case reports 2022; 8(2)

https://doi.org/10.15446/cr.v8n2.93840

THE POTENTIAL ROLE OF TRIGEMINAL NERVE IRRITATION IN

THE PATHOPHYSIOLOGY OF BELL’S PALSY.
A CASE REPORT FROM A NEURAL THERAPY PERSPECTIVE
Keywords: Anesthetics, Local; Bell Palsy; Facial Nerve; Trigeminal Nerve; Periapical
Diseases; Neurophysiology.
Palabras clave: Anestésicos locales; Parálisis de Bell; Nervio facial; Nervio trigémino;
Enfermedades periapicales; Neurofisiología.

Maura Kawano-Hokama
Universidad Federal de Mato Grosso do Sul -
Faculty of Medicine
Mato Grosso do Sul - Brasil

Lucy Naomi Shiratori-Tusita

Universidad de São Paulo - School of Dentistry
São Paulo - Brasil

Laura Bibiana Pinilla-Bonilla

Universidad Nacional de Colombia
- Faculty of Medicine -
Master’s Degree in Alternative Medicine
- Bogotá - Colombia

Yamile Cruz-Rodríguez
Asociación Colombiana de Terapia Neural
- Bogotá - Colombia

Corresponding author
Laura Bibiana Pinilla-Bonilla.
Universidad Nacional de Colombia, Facultad de
Medicina, Maestría en Medicina Alternativa. Bogotá.
Colombia. Email: [email protected]

Received: 22/02/2021 Accepted: 08/11/2021

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INTRODUCTION

Bell’s palsy is a facial neuropathy that has a sudden onset with loss or decrease of
motor and sensory function of the facial nerve. This disorder may affect partially or
completely, and unilaterally or bilaterally, facial mimicry (1,2).
Full recovery has been observed in 70% of cases, while 16% of them show
moderate to severe sequelae. Convalescence time varies from 15 days to 2 months,
and, in more severe cases, it can last up to 4 years (3). Patients who have expe-
rienced an episode of Bell’s palsy have an 8% risk of recurrence (3,4). Different
incidence rates have been reported depending on the geographic location. In most
published series, incidence rates range from 11 to 40 cases per 100 000 inhabitants
every year, as reported by epidemiological studies in the United States, the United
Kingdom, and Mexico (3-7). The disease has a peak incidence between 15 and
45 years of age, with no sex distinction, and the following are described as risk
factors: diabetes, obesity, high blood pressure, upper respiratory tract infections,
immunosuppression, and pregnancy (1,5).
In 75% of the cases, the cause of this paralysis is unknown (8), but two theories
have been suggested to explain its possible etiology. On the one hand, the vascular
theory describes an imbalance in the extrinsic and intrinsic vascular system of the
intrapetrosal facial nerve. On the other hand, the viral theory suggests that it is the
consequence of a reactivation of the herpes simplex virus type 1 (HSV-1) (1,2,5).
However, one of the possible hypotheses that could support the etiology of Bell’s
palsy is based on the neuroanatomical connection between the V-VII cranial nerves
(9-11), since the maxillary branch has approximately 95% of the communication
with the facial nerve, while the mandibular branch has 75%, followed by the
ophthalmic branch with 34% (12,13).
Neural Therapy has its roots in the physiological current of Nervism, which
emerged in the mid-nineteenth century (14). Nervism proposed that the nervous
system behaved as a functional and integrative unit, playing a leading role in all
the processes of the organism; this approach allowed for a radical change in the
concept of the pathological origin of diseases (15,16). In this approach, disease
started to be defined as a dystrophy that begins with an irritation in the nervous
system that could be cumulative, reflexive, non-linear and irreversible, altering
the final trophism of the tissues (15-18).
From the perspective of Nervism, it could be argued that both nervous and
embryological connections are responsible for the spread of the pathologic
process of the nervous system from a focus lesion point to its segmental connec-
tions (15). Thus, therapeutic and Nervism approaches are directed towards the
modulation of nervous tone and irritations of the nervous system.
The present case report aims to propose that idiopathic facial paralysis or Bell’s
palsy is caused by a cumulative and irritative involvement of the trigeminal nerve, a
hypothesis that is based on a neural therapy approach and the physiological current
of Nervism.
 the potential role of trigeminal nerve irritation in the pathophysiology of bell’s palsy

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CASE REPORT

A 32-year-old woman, an early childhood educator, housewife, from a middle-class

household residing in Mato Grosso do Sul, Brazil, presented in 2018, without an
apparent cause, with an episode of right facial paralysis due to a decrease in fronta-
lis muscle strength. Her symptoms at the time of consultation included incomplete
closure of the right eye, decreased strength of the right eyelid, face asymmetry, and
sensory alterations of the middle and lower segment of the right side of the face.
She did not report pain, alteration in taste, or changes in salivary and lacrimal gland
secretions (Figure 1).

Figure 1. Grade III and incomplete right facial asymmetry.

Source: Image obtained during the study.

At first, the patient opted for a private consultation to the neurology service
at a secondary care institution in the city of Campo Grande, Mato Grosso do Sul,
Brazil, where, due to her symptoms and on the basis of the physical examination,
she was diagnosed with grade III right peripheral incomplete facial palsy, severity
established according to the House–Brackmann score. As a result of her neurology
appointment, she was prescribed treatment with oral prednisone 20 mg/day,
which was administered for 5 days. During the same appointment, a brain MRI
was performed in order to rule out any neurological involvement, obtaining a
normal result. Given the persistence of the symptoms, the patient decided to
consult the private Neural Therapy service after 10 days.
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During the consultation with the Neural Therapy service, upon reviewing the
patient’s medical history, a number of personal medical records were found that
showed previous irritations in the trigeminal nerve area that began at the age of
12 (Table 1).

Table 1. Patient’s medical history in chronological order, specifying laterality,

innervation, and facial nerve branches with anastomoses.

Condition Age Laterality Innervation Anastomosis

Otitis 12 years Right V3, X, VII Facial nerve trunk, sensory

branch of the facial nerve

Parotiditis 15 years Bilateral V3 Facial nerve trunk through

the chorda tympani.
Tonsillitis 23 and 31 years Bilateral IX, X, V2 Zygomatic branch of the
facial nerve
Stye 24 years Right V1, V2 Temporal and zygomatic
branches of the facial nerve

Source: Own elaboration.

At the same consultation, a panoramic X–ray of the mouth was requested

because of her dental history, in which an irritative focus was identified in tooth
16. With this result, the patient was referred to the Dentistry service for treatment
21 days after the onset of symptoms. At that visit, the dentist determined that
there was a chronic periapical lesion in tooth 16 (Table 2).

Table 2. Dental history in chronological order specifying the intervention performed,

dental piece, innervation, and facial nerve branch with anastomosis.

Procedure Age Tooth Innervation Anastomosis

Restoration 21-22 16 V2R* Zygomatic branch of the facial nerve

years
Dental 23 years 28, 38, V2R&L*, Zygomatic branch of the facial nerve,
extraction 48 V3R* facial trunk through the chorda tympani
Damage of 30 years 16 V2R* Zygomatic branch of the facial nerve
restoration in
tooth 16
Restoration 30-31 16 V2R* Zygomatic branch of the facial nerve
years

*R: right.
Source: Own elaboration.
 the potential role of trigeminal nerve irritation in the pathophysiology of bell’s palsy

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At the Neural Therapy consultation, it was decided to start treatment from the
first day of care with 1% procaine infiltrations, subject to prior informed consent.
In this case, a better outcome was obtained after neural therapy stimulation with
submucosal infiltration of 1% procaine in the alveolar branches of tooth 16, which
was performed 20 days after the onset of symptoms. The following day, at the
dental appointment, endodontics was performed on tooth 16 due to the lesion
found. Table 3 shows the dental and neural therapy interventions performed in
chronological order.

Table 3. Neural therapy and dental interventions correlated with patient clinical
response.

Intervention (neural therapy

Course (days from
stimulation with 1% procaine Response
symptom onset)
injection)

10 days Neural therapy stimulation with 1 No clinical changes.

cc of procaine in the right supra-
orbital and infraorbital nerve and
tooth 18.

13 days Neural therapy stimulation near No clinical changes.

the right stellate ganglion with 3 cc
of procaine.

20 days Neural therapy stimulation with 1 Irritation of the right eye

cc of procaine in tooth 16. conjunctiva 8 hours later.

21 days Dental care. Progressive improvement of

Endodontic treatment tooth 16 facial mimicry in 48 hours.
Evolution towards grade I on
the House–Brackmann score.

24 days Dental care. The improvement of facial

Extraction of tooth 18. mimicry is maintained.

25 – 30 days Control without neural therapy Complete recovery of facial

stimulus. mimicry.

2 years later Control. Normal facial mimicry.

Source: Own elaboration.

Within 48 hours of performing endodontic treatment on tooth 16, Bell’s

palsy improved from grade III to grade I on the House–Brackmann score, and
facial mimicry symmetry was recovered. During the treatment, no concurrent
interventions were performed other than those practiced by the Neural Therapy
and Dentistry services (Figure 2).
 case reports vol. 8 no. 2

Figure 2. Symmetry of facial mimicry grade I.

Source: Image obtained while conducting the study.

Two years after undergoing the neural therapy and dental intervention, the
patient returned for a follow-up, in which no adverse reactions to the treatment
were reported, and no neurological sequelae were evidenced in the trigeminal and
facial nerve area. During follow-up, the patient reported feeling satisfied with the
treatment and authorized the publication of the case report.

DISCUSSION

The theory of Nervism defines what happened with the patient as a primary dys-
trophy of the trigeminal nerve, which correlates with her dental history of chronic
periapical lesion in tooth 16 that caused a secondary dystrophy in the area of the
facial nerve by reflex nerve mechanisms. Such dystrophy finally appeared in the
form of paralysis due to the principle of Nervism as stated in Speransky’s theory of
the second stroke or sum of irritations (15,16).
The neuroanatomical connection between the V-VII cranial nerves enables
the association of new theories with Bell’s palsy:

• Bell’s palsy cases have been reported following dental procedures, trigeminal nerve
injuries, and dental and bone infections (19-22).
• Another theory refers to the vascular relationship between the middle meningeal
artery that irrigates both nerves and the ischemic sympathetic reflex of the stylo-
mastoid artery with the motor branch of the facial nerve (23,24).
 the potential role of trigeminal nerve irritation in the pathophysiology of bell’s palsy

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• According to Friedman, the proprioceptive fibers of the facial nerve are received by
the trigeminal nerve at its mesencephalic nucleus (9,25).
• Finally, Bell’s palsy may be related to the cross-connection between the afferent
nerve fibers of the intermediate nerve with the V2 fibers (maxillary nerve or ptery-
gopalatine ganglion) (26).

From an embryological point of view, the trigeminal and facial nerves have
an anastomotic association. In the fourth week of pregnancy, the first branch of
the facial nerve appears and, at the end of the seventh week, the trunk of the facial
nerve bifurcates into a temporal branch and a cervicofacial branch, creating an
anastomosis with the V2 and V3 branches of the trigeminal nerve (27-29).
In the specific field of Neural Therapy, only cases of clinical improvement
of facial paralysis have been reported, but without mentioning the pathogenic
involvement of trigeminal irritation or dystrophy, nor the synergy with the Den-
tistry service (30-32). So far, clinical accounts have been limited to demonstrating
that Neural Therapy can be a viable treatment option after conventional medical
treatment has failed. However, these case reports did not take into consideration
the evaluation of trigeminal nerve irritations as a possible etiologic factor. In fact,
only 2 of the 7 published case reports cite the presence of dystrophic irritations in
the area of the trigeminal nerve, such as dental treatments, temporomandibular
joint dysfunction, tonsillitis, and chronic sinusitis. In these cases, reported in
Turkey, mainly segmental Neural Therapy was performed in the head and neck
area obtaining favorable outcomes (30-32).
The aim of this case report was to propose that Bell’s palsy is caused by a cumu-
lative involvement of the trigeminal nerve, a hypothesis based on the Neural Therapy
approach and the physiological current of Nervism. In this case, the patient who
consulted the Neural Therapy service presented with a clear history of trigeminal
field irritations during her lifetime, with a predominance in the V2 branch, which
were related to the interventions and dental foci described in Tables 1 and 2. Thus, a
new etiologic hypothesis on the pathophysiologic relationship between the trigemi-
nal and facial nerves is hereby proposed, which should be analyzed in further studies
given the limitations of the present study as it is a case report.
Finally, this case exemplifies a situation in which a previous dystrophy or
anterior alteration of the trigeminal nerve through its different branches, cumu-
lative over time, ends up affecting via anastomosis the nervous tone or trophism
of the facial nerve, which has a clear morphological and physiological support
under the premise of the unity of the nervous system.

CONCLUSIONS

This case report not only highlights the role of Neural Therapy in the therapeutic
support of Bell’s palsy, but also represents a contribution to medical knowledge from
a different physiological conceptual framework such as Nervism. It is suggested that
 case reports vol. 8 no. 2

8
obtaining more information on the patient’s clinical history is important to deter-
mine the relationship between the facial nerve and the trigeminal nerve (Table 2), as
it is a useful tool to demonstrate these findings. Furthermore, this article is the first
case report showing the synergy between the Neural Therapy and Dentistry services
for successful therapeutic support in Bell’s Palsy.

ETHICAL CONSIDERATIONS

Informed consent was obtained from the patient, along with authorization for the
publication of her photographs.

CONFLICT OF INTEREST

None stated by the authors.

FUNDING

None stated by the authors.

ACKNOWLEDGMENTS

To the patient, who trusted in the treatment’s purpose and granted us permission to
carry out this report. Also, to our relatives for their support during the development
of this paper.

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