Prevention and management of persistent idiopathic facial pain after dental implant placement Joo N.

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Prevention and management of persistent idiopathic facial pain after dental implant placement
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Joo N. Ferreira, DDS, MS, PhD; Rui Figueiredo, DDS, MS

CLINICAL PROBLEM

69-year-old woman visited us with a three-week history of facial pain in the right infraorbital region after dental implant placement. Her medical history was significant for general anxiety disorder (GAD) and chronic pain (CP) in the lower back. The patients neurologist had been treating her with lorazepam for GAD and tramadol for CP. The referring dentist had placed two dental implants in the maxilla under local anesthesia to replace teeth nos. 3 and 5. The patient did not report any intraoperative complications. Immediately after surgery, the patient complained of a daily, spontaneous, deep dull pain located in the right upper lip, with an intensity of 8 on a scale from 0 to 10. The facial pain had no identifiable triggers and the patient had no neurosensory deficits. The referring dentist initially prescribed sodium diclofenac and an antibiotic for facial pain and to prevent postoperative infection. At the three-week postsurgical follow-up visit, neither the frequency nor the intensity of the pain had improved. Also, no peripheral signs or symptoms such as redness, swelling or purulent drainage were observed, and no gross pathology was present on periapical films. After consulting with a neurologist, we performed magnetic resonance imaging of the brain, with and without contrast, the results of which were normal. No maxillary sinus pathology was found on a computed tomographic scan performed during 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

a common complication? What other sources of pain should clinicians rule out first? Can this type of problem be prevented? What can clinicians do to manage the care of patients appropriately?
EXPLANATION

Persistent pain after dental implant placement may occur immediately after surgery with no apparent organic cause and without any neurosensory deficits.1 The incidence of trigeminal neuropathic symptoms after dental procedures in the maxilla, including implant surgery, is extremely low (approximately 0.9 percent) and rarely is reported in the literature.1-3 These outcomes sometimes are due to direct trauma to a trigeminal nerve trunk or major branch, but this review focuses mainly on the idiopathic onset of such problems. The etiology and pathophysiology of persistent idiopathic facial pain (PIFP)also known as atypical facial painare poorly understood, and the differential diagnosis is challenging and often requires the involvement of several clinicians, including dentists, neurologists and ENT specialists. Indeed, clinicians must rule out several pain conditions before reaching a final diagnosis of PIFP (Box4-8). In fact, many of these conditions can be excluded because they are associated with specific pathognomonic clinical features.4 A dentist also can administer local or regional diagnostic anesthetic blocks to rule out more common conditions such as odontogenic pain, pain associated with temporomandibular disorders and traumatic neuropathic pain. However, with this anesthetic block approach, the pain must be

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reduced dramatically or eliminated completely to rule out these pathologies. The International Headache Society (IHS) provides four diagnostic criteria for PIFP (IHS/ International Classification of Headache Disorders, 2nd edition [ICHD-II], code 13.18.49). The corresponding International Classification of Diseases, 10th Revision, code is G50.1.10 dDaily pain must be present for most of the day. dThe pain must be deep, dull and unilateral and not well localized. dThe pain is not associated with focal neurological signs or sensory deficits. dNo abnormality should be found with laboratory and radiographic investigations, which must include imaging studies of the face, jaw, cervical spine and chest.4,11 The clinical case scenario described here should be diagnosed as PIFP, because the characteristics of the pain fulfill the IHS criteria, and because the clinical features and laboratory parameters seem to rule out other conditions (Box4-8). In this case, no direct evidence of trigeminal nerve damage is available, and, therefore, the diagnosis relies on symptoms and signs alone. We must acknowledge that idiopathic pain is a temporary concept until clarification of pathophysiological mechanisms (for example, deafferentation) is obtained.11
PreVention

box

Differential diagnosis before reaching a nal diagnosis of PIFP.*

dPeripheral traumatic neuropathic pain dPostherpetic neuralgias dTypical trigeminal neuralgia or other cranial
neuralgias Differential DiaGnosis List

dAtypical odontalgia (also known as persistent

dentoalveolar pain )

dOdontogenic pain (such as pulpitis, periapical

periodontitis, cracked tooth syndrome)

dSinus-related pathologies (acute or chronic sinusitis) dTemporomandibular disorders (arthralgia/

osteoarthritis, masticatory myofascial pain) headache, migraine, cluster headache)

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dPrimary headache conditions (tension-type dTolosa-Hunt syndrome dCarotidynia dFacial pain secondary to intracranial or extracranial
infections or tumors (for example, lung cancer)

dFacial pain secondary to cervical spine disease (C2-C8

cervical nerve root compression, facet injury or both) * PIFP: Persistent idiopathic facial pain. Sources: Agostoni and colleagues,4 Evans and Agostoni,5 Eliav and Max.6 Source: Benoliel and colleagues.7 Source: Nixdorf and colleagues.8

In cases such as the one described here, postoperative PIFP symptoms may be preventable to some extent if the potential risk factors are identified.12 An appropriate medical history, diagnosis and treatment are paramount to reducing the risk of developing PIFP after implant surgery. It is highly unlikely that the drilling or implant placement caused direct infraorbital nerve damage. However, factors such as incision size (particularly with flap elevation), type of surgery, anxiety, age, sex and especially the existence of preoperative chronic pain conditions have emerged as independent predictors of pain immediately after surgical procedures.13-15 Highly anxious patients appear to be more resistant to local anesthesia and may be at higher risk of experiencing trigeminally mediated pain after invasive dental procedures such as implant placement.16 Also, lower patient satisfaction has been associated with higher preoperative anxiety (independent of the patients postoperative satisfaction with the surgeon), particularly in women and in younger patients.16,17 Consequently, clinicians should discuss with patients the association of height-

ened anxiety with the resistance to anesthetic efficacy during the decision-making process for implant placement, and they can use screening questionnaires or scales to assess anxiety levels. Clinicians can estimate patients anxiety levels by using a 10-centimeter visual analog scale or measure anxiety by using valid and reliable psychometric tools (for example, Corah Dental Anxiety Scale).17-19 Managing the care of patients who are moderately to severely anxious may include use of conscious sedation or cognitive behavioral therapy (CBT) or prescription of short-acting benzodiazepines before the dental procedure.16,20-22 In the case presented here, the presence of preoperative comorbidities (for example, anxiety, CP) may have predisposed the patient to developing postoperative pain, particularly because these comorbidities were not well controlled.13-15
ManaGement

In patients diagnosed with PIFP, screening questionnaires and specific neurosensory testing are important to identify possible sensory
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Common medications used to treat persistent idiopathic facial pain.

DruG Class Example of actiVe substance Amitriptyline Nortriptyline Duloxetine Propranolol Gabapentin Pregabalin Clonazepam Baclofen Tramadol MecHanism of action Inhibit reuptake of serotonin and norepinephrine Block 1- and 2adrenergic receptors Inhibit voltage-gated Ca2+* inux Modulate GABA A receptors GABA B receptor agonist Weak microopioid receptor agonist, induces serotonin release, inhibits reuptake of norepinephrine Local anesthetic NMDA receptor antagonist Agonist of TRPV1 ion channels Tricyclic and Nontricylic Antidepressants -Blockers Anticonvulsants Benzodiazepines GABAergics Minor Opioid Analgesics

ment.4,5,22,28,29 Randomized controlled trials (RCTs) addressing PIPF management have not been performed systematically, to our knowledge, which complicates an evidence-based treatment decision.28 However, pharmacological therapy, including topical medications, nontricyclic and tricyclic antidepressants (TCAs), anticonvulsants and benzodiazepines, is recommended widely as the first line of treatment for PIFP (Table).4-6,22,26-28 Yet, in the majority of cases of PIFP, complete pain remission is not achieved.4,28
CONCLUSIONS

Topical Pain Medications

Lidocaine Ketamine Capsaicin

* Ca 2+: Calcium. GABA: -aminobutyric acid. NMDA: N-methyl-D-aspartate. TRPV1: Transient receptor potential cation channel, subfamily V, member 1.

disturbances (paresthesia, dysesthesia, allodynia) in the trigeminal area.12,23,24 If acute neuropathic pain symptoms are present immediately after implant surgery and nerve injury is suspected, patients may undergo removal of their implants within 24 hours to resolve their pain or may undergo an immediate repair if nerve section is detected.22,25 Clinicians should treat acute postoperative nerve injuries immediately with topical or systemic anti-inflammatories, peripheral nerve blocks with local anesthetics and glucocorticoids, as well as with neuropathic pain medications to reduce potential neurogenic inflammation and regain typical neuronal transmission.1,26-28 When intractable PIFP is diagnosed after implant surgery, patients potential to recover their normal trigeminal sensations is reduced.22 Therefore, consultations with patients should include a full explanation of pain symptoms to alleviate many concerns and, we hope, persuade patients to avoid unnecessary invasive dental or medical treatments. Clinicians should consider referring patients to an orofacial pain clinician or a neurologist for further pain assessment, stimulus-response testing and CP manage1360JADA 144(12)http://jada.ada.orgDecember 2013

In our clinical scenario, a multidisciplinary pain team can propose treatment with topical compound medications (for example, lidocaine 1 percent, carbamazepine 4 percent and gabapentin 4 percent) to achieve better local pain control without increasing adverse effects or drug interactions in this elderly patient. If not contraindicated, systemic nontricyclics and TCAs would be the second treatment option, followed by anticonvulsants and minor opioids, though none of these drugs has been tested in well-designed RCTs to study their efficacy in patients with PIFP.4,28 Patients who are refractory to conventional pharmacological treatment may benefit from hypnosis. In a patient-masked controlled RCT, hypnosis offered clinically relevant pain relief for PIFP compared with a relaxation intervention, particularly in patients with high susceptibility to hypnosis.29 Stress coping skills and CBT for unresolved psychological problems (such as pain catastrophizing, anxiety, depression, obsessive compulsive disorder) must be included in a comprehensive pain management approach to control psychological factors and improve patients quality of life.22,28,29 n
Dr. Ferreira is a clinical research fellow and a TMD and orofacial pain clinician, National Institute of Dental and Craniofacial Research, National Institutes of Health Clinical Center, 30 Convent Drive, Building 30, Room 429, Bethesda, Md. 20892, e-mail andraderequicj@ mail.nih.gov. Address reprint requests to Dr. Ferreira. Dr. Figueiredo is an associate professor, Oral Surgery, School of Dentistry, University of Barcelona, and a researcher at Institut dInvestigaci Biomdica de Bellvitge, Barcelona, Spain. Disclosure. Drs. Ferreira and Figueiredo did not report any disclosures. This study was supported in part by the Intramural Research Program of the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md. The authors thank Drs. Katiucha Sales and Dean Aria for helpful discussions and critical reading of the manuscript of this article. Pain Update is published in collaboration with the Neuroscience Group of the International Association for Dental Research. 1. Gregg JM. Neuropathic complications of mandibular implant surgery: review and case presentations. Ann R Australas Coll Dent

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Surg 2000;15:176-180. 2. Hillerup S. Iatrogenic injury to oral branches of the trigeminal nerve: records of 449 cases. Clin Oral Investig 2007;11(2):133-142. 3. Rodriguez-Lozano FJ, Sanchez-Perz A, Moya-Villaescusa MJ, Rodrguez-Lozano A, Sez-Yuguero MR. Neuropathic orofacial pain after dental implant placement: review of the literature and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(4):e8-e12. doi:10.1016/j.tripleo.2009.12.004. 4. Agostoni E, Frigerio R, Santoro P. Atypical facial pain: clinical considerations and differential diagnosis. Neurol Sci 2005;26 (suppl 2):s71-s74. 5. Evans RW, Agostoni E. Persistent idiopathic facial pain. Headache 2006;46(8):1298-1300. 6. Eliav E, Max MB. Management of neuropathic pain. In: Sessle BJ, Lavigne GJ, Lund JP, Dubner R, eds. Orofacial Pain: From Basic Science to Clinical Management. 2nd ed. Hanover Park, Ill.: Quintessence Publishing; 2008:195-202. 7. Benoliel R, Zadik Y, Eliav E, Sharav Y. Peripheral painful traumatic trigeminal neuropathy: clinical features in 91 cases and proposal of novel diagnostic criteria. J Orofac Pain 2012;26(1):49-58. 8. Nixdorf DR, Drangsholt MT, Ettlin DA, et al. Classifying orofacial pains: a new proposal of taxonomy based on ontology. J Oral Rehabil 2012;39(3):161-169. 9. IHS Classification ICHD-II. http://ihs-classification.org/en/. Accessed Oct. 28, 2013. 10. ICD-10 Version: 2010. http://apps.who.int/classifications/icd10/ browse/2010/en. Accessed Oct. 28, 2013. 11. Woda A, Tubert-Jeannin S, Bouhassira D, et al. Towards a new taxonomy of idiopathic orofacial pain. Pain 2005;116(3):396-406. 12. Hillerup S. Iatrogenic injury to the inferior alveolar nerve: etiology, signs and symptoms, and observations on recovery. Int J Oral Maxillofac Surg 2008;37(8):704-709. 13. Kalkman CJ, Visser K, Moen J, Bonsel GJ, Grobbee DE, Moons KG. Preoperative prediction of severe postoperative pain. Pain 2003; 105(3):415-423. 14. Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology 2009;111(3):657-677. 15. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367(9522):1618-1625. 16. Gonzlez-Lemonnier S, Bovaira-Forner M, Pearrocha-Diago M, Pearrocha-Oltra D. Relationship between preoperative anxiety and postoperative satisfaction in dental implant surgery with intravenous conscious sedation. Med Oral Patol Oral Cir Bucal 2010;15(2):e379-e382.

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17. Pekkan G, Kilicoglu A, Hatipoglu H. Relationship between dental anxiety, general anxiety level and depression in patients attending a university hospital dental clinic in Turkey. Community Dent Health 2011;28(2):149-153. 18. Edwards DJ, Brickley MR, Horton J, Edwards MJ, Shepherd JP. Choice of anaesthetic and healthcare facility for third molar surgery. Br J Oral Maxillofac Surg 1998;36(5):333-340. 19. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48(4):596. 20. Little JW, Falace DA, Miller CS, Rhodus NL. Little and Falaces Dental Management of the Medically Compromised Patient. 8th ed. St. Louis: Elsevier Mosby; 2013:417-438. 21. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The management of dental anxiety: time for a sense of proportion? Br Dent J 2012;213(6):271-274. 22. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Postimplant neuropathy of the trigeminal nerve: a case series (published online June 8, 2012). Br Dent J 2012;212(11):E17. doi:10.1038/sj.bdj. 2012.497. 23. Wismeijer D, van Waas MA, Vermeeren JI, Kalk W. Patients perception of sensory disturbances of the mental nerve before and after implant surgery: a prospective study of 110 patients. Br J Oral Maxillofac Surg 1997;35(4):254-259. 24. Baad-Hansen L, Abrahamsen R, Zachariae R, List T, Svensson P. Somatosensory sensitivity in patients with persistent idiopathic orofacial pain is associated with pain relief from hypnosis and relaxation (published online ahead of print Jan. 16, 2013). Clin J Pain 2013;29(6):518-526. doi:10.1097/AJP.06013e318268e4e7. 25. Worthington P. Injury to the inferior alveolar nerve during implant placement: a formula for protection of the patient and clinician. Int J Oral Maxillofac Implants 2004;19(5):731-734. 26. Hegedus F, Diecidue RJ. Trigeminal nerve injuries after mandibular implant placement: practical knowledge for clinicians. Int J Oral Maxillofac Implants 2006;21(1):111-116. 27. Eker HE, Cok OY, Aribogan A, Arslan G. Management of neuropathic pain with methylprednisolone at the site of nerve injury. Pain Med 2012;13(3):443-451. 28. List T, Axelsson S, Leijon G. Pharmacologic interventions in the treatment of temporomandibular disorders, atypical facial pain, and burning mouth syndrome: a qualitative systematic review. J Orofac Pain 2003;17(4):301-310. 29. Abrahamsen R, Baad-Hansen L, Svensson P. Hypnosis in the management of persistent idiopathic orofacial pain: clinical and psychosocial findings. Pain 2008;136(1-2):44-52.

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