Delayed Paresthesia: any thoughts?

Last Updated: Jun 05, 2015

An implant was placed over 18 months ago in the lower premolar region of a 58 year old female.Healing proceeded uneventfully but three months after during a routine visit the patient mentioned in passing that she had some very slight tingling in her lower lip. I put it down to a traumatic ulcer visible on the mucosa of the area and thought no more of it. Another visit three months later revealed slightly increased numbness and her response to a prick test was however positive. Fitting of prosthesis was completed and patient was scheduled to be examined again after three months. Patient was then diagnosed with osteosarcoma in her femur for which she commenced methotrexate, doxorubicin, and cisplatin chemotherapy. She is presently receiving biphosphonate treatment on a monthly basis.

Having postponed her dental exam for 9 months I finally examined her last week. Implant is clinically fine but her numbness which is limited to her lower left lip increased to a point where she has lost all sensation. Patient was not overly concerned but was more worried that there might be some connection with her osteosarcoma. I obtained a cbct image which shows the most distal surface of the implant in close proximity but not infringing the mental nerve. I am at a loss to understand how patient gradually developed paresthesia and would be grateful for any assistance.

Distal view of implant.

13 Comments on Delayed Paresthesia: any thoughts?

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CRS

06/06/2015

Doubtful of dental origin did you notify her MD? I would be suspicious of a central lesion.

06/07/2015

Thank you for your reply. I did in fact refer her to her treating oncologist and await results of investigations on his part. I was also doubtful of dental origin as numbness would have occurred immediately post surgery and we were in constant communication with the patient. Would any one have any thoughts on which central pathway could be disturbed? I cannot find anything in the literature regarding mental nerve paresthesia from a central origin.

CRS

06/07/2015

The mental nerve is a terminal branch of the fifth cranial nerve, third division so logically if something is going on near the trigeminal ganglia or perhaps somewhere along the nerve pathway you could see this. The chemotherapy or bisphospanates may be a cause? Osteosarcoma is a very aggressive disease. I think it is enough to rule out an implant related cause and alert the oncologist. Hope your patient beats this, sorry to hear about this.

John T

06/07/2015

80% of patients with osteosarcoma of a long bone have metastases at the time of first diagnosis, although they may not be clinically apparent. Usually pulmonary but this history of progressive mental nerve paraesthesia sounds worrying. Probably a candidate for radionuclide scintiscan +/- MRI. Please keep us posted

06/08/2015

Thank you, your views and insights all very useful and helpful. I will be updating with oncological investigation results once they are in hand.

Dennis Flanagan DDS MSc

06/09/2015

I had a case with delayed altered sensation a number of years ago that I published. This is uncommon. My pt had no systemic except diabetes. The breakdown products of porphyryn, ferric free radicals can cause neuropathy. Was there a mental block given for the implant placement? Was there an intraosseous V-3 block? Dennis Flanagan DDS MSc

CRS

06/10/2015

Can you share a reference and was it a permanent parestesia? Thanks I had something odd like this happen also. Thanks

Dennis FlanaganDDS MSc

06/11/2015

My case the altered sensation lasted only about 2 months.Flanagan D. Delayed onset of altered sensation following dental implant placement and mental block local anesthesia: a case report. Implant Dent. 2002;11(4):324-30. PubMed PMID: 12518698.

CRS

06/11/2015

Thanks

RRO

06/14/2015

I had a case which I completed over twenty years ago. It was a three unit bridge on two implants in the lower right quadrant. After twenty years the patient started reporting pain. She was well into her 70's when she reported the pain in "her jaw" at that location. I did not know what the problems was. She went to an oral surgeon who came to the conclusion that the implant treatment was done all wrong and that they should be removed and replaced ( despite the fact that there was no bone loss around the implants and implants and prosthesis had functioned without discomfort for over twenty years). She reported this discussion with the oral surgeon to me and I took a day or two to think it over. After some thought I connected these "dots." She was in her mid 70's. She had osteoporosis. She was taking oral bisphosphonates and the implants were placed virtually as close to the inferior alveolar canal as could be without causing numbness. These dots led me to a theory: Heavy occlusion on the implant prosthesis was causing micro-strain and micro-movement on the supporting bone over the canal, enough to cause pain when functioning. Over the twenty years since the prosthesis had been placed, the rest of her dentition had worn much more than the implant prosthesis causing an ever increasingly heavy load on the implants year by year. Her bone density on the other hand, had decreased. She came back, I checked her occlusion and it was indeed very heavy on the implant bridge. I adjusted the occlusion, lightened the load and the pain disappeared and never came back. These are a lot of dots to connect and very anecdotal. Take it for what it is worth. It did save my patient a lot of pain, expense and grief.

Dr shyam mahajan Aurangab

06/26/2015

Dear Dr Pro Very well tackled case. We need more conservative clinicians like you than oral surgeon who advised such radical treatment plan. For the first question - Is implant close to the loop that inferior alveolar nerve takes before coming out of mental foramen.?

rro

06/27/2015

Not near the loop, just over and very near the canal.

06/15/2015

Very interesting...it could very well be that a combination of bone altering medication and occlusal load combine to stimulate previously unaffected neural areas.

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