Typical
.!

trigemillal

Radjating.
.

"

".

TIigger zones are also located

'The ppin radiates out in one oCthebranchesof the trigeminalnerve.In

rarcr instances, thc pain will occur in two branches.

; "

!i1'(~

1. the sidc and under tl1e tongue

t
2. in the medial and lateral pterygoideus

by:

neuralgic pains which occur during attacks which last up to

several mimJtes.
,

lIeuralgia is characterised

The pain most often occurs during the day and can be triggeredby
talking, chcwing, brushing the teeth, or while eating and drinking.
Many patients have an area of skin or mucous membrane which is
scns,itivc to slight stimulations which set off the pains, a so-called
."trigger zone",

I~ 1.'
,-

..~

.1.

--

The points
h~veTlus
beenwill
located
are treated
with an
appJ1
dosage
fromwhich
0.5 - 4!/.
be discussed
in more
detailla

- ---

.,

.i.

TI1prinriple, wc do not dillhcntiate bctwecn thc various types offhcial

pain.

Pain

Fig.t5.2

",t

On thc other hand, the objcctive examination as well as the patient's

reaction \\;11result in a difTerence in the way various types of f.'1cial
pain are treated.

"

~"'ii>

~.. q

Thus, a typical case of trigeminal neuralgia will usually only rcquirc

treatment at a few points, and with a lowcr dosage than that needed in
thc trcatmcnt of an atypical case"

'" ~
;;~

"

,<,

~,

I
.
.

If, during the coursc ofthcrapy, positivc trcatment rcsponsc does not
occur, thc paticnt should bc recxamincu in order tu locate any,tcmJcr
spots which may have been overlooked earlier. It is also important to
note any new tender spots which have appeared as a result of the
changes which have taken place during therapy.

.:

..
.:

"::

Palpation tenderness 0
::"
'---~'

" '--

I'

II
o'

With regard to trigeininal patients who have undergone a neurosurgical procedure or alcohol blocks, please refer to the section on deafTcrent pain.

',',

',:,'.

'.

':'

,/

.::..~,,;

,'::r.j;,

1 ...
I., '.

.I "'
:~ ""

---,'

,...

Time

Pain phase

I Dosages

First trcatment
Points/duration

acutc

- dosagc

A schcmatic rcpresentalion of the course of therapy over a period 00

6 rhonths for
a patient suffering from chronic trigeminal neuralgia. The pain curve i~ mcant to
symbolise the fact that pain peaks become less and less intense as whll as less
frequen\. The eonstant'pain also decreases.',
The most important physical sign whcn determining thc patient's prognosis is
decreased palpation lenderness.
~.
Most patients will pass through a phase where there is limitcd pain. but pronounced
palpation tenderness still exists. In these cases;"the 'Pain will return within 2 3
months. The dOlled line illustrates this course.Therefore. laser therapy treatments
should be administered about every 4 weeks until palpation tenderness is gone. The

PCI'point

subacute

chronic

tcnder spots

IJ

1.5 J

2J

trigger points

0.5 J

0.5 - I J

0,5 - I J

Chronic paticnts should not receive a total dosage which is in excess of

20 25 J during the first treatment. Acute patients can toleratc slightly
higher dosages. During intraoral treatment, acute patients will often
experience increased pain which later subsides.
,

long-term prognosis is good.

Treatment reaction

t,

tntermediate phase Symptom.frbe

"'.

~ '..~

'.
,

'"

",

If no treatment reaction occurs following thc first treatment, the

dosagc should bc doubled for thc next treatment. This can be repcated
if necessary.

The first part of the course of therapy is called the "pain phase", which

The treatment reaction will typic;tly be quite pronounced.

I. "pain peaks" during attacks will become less intense.

2. Tile time interval between atlacks will become longer.

Whcn treating acute conditions. an immediate improvement can be

made. In all other cases. it is imp0l1ant to prepare the patient for the
intensified attacks of pain which will fotlow, This reaction usually
occurs during the first 24-hour period, but in some cases will occur
within a matt.er of minutes. The reaction can last (j'OInsevcral \tours
up to an cntirc day. Ilowevcr, in some cases these intcnsified symptoms can last for sevcl-al days and in mre instances evcn longcr.
I
'
The basicprineiplc to remcmber is that the patient should hot be
treated again before the previous. treatmcnt reaction has completcly
subsided.

The typiCalcourse of therapy is iIIustratcdin Fig. 15.2.

This graph
.. ., shows
"_.. ,'the relationship
:--' --.:--. between timc and pain Icvclin a

nonnally lasts 3

-,6 weeks.

During this phase:

3. Th~ levcl of the patient's "basic pain", often described as a constant

throbbing will decrea,se.
As shown in 'Fig. \5.2, the paticnt's palpation tcnderness will also
,

(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 prcsent
during thc entire intcrnlcdiatc phasc.
\t is important to continue laser treatment of tender spots until all
tenderness is gone. In other words. even though the patient may not be
experiencing attacks of pain. therapy should continue, If therapy is
cominued, the remaining tenderness will eventually disappear and the
uain allacks wil! '!otreturn.

III.15.2

fig. ]5.] :'.

Allhc
suproaorbital
fofamc n
At the ruot
of the nose,
near the eye i
At the
inIl'aorbital
foramcn

Temple

Jaw joint

:.
Ramus

Ncar the
caninc tceth

Angulus

At the base
of the foramen
mcntalis

A patienl with trigeminal

neuralgia is usuall\' Irealed
altender spots at ihe hinge
of the jaw and the angulus.

Ill. 15.3

A schemalic represenlation of Ihe most common extraoral POinlS trcaled in conjunclion wilh facial pain. The allachmenl of slcrnocleidomasloideus
as well as al
v~rtebrae C I-C2 should be normally be treated. 100.

'\

,..~,\

Ill. 15.] and 15.2

'...
-'-""

111.15.1

..,~. '.:'

111.15.4

i"
I

..

.,i'

"

~.

III. 15.3 slid 15.4

'-,

II is importanilO find and

(real all intraoraltcnda
sputs. \\'hen Ireating these

spots. the patienl

\\

ill uften

e~periencc a period of
more inlense pain IQllo\\cd
b)' a ~riod of relaxation.
\