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Neurological conundrum after implant placement: Thoughts?

Last Updated: Jun 05, 2016

This case concerns a 45 year old female who presents to my office after being in pain following implant placement (please see outline of case below). She has trigeminal neuralgia type of symptoms when I press more in the canine area apically. There does not seem to be much discomfort when pressing on the buccal or lingual tissues of #12. Soft tissue has overgrown the healing abutment by about 1mm, but the tissues look healthy with no redness or suppuration. I do not see much of a problem on the CT which she provided from the oral surgeons office. There appears to be a good cortical layer of bone around the implant. She is fairly adamant in wanting to remove the implant to reduce her sypmtoms, but I am not inclined because I am not sure of the diagnosis for her pain. I told her to go see an endodontist to evaluate her pulps on the teeth on that side of her mouth. What your thoughts? The patient could possibly have some trigeminal pain issues if she had an infiltration for the surgery that approached or contacted the infraorbital nerve. I am not a pain doctor so I do not know where to go from here. I look forward to some elucidating thoughts. Thanks

A bit more on the case timeline from the patient:
Oct. 30 2015: Dentist removed tooth, did a bone graft and installed the implant in one visit.
Nov 5 2015: Dentist found the implant was infected. Prescribed antibiotic and pain med.
Between Nov 5 and Dec 3: Patient in pain and was decided between family dentist and the oral surgeon that the pain must be originating from back molar as it was high. The crown was removed and a temp put on. Still no pain relief. Prescribed a steroid medrol dose pack and a pain medicine.
Dec 4 2015: Oral surgeon pulled back molar. Still had pain but things seemed to settle down a little over the next 4 months.
April 5th 2016: Had healing cap removed and crown screwed in. A lot of the pain came back at this point along with a feeling of tightness and pressure around the implant. Family dentist adjusted it
April 6 2016: New Symptom– Area around implant sometimes tingles, gets numb, and has a crawling sensation.
April 9 2016: Family dentist removes crown and puts healing cap back on.
April 15: Went to oral surgeon to ask about removing it. He says it can’t be removed without removing the teeth next to it too, and he does not want to do it. He said implant triggered Trigeminal Neuralgia ( but didn’t cause it), and to go see a neurologist.
April 17th: Pimary care physician prescribes Neurotin, Elavil, and Tramadol. She puts in a referral rest for neurologist.
May 25 2016: Sees neurologist, and he wonders if this has more to do with the implant because not presenting like a classic case of Trigeminal neuralgia but will treat it like Trigeminal neuralgia anyway. He adds Tegretol to meds and schedules MRI
Pressure, discomfort, tightness, tingling, numbness, crawling sensation is not constant. It comes and goes throughout the day.

8 Comments on Neurological conundrum after implant placement: Thoughts?

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Jawdoc

6/7/2016

Looks & sounds to me like neuroma. Prob is that this mimics neuralgia/ psychogenic pain. & yes, distal teeth are heavily restored & there lies a possibility of endodontically transferred pain, though a simple vitality / cold test on those teeth will elucidate you. :)

William

6/7/2016

Bone loss around the implant with apical lucency. Reverse torque value I bet is very low or better yet check the ISQ. Both will show there is no integration. Get the thing out! I bet it backs out easily. With atypical facial pain or trigeminal neuralgia, the longer the triggering agent is present, the harder and longer the road to recovery. With those entities, treating the obvious first is often the answer but occasionally it is a diagnosis of exclusion. I would have got that out a while ago however.

Amir Mostofi

6/7/2016

You need to find the pain source first. Probably the best way is to use infiltration local anaesthesia slowly and tooth by tooth and next to the implant. It takes time but you will eventually find the spot. To remove the implant the neighbouring tooth does not need to be extracted. There are some implant removal kits available which mainly working on reverse torque principle.

Dan boyko

6/7/2016

First off the implant is too wide for that site .Remove the implant regraft the site see if symptoms resolve .

CRS

6/9/2016

I agree with this comment the implant is too big, find someone who is comfortable removing implants and graft. See what you get no shame with placing a bridge in future. The reason is immaterial the pain is. If there is a neurogolic component the neurologist can manage this in tandem with the restoring dentist. I was not there at the original surgery and but the neuroma theory is a stretch. What strikes me is a post op infection so soon, that would have been the time to remove and graft. Possibly this is a low grade osteomyelitis I've seen these, doubtful the other teeth are the cause. Took a bit of a risk trying to do too much at once, clouds the diagnostic picture. Learn from this if the implant surgeon was not trained in managing sequela then should have not attempted this. If this implant was assymptomatic would you be comfortable restoring it?

Jean Furuyama

6/7/2016

Residual infection left over from the extracted tooth is the most likely cause of this patient's discomfort. Immediate placement only works when the infection is totally removed at extraction. I suspect that it will be fairly easy to back the implant out and I don't see why it would result in losing the teeth next door.

6/8/2016

It is about 6 months from the date of initial procedure, and despite several other evaluation and consultation the patient still has the same pain and complain. Don't forget that the implant is a foreign body and with the possibility of an infection and proximity to the nerve one could experience these symptoms. I will agree with William. I would start by trying to find the problem by diagnosis of exclusion. Remove the implant, test and treat for infection, and still get a primary care and neurologist consult. Until the possible irritant is removed, recover may be long and tough.

John T

6/8/2016

1. There is a tendency to label all inexplicable facial pains as either trigeminal neuralgia or atypical facial pain. This lady does not have either. She has chronic post-surgical nociceptive pain reinforced by overinvestigation and over treatment. This sort of presentation is all too familiar on any pain clinic. 2. Limit any further treatment to: (a) a plain radiograph such as a periapical view =/- an OPG. Do not rely on the CBCT which can throw up false images such as the "apical lucency" described above, a plain view is diagnostically much more useful. (c) if she absolutely insists, remove the implant with a Neo Biotech implant removal kit and allow the socket to heal as you would a tooth socket. No need to spray it with lasers, curette the bone, put her on huge doses of antibiotics, shove foreign materials down the hole or perform any of the manoeuvres beloved of contributors to this site. Unfortunately it's most unlikely that this will make any difference to her symptoms. (d) don't even think of putting in another implant unless and until she has been rendered entirely pain free (maybe!) and don't waste her time and money sending her to other specialists.

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