Dr.

Carmen Adella
Sirbu
MD, PhD, MPH,
 12 perechi
echivalenti cu nnv. spinali
functional - 3 grupe :
motori - III , IV , VI , XI , XII (3461112)
senzoriali - I , II , VIII (128)
micsti - V , VII , IX , X (57910)

2
 Receptorii in mucoasa nazala
Controleaza mirosul.
De examinat cand pacientul se
plange de inapetenta
Sapun sau cafea, teste standardizate cu 12-40
subst.
nu substante intens odorizante precum
amoniacul care se deceleaza si prin trigemen (
pentru conversivi, simulanti)
Cu ochii inchisi pe rand ambele nari
Analiza cantitativa a olfactiei in depistarea
precoce a B Parkinson si B Alzheimer (hiposmia e
prezenta in fazele timpurii la 85-95%)
Figure I from Table 13.2
 Permite virusilor,
prionilor si
anumitor metale
grele sa patrunda
in creier de-a
lungul cailor
olfactive
 A plecat din Timioara
Singurul "nas" romnesc
din cele 400 ai lumii.
distinge peste 3000 de
ingrediente.
Un romn care a studiat
la Versailles,
A deschis un laborator
lng Turnul Eiffel,
A publicat trei crti de
specialitate
Om-6 mil R olfactivi-25 cmp-mucoasa nazala
Iepure-100 mil
Caine- 220 mil

Nasul este cunoscut ca organul pt miros dar si

gust, limba deceland doar cateva gusturi
-amar,
-dulce
-sarat
-acru
Restul gusturilor sunt decelate de R olfactivi din
nas.
 chimistul Kikunae
Ikeda de la
Universitatea din
Tokyo, Japonia.
Umami-glutamatul de
sodiu, un aminoacid
Umami=asemanator
Kikunae Ikeda
parmezanului
Born-8 October 1864
Extras din grau si soia Died-3 May 1936 (aged
71)
Science Faculty of the
Tokyo Imperial University
 Anosmia absenta mirosului
Disosmia distorsiunea
Hiperosmia accentuarea
Hiposmia scaderea
Parosmia interpretarea eronata
Fantosmia halucinatii olfactive
Cacosmia-neplacte
Agnozii olfactive-imposib. discriminarii olfactive
Daltonism olfactiv-neperceperea unor mirosuri
Olfactory Reference Syndrome psychological
disorder which causes the patient to imagine he
or she has strong body odor
 Simtul mirosului diminua cu inaintarea in
varsta.
cauze de anosmie bilaterala sunt raceala si
traumatismul nasului.
boli neurologice associate cu hiposmia sunt
Boala Parkinson, dementa, deficitul de vit. B12.
Anosmia unilaterala poate indica o tumora
frontala.
De obicei hiposmia este asociata cu tulburarea
gustului.
 Clorfeniramina
Antib-ampic.,streptomicina, tetraciclina, metron.
Azatioprina
Doxorubicina
Metotrexat
Captopril
Alopurinol
Metformin
Carbamazepin
Fenitoin
Codeina
Morfina
http://www.lung.org/our-initiatives/healthy-air/indoor/indoor-air-
pollutants/
Asbestos
Bacteria and viruses
Building and paint products
Carbon monoxide
Carpets
Cleaning supplies and household chemicals
Cockroaches
Floods and water damage
Formaldehyde
Lead
Pet dander
Radon
Residential wood burning
Secondhand smoke
Volatile Organic Compounds
Poor indoor air quality can cause or contribute to the development
of infections, lung cancer and chronic lung diseases such as
asthma. People who already have lung disease are at greater risk.
Find out what makes indoor air unhealthy and how pollution can
hurt your body.
 Receptorii la nivelul retinei in
globii oculari, conuri si bastonase
controleaza ved. centr si perif
fovea in centrul retinei e
responsabila de vederea centrala.
Punem pacientul sa citeasca si
apoi sa vada degetele exam in
fata lui.
Vederea periferica testata pe rand
, pacientul privind la nasul exam.
 Oamenii reusesc sa distinga in medie 100 de
nuante cromatice (intre 140 si 50).
Acestea sunt nuante cromatice pe care oamenii
obisnuiti le pot utiliza.
Standardele industriale utilizeaza cca.5000 de
nuante cromatice, iar numarul de combinatii si
nuante posibile pe cale digitala a ajuns la
aproximativ 70.000.
Intensitatea radiatiei sau stralucirea, provoaca
modificarea nuantelor cromatice
 Snellen Test - ask them to stand at 6
metres (measure it out if you need to) and
read out the lowest set of letters they can
see. In a traditional test, there will be 11
rows of letters, the row with 8th row being
the smallest a person with 6/6 vision can
read. The biggest letters represent 6/60
vision. Often a smaller 3m Snellen test is
used on the ward due to lack of
space! Patients should wear their normal
glasses if they have any. You are not an
optician just looking for any serious
visual defects! Make sure to test one eye
at a time! ask the patient to cover their
eye; just asking them to close it isnt good
enough (as it can be difficult for patient,s
and they may partially close the eye you
are assessing, which obviously has
implications for your results!)
Near Vision using the appropriate
booklet, ask the patient to read some
lines to test near vision
Cecitate
cromatica/discromatopsie/ Protanopie daltonism=nu vede
rosu
Deuteranopie-nu vede verde
Cecitatea cromatica apare mai des
la barbati (in proportie de 3-4%) si
mai rar la femei (0.5%).
Atunci cnd este motenit (n cele
mai multe cazuri),discromatopsia
este provocat de un cromozom X
care are un mic defect.
Vederea cromatic n zona rou-
verde este codat pe cromozomul X,
de aceea este numit trstur legat
de sex (englez: sex-linked trait).
Daca un brbat are un cromozom X
defect, va suferi de discromatopsie.
Dac femeia are unul defect i unul
corect, ea va fi doar
purttoare de defect.

http://colorvisiontesting.com/ishihara.htm
 controleaza pupilele-mioza.
ridica pleoapa
acomodeaza cristalinul
Figure III from Table 13.2
 Exclusiv motor
Cel mai scurt nerv
Misca GO in jos si
ext
Diplopie verticala
Nu poate cobori
scarile
F rar afectat singur
Figure IV from Table 13.2
 Inerveaza toata fata mai
putin unghiul extern al
mandibulei-C3
Testam sensibilitatea fetei
si a scalpului.
Motor: temporal, maseter.
Corneal reflex
Figure V from Table 13.2
Motor:
Se palpeaza muschii masticatori, contractia muschilor
maseteri si temporali cu gura inchisa; se examineaza
rezistenta la inchiderea si la deschiderea gurii.
Reflexul mandibular: Se roaga pacientul sa deschida gura
usor, cu muschii relaxati. Se percuta degetele asezate usor
pe mandibula pacientului. Pacientii normali nu au nici un
reflex. Un reflex accentuat indica leziunea neuronului motor
central.
Reflexul corneean: Se executa la pacienti cu pareza Bell, la
comatosi, sau la cei suspicionati a avea leziuni in trunchiul
cerebral sau in sinusul cavernos. Fascicolul aferent al
acestui reflex este reprezentat de NC V iar cel eferent de NC
VII.Reflexul corneean se testeaza atingand usor corneea (nu
sclera), cand pacientul priveste in directia opusa. Cand
reflexul este absent bilateral se ia in considerare o leziune a
nervului trigemen sau o leziune pontina; daca e absent
unilateral, o leziune pontina sau cerebelopontina.
 afecteaza rar ramura oftalmic, frecvent ramura maxilar i
mandibular. Se caracterizeaza prin dureri fulgurante,
unilaterale, fr deficit senzitiv i fr tulburri reflexe aprute
la aduli i vrstnici. Vrsta de apariie este n medie 56- 58 de
ani, raportul femei/brbai 3/2.
Localizare: frecvent unilateral (buze, obraz, menton, foarte rar
oftalmic)
Caracter: paroxisme dureroase intolerabile, tresriri (tic
dureros).Sunt declanate prin stimularea unor zone ale feei,
buzelor, limbii, prin mobilizarea lor, mai frecvent prin stimuli
tactili dect prin stimuli termoalgici. ntre crize: fr dureri.
Durata: cteva secunde pn la 1-2 minute
Frecven: ziua i noaptea, mai multe sptmni.
Se asociaz cu: roeaa tegumentelor i mucoaselor, cu sau fr
lcrimare, spasme ale muchilor hemifeei (orbicularul
pleoapelor).
Examenul obiectiv este normal.
Confirmarea diagnosticului se face prin excluderea cauzelor de
nevralgie secundar.
1.Vasculare
ncruciarea nervului V cu artere ce au pulsatilitate crescut (artera bazilar
cu ectazii), alteori ramuri bazilare redundante ce ncrucieaz traiectul lui
V.
Aici poate s apar hemispasm facial prin ncruciarea nervului VII de
ctre aceste artere. Apar focare ectopice prin contactul cu vasele de pe
parcursul nervilor, care produc excitarea nervului.
nregistrrile cu microelectrozi arat o activitate paroxistic similar
epilepsiei, ceea ce explic caracterul paroxistic.
2.Traumatisme:
prin ntreruperea ramurilor nervoase.
3.Neoplazii
gliomul infiltrativ de trunchi cerebral irit prin substanele pe care le
emite pe traiectul intranevraxial al nervului V. Apoi, odat cu invazia ramurilor
nervoase apare nevralgia secundar de trigemen (tulburri obiective de
sensibilitate, mai ales la tineri)
4.Boli demielinizante: placa demielinizant se comport la fel; 30% din
nevralgiile eseniale la tineri sunt un debut de scleroz multipl.
5.Infecii:
herpes zoster (keratit herpetic)
herpes simplex (ramura maxilar i mandibular)
Medicamentos:
1)Carbamazepin- eficace la debut n 75% din
cazuri, apoi apare toleran n aproximativ 3 ani.
100mg ntr-o priz, apoi se crete treptat pn la
200mg de 5 ori pe zi, cu monitorizarea nivelului
seric si a probelor hepatice. Doze mai mari de
1200mg nu aduc beneficii suplimentare.
2)Fenitoin 300- 400mg/zi sau i.v. n criz
3)Antidepresive triciclice sau fenotiazine
4)Baclofen 50- 60mg/zi
5)Gabapentin: un nou antialgic central eficient,
mai bun dect n epilepsie unde e folosit ca
adjuvant (de a doua alegere).
Aproximativ 70- 80% rspund la medicaia conservatoare.
Restul se trateaz chirurgical:
-Seciuni pariale de nerv oftalmic (s-a cam renunat pentru c dau keratit)
-Rizotomii selective n regiunea bulbar pe ramul descendent pentru
sensibilitatea nociceptiv cu pstrarea celor ascendente pentru
sensibilitatea tactil.
-Termocoagulare stereotactic
-Infiltraii prin gaura oval:
-cu alcool n ganglionul Gasser
-cu glicerol (efect probabil prin apoptoz local)
-Decompresiune microvascular prin craniectomie suboccipital- 80%
eficacitate. Mortalitate: 0,4- 1,6%.Reacii adverse: afectarea nervilor VII, VIII,
recidiv, herpes labial 50%.
 17 November 2013
 When you speak with a dental malpractice attorney at our Florida
law firm, he or she will first determine whether you have a case.
While dentists cannot guarantee the success of any treatment or a
specific medical result, they can be held accountable when their
negligence leads to a patients injury.
If our attorneys determine that your dentist was negligent, you
may have a claim for medical malpractice.
In preparing your claim, our attorneys will collect evidence and
witness statements; request medical files and other documents;
analyze the prevailing case law which relates your claim; file
motions and other paperwork;
and handle correspondence with the insurance company.
Additionally, we will work with medical experts who can help
prove that your dentist was negligent, as there are often varying
opinions in the medical field as to the definition of reasonable
care.
 Introduction. Trigeminal neuropathy is most often secondary to trauma.
Material and methods. A retrospective case study was made involving 63
patients with trigeminal neuropathy of traumatologic origin, subjected to
follow-up for at least 12 months. Results. Fifty-four percent of all cases were
diagnosed after mandibular third molar surgery. In 37 and 19 patients the
sensory defect was located in the territory innervated by the mental and lingual
nerve, respectively. Pain was reported in 57% of the cases, and particularly
among the older patients. Regarding patient disability, quality of life was not
affected in three cases, while mild alterations were recorded in 25 subjects and
severe alterations in 8. Partial or complete recovery was observed in 25 cases
after 6 months, and in 32 after one year. There were few recoveries after this
period of time. Recovery proved faster in the youngest patients, who moreover
were the individuals with the least pain. Conclusion. Our patients with
trigeminal neuropathy recovered particularly in the first 6 months and up to
one year after injury. The older patients more often suffered pain associated to
the sensory defect. On the other hand, their discomfort was more intense, and
the patients with most pain and the poorest clinical scores also showed a
comparatively poorer course.
 Br Dent J. 2010 Nov;209(9):E15. doi: 10.1038/sj.bdj.2010.978.
Abstract
OBJECTIVE:
This study reports the signs and symptoms that are the features of trigeminal nerve
injuries caused by local anaesthesia (LA).
METHODS:
Thirty-three patients with nerve injury following LA were assessed. All data were
analysed using the SPSS statistical programme and Microsoft Excel.
RESULTS:
Lingual nerve injury (LNI; n = 16) and inferior alveolar nerve injury (IANI; n = 17)
patients were studied. LNI were more likely to be permanent. Neuropathy was
demonstrable in all patients with varying degrees of paraesthesia, dysaesthesia (in the
form of burning pain) allodynia and hyperalgesia. All injuries were unilateral. A
significantly greater proportion of LNI patients (75%) had received multiple injections,
in comparison to IANI patients (41%) (p <0.05). Fifty percent of patients with LNI
reported pain on injection. The presenting signs and symptoms of both LNI and IANI
included pain. These symptoms of neuropathy were constant in 88% of the IANI group
and in 44% of LNI patients. Functional difficulties were different between the LNI and
IANI groups, a key difference being the presence of severely altered taste perception in
nine patients with LA-induced LNI.
CONCLUSIONS:
Chronic pain is often a symptom after local anaesthetic-induced nerve injury. Patients
in the study population with lingual nerve injury were significantly more likely to have
received multiple injections compared to those with IANI.
 J Oral Maxillofac Res. 2014 Dec 29;5(4):e2. doi: 10.5037/jomr.2014.5402.
Shavit I1, Juodzbalys G1.
OBJECTIVES:
The purpose of this article is to systematically review diagnostic procedures and risk factors
associated with inferior alveolar nerve injury following implant placement, to identify the time
interval between inferior alveolar nerve injury and its diagnosis after surgical dental implant
placement and compare between outcomes of early and delayed diagnosis and treatment given
based on case series recorded throughout a period of 10 years.
MATERIAL AND METHODS:
We performed literature investigation through MEDLINE (PubMed) electronic database and
manual search through dental journals to find articles concerning inferior alveolar nerve injury
following implant placement. The search was restricted to English language articles published
during the last 10 years, from December 2004 to March 2014.
RESULTS:
In total, we found 33 articles related to the topic, of which 27 were excluded due to
incompatibility with established inclusion criteria. Six articles were eventually chosen to be
suitable. The studies presented diagnostic methods of inferior alveolar nerve sensory deficit,
and we carried out an assessment of the proportion of patients diagnosed within different time
intervals from the time the injury occurred.
CONCLUSIONS:
Various diagnostic methods have been developed throughout the years for dealing with 1 quite
frequent complication in the implantology field - inferior alveolar nerve injury. Concurrently, the
importance of early diagnosis and treatment was proved repeatedly. According to the results of
the data analysis, a relatively high percentage of the practitioners successfully accomplished
this target and achieved good treatment outcomes.
 The plaintiff, age thirty-three, went to the defendant dentist for evaluation. At
the plaintiffs next visit to the defendant, three of the plaintiffs wisdom teeth
were extracted. The procedure took six hours.

The plaintiff claimed that she suffered injury to the trigeminal nerve, causing
permanent trigeminal neuropathic pain. The plaintiff claimed that the defendant
dentist failed to appreciate the significance of the bony involvement of her third
molars and the proximity of the third molars to the inferior alveolar canal.
The plaintiff argued that a specialist in complex third molar removal should have
been consulted. The plaintiff also claimed that she was not informed of the
complexity of the third molar extraction and the risk of nerve injury.

The defendant dentist argued that the nerve injury was a known risk of the
extraction and denied any negligence.

According to reports, a $1 Million policy-limits settlement was reached.

With permission from Medical Malpractice Verdicts, Settlements & Experts; Lewis
Laska, Editor, 901 Church St., Nashville, TN 37203-3411, 1-800-298-6288.
 http://www.dentists-
advantage.com/sites/DA/rskmgt/CaseStudy/Pages/CaseStudyI
ndex.aspx

October 2015
Failure to Prescribe Antibiotics Following Tooth Extraction -
Abcess Requires Surgery
Defense Verdict
September 2015
Man Claims Bridge for Upper Teeth Didn't Fit Properly
$71,100 Settlement
June 2015 Mental Nerve Injured During Extraction of
Ankylosed Tooth $950,000 Settlement

May 2015
Failure to Recognize and Treat Periodontal
Disease
$295,378 Net Verdict

April 2015
Lingual Nerve Injury During Wisdom Tooth
Extraction
$875,000 Settlement

March 2015
Failure to Recognize and Properly Treat Oral
Infection Following Bone Grafting Debridement
Required
$55,500 Verdict
 adbuc.GO
Priveste catre fiecare
ureche.
 orig. in tegmentul pontin
cel mai lung traseu pe baza de craniu-
sensibiliate crescuta la compresie (HIC)
trece pe langa vf. stancii temporalului
pareza:
abd ochii afectata
strabism convergent
diplopie orizontala

68
 Fibers leave the inferior pons and enter the
orbit via the superior orbital fissure
Primarily a motor nerve innervating the lateral
rectus muscle

Figure VI from Table 13.2

 Inerveaza motor mm. mimicii-expresia
faciala
senzitiv - conca auriculara
conductul auditiv extern
timpanul
tegumentul retroauricular
are in componenta fibre gustative pentru
cele 2/3 ant. ale limbii,
fibre vegetative si proprioceptiva (salivatie si
lacrimare)
Nervul facial este afectat cel mai frecvent in
ultima 1/3 a canalului Fallope.
 static:
-pliurile fruntii sunt sterse
- clipitul lipseste
- reflexul corneean este absent
-lagoftalmie marirea fantei palpebrale prin afectarea
orbicularului pleoapei (ochi de iepure)
-ectropion pleoapa inferioara coborata
-epiphora afectarea mm. Horner lacrimile se scurg pe
obraz
-marirea distantei intre iris si pleoapa inf.la privirea inainte
din cauza lagoftalmiei (s. Negro)
-narina deprimata nu se dilata in inspir
-santul nazogen sters
-comisura gurii coborata
-saliva curge prin coltul gurii
dinamic
- ochiul nu se inchide
-devierea gurii cand arata dintii
-nu poate fluiera
-alimentele se acumuleaza intre buze si dinti
-platysma (m. pielos al gatului) nu are pliuri
-semnul Charles Bell- devierea in sus a globului
ocular cand pacientul este rugat sa inchida ochii
-semnul Souques
 Paralizia faciala idiopatica ( a frigore)
este cea mai frecventa dintre paraliziile
faciale- 23/100.000/an:
apare frecvent dupa expunere la frig se
crede ca ar fi data de edematierea
nervului in canalul Fallope
apare la orice varsta dar mai frecventa in
decada 3-5
uneori apare bilateral
recurenta in acelasi loc sau opus
ocazional aparitie familiala
debut brutal in maxim 48 de ore
durere retroauriculara poate preceda
paralizia cu 1-2 zile
ageuzie si hiperacuzie (rareori)
semnele motorii (deja amintite)
 Antiinflamatoare
Masaj facial
Gimnastica faciala
Pansament ocluziv
 Receptorii localizati in
ureche, controleaza
auzul
Testam separat pt
fiecare U.
Figure VIII from Table 13.2
 Panda and his colleagues found that people who had talked
on cell phones for more than four years and those who talked
more than an hour daily were more likely to have these high-
frequency losses. These losses can make it difficult to hear
consonants such as s, f, t and z, making it hard to
understand words.

evaluated 100 people, aged 18 to 45, who had used mobile

phones for at least a year, dividing them into three groups
according to length of use. One group of 35 had used phones
for one to two years; another group of 35 had used them for
two to four years, and a group of 30 had used them for more
than four years.

"We asked them if they had been using the phones less than
60 minutes or more than 60 minutes per day," Panda tells
WebMD. They compared the phone users with 50 people who
had never used cell phones and served as a control group.
The study was conducted in India.
 cell phone use exceeding 60
minutes per day could result in
lasting damage such as high
frequency hearing loss, 2,000 to
8,000 Hertz, which can affect the
ability to understand speech and
discern consonants.

American Academy of
Otolaryngology, the
electromagnetic waves emitted
by the phone caused damage,
and this hearing loss is not
necessarily caused by the high
volume.
 Fibers arise from the hearing and equilibrium
apparatus of the inner ear, pass through the
internal acoustic meatus, and enter the
brainstem at the pons-medulla border
Two divisions cochlear (hearing) and
vestibular (balance)
Functions are solely sensory equilibrium
and hearing
 Bulb-jugular foramen,
and run to the throat
mixed nerve with motor
and sensory functions
Motor innervates part
of the tongue and
pharynx, and provides
motor fibers to the
parotid salivary gland
Sensory fibers conduct
taste and general
sensory impulses from
the tongue and pharynx

Figure IX from Table 13.2

 The only cranial nerve that
extends beyond the head
and neck
Fibers emerge from the
medulla via the jugular
foramen
The vagus is a mixed nerve
Most motor fibers are
parasympathetic fibers to
the heart, lungs, and
visceral organs
Its sensory function is in
taste
Figure X from Table 13.2
 Muschii trapez si SCM,
laringe, faringe si
palatul moale
Miscarile gat si umar
Ridica umarul contra
greutatii si examinam
trapezul
Punem sa roteasca gatul
impotriva rezist si
palpam SCM
 Formed from a cranial root emerging from
the medulla and a spinal root arising from the
superior region of the spinal cord
The spinal root passes upward into the
cranium via the foramen magnum
The accessory nerve leaves the cranium via
the jugular foramen
Figure XI from Table 13.2
 Inerveaza motor limba.
Limba afara in pozitie
mediana, fara atrofii.
Figure XII from Table 13.2
 Fibers arise from the medulla and exit the
skull via the hypoglossal canal
Innervates both extrinsic and intrinsic
muscles of the tongue, which contribute to
swallowing and speech
 A accepta dialogul cu cei ce au opinii diferite
este o dovada de normalitate, dar, a accepta
o prere sau o opinie diferita este o msur a
inteligenei!