Establishing universal sectioning depth and angle for surgical coronectomy of impacted mandibular third molars: an imaging-based study.

Introduction: Coronectomy is a safer option than extraction for third molars with an increased risk of injury to the inferior alveolar nerve. However, it can still cause complications due to a lack of standardized and effective tooth sectioning techniques. We proposed a standardized protocol for third molar coronectomy involving standardized tooth sectioning parameters to minimize potential complications, surgical failure, and the need for further procedures. Methods: The study was conducted on 69 eligible archived CBCTs. The coronal sections of the mandibular at the anterior-most level of the lower third molar were used to determine various axes and reference points. This was done to establish the target angle and depth for the coronectomy sectioning. The data on the depth and angle of the sectioning was presented in means and standard deviation. A multivariate analysis of variance was used to determine the impact of study variables on drill depth and angle. Linear regression and correlation between study variables were also used to predict the drill depth and angle. Results: The samples included 46 males and 23 females aged from 21 to 47 years. The mean drill angle was determined as 25.01 ± 3.28. The mean drill depth was 9.60 ± 9.90 mm. The bucco-lingual tilt had a significant effect on the drill depth, F(1, 62) = 5.15, p < 0.05, but no significant impact on the drill angle, F(1, 62) = 29.62, p > 0.05. The study results suggest that a standardized sectioning protocol can be effective during surgical coronectomy procedures. Discussion: Drilling at a 25-degree angle to a depth of 9.5 mm is advisable to obtain the desired results. This approach will ensure no remaining enamel is left, minimize the chances of root extrusion and future eruption, and improve the outcome.

Impact of migraine and fibromyalgia on temporomandibular disorder: A retrospective study on pain, psychological factors and quality of life.

OBJECTIVES: This study assessed the impact of migraine and fibromyalgia (FM) in TMD patients, focusing on pain, anxiety, depression, and quality of life (QoL). Additionally, we investigated how these variables relate to the total number of comorbidities to gain insights into their interactions. METHODS: A retrospective data collection was conducted during January 2016 to December 2022, involving 409 adult TMD patients. TMD patients were categorised into four groups: those without comorbidity (TMD-only) and those with comorbid migraine and/or fibromyalgia (TMD + MG, TMD + FM and TMD + MG + FM). Quantitative variables were compared among them. Linear regression was used to analyse the associations between these variables. RESULTS: Most of study population were women (79%) with a mean age of 44.43 years. TMD + MG patients reported longer pain duration, higher pain scores and greater pain interference compared with TMD-only patients. Similarly, TMD + FM patients had higher pain intensity than patients with TMD only. Both the TMD + MG and TMD + FM groups had higher levels of anxiety, depression, and health impairment compared with patients with TMD only. Patients with all three pain conditions (TMD + MG + FM) experienced the longest pain duration, highest pain intensity, psychological distress, and impaired QoL. The result showed positive associations between pain outcomes, psychological measures, pain's impact on QoL, and the number of comorbidities and a negative association between overall health states and the number of comorbidities. CONCLUSIONS: These findings underscore the importance of considering the presence of comorbidities and addressing physical and psychological aspects in the management of TMD patients.

Temporomandibular Disorders and Fibromyalgia Prevalence: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the prevalence of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS) in TMD patients and the prevalence of TMDs in patients with FMS. METHOD: A systematic search was performed in electronic databases. Studies published in English examining the prevalence of comorbid TMDs and CWP/FMS were included. The Newcastle-Ottawa Scale was used to assess study quality, and meta-analyses using defined diagnostic criteria were conducted to generate pooled prevalence estimates. RESULTS: Nineteen studies of moderate to high quality met the selection criteria. Meta-analyses yielded a pooled prevalence rate (95% CI) for TMDs in FMS patients of 76.8% (69.5% to 83.3%). Myogenous TMDs were more prevalent in FMS patients (63.1%, 47.7% to 77.3%) than disc displacement disorders (24.2%, 19.4% to 39.5%), while a little over 40% of FMS patients had comorbid inflammatory degenerative TMDs (41.8%, 21.9% to 63.2%). Almost a third of individuals (32.7%, 4.5% to 71.0%) with TMDs had comorbid FMS, while estimates of comorbid CWP across studies ranged from 30% to 76%. CONCLUSIONS: Despite variable prevalence rates among the included studies, the present review suggests that TMDs and CWP/FMS frequently coexist, especially for individuals with painful myogenous TMDs. The clinical, pathophysiologic, and therapeutic aspects of this association are important for tailoring appropriate treatment strategies.

Posttraumatic Trigeminal Neuropathic Pain in Association with Dental Implant Surgery.

Posttraumatic trigeminal neuropathy in association with dental implant surgery is preventable, and this should be the emphasis for all clinicians considering this treatment for a patient. Once the nerve injury and posttraumatic neuropathy with or without pain ensues, there is very little the clinician can do to reverse it and the high pain and permanency of the neuropathy will have a significant functional and psychological impact on the patient. Immediate implant removal is required, and home check should be routine for all cases. International diagnostic criteria are available and should be implemented in everyday practice.

Healthcare costs of post-traumatic trigeminal neuropathy in Belgium - A retrospective analysis.

The present aim was to estimate direct health care costs of patients suffering from post-traumatic trigeminal neuropathy (PTTN) and to compare the use of health care services, medications, and costs between temporary and persistent (>3 months) PTTN cohorts. A pre-existing clinical dataset of PTTN patients visiting a tertiary orofacial pain clinic in Belgium was utilized, including symptoms and quality of life measurements. Cost and resource utilization data were obtained by Belgium's largest health insurance provider for a period of 5 years after onset. Data from 158 patients was analyzed. The average cost per patient in the first year after injury was €2353 (IQR 1426-4499) with an out-of-pocket expense of 25% of the total cost. Hospitalization and technical interventions were the main drivers of cumulative costs, followed by consultation costs. For each cost category, expenditure was significantly higher in patients with persistent PTTN than in those with temporary PTTN (median 5-year total costs in persistent PTTN patients yielded €8866 (IQR 4368-18191) versus €4432 (IQR 2156-9032) in temporary PTTN, p <0.001) PTTN patients received repeated and frequent head and neck imaging (mean number of imaging investigations per patient was 10 ± 12). Medication consumption was high, with an unwarranted higher use of opioids and antibiotics in persistent PTTN patients. Within the limitations of this study, it seems there is a need for informing patients in detail on the inherent risks of nerve damage during dental and oromaxillofacial procedures. Every surgery should be preceded by a risk-benefit assessment in order to avoid unnecessary nerve damage.

Patient safety in dentistry - the bigger picture.

Background Patient safety incidents (PSIs) have recently become a topic of discussion within dentistry. NHS England data has highlighted that wrong tooth extraction is the most common surgical Never Event (NE); however, this data reflects mainly a secondary care picture. Consideration needs to be given to reporting of PSIs occurring in primary care.Aims To establish the current attitudes of both primary and secondary care dentists within this field and to use this to promote a positive, supportive culture.Methods A national electronic survey was sent to dentists for data capture related to this topic, from April to September 2019 inclusively.Results There were 104 responses to the survey. Responses included that 39% of responders were general dental practitioners (GDPs), 90% were aware of NEs, 48% were not aware of how to report PSIs and 74% of dentists felt that fear of the General Dental Council/Care Quality Commission repercussions was a barrier to them reporting PSIs. Additionally, 86% of dentists felt that a trainee/GDP support network would be useful to share learning regarding PSIs.Conclusion The survey results highlighted that there is a lack of knowledge concerning PSI reporting, combined with a culture of fear of the repercussions of reporting. The survey data will aim to be used to implement a supportive network for dentists, develop a positive ethos surrounding PSIs and optimise patient care.

Prognostic factors, symptom evolution, and quality of life of posttraumatic trigeminal neuropathy.

ABSTRACT: Neurosensory disturbances (NSDs) caused by injury to the trigeminal nerve can affect many aspects of daily life. However, factors affecting the persistence of NSDs in patients with posttraumatic trigeminal neuropathies (PTTNs) remain largely unknown. The identification of such risk factors will allow for the phenotyping of patients with PTTNs, which is crucial for improving treatment strategies. We therefore aimed to identify the prognostic factors of NSD persistence, pain intensity, and quality of life (QoL) in patients with PTTNs and to use these factors to create a prognostic prediction model. We first performed a bivariate analysis using retrospective longitudinal data from 384 patients with NSDs related to posttraumatic injury of the trigeminal nerve (mean follow-up time: 322 ± 302 weeks). Bivariate and multivariate analyses were performed. The multivariable prediction model to predict persistent NSDs was able to identify 76.9% of patients with persistent NSDs, with an excellent level of discrimination (area under the receiver operating characteristic curve: 0.84; sensitivity: 81.8%; specificity: 70.0%). Furthermore, neurosensory recovery was significantly associated with sex; injury caused by local anesthesia, extraction, third molar surgery, or endodontic treatment; and the presence of thermal hyperesthesia. Pain intensity and QoL analysis revealed several factors associated with higher pain levels and poorer QoL. Together, our findings may aid in predicting patient prognosis after dental, oral, and maxillofacial surgery and might lead to personalized treatment options and improved patient outcomes.

Post-traumatic trigeminal neuropathy: correlation between objective and subjective assessments and a prediction model for neurosensory recovery.

BACKGROUND: Post-traumatic trigeminal neuropathy (PTN) can have a substantial effect on patient well-being. However, the relation between the neuropathic symptoms and their effect on psychosocial functioning remains a matter of debate. The purpose of this study was to evaluate the association between objective and subjective assessments of neurosensory function in PTN and predict neurosensory outcome using baseline measurements. METHODS: This prospective observational cohort study included patients diagnosed with PTN at the Department of Oral and Maxillofacial Surgery, University Hospital Leuven, Belgium, between April 2018 and May 2020. Standardized objective and subjective neurosensory examinations were recorded simultaneously on multiple occasions during the follow-up period. Correlation analyses and principal component analysis were conducted, and a prediction model of neurosensory recovery was developed. RESULTS: Quality of life correlated significantly (P < 0.05) with percentage of affected dermatome (ρ = - 0.35), the presence of brush stroke allodynia (ρ = - 0.24), gain-of-function sensory phenotype (ρ = - 0.41), Medical Research Council Scale (ρ = 0.36), and Sunderland classification (ρ = - 0.21). Quality of life was not significantly correlated (P > 0.05) with directional discrimination, stimulus localization, two-point discrimination, or sensory loss-of-function. The prediction model showed a negative predictive value for neurosensory recovery after 6 months of 87%. CONCLUSIONS: We found a strong correlation of subjective well-being with the presence of brush stroke allodynia, thermal and/or mechanical hyperesthesia, and the size of the neuropathic area. These results suggest that positive symptoms dominate the effect on affect. In patients reporting poor subjective well-being in the absence of positive symptoms or a large neuropathic area, additional attention towards psychosocial triggers might enhance treatment outcome. The prediction model could contribute to establishing realistic expectations about the likelihood of neurosensory recovery but remains to be validated in future studies.

The Diagnostic Value of Magnetic Resonance Imaging in Posttraumatic Trigeminal Neuropathic Pain.

AIMS: To evaluate the diagnostic value of non-nerve-selective MRI sequences in posttraumatic trigeminal neuropathic pain (PTNP). METHODS: This study retrospectively analyzed all MRI protocols performed between February 2, 2012 and June 20, 2018 commissioned by the Department of Oral and Maxillofacial Surgery, University Hospitals Leuven. Demographic, clinical, and radiologic data were extracted from the records of patients with an MRI in the context of PTNP. A contingency table was constructed based on the opinions of the treating physician and the radiologist who initially evaluated the MRI. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS: The sample consisted of 27 women (65.9%) and 14 men (34.1%). The sensitivity and negative predictive value of MRI in PTNP were 0.18 and 0.77, respectively. Artifacts interfered with visualization of a possible cause of the trigeminal pain in 24.4% of MRIs. Almost all artifacts (90%) were caused by metal debris originating from the causal procedure or posttraumatic surgeries. MRI resulted in changed management for PTNP patients only once. CONCLUSION: The diagnostic value of non-nerve-selective MRI sequences for PTNP is low and has little impact on clinical management. Therefore, there is a need for dedicated sequences with high resolution and low artifact susceptibility for visualizing the posttraumatic injuries of the trigeminal branches.

Surgical techniques for the removal of mandibular wisdom teeth.

BACKGROUND: Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity. OBJECTIVES: To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication. SELECTION CRITERIA: Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth. DATA COLLECTION AND ANALYSIS: Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies. MAIN RESULTS: We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported. AUTHORS' CONCLUSIONS: In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

Introduction to Pain.

This edition of PDJ is intended to provide a wide overview on orofacial pain for dental and medical teams. Both acute and chronic orofacial conditions relevant to dentistry and medicine will be covered, and emphasising a holistic and pragmatic approach. Orofacial pain is the most common presenting symptom for patients presenting to their dentist and increasingly commonly presenting to doctors in general practice and A&E departments.
Pain in the trigeminal system causes much higher psychological and neurophysiological distress compared with other body regions, as the trigeminal nerve is the great sensory protector to the eyes, ears, nose, mouth and meninges, the senses that underpin our very existence. It is an anathema that surgery in and around the face and mouth is predominantly undertaken by dentists on conscious patients, unlike other surgical specialties. This explains the expectation of pain by patients when seeing their dentists, sadly an expectation which is frequently fulfilled, fuelling high levels of anxiety and fear, which in turn increases the pain experience.

Optimal Local Anaesthesia for Dentistry.

Dentistry is unique in that high-volume surgery is undertaken efficiently on conscious patients, an anathema to most other surgical specialties, who predominantly operate on unconscious patients. local anaesthesia (LA) provides an efficient block to nociceptive pain (the first stage of the pain pathway) but only addresses one small part of the pain experience. Currently the inferior dental block is the "go to" standard for dental LA for mandibular dentistry, despite its significant short comings. Unfortunately, habit means that we continue to practise what is taught to us at dental school, thus, not developing safer modern LA practice.
The dental syringe and deep injections are also the main triggers for fear and anticipated pain by patients expecting their dental appointment. The uptake of infiltration dentistry has been swift in implant dentistry, despite lack of an evidence base, and now other branches of specialty dentistry, general practice is awakening to the advantages of infiltration or "smart" local anaesthetic practices.
Inferior dental blocks are inefficient in providing swift pulpal anaesthesia. Stanley Malamed Stated: "The rate of inadequate anaesthesia ranged from 31% to 81%, which when expressed as success rates, indicates a range of 19% to 69%. These numbers are so wide ranging as to make selection of a standard for rate of success for inferior alveolar nerve block (IANB) seemingly impossible".
Any block injection is also associated with an increase in the risk of systemic and local complications (including nerve injury), possible heightened medical complications and patient discomfort and fear. Fear of deep dental injections is a key factor in dental anxiety and phobia.

Identifying criteria for diagnosis of post-traumatic pain and altered sensation of the maxillary and mandibular branches of the trigeminal nerve: a systematic review.

OBJECTIVE: The aim of the study was to systematically identify criteria used to diagnose patients with trigeminal nerve injury. STUDY DESIGN: A systematic review of the literature registered in the PROSPERO database. Inclusion criteria were patients diagnosed with nerve injury of the sensory divisions of the maxillary or mandibular branches of the trigeminal nerve, with reported tests and criteria used for diagnosis and persistent pain or unpleasant sensation associated with nerve injury. RESULTS: In total, 28 articles were included. Diagnostic tests included clinical neurosensory tests (89%), thermal quantitative sensory testing (QST; 25%), electromyography (7%), and patient interview (14%). Neuropathic pain was assessed by using the visual analogue scale (39%); patient use of neuropathic medication (7%); questionnaires, including McGill and PainDETECT (21%). Functional impact was assessed in 14% and psychological impact in 7% of articles. Methodology in performing clinical neurosensory tests, application of diagnostic terms and diagnostic grading of nerve injury was found to be inconsistent among the included articles, making direct comparison of results difficult. CONCLUSIONS: Recommendations for assessment and diagnosis of trigeminal nerve injury have been made based on the best available evidence from the review. There is an urgent requirement for a consensus in diagnostic criteria, criteria for assessment, and outcome reporting among stakeholder organizations to improve knowledge in this field.

Prevalence of neuropathic pain and sensory alterations after dental implant placement in a university-based oral surgery department: A retrospective cohort study.

OBJECTIVE: To determine the prevalence and the clinical features of patients with neuropathic pain and sensory alterations after dental implant placement. BACKGROUND: Literature is very scarce concerning the prevalence of neuropathic pain after dental implant placement. PATIENTS AND METHODS: A retrospective cohort study was made in patients submitted to dental implant placement in the Dental Hospital of the University of Barcelona. A descriptive analysis of the data was made, and the 95% confidence intervals (95% CI) were calculated for the prevalences. RESULTS: The study sample was composed of 1156 subjects of whom, 1012 patients (3743 dental implants) met the study inclusion criteria. Four hundred and seventeen patients (41.2%) were male and 595 (58.8%) were female, with a mean age of 60.7 years (range 16-90 years). Three patients were diagnosed as having painful post-traumatic trigeminal neuropathy (PPTN), which corresponds to a prevalence of 0.3% (95% CI: 0%-0.6%). Additionally, 5 patients (0.5%; 95% CI: 0%-1.07%) presented trigeminal neuropathy without pain (TNWP). The combined prevalence of both disorders was 0.8% (95% CI: 0.02%-1.3%). All patients with PPTN and TNWP were 60 years old or older, with a total combined prevalence of 1.48% (95% CI: 0.46%-2.5%) in this age group. Additionally, the prevalence in this age group for women was 1.85% (95%CI: 0.38%-3.31%). CONCLUSIONS: Neuropathic pain after dental implant placement is very infrequent (0.3%) in a University Oral Surgery department. However, the presence of trigeminal neuropathies can be slightly higher and can affect up to 0.5% of patients. Older female patients seem to be more prone to this rare and disabling complication.

Oral surgery II: Part 6. Oral and maxillofacial trauma.

Oral and maxillofacial trauma can range from an avulsed tooth as a result of a simple fall, to pan-facial injuries in the context of a polytraumatised patient involved in a road traffic accident. Regardless of aetiology, similar principles apply to all oral and maxillofacial injuries, and this chapter broadly outlines the more common forms of oral and maxillofacial trauma and the options available for their management. Throughout the chapter all references and values are for adult patients unless indicated.

A Survey of the Opinion and Experience of UK Dentists Part 3: An Evidence-Based Protocol of Surgical Risk Management Strategies in the Mandible.

BACKGROUND: Implant surgery in the mandible can cause serious complications that can be life threatening. The incidence and cause of iatrogenic trigeminal nerve injury (TNI) related to dental implant surgery was investigated in a survey of the opinion and experience of the UK dentists and reported by the authors in part 1 of this series of articles. Part 2 reported on the risk assessment and management of implant-related inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve (LN) injuries. This article evaluates the significance of these findings and recommends an evidence-based protocol of risk management strategies to reduce the risk of TNI related to dental implant surgery. METHODS: A survey was distributed among 405 dentists attending an Association of Dental Implantology (ADI) congress, of which 187 completed the survey. RESULTS: In this study, the strategies to manage the risk of TNI included unilateral staging of implant placement (57%) and identification the MN when placing implants (43%). Twelve percent used drill stops when operating in the mandible. Nineteen dentists used steroids (eg, dexamethasone) routinely preoperatively and postoperatively. Twenty-six dentists used basic cone beam computed tomography minimally invasive techniques, and 70% encountered a large anterior loop of the IAN. Most dentists (76%) allowed a 2- to 4-mm safety zone radiologically above the IAN when placing implants, and over half of the responders (56%) used implants that were 10 mm in length. CONCLUSION: Given the elective nature of implant surgery, TNI should be fully avoidable. The evidence suggest that TNI can be minimized with meticulous attention to accurate assessment and surgical planning as well as carrying out the surgery with a high degree of precision. In part 3 of their series of articles, the authors presented an evidence-based protocol that comprises preoperative, intraoperative, and postoperative risk management strategies for dental implant surgical procedures in the mandible.

A Survey of the Opinion and Experience of UK Dentists: Part 2: Risk Assessment Strategies and the Management of Iatrogenic Trigeminal Nerve Injuries Related to Dental Implant Surgery.

BACKGROUND: Dental implant-related iatrogenic injuries are proportionally increasing with dental implant surgery. This study assessed the experience of implant-related trigeminal nerve (TG) injuries among UK dentists. Risk management strategies and management of implant-related inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve injuries were investigated. METHODS: A survey was distributed among 405 dentists attending an Association of Dental Implantology (ADI) congress, of which 187 completed the survey. RESULTS: Most dentists (76% of 134 responses) allowed a 2 to 4 mm safety zone radiologically above the IAN when placing implants, and over half of the responders (56%) used implants that were 10 mm in length. The most frequent precautionary measure used by 73 (80%) responders was antibiotic coverage routinely to reduce the risk of infection when placing grafts in the posterior mandible. Other precautionary measures included unilateral staging of implant placement (57%), and 43% always identified the MN when placing implants. Nineteen dentists used steroids (eg, dexamethasone) routinely preoperatively and postoperatively. Twenty-six dentists used basic cone-beam CT (CBCT) minimally invasive techniques, and drill stops during implant placement were used by 14 responders. Although it is not highly recommended, steroids were used to manage the neuropathic pain and discomfort experienced by patients with IAN injuries in 40% of cases. CONCLUSION: Further training of dentists undertaking implant surgery is required so that they acquire up-to-date and evidence-based knowledge and skills in the prevention, diagnosis, and management of dental implant-related TG injuries. This training should also involve the justification and interpretation of CBCTs.

A Survey of the Opinion and Experience of UK Dentists: Part 1: The Incidence and Cause of Iatrogenic Trigeminal Nerve Injuries Related to Dental Implant Surgery.

BACKGROUND: Dental implant-related iatrogenic trigeminal nerve (TG) injuries are proportionally increasing with dental implant surgery. This study, which is presented in greater detail over a series of articles, assessed the experience of implant-related TG nerve injuries among UK dentists. Incidence and cause of inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve (LN) injuries, together with preoperative assessment and the consent process, are presented in this article. METHODS: A survey was distributed among 405 dentists attending an Association of Dental Implantology congress in the United Kingdom, of which 187 completed the survey. RESULTS: Most responding dentists were full-time general practitioners. Implant dentistry training was predominately through industry-organized courses. Eighty dentists encountered implant-related IAN injuries, whereas 8 encountered LN injuries. Inaccurate radiological identification of the IAN/MN and their anatomical variations (48%) were seen to be the most frequent cause of TG injuries. Disclosure of the relative risk and benefits of alternative implant treatment strategies as part of the informed consent process was not deemed to be essential by 47 (25%) of the participants. CONCLUSION: Inadequate radiological assessment was the most common cause of TG nerve injury. The use of small field of view cone beam computer tomography (CBCT) is therefore recommended when placing implants in the posterior mandible. Implant surgeons should acquire evidence-based skills in the prevention, diagnosis, and management of TG nerve injury as well as specific training on justification and interpretation of CBCT scans.

Relevance of Bisphosphonate Therapy in Osteoporosis and Cancer--No Cause for Alarm in Dentistry.

This report provides important background information on osteoporosis (OP) and bone complications of cancer for the dental team, and discusses why bisphosphonate (BP) therapy is vital for patients with the two conditions. It also addresses several questions, including in particular: 'Is withholding BP therapy the best way to prevent osteonecrosis of the jaw (ONJ) occurrence?' Also,'Of the two, which is more important: ONJ or OP fracture prevention?' CPD/Clinical Relevance: BP therapy offers OP patients the promise of a fracture-free life and the prevention of fracture-related pain, disability, loss of qualify of life (QOL) and the shortening of life. Without BP therapy, the lifetime risk of fracture occurrence in OP patients is as high as 1 in 2 women and 1 in 5 men; whilst using it, the relative risk of ONJ occurrence is as low as between 1 in 10, 000 and 1 in 100, 000. To cancer patients with bone complications, it offers the much needed pain relief and improvement in QOL. In cancer patients, the risk of ONJ is almost 100 times higher but, despite that, oncologists advocate BP therapy for virtually all the patients. Therefore, when prescribed, BP therapy merits the whole-hearted support of the dental team.

Chronic post-surgical pain following the placement of dental implants in the maxilla: A case series.

PURPOSE: To present ten cases of chronic post-surgical neuropathic pain (CPSP) arising after placement of maxillary dental implants, in order to raise awareness of this potential complication of treatment. MATERIALS AND METHODS: Data collected from the case notes of consecutive patients presenting to the orofacial pain clinic, with neuropathic pain arising after placement of maxillary dental implants. RESULTS: Nine out of 10 patients were female, with an average age 55.4 years. Six patients had a significant medical history (depression, peripheral neuropathic pain, irritable bowel syndrome and fibromyalgia). Six patients had single implants placed, four had multiple implants. Four patients experienced pain during implant placement. Onset of pain was immediate in nine patients. Pain intensity (visual analogue scale) ranged from 2 to 9 (average 5.6). Pain was constant in all patients. Exacerbating factors included stress, tiredness, low mood and cold weather. Implants were removed in two patients however pain did not resolve. Pain management was complex; including medication (anti-epileptics and tricyclic antidepressants), Botox injections and cognitive behavioural therapy, however pain did not completely resolve in nine cases. CONCLUSIONS: Persistent pain after dental implant placement may occur with no apparent organic cause and without any neurosensory deficits. Practitioners must be aware of chronic post-surgical neuropathic pain as a possible complication of implant placement, particularly in patients with a significant medical history. Consideration should be given as to whether these patients are suitable for implant rehabilitation. Patients reporting very severe and prolonged postoperative pain following implant surgery should be considered at risk of CPSP and referred to a specialist in orofacial pain.