Lingual nerve damage and implant: recommendations?
I have a patient who is interested in getting an implant to replace missing #19 [mandibular left first molar; 36]. This patient is currently presenting lingual nerve pain such as burning when his tongue touches #20 [mandibular left second premolar; 35]. According to the patient, the lingual nerve pain started after having a bridge [fixed partial denture] placed 4 years ago from #18-20 [mandibular left second molar to second premolar; 37 – 35]. His left side of jaw was left with numbness and burning sensation. That bridge cracked and became loose. A new dentist replaced the old bridge with a new bridge and the burning sensation got worse.
The patient then had root canal treatment on #18 suspecting crack tooth on cracked root or infection causing the pain. But after the root canal treatment on #18 the patient started having severe pain different from the kind of burning pain he had been previously experiencing. #18 was then extracted by an oral surgeon. Now he only experiences burning sensation on the left posterior side of his tongue. No more burning pain or any pain in the rest of his mouth. Patient wants an implant on #19 site but is worried that the pain will get worse since his endodontist once warned him this might happen. Right now #18-19 area has normal sensation. I have cautioned the patient that installing an implant in #19 might not cause any more lingual nerve pain but that he might experience burning pain again when his tongue rubs against the crown on #19 implant. If that happens I will remove the implant. Have any of you treated cases like this? What do you recommend?
11 Comments on Lingual nerve damage and implant: recommendations?
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CRS
9/25/2013
Refer him to a neurologist. The symptoms are not consistant with the dental treatment rendered. The pain may be able to be managed with medication. I wouldn't place an implant on this patient.
Rateb Sadek
9/26/2013
I agree with Dr CRS you can refer the patient to neurologist . maybe it is appear to be
Atypical Trigeminal Neuralgia in this case you can give the pt Tegretol 200 – 1200 mg a day according to the pt age .
Frank Avason DMD,MS
10/1/2013
Run from this guy. Your asking to become another one named on his future litigation claim. I can't believe your even thinking of doing surgery on this guy. Lingual pain from a tooth borne fixed bridge?!?
timothy Hacker DDS D-ABOI
10/1/2013
Neurologist referral for Trigeminal Neuralgia. Do not prescribe any medications other than a steroid that will mitigate inflammation until the patient can get in to see the Neurologist. This case is high morbidity, and too bad for the other dentists who did not recognize how deep into excrement they were getting. You may be called to be an expert witness in this case.
gary OMFS
10/2/2013
His lingual neuropathy is probably due to the IAN block given when the teeth were prepared for the bridge. This is untreatable but the fact that after several years there' s still some recovery is good though. If you work in US or UK I think it may be wise to have it documented and medicated by an 'independent' neurologist, Lyrica should do a lot. Don't give any IAN block. Have a written informed consent. And, do a CBCT beforehand. Maybe even MRI: radiologists don't know what to look for in jawbone but they are viewed as the experts by both patients and the judicial system. If you don't feel confident, send patient to a university clinic. I think good communication is the key to succes here.
Mich
10/2/2013
Thank you for comments from all of you. I do think that the neuropathy is from the IAN block. I will have him go see neurologist for evaluation and treatment.
Appreciate your expertise in this!
CRS
10/2/2013
Good advice I think the prognosis four years out with a traumatic neuroma is poor. I think microsurgery would be difficult at the lingula would be tough at least the main trunk recovered. However your documentation is excellent advice, infiltration on the buccal and lingual is indicated. I would refer to a university clinic personally I'm too old for this!
Haraldo
10/2/2013
potentially nothing to do with bridge itself.........may be the result of LA trauma given for bridge preparation. You don't need to run, refer for diagnosis. patient may be thankful if you can clarify his situation so that he can come to terms with his problem. Not that common but considering the number of LA given..........
CRS
10/3/2013
Doctor since you seem to know that the patient has a lingual dysethesia from a possible nerve block from previous treatment you feel confident enough to just clarify the situation without referring to a neurogist for medical management? Were you present at the time of initial injury? Do you feel confident to defend your failure to refer? Are you an expert in lingual nerve damage and treatment? How many of these cases have you managed? Do you feel confident enough to deny the patient medical evaluation of a non dental neurological complication? How can you assume that the patient would be grateful for not having an appropriate evaluation and treatment by a physician trained in management of nerve injuries assuming that this clinical condition was indeed caused by a dental nerve block? These are the questions a good malpractice attorney will pose, you may not want to go solo on this case and it more importantly not in the best interest of the patient not to be referred to at least a md prior to starting treatment. Believe me I've been there as a witness.
haraldo
10/3/2013
CRS, It saddens me to read the condescending tone of your reply although I accept this is an international website and English may not be your first language. I accept your apology in advance.
"may be the result of LA" - does it sound like I was there?
" You don’t need to run, refer for diagnosis. " - does it sound like I am abandoning the patient or have I indeed recommended he be referred for a diagnosis?
Does it say You don't need to run or refer for a diagnosis?? no it does not.
"patient may be thankful if you can clarify his situation so that he can come to terms with his problem"- does it sound like I an denying a medical evaluation. That referred evaluation would clarify (hopefully) the cause of his problem and the if any management was required in secondary care
is that simpler for you to understand, Doctor.
We normally refer cases to oral medicine where they liase with other clinicians rather than directly to neurologists.
CRS
10/7/2013
Actually speaking English all my life I appreciate your clarification of your terse initial comments. It was unclear. Now my comments are the condescending tone of a malpractice lawyer so hopefully now you can understand that simple explanation which was in the original comment which you may have missed the first time. Actually I have quite a bit of experience diagnosing paresthesias gratefully not causing them. The point is it is prudent to have medical backup and treatment if one is not familiar in treating this complication. I think you may have taken my comments personally and very easily became arrogant and defensive which is exactly the reaction a malpractice attorney will try to provoke. Thank you for proving my point you made it very easy. Maybe I should switch careers! It is a shame that in the US one has to be so wary of lawyers and malpractice especially with newly trained practitioners expanding their scope of practice and trying to get experience. Also in re-reading the post it seems that the paresthesia was not addressed for four years and several practioners treated the patient a probable unnecessary root canal and extraction. Don't have a film but when I read it it seems that RCT and extraction was used to treat the paresthesia which is not the correct management. I hope that was not the case, but it seems. This patient needs a diagnosis and in the US that means referral to a neurologist or an OMFS who treats these situations. I am confident that the poster will do the right thing and applaud his response. Thanks for carefully reading!
