Patient with Paresthesia: What’s the Proper Treatment Plan?

The delayed onset of dysfunction in the area of anesthesia gives rise to several etiologic questions: the flap design and extent of dissection, the loop of the mandibular nerve as it approaches the mental foramen, the compressibility of cancellous mandibular bone and its ability to transfer force or pressure to a nearby nerve from an implant (remote nerve compression), surgical trauma of treatment, postoperative inflammation, Herpes zoster and other viral or bacterial infections, mental nerve block, neoplastic compression, compartment syndrome, and hematoma. Postoperative nerve dysfunction is a condition that is almost totally dependent on the patient’s perception and reporting of the deficit. We must rely on this perception to assess an occurrence, improvement, recovery, or non-recovery of a sensory nerve dysfunction. During surgery, nerves can be stretched, compressed, or partially or totally transected. The factors that affect nerve response to injury include the size, number, and pattern of nerve bundles in the nerve trunk; the amount of epineural tissue surrounding the nerve; the position of the nerve fibers in the nerve trunk (the most distal fibers are at the center of the trunk); the type of injury (compressed nerves regenerate faster than severed nerves); and physiologic susceptibility. Peripheral nerves show a greater capacity for regeneration than central nervous system nerves. A nerve can be compressed by various materials that can cause an altered sensation. Compression of the pudendal nerve while bicycle riding has been shown to cause neuropathy. Cancellous bone that is compressed by a dental implant might press against the nerve, causing a dysfunction. Implants are slightly larger that the receiving osteotomy, usually about 0.5 mm. When the implant is placed, a compression of bone may occur. Human trabecular bone has variable Young’s modulus related to its density and a compressive strength range between 18,000 and 24,000 pounds per square inch. A trabeculation of cancellous bone would have enough induration to transfer compression force and subsequent stretching of the nerve. If an implant is seated and the apex presses on a segment of trabecular bone that happens to be positioned in the same axis as the implant, it is conceivable that the piece of trabecular bone could be displaced 0.5 mm toward the mental nerve, distal to the bifurcation, inducing a neural inflammatory degenerative process .The bifurcation of the mandibular nerve into the mental and incisive nerves occurs in the molar area well before reaching the mental foramen. The possibility also exists of an interposition of the mental artery that may act to compress the nerve, as has been found in some cases of blood-vessel compression trigeminal neuralgia; decompression of the nerve in this situation can produce rapid relief, probably from release of demyelinated axonal distortion from the compression and remyelination. An arterial compression of the nerve may induce a delayed neural inflammatory process. The implant in this case does not radiographically show to touch the nerve. The term “remote nerve compression” might be used in these situations to better characterize the condition, if it indeed exists. Some clinicians recommend reversing fully seated implants a quarter of a turn to alleviate bone compression.

Consider a late infection from either the apical end of the implant or another tooth in that quadrant. Seems like a pressure phenomenon and at this point you certainly can't back out the implant. Also, the basic principles of antibiotic prophylaxis would dictate it been given prior to surgery. Prescribing an antibiotic postoperatively has no protective benefit to infection and only increases issues of side effects, resistant strains, etc.

Get a neuro consult. Patient may have other neurological problems, such s MS etc.

I have had a referral of a patient with with a similar presentation of reccurent parestheisia. There was endodontic involvement of the adjacent molar where the apies were immediately adjacent to the IAN

Thank you for the important and insightful comments on antibiotic use, Dr. Leiblich. There has never been any good evidence to support the post-operative administration of antibiotics as a means of reducing the incidence of infection from dentoalveolar surgery in immunocompetant individuals. Sound surgical principles dictate that a loading dose of antibiotics in the blood stream at the time of incision is the best way to reduce iatrogenic infections, along with sterile technique. The problem with antibiotic resistant bacteria is not going away, and we only have ourselves to blame for the overuse of antibiotics for so many years. Think seriously about the consequences before you prescribe!

Sorry. There was a misprint. The patient began Amoxicillin 500 tid, 48 hrs pre extraction/immediate implant and continued for 8 days post op. In addition, the socket was thoroughly curretted and debrided with sterile saline and betadine prior to implant preparation and grafting. I perform these procedures following Branemamrk OR sterility standards, etc. Thanks for the input. As an OMS, I respect the IAN and at no time during the surgery, did I visualize or get any feedback indicating its proximity. I appreciate the opportunity to discuss this event with colleagues. Richard

Assuming the reflection incision did not go thur raphae and the lingual nerve damaged, parathesia is very limited, if not completely, from mandibular inflitration anesthesia. Block anesthesia is not necessary and is contraindicated with mandibular implants distal to mental nerve. After placing over 18,000 implants since 1969, three patients had parathesia lasting longer than two months. Approximately ten have had some nerve alteration lasting one month or less. Alfred L. Heller, DDS MS Director Midwest Implant Institute midwestimplantinstitute

Try, with, B complex, 2 weeks and see waht happend,

Well again I would comment about antibiotic usage 48 hours before surgery. Again, prophylaxis against infection would dictate administration of antibiotics in the perioperative period (just before the incision is made). In the case where intravenous antibiotics are not being given, then one hour before surgery is the time to start, not 48 hours before.

Initial paresthesia was more likely from needle trauma to bundle which resolved as most do. the new paresthesia is possible a neuroma from the intial insult or a new etiology. would suggest a neuro consult and a Cat Scan and/or MRI of brain and a full work up for other nerve problems. Return of this late would lead me to other areas

Dr.R May I suggest getting an i-cat scan on your patient to see if there was compressive calcification on the IAN.Once you use cone beam tech you'll never go back. Bill Pace

In my experience you can try to unscrew only for 180 ° the implant. is the best choice with eventually the subministratio of 4 mg betametasone intramuscular for three days.

I am looking into using low level laser therapy to treat similar situation to this case. There is an article discussing the use of LLLT on patient with injured IAN. Report on only four patients, though all were reversed after a year with paresthesia before treatment. I will do the study on my own and let all of you know what happen.

Hello, I have been reading this website because I have mental paresthesia since 1/2/07 from nerve decompression surgery. I would love to talk with anyone who thinks they know how to solve this problem and am willing to fly anywhere. My email is: [email protected] Sincerely, Dawn O'Malley

How soon do ou recommend reverse the screw after accurence of parasthesia

Dr. K, The sooner the better is the short answer but this comes with precautions. If you can simple reverse the implant out then do so immediately. If the the implant is integrated and reversing is not possible than weigh the pros and cons since removal may mean more trauma to the nerve. The area above the mental nerve can be a tricky place for implant surgery. Be careful of releasing incisions and releasing the flap in this area. If you compress the nerve or even think there is a chance that you did, then take an xray before you suture so that you can back it out. A tip: if you're working above the canal then don't give a block injection so the patient will inform you when you get close to the canal. Of course, this does not mean don't take an xray, but it helps.

Thank you for sharing a very interesting case. I would subscribe with those who recommend a CT scan. This will rule out a potential misfortune with respect to the 2 mm rule of safety from any vital structures. I too have placed many implants in the 1st molar site, the location where most mandibular nerves cross under the 1st molar and move buccally. Your implant placement maay have nothing to do with the parasthesia. As a side note I will utilize the Misch technique and place a steroid in the site if I feel that I have traumatized the nerve or encroached upon it in any way whatsoever, a beautiful technique. The only reason to administer antibiotics is if you suspect infection upon the extraction site. In hindsite it may have been better to have extracted the tooth, #18 and waited two months to place the implant once you had primary closure. However, this does nothing for the case at this time. Indeed you may have "speared" the mandibular trunk. This should have no long term results. A couple of thoughts for those patients that I have had who have experienced this same type of result. Assuming that you have palpated the implant and the gingival healing screw is tight (no anaerobes)and there is no purulent material then I would try a delayed dose of steroids (probably won't help however, worth the try), make sure that you have a CT scan, accessory nerve, mylohyoid enters at the 2nd molar on the lingual aspect, thermal test the adjacent dentition, when the patient is having the problem bring them in and administer L/A to see if you can isolate it or have them take a sharpie and mark out the course of discomfort. You may be surprised as this may be a trigeminal neuralgia that has nothing to do with you. If the implant has been in less than 2 months then you will only have woven bone and you may wnat to simply back it out. Two months is the weakest time of interface if you look at Eugene Roberts and Mohammad Sharawy's work. Hope this helps. At the very minimum get the CT to cover your Butt. Hope this helps........Duke Aldridge, MICOI, MAGD

To all: I am a healthy 40yr old female who had 2 dental implants placed on the lower right side in 2003. They replaced the first molar and the tooth in front of it. I lost the first implant within 6 months of placement, however the molar implant was sucessful. The x-ray showed the implant was sitting very close to the inferior nerve, however I had no symptoms of any nerve damage. October 2008 I experenced a failure of the molar implant. I had swelling and infection involving the majority of my right lower face and jaw. I also experenced numbness in the chin area. I was placed on Clindamycin for 7 days and was told to come back a week later for the removal. The numbness to the chin ceased after 3 days of the Clindamycin use. On October 8th, 2008 the implant was removed. Bone grafting was done and tissue was placed in the areas of both dental implants. Since the day of the removal I have experenced numbness to the lower right side of lip,chin,jaw and a constant burning pain to the chin and lip area. I have moderate/severe spontanious pain and sensory disturbences on lower lip and chin. My oral suergon is taking the wait and see approach. What should I do? I can not see a neuro without a referral and the oral suergon says, wait and see what happens in 3 months. This has been a life changing experience for me. I am having panic attacks and bouts of depression from the constant burning sensation. It has disrupted my sleep and is MAKING ME CRAZY. I am desperate for any help or recommendations. I am not a "wait and see" kind of person. I need to know that I have followed the recommended protocall for this type of injury. Any suggestions or comments would be appreciated. Debbie Arizona

Don't let go too long. TX with steriods, vit B-6 & VIT B-12, NASAIDS. See a neurosurgeon (James Campbell at Johns Hopkins. Don't mess around! Also antibiotics may be in order.

friends, i did furcation debridement of lower 1st molar & periapical debridement of lower 2nd premolar simultaneously. Patient had no problems for the first 2 days but later on he developed paresthesia of chin on that side. I went thru literarure and got to know that it usually disappears within 2 months. I prescribed him vitamins, analgesics and hot fomantation. It has been more than 2 months but his paresthesia has not resolved. Althogh I personally feel that the condition has slightly improved. But, the patient says thee has been no improvement. He has no fever or any other complications. What should I do???

Refer to a good neurosurgeon.

I feel you should give it more time. There is not much you can do. I think most parestesia cases takes few to several months to resolve. According to literature, taking multi vitamins helps. Wish you best,

I had a permanent crown placed on tooth 18 and when my dentist put me in a bite to hold I felt a pain on an above tooth. It is now 2 and a half months since and several specialists and 10 acupuncture treatments and I STILL HAVE NUMBNESS AND TINGLING in my front teeth and tounge tip. I also had excruciating ear pain that first weekend and was put on antibiotics. I feel like I am slowly going crazy as this is 24|7 with no relief.. I did have some improvement after 5 weeks of acupuncture twice a week but for no real reason I am back to where I started. Initially it was really on the left but now IT seems to be generalized hard to tell. It is definitely making life miserable

Hello and thank you for your advise.. I have had paresthesia in my left jaw and chin area since 1995, following the removal of a wisdom tooth that was growing sideways.I feel like the numbness is actually GROWING with age, not shrinking.. Is it still possible to do anything to improve this..? Unfortunately, I can't use Dr. Campbell at Johns Hopkins as he is beyond the reach of my healthcare plan. Can you recommend another neurologist of his caliber in the NY/NJ area..? Many thanks Edward in NJ

Edward, I suggest that you give Dr. James Campbell a call or write a letter, to see if he can suggest a Doc in NJ or NY. I have referred to Dr. Campbell in the past when patients present with injuries. I think he is one of the best, if not the best in the land.

While scant science and literature publications, there is a significant number of clinical cases of nerve paresthesia and dysthesia reversal and eliomination using low level and ligh level laser irradiation, especially in the 1064nm wavelength. Emperical data shows 90% success rate of any length of duration and any cause including compression, needle stick, surgical trauma.

The hardware may have to be skillfully removed. You most likely will have to have a CT prior to said procedure. Find someone that knows what they are doing, perhaps at an academic center!

Avril..the symptoms that you had after placement of a posterior crown is a sign of Temporomandibular dysfunction. Better see a Doctor who specialize in TMD. The pain will never go away unless the root cause of the problem is removed.