Quantitative and qualitative sensory testing results are associated with numbness rather than neuropathic pain in patients with post-implant trigeminal neuropathy: a cross-sectional pilot study.

Purpose: This study aimed to characterize the sensory profile of patients with post-implant trigeminal neuropathy and identify the association between subjective symptoms and objective signs including psychophysical testing and radiographic imaging. This study further evaluated to the association between quantitative sensory testing (QST)/qualitative sensory testing (QualST) and the severity of nerve injury graded by radiographic imaging. Materials and methods: This retrospective study included 34 patients diagnosed with post-implant trigeminal neuropathy. Data on the neuropathic pain symptom inventory (NPSI), thermal and electric QST, bedside QualST, and cone beam computed tomography (CBCT) was collected and the association between these variables were analysed. Results: Numbness was the most common subjective symptom and evoked pain was the most frequent neuropathic pain. There was no significant correlation between negative and positive symptoms. Spearman's rank correlation analyses indicated that objective findings including QST/QualST correlated with a sensory loss profile rather than a gain of function profile. Moderate positive correlations between some positive symptoms and the score of QualST were observed. The Mann-Whitney U test showed that subjective symptoms did not differ according to the severity of nerve damage according to CBCT, but the electric QST and QualST was discriminative. Conclusions: This study suggests that QST/QualST associated with the severity of nerve damage according to CBCT might be useful in assessing numbness in patients with negative and positive symptoms after implant surgery, but may be of marginal utility in the evaluation of neuropathic pain within the limitation of this cross-sectional study with small sample size.

[Spontaneous numbness along with pre-existing deviations in the pigmentation of the lower lip]. / Een spontaan dove lip met reeds bestaande pigmentafwijkingen van de onderlip.

A 48-year-old man was referred for an evaluation of deviations in the pigmentation of the lower lip, intra-oral swelling and persistent numbness of the sensory area of the left mental nerve. In 2011, the diagnosis lentigo maligna of the lower lip was missed by histopathology of a biopsy performed elsewhere. In 2016, the numbness of the lower lip and chin was diagnosed by a neurologist as numb chin of unknown cause. A biopsy in 2017 showed lentigo maligna of the lower lip alongside a primary mucosal melanoma with significant local invasion. Treatment consisted of a hemimandibulectomy with a supraomohyoid neck dissection of the left side. This case shows the importance of the alarm symptom 'a numb lip' and the corresponding necessity of additional investigation. This article shows avoidable pitfalls that general practitioners, dentists and medical specialists need to be vigilant about.

Numb chin syndrome: What all oral health care professionals should know.

BACKGROUND: Numb chin syndrome (NCS) is a rare sensory neuropathy involving the mental nerve. Symptoms of NCS are often overlooked because of their apparent innocent nature; however, owing to the frequent association of NCS with malignancies, the opposite should be the rule. Oral health care professionals may be the first to encounter patients with NCS and should be aware of its clinical characteristics in an effort to decrease patient morbidity and mortality. TYPES OF STUDIES REVIEWED: A search in PubMed (MEDLINE) and the Cochrane Library was performed using the terms numb chin syndrome, numb chin, mental neuropathy, mental nerve neuropathy, and malignant mental nerve neuropathy, yielding 2,374 studies. After inclusion and exclusion criteria were applied, 102 studies remained. Descriptive statistics were performed, analyzing the etiology responsible for NCS, characteristics of NCS including associated symptoms, unilateral or bilateral nature, and information on professionals visited and examinations requested to make a diagnosis. RESULTS: NCS was associated with malignancy in 29% through 53% of the published cases. Twenty-eight percent of patients initially consulted an oral health care professional with the symptom of a numb chin. Patients more likely to have NCS were those from the ages of 61 through 70 years; 74% were unilateral; and the most common symptoms reported were numbness (100%), paresthesia (18%), and pain (17%). Forty-seven percent of the NCS cases were associated with a recurrent malignancy, and the most prevalent associated diagnoses were breast cancer (32%) and lymphoma and leukemia (24%). CONCLUSIONS: Oral health care professionals should be aware of the characteristics of NCS as they may be the first health care providers consulted for these symptoms. PRACTICAL IMPLICATIONS: A thorough medical and dental history as well as a complete cranial nerve screening should be performed on all patients, especially those with numbness, as this may prevent misdiagnosis and allow a timely referral and a substantial improvement of treatment course and prognosis.

Peripheral painful traumatic trigeminal neuropathy: clinical features in 91 cases and proposal of novel diagnostic criteria.

AIMS: To field-test carefully designed criteria for pain following trigeminal nerve trauma. METHODS: In order to characterize the clinical phenotype, posttraumatic pain patients were studied and compared with classical trigeminal neuralgia patients (CTN, defined according to the International Headache Society's criteria). Based on etiology and features, trigeminal pain following trauma was defined as "peripheral painful traumatic trigeminal neuropathy" (PPTTN). Data were analyzed with t tests, ANOVA, chi-square, and regression analyses. RESULTS: A total of 145 patients were included: 91 with PPTTN and 54 with CTN. Findings indicated that PPTTN criteria are clinically applicable in the detection and characterization of relevant cases. In contrast to accepted characteristics for PPTTN, the observed profile included both continuous and paroxysmal pain that was stabbing and/or burning. The quality, duration, and intensity were significantly different from the CTN patients (P < .05). PPTTN was consistently accompanied by trigeminal sensory abnormalities (96%) that were mostly allodynia, hyperor hypoalgesia, and only 1% of the PPTTN cases had anesthesia. CONCLUSION: Overall, the proposed PPTTN criteria have proven to be clinically useful. In view of these results, modified PPTTN diagnostic criteria are proposed for use in future research.

Septoplasties are unlikely to cause postoperative numbness of the anterior palate.

BACKGROUND: Septoplasties and septorhinoplasties are very commonly performed surgical procedures in modern aesthetic and functional medicine. Throughout the surgery, close manipulation to the incisive nerves' course is being executed. This retrospective analysis followed up on potential sensitivity disorders of the anterior palate due to nerve damage. METHODS: This retrospective review of 2000 patients' charts, who had undergone the procedure of a septoplasty or septorhinoplasty between June 2013 and January 2019 was conducted at the Department of General Otorhinolaryngology, Medical University of Graz. Medical records of all included patients were reviewed with special attention to postoperative numbness of the anterior palate. RESULTS: Among the 2000 included patients, a septoplasty was performed in 48% (n = 955), a septorhinoplasty in 35% (n = 703) and a septoplasty in combination with a functional endoscopic sinus surgery in 17% (n = 342). In total, 86% (n = 1721) showed no complications at all during the follow-up period. In 0.25% (n = 5) a sensitivity disorder of the anterior palate occurred. Of the five cases with a postoperative numbness of the anterior palate four occurred after a septoplasty and the fifth occurred following a septorhinoplasty. CONCLUSION: At this current time, this is the largest study investigating postoperative numbness of the anterior palate retracing septoplasty or septorhinoplasty. As a result, the currently used techniques for the operations do not pose a risk for the incisive nerve despite close surgical manipulation to the nerves' course. Nevertheless, patients should be informed and educated about the possibility of an occurring sensitivity disorder regarding the anterior palate during informed consent.

Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve.

AIMS: To describe the cause, clinical signs, and symptoms of patients presenting to a tertiary care center with iatrogenic lesions to the mandibular branches of the trigeminal nerve. METHODS: Pain history, pain scores using the visual analog scale, and mechanosensory testing results were recorded from 93 patients with iatrogenic lingual nerve injuries (LNI) and 90 patients with iatrogenic inferior alveolar nerve injuries (IANI). Results were analyzed using the SPSS statistical software. Chi-square tests were applied for nonparametric testing of frequencies, where P ⋜ .05 indicated statistical significance. Appropriate correlations were also carried out between certain data sets. RESULTS: Significantly more females were referred than males (P < .05). Overall, third molar surgery (TMS) caused 73% of LNI, followed by local anesthesia (LA) (17%). More diverse procedures caused IANI, including TMS (60%), LA (19%), implants (18%), and endodontics (8%). Approximately 70% of patients presented with neuropathic pain coincident with anesthesia and÷or paresthesia. Neuropathy was demonstrable in all patients with varying degrees of loss of mechanosensory function, paresthesia, dysesthesia, allodynia, and hyperalgesia. Functionally, IANI and LNI patients mostly had problems with speech and eating, where speech was affected amongst significantly more patients with LNI (P < .001). Sleep, brushing teeth, and drinking were significantly more problematic for IANI patients (P < .05, P < .001, and P < .0001, respectively). CONCLUSION: Neuropathic pain, as well as anesthesia, frequently occurs following iatrogenic trigeminal nerve injury similar to other posttraumatic sensory nerve injuries. This must be acknowledged by clinicians as a relatively common problem and informed consent appropriately formulated for patients at risk of trigeminal nerve injuries in relation to dentistry requires revision.

Numb chin syndrome: a metastatic deposit in the mandible.

UNLABELLED: Metastatic deposits in the mandible are discussed and a case of leiomyosarcoma arising from a testicular primary is presented. The patient presented with symptoms typical of those that would present to a general dental practitioner. The various stages involved in the diagnosis and management of the condition are discussed. CLINICAL RELEVANCE: Intra-oral malignant secondary tumours may present to dentists with signs and symptoms similar to those of benign, cystic or infectious processes. Metastatic tumours in the oral cavity are uncommon, most commonly arising in the mandible. Owing to their relative infrequency, these tumours present a challenge in diagnosis and treatment.

[Isolated mandibular B-cell lymphoma revealed by inferior alveolar nerve anesthesia]. / Lymphome B mandibulaire isolé révélé par une anesthésie du nerf alvéolaire inférieur.

INTRODUCTION: Mandibular lymphomas are rare and most often revealed by painless swelling. The authors report the case of a mandibular lymphoma revealed by an isolated lesion of the inferior alveolar nerve evolving for eight months. CASE REPORT: A 41-year-old male patient was followed for left mandibular pain, with progressive hypoesthesia of the left inferior alveolar nerve. The radiological assessments remained normal during eight months. Then a vestibular tumor developed in front of tooth 34. The biopsy revealed a B-cell lymphoma. No other localization was found. The patient was in complete remission two years after polychemotherapy. DISCUSSION: Our observation is unusual in its clinical presentation. Mandibular lymphomas most often present as a painless swelling, sometimes ulcerated in the mouth. They are very rarely diagnosed after an isolated hypoesthesia of V3. Lymphomas are the second most frequent head and neck lymphomas after epidermoid carcinomas, but the frequency seems to be increasing. In almost all the cases, they present as B-cell tumours of the DLBCL subtype in the WHO classification. Mandibular localizations account for only 0.6% of the cases. They are often misdiagnosed as a dental problem. The complete remission rate after chemotherapy ranges from 60 to 80% at one year. Nevertheless, the prognosis remains bad with a survival rate of only 50% at five years.

Spatial and temporal assessment of orofacial somatosensory sensitivity: a methodological study.

AIMS: To evaluate the sensitivity and reproducibility of a multimodal psychophysical technique for the assessment of both spatial and temporal changes in somatosensory function after an infraorbital nerve block. METHODS: Sixteen healthy volunteers with a mean (+/- SD) age of 22.5 +/- 3.4 years participated in 2 identical experimental sessions separated by 2 weeks. The subjects rated the perceived intensity of standardized nonpainful tactile, painful pinprick, warm, and cold stimuli applied to 25 points in 5 x 5 matrices in the infraorbital region of each side. The reproducibility of single points was tested, and a mean difference of 1.4 +/- 0.5 was found. A 0-50-100 numerical rating scale (NRS) with 50 denoting "just barely painful" was used. A modified ice hockey mask with adjustable settings was developed as a template to allow stimulation of the same points in the 2 sessions. Assessment of somatosensory function was carried out before the injection (baseline) and after 30 and 60 minutes on both the anesthetized and contralateral (control) side. In addition, the applicability of the psychophysical techniques was tested in pilot experiments in 2 patients before maxillary osteotomy and 3 months afterward. RESULTS: The overall analysis of mean NRS scores, number of points, and center-of-gravity coordinates for all stimulus modalities showed no significant main effects of session. Post-hoc tests for all stimulus modalities demonstrated significantly lower mean NRS scores and significantly more points (hyposensitivity) at 30 and 60 minutes postinjection compared to baseline values on the injection side (Tukey tests: P < .002). In the 2 maxillary osteotomy patients, the psychophysical techniques could successfully be applied, and bilateral hyposensitivity to all stimulus modalities was demonstrated at the 3-month follow-up. CONCLUSION: The present findings indicate that the psychophysical method is sufficiently reproducible, with no major differences between sessions in healthy subjects. All stimulus modalities demonstrated adequate sensitivity. Furthermore, measurement of points in 5 x 5 matrices allowed a spatial description of somatosensory sensitivity. This method may be valuable for studies on changes in somatosensory sensitivity following trauma or orthognathic surgery on the maxilla.

A comparison of postoperative hypoesthesia between two types of sagittal split ramus osteotomy and intraoral vertical ramus osteotomy, using the trigeminal somatosensory-evoked potential method.

The purpose of this study was to evaluate hypoesthesia of the lower lip using trigeminal somatosensory-evoked potential following 2 types of sagittal split ramus osteotomy (SSRO) and intraoral vertical ramus osteotomy (IVRO). There were 30 patients with mandibular prognathism, with and without asymmetry, who were divided into three groups: the Obwegeser method (Ob) group, the Obwegeser-Dal Pont method (ODP) group and the intraoral vertical ramus osteotomy (IVRO) group. The trigeminal somatosensory-evoked potential was recorded in the region of the lower lip and evaluated preoperatively and postoperatively. The average recovery periods from lower lip hypoesthesia in the IVRO and the Ob group were significantly shorter than in the ODP group (P<0.05). In conclusion, IVRO showed the earliest recovery from hypoesthesia or an absence of hypoesthesia, and lower lip hypoesthesia was less with the Ob method than the ODP method.

Simplifying the assessment of the recovery from surgical injury to the lingual nerve.

OBJECTIVE: To determine the sensitivity of conventional sensory assessment in monitoring lingual nerve recovery subsequent to third molar surgery and to evaluate if the assessment methods can be predictive of injury outcome. METHOD: A prospective case series of 94 patients presenting with lingual nerve injuries evaluated using objective mechanosensory and subjective methods during the recovery period of up to 12 months. RESULTS: The conventional tests were often unable to diagnose the presence of injury due to variability and they were not predictive of outcome. As a result of this study, we are able to identify patients more likely to have permanent rather than temporary lingual nerve injury at four to eight weeks post injury, using patient reported subjective function. The subjective function test also minimises the requirements for specialist training or equipment providing an ideal method for general dental practice. CONCLUSIONS: The development of these simple subjective tests may enable us to identify which patients are at risk of permanent lingual nerve injuries in the early post injury phase, thus allowing expeditious therapy when indicated.

Burdensome Physical and Depressive Symptoms Predict Heart Failure-Specific Health Status Over One Year.

CONTEXT: Heart failure (HF)-specific health status (symptom burden, functional status, and health-related quality of life) is an important patient-reported outcome that is associated with palliative care needs, hospitalizations, and death. OBJECTIVES: To identify potentially modifiable patient-reported factors that predict HF-specific health status over one year. METHODS: This was a prospective cohort study using data from the Patient-Centered Disease Management trial. Participants were identified using population-based sampling of all patients with an HF diagnosis at four VA Medical Centers. Patients were enrolled with reduced HF-specific health status (i.e., significant HF symptoms, limited functional status, and poor quality of life, defined by a Kansas City Cardiomyopathy Questionnaire [KCCQ] score <60). Patient-reported factors at baseline were chest pain, other noncardiac pain, dry mouth, numbness/tingling, constipation, nausea, cough, dizziness, depressive symptoms (Patient Health Questionnaire-9), and spiritual well-being (validated, single-item measure). Patients reported HF-specific health status (KCCQ) at 3, 6, and 12 months. RESULTS: Of 384 U.S. veterans, 42% screened positive for depression and 76% described burdensome physical symptoms at baseline. In bivariate analyses, all patient-reported factors were correlated with KCCQ score over one year. Multivariable mixed-effect modeling showed that baseline chest pain, numbness/tingling, depressive symptoms, and higher comorbidity count predicted HF-specific health status over the following year. CONCLUSION: Burdensome physical and depressive symptoms independently predicted subsequent HF-specific health status in patients with symptomatic HF. Whether addressing these aspects of the patient experience can improve health status and well-being in symptomatic HF should be studied further.

Mental neuropathy from systemic cancer.

Nineteen patients with mental neuropathy secondary to systemic cancer are described. In nine patients, the numb chin was the presenting symptom of a neoplasm. Nine patients had lymphoreticular malignancies, and the others had a variety of solid tumors. Radiograms of the mandible were abnormal in 5 of 12 patients. The cerebrospinal fluid contained malignant cells in two. Resolution, complete or partial, occurred in 16 of 19 patients receiving radiation or chemotherapy, including 8 who received chemotherapy alone. Sixteen of the 19 patients died within 17 months of the onset of the neuropathy. A nontraumatic mental neuropathy should initiate a search for cancer.

Chronic granulomatous neuritis in idiopathic trigeminal sensory neuropathy. Report of two cases.

Idiopathic trigeminal sensory neuropathy is a clinically benign disorder in which the main feature is facial numbness limited to the territory of one or more divisions of the trigeminal nerve; the disorder persists for a few weeks to several years. and no underlying disease can be identified. Magnetic resonance (MR) imaging findings are occasionally consistent with a small trigeminal neuroma of the left gasserian ganglion associated with idiopathic trigeminal sensory neuropathy. The authors report on two patients who were treated using a skull base approach in which the gasserian ganglion was exposed and the lesion was removed. The pathological diagnosis was chronic granulomatous neuritis. The authors conclude that, in patients with MR findings suggestive of a small trigeminal neuroma, benign idiopathic trigeminal sensory neuropathy should also be considered in the differential diagnosis. A conservative approach featuring sequential MR imaging studies may avoid an unnecessary surgical exploration.

Metastatic transitional cell carcinoma of the urinary bladder presenting as a mandibular gingival swelling.

Oral cavity metastases mostly originate from the breasts, lungs, or kidneys. Transitional cell carcinoma (TCC), the most frequent malignant tumor of the urinary bladder, rarely metastasizes to the jaws. To the best of our knowledge, only 8 cases of bladder carcinoma have been reported in the English literature to metastasize to the jawbones. A new case of mandibular metastasis of urinary bladder TCC with extension to the gingiva is presented in a 64-year-old white man. The patient was referred for a periodontal infection of the upper right first molar. The clinical examination also showed a gingival swelling located in the lower left premolar region with a hypoasthesia of the left side of the lower lip. The gingival mass was biopsied, and the microscopy showed a mandibular metastatic TCC of the urinary bladder extending to the gingiva. Periodontists should be aware that, although gingival metastases are rare, when they occur they may mimic other local benign pathological conditions.

Thermography for the clinical assessment of inferior alveolar nerve deficit: a pilot study.

Neurosensory deficit is a major complication encountered in maxillofacial surgery. This study assessed the ability of electronic thermography to identify inferior alveolar nerve deficits in a pilot clinical study. The study population comprised six patients with inferior alveolar nerve deficit and 12 normal subjects. Frontally projected facial thermograms were taken on 18 subjects and measured using an Agema 870 unit and thermal image computer. Mathematical analysis of thermal measurements included temperature and delta T calculations of the anatomic zone over the mental region of the face. Results included (1) high levels of thermal symmetry of the chin in normal subjects (delta T = 0.1 degree C, standard deviation = 0.1 degree C); (2) low levels of thermal symmetry in patients with inferior alveolar nerve deficits (delta T = +0.5 degree C, standard deviation = 0.2 degree C); (3) statistically significant differences in delta T values (t = 4.82, P > .001) in patients with inferior alveolar nerve deficit; and (4) absolute temperature variations of the mental region in both groups. This pilot study demonstrated thermal asymmetry in patients with inferior alveolar nerve deficit and suggests that electronic thermography has promise as a simple, objective, noninvasive method for evaluating nerve deficits. However, more extensive studies are needed before thermographic procedures are accepted clinically.

[Quantitative analysis of contrast enhanced MRI of the inferior alveolar nerve in inflammatory changes of the mandible]. / Magnetresonanztomographische Signalanalyse im N. alveolaris inferior bei entzündlichen Veränderungen der Mandibula.

PURPOSE: To evaluate the role of contrast enhanced MRI in quantifying signal changes of the inferior alveolar nerve following inflammatory changes of the mandible. MATERIAL AND METHODS: 30 patients with inflammatory changes of the mandible underwent MRI of the face. Both sides of the mandible, the affected as well as the unaffected healthy side were evaluated retrospectively. Regions of interest were placed at 5 defined places on both sides to assess signal intensity before and after intravenous application of paramagnetic contrast agent. The results of the measurements were compared between the healthy and the affected side (t-test, p < 0.05) and correlated with clinical findings (t-test, p < 0.05). RESULTS: All patients with hypesthesia of the inferior alveolar nerve in areas of the lips or chin (n = 4) showed a marked increase in signal intensity from 35 % to 83 % distal to the inflammatory process. Patients without sensitivity disorders showed less increase in signal intensity with a maximum of 51 % distal to the inflammatory process. In nearly all patients no contrast enhancement was observed distal to the first molar on the unaffected side. CONCLUSIONS: Quantitative analysis of contrast enhanced MRI of the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible, the neurovascular bundle shows a significant increase in signal intensity distal to the lesion compared to the unaffected healthy side of the mandible.

Impairment of the inferior alveolar nerve after sagittal split osteotomy.

The incidence and degree of neurosensory disturbance of the inferior alveolar nerve, as well as its recovery course, were studied on 46 sides in 23 patients who had undergone bilateral sagittal split osteotomies, by means of subjective symptoms, light touch, anaesthesiometer and two-point discrimination. The degree of disturbance was classified into mild, moderate and severe grades by the threshold pressure shown in tests with the anaesthesiometer. The disturbance, which was almost exclusively limited to mild (37%) and severe (28%) grades, was observed in 67% of the sample at one week. The disturbance disappeared completely within one to three months postoperatively in most sites with mild disturbance, and within three months to one year in half of the severely affected sites. Although the recovery was delayed in the other half of the severely disturbed sites, the disturbance was of mild grade at one and a half years. The overall incidence of disturbance at one year was 15%. Computed tomographic examination of the ascending ramus showed that the narrowest width between the mandibular canal and the buccal cortical plate ranged from 0 mm to 3.2 mm with a mean of 1.6 +/- 0.9 mm (SD) and it was less than 1.2 mm in 91% of sites with a severe grade disturbance, whereas it was distributed in a range of 0.9 mm to 3.2 mm in sites with no disturbance or with mild or moderate disturbance. The importance of preoperative computed tomography to indicate the location of the mandibular canal and the use of a thin cement spatula for the osteotomy was stressed, to avoid or reduce postoperative development of neurosensory impairment.

Somatosensory evoked potential assessment of the inferior alveolar nerve following third molar extraction.

Injury to the inferior alveolar nerve can occur during 3rd molar removal. In this study, 14 patients who had 3rd molars removed were evaluated by 4 methods: 1) threshold to electrical stimulation, 2) visual analogue scale subjective ratings of electrical stimulation, 3) two-point discrimination in mental nerve area, and 4) analysis of somatosensory evoked potentials. The last technique proved to be the most sensitive of the methods, providing an objective evaluation as compared to other methods which require a subjective interpretation by the patient.