PainDETECT: a suitable screening tool for neuropathic pain in patients with painful post-traumatic trigeminal nerve injuries?

The PainDETECT questionnaire (PD-Q), originally developed and validated in a multicentre study of neuropathic pain (NeP) patients with back pain, is increasingly being applied to other pain conditions. The present study assessed whether the PD-Q would be a suitable screening tool for detecting NeP in patients with post-traumatic inferior alveolar nerve injury (IANI) and lingual nerve injury (LNI). A prospective cohort of patients with clinically diagnosed neuropathy was given the PD-Q at their clinic appointment, or it was sent to them after their consultation. Eighty-nine patients (IANI = 56, LNI = 33) were included in the study, 75 of whom suffered from painful neuropathy. Of the patients who completed the questionnaire fully (n = 56), allowing a summary score to be calculated, 34% were classified as having ‘likely NeP’ according to the PD-Q; 41% of patients scored in the uncertain classification range and the remaining quarter in the ‘likely nociceptive’ classification. There was a significant association between PD-Q scores and pain intensity levels across the sample, with those classified as likely NeP reporting high levels of pain. The results suggest that the PD-Q in its current format is not a suitable screening tool for NeP associated with IANI or LNI.     

Clinical outcomes of lingual nerve repair

Lingual nerve injury, a well-described complication of third molar removal, may result in permanent lingual sensory deficit leading to symptoms including lost or altered sensation, inadvertent tongue biting, and the development of unpleasant neuropathic pain, with consequent impaired quality of life. We analysed outcomes of a prospective case series to determine whether direct anastomosis of the lingual nerve results in improved sensory recovery and reduced neuropathic pain, and whether delayed surgery is worthwhile. In 114 patients who underwent nerve repair at our nerve injury clinic following damage sustained during mandibular third molar removal, sensory deficit was assessed before and after surgery using a questionnaire and visual analogue scales (VAS) to assess pain, tingling, and discomfort. Neurosensory tests were utilised to evaluate light touch, pin-prick, and two-point discrimination thresholds. Subjectively, 94% patients felt their sensation had improved following nerve repair, with significant reductions in the incidence of tongue biting (p < 0.0001), impaired speech (p < 0.0001), and neuropathic pain (p = 0.0017). Quantitative neurosensory data showed highly significant improvements in light touch, pin-prick, and two-point discrimination (all p < 0.0001), and VAS scores for pain (p = 0.0145), tingling (p < 0.0025), and discomfort (p < 0.0001) were significantly reduced. Patients with high levels of pain preoperatively (VAS > 40) showed highly significant reductions in pain (p < 0.0001). No correlation was found between surgical outcome and patient’s age or delay until surgery. Lingual nerve repair results in good sensory outcomes and significant improvements in the incidence and degree of neuropathic pain, even when delayed.     

Sensory purinergic receptor P2X3 is elevated in burning mouth syndrome

Recent studies show that P2X₃ may play a role in neuropathic pain, including orofacial pain. Burning mouth syndrome (BMS) is a chronic neuropathic pain condition affecting 0.6–12% of post-menopausal women in the Western world. This study evaluates, for the first time, P2X₃ immunoreactivity levels in lingual mucosa in BMS patients. Patients diagnosed with BMS (n = 9) in accordance with International Association for the Study of Pain criteria and patients attending for wisdom tooth removal (n = 10, controls), were involved in this study. A pain history and score was recorded on a visual analogue scale (VAS) prior to obtaining a lingual biopsy. Immunohistochemistry and image analysis were used to quantify submucosal nerve fibres expressing P2X₃ and the structural marker neurofilaments. P2X₃ positive fibres were significantly increased in BMS compared with controls (p = 0.024). In contrast, neurofilament-staining fibres were reduced in BMS, and when expressed as a ratio of the neurofilament percentage area, there was a trend for an increase of P2X₃ positive fibres in the BMS group. Increased P2X₃ immunoreactivity in the trigeminal sensory system may play a role in the symptoms observed in BMS. P2X₃ may therefore be a therapeutic target for treating BMS and trigeminal neuropathic pain.     

Immediate dental implant placement with a horizontal gap more than two millimetres: a randomized clinical trial

The purpose of this study was to evaluate the horizontal dimensional changes in buccal alveolar bone immediately after dental implant placement in the upper premolar area with horizontal gaps >2 mm. A total of 48 patients were enrolled in this randomized clinical trial and were randomly assigned to one of three groups. Group I (flap with graft; n = 16) patients received an immediate implant with bone graft, membrane, and primary flap closure. Group II (flap without graft; n = 16) patients received an immediate implant with primary flap closure only. Group III (flapless without graft; n = 16) patients received an immediate implant without graft, membrane, or primary closure. Cone beam computed tomography (CBCT) scans were obtained preoperatively, immediately after implant placement, and at 6 months postoperative to evaluate horizontal dimensional changes in the buccal alveolar bone. Pain intensity was measured using a numerical rating scale. CBCT examinations revealed that bone had filled the horizontal gap in all three groups. Group II showed the greatest horizontal dimensional changes in the buccal alveolar bone, followed by group I. The least amount of change was recorded for group III. Furthermore, significantly less postoperative pain was recorded in group III when compared to the other groups. Short-term results suggest that the ‘flapless without graft’ technique shows similar results to the ‘flap with graft technique’ for immediate implant placement in the maxillary premolar extraction site with a horizontal gap >2 mm, when the bone plate is intact.     

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.     

Post-discharge pain experience following primary total hip or knee arthroplasty in patients whose primary language is not English

Pain following total hip or total knee arthroplasty post-discharge from hospital is not well understood, especially in patients whose primary language is not English. The objective of this study was to examine pain in patients whose primary language is not English following discharge from acute care to home or to a rehabilitation unit from post-operative days 5 to 9. During the study period 22 patients met the study criteria, 19 consented to participate, and 18 completed the study. Participants were asked to complete the Pain Self-Assessment Form (PSAF) for 5 days after discharge from acute care. The response rate was 95% (n = 18). The most common languages spoken were Greek (n = 7) and Italian (n = 5). Mean daily pain scores ranged from 4.4 to 5.1 out of 10. The most commonly used analgesics included oxycodone, acetaminophen, and hydromorphone. The most commonly reported adverse effect was nausea (n = 9). When asked what could be done to improve pain management participants reported that they would have liked more information regarding managing their pain from a translator, including information regarding when to use analgesics.     

Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars

The purpose of this study was to compare the effects of flap design on the postoperative sequelae of pain, swelling, trismus and wound dehiscence after surgical removal of bilateral impacted mandibular third molars (M3). 20 patients aged 20–30 years who required removal of bilateral impacted M3 were included in the study. Maximum interincisal opening and facial measurements were recorded preoperatively. Bayonet flap was used on one side and envelope flap on the other side for the removal of impacted M3. The effect of flap design on pain, swelling, trismus and wound dehiscence was evaluated postoperatively. Pain and wound dehiscence were significantly greater in the envelope flap group compared with the bayonet flap group (P < 0.05). No significant difference in postoperative swelling and trismus was found in either group (P > 0.05). The bayonet flap was superior to the envelope flap for postoperative pain and wound dehiscence. There was no difference in postoperative swelling and trismus between the two groups.     

Treatment of trigeminal neuralgia with bupivacaine HCL using a temporary epidural catheter and pain pump: Preliminary study

ObjectivesTrigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterised by severe paroxysmal pain in the face. The treatment for trigeminal neuropathic pain disorder continues to be a major therapeutic challenge, as relief provided by medical therapy generally decreases over time. When medical therapy fails either due to poor or diminishing responses to drugs or to unacceptable side effects, peripheral intervention or surgical management of TN should be considered.Study designFourteen patients (eight men and six women) who were not responsive to further medical treatment and who were diagnosed with TN previously at other health centres were selected for treatment. For this purpose, the affected nerve was infused with 60 mL (1 mL h^?1) of 0.5% bupivacaine HCl with a pain pump via an temporary epidural catheter. Patient’s visual analogue scores (VAS) were recorded on the fifth preoperative day and on postoperative day 5, 2 weeks, 1, 3, 6 and 9 months.ResultsThere was a significant difference between mean preoperative and postoperative VAS value at day 5, 2 weeks, 1, 3, 6 and at the end of 9 months ((68.85 ± 1.43) (13.57 ± 6.68) (11.43 ± 6.70) (14.29 ± 6.52) (20.71 ± 6.41) (20.71 ± 6.41) and (21.43 ± 6.10) respectively; 1P < 0.05). Two of 14 patients did not show any pain relief.ConclusionsContinuous administration of 60 mL of 0.5% bupivacaine HCl at 1 mL h^?1 with a pain pump and epidural catheter can be used as a transition treatment for patients with side effects from high-dose antiepileptic drugs and for patients awaiting neurosurgery or individuals who refuse cranial surgery. It should not be considered as an alternative treatment of neurosurgical approaches, such as MVD, which has a definite long-lasting results.     

A cohort study of patients with juvenile idiopathic arthritis and arthritis of the temporomandibular joint: outcome of arthrocentesis with and without the use of steroids

The purpose of this study was to evaluate the effects of intra-articular temporomandibular joint (TMJ) treatment in patients with juvenile idiopathic arthritis (JIA). The inclusion criteria were met by 21 patients (38 joints). Joints were randomly selected for either arthrocentesis alone (n = 17) or arthrocentesis with the additional use of triamcinolone hexacetonide (n = 21) using a closed single-needle system. Measurements of pain and function were performed at baseline and at follow-up after 3 and 8 months. Pain on opening and lateral excursion improved significantly after injections. Pain decreased significantly from baseline to first and second control on a visual analogue scale (VAS) for overall pain (49–18–8) and overall function (41–19–4). Significant improvement was recorded for pain on palpation of muscles and joints. There was no statistically significant difference between the treatment modalities, with or without glucocorticoid injection. Arthrocentesis in the TMJ treatment of patients with JIA may be beneficial and steroids had no additional effect. Further studies are needed to evaluate the long-term effects on the TMJ structures and on condylar growth from arthrocentesis and intra-articular steroid injections.     

Coronoidectomy,masticatory myotomy and buccal fat pad graft in management of advanced oral submucous fibrosis

The purpose of this study is to evaluate coronoidectomy, masticatory myotomy and buccal fat pad graft in advanced (Stage III–IV) oral sub mucous fibrosis (OSF). 10 patients with clinically and histologically confirmed advanced OSF underwent surgery entailing bilateral coronoidectomy, masticatory muscle myotomy and closure with a pedicled buccal fat pad graft followed by vigorous mouth opening exercises. The result was evaluated using the interincisal distance at maximum mouth opening as the objective outcome measure over a follow up period of 12 months. Results showed a mean interincisal opening of 14.7 mm preoperatively and 32.5 mm at 12 months postoperatively. Relapse was encountered in one patient who did not cooperate with the postoperative exercise regime. Results suggest this regime is effective.     

Applicability of buccal fat pad grafting for oral reconstruction

This study evaluated the applicability of pedicled buccal fat pad grafting for the reconstruction of defects surgically created during oral surgery. A buccal fat pad graft was applied in 23 patients (5 males, 18 females; mean age 68.3 years) between 2003 and 2011. The graft was used to cover surgical defects of the palate, maxilla, upper gingiva, buccal mucosa, lower gingiva, oral floor, and temporomandibular joint region. Size of the surgical defects ranged from 15 mm × 12 mm to 30 mm × 40 mm; size of the buccal fat pad ranged from 15 mm × 12 mm to 43 mm × 38 mm. A pedicled buccal fat pad was prepared by incising the maxillary vestibule following primary surgery, and the surrounding connective tissue was preserved to supply nutrition to the pedicle during surgery. The buccal fat pad was placed on the raw surface of soft tissue or bone surface and sutured to the surrounding tissue of the defect. Complete epithelialization was observed within 4 weeks postoperatively. There were no complications or functional disorders during follow-up. Buccal fat pad grafting appears to be feasible for the reconstruction of surgically induced defects, and can be extended to the palate, mandible, mouth angle, and temporomandibular joint region.     

Preemptive effect of ketoprofen on postoperative pain following third molar surgery. A prospective,randomized, double-blinded clinical trial

The authors examined whether ketoprofen administered 60 min before surgical extraction of the lower wisdom teeth provides effective postsurgical analgesia and reduces rescue analgesic intake compared with ketoprofen administered 60 min after surgery or placebo. The 96 patients were placed into three groups: pre-group (ketoprofen 60 min preoperatively); post-group (ketoprofen 60 min postoperatively); and no-group (placebo). Study interventions had a significant effect on pain sensations in the 12 h after surgery. The initial onset of pain was significantly delayed only in the post-group. Pain intensity at the first onset of pain was significantly lower only in the post-group. Patients in the pre- and post-groups required significantly less rescue analgesic than those in the no-group. Ketoprofen administered after third molar surgery provides more effective pain control than ketoprofen administered before the surgery or placebo.     

Benign temporomandibular joint tumours with extension to infratemporal fossa and skull base: condyle preserving approach

This article introduces a modified surgical approach combining condylotomy with posterior disc attachment release for the resection of large non-malignant masses located in the infratemporal fossa and involving the skull base. This retrospective study included 14 patients treated at Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University between January 2010 and December 2016. Clinical evaluations (visual analogue scale (VAS) for pain, maximum inter-incisal opening (MIO), and complications) and radiological findings (magnetic resonance imaging (MRI) and computed tomography (CT)) were collected pre- and postoperatively. All patients had satisfactory surgical exposure and complete resection of the neoplasms. During an average follow-up of 54.8 months, no clinical or radiographic signs of recurrence were reported. MIO increased from 28 mm preoperatively to 35.4 mm postoperatively (P < 0.001). The pain VAS score changed from 5.4 preoperatively to 0.7 postoperatively (P < 0.001). Neural function was normal for all patients. Postoperative MRI and CT scans showed a satisfactory disc position and condyle morphology, with no resorption. Three-dimensional reconstruction of the postoperative CT scan also demonstrated healing of the skull base defects. The modified surgical approach combining condylotomy with posterior disc attachment release is suitable for the removal of large non-malignant masses involving the infratemporal fossa and skull base.     

The effects of melatonin prophylaxis on sensory recovery and postoperative pain following orthognathic surgery: a triple-blind randomized controlled trial and biochemical analysis

Post-surgical neuropathy is a known complication of many surgical procedures for which few remedies are effective. This study used neurosensory assessments and biochemical assays to evaluate the efficacy of melatonin on nerve healing following orthognathic surgery. Thirty randomly allocated orthognathic patients were prophylactically administered either oral melatonin or identical placebo for 21 consecutive days. Pre- and post-surgical clinical parameters included subjective pain, numbness, and objective neurosensory function. Pre- and post-surgical biochemical parameters were serum hydrogen peroxide and antioxidant enzyme levels. Melatonin was found to significantly reduce subjective pain perception by 50% in the early postoperative days. A 30% reduction in subjective numbness perception was observed at 1-week postoperative, increasing to an over 80% reduction by 3 months postoperative (P < 0.00001). Objective neurosensory testing showed a significant improvement in healing profile in the melatonin group. Postoperatively, the hydrogen peroxide concentration was lower in the melatonin group (P < 0.00001), and the levels of antioxidant enzymes were higher (P < 0.00001). The strong correlations between clinical outcomes and biochemical changes suggest a link between antioxidant effects and reduced postsurgical pain and sensory recovery. The study findings suggest that the prophylactic administration of melatonin confers significant clinical benefits in terms of reduced postoperative pain and opioid use and improved sensory recovery following surgery.     

Clinical comparison of a xenogeneic collagen matrix versus subepithelial autogenous connective tissue graft for augmentation of soft tissue around implants

Dental implant placement is a predictable therapy for replacing teeth. Nevertheless, mechanical, biological, and aesthetic complications frequently occur. The aim of this study was to compare the clinical outcomes of a xenogeneic collagen matrix (XCM) used at the time of implant placement as an alternative to a subepithelial connective tissue graft (SCTG), for soft tissue augmentation. This was a prospective clinical trial with 12 months of follow-up. In the control group, soft tissue augmentation at the time of implant placement was performed with a SCTG, while in the test group, a XCM was employed. At 12 months postoperative, all xenografts showed no postoperative complications. In both groups, a significantly greater thickness was observed on the buccal and occlusal sides from preoperative to 3 months postoperative (P < 0.05). No statistically significant difference in pink aesthetic score (P = 0.379, 6 months postoperative) or marginal bone loss (P = 0.449 at 3 months postoperative, P = 0.778 at 6 months postoperative) was observed between the groups. Statistically significant differences in pain perceived by the patients (P < 0.0001) and the time to complete the surgical procedure (P = 0.0008) were detected. At 12 months after surgery, XCM provided similar clinical results in terms of soft tissue augmentation on the buccal and occlusal sides as compared with the SCTG.     

Risk factors for bad splits during sagittal split ramus osteotomy: a retrospective study of 964 cases

To identify the potential risk factors for bad splits, we calculated the incidence of bad splits from 484 patients with 964 cases of sagittal split ramus osteotomy (SSRO) and investigated the association between the occurrence of bad splits and risk factors such as gender, patients’ age, class of occlusion, unimaxillary or bimaxillary surgery, presence of the lower third molar, thickness of the ascending ramus, and the distance from the mandibular canal to the buccal cortical bone. The results showed that 40 sides (4.149%) with bad splits occurred in 36 patients (7.438%). The mean (SD) gap width from the canal to the buccal cortex for the bad split group, at 4.02 (1.20) mm, was narrower (p = 0.003; OR = 0.689; 95% CI = 0.538 to 0.882) than the normal split group 4.80 (1.72) mm. On the contrary, no statistical significance (p > 0.05) was detected between the patients with bad splits and those with normal splits for the other factors. In conclusion, SSRO patients with narrower distances from the mandibular canal to the buccal cortex were more prone to bad splits. More attention should be paid to patients with this risk factor during future surgeries.     

Effectiveness of green tea mouthwash in comparison to chlorhexidine mouthwash in patients with acute pericoronitis: a randomized clinical trial

The objective of this study was to evaluate the effectiveness of green tea mouthwash in controlling the pain and trismus associated with acute pericoronitis in comparison to chlorhexidine (CHX) mouthwash. Ninety-seven patients with acute pericoronitis underwent debridement and received 5% green tea mouthwash (study group) or 0.12% CHX mouth rinse (control group). Pain (visual analogue scale; VAS), number of analgesics, maximum mouth opening (MMO), and number of patients with trismus were determined. There were no significant differences in demographic variables (P > 0.05), or baseline VAS (P > 0.006), MMO (P > 0.017) or number of patients with trismus (P > 0.017) between the two groups. The mean VAS score of the study group was statistically lower than that of the control group between post-treatment days 3 and 5 (P < 0.006). A significantly lower number of analgesics were taken by the study group (P < 0.05). Although the MMO of the study group was significantly lower on day 3 (P < 0.017), no significant difference was observed on day 7 (P > 0.017). Fewer of the patients rinsing with green tea had trismus on days 3 and 7, but the difference was non-significant (P > 0.017). Hence, green tea mouth rinse could be an appropriate and effective choice for the control of pain and trismus in acute pericoronitis.     

Are women more susceptible than men to iatrogenic inferior alveolar nerve injury in dental implant surgery?

An over-representation of women in dental implant-related inferior alveolar nerve injuries (IANIs) is recognized in the literature but has not been investigated. Therefore, a nationwide retrospective register study was conducted to analyse how IANIs compare with other implant-related complications (infection, implant malposition, lack of bone at implant site, mechanical damage, or failed osseointegration) separately in women and men. Financially compensated malpractice claims related to dental implant surgery were collected from the Finnish Patient Insurance Centre for the years 1997—2013, while the total number of nationally placed implants was ascertained from the implant register held by the Finnish Institute for Health and Welfare. In the 242 complications, the following were analysed: age of subject, absolute risk for complication, and aetiological factor of IANI. Statistical tests applied include Mann–Whitney U-test, Chi-squared test, and Fisher’s exact test. Women sustaining IANI were more likely older than those having infection, mechanical damage, or failed osseointegration (P < 0.05), while no significant differences emerged in men. Women were more likely at risk for IANI (P < 0.01) or implant malposition (P < 0.05) than men. The results support earlier propositions that women are more vulnerable than men to iatrogenic IANI.     

Does pain in the masseter and anterior temporal muscles influence maximal bite force?

ObjectiveThe aim of this study was to evaluate changes in pain and muscle force, and the relationship between them, in patients with muscle pain and bruxism, prior to and after treatment.MethodsThirty women with bruxism and myofascial pain (Ia) were included in this study. Sleep bruxism diagnosis was made based on clinical diagnostic criteria, and awake bruxism diagnosis was made by patient questionnaires and the presence of tooth wear. The diagnosis of myofascial pain was established according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC-TMD). Dentulous or partially edentulous patients (rehabilitated with conventional fixed prostheses) were included in the study according to the inclusion and exclusion criteria. The pain treatment protocol included occlusal splints, patient education, and physiotherapy for 30 days. Bite force was measured using a dynamometer at the central incisor and the first molar regions on both sides. The exams were performed at baseline, after 7 days, and 30 days after treatment. The Wilcoxon test was used to compare patient pain level response among the periods analyzed in the study. Bite force data were submitted to two-way repeated-measures ANOVA, followed by the Tukey HSD test (p < 0.05). A simple regression analysis was performed to verify the relation between pain level and bite force.ResultsResults revealed that there was a statistical difference in pain level over time for both muscles and sides (p < 0.01). In the molar region, the bite force exhibited significantly higher values after 30 days of treatment, when compared with the baseline (p < 0.001). There was a correlation between pain level and bite force only for the temporal muscle in all periods analyzed (p < 0.05). There was no strong correlation in the response level points to support the association of pain and bite force.ConclusionsPain level decreased and bite force increased in the molar region after treatment. No strong correlation or dispersion in the relationship between pain levels and bite force was seen in women with myofascial pain and bruxism.