Persistent pain after dental implant placement
The present case has been reported in the Journal of the American Dental Association.

A 48-year-old woman visited for a second opinion regarding severe pain that began six weeks earlier after placement of an implant into her mandibular right first premolar region. She recalled that profuse bleeding had to be controlled when the implant site was prepared, and she experienced sharp pain as the implant was being inserted.

As the local anesthetic wore off, she developed severe deep aching and burning pain at the implant site. She then experienced sharp stabbing pains whenever she touched or brushed the area around the implant. Also, her right lower lip felt unpleasant, which caused difficulty in drinking. The patient reported that she had been pain free before the implant procedure.

A radiograph revealed that the implant was not impinging on the inferior alveolar canal (IAC). Initial treatments included a course of antibiotics, a combination of analgesics and anti-inflammatory drugs. A moderate degree of pain relief was achieved, and the dentist advised her to wait and see if the pain resolved before possibly referring her to a neurologist or pain specialist.

The incidence of nerve injury after dental surgical procedures, including third-molar extractions and placement of implants, is higher than that commonly believed (possibly up to 40%). The term “peripheral painful traumatic trigeminal neuropathy” (PPTTN) has been proposed for neuropathic pain (NP) that occurs within three months of such procedures.

Intraoperative factors associated with an increased risk of experiencing implant-related NP include the following:-
• intense sudden pain during the injection or implant preparation and placement

• brisk persistent bleeding during preparation of the implant site

• possible nerve injury when local anesthetic injection is administered or during flap retraction

• sudden “give” of the drill during preparation of the implant site may indicate breaching of the roof of the IAC

• heat generation during preparation of the implant site

• potential torquing forces within mandibular cancellous bone created as the implant is inserted into the prepared site

• less than 2-mm proximity to the roof of the IAC

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