JADA-2013-Ferreira-1358-61.pdf

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1014219jadaarchive201300712013144(12)1358-1361 JADA

Joatildeo N Ferreira and Rui Figueiredoplacementidiopathic facial pain after dental implantPrevention and management of persistent

2014) 25 online at jadaadaorg (this information is current as of May

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1358 JADA 144(12) httpjadaadaorg December 2013

C L I N I C A L P R A C T I C E P A I N U P D A T E

Copyright copy 2013 American Dental Association All Rights Reserved

a common complication What other sources ofpain should clinicians rule out first Can thistype of problem be prevented What can clini-cians do to manage the care of patientsappropriately

EXPLANATION

Persistent pain after dental implant placementmay occur immediately after surgery with noapparent organic cause and without any neu-

rosensory deficits1

The incidence of trigeminalneuropathic symptoms after dental proceduresin the maxilla including implant surgery isextremely low (approximately 09 percent) andrarely is reported in the literature1-3 Theseoutcomes sometimes are due to direct traumato a trigeminal nerve trunk or major branchbut this review focuses mainly on the idio-pathic onset of such problems The etiology andpathophysiology of persistent idiopathic facialpain (PIFP)mdashalso known as atypical facialpainmdashare poorly understood and the differen-tial diagnosis is challenging and often requiresthe involvement of several clinicians includ-ing dentists neurologists and ENT specialistsIndeed clinicians must rule out several painconditions before reaching a final diagnosis ofPIFP (Box4-8) In fact many of these conditionscan be excluded because they are associatedwith specific pathognomonic clinical features4 Adentist also can administer local or regional di-agnostic anesthetic blocks to rule out more com-mon conditions such as odontogenic pain painassociated with temporomandibular disordersand traumatic neuropathic pain However with

this anesthetic block approach the pain must be

CLINICAL PROBLEM

A69-year-old woman visited us with athree-week history of facial pain in theright infraorbital region after dentalimplant placement Her medical his-

tory was significant for general anxiety disorder(GAD) and chronic pain (CP) in the lower backThe patientrsquos neurologist had been treating herwith lorazepam for GAD and tramadol for CP

The referring dentist had placed two dental

implants in the maxilla under local anesthesiato replace teeth nos 3 and 5 The patient didnot report any intraoperative complications Im-mediately after surgery the patient complainedof a daily spontaneous deep dull pain locatedin the right upper lip with an intensity of 8on a scale from 0 to 10 The facial pain had noidentifiable triggers and the patient had no neu-rosensory deficits The referring dentist initiallyprescribed sodium diclofenac and an antibioticfor facial pain and to prevent postoperative in-fection At the three-week postsurgical follow-upvisit neither the frequency nor the intensityof the pain had improved Also no peripheralsigns or symptoms such as redness swelling orpurulent drainage were observed and no grosspathology was present on periapical films Afterconsulting with a neurologist we performedmagnetic resonance imaging of the brain withand without contrast the results of which werenormal No maxillary sinus pathology was foundon a computed tomographic scan performed dur-ing a consultation with an ear nose and throat(ENT) specialist

Is there an association between this pain and

the implant placement procedure If so is this

Prevention and management of persistentidiopathic facial pain after dental implantplacement

Joatildeo N Ferreira DDS MS PhD Rui Figueiredo DDS MS

on May 25 2014 jadaadaorgDownloaded from



JADA 144(12) httpjadaadaorg December 2013 1359



ened anxiety with the resistance to anestheticefficacy during the decision-making process forimplant placement and they can use screen-ing questionnaires or scales to assess anxietylevels Clinicians can estimate patientsrsquo anxietylevels by using a 10-centimeter visual analogscale or measure anxiety by using valid andreliable psychometric tools (for example CorahDental Anxiety Scale)17-19 Managing the care ofpatients who are moderately to severely anxiousmay include use of conscious sedation or cogni-tive behavioral therapy (CBT) or prescription ofshort-acting benzodiazepines before the dentalprocedure1620-22

In the case presented here the presence ofpreoperative comorbidities (for example anxi-ety CP) may have predisposed the patient todeveloping postoperative pain particularlybecause these comorbidities were not wellcontrolled13-15

MANAGEMENT

In patients diagnosed with PIFP screeningquestionnaires and specific neurosensory test-

ing are important to identify possible sensory

reduced dramatically or eliminated completelyto rule out these pathologies

The International Headache Society (IHS)provides four diagnostic criteria for PIFP (IHS International Classification of Headache Disor-ders 2nd edition [ICHD-II] code 131849) Thecorresponding International Classification of

Diseases 10th Revision code is G50110

dDaily pain must be present for most of thedaydThe pain must be deep dull and unilateraland not well localizeddThe pain is not associated with focal neuro-logical signs or sensory deficitsdNo abnormality should be found with labo-ratory and radiographic investigations whichmust include imaging studies of the face jawcervical spine and chest411

The clinical case scenario described here

should be diagnosed as PIFP because the char-acteristics of the pain fulfill the IHS criteriaand because the clinical features and laboratoryparameters seem to rule out other conditions(Box4-8) In this case no direct evidence of tri-geminal nerve damage is available and there-fore the diagnosis relies on symptoms and signsalone We must acknowledge that idiopathicpain is a temporary concept until clarificationof pathophysiological mechanisms (for exampledeafferentation) is obtained11

PREVENTION

In cases such as the one described here post-operative PIFP symptoms may be preventableto some extent if the potential risk factors areidentified12 An appropriate medical history di-agnosis and treatment are paramount to reduc-ing the risk of developing PIFP after implantsurgery It is highly unlikely that the drillingor implant placement caused direct infraorbitalnerve damage However factors such as incisionsize (particularly with flap elevation) type ofsurgery anxiety age sex and especially the ex-istence of preoperative chronic pain conditionshave emerged as independent predictors of painimmediately after surgical procedures13-15

Highly anxious patients appear to be moreresistant to local anesthesia and may be athigher risk of experiencing trigeminally medi-ated pain after invasive dental procedures suchas implant placement16 Also lower patientsatisfaction has been associated with higherpreoperative anxiety (independent of the pa-tientrsquos postoperative satisfaction with the sur-geon) particularly in women and in youngerpatients1617 Consequently clinicians should

discuss with patients the association of height-

BOX

Differential diagnosisbefore reaching a finaldiagnosis of PIFPdagger

DIFFERENTIAL DIAGNOSIS LISTdPeripheral traumatic neuropathic painDagger

dPostherpetic neuralgias

dTypical trigeminal neuralgia or other cranialneuralgias

dAtypical odontalgia (also known as persistentdentoalveolar painsect)

dOdontogenic pain (such as pulpitis periapicalperiodontitis cracked tooth syndrome)

dSinus-related pathologies (acute or chronic sinusitis)

dTemporomandibular disorders (arthralgia osteoarthritis masticatory myofascial pain)

dPrimary headache conditions (tension-type

headache migraine cluster headache)dTolosa-Hunt syndrome

dCarotidynia

dFacial pain secondary to intracranial or extracranialinfections or tumors (for example lung cancer)

dFacial pain secondary to cervical spine disease (C2-C8cervical nerve root compression facet injury or both)

PIFP Persistent idiopathic facial paindagger Sources Agostoni and colleagues4 Evans and Agostoni5 Eliavand Max6

Dagger Source Benoliel and colleagues7

sect Source Nixdorf and colleagues8







ment45222829 Randomized controlled trials(RCTs) addressing PIPF management have notbeen performed systematically to our knowl-edge which complicates an evidence-basedtreatment decision28 However pharmacologicaltherapy including topical medications non-tricyclic and tricyclic antidepressants (TCAs)

anticonvulsants and benzodiazepines is recom-mended widely as the first line of treatmentfor PIFP (Table)4-62226-28 Yet in the majority ofcases of PIFP complete pain remission is notachieved428

CONCLUSIONS

In our clinical scenario a multidisciplinarypain team can propose treatment with topicalcompound medications (for example lidocaine1 percent carbamazepine 4 percent and gaba-pentin 4 percent) to achieve better local pain

control without increasing adverse effects ordrug interactions in this elderly patient If notcontraindicated systemic nontricyclics andTCAs would be the second treatment optionfollowed by anticonvulsants and minor opioidsthough none of these drugs has been tested inwell-designed RCTs to study their efficacy in pa-tients with PIFP428 Patients who are refractoryto conventional pharmacological treatment maybenefit from hypnosis In a patient-masked con-trolled RCT hypnosis offered clinically relevantpain relief for PIFP compared with a relaxation

intervention particularly in patients with highsusceptibility to hypnosis29 Stress coping skillsand CBT for unresolved psychological problems(such as pain catastrophizing anxiety depres-sion obsessive compulsive disorder) must beincluded in a comprehensive pain managementapproach to control psychological factors andimprove patientsrsquo quality of life222829 983150

Dr Ferreira is a clinical research fellow and a TMD and orofacialpain clinician National Institute of Dental and Craniofacial ResearchNational Institutes of Health Clinical Center 30 Convent DriveBuilding 30 Room 429 Bethesda Md 20892 e-mail andraderequicjmailnihgov Address reprint requests to Dr Ferreira

Dr Figueiredo is an associate professor Oral Surgery School of

Dentistry University of Barcelona and a researcher at InstitutdrsquoInvestigacioacute Biomegravedica de Bellvitge Barcelona Spain

Disclosure Drs Ferreira and Figueiredo did not report anydisclosures

This study was supported in part by the Intramural Research Pro-gram of the National Institute of Dental and Craniofacial ResearchNational Institutes of Health Bethesda Md

The authors thank Drs Katiucha Sales and Dean Aria for helpfuldiscussions and critical reading of the manuscript of this article

Pain Update is published in collaboration with the NeuroscienceGroup of the International Association for Dental Research

1 Gregg JM Neuropathic complications of mandibular implantsurgery review and case presentations Ann R Australas Coll Dent

disturbances (paresthesia dysesthesia allodyn-ia) in the trigeminal area122324 If acute neuro-pathic pain symptoms are present immediatelyafter implant surgery and nerve injury is sus-pected patients may undergo removal of theirimplants within 24 hours to resolve their painor may undergo an immediate repair if nervesection is detected2225 Clinicians should treatacute postoperative nerve injuries immediatelywith topical or systemic anti-inflammatoriesperipheral nerve blocks with local anestheticsand glucocorticoids as well as with neuropathicpain medications to reduce potential neuro-genic inflammation and regain typical neuronaltransmission126-28

When intractable PIFP is diagnosed afterimplant surgery patientsrsquo potential to recovertheir normal trigeminal sensations is reduced22 Therefore consultations with patients shouldinclude a full explanation of pain symptoms toalleviate many concerns and we hope persuadepatients to avoid unnecessary invasive dental ormedical treatments Clinicians should considerreferring patients to an orofacial pain clinicianor a neurologist for further pain assessment

stimulus-response testing and CP manage-

TABLE

Common medications usedto treat persistent idiopathicfacial painDRUG CLASS EXAMPLE

OF ACTIVESUBSTANCE

MECHANISM OF ACTION

Tricyclic andNontricylic

Antidepressants

AmitriptylineNortriptylineDuloxetine

Inhibit reuptakeof serotonin andnorepinephrine

szlig-Blockers Propranolol Block β1- and β2-adrenergic receptors

Anticonvulsants GabapentinPregabalin

Inhibit voltage-gatedCa2+ influx

Benzodiazepines Clonazepam Modulate GABAAdagger

receptors

GABAergics Baclofen GABAB receptoragonist

Minor Opioid Analgesics

Tramadol Weak micro-opioid receptor

agonist inducesserotonin releaseinhibits reuptake ofnorepinephrine

Topical PainMedications

LidocaineKetamine

Capsaicin

Local anestheticNMDADagger receptorantagonistAgonist of TRPV1sect ion channels

Ca2+ Calciumdagger GABA γ -aminobutyric acidDagger NMDA N -methyl-D-aspartatesect TRPV1 Transient receptor potential cation channel subfamily

V member 1







17 Pekkan G Kilicoglu A Hatipoglu H Relationship betweendental anxiety general anxiety level and depression in patientsattending a university hospital dental clinic in Turkey CommunityDent Health 201128(2)149-153

18 Edwards DJ Brickley MR Horton J Edwards MJ ShepherdJP Choice of anaesthetic and healthcare facility for third molarsurgery Br J Oral Maxillofac Surg 199836(5)333-340

19 Corah NL Development of a dental anxiety scale J Dent Res196948(4)596

20 Little JW Falace DA Miller CS Rhodus NL Little and Fal-acersquos Dental Management of the Medically Compromised Patient8th ed St Louis Elsevier Mosby 2013417-438

21 Newton T Asimakopoulou K Daly B Scambler S Scott S Themanagement of dental anxiety time for a sense of proportion BrDent J 2012213(6)271-274

22 Renton T Dawood A Shah A Searson L Yilmaz Z Post-implant neuropathy of the trigeminal nerve a case series (publishedonline June 8 2012) Br Dent J 2012212(11)E17 doi101038sjbdj2012497

23 Wismeijer D van Waas MA Vermeeren JI Kalk W Patientsrsquoperception of sensory disturbances of the mental nerve before andafter implant surgery a prospective study of 110 patients Br J OralMaxillofac Surg 199735(4)254-259

24 Baad-Hansen L Abrahamsen R Zachariae R List T SvenssonP Somatosensory sensitivity in patients with persistent idiopathicorofacial pain is associated with pain relief from hypnosis and re-

laxation (published online ahead of print Jan 16 2013) Clin J Pain201329(6)518-526 doi101097AJP06013e318268e4e725 Worthington P Injury to the inferior alveolar nerve during

implant placement a formula for protection of the patient and clini-cian Int J Oral Maxillofac Implants 200419(5)731-734

26 Hegedus F Diecidue RJ Trigeminal nerve injuries after man-dibular implant placement practical knowledge for clinicians Int JOral Maxillofac Implants 200621(1)111-116

27 Eker HE Cok OY Aribogan A Arslan G Management of neuro-pathic pain with methylprednisolone at the site of nerve injury PainMed 201213(3)443-451

28 List T Axelsson S Leijon G Pharmacologic interventions in thetreatment of temporomandibular disorders atypical facial pain andburning mouth syndrome a qualitative systematic review J OrofacPain 200317(4)301-310

29 Abrahamsen R Baad-Hansen L Svensson P Hypnosis in themanagement of persistent idiopathic orofacial pain clinical and

psychosocial findings Pain 2008136(1-2)44-52

Surg 200015176-1802 Hillerup S Iatrogenic injury to oral branches of the trigeminal

nerve records of 449 cases Clin Oral Investig 200711(2)133-1423 Rodriguez-Lozano FJ Sanchez-Pereacutez A Moya-Villaescusa

MJ Rodriacuteguez-Lozano A Saacuteez-Yuguero MR Neuropathic orofacialpain after dental implant placement review of the literature andcase report Oral Surg Oral Med Oral Pathol Oral Radiol Endod2010109(4)e8-e12 doi101016jtripleo200912004

4 Agostoni E Frigerio R Santoro P Atypical facial pain clinical

considerations and differential diagnosis Neurol Sci 200526 (suppl2)s71-s745 Evans RW Agostoni E Persistent idiopathic facial pain Head-

ache 200646(8)1298-13006 Eliav E Max MB Management of neuropathic pain In Sessle

BJ Lavigne GJ Lund JP Dubner R eds Orofacial Pain From BasicScience to Clinical Management 2nd ed Hanover Park Ill Quintes-sence Publishing 2008195-202

7 Benoliel R Zadik Y Eliav E Sharav Y Peripheral painfultraumatic trigeminal neuropathy clinical features in 91 cases andproposal of novel diagnostic criteria J Orofac Pain 201226(1)49-58

8 Nixdorf DR Drangsholt MT Ettlin DA et al Classifying oro-facial pains a new proposal of taxonomy based on ontology J OralRehabil 201239(3)161-169

9 IHS Classification ICHD-II httpihs-classificationorgen Accessed Oct 28 2013

10 ICD-10 Version 2010 httpappswhointclassificationsicd10

browse2010en Accessed Oct 28 201311 Woda A Tubert-Jeannin S Bouhassira D et al Towards a newtaxonomy of idiopathic orofacial pain Pain 2005116(3)396-406

12 Hillerup S Iatrogenic injury to the inferior alveolar nerve eti-ology signs and symptoms and observations on recovery Int J OralMaxillofac Surg 200837(8)704-709

13 Kalkman CJ Visser K Moen J Bonsel GJ Grobbee DE MoonsKG Preoperative prediction of severe postoperative pain Pain 2003105(3)415-423

14 Ip HY Abrishami A Peng PW Wong J Chung F Predictors ofpostoperative pain and analgesic consumption a qualitative system-atic review Anesthesiology 2009111(3)657-677

15 Kehlet H Jensen TS Woolf CJ Persistent postsurgical painrisk factors and prevention Lancet 2006367(9522)1618-1625

16 Gonzaacutelez-Lemonnier S Bovaira-Forner M Pentildearrocha-DiagoM Pentildearrocha-Oltra D Relationship between preoperative anxietyand postoperative satisfaction in dental implant surgery with

intravenous conscious sedation Med Oral Patol Oral Cir Bucal201015(2)e379-e382







a common complication What other sources ofpain should clinicians rule out first Can thistype of problem be prevented What can clini-cians do to manage the care of patientsappropriately

EXPLANATION

Persistent pain after dental implant placementmay occur immediately after surgery with noapparent organic cause and without any neu-

rosensory deficits1

The incidence of trigeminalneuropathic symptoms after dental proceduresin the maxilla including implant surgery isextremely low (approximately 09 percent) andrarely is reported in the literature1-3 Theseoutcomes sometimes are due to direct traumato a trigeminal nerve trunk or major branchbut this review focuses mainly on the idio-pathic onset of such problems The etiology andpathophysiology of persistent idiopathic facialpain (PIFP)mdashalso known as atypical facialpainmdashare poorly understood and the differen-tial diagnosis is challenging and often requiresthe involvement of several clinicians includ-ing dentists neurologists and ENT specialistsIndeed clinicians must rule out several painconditions before reaching a final diagnosis ofPIFP (Box4-8) In fact many of these conditionscan be excluded because they are associatedwith specific pathognomonic clinical features4 Adentist also can administer local or regional di-agnostic anesthetic blocks to rule out more com-mon conditions such as odontogenic pain painassociated with temporomandibular disordersand traumatic neuropathic pain However with

this anesthetic block approach the pain must be

CLINICAL PROBLEM

A69-year-old woman visited us with athree-week history of facial pain in theright infraorbital region after dentalimplant placement Her medical his-

tory was significant for general anxiety disorder(GAD) and chronic pain (CP) in the lower backThe patientrsquos neurologist had been treating herwith lorazepam for GAD and tramadol for CP

The referring dentist had placed two dental

implants in the maxilla under local anesthesiato replace teeth nos 3 and 5 The patient didnot report any intraoperative complications Im-mediately after surgery the patient complainedof a daily spontaneous deep dull pain locatedin the right upper lip with an intensity of 8on a scale from 0 to 10 The facial pain had noidentifiable triggers and the patient had no neu-rosensory deficits The referring dentist initiallyprescribed sodium diclofenac and an antibioticfor facial pain and to prevent postoperative in-fection At the three-week postsurgical follow-upvisit neither the frequency nor the intensityof the pain had improved Also no peripheralsigns or symptoms such as redness swelling orpurulent drainage were observed and no grosspathology was present on periapical films Afterconsulting with a neurologist we performedmagnetic resonance imaging of the brain withand without contrast the results of which werenormal No maxillary sinus pathology was foundon a computed tomographic scan performed dur-ing a consultation with an ear nose and throat(ENT) specialist

Is there an association between this pain and

the implant placement procedure If so is this

Prevention and management of persistentidiopathic facial pain after dental implantplacement

Joatildeo N Ferreira DDS MS PhD Rui Figueiredo DDS MS









MANAGEMENT









PREVENTION




BOX











dCarotidynia














CONCLUSIONS















TABLE


OF ACTIVESUBSTANCE

MECHANISM OF ACTION


Antidepressants







receptors






LidocaineKetamine

Capsaicin



V member 1
















































MANAGEMENT









PREVENTION




BOX











dCarotidynia














CONCLUSIONS















TABLE


OF ACTIVESUBSTANCE

MECHANISM OF ACTION


Antidepressants







receptors






LidocaineKetamine

Capsaicin



V member 1
















































CONCLUSIONS















TABLE


OF ACTIVESUBSTANCE

MECHANISM OF ACTION


Antidepressants







receptors






LidocaineKetamine

Capsaicin



V member 1









































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