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.

A systematic review on diagnostic test accuracy of magnetic resonance neurography versus clinical neurosensory assessment for post-traumatic trigeminal neuropathy in patients reporting neurosensory disturbance.

OBJECTIVES: To perform a systematic review of published studies on diagnostic accuracy of magnetic resonance neurography (MRN) vs clinical neurosensory testing (NST) for post-traumatic trigeminal neuropathy (PTTN) in patients reporting neurosensory disturbances (NSD). METHODS: Human studies except case reports, reviews, systematic reviews and meta-analyses were included. PubMed, Embase, Web of Science and Cochrane Library were consulted. Risk of bias assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Predetermined data extraction parameters were noted and summarized. RESULTS: 8 studies met eligibility criteria of which 7 were retrospective, representing 444 subjects. Most studies were at high risk of bias with low applicability concerns. Populations and objectives were divergent with a large variation in timing (3 days-17 years post injury) and parameters (multiple coil designs, fat suppression techniques, additional contrast agent) of MRI acquisition. T2 weighted 3 T imaging with short echo times (2.2-100 ms) and fat suppression was applied in seven studies, techniques varied. Determination of sensitivity and specificity could not be performed due to the methodological variation between studies and lacking comparative data between index and reference tests. Based on limited data, PTTN correlated reasonably well between clinical assessment, intraoperative findings and MRN abnormalities (k = 0.57). Increased signal intensity correlated with persistency of neurosensory disturbances in one study. Intra- (ICC 0.914-0.927) and interobserver (k = 0.70-0.891) MRN variability was considered good to excellent. One retrospective study showed substantial impact of MRN on clinical decision making in one-third of patients. CONCLUSION: Currently, there is insufficient scientific knowledge to support or refute the use of MRN. Based on limited data, MRN seems promising and reliable in detection and grading of PTTN. Methodological issues underline the importance for prospective blinded studies with standardization of signal intensity calculation and rigorous reporting of MRI acquisition parameters.

Prophylactic removal of impacted mandibular third molars: a systematic review and economic evaluation.

BACKGROUND: Impacted third molars are third molars that are blocked, by soft tissue or bone, from fully erupting through the gum. This can cause pain and disease. The treatment options for people with impacted third molars are removal or retention with standard care. If there are pathological changes, the current National Institute for Health and Care Excellence guidance states that the impacted third molar should be removed. OBJECTIVE: The objective of this study was to appraise the clinical effectiveness and cost-effectiveness of the prophylactic removal of impacted mandibular third molars compared with retention of, and standard care for, impacted third molars. METHODS: Five electronic databases were searched (1999 to 29 April 2016) to identify relevant evidence [The Cochrane Library (searched 4 April 2016 and 29 April 2016), MEDLINE (searched 4 April 2016 and 29 April 2016), EMBASE (searched 4 April 2016 and 29 April 2016), EconLit (searched 4 April 2016 and 29 April 2016) and NHS Economic Evaluation Database (searched 4 April 2016)]. Studies that compared the prophylactic removal of impacted mandibular third molars with retention and standard care or studies that assessed the outcomes from either approach were included. The clinical outcomes considered were pathology associated with retention, post-operative complications following extraction and adverse effects of treatment. Cost-effectiveness outcomes included UK costs and health-related quality-of-life measures. In addition, the assessment group constructed a de novo economic model to compare the cost-effectiveness of a prophylactic removal strategy with that of retention and standard care. RESULTS: The clinical review identified four cohort studies and nine systematic reviews. In the two studies that reported on surgical complications, no serious complications were reported. Pathological changes due to retention of asymptomatic impacted mandibular third molars were reported by three studies. In these studies, the extraction rate for retained impacted mandibular third molars varied from 5.5% to 31.4%; this variation can be explained by the differing follow-up periods (i.e. 1 and 5 years). The findings from this review are consistent with the findings from previous systematic reviews. Two published cost-effectiveness studies were identified. The authors of both studies concluded that, to their knowledge, there is currently no economic evidence to support the prophylactic removal of impacted mandibular third molars. The results generated by the assessment group's lifetime economic model indicated that the incremental cost-effectiveness ratio per quality-adjusted life-year gained for the comparison of a prophylactic removal strategy with a retention and standard care strategy is £11,741 for people aged 20 years with asymptomatic impacted mandibular third molars. The incremental cost per person associated with prophylactic extraction is £55.71, with an incremental quality-adjusted life-year gain of 0.005 per person. The base-case incremental cost-effectiveness ratio per quality-adjusted life-year gained was found to be robust when a range of sensitivity and scenario analyses were carried out. LIMITATIONS: Limitations of the study included that no head-to-head trials comparing the effectiveness of prophylactic removal of impacted mandibular third molars with retention and standard care were identified with the assessment group model that was built on observational data. Utility data on impacted mandibular third molars and their symptoms are lacking. CONCLUSIONS: The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy. FUTURE WORK: Effectiveness evidence is lacking. Head-to-head trials comparing the prophylactic removal of trouble-free impacted mandibular third molars with retention and watchful waiting are required. If this is not possible, routine clinical data, using common definitions and outcome reporting methods, should be collected. STUDY REGISTRATION: This study is registered as PROSPERO CRD42016037776. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 30. See the NIHR Journals Library website for further project information.

Third molars, commonly known as wisdom teeth, may come through the gum (erupt) without any problems, usually during young adulthood (aged 18­24 years). However, in some cases they are unable to erupt because they are poorly aligned or obstructed by other teeth, gums or bone. They are then referred to as 'impacted'. Historically, dentists often recommended that these teeth be removed, so as not to cause problems later in life. This is referred to as 'prophylactic' removal. In 2000, the National Institute for Health and Care Excellence reviewed this practice and recommended that these teeth should not be removed if they are not bothersome to the person. Many dentists and oral surgeons have disagreed with this decision, believing that it is more difficult to remove these teeth later in life, and that there are more complications for the patient if they are removed later in life. Our review group carried out a systematic review of the available clinical effectiveness and cost-effectiveness evidence of the prophylactic removal of impacted third molars. The review identified four clinical studies, none of which provided strong evidence for or against the prophylactic removal of these teeth. These findings are similar to those of nine previous reviews. There is also very little research reported that relates to the cost-effectiveness of the procedure, with only three studies identified. With the available evidence on the rates of extraction and the symptoms experienced by people who keep their impacted mandibular third molar, we built an exploratory economic model to assess the cost-effectiveness of recommending prophylactic removal compared with that of recommending watchful waiting. Results from the model suggested that a prophylactic removal strategy costs more than a watchful waiting strategy, but leads to improvements in quality of life. When the costs and quality-of-life measures that are associated with the two strategies are compared, the resulting statistic is £11,741 per quality-adjusted life-year gained, which would probably be good value for money for the NHS.

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.

Pain paper 2b: classification of orofacial pain and an update on assessment and diagnosis.

The classification of chronic orofacial pain remains a contentious area. However, more recently, with the clarification of pain mechanisms and improved understanding of the underlying neurophysiology and modulation factors, there is more clarity of the possible division of pain conditions. Interestingly, the pathophysiology provides a basis for classification that has more clinical relevance. The principles of assessing and managing patients with pain have modified significantly, in line with recent improved understanding of the affective and emotional components in pain behaviour and suffering. Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the classification of trigeminal pain with an overview of how to assess and diagnose patients with trigeminal pain.