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Trigeminal nerve injuries related to restorative treatment

From Volume 45, Issue 6, June 2018 | Pages 522-540

Authors

Tara Renton

BDS, MDSc, PhD

Professor of Oral Surgery, King's College London; Honorary Consultant in Oral Surgery, King's College Hospital NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust, London

Articles by Tara Renton

Abstract

Abstract: Restorative dentistry provides many opportunities to cause trigeminal nerve damage. Chronic post-surgical pain, resulting from nerve damage, is rarely associated with dentistry as a result of local anaesthetic (LA) infiltration injections but is more commonly associated with injuries to the nerve trunks of division two and three caused by LA blocks, implants and endodontics.

In dentistry, the term paraesthesia is often used inappropriately to mean neuropathy. Paraesthesia is only a descriptive term of symptoms, meaning altered sensation, and not a diagnosis. When sensory nerves are injured, a neuropathy (malfunction) may arise and this may be painful or non-painful. Fortunately, painful post-traumatic neuropathy, caused by injury to nerves, is rare in dentistry compared with other common general surgical procedures, where up to 20–40% of patients experience chronic post-surgical pain after limb amputation, thoracotomy and breast surgery. This article aims to highlight how to prevent nerve injuries using strategies for risk assessment, appropriate surgical techniques and suitable follow-up protocols to allow urgent management to optimize resolution of the nerve injuries when they occur.

CPD/Clinical Relevance: Prevention of rare nerve injuries arising from common dental procedures is key, as many high risk procedures can cause lifelong neuropathic pain, functional and immense psychological impact for the patients involved, for which there is no simple remedy.

Article

Trigeminal nerve injury is the most problematic consequence of dental surgical procedures with major medico-legal implications.1 The incidence of lingual nerve injury has remained static in the UK over the last 30 years, however, the incidence of inferior alveolar nerve injury has increased; the latter being due to implant surgery and endodontic therapy.2 Causes of trigeminal nerve injury (TNI) are varied but many occur in relation to restorative dentistry. These include TNIs caused by local anaesthetic injections, implants and endodontics. The inferior alveolar nerve (IAN) neuropathy related to third molar surgery or inferior alveolar block injections is usually temporary but can persist and become permanent (by definition at 3 months). There are rare reports of resolution of implant-related IAN neuropathies at over 4 years,3 but these do not comply with normal reports of peripheral sensory nerve injuries.4 Many authors recommend referral of injuries after 6 months,5 but this may be too late for many peripheral sensory nerve injuries related to restorative care. We now understand that many dentally induced nerve injuries require intervention ideally immediately, within 30 hours, or within 3 months, dependent upon the mechanism of injury, to optimize resolution from injury and prevent the permanent central and peripheral changes within the nervous system.6

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