Chronic pain after injury to mucous membranes(torquing): treatment?
On May 10 , while torquing the abutment, my dentist trapped some mucuous membranes in the screw. After 3 weeks of terrible pain another dentist diagnosed the problem, the trapped membranes had caused an infection and oral surgery was performed.
Pain continued at the site of the wound for weeks afterwards until another specialist recommended removing the crown, as it was possibly too large and was causing a build up of pressure in the area where tissue was still healing. Removal of the crown brought some relief but a constant ache alternating with numb sensation in my upper right jaw – sometimes changing to a sharp pain starting at the site where surgery had been performed – has been present until today. I am desperate.
A professor who saw me yesterday says the implant looks ok and that if the abutment is removed, the tissue will heal. Does this make sense? The abutment was never comfortable from the beginning. Could the abutment be too large for my jaw? if it is removed, can a thin abutment be inserted after tissue healing? 3 months pain is pretty bad and the dentist who did the torquing that caused the ingflammation to this day says i am making a mountain out of a molehill. Help! Thank you Cathy
16 Comments on Chronic pain after injury to mucous membranes(torquing): treatment?
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jack DDS
9/12/2013
Dear Cathy
It is very weird to have this kind of pain with the insertion of the abutment; generally the abutment is inside the implant and there is reason at all for the patient to experience any disconfort at all. Imagining the entrapment of some tissue, as you described should not lead to all this pain, but let's consider that all this has happened, why don't you ask your dentist to remove the abutment? if the pain remains( or as you wrote:numb sensation in my upper right jaw – sometimes changing to a sharp pain starting at the site where surgery had been performed) this might make us think that during the torquing of the abutment the implant has moved, because the osteointegration was not achieved and this not the abutment has caused all the rest.
Best Wishes
Stanley Markman
9/12/2013
At the Orofacial pain center at Rutgers School of Dental Medicine we see may patients with this type of problem. The patient has neuropathic pain which can be treated with medication. There are two medication approaches: we use either systemic meds or we can sometimes use a medical delivery splint with a compounded topical medication.
The majority of dentists do not recognize neuropathic type pain for we are primarily trained in treating somatic pain. The treatment to correct the entrapped tissue was probably unneeded. When a patient's response to a procedure appears to be unreasonable, and the imaging appears to be normal, then dentists have to stop doing corrective procedures. Removing the implant will likely cause the reference pain area to expand. A small percentage of patients have this problem. Practitioners have likely experienced patients who have had root canal treatments which appear to meet standards and the patient continues to have pain.
The problem that the patients has cannot be reversed with another dental procedure.
Stanley Markman, DDS
Clinical Assistant Professor, Orofacial pain, Rutgers School of Dental Medicine
Samuel Barr, DMD
9/12/2013
I am more inclined to go along with the first comment. The beginning of pain is associated with the abutment placement. Osseointegration of the implant may not have been sufficient to withstand the torquing forces, and may indeed have moved. Its true that in a certain small number of cases, osseointegration does not happen, or happens extremely slowly, for reasons that we sometimes do not understand.
At this point, the implant is either integrated, or its not. I would recommend that the implant be tested by reverse torquing. If the implant fails the test, then have the implant removed. If the implant passes the test, then follow the second comment's neuropathic approach
K. Sam Szeto DDS LAc
9/12/2013
Try acupuncture treatment first before removal of the crown or abutment.
A good overall balanced health should be able to bring small imbalances back to BALANCE !
EB DMD
9/12/2013
See a periodontist sounds like soft tissue problem may need ct graft.
Vipul G Shukla
9/12/2013
Dear Cathy,
The pain you have described is unusual in its intensity and duration. Going by the panoramic X-ray you have attached, the implant looks well-integrated, but without a clinical exam, cannot comment definitively. Need more information, besides maybe close-up X-ray of the implant (intra-oral view) and some colour photos.
The first poster has hinted at osseointegration failure, which means the implant had not completed its fusion with your living jawbone, when your restorative dentist went in with the crown. It is possible, although I highly doubt that would be the case, because it would clearly show up on the X-ray afterwards, and the symptoms are different.
There could be a neurogenic/neuropathic origin to this all, but that kind of pain usually comes after deep bone surgery, if its is iatrogenic, not on something simple as abutment tightening.
Looking closely at your panoramic X-ray and your described symptoms, your upper right pain may also be due to tooth #16 slowly undergoing irreversible pulpitis. In other words, this pain could be from the upper last molar in your mouth slowly dying, the one that has a crown on it. Maybe it needs a good Root Canal, and all your pain disappears! This is called 'referred Pain'
Someone should take a good look at it.
Keep us posted, Cathy from Germany.
Dr David E Azar
9/13/2013
it could simply be that there is a problem around the implant...not the abutment. It might be wise to get a 3D X-ray, cone beam cat scan, to evaluate the bone around the implant
Cathy
9/13/2013
Thank you very much guys for your interest and suggestions.it certainly means a lot to me that professionals such as yourselves take an interest and point out where a solution might be found.I am still very frightened since my pain symptoms fit the category of neuropathic orafacial pain.Prior ro the insertion of the abutment on May 10, i was - for my age- healthy .I can post more facts later but at this point - deciding how to best preserve my health - it seems to me that the abutment and crown created such tremedous pressure in my jaw that a compartment syndrome ensued. The good dentist I have finally found in Berlin looked at the crown and abutment and said it was the worst construction he had ever seen and that any patient who had that in their jaw would get sick. Removing the crown helped decrease the pressure and the pain, and removal of the titanium abutment really saved me from excruciating pain. My current dentist says that the dental job done since the implant must have led up to pressure on capillaries and tissue. He cannot say how nerves were affected. But ever since May 10, there has been a recurring pattern of numbing and tingling and a dull ache which i have no power over.The neurologist I saw ten days ago told me i have a chronic pain syndrome, he prescribed Gabapentin, and told me to shut up and cope with it. I have decided to have the implant removed and afterwards to move heaven and hell to get to a clinic where Viertnamese acupuncture is performed.I only hope i can help my poor nerves. Thanks to all of you guys!!! Cathy from Germany
John Dentist
9/14/2013
The dentist who told you that it was the worst construction job he's ever seen was completely unprofessional. Even if the construction of the abutment and crown were horrific, it would not cause the type of pain that you are experiencing. Implants are titanium and bone doesn't have nerve tissue running through it. If the implant had failed to integrate (fuse to the bone), it would also not be extremely painful. Implants that do not integrate tend to get loose and become annoying to bite on - they don't become incredibly painful. Find a dentist who truly has experience in placing and restoring implants and one who isn't so quick to criticize a colleague's work, especially when it is not the root of the pain.
John Dentist
9/14/2013
Furthermore, despite the coincidence of the pain occurring soon after the abutment was placed, all of the teeth on the upper right side of your mouth have had multiple fillings and dental treatment. Any one of those teeth could have an irreversible pulpits or incipient abscess which could lead to referred pain in that area. Since all of those teeth have nerve tissue, it would be more reasonable to make sure that those teeth are completely sound before having periodontal therapy and needless procedures that are expensive and potentially painful.
Loyd Dowd, DDS
9/17/2013
All of the above recommendations have merit. I agree that the dentist who told you that you have the worst implant he's ever seen is not only unprofessional but is also pandering to your anxiety. Your pain sounds like neuropathic pain from an unknown origin unless a CT scan can demonstrate dental pathology either with the implant or an adjacent tooth. It's very rare but I've seen perfectly normal appearing teeth without any history of trauma, fillings, or crown abscess. I'd recommend heat, cold, and electric pulp testing of the adjacent teeth. I've seen virgin teeth abscess twice in 36 years of practice so it's exceedingly rare but does occur. I'd recommend that you find the most experienced implantologist you can find, one that has a cone beam CT machine in his or her office, and get a scan of the implant area to properly evaluate it. I use the Osstell ISQ meter in my office to see if an implant is properly integrated. The ISQ meter gives a numeric reading of integration. Once you properly rule out abscess from any of the adjacent teeth and establish that the implant is properly integrated that leaves neuropathic pain. I've seen this a number of times and have experienced it myself. It's very real and can drive you to distraction for sure. Gabapentin is the first line of treatment for neuropathic pain with other meds being brought into the mix as necessary. Additional meds such as Tegretol or Trileptal are sometimes added as needed. Personally I'd prefer Trileptal as it doesn't have as many nasty potential side effects as Tegretol and doesn't require periodic blood level tests.
Baker Vinci
9/22/2013
John, I have to agree with your suggestion. I'm afraid too many people are attempting to treat, whilst overlooking a simple dental diagnostic work up. If this gets into the hands of a non-dental specialist, she could find herself in a mess. Bv
Baker Vinci
9/20/2013
Any suggestion other than to remove the entire supra structure, is absurd. This patient had no pain prior to the second stage procedure. Had the patient taken the advice of the fist ten doctors( she did take some of the advice ), she would still be hurting. It's time to return to the obvious. In this scenario, if the patient went to someone with a hammer, she was getting a hammer and when she went to the doctor with drugs, she would have gotten drugs. I am frankly flabbergasted by what I have read here. Baker K. Vinci
Cathy
9/21/2013
Thank you everybody for your interest.Update: my current dentist is willing to remove the implant if it will help. But he says he cannot promise that the extraction will clear up the problem with pain.So I have arrnged to see a neurologist at a respected neurological center in berlin - and asked them to please do as good a diagnostic check as they can to pin-point where nerve damage occurred.Getting this appointment was pure luck- all the most up-to-date neurological clinics and hospital faculties I contacted in Berlin were booked through December and i had to explain that this was an emergency. Staff everywhere had never heard of this kind of post-implant complication.But someone cancelled and Monday I will be seeing people with a good reputation for diagnosing nerve injuries.Hopefully based on this new data the dentist will be able to act.Also on Tuesday I went to see an acupuncturist who has some experience treating patients with dental pain.he said all we can do is try. Nerve damage he thinks occurred in May June `13 The immediate effect of the acupuncture was to reawaken the sensation of soreness and pain where the trapped mucous membranes had been surgically removed.I could not find any information on these effects but feel i should stay with the acupucture and persist, while waiting for the new neurologist#s data. Thank you God bless. Cathy
Baker Vinci
9/21/2013
Cathy, do you have a crown on the implant? Until you have been" taken back" to the dental scenario that was painless, there is absolutely no way to begin the diagnostic process. Your dentist can remove the abutment and crown and make a suitable temporary. I would hold off, on the consideration of removing the implant. If I understood correctly, you had no pain, until after the second stage. This could have been a single stage procedure and if so, removing the implant is a reasonable consideration. . I know that getting this appointment seemed like a stroke of luck, but lets not let reason be overlooked. Bv
Baker Vinci
9/21/2013
Cathy, in an attempt to ease your mind a bit, the nerve involved ( the second branch of the fifth cranial nerve ) is sacrificed in a lot of scenarios, so I feel pretty confident that this can be managed by simply removing the crown, until your discomfort resolves. Yes, a bit of mucosa can heal over the implant. This a simple issue to handle. The biggest concern I have is, when you see a specialist that has little or no knowledge about what you have had done, the care can be less than ideal. B. Vinci
