REMEMBERING PROF. T. N. CHAWLA BY HIS LECTURE ON DENTOFACIAL PAIN

 

Professor T.N. Chawla, was the Head of Dental Department of King George’s Medical College when we were in 7^th Semester. In fact, he headed the Dental Department from 1950 to 1980 and was an extremely well known and respected name in Dental Education. He later served as the first Dean of the prestigious Faculty of Dental Sciences, as a separate dental faculty at KGMC. He established the Department of Periodontology at KGMC in 1965 with a grant from PL 480 and was recognized for his contributions to the field of periodontology.

 

Prof. Chawla was an excellent teacher and many of his students went on to head several teaching units in India and abroad. His contributions to Periodontics is commemorated by the 'Dr. T. N. Chawla Award’  which is given annually in his name for the best thesis in Periodontics.

 

After finishing his Graduation, Prof. Chawla went on to do his MS under the stewardship of the legendary Prof. Irving Glickman at Tufts University, Boston. He returned to India to establish a full- fledged, Dental Department at King George Medical College Lucknow, as early as in 1952. Prof. T.N. Chawla was the first Dean of the Faculty of Dental Sciences at King George's Medical College. A keen researcher in periodontology, he was recognized for his research on fluorides and dental caries control; and oral prophylaxis' impact on periodontal tissues and oral health.

Periodontics is a branch of dentistry that deals with the prevention, diagnosis, and treatment of diseases affecting the tissues surrounding and supporting the teeth, collectively known as the periodontium, which includes the gums (gingiva), alveolar bone, cementum, and periodontal ligament. The term comes from the Greek words “peri” (around) and “odont” (tooth), reflecting its focus on the structures around the teeth

 

Prof. Chawla was always very smartly dressed in suit and wore a white starched apron. I remember him visiting our school, Colvin Taluqdar’s College, and in a zero-hour period, explain to us, the school kids, the importance of dental health. The impact which he left on our impressionable minds was truly mesmerizing. He was a very good under-graduate teacher and as the teachers from Dental Faculty had only a handful of lectures in our MBBS curriculum, this lecture on Dentofacial Pain is still vivid in my memory.

 

Dentofacial pain can be either odontogenic or non-odontogenic in origin

A. Odontogenic

1. Tooth

·         Pulp

·         Periodontal  - priodontitis, pericementitis

2. Jaw

·         Alveolitis

·         Dry socket

·         Osteomylitis

B. Non odontogenic

1.Tempor-mandibular joint

·         Arthritis – Arthralgia, Subluxation, Clicking

·         Neuritis – Costen’s Syndrome

·         Bruxism

2. Para nasal sinuses – Sinusitis, CA. Maxillary Antrum

3. Otalgia – Ac. External otitis, Chronic Suppurative Otitis Media (CSOM)

4. Ophthalmic

·         Iritis / Iridocyclitis

·         Herpes Zoster Ophthalmicus

·         Retrobulbar Neuritis

·         Heterophoria

·         Acute Glaucoma

·         Chronic Blind Eye

5. Inflammatory

·         Sialadenitis – Parotitis, Submandibular sialadenitis

·         Lymphadenitis – Pre auricular, Submandibular

6. Malignancy

·         CA. Tongue

·         CA. Oropharynx / Nasopharynx / Laryngopharynx

·         Ca. Maxillary Antrum

7. Spirochetes – Lymes Disease

8. Idiopathic

Myo-facial pain - muscular

Neuralgia

·         Trigeminal

·         Sphenopalatine

·         Glossopharyngeal

Neurovascular

·         Migraine

·         Temporal Arteritis

·         Histamine Cephalgia

·         Tension Headache

9. Psychosomatic – Psychalgia, Hysteria

10. Referred pain – Angina pectoris

Idiopathic pains and psychosomatic pains are non-organic and all the rest have an organic cause, which the treatment protocol needs to address.

 

Odontalgia: Odontalgia can either arise from the pulp or the periodontium. Pulpitis is the inflammation of the vessels and nerves in the pulp and it occurs when the pulp is exposed to various irritants – thermal, mechanical, chemical or bacterial. Pulpal pain is difficult to localize, as no proprioceptive fibers are present in the pulp chamber. It is only when the inflammation extends to the adjoining periodontium that localization of pain is possible. Careful clinical examination and radiography helps in differentiating pulpal pain from periodontal pain. However gingival recession, looseness of tooth, pocket formation or loss of bone points towards a periodontal disease.

      

 

Trigeminal Neuralgia: Trigeminal Neuralgia or tic douloureux is an intermittent pain of great severity, which commences in the 3^rd. or 2^nd. division and extends in time to the adjacent division, the ophthalmic division usually escaping. Occurring predominantly in females, the cause is usually unknown but considered related to the infection of the nerve by herpes simplex virus. The duration of the pain is brief to start with but gradually the pain free interval reduces, and eventually the patient has almost continuous pain and may become suicidal. The pain is described as red-hot needles searing the flesh and often has certain definite trigger zones. Spasms of pain are initiated by external stimuli like cold draughts, brushing teeth, washing, speaking, eating or drinking hot or cold substances. Treatment starts with oral analgesics like Tegretal. If pain gets incapacitating then 4-5 ml of absolute alcohol is injected into the Gasserian Ganglion. Relief from pain and anaesthesia stays from 6 months to 2 years after which the sensations return and so does the pain. 7.5% phenol in myodil injected into the ganglion under X ray control produces relief of pain without loss of sensation. Partial division of the sensory root of V cranial nerve, preserving the upper and inner 1/3 of the root, which has the fibers of ophthalmic division, by micro-neurosurgery, may bring lasting relief.

 

Sphenopalatine Neuralgia: Sphenopalatine Neuralgia or Sluder’s syndrome is a condition where there is pain about the eye, upper teeth and upper jaw, extending sometimes to zygoma and temple and occasionally producing earache and pain in and around the ear and mastoid. Photophobia, lachrymation, rhinorrhea, glossodynia and loss or diminished taste sensations are also frequent. Unlike Trigeminal Neuralgia the pain is more constant, lacking the severe paroxysms. The Sphenopalatine (Meckel’s) ganglion is believed to be irritated by infection or hyperplasia of sphenoid or posterior Ethmoid sinuses. The best diagnostic tool is to anaesthetize the Meckel’s ganglion and most permanent result is obtained by injecting absolute alcohol.

 

Glossopharyngeal Neuralgia: Severe explosion of pain either in the region of tonsils or deep in the ear with a trigger zone in the tonsillar area is characteristic. The diagnosis is clinched by the fact that instilling or injecting local anaesthesia in this region relives the pain. In genuine cases the Glossopharyngeal nerve needs to be divided. The nerve can be approached in the tonsillar fossa after tonsillectomy, or through the posterior fossa as it enters the jugular foramen.

 

Paranasal sinusitis: Very hard to differentiate from odontalgia because of the close proximity of the teeth and maxillary sinuses, there is always a suggestive history of recent cold or influenza. If the pain is bilateral and improves on sitting up it is often frontal sinusitis. If the pain is unilateral and gets relieved on recumbent posture it is maxillary sinusitis. Bony tenderness over sinuses and painful tapping over more than one tooth of the upper jaw suggests a sinus lesion rather than a tooth lesion. Sinus pain is aggravated on walking and bending over. Transilluminating the sinus in a dark room clinically and cloudy sinus on radiography confirms the diagnosis. One should never be in a hurry in extracting teeth in presence of an existing allergy or cold.

That is how our lecture on Dento-facial pain ended. Whenever I see a patient of Dento-facial pain this lecture comes up vividly in my mind and helps me to come to a diagnosis.

Prof. Chawla's son Shobhit is a very accomplished Ophthalmologist, practicing in Lucknow and a wonderful friend, doing justice to the family legacy.