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• W45351335 abstract "A 48-year-old woman visited one of us (R.D.) for a second opinion regarding severe pain that began six weeks earlier after placement of an implant into her mandibular right first premolar region (Figure). She recalled that profuse bleeding had to be controlled when the implant site was prepared, and she experienced sharp pain as the implant was being inserted. As the local anesthetic wore off, she developed severe deep aching and burning pain at the implant site. She then experienced sharp stabbing pains whenever she touched or brushed the area around the implant. Also, her right lower lip felt unpleasant, which caused difficulty in drinking and affected kissing. The patient reported that she had been pain free before the implant procedure. The patient returned to the dentist who had placed the implant. A radiograph revealed that the implant was not impinging on the inferior alveolar canal (IAC). Initial treatments included a course of antibiotics, a combination of analgesics and anti-inflammatory drugs. A moderate degree of pain relief was achieved, and the dentist advised her to wait and see if the pain resolved before possibly referring her to a neurologist or pain specialist. The patient's medical history was significant for depression, anxiety, insomnia, irritable bowel syndrome (IBS) and gastroesophageal reflux disease. The patient was taking the combination analgesic hydrocodone-acetaminophen, as well as escitalopram and esomeprazole. Is this pain related to the implant placement? Is this a common complication? What questions should be asked and how should the dentist evaluate the complaint? What is the appropriate management of this patient? Dentists should understand the differences between nociceptive, inflammatory and neuropathic pain (NP) (Box1Klasser GD Gremillion HA Neuropathic orofacial pain patients in need of dental care.J Can Dent Assoc. 2012; 78: c83PubMed Google Scholar). Typically, pain following surgical procedures is of a nociceptive or inflammatory nature and is short lasting. The inflammatory process is a complex biological response to tissue injury by normally functioning vascular and somatosensory nervous systems. It is a protective response intended to eliminate the initial cause of the injury and to foster healing and repair of the injured part. By contrast, NP is “caused by a lesion or disease of the somatosensory nervous system.”2Jensen TS Baron R Haanpää M et al.A new definition of neuropathic pain.Pain. 2011; 152: 2204-2205Abstract Full Text Full Text PDF PubMed Scopus (897) Google Scholar Because it is not feasible clinically to determine the degree of nerve contusion or injury or the extent of ongoing inflammation in the surgical area, clinicians should presume that both nociceptive and neuropathic factors are present. Authors of previous Pain Updates in The Journal of the American Dental Association (JADA) have reviewed NP,3Klasser GD Gremillion HA Epstein JB Dental treatment for patients with neuropathic orofacial pain.JADA. 2013; 144: 1006-1008Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 4Greene CS Murray GM Atypical odontalgia: an oral neuropathic pain phenomenon.JADA. 2011; 142: 1031-1032Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 5Svensson P Drangsholt M Pfau DB List T Neurosensory testing of orofacial pain in the dental clinic.JADA. 2012; 143: e37-e39https://doi.org/10.14219/jada.archive.2012.0301Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 6Ferreira JN Figueiredo R Prevention and management of persistent idiopathic facial pain after dental implant placement.JADA. 2013; 144: 1358-1361PubMed Google Scholar which is characterized by its burning, prickling, electrical and sharp nature. NP can be spontaneous or evoked, with distinctive associated positive (heightened sensation) signs, negative (sensory deficit) signs or both. There almost always is an area of abnormal sensation (Table 1, page 1270).TABLE 1Positive and negative sensory symptoms of neuropathy.SENSORY SYMPTOMDEFINITIONPositiveSpontaneous painPainful sensations felt with no evident stimulusAllodyniaPain due to a stimulus that normally does not provoke pain (such as touching, movement, cold, heat)HyperalgesiaAn increased response to a stimulus that normally is painful (for example, cold, heat, pinprick)DysesthesiaAn unpleasant abnormal sensation, either spontaneous or evoked (such as a shooting sensation)ParesthesiaAn abnormal sensation, either spontaneous or evoked (such as tingling, buzzing, vibrating sensations)NegativeHypoesthesiaDiminished sensitivity to stimulation, excluding the special senses (for example, touch, pain)AnesthesiaA total loss of sensation (especially tactile sensitivity)HypoalgesiaDiminished pain in response to a normally painful stimulusAnalgesiaAbsence of pain in response to stimulation that normally would be painful Open table in a new tab The incidence of nerve injury after dental surgical procedures, including third-molar extractions and placement of implants, is higher than that commonly believed (possibly up to 40 percent), and, for the latter, the incidence is increasing.7Renton T Dawood A Shah A Searson L Yilmaz Z Post-implant neuropathy of the trigeminal nerve: a case series.Br Dent J. 2012; 212: E17https://doi.org/10.1038/sj.bdj.2012.497Crossref PubMed Scopus (53) Google Scholar, 8Hillerup S Iatrogenic injury to oral branches of the trigeminal nerve: records of 449 cases.Clin Oral Investig. 2007; 11: 133-142Crossref PubMed Scopus (97) Google Scholar, 9Bartling R Freeman K Kraut RA The incidence of altered sensation of the mental nerve after mandibular implant placement.J Oral Maxillofac Surg. 1999; 57: 1408-1412Abstract Full Text PDF PubMed Scopus (128) Google Scholar, 10Ellies LG Altered sensation following mandibular implant surgery: a retrospective study.J Prosthet Dent. 1992; 68: 664-671Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 11Ellies LG Hawker PB The prevalence of altered sensation associated with implant surgery.Int J Oral Maxillofac Implants. 1993; 8: 674-679PubMed Google Scholar, 12Gregg JM Neuropathic complications of mandibular implant surgery: review and case presentations.Ann R Australas Coll Dent Surg. 2000; 15: 176-180PubMed Google Scholar, 13Kraut RA Chahal O Management of patients with trigeminal nerve injuries after mandibular implant placement.JADA. 2002; 133: 1351-1354PubMed Google Scholar The term “peripheral painful traumatic trigeminal neuropathy” (PPTTN) has been proposed for NP that occurs within three months of such procedures.14Benoliel R Kahn J Eliav E Peripheral painful traumatic trigeminal neuropathies.Oral Dis. 2012; 18: 317-332Crossref PubMed Scopus (56) Google Scholar In the mandible, NP after dental implant placement may occur without evidence of direct implant intrusion into the IAC. The course of the IAC within the mandible is variable, so furcations and small branches of the inferior alveolar nerve (IAN) outside the main canal may have been traumatized. To further minimize the risk of injury's occurring to the IAN, the usually recommended 2-millimeter safety zone above the IAC could be increased to 4 mm.15Greenstein G Tarnow D The mental foramen and nerve: clinical and anatomical factors related to dental implant placement—a literature review.J Periodontol. 2006; 77: 1933-1943Crossref PubMed Scopus (265) Google Scholar, 16Renton T Implant related inferior alveolar nerve neuropathy: assessment and management of nerve injuries. Dental Protection. DPL Seminar Series–August 2013. Presentation 2.http://www.dentalprotection.org/adx/aspx/adxGetMedia.aspx?DocID=583bc239-3fcf-4ee2-b09e-0cfde61c0b59Google Scholar Risk factors for persistent postsurgical pain include preoperative pain, genetic predisposition, female sex and a younger age. Other identified predictors include psychological vulnerability, anxiety and depression.17Kehlet H Jensen TS Woolf CJ Persistent postsurgical pain: risk factors and prevention.Lancet. 2006; 367: 1618-1625Abstract Full Text Full Text PDF PubMed Scopus (2696) Google Scholar, 18Schug SA Pogatzki-Zahn EM Chronic pain after surgery or injury.IASP Pain Clinical Updates. 2011; 19: 1-5Google Scholar A genetic predisposition to increased susceptibility to pain has been identified in patients with chronic pain conditions, such as fibromyalgia, temporomandibular disorders and visceral pain hypersensitivity disorders.19Diatchenko L Nackley AG Tchivileva IE Shabalina SA Maixner W Genetic architecture of human pain perception.Trends Genet. 2007; 23: 605-613Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar However, no specific genetic markers have been identified for the increased likelihood of experiencing postsurgical pain.18Schug SA Pogatzki-Zahn EM Chronic pain after surgery or injury.IASP Pain Clinical Updates. 2011; 19: 1-5Google Scholar Because the patient described in this report had a preexisting chronic pain condition, depression, anxiety and IBS, she may have been predisposed to the development of persistent postsurgical pain. Intraoperative factors associated with an increased risk of experiencing implant-related NP include the following16Renton T Implant related inferior alveolar nerve neuropathy: assessment and management of nerve injuries. Dental Protection. DPL Seminar Series–August 2013. Presentation 2.http://www.dentalprotection.org/adx/aspx/adxGetMedia.aspx?DocID=583bc239-3fcf-4ee2-b09e-0cfde61c0b59Google Scholar, 20Leckel M Kress B Schmitter M Neuropathic pain resulting from implant placement: case report and diagnostic conclusions.J Oral Rehabil. 2009; 36: 543-546Crossref PubMed Scopus (15) Google Scholar: intense sudden pain during the injection or implant preparation and placement;brisk persistent bleeding during preparation of the implant site;possible nerve injury when local anesthetic injection is administered or during flap retraction;sudden “give” of the drill during preparation of the implant site may indicate breaching of the roof of the IAC;heat generation during preparation of the implant site;potential torquing forces within mandibular cancellous bone created as the implant is inserted into the prepared site;less than 2-mm proximity to the roof of the IAC. The key to diagnosis is a thorough medical history and examination, with an awareness of the possibility of NP. In taking the medical history, the clinician should focus on the seven intraoperative factors above. BOXCharacteristics of nociceptive, inflammatory and neuropathic pain. *Adapted with permission of the Canadian Dental Association from Klasser and Gremillion.1Klasser GD Gremillion HA Neuropathic orofacial pain patients in need of dental care.J Can Dent Assoc. 2012; 78: c83PubMed Google Scholar *Adapted with permission of the Canadian Dental Association from Klasser and Gremillion.1Klasser GD Gremillion HA Neuropathic orofacial pain patients in need of dental care.J Can Dent Assoc. 2012; 78: c83PubMed Google ScholarNOCICEPTIVE PAINPain caused by noxious mechanical, thermal or chemical activation of nociceptorsNormal neural structures: transduction with peripheral and central sensitizationAbnormal somatic structuresPain at site of injury with or without referred painBiologically adaptiveProtects by signaling potential tissue damageINFLAMMATORY PAINNormal response of somatosensory system to address consequences of tissue injuryNormal neural structures with peripheral sensitizationResponse to tissue injuryPain or tenderness at or close to site of injuryBiologically adaptive and reversible after resolution of the initial tissue injuryProtects by producing pain hypersensitivity during healing and repairNEUROPATHIC PAINPain caused by lesion or disease of the somatosensory systemAbnormal neural structures with ectopic impulses, central sensitization, loss of inhibitory controlNormal somatic structuresPain typically distant from site of nerve injury in the territory of innervationMaladaptive and potentially persistentNot protective and unsupportive of healing and repair Pain caused by noxious mechanical, thermal or chemical activation of nociceptorsNormal neural structures: transduction with peripheral and central sensitizationAbnormal somatic structuresPain at site of injury with or without referred painBiologically adaptiveProtects by signaling potential tissue damage Normal response of somatosensory system to address consequences of tissue injuryNormal neural structures with peripheral sensitizationResponse to tissue injuryPain or tenderness at or close to site of injuryBiologically adaptive and reversible after resolution of the initial tissue injuryProtects by producing pain hypersensitivity during healing and repair Pain caused by lesion or disease of the somatosensory systemAbnormal neural structures with ectopic impulses, central sensitization, loss of inhibitory controlNormal somatic structuresPain typically distant from site of nerve injury in the territory of innervationMaladaptive and potentially persistentNot protective and unsupportive of healing and repair The clinician needs to rule out dental or soft-tissue pathology, orofacial infection, swellings, fistula tracts and conditions known to mimic orofacial NP.1Klasser GD Gremillion HA Neuropathic orofacial pain patients in need of dental care.J Can Dent Assoc. 2012; 78: c83PubMed Google Scholar Imaging should include preoperative and postoperative panoramic and cone-beam computed tomographic scans and periapical radiographs. The clinician should note the distance from the implant to the IAC. Simple screening questionnaires such as Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), DN4 and PainDETECT can be used to assist in the diagnosis of NP.21Bennett MI Attal N Backonja MM et al.Using screening tools to identify neuropathic pain.Pain. 2007; 127: 199-203Abstract Full Text Full Text PDF PubMed Scopus (427) Google Scholar Neurosensory testing is the most important part of the clinical examination. In a previous JADA Pain Update, Svensson and colleagues5Svensson P Drangsholt M Pfau DB List T Neurosensory testing of orofacial pain in the dental clinic.JADA. 2012; 143: e37-e39https://doi.org/10.14219/jada.archive.2012.0301Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar explored such testing for the orofacial region. In the early stages at least, NP and altered sensation usually are confined to the territory innervated by the injured nerve. The clinician compares the affected area with adjacent and contralateral nonpainful areas.22Haanpää M Attal N Backonja M et al.NeuPSIG guidelines on neuropathic pain assessment.Pain. 2011; 152: 14-27Abstract Full Text Full Text PDF PubMed Scopus (785) Google Scholar, 23Meyer RA Bagheri SC Clinical evaluation of peripheral trigeminal nerve injuries.Atlas Oral Maxillofac Surg Clin North Am. 2011; 19: 15-33Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Any areas of altered sensation should be mapped on the patient's face, and a drawing or photograph placed in the medical record. These findings allow for the diagnosis of possible, probable and definite NP, according to the proposed diagnostic criteria for PPTTN.14Benoliel R Kahn J Eliav E Peripheral painful traumatic trigeminal neuropathies.Oral Dis. 2012; 18: 317-332Crossref PubMed Scopus (56) Google Scholar The use of topical anesthetic gel and block injections may aid diagnosis by establishing the extent of peripheral and central involvement. If the patient complains of severe pain with features of neuropathy developing within hours of the procedure, watchful waiting is contraindicated. The clinician should remove the offending implant and prescribe oral prednisone (either 10 milligrams three times per day for seven days or a five-day tapering schedule of 50, 40, 30, 20 and 10 mg per day). Adjunctive high-dose anti-inflammatory (for example, ibuprofen 800 mg every six hours) and analgesic (for example, tramadol or tapentadol) medications may be required for additional pain control. Although the data are limited and case based, it appears that beyond 36 hours, the success rate of minimizing or reversing symptoms of neuropathy by removing the implant is reduced markedly. Also, additional surgery may cause further damage, particularly once osseointegration has occurred.24Khawaja N Renton T Case studies on implant removal influencing the resolution of inferior alveolar nerve injury.Br Dent J. 2009; 206: 365-370Crossref PubMed Scopus (76) Google Scholar After a few days, established NP should be treated with pharmacological agents that have demonstrated efficacy, including tricyclic antidepressants, gabapentinoids, selective serotonin and norepinephrine reuptake inhibitors and minor opioids.25Dworkin RH O’Connor AB Audette J et al.Recommendations for the pharmacological management of neuropathic pain: an overview and literature update.Mayo Clin Proc. 2010; 85: S3-S14Abstract Full Text Full Text PDF PubMed Scopus (1023) Google Scholar, 26Attal N Cruccu G Baron R European Federation of Neurological Societies et al.EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision.Eur J Neurol. 2010; 17 (1113-1e88)Crossref Scopus (1397) Google Scholar, 27Tan T Barry P Reken S Baker M Guideline Development Group Pharmacological management of neuropathic pain in non-specialist settings: summary of NICE guidance.BMJ. 2010; 340: c1079Crossref PubMed Scopus (94) Google Scholar, 28Smith BH Lee J Price C Baranowski AP Neuropathic pain: a pathway for care developed by the British Pain Society.Br J Anaesth. 2013; 111: 73-79Crossref PubMed Scopus (29) Google Scholar Because of reduced systemic adverse effects, some researchers have advocated the use of topical medications as a first-line treatment (Table 225Dworkin RH O’Connor AB Audette J et al.Recommendations for the pharmacological management of neuropathic pain: an overview and literature update.Mayo Clin Proc. 2010; 85: S3-S14Abstract Full Text Full Text PDF PubMed Scopus (1023) Google Scholar, 26Attal N Cruccu G Baron R European Federation of Neurological Societies et al.EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision.Eur J Neurol. 2010; 17 (1113-1e88)Crossref Scopus (1397) Google Scholar, 27Tan T Barry P Reken S Baker M Guideline Development Group Pharmacological management of neuropathic pain in non-specialist settings: summary of NICE guidance.BMJ. 2010; 340: c1079Crossref PubMed Scopus (94) Google Scholar, 28Smith BH Lee J Price C Baranowski AP Neuropathic pain: a pathway for care developed by the British Pain Society.Br J Anaesth. 2013; 111: 73-79Crossref PubMed Scopus (29) Google Scholar).29Khawaja N Yilmaz Z Renton T Case studies illustrating the management of trigeminal neuropathic pain using topical 5% lidocaine plasters (published online before print April 11, 2013).Br J Pain. 2013; 7: 107-113https://doi.org/10.1177/2049463713483459Crossref Google Scholar Peripheral nerve blocks combining lidocaine and methylprednisolone also may provide benefit.30Eker HE Cok OY Aribogan A Arslan G Management of neuropathic pain with methylprednisolone at the site of nerve injury.Pain Med. 2013; 13: 443-451Crossref Scopus (46) Google Scholar Bagheri and Meyer31Bagheri SC Meyer RA Management of mandibular nerve injuries from dental implants.Atlas Oral Maxillofac Surg Clin North Am. 2011; 19: 47-61Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar reviewed microneurosurgical procedures for the management of IAN injuries. These also are case-based studies with success claimed in improving sensory dysfunction, but there is little discussion of their benefits for treating NP. After three months, permanent nervous system responses to nerve injury render the success of surgical intervention unlikely.32Renton T Yilmaz Z Managing iatrogenic trigeminal nerve injury: a case series and review of the literature.Int J Oral Maxillofac Surg. 2012; 41: 629-637Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Patients diagnosed with PPTTN should be fully informed in an empathetic manner about the nature of nerve injury, management options and likely—albeit unfortunately poor—outcomes. The Trigeminal Foundation's website is a useful resource.33Trigeminal Foundation Nerve injuries: helping to prevent, educate and manage.http://www.trigeminalnerve.org.ukGoogle Scholar Obtaining preoperative informed consent after discussing the risks and possible complications of surgery should assist with patient acceptance.TABLE 2Medications used to treat postsurgical neuropathic pain.*Patients should be evaluated every two weeks to assess effectiveness and adverse effects, as well as to titrate dose if required. Clinicians should assess the need to add second- or third-line medications to achieve pain control or for referral to a specialist.DRUG CLASSNAME OF DRUGRECOMMENDED USETricyclic Antidepressants (TCAs)Amitriptyline, nortriptylineOften used as first-line medication; can be added to gabapentinoidsGabapentinoidsGabapentin, pregabalinGabapentinoids now recommended as first-line medication†Sources: Dworkin and colleagues25; Attal and colleagues26; Tan and colleagues27; Smith and colleagues.28Selective Serotonin and Norepinephrine Reuptake InhibitorsDuloxetine, venlafaxineGenerally recommended as second-line medication added to TCAs, gabapentinoids or bothMinor Opioid AnalgesicsTramadol, tapentadolUsed as second- or third-line treatment added to TCAs, gabapentinoids or bothTopical Local Anesthetics5 percent lidocaine transdermal patch, topical benzocaine gelUsed as first-line treatment; topical medications minimize adverse effects and drug interactionsTopical TRPV1‡TRPV1: Transient receptor potential cation channel, subfamily V, member 1. AgonistsCapsaicin 8 percent patch, capsaicin 0.075 percent creamFirst-line treatment minimizes adverse effects and drug interactions* Patients should be evaluated every two weeks to assess effectiveness and adverse effects, as well as to titrate dose if required. Clinicians should assess the need to add second- or third-line medications to achieve pain control or for referral to a specialist.† Sources: Dworkin and colleagues25Dworkin RH O’Connor AB Audette J et al.Recommendations for the pharmacological management of neuropathic pain: an overview and literature update.Mayo Clin Proc. 2010; 85: S3-S14Abstract Full Text Full Text PDF PubMed Scopus (1023) Google Scholar; Attal and colleagues26Attal N Cruccu G Baron R European Federation of Neurological Societies et al.EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision.Eur J Neurol. 2010; 17 (1113-1e88)Crossref Scopus (1397) Google Scholar; Tan and colleagues27Tan T Barry P Reken S Baker M Guideline Development Group Pharmacological management of neuropathic pain in non-specialist settings: summary of NICE guidance.BMJ. 2010; 340: c1079Crossref PubMed Scopus (94) Google Scholar; Smith and colleagues.28Smith BH Lee J Price C Baranowski AP Neuropathic pain: a pathway for care developed by the British Pain Society.Br J Anaesth. 2013; 111: 73-79Crossref PubMed Scopus (29) Google Scholar‡ TRPV1: Transient receptor potential cation channel, subfamily V, member 1. Open table in a new tab The case described here of implant-related IAN injury fulfills the proposed diagnostic criteria for PPTTN.14Benoliel R Kahn J Eliav E Peripheral painful traumatic trigeminal neuropathies.Oral Dis. 2012; 18: 317-332Crossref PubMed Scopus (56) Google Scholar Because six weeks had elapsed since the patient had received the implant, it is likely that the initial acute inflammatory phase had subsided, and the pain probably was NP, which has characteristic features. Careful history taking and a thorough clinical examination (including simple neurosensory testing) can reveal the nature and extent of neuropathy and allow the clinician to make a tentative diagnosis. We recommend referral to a dentist trained in orofacial pain. Current medical and dental research findings indicate that persistent postsurgical pain is relatively common and often due to neuropathy. Further research into the mechanisms of NP is required to better understand, assess and treat this problem. ▪" @default.
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• W45351335 title "Persistent pain after dental implant placement" @default.
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