Consensus guidelines on training, diagnosis, treatment and follow-up care of trigeminal nerve injuries.

The aim was to present expert-based guidelines on the management of trigeminal nerve injuries. A two-round multidisciplinary Delphi study was conducted amongst international trigeminal nerve injury experts with a set of statements and three summary flowcharts using a nine-point Likert scale (1 = strongly disagree; 9 = strongly agree). An item was deemed appropriate if the median panel score was within the range of 7-9, undecided if the score was 4-6, and inappropriate if the score was 1-3. Consensus was achieved if at least 75% of panelists scored within one range. Eighteen specialists from dental, medical, and surgical specialties participated in both rounds. Consensus was reached on most statements related to training/services (78%) and diagnosis (80%). Statements related to treatment were mainly undecided due to a lack of sufficient evidence for some of the proposed treatments. Nevertheless, the summary treatment flowchart reached consensus with a median score of eight. Recommendations on follow-up and opportunities for future research were discussed. None of the statements were deemed inappropriate. A set of recommendations and accepted flowcharts are presented; these will aid professionals involved in managing patients with trigeminal nerve injuries.

Where is the 'wisdom' in wisdom tooth surgery? A review of national and international third molar surgery guidelines.

The objective of this narrative review was to identify and evaluate published international guidelines on mandibular third molars (M3M) and to assess their clinical scope and the validity of the recommendations. The search strategy used data obtained from a variety of sources including MEDLINE, national regulatory bodies, national dental and surgical colleges and associations, and military medical departments. Adherence to clinical guideline development was investigated using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation). Sixteen guidelines pertaining to M3M were included in this review. The guidelines produced by the Faculty of Dental Surgery of the Royal College of Surgeons of England (FDS RCS) and Scottish Intercollegiate Guidelines Network (SIGN) were recommended as meeting the criteria for use. Seven other guidelines were recommended but required modifications. The AGREE II instrument provides an excellent framework for guideline assessment. Unfortunately, very few guidelines scored highly across all domains and therefore were not believed to be of high quality. Due to the significant lack of structure and variable standards in guideline development, the conclusions and recommendations of these guidelines are compromised. There is a need for organizations involved in developing M3M guidelines to update guidance periodically in order to ensure that the information available to clinicians and patients is accurate and relevant to clinical practice.

Trigeminal autonomic cephalalgias presenting in a multidisciplinary tertiary orofacial pain clinic.

Orofacial pain may have a variety of causes and offers a significant clinical challenge for its diagnosis and management. OBJECTIVE: To assess the headache disorders presenting in a tertiary multidisciplinary orofacial pain clinic, after dental causes have been excluded. METHODS: Clinic letters from the initial consultation and subsequent follow up reviews of the 142 patients, who were seen in the tertiary Multidisciplinary Orofacial Pain clinic between January 2015 until January 2018 were reviewed as a clinical audit. RESULTS: The most common diagnoses were possible trigeminal autonomic cephalalgia (n = 62, 44%), migraine (n = 38, 27%) and painful post-traumatic trigeminal neuropathy (n = 17, 12%). The most common trigeminal autonomic cephalalgia diagnosis was hemicrania continua (n = 13, 9%), which is higher than the reported prevalence in neurology and headache clinics. CONCLUSION: This study demonstrates the importance of a multidisciplinary approach to diagnosing complex orofacial pain patients and the importance of awareness of primary headache disorders, in particular trigeminal autonomic cephalalgias, thereby reducing unnecessary diagnostic delays or procedures.

Evaluation of routine magnetic resonance imaging of patients with chronic orofacial pain.

The aim of this study was to evaluate the reported presence of magnetic resonance imaging (MRI) pathologies (demyelination, space-occupying lesions, or trigeminal neurovascular contact within the transition zone) in patients with orofacial pain. Patient histories, demographic characteristics, and clinical features were compared between those with and without a reported MRI pathology. A retrospective service evaluation of all patients who had undergone MRI scanning to aid the diagnosis of orofacial pain conditions between 2012 and 2016 was conducted. Data were collected and statistical analyses (frequency and descriptive) performed. One hundred and twenty-five patients (34 male and 91 female) with a mean age of 50 years were included. MRI pathologies included space-occupying lesions (2.4%), trigeminal neurovascular contact (22.4%), other pathology including small vessel cerebrovascular disease (20%), pineal cyst (1.6%), sinus pathologies (1.6%), and degenerative changes to the cervical spine (0.8%). This study found that patients with a provisional diagnosis of trigeminal neuralgia or trigeminal autonomic cephalalgia, as well as patients with elicited pain, were more likely to have abnormal findings on MRI scanning.

Changing face of orofacial pain: The diagnostic impact of working with Neurology on an orofacial pain clinic.

This study assessed the impact of collaborative working with a headache neurologist on diagnoses of patients attending orofacial pain (OFP) clinic. Patient diagnostic data was collected from adult patients attending an Orofacial Pain Service from January 2013 to January 2017. A liaison headache neurologist was appointed late 2015; OFP clinics were co-run with the neurologist specialist thereafter. Overall, 639 patients attended the service; 315 in 2013-2015 and 324 in 2016-2017. Compared to 2013-2015, there were increased rates of diagnoses related to neurovascular (27.5% vs. 19.0%; P=.012) and musculoskeletal pain (36.9% vs. 26.0%; P=.003) in the 2016-2017 cohort and decreased rates of neuropathic (55.6% vs. 70.2%; P<.001) and atypical/idiopathic pain (1.3% vs. 5.4%; P=.003) diagnoses. There was a trend towards an increased rate of comorbid diagnoses (26.3% vs. 20.3%; P=.077), especially those relating to headache conditions. The findings suggest that introduction of a specialist headache neurologist into the OFP clinic widened its remit of assessment, increasing recognition of (co-morbid) neurovascular-related pain and decreasing atypical/idiopathic pain diagnoses in patients with complex OFP. The increase rate of musculoskeletal pain diagnosis in the later cohort is likely attributable to service expansion and normalisation of diagnostics reportedly seen in other OFP services. Statement of clinical relevance: Orofacial pain is a complex diagnosis, it requires a multidisciplinary approach that includes neurological input.

The psychosocial impact of orofacial pain in trigeminal neuralgia patients: a systematic review.

Trigeminal neuralgia (TN) is characterized by sharp, electric shock-like pain, which can be triggered by trivial stimuli. Although medical and surgical treatments are available for TN, some patients experience refractory pain, which has a significant impact on their quality of life. The aim of this systematic review was to determine the psychosocial impact of orofacial pain in patients with diagnosed TN. A search was initiated in three electronic databases (Embase, MEDLINE, PubMed) to identify potential studies for inclusion in the review. All types of study published in English that reported psychosocial measures using validated psychometric questionnaires were included. A total of 585 articles were retrieved from the search. These were screened thoroughly, leading to the selection of 13 articles for data extraction and final analysis. The results show the chronic overwhelming nature of TN, with pain levels varying from mild to severe. Psychometric scores indicated mild to moderate depression, moderate to severe anxiety, and moderate to severe functional limitation of daily life activities in TN patients. Therefore, psychological support within a multidisciplinary team is recommended for TN patients to help them cope better with their chronic disorder and to improve the efficacy of treatment.

Iatrogenic trigeminal post-traumatic neuropathy: a retrospective two-year cohort study.

With the growing demand for dental work, trigeminal nerve injuries are increasingly common. This retrospective cohort study examined 53 cases of iatrogenic trigeminal nerve injury seen at the Department of Oral and Maxillofacial Surgery, University Hospitals of Leuven between 2013 and 2014 (0.6% among 8845 new patient visits). Patient records were screened for post-traumatic trigeminal nerve neuropathy caused by nerve injury incurred during implant surgery, endodontic treatment, local anaesthesia, tooth extraction, or specifically third molar removal. The patients ranged in age from 15 to 80years (mean age 42.1years) and 68% were female. The referral delay ranged from 1day to 6.5years (average 10months). The inferior alveolar nerve (IAN) was most frequently injured (28 cases), followed by the lingual nerve (LN) (21 cases). Most nerve injuries were caused during third molar removal (24 cases), followed by implant placement (nine cases) and local anaesthesia injuries (nine cases). Pain symptoms were experienced by 54% of patients suffering IAN injury, compared to 10% of patients with LN injury. Persistent neurosensory disturbances were identified in 60% of patients. While prevention remains the key issue, timely referral seems to be a critical factor for the successful treatment of post-traumatic neuropathy.

Oral surgery II: Part 5. Chronic orofacial pain.

Chronic orofacial pain syndromes represent a diagnostic challenge for any practitioner. Patients are frequently misdiagnosed or attribute their pain to a prior event such as a dental procedure, ENT problem or facial trauma. Psychiatric symptoms of depression and anxiety are prevalent in this population and compound the diagnostic conundrum. Treatment is less effective than in other pain syndromes and thus often requires a multidisciplinary approach to address the many facets of these conditions.

Oral surgery II: Part 4. Common oral lesions.

Lesions of the mouth are surprisingly common and vary from the totally innocuous to highly malignant neoplasms. As required for the management of all patients, a clear and concise history and a thorough clinical examination are essential. In addition, radiographs and other laboratory investigations may be required to formulate a differential diagnosis. A definitive diagnosis, on which treatment planning should always be based, can usually only be confirmed following a histological examination. This may be obtained through a biopsy or following total excision of a lesion.

Oral surgery II: Part 2. The maxillary sinus (antrum) and oral surgery.

The maxillary sinus is the largest of the four paranasal sinuses and, being anatomically adjacent to the dentate region of the maxilla, is commonly a source of problems - not simply in terms of conditions affecting the sinus but also in establishing an accurate diagnosis. As anyone who has suffered both sinusitis and a dental abscess in the posterior maxilla will tell you, the symptoms are almost indistinguishable. For this reason, a sound understanding of the maxillary sinus is an essential requisite for all dentists.

Oral surgery II: Part 3. Cysts of the mouth and jaws and their management.

A cyst may be defined as a pathological (or abnormal) body cavity, usually lined by epithelium, which contains fluid (gas or liquid) or semi-solid substances other than (primarily) pus. Even this definition is contentious, as some pathologists prefer the term pseudocyst or cavity when there is no epithelial lining. However, the above definition, based on that of Kramer, is as inclusive as possible. Cysts of the mouth and jaws are fairly common and their management is an essential component of oral surgery. This third article in the series deals with the classification, diagnosis and management of the common cysts of the head and neck.

Observational study investigating tooth extraction and the shortened dental arch approach.

The shortened dental arch (SDA) provides a cost-effective dentition, considering the population is ageing and retaining teeth for longer. The aims were to observe the reasons and sites of tooth extraction and assess the functional dentition over 15 years in dental practice. Subjects were recruited who required permanent tooth extractions between 2000 and 2015. The reasons for extractions were chosen from twelve extraction codes. Data were also collected for demographics, tooth position, root treated teeth and functional pairs remaining. Patient-centred factors on reasons for tooth extraction and comments on chewing ability and aesthetics following extractions were recorded. Nine hundred and fifty-one teeth were extracted in 900 patients. The mean age was 60 years (SD 20, SE 7, 95% CI 46, 74). Reasons for extraction were periodontal disease (n = 361, 38%), periapical infection (n = 288, 34%) or tooth and tooth-root fractures (15%). Extractions included 201 (21%) second molars, 179 (19%) first molars, 152 (16%) second premolars, 95 (10%) first incisors, 86 (9%) second incisors, 76 (8%) canines and 67 (7%) first premolars. Following extractions, median functional pairs were 12, interquartile range (IQR) 19-7. Individuals with ≥10 functional pairs including anterior teeth (60%, n = 571) had no complaints with chewing ability or aesthetics. They did not require additional prostheses. Periodontal disease and periapical infection were the main causes for the extraction. First and second molars followed by second premolars were the most commonly extracted teeth. This study supports the SDA in creating a cost effective, functional dentition in an aging population, provided remaining teeth and restorations are preserved/maintained, oral health is promoted, and anterior aesthetic tooth replacement is ensured.

A case series of trigeminal nerve injuries caused by periapical lesions of mandibular teeth.

Aims Periapical lesions have been implicated in mandibular trigeminal sensory neuropathy. This study aimed to report on a case series of consecutive patients presenting with mandibular division trigeminal nerve injuries (TNI) caused by periapical lesions. Common presenting characteristics and possible strategies for management were also investigated.Materials and methods A retrospective study of 22 patients with TNI caused by periapical lesions. Data were extracted from patient records and analysed using Microsoft Excel and SPSS. Factors associated with TNI resolution were assessed using Student's t-Tests and one-way Analysis of Variance (ANOVA), where P <0.05 indicated statistical significance.Results Twenty-one patients had inferior alveolar nerve injuries (IANI) and one had a lingual nerve injury (LNI). The most commonly affected teeth were the first molars (11 patients; 50%). TNI symptoms included numbness, pain and/or paraesthesia. IANI resolved completely among five patients within a mean time of 4.7 months (range 1.5-12 months). Patients who showed complete resolution had the affected teeth extracted or primary endodontic treatment with antibiotics.Conclusions Patients with TNI caused by periapical lesions can suffer significantly from combined numbness, pain and paraesthesia. Resolution of these injuries may be maximised upon early diagnosis and treatment of the periapical lesion by tooth extraction or primary endodontic treatment.

The paradox of painless periodontal disease.

Periodontal diseases, primarily gingivitis and periodontitis, are characterised by progressive inflammation and tissue destruction. However, they are unusual in that they are not also accompanied by the pain commonly seen in other inflammatory conditions. This suggests that interactions between periodontal bacteria and host cells create a unique environment in which the pro-algesic effects of inflammatory mediators and factors released during tissue damage are directly or indirectly inhibited. In this review, we summarise the evidence that periodontal disease is characterised by an accumulation of classically pro-algesic factors from bacteria and host cells. We then discuss several mechanisms by which inflammatory sensitisation of nociceptive fibres could be prevented through inactivation or inhibition of these factors. Further studies are necessary to fully understand the molecular processes underlying the endogenous localised hypoalgesia in human periodontal disease. This knowledge might provide a rational basis to develop future therapeutic interventions, such as host modulation therapies, against a wide variety of other human pain conditions.

Chronic orofacial pain.

The issues specific to trigeminal pain include the complexity of the region, the problematic impact on daily function and significant psychological impact (J Dent, 43, 2015, 1203). By nature of the geography of the pain (affecting the face, eyes, scalp, nose, mouth), it may interfere with just about every social function we take for granted and enjoy (J Orofac Pain, 25, 2011, 333). The trigeminal nerve is the largest sensory nerve in the body, protecting the essential organs that underpin our very existence (brain, eyes, nose, mouth). It is no wonder that pain within the trigeminal system in the face is often overwhelming and inescapable for the affected individual.

The complexity of patient safety reporting systems in UK dentistry.

Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

Review of never and serious events related to dentistry 2005-2014.

Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI).Results From the NRLS dataset, 32,263 patient safety events were reported between 1 January 2005 and 30 May 2014. Never events (NEs) from STEIS files were all wrong site extractions (WSS), reported separately for 2012-2013 and 2013-2014. The total number was 43.36 of the 43 PSIs were WSS involving: multiple extractions and bimodal age distribution (very young or over 60 years). Forty-seven percent of never events resulted in no harm, 20% low harm, 7% moderate harm, less than 1% severe harm and 23 deaths over this period (five of which were not related to dentistry). Serious harm and death risk factors included: care in an acute trust ward, peri oncological, reconstructive surgery (OMFS), patient age over 67 years with concurrent medical complexity (Ischaemic heart disease). Sixty percent of PSIs occurred in OS/OMFS in acute trust inpatients and 20% in primary care. From STEIS 2012-2013, 21 WSS were reported of which 50% occurred in oral surgery (OS) or oral and maxillofacial surgery (OMFS). The reported sites were 45% in operating theatre and 42% in dental surgery.Conclusion Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely carried out. Improved awareness and training, simplifying the reporting systems improved non-punitive support by regulators would allow the improvement of patient safety in dental practise.

An update on the causes, assessment and management of third division sensory trigeminal neuropathies.

Introduction Sensory neuropathies of the mandibular division of the trigeminal (V3) nerve can be debilitating, causing difficulty with daily function. It has a variety of causes, including iatrogenic injury, usually caused by third molar removal, local anaesthetic administration, implant placement or endodontic treatment. Non-iatrogenic causes include infection, primary or secondary neoplasia and various medical conditions.Objective To review the aetiology, evaluation and management of V3 neuropathy in a retrospective case-series of patients referred to a specialist nerve injury clinic over an eight-year period, particularly focusing on the non-iatrogenic causes of this presentation.Methods A retrospective analysis of the case notes of 372 patients referred to the specialist nerve injury clinic between 2006 and 2014 was carried out to establish the cause of the neuropathy and subsequent management or referral. The assessment protocol of trigeminal neuropathy used in the clinic is also outlined.Results Most patients (89.5%) presented with neuropathy due to iatrogenic injury. Of the non-iatrogenic causes (10.5%), malignancy accounted for a fifth of presentations, and infection almost two-fifths, demonstrating the importance of prompt identification of a cause and management by the clinician, or referral to the appropriate specialty. Other, more rare causes are also presented, including multiple sclerosis, sickle-cell anaemia and Paget's disease, highlighting the importance to the clinician of considering differential diagnoses.Conclusions This case series demonstrates the less frequent, but nevertheless important, non-iatrogenic causes which clinicians should consider when assessing patients with trigeminal neuropathy.