Clinical Guideline 7 - Version 4

Valid to: September 2016

Nerve Injury Follow Up

Purpose
The aim of this Clinical Guideline is to provide advice to public oral health clinicians
regarding nerve injury follow up. Evidence-based clinical guidelines are intended to provide
guidance, and are not a standard of care, requirement, or regulation. However, the
application of clinical guidelines in publicly-provided oral health services allows for
consistency to occur across large patients cohorts with a variety of oral health clinicians.
All clinicians should be aware that nerve injury and subsequent loss of sensation is a
serious complication of oral surgical procedures and potentially has a very high risk of legal
consequences. Nerve injury may result in transient or permanent paresthesia or
anaesthesia. It occurs most commonly during the removal of mandibular premolars and
molars, the roots of which are in close relationship to the inferior alveolar or mental nerves.
This clinical guideline details the procedure that should be followed to ensure uniform
assessment of all patients in which this complication arises.

Guideline
Clinical considerations
Patients should be given appropriate pre- and post-operative instructions after any
extraction or other oral surgery procedure, including advice regarding the expected
duration of the local anaesthetic (LA) which has been administered. Although routine review
of patients who have had an extraction is not undertaken within a general dental practice,
patients should be advised to contact the clinic where the procedure was undertaken or
given another alternative where this is impractical, should any complications such as
excessive bleeding arise. Written post-operative instructions including clinic contact details
should be given to the patient and this documented in the patient record.
Patients undergoing removal of lower third molars within the Oral and Maxillofacial Surgery
(OMFS) Department and Day Surgery Unit (DSU) of the Royal Dental Hospital of Melbourne
(RDHM) sign a consent form detailing possible risks and complications of this type of
procedure. A post-operative check appointment is scheduled two weeks after the
procedure, and, if the surgery was not complicated, may be with the referring community
dentist.
Diagnosis of nerve injury
Any patients with signs of nerve injury as demonstrated by altered sensation in the nerve
distribution 2 weeks after a surgical procedure should be urgently referred to the OMFS
Department of the RDHM. Completion of the appropriate Specialist Services Referral form is
required and should be faxed to the RDHM on 9341 1306. The referral form should include
details regarding the surgical procedure, details of the anaesthetic /site/s, the extent of the
paraesthetic field (via a drawing) and an estimation of the depth of anaesthesia. Depending
on local arrangements, a Clinical Incident form should also be completed and submitted to
the relevant line manager for processing 1. An explanation and reassurance should be
provided to the patient. This would include information regarding the likelihood of return of
normal sensation (approximately 99% of cases of nerve injury resolve).
The clinician within OMFS, either at the OMFS routine review appointment or at the
appointment made as a result of a referral should:

Undertake an examination and confirm a diagnosis of nerve injury. This should be

recorded in the patients file.
Determine the nerve injured and the extent of the paraesthetic field. A drawing
depicting the affected area should be made in the patients file.
Determine the status of sensation by enquiring about the remaining sensation. The
remaining sensation should be assessed by the visual analogue scale from 0 to 10,

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Clinical Guideline 7 - Version 4

Valid to: September 2016

with figure 0 being no sensation at all and 10 being normal sensation. Do not
numerically assess paraesthesia because that brings confusion in the assessment
assess sensation and not paraesthesia.
Inform the patient regarding the most commonly expected outcome, i.e. recovery,
but also advise the patient about the small rare risk of permanent partial or complete
loss of sensation in the affected nerve anatomic distribution area.
Provide patients with advice regarding surgical options should sensation not return to
normal.
Complete a Clinical Incident form and submit to the relevant line manager for
processing in accordance with DHSVs Management of Adverse Clinical Events
Procedure.
This assessment will serve as a benchmark in the patients follow up and should be
repeated at each new follow up appointment.

Follow-up
Three months after injury is a critical time when a decision should be made as to whether
the OMFS Department will continue to follow up the patient at regular intervals or whether
a surgical intervention option should be offered. If there is no improvement, it is imperative
that arrangements be made with an appropriate specialist for evaluation regarding a
surgical intervention within the 3 month time frame.
Therefore, it is suggested that follow-up appointments be scheduled as detailed below:

After the surgical procedure that results in nerve injury

1st follow-up 2 weeks post surgery
2nd follow-up 1 month post surgery
3rd follow-up 2 months post surgery

At the 3rd follow-up appointment, the patient should be given a detailed explanation about
treatment options and should be offered to be referred to a neurosurgeon or appropriate
specialist for consultation about possible surgical treatment. The patient should be made
fully aware of consequences of no surgical treatment or of the surgical treatment options.
This should be documented in the patients record, including comments made by the
patient.
Should the patient elect conservative treatment, the follow up should continue in monthly
intervals up to six months after the injury and then in two monthly intervals up to twelve
months after the nerve injury. At each appointment the same registration of affected area
and the visual analogue scale assessment of sensation should be performed. Follow-up will
usually conclude twelve months after the date of the surgical procedure, with definitive
assessment of the status, and the clinical situation will usually be considered permanent if
there has been no recent change to the level of sensation.
At the end of the twelve month period a new Clinical Incident form should be completed
with an assessment of probable risk level from the legal perspective, and again the form
should be submitted to the relevant line manager.
The above procedure should also be followed where neurotoxicity could have occurred
following deposition of higher concentration agents in proximity to major nerves such as
during mandibular and lingual nerve blocks. Examples of higher concentration anaesthetics
include 4% articaine, 3% Prilocaine hydrochloride and 3% Mepivacaine hydrochloride.

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Clinical Guideline 7 - Version 4

Valid to: September 2016

Revision date

Policy owner

September 2016

Clinical Leadership Council

Approved by

Date approved

Director of Clinical Leadership, Education

and Research

August 2013

References and related documents

DHSV Procedure Management of Adverse Clinical Events PR-A054-02

Fielding AF, Rachiele DP, Frazier G; Lingual nerve paresthesia following third molar
surgery: a retrospective clinical study; Oral Surg Oral Med Oral Path Oral Radiol
Endod. 1997 Oct; 84 (4): 345-348

Howe GL; Minor Oral Surgery; 3rd edition, Bristol, John Wright & Sons Ltd, 1985

A Kingston, P Sambrook, A Goss; Higher concentration local anaesthetics causing

prolonged anaesthesia. Do they? Literature review and case reports; Aust Dent J
2011;56:348-351.

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