10.14219/jada.archive.2013.

0071
2013;144(12):1358-1361 JADA
Joo N. Ferreira and Rui Figueiredo
placement
idiopathic facial pain after dental implant
Prevention and management of persistent
2014):
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a common complication? What other sources of
pain should clinicians rule out first? Can this
type of problem be prevented? What can clini-
cians do to manage the care of patients
appropriately?
EXPLANATION
Persistent pain after dental implant placement
may occur immediately after surgery with no
apparent organic cause and without any neu-
rosensory deficits.
1
The incidence of trigeminal
neuropathic symptoms after dental procedures
in the maxilla, including implant surgery, is
extremely low (approximately 0.9 percent) and
rarely is reported in the literature.
1-3
These
outcomes sometimes are due to direct trauma
to a trigeminal nerve trunk or major branch,
but this review focuses mainly on the idio-
pathic onset of such problems. The etiology and
pathophysiology of persistent idiopathic facial
pain (PIFP)also known as atypical facial
painare poorly understood, and the differen-
tial diagnosis is challenging and often requires
the involvement of several clinicians, includ-
ing dentists, neurologists and ENT specialists.
Indeed, clinicians must rule out several pain
conditions before reaching a final diagnosis of
PIFP (Box
4-8
). In fact, many of these conditions
can be excluded because they are associated
with specific pathognomonic clinical features.
4
A
dentist also can administer local or regional di-
agnostic anesthetic blocks to rule out more com-
mon conditions such as odontogenic pain, pain
associated with temporomandibular disorders
and traumatic neuropathic pain. However, with
this anesthetic block approach, the pain must be
CLINICAL PROBLEM
A
69-year-old woman visited us with a
three-week history of facial pain in the
right infraorbital region after dental
implant placement. Her medical his-
tory was significant for general anxiety disorder
(GAD) and chronic pain (CP) in the lower back.
The patients neurologist had been treating her
with lorazepam for GAD and tramadol for CP.
The referring dentist had placed two dental
implants in the maxilla under local anesthesia
to replace teeth nos. 3 and 5. The patient did
not report any intraoperative complications. Im-
mediately after surgery, the patient complained
of a daily, spontaneous, deep dull pain located
in the right upper lip, with an intensity of 8
on a scale from 0 to 10. The facial pain had no
identifiable triggers and the patient had no neu-
rosensory deficits. The referring dentist initially
prescribed sodium diclofenac and an antibiotic
for facial pain and to prevent postoperative in-
fection. At the three-week postsurgical follow-up
visit, neither the frequency nor the intensity
of the pain had improved. Also, no peripheral
signs or symptoms such as redness, swelling or
purulent drainage were observed, and no gross
pathology was present on periapical films. After
consulting with a neurologist, we performed
magnetic resonance imaging of the brain, with
and without contrast, the results of which were
normal. No maxillary sinus pathology was found
on a computed tomographic scan performed dur-
ing a consultation with an ear, nose and throat
(ENT) specialist.
Is there an association between this pain and
the implant placement procedure? If so, is this
Prevention and management of persistent
idiopathic facial pain after dental implant
placement
Joo N. Ferreira, DDS, MS, PhD; Rui Figueiredo, DDS, MS
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C L I N I C A L P R A C T I C E P A I N U P D A T E
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ened anxiety with the resistance to anesthetic
efficacy during the decision-making process for
implant placement, and they can use screen-
ing questionnaires or scales to assess anxiety
levels. Clinicians can estimate patients anxiety
levels by using a 10-centimeter visual analog
scale or measure anxiety by using valid and
reliable psychometric tools (for example, Corah
Dental Anxiety Scale).
17-19
Managing the care of
patients who are moderately to severely anxious
may include use of conscious sedation or cogni-
tive behavioral therapy (CBT) or prescription of
short-acting benzodiazepines before the dental
procedure.
16,20-22

In the case presented here, the presence of
preoperative comorbidities (for example, anxi-
ety, CP) may have predisposed the patient to
developing postoperative pain, particularly
because these comorbidities were not well
controlled.
13-15

MANAGEMENT
In patients diagnosed with PIFP, screening
questionnaires and specific neurosensory test-
ing are important to identify possible sensory
reduced dramatically or eliminated completely
to rule out these pathologies.
The International Headache Society (IHS)
provides four diagnostic criteria for PIFP (IHS/
International Classification of Headache Disor-
ders, 2nd edition [ICHD-II], code 13.18.4
9
). The
corresponding International Classification of
Diseases, 10th Revision, code is G50.1.
10
dDaily pain must be present for most of the
day.
dThe pain must be deep, dull and unilateral
and not well localized.
dThe pain is not associated with focal neuro-
logical signs or sensory deficits.
dNo abnormality should be found with labo-
ratory and radiographic investigations, which
must include imaging studies of the face, jaw,
cervical spine and chest.
4,11
The clinical case scenario described here
should be diagnosed as PIFP, because the char-
acteristics of the pain fulfill the IHS criteria,
and because the clinical features and laboratory
parameters seem to rule out other conditions
(Box
4-8
). In this case, no direct evidence of tri-
geminal nerve damage is available, and, there-
fore, the diagnosis relies on symptoms and signs
alone. We must acknowledge that idiopathic
pain is a temporary concept until clarification
of pathophysiological mechanisms (for example,
deafferentation) is obtained.
11

PREVENTION
In cases such as the one described here, post-
operative PIFP symptoms may be preventable
to some extent if the potential risk factors are
identified.
12
An appropriate medical history, di-
agnosis and treatment are paramount to reduc-
ing the risk of developing PIFP after implant
surgery. It is highly unlikely that the drilling
or implant placement caused direct infraorbital
nerve damage. However, factors such as incision
size (particularly with flap elevation), type of
surgery, anxiety, age, sex and especially the ex-
istence of preoperative chronic pain conditions
have emerged as independent predictors of pain
immediately after surgical procedures.
13-15
Highly anxious patients appear to be more
resistant to local anesthesia and may be at
higher risk of experiencing trigeminally medi-
ated pain after invasive dental procedures such
as implant placement.
16
Also, lower patient
satisfaction has been associated with higher
preoperative anxiety (independent of the pa-
tients postoperative satisfaction with the sur-
geon), particularly in women and in younger
patients.
16,17
Consequently, clinicians should
discuss with patients the association of height-
BOX
Differential diagnosis
before reaching a nal
diagnosis of PIFP.*

DIFFERENTIAL DIAGNOSIS LIST
dPeripheral traumatic neuropathic pain

dPostherpetic neuralgias
dTypical trigeminal neuralgia or other cranial
neuralgias
dAtypical odontalgia (also known as persistent
dentoalveolar pain

)
dOdontogenic pain (such as pulpitis, periapical
periodontitis, cracked tooth syndrome)
dSinus-related pathologies (acute or chronic sinusitis)
dTemporomandibular disorders (arthralgia/
osteoarthritis, masticatory myofascial pain)
dPrimary headache conditions (tension-type
headache, migraine, cluster headache)
dTolosa-Hunt syndrome
dCarotidynia
dFacial pain secondary to intracranial or extracranial
infections or tumors (for example, lung cancer)
dFacial pain secondary to cervical spine disease (C2-C8
cervical nerve root compression, facet injury or both)
* PIFP: Persistent idiopathic facial pain.
Sources: Agostoni and colleagues,
4
Evans and Agostoni,
5
Eliav
and Max.
6
Source: Benoliel and colleagues.
7
Source: Nixdorf and colleagues.
8

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ment.
4,5,22,28,29
Randomized controlled trials
(RCTs) addressing PIPF management have not
been performed systematically, to our knowl-
edge, which complicates an evidence-based
treatment decision.
28
However, pharmacological
therapy, including topical medications, non-
tricyclic and tricyclic antidepressants (TCAs),
anticonvulsants and benzodiazepines, is recom-
mended widely as the first line of treatment
for PIFP (Table).
4-6,22,26-28
Yet, in the majority of
cases of PIFP, complete pain remission is not
achieved.
4,28

CONCLUSIONS
In our clinical scenario, a multidisciplinary
pain team can propose treatment with topical
compound medications (for example, lidocaine
1 percent, carbamazepine 4 percent and gaba-
pentin 4 percent) to achieve better local pain
control without increasing adverse effects or
drug interactions in this elderly patient. If not
contraindicated, systemic nontricyclics and
TCAs would be the second treatment option,
followed by anticonvulsants and minor opioids,
though none of these drugs has been tested in
well-designed RCTs to study their efficacy in pa-
tients with PIFP.
4,28
Patients who are refractory
to conventional pharmacological treatment may
benefit from hypnosis. In a patient-masked con-
trolled RCT, hypnosis offered clinically relevant
pain relief for PIFP compared with a relaxation
intervention, particularly in patients with high
susceptibility to hypnosis.
29
Stress coping skills
and CBT for unresolved psychological problems
(such as pain catastrophizing, anxiety, depres-
sion, obsessive compulsive disorder) must be
included in a comprehensive pain management
approach to control psychological factors and
improve patients quality of life.
22,28,29
n
Dr. Ferreira is a clinical research fellow and a TMD and orofacial
pain clinician, National Institute of Dental and Craniofacial Research,
National Institutes of Health Clinical Center, 30 Convent Drive,
Building 30, Room 429, Bethesda, Md. 20892, e-mail andraderequicj@
mail.nih.gov. Address reprint requests to Dr. Ferreira.
Dr. Figueiredo is an associate professor, Oral Surgery, School of
Dentistry, University of Barcelona, and a researcher at Institut
dInvestigaci Biomdica de Bellvitge, Barcelona, Spain.
Disclosure. Drs. Ferreira and Figueiredo did not report any
disclosures.
This study was supported in part by the Intramural Research Pro-
gram of the National Institute of Dental and Craniofacial Research,
National Institutes of Health, Bethesda, Md.
The authors thank Drs. Katiucha Sales and Dean Aria for helpful
discussions and critical reading of the manuscript of this article.
Pain Update is published in collaboration with the Neuroscience
Group of the International Association for Dental Research.
1. Gregg JM. Neuropathic complications of mandibular implant
surgery: review and case presentations. Ann R Australas Coll Dent
disturbances (paresthesia, dysesthesia, allodyn-
ia) in the trigeminal area.
12,23,24
If acute neuro-
pathic pain symptoms are present immediately
after implant surgery and nerve injury is sus-
pected, patients may undergo removal of their
implants within 24 hours to resolve their pain
or may undergo an immediate repair if nerve
section is detected.
22,25
Clinicians should treat
acute postoperative nerve injuries immediately
with topical or systemic anti-inflammatories,
peripheral nerve blocks with local anesthetics
and glucocorticoids, as well as with neuropathic
pain medications to reduce potential neuro-
genic inflammation and regain typical neuronal
transmission.
1,26-28
When intractable PIFP is diagnosed after
implant surgery, patients potential to recover
their normal trigeminal sensations is reduced.
22

Therefore, consultations with patients should
include a full explanation of pain symptoms to
alleviate many concerns and, we hope, persuade
patients to avoid unnecessary invasive dental or
medical treatments. Clinicians should consider
referring patients to an orofacial pain clinician
or a neurologist for further pain assessment,
stimulus-response testing and CP manage-
TABLE
Common medications used
to treat persistent idiopathic
facial pain.
DRUG CLASS EXAMPLE
OF ACTIVE
SUBSTANCE
MECHANISM OF
ACTION
Tricyclic and
Nontricylic
Antidepressants
Amitriptyline
Nortriptyline
Duloxetine
Inhibit reuptake
of serotonin and
norepinephrine
-Blockers Propranolol Block 1- and 2-
adrenergic receptors
Anticonvulsants Gabapentin
Pregabalin
Inhibit voltage-gated
Ca
2+
*
inux
Benzodiazepines Clonazepam Modulate GABA
A

receptors
GABAergics Baclofen GABA
B
receptor
agonist
Minor Opioid
Analgesics
Tramadol Weak micro-
opioid receptor
agonist, induces
serotonin release,
inhibits reuptake of
norepinephrine
Topical Pain
Medications
Lidocaine
Ketamine
Capsaicin
Local anesthetic
NMDA

receptor
antagonist
Agonist of TRPV1

ion channels
* Ca
2+
: Calcium.
GABA: -aminobutyric acid.
NMDA: N-methyl-D-aspartate.
TRPV1: Transient receptor potential cation channel, subfamily
V, member 1.
on May 25, 2014 jada.ada.org Downloaded from
JADA 144(12) http://jada.ada.org December 2013 1361
C L I N I C A L P R A C T I C E P A I N U P D A T E
Copyright 2013 American Dental Association. All Rights Reserved.
17. Pekkan G, Kilicoglu A, Hatipoglu H. Relationship between
dental anxiety, general anxiety level and depression in patients
attending a university hospital dental clinic in Turkey. Community
Dent Health 2011;28(2):149-153.
18. Edwards DJ, Brickley MR, Horton J, Edwards MJ, Shepherd
JP. Choice of anaesthetic and healthcare facility for third molar
surgery. Br J Oral Maxillofac Surg 1998;36(5):333-340.
19. Corah NL. Development of a dental anxiety scale. J Dent Res
1969;48(4):596.
20. Little JW, Falace DA, Miller CS, Rhodus NL. Little and Fal-
aces Dental Management of the Medically Compromised Patient.
8th ed. St. Louis: Elsevier Mosby; 2013:417-438.
21. Newton T, Asimakopoulou K, Daly B, Scambler S, Scott S. The
management of dental anxiety: time for a sense of proportion? Br
Dent J 2012;213(6):271-274.
22. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-
implant neuropathy of the trigeminal nerve: a case series (published
online June 8, 2012). Br Dent J 2012;212(11):E17. doi:10.1038/sj.bdj.
2012.497.
23. Wismeijer D, van Waas MA, Vermeeren JI, Kalk W. Patients
perception of sensory disturbances of the mental nerve before and
after implant surgery: a prospective study of 110 patients. Br J Oral
Maxillofac Surg 1997;35(4):254-259.
24. Baad-Hansen L, Abrahamsen R, Zachariae R, List T, Svensson
P. Somatosensory sensitivity in patients with persistent idiopathic
orofacial pain is associated with pain relief from hypnosis and re-
laxation (published online ahead of print Jan. 16, 2013). Clin J Pain
2013;29(6):518-526. doi:10.1097/AJP.06013e318268e4e7.
25. Worthington P. Injury to the inferior alveolar nerve during
implant placement: a formula for protection of the patient and clini-
cian. Int J Oral Maxillofac Implants 2004;19(5):731-734.
26. Hegedus F, Diecidue RJ. Trigeminal nerve injuries after man-
dibular implant placement: practical knowledge for clinicians. Int J
Oral Maxillofac Implants 2006;21(1):111-116.
27. Eker HE, Cok OY, Aribogan A, Arslan G. Management of neuro-
pathic pain with methylprednisolone at the site of nerve injury. Pain
Med 2012;13(3):443-451.
28. List T, Axelsson S, Leijon G. Pharmacologic interventions in the
treatment of temporomandibular disorders, atypical facial pain, and
burning mouth syndrome: a qualitative systematic review. J Orofac
Pain 2003;17(4):301-310.
29. Abrahamsen R, Baad-Hansen L, Svensson P. Hypnosis in the
management of persistent idiopathic orofacial pain: clinical and
psychosocial findings. Pain 2008;136(1-2):44-52.
Surg 2000;15:176-180.
2. Hillerup S. Iatrogenic injury to oral branches of the trigeminal
nerve: records of 449 cases. Clin Oral Investig 2007;11(2):133-142.
3. Rodriguez-Lozano FJ, Sanchez-Perz A, Moya-Villaescusa
MJ, Rodrguez-Lozano A, Sez-Yuguero MR. Neuropathic orofacial
pain after dental implant placement: review of the literature and
case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2010;109(4):e8-e12. doi:10.1016/j.tripleo.2009.12.004.
4. Agostoni E, Frigerio R, Santoro P. Atypical facial pain: clinical
considerations and differential diagnosis. Neurol Sci 2005;26 (suppl
2):s71-s74.
5. Evans RW, Agostoni E. Persistent idiopathic facial pain. Head-
ache 2006;46(8):1298-1300.
6. Eliav E, Max MB. Management of neuropathic pain. In: Sessle
BJ, Lavigne GJ, Lund JP, Dubner R, eds. Orofacial Pain: From Basic
Science to Clinical Management. 2nd ed. Hanover Park, Ill.: Quintes-
sence Publishing; 2008:195-202.
7. Benoliel R, Zadik Y, Eliav E, Sharav Y. Peripheral painful
traumatic trigeminal neuropathy: clinical features in 91 cases and
proposal of novel diagnostic criteria. J Orofac Pain 2012;26(1):49-58.
8. Nixdorf DR, Drangsholt MT, Ettlin DA, et al. Classifying oro-
facial pains: a new proposal of taxonomy based on ontology. J Oral
Rehabil 2012;39(3):161-169.
9. IHS Classification ICHD-II. http://ihs-classification.org/en/.
Accessed Oct. 28, 2013.
10. ICD-10 Version: 2010. http://apps.who.int/classifications/icd10/
browse/2010/en. Accessed Oct. 28, 2013.
11. Woda A, Tubert-Jeannin S, Bouhassira D, et al. Towards a new
taxonomy of idiopathic orofacial pain. Pain 2005;116(3):396-406.
12. Hillerup S. Iatrogenic injury to the inferior alveolar nerve: eti-
ology, signs and symptoms, and observations on recovery. Int J Oral
Maxillofac Surg 2008;37(8):704-709.
13. Kalkman CJ, Visser K, Moen J, Bonsel GJ, Grobbee DE, Moons
KG. Preoperative prediction of severe postoperative pain. Pain 2003;
105(3):415-423.
14. Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of
postoperative pain and analgesic consumption: a qualitative system-
atic review. Anesthesiology 2009;111(3):657-677.
15. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain:
risk factors and prevention. Lancet 2006;367(9522):1618-1625.
16. Gonzlez-Lemonnier S, Bovaira-Forner M, Pearrocha-Diago
M, Pearrocha-Oltra D. Relationship between preoperative anxiety
and postoperative satisfaction in dental implant surgery with
intravenous conscious sedation. Med Oral Patol Oral Cir Bucal
2010;15(2):e379-e382.
on May 25, 2014 jada.ada.org Downloaded from