Nonsurgical Management
of Trigeminal Nerve Injuries
12
Tara Renton
12.1 Introduction
The most significant complications from dental and oral surgical interventions are iatrogenic trigeminal nerve injuries that can result in perma- nent altered sensation and pain causing significant functional and psychological disability [1]. These injuries are best prevented, and management is complex and currently often inadequate [1]. Dependent upon the mechanism and duration of trigeminal nerve injury, results on relatively few patients undergoing reparative surgery, this chap- ter aims to provide an outline of the nonsurgical management of these injuries. The trigeminal nerve is the largest peripheral sensory nerve in the body with representation occupying over half of the sensory cortex. Altered feedback from a sensory nerve can cause permanent changes in the sensory cortex after 3 months [2] and, in addi- tion, results in significant functional and affective problems. Since the face and mouth are rather “important” parts of a human being, challenges and changes to the orofacial area are likely to have a high psychological impact and altered self-perception [3].
Altered sensation and pain in the orofacial region may interfere with speaking, eating,
T. Renton, BDS, MDSc, PhD, FRACDS (OMS), FDS, RCS, FHEA, ILTM
Department of Oral Surgery, Kings College London, Kings College Hospital London,
Bessemer Rd, Denmark Hill, London SE5 9RS, UK e-mail: tara.renton@kcl.ac.uk
12.1 Introduction
The most significant complications from dental and oral surgical interventions are iatrogenic trigeminal nerve injuries that can result in perma- nent altered sensation and pain causing significant functional and psychological disability [1]. These injuries are best prevented, and management is complex and currently often inadequate [1]. Dependent upon the mechanism and duration of trigeminal nerve injury, results on relatively few patients undergoing reparative surgery, this chap- ter aims to provide an outline of the nonsurgical management of these injuries. The trigeminal nerve is the largest peripheral sensory nerve in the body with representation occupying over half of the sensory cortex. Altered feedback from a sensory nerve can cause permanent changes in the sensory cortex after 3 months [2] and, in addi- tion, results in significant functional and affective problems. Since the face and mouth are rather “important” parts of a human being, challenges and changes to the orofacial area are likely to have a high psychological impact and altered self-perception [3].
Altered sensation and pain in the orofacial region may interfere with speaking, eating,
T. Renton, BDS, MDSc, PhD, FRACDS (OMS), FDS, RCS, FHEA, ILTM
Department of Oral Surgery, Kings College London, Kings College Hospital London,
Bessemer Rd, Denmark Hill, London SE5 9RS, UK e-mail: tara.renton@kcl.ac.uk
kissing, shaving, applying makeup, toothbrush-
ing, and drinking, in fact just about every social
interaction we take for granted on a daily basis
[4]. Usually after oral rehabilitation, the patient
expects and experiences significant improve-
ments, not only regarding jaw function, but also
in relation to dental, facial, and even overall body
image. Thus, these injuries have a significant
negative effect on the patient’s self-image and
quality of life and may lead to significant psycho-
logical effects [5].
Iatrogenesis is damage to the patient caused by surgical or medical intervention. Surprisingly very little research attends to this unfortunate side of surgery and medicine.
It is well known that chronic pain causes stress and anxiety in over 50 % of affected patients [6] and postsurgical sensory neuropathy is often associated with chronic neuropathic pain [7]. As 50–70 % of patients presenting at a specialist clinic present with neuropathic pain [3] that does not respond to surgery [8, 9], there is a huge demand for nonsurgical management for these patients.
Current management of these nerve injuries is inadequate. The World Health Organization’s model of health suggests that nerve injury out- comes should be assessed in terms of impairment, activity limitations, and participation restrictions [6]. The focus for trigeminal nerve injury man- agement misguidedly remains on surgical cor- rection or laser therapy of the nerve itself with little or no attention to the patient’s complaints. A more holistic approach, such as medical or
Iatrogenesis is damage to the patient caused by surgical or medical intervention. Surprisingly very little research attends to this unfortunate side of surgery and medicine.
It is well known that chronic pain causes stress and anxiety in over 50 % of affected patients [6] and postsurgical sensory neuropathy is often associated with chronic neuropathic pain [7]. As 50–70 % of patients presenting at a specialist clinic present with neuropathic pain [3] that does not respond to surgery [8, 9], there is a huge demand for nonsurgical management for these patients.
Current management of these nerve injuries is inadequate. The World Health Organization’s model of health suggests that nerve injury out- comes should be assessed in terms of impairment, activity limitations, and participation restrictions [6]. The focus for trigeminal nerve injury man- agement misguidedly remains on surgical cor- rection or laser therapy of the nerve itself with little or no attention to the patient’s complaints. A more holistic approach, such as medical or
M. Miloro (ed.), Trigeminal Nerve Injuries,
DOI 10.1007/978-3-642-35539-4_12, © Springer-Verlag Berlin Heidelberg 2013
DOI 10.1007/978-3-642-35539-4_12, © Springer-Verlag Berlin Heidelberg 2013
213
214
T. Renton
counseling intervention with consideration for
the patients’ psychological, functional, or pain-
related complaints, is required. The fault partly
rests with how we assess these patients clini-
cally. Neurosensory assessment tends to show
little regard for the functional or pain evaluation,
with the main focus remaining on basic mecha-
nosensory evaluation, which is not necessarily
reflective of the patients’ subjective difficulties.
Oral and maxillofacial surgery specialists assess-
ing these injuries should therefore follow guide-
lines from the World Health Organization, which
suggests that nerve injury assessment should
focus on level of impairment, activity limitations,
and participation restrictions [9]. Guidelines for
management of chronic neuropathic pain are set
out by NICE, the International Association for
the Study of Pain, and the American Academy of
Neurology [10–12].
Specific recommendations have been made with regard to the assessment of trigeminal neu- ropathy using qualitative sensory testing (QST), pain profiling, and quality of life (QoL) question- naires containing psychometric scales reflecting the important criteria by which we should assess the effectiveness of our therapeutic interventions [13]. These recommendations, without excep- tion, are holistic when compared with current reports evaluating the management of trigeminal nerve injuries.
To date, as dental clinicians, we have mistak- enly applied a sit and wait observation policy to these iatrogenic trigeminal nerve injuries based upon research regarding lingual access for third molar surgery (mostly now only of historic inter- est) causing predominantly temporary lingual nerve injuries, with approximately 90 % resolv- ing by 8 weeks post-surgery [14, 15]. This expect- ant approach is not applicable to other trigeminal nerve injuries or indeed to other causes. More recently, researchers have taken a more holistic approach to assessing patients with these nerve injuries and they have identified significant neu- ropathic pain incidence, functional problems with related psychological problems that require man- agement of the type not usually corrected or addressed by surgical intervention [3].
Specific recommendations have been made with regard to the assessment of trigeminal neu- ropathy using qualitative sensory testing (QST), pain profiling, and quality of life (QoL) question- naires containing psychometric scales reflecting the important criteria by which we should assess the effectiveness of our therapeutic interventions [13]. These recommendations, without excep- tion, are holistic when compared with current reports evaluating the management of trigeminal nerve injuries.
To date, as dental clinicians, we have mistak- enly applied a sit and wait observation policy to these iatrogenic trigeminal nerve injuries based upon research regarding lingual access for third molar surgery (mostly now only of historic inter- est) causing predominantly temporary lingual nerve injuries, with approximately 90 % resolv- ing by 8 weeks post-surgery [14, 15]. This expect- ant approach is not applicable to other trigeminal nerve injuries or indeed to other causes. More recently, researchers have taken a more holistic approach to assessing patients with these nerve injuries and they have identified significant neu- ropathic pain incidence, functional problems with related psychological problems that require man- agement of the type not usually corrected or addressed by surgical intervention [3].
A priority in managing these patients is reas-
surance and an honest opinion as to whether the
nerve injury is likely to be temporary or perma-
nent. This approach will first provide the patient
a realistic platform on which to decide on future
treatment and secondly whether pain control and
rehabilitation need to be instituted as early as
possible. Reparative surgery may be indicated
when the patient complains of persistent prob-
lems related to the nerve injury, is important for
optimal physiologic and functional recovery, and
is generally undertaken within 3 months post-
injury [17]; however, there remains a significant
deficiency in evidence-based research to support
this practice pattern.
The presenting complaints of patients may include functional problems due to the reduced sensation, or intolerable sensations or pain, with the latter being predominantly intransigent to surgery. Frequently, poorly expressed psycho- logical problems relating the iatrogenesis of the injury to the chronic pain are overlooked [18]. Generally for lesions of the peripheral sensory nerves in man, the gold standard is to repair the nerve as soon as possible after injury [2]. However, the relatively few series of reports on trigeminal nerve repair on human subjects relate mainly to repairs undertaken at significantly more than 6 months after injury, which is unsatisfac- tory. This phenomenon is peculiar only to den- tistry and may be based upon the misconception that the majority of trigeminal nerve injuries resolve, when, in fact, it is only lingual nerve injuries related to lingual access for third molar surgery that usually resolve at 10 weeks in 88 % of cases [14, 15].
It is evident from a review of the literature that there needs to be a cultural and philosophical change in the choice of intervention, timing, and outcome criteria that should be evaluated for ther- apeutic modalities for trigeminal nerve injuries. To date, there have been a very limited number of prospective randomized studies to evaluate the effect of treatment delay, as well as the surgical, medical, or counseling outcomes for trigeminal nerve injuries in humans; this is probably due to the ethical difficulties in initiating such a study.
The presenting complaints of patients may include functional problems due to the reduced sensation, or intolerable sensations or pain, with the latter being predominantly intransigent to surgery. Frequently, poorly expressed psycho- logical problems relating the iatrogenesis of the injury to the chronic pain are overlooked [18]. Generally for lesions of the peripheral sensory nerves in man, the gold standard is to repair the nerve as soon as possible after injury [2]. However, the relatively few series of reports on trigeminal nerve repair on human subjects relate mainly to repairs undertaken at significantly more than 6 months after injury, which is unsatisfac- tory. This phenomenon is peculiar only to den- tistry and may be based upon the misconception that the majority of trigeminal nerve injuries resolve, when, in fact, it is only lingual nerve injuries related to lingual access for third molar surgery that usually resolve at 10 weeks in 88 % of cases [14, 15].
It is evident from a review of the literature that there needs to be a cultural and philosophical change in the choice of intervention, timing, and outcome criteria that should be evaluated for ther- apeutic modalities for trigeminal nerve injuries. To date, there have been a very limited number of prospective randomized studies to evaluate the effect of treatment delay, as well as the surgical, medical, or counseling outcomes for trigeminal nerve injuries in humans; this is probably due to the ethical difficulties in initiating such a study.
12 Nonsurgical Management of Trigeminal Nerve Injuries 215
12.2 Trigeminal Nerve Injury
Management Protocols
Management of nerve injuries should be consid- ered in terms of immediate early interventions and later delayed interventions.
12.2.1 Early/ImmediateInterventions
Early/immediate interventions would be repair of a known nerve transections or severely damaged nerves. Endodontic- and implant-related nerve injuries may also warrant early intervention [19]. A strategy for management of trigeminal nerve injuries based upon the mechanism (Fig. 12.1) and duration of the injury (Table 12.1).
Management of nerve injuries should be consid- ered in terms of immediate early interventions and later delayed interventions.
12.2.1 Early/ImmediateInterventions
Early/immediate interventions would be repair of a known nerve transections or severely damaged nerves. Endodontic- and implant-related nerve injuries may also warrant early intervention [19]. A strategy for management of trigeminal nerve injuries based upon the mechanism (Fig. 12.1) and duration of the injury (Table 12.1).
High-dose corticosteroids and/or nonsteroidal
anti-inflammatory medications administered in
the early days following nerve injury should
reduce local inflammation and, in theory, should
minimize further damage to the injured nerve, but
paradoxically these medications could interfere
with the neural healing process. To date, there is
little or no evidence that this pharmacologic
intervention will minimize the extent and dura-
tion of trigeminal nerve injury [20].
The clinician responsible for the nerve injury must be honest and caring with the patient and show concern with a home check, or a phone call to the patient within 6–24 h post-surgery, to ensure that the clinician knows if there is any extreme pain or neuropathy that may be associ- ated with the nerve injury and avail the patient of
The clinician responsible for the nerve injury must be honest and caring with the patient and show concern with a home check, or a phone call to the patient within 6–24 h post-surgery, to ensure that the clinician knows if there is any extreme pain or neuropathy that may be associ- ated with the nerve injury and avail the patient of
80
70
60
50
40
30
20
10
0
IANI
LNI
IANI = inferior alveolar nerve injuries
LNI = lingual nerve injuries
TMS = third molar surgery
LA = local anesthestic injuries
TMS = third molar surgery
LA = local anesthestic injuries
Fig. 12.1 Etiology of IANI and LNI [16]. The majority
of IANI and LNI are caused by third molar surgery, fol-
lowed by local anesthetics (LA). Only IANIs were also
caused by implants and endodontics. IANI inferior alveo-
lar nerve injuries, LNI lingual nerve injuries, TMS third
molar surgery, LA local anesthetic injuries
Endodontics
Apicectomy
Pathological
excision
Apical
infections
TMS
Implants
Other
LA
Percentage of patients
216 T. Renton
Table 12.1 Management strategies for iatrogenic trigeminal nerve injuries [16]
|
Mechanism
|
Duration
|
Treatment
|
|
Known or suspected nerve transection
|
Immediate nerve exploration
|
|
|
TMS IANI – retained roots
|
<30 h
|
Immediate nerve exploration
|
|
Implant
|
<30 h
|
Remove implant
|
|
Implant
|
>30 h
|
Treat patient therapeutically
|
|
Endodontic
|
<30 h
|
Remove tooth/overfill
|
|
Endodontic
|
>30 h
|
Treat patient therapeutically
|
|
TMS IANI – large neuropathic area, pain, and disability
|
<3 months
|
Consider nerve exploration
|
|
TMS LNI – large neuropathic area, pain, and disability
|
<3 months
|
Consider nerve exploration
|
|
TMS IANI
|
>6 month
|
Treat patient therapeutically
|
|
TMS LNI
|
>6 month
|
Treat patient therapeutically
|
|
Local anesthesia, jaw fracture, orthognathic, other surgery
|
Treat patient therapeutically
|
Adapted from Renton and Yilmaz [16]
TMS third molar surgery, IANI inferior alveolar nerve injury, LNI lingual nerve injury
TMS third molar surgery, IANI inferior alveolar nerve injury, LNI lingual nerve injury
the appropriate intervention options, if required.
Poor management by the clinician, extreme
defensive behavior, and/or ignoring the patient’s
complaints will only add to the frustration and
anger of the patient, compounding the injured
patients’ experience, so these injuries must be
managed empathetically.
12.2.2 LaterorDelayedManagement
Later or delayed management of nerve injuries will depend upon the mechanism and the dura- tion of the event (Table 12.1) [16]. The patient’s ability to cope with the neuropathy and pain, functional problems, and their overall psycho- logical status will drive the need for therapeutic intervention. Considering that the majority of these patients present with neuropathic pain, most are managed with reassurance and medica- tions; however, psychological techniques are being developed for these patients. Many inju- ries have limited benefit from surgical interven- tion and should be managed symptomatically using medication or counseling. In order to manage the patient appropriately, you must assess what is causing the patient’s problems. It is important to identify key symptoms including pain or altered sensory perception that may be impairing the patient’s functional abilities. Secondly, it is critical to inquire about func- tional problems (Fig. 12.2) in order to identify
12.2.2 LaterorDelayedManagement
Later or delayed management of nerve injuries will depend upon the mechanism and the dura- tion of the event (Table 12.1) [16]. The patient’s ability to cope with the neuropathy and pain, functional problems, and their overall psycho- logical status will drive the need for therapeutic intervention. Considering that the majority of these patients present with neuropathic pain, most are managed with reassurance and medica- tions; however, psychological techniques are being developed for these patients. Many inju- ries have limited benefit from surgical interven- tion and should be managed symptomatically using medication or counseling. In order to manage the patient appropriately, you must assess what is causing the patient’s problems. It is important to identify key symptoms including pain or altered sensory perception that may be impairing the patient’s functional abilities. Secondly, it is critical to inquire about func- tional problems (Fig. 12.2) in order to identify
Fig. 12.2 Incidence (%) of pain, anesthesia, and par-
esthesia among all patients [16]
what specifically is most responsible for the patient’s distress. Symptoms like numbness with pain with light touch (mechanical allodynia) or pain with cold stimuli (cold allodynia) often confuses and distresses the patient. An explana- tion of these symptoms by the clinician often alleviates the patient’s anxiety in most cases. Therapeutic interventions may include the following:
1. Consultation, reassurance, and understanding will assist many patients in dealing with these
what specifically is most responsible for the patient’s distress. Symptoms like numbness with pain with light touch (mechanical allodynia) or pain with cold stimuli (cold allodynia) often confuses and distresses the patient. An explana- tion of these symptoms by the clinician often alleviates the patient’s anxiety in most cases. Therapeutic interventions may include the following:
1. Consultation, reassurance, and understanding will assist many patients in dealing with these
Anaesthesia
6
17
17
10
Paraesthesia
6
32
18.5
18.5
Pain
5.5
12 Nonsurgical Management of Trigeminal Nerve Injuries 217
nerve injuries. Education about their condition
and reassurance that the damaged nerves will
not lead to more serious diseases probably is
the first and most powerful intervention for the
patient. Psychological intervention is recom-
mended for irreversible injuries and injuries
that cannot be surgically rectified (e.g.,
LA-related, endodontic chemical damage, and
gross surgery) in patients who are challenged
by coming to terms with the permanent non-
operative nerve injury.
2. Medical pharmacologic symptomatic therapy may be indicated for patients with pain or dis- comfort. Medications for chronic pain may include:
2. Medical pharmacologic symptomatic therapy may be indicated for patients with pain or dis- comfort. Medications for chronic pain may include:
-
Topical agents for pain
-
Systemic agents for pain
3. Surgical exploration (as discussed in other
chapters)
-
Immediate repair if nerve transection is
known or suspected
-
Removal of an implant or endodontic filling
material within 30 h
-
Exploration of IAN injuries through the
extraction socket (less than 4 weeks)
-
Exploration of LN injuries before 12
weeks
The surgical management for trigeminal nerve
injuries is discussed in the other chapters of this book, and this chapter addresses several nonsur- gical strategies that can be used to assist the prac- titioner in preventing and managing complications related to some common dental surgical proce- dures. In a recent study, surgery with no other form of treatment was a management option for only 22 % of all patients presenting with trigemi- nal nerve injuries [16 ] .
The planned treatment must address the patient’s concerns appropriately, and the aims of treatment would ideally include the reduction of pain and discomfort and ultimately provide improved neurosensory function. It is important to stress that treatment may not completely restore function, such as eating, drinking, speak- ing, and sleeping; in addition, any treatment will not restore normal sensation in the neuropathic area, including general sensory (i.e., mecha- nosensory function) or special sensory function
(i.e., taste). Escalation of a patient’s symptoms
from intermittent pain to persistent pain would be
a significant negative outcome, as would causing
a patient to have discomfort or pain when previ-
ously they only reported anesthesia. Therefore,
particularly with surgery, each patient must be
warned of the potential risk of escalating their
neuropathic symptoms, which in this study [16]
resulted in 40 % of patients declining offered
reparative nerve surgery.
12.3 Nonsurgical Management of Trigeminal Nerve Injuries
The strategy for selecting the mode and timing of intervention must be based upon the etiology of the injury, the patient’s current symptoms, the extent and permanency of the injury, and ultimately the patients’ choice of treatment fol- lowing informed consent and education by the clinician. The key management strategies include counseling and reassurance, medication, and surgery.
In order to successfully manage patients with nerve injuries, the clinician must consult with the patient in an in-depth fashion, provide realistic expectations by reaffirming the nerve injury is permanent if the patient has had their symptoms for more than 3 months, and provide reassurance that these injuries do not predispose them to other disease processes (e.g., cancer), and indeed will likely not worsen. Such reassurance can success- fully manage patients who can manage their pain but cannot cope with the consequences of their nerve injury and have associated functional chronic neuropathic pain and resultant psycho- logical difficulties that significantly impact upon their social life or professional life, or usual activities of daily living.
12.3.1 Functional Morbidity
Despite recognition that lingual nerve injuries can cause significant deficiencies in pronuncia- tion [21], there is no evidence that patients suffer- ing with speech problems due to their nerve
12.3 Nonsurgical Management of Trigeminal Nerve Injuries
The strategy for selecting the mode and timing of intervention must be based upon the etiology of the injury, the patient’s current symptoms, the extent and permanency of the injury, and ultimately the patients’ choice of treatment fol- lowing informed consent and education by the clinician. The key management strategies include counseling and reassurance, medication, and surgery.
In order to successfully manage patients with nerve injuries, the clinician must consult with the patient in an in-depth fashion, provide realistic expectations by reaffirming the nerve injury is permanent if the patient has had their symptoms for more than 3 months, and provide reassurance that these injuries do not predispose them to other disease processes (e.g., cancer), and indeed will likely not worsen. Such reassurance can success- fully manage patients who can manage their pain but cannot cope with the consequences of their nerve injury and have associated functional chronic neuropathic pain and resultant psycho- logical difficulties that significantly impact upon their social life or professional life, or usual activities of daily living.
12.3.1 Functional Morbidity
Despite recognition that lingual nerve injuries can cause significant deficiencies in pronuncia- tion [21], there is no evidence that patients suffer- ing with speech problems due to their nerve
218
T. Renton
35
30
25
20
15
10
5
0
**
**
***
*
LNI
IANI = inferior alveolar nerve injuries
LNI = lingual nerve injuries
IANI
Fig. 12.3 Interference with functionality of the IANI and
LNI patients. The majority of IANI and LNI patients had
problems with speech and eating, where speech was
injury may also benefit from speech therapy. A patient with a nerve injury that complains of dis- ability associated with altered sensation, severe discomfort, pain and/or numbness, or a large neu- ropathic area may also complain of interference with daily functions, such as eating and drinking (Fig. 12.2) [3]. Taste is also a function that may be impaired with some lingual nerve injuries due to involvement of the chorda tympani branch of the facial nerve as it courses with the lingual nerve. Inability to perform functional activities of daily life, such as applying lipstick, toothbrush- ing, kissing, or shaving due to an inferior alveolar nerve injury, may also occur. Also, sleep patterns may be affected (Fig. 12.3).
12.3.2 PainManagement
Neuropathic pain is defined as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system” [11]. Unlike nocicep- tive pain, neuropathy is associated with “shoot- ing” or “burning” pains, sensations similar to
injury may also benefit from speech therapy. A patient with a nerve injury that complains of dis- ability associated with altered sensation, severe discomfort, pain and/or numbness, or a large neu- ropathic area may also complain of interference with daily functions, such as eating and drinking (Fig. 12.2) [3]. Taste is also a function that may be impaired with some lingual nerve injuries due to involvement of the chorda tympani branch of the facial nerve as it courses with the lingual nerve. Inability to perform functional activities of daily life, such as applying lipstick, toothbrush- ing, kissing, or shaving due to an inferior alveolar nerve injury, may also occur. Also, sleep patterns may be affected (Fig. 12.3).
12.3.2 PainManagement
Neuropathic pain is defined as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system” [11]. Unlike nocicep- tive pain, neuropathy is associated with “shoot- ing” or “burning” pains, sensations similar to
significantly affected more in lNI patients than IANI
patients. (**p<.001) drinking (***p<.0001) confidence
(**p<.001), and sleep (*p<.05) [3]
electric shocks, and abnormal responses to touch, heat, or cold. This type of pain typically does not respond to anti-inflammatory analgesics.
Neuropathic pain is reported to be present in 50–70 % of patients attending specialist nerve injury clinics [3, 16, 22]. Despite the additional presence of anesthesia and/or paresthesia, a sim- ilar cohort of patients was reported to have a 45 % incidence of dysesthesia (Robinson, JOMS 2011). Neuropathy was evident in all patients with varying degrees of mechanosensory func- tional loss, paresthesia, dysesthesia, allodynia, and hyperalgesia. Patients with chronic neuropa- thy were treated by one or more of the following three key modalities: counseling, medical inter- vention usually for pain (antiepileptics or antide- pressants), the application of topical 5 % lidocaine patches, and/or lastly surgery (Table 12.2) [11]. In order to make the correct choice of management of patients with nerve injury, the clinician must discern what he/she is attempting to treat; is it poor mechanosensory function, or, more pertinently, should it be the patient’s chief complaint? Therefore, a thorough
electric shocks, and abnormal responses to touch, heat, or cold. This type of pain typically does not respond to anti-inflammatory analgesics.
Neuropathic pain is reported to be present in 50–70 % of patients attending specialist nerve injury clinics [3, 16, 22]. Despite the additional presence of anesthesia and/or paresthesia, a sim- ilar cohort of patients was reported to have a 45 % incidence of dysesthesia (Robinson, JOMS 2011). Neuropathy was evident in all patients with varying degrees of mechanosensory func- tional loss, paresthesia, dysesthesia, allodynia, and hyperalgesia. Patients with chronic neuropa- thy were treated by one or more of the following three key modalities: counseling, medical inter- vention usually for pain (antiepileptics or antide- pressants), the application of topical 5 % lidocaine patches, and/or lastly surgery (Table 12.2) [11]. In order to make the correct choice of management of patients with nerve injury, the clinician must discern what he/she is attempting to treat; is it poor mechanosensory function, or, more pertinently, should it be the patient’s chief complaint? Therefore, a thorough
Percentage of patients
Speech
Eating
Brushing teeth
Kissing
Drinking
Confidence
Sleep
Make-up application
Shaving
Pronunciation
Smell
Smell
Work
12 Nonsurgical Management of Trigeminal Nerve Injuries 219
Table 12.2 Medical management of neuropathic pain [11]
|
Drug
|
Starting dose
|
Maximum
dose
|
Cost of 4 week
treatment
|
Comments
|
|
Oral agents: refer to product literature for full list of doses, cautions, contraindications and drug interactions
|
||||
|
Amitriptyline
|
10 mg/day
|
75 mg/day
|
10 mg/day = £1.12
|
Higher doses could be consid-
ered in consultation with a
specialist pain service
|
|
25 mg/day = £1.13
|
||||
|
75 mg/day = £2.39
|
||||
|
Duloxetine
|
60 mg/day
|
120 mg/day
|
60 mg/day = £27.72
|
Maximum of 120mg daily in
divided doses
|
|
120 mg/day = £55.44
|
||||
|
Gabapentin
|
300 mg/day (see
comments)
|
3.6 g/day
|
900 mg/day = £4.19
|
300 mg once daily on day 1,
then 300 mg twice daily on day
2, then 300 mg three times daily
(approx. every 8 h) on day 3 or
initially 300 mg 3 times daily on
day 1, then increased according
to response in steps of 300 mg
daily (in three divided doses)
every 2–3 days to max. 3.6 g
|
|
1.8 g/day = £8.38
|
||||
|
2.7 g/day = £12.57
|
||||
|
3.6 g/day = £15.12
|
The titration above has been
recommended by the BNF 59.
Local expert opinion suggests
that a slower titration than the
BNF recommendation may
improve tolerance to gabapentin
|
|||
|
Pregabalin
|
150 mg/day in two
divided dosed
|
600 mg/day
|
150 mg/day = £64.40
|
A lower starting dose may be
appropriate for some
|
|
200 mg/day = £64.40
|
||||
|
300 mg/day = £64.40
|
||||
|
600 mg/day = £64.40
|
||||
|
Tramadol
|
50–100 mg not more
often than every 4 h
|
400 mg/day
|
400 mg/day = £6.38
|
There is a possible interaction
between duloxetine and
tramadol: possible increased
serotonergic effects when
duloxetine given with trama-
dol—use with caution
|
|
Prices based on the Drug Tariff August 2010
|
||||
|
Full range of doses not listed under cost. Costs based on 4 week treatment and is stated for information purposes
only
|
||||
|
Topical agents: refer to product literature for full list of doses, cautions, contraindications and drug interactions
|
||||
|
Lidocaine Patch
|
Apply patch to skin
once daily for up to
12 h followed by a
12 h plaster free
period
|
Up to 3
plasters may
be used to
cover large
areas
|
1 patch daily = £67.57
|
Apply to intact, dry, non-hairy,
non-irritated skin once daily for
up to 12 h, followed by a 12-h
plaster-free period; discontinue
if no response after 4 weeks
|
|
3 patch daily = £202.72
|
Up to 3 plasters may be used to
cover large areas; plasters may
be cut
|
|||
|
Prices based on the BNF 59 March 2010
|
||||
assessment of the patient is vital before making
such an important decision.
Nonsurgical interventions for pain include medications that may be topical or systemic analgesic agents, or psychological interventions.
Nonsurgical interventions for pain include medications that may be topical or systemic analgesic agents, or psychological interventions.
Psychological interventions include reassurance,
counseling, and cognitive behavioral therapy.
Patients suffering from chronic neuropathic pain
and for whom surgical and pharmacological
interventions did not provide satisfactory pain
220
T. Renton
relief may benefit from a psychological approach
to pain management. Therapies with the best
evidence for improvement in chronic pain are
cognitive behavioral therapy (CBT) and accep-
tance and commitment therapy (ACT). These
therapies are not intended to lower the patient’s
perceived pain levels, but enable the patient to
better cope with their pain, and this therapy often
includes the patient’s acceptance of a chronic
condition.
12.3.2.1 TopicalAnalgesia
Novel strategies that include a combination of topical 5 % lidocaine patches, topical clonaze- pam, and botulinum toxin injections may be effective for managing posttraumatic trigeminal neuropathic pain.
Patches containing lidocaine have success- fully reduced the pain experience among patients with postherpetic neuralgia (PHN), painful dia- betic neuropathy, and low back pain [23, 24] . A small proportion of IANI patients experiencing neuropathic pain in a recent study were managed by applying topical 5 % lidocaine patches to the area in which they were experiencing pain, and
12.3.2.1 TopicalAnalgesia
Novel strategies that include a combination of topical 5 % lidocaine patches, topical clonaze- pam, and botulinum toxin injections may be effective for managing posttraumatic trigeminal neuropathic pain.
Patches containing lidocaine have success- fully reduced the pain experience among patients with postherpetic neuralgia (PHN), painful dia- betic neuropathy, and low back pain [23, 24] . A small proportion of IANI patients experiencing neuropathic pain in a recent study were managed by applying topical 5 % lidocaine patches to the area in which they were experiencing pain, and
this therapy provided significant pain relief [16].
However, clinicians prescribing these topical
patches should warn the patients to discontinue
use of the patch if they develop a rash, since the
patches are applied overnight on a 12-h-on and
12-h-off cycle. This modality is very useful for
patients suffering from sleep interruption due to
mechanical allodynia. The combined application
of topical 5 % lidocaine patches with other
modalities is potentially a simple useful strategy
for patients with permanent inferior alveolar
nerve injury suffering from neuropathic pain
(Fig. 12.4).
Some evidence has shown that botulinum toxin injections are useful in managing periph- eral extraoral or intraoral sensory neuropathic pain [25]; however, evidence of its effective use for posttraumatic trigeminal pain remains limited.
Clonazepam (used topically as a crushed 300 mg tablet) applied to the mucosa for 3–5 min, and not swallowed, followed by rinsing, may reduce oral mucosal neuropathic pain, but evi- dence is weak for widespread application of this technique.
Some evidence has shown that botulinum toxin injections are useful in managing periph- eral extraoral or intraoral sensory neuropathic pain [25]; however, evidence of its effective use for posttraumatic trigeminal pain remains limited.
Clonazepam (used topically as a crushed 300 mg tablet) applied to the mucosa for 3–5 min, and not swallowed, followed by rinsing, may reduce oral mucosal neuropathic pain, but evi- dence is weak for widespread application of this technique.
Topical 5% lidocaine
patches
Medication
Informed about surgery
Surgery carried out
CBT
Reassurance: patient discharged
Reassurance
Medication
Informed about surgery
Surgery carried out
CBT
Reassurance: patient discharged
Reassurance
0 10 20 30 40 50 60 70
Number of patients
LNI
IANI
Fig. 12.4 Key management modalities for IANI and LNI patients [16]
Management method
12 Nonsurgical Management of Trigeminal Nerve Injuries 221
12.3.2.2 SystemicAnalgesia
Guidelines for the medical management of chronic neuropathic pain have been made by NICE, set out by the International Association for the Study of Pain and the American Academy of Neurology [10–12]. A flow chart summarizes the NICE guidelines for the medical management of neuropathic pain (Fig. 12.5).
Low-dose antidepressants (amitriptyline, nor- triptyline) and/or antiepileptic agents (carbam- azepine, oxcarbazepine, gabapentin, pregabalin) can be used to manage pain experienced by patients with posttraumatic neuropathy [12] . However, such systemic medications can cause a multitude of side effects that the patients would find hard to cope with in addition to their other symptoms, and only 8 % of patients treated medi- cally for posttraumatic trigeminal nerve pain were compliant with the medication despite the side effects [16]. In contrast, many patients in this study reported that they were reluctant to take medication because they had previously tried multiple chronic pain medications prior to being referred to the clinic without any success in reducing their pain. In some cases, the level of pain was not significant enough to justify the use of medication [16].
Currently recommended neuropathic pain management strategies include systemic pregab- alin, oxcarbazepine, venlafaxine, and nortrip- tyline as illustrated in Fig. 12.5 and Table 12.2. The primary outcomes assessed included pain relief, improved functionality, and ability of the patient to cope with their iatrogenic posttraumatic neuropathy [26].
12.3.3 PsychologicalMorbidity
Many patients find acceptance or coping with even minimal iatrogenic nerve injuries very difficult. This may be due to the unexpected nature of the injury, poor informed consent (or lack of recall), poor postoperative management of the patient, and an overall lack of information regarding their injury.
Patients with iatrogenic posttraumatic neu- ropathy of the trigeminal nerve not only often
Guidelines for the medical management of chronic neuropathic pain have been made by NICE, set out by the International Association for the Study of Pain and the American Academy of Neurology [10–12]. A flow chart summarizes the NICE guidelines for the medical management of neuropathic pain (Fig. 12.5).
Low-dose antidepressants (amitriptyline, nor- triptyline) and/or antiepileptic agents (carbam- azepine, oxcarbazepine, gabapentin, pregabalin) can be used to manage pain experienced by patients with posttraumatic neuropathy [12] . However, such systemic medications can cause a multitude of side effects that the patients would find hard to cope with in addition to their other symptoms, and only 8 % of patients treated medi- cally for posttraumatic trigeminal nerve pain were compliant with the medication despite the side effects [16]. In contrast, many patients in this study reported that they were reluctant to take medication because they had previously tried multiple chronic pain medications prior to being referred to the clinic without any success in reducing their pain. In some cases, the level of pain was not significant enough to justify the use of medication [16].
Currently recommended neuropathic pain management strategies include systemic pregab- alin, oxcarbazepine, venlafaxine, and nortrip- tyline as illustrated in Fig. 12.5 and Table 12.2. The primary outcomes assessed included pain relief, improved functionality, and ability of the patient to cope with their iatrogenic posttraumatic neuropathy [26].
12.3.3 PsychologicalMorbidity
Many patients find acceptance or coping with even minimal iatrogenic nerve injuries very difficult. This may be due to the unexpected nature of the injury, poor informed consent (or lack of recall), poor postoperative management of the patient, and an overall lack of information regarding their injury.
Patients with iatrogenic posttraumatic neu- ropathy of the trigeminal nerve not only often
have to face a future of chronic altered sensation
or pain afflicting their orofacial region with the
attendant severe compromised daily function but
also have to come to terms with the fact that it has
been caused by someone whom they trusted. This
iatrogenic factor does have a significant psycho-
logical effect on many of these patients who often
become fearsome of dental or medical practitio-
ners and office visits. Empirically, many patients
seen in specialist clinics have significant psycho-
logical distress, as indicated by hospital anxiety
and depression scale (HADS) scores higher than
15. A recent study reported that a limited number
of patients were treated with individualized cog-
nitive behavioral therapy (CBT), and early signs
of fear and avoidance of attending their general
dental practitioner indicate that this group may
be suffering from a form of posttraumatic stress
disorder (PTSD) [16]. This situation is often
compounded by lack of prior informed consent
(or, at least, lack of recall of the informed
consent discussion) and poor postoperative
management by the practitioner subsequent to
the nerve injury. There is a need for research into
the psychological effects of these iatrogenic inju-
ries, and the benefits of nonsurgical interventions
for these patients.
12.3.3.1 Psychiatric and Psychological Therapies
It is well established that patients who develop chronic orofacial pain conditions undergo marked negative psychological and personality changes [27, 28] and display increased levels of anxiety, depression, and psychosocial distress [29]. Significantly, a number of recent studies have reported reduced quality of life, impaired psycho- social functioning, and elevated levels of anxiety and depression in patients suffering from orofa- cial pain with a neuropathic component, such as patientsdiagnosedwithtrigeminalneuralgiaand idiopathiccontinuousorofacialpain[30].
Assessment and treatment by a psychiatrist and clinical psychologist can help in the manage- ment of these psychological changes in these patients. The iatrogenic nature of many nerve injuries can compound preexisting mental health problems, and, interestingly, evidence suggests
12.3.3.1 Psychiatric and Psychological Therapies
It is well established that patients who develop chronic orofacial pain conditions undergo marked negative psychological and personality changes [27, 28] and display increased levels of anxiety, depression, and psychosocial distress [29]. Significantly, a number of recent studies have reported reduced quality of life, impaired psycho- social functioning, and elevated levels of anxiety and depression in patients suffering from orofa- cial pain with a neuropathic component, such as patientsdiagnosedwithtrigeminalneuralgiaand idiopathiccontinuousorofacialpain[30].
Assessment and treatment by a psychiatrist and clinical psychologist can help in the manage- ment of these psychological changes in these patients. The iatrogenic nature of many nerve injuries can compound preexisting mental health problems, and, interestingly, evidence suggests
222
T. Renton
Care pathway for the management of neuropathic pain in adults in
non-specialist settings including primary care
This flow diagram was adapted from the NICE Neuropathic Pain Guideline and is used for the management of neuropathic pain for adult patients within ***(change accordingly)***
This flow diagram was adapted from the NICE Neuropathic Pain Guideline and is used for the management of neuropathic pain for adult patients within ***(change accordingly)***
Early clinical review
• After starting or changing
a treatment, perform an
early clinical review of dosage titration, tolerability
and adverse effects to assess suitability of chosen
treatment.
• Local expert opinion suggests 4 weeks as a trial
period for treatment before considering another agent.
• After starting or changing
a treatment, perform an
early clinical review of dosage titration, tolerability
and adverse effects to assess suitability of chosen
treatment.
• Local expert opinion suggests 4 weeks as a trial
period for treatment before considering another agent.
Discuss aims of pharma-
cological treatment. Advise
patient that it may not
be possible to be pain free with treatment and that the aim of treatment is to achieve pain reduction.
be possible to be pain free with treatment and that the aim of treatment is to achieve pain reduction.
After the diagnosis of neuropath ic pain and appropriate
management of the underlying condition(s)
People with painful diabetic neuropathy
First-line treatment
• Offer oral duloxetine
• Offer oral amitriptyline- if duloxetine is contraindicated
• Offer oral duloxetine
• Offer oral amitriptyline- if duloxetine is contraindicated
Second-line treatment
• Offer treatment with another drug instead of or
in combination with the original drug, after informed discussion with the person:
– if first-line treatment was with duloxetine,
switch to amitriptyline or pregabalin or gabapentin*, or combine with pregabalin or gabapentin
– if first-line treatment was with amitriptyline,
switch to or combine with pregabalin or gabapentin
• Offer treatment with another drug instead of or
in combination with the original drug, after informed discussion with the person:
– if first-line treatment was with duloxetine,
switch to amitriptyline or pregabalin or gabapentin*, or combine with pregabalin or gabapentin
– if first-line treatment was with amitriptyline,
switch to or combine with pregabalin or gabapentin
People with other neuropathic pain conditions
Third-line treatment
• Refer the person to a specialist pain service
and/or a condition-specific service.
• While waiting for referral:
– consider oral tramadol ** instead of or in combination with second-l ine treatment
– consider topicallidocaine*** for treatment of
localised pain for people who are unable to take
oral medication because of medical conditions
and/or disability.
• Refer the person to a specialist pain service
and/or a condition-specific service.
• While waiting for referral:
– consider oral tramadol ** instead of or in combination with second-l ine treatment
– consider topicallidocaine*** for treatment of
localised pain for people who are unable to take
oral medication because of medical conditions
and/or disability.
***Please note:
Under current Joint formulary guidance the initiation
of topical lidocaine patches for unlicensed indications should be initiated following recommendation from a consultant with interest in pain.
Under current Joint formulary guidance the initiation
of topical lidocaine patches for unlicensed indications should be initiated following recommendation from a consultant with interest in pain.
First-line treatment
• Offer oral amitriptyline
• If satisfactory pain reduction is obtained with
amitriptyline but the person cannot tolerate the adverse effects, consider oral imipramine or nortriptyline as an altemative
• Offer oral amitriptyline
• If satisfactory pain reduction is obtained with
amitriptyline but the person cannot tolerate the adverse effects, consider oral imipramine or nortriptyline as an altemative
Second-line treatment
• Offer treatment with pregabalin or gabapentin'
instead of or in combination with the amitriptyline after informed discussion with the person
• Offer treatment with pregabalin or gabapentin'
instead of or in combination with the amitriptyline after informed discussion with the person
*Please note:
• Gabapentin is outside of NICE guidance, however,
it is still a viable agent.
• Local expert opinion suggest slower titration
than recommended in the BNF may improve tolerance.
• Gabapentin is outside of NICE guidance, however,
it is still a viable agent.
• Local expert opinion suggest slower titration
than recommended in the BNF may improve tolerance.
**Please note:
There is a possible interaction between duloxetine and tramadol: possible increased serotonergic effects when duloxetine given with tramadol.
There is a possible interaction between duloxetine and tramadol: possible increased serotonergic effects when duloxetine given with tramadol.
Regular clinical reviews
Perform regular clinical reviews to assess and monitor effectiveness of chosen treatment. Include assessment of: • pain reduction
• adverse effects
• daily activities and participation (such as ability to work
and drive)
• mood (in particular, possible depression and/or anxiety) • quality of sleep
• overall improvement as reported by the person.
Perform regular clinical reviews to assess and monitor effectiveness of chosen treatment. Include assessment of: • pain reduction
• adverse effects
• daily activities and participation (such as ability to work
and drive)
• mood (in particular, possible depression and/or anxiety) • quality of sleep
• overall improvement as reported by the person.
Referrals
Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including
at initial presentation and at the regular clinical reviews, if:
• they have severe pain or
• pain significantly limits their daily activities and participation or • their undertying health condition has deteriorated.
Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including
at initial presentation and at the regular clinical reviews, if:
• they have severe pain or
• pain significantly limits their daily activities and participation or • their undertying health condition has deteriorated.
Approved <<<insert month 2010>>>
Fig. 12.5 Algorithm for medical intervention for neuropathic pain [11]
Fig. 12.5 Algorithm for medical intervention for neuropathic pain [11]
12 Nonsurgical Management of Trigeminal Nerve Injuries 223
that treating concomitant anxiety and depression
can lead to a decrease in pain [31] .
Therapies with the best evidence for chronic pain are cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). These therapies are not intended to lower the patients perceived pain levels, but enable the patient to better cope with their pain. This often includes the acceptance by the patient of the pres- ence of their chronic condition.
CBT
CBT currently has the largest amount of research carried out on its effectiveness and is recom- mended by NICE for a wide variety of mental health and behavioral conditions [32]. CBT focuses on what people think, how those thoughts affect them emotionally, and how they ultimately behave as a result. When a patient is distressed or anxious, the manner in which they see and evalu- ate themselves can become negative. CBT thera- pists work alongside the patient to help them begin to see the link between negative thoughts and mood. This empowers patients to assert con- trol over negative emotions and to change or modify their behaviors.
CBT can be delivered at a number of levels in a stepped care model. In the lower levels of the stepped care model, techniques such as guided self-help are used, placing emphasis on the patient to maintain diary sheets and other inter- ventions with the support and guidance of a trained worker. Self-help patient resources are often CBT-based and are suitable for a range of conditions and can be carried out over the phone or face-to-face by a trained therapist.
Further up the stepped care model is pure CBT, for problems of a more complex and long- standing nature. CBT is delivered by a trained therapist, usually in a clinical setting. During CBT, the therapist will first assist in identifying the problem (along with the behavior, thoughts, and feelings that may be linked to the problem). Once the problem has been explored, the thera- pist will help to examine the thought and behav- ior patterns and help to work on ways of changing these patterns. If the patient accesses this type of therapy, they will often be provided
Therapies with the best evidence for chronic pain are cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). These therapies are not intended to lower the patients perceived pain levels, but enable the patient to better cope with their pain. This often includes the acceptance by the patient of the pres- ence of their chronic condition.
CBT
CBT currently has the largest amount of research carried out on its effectiveness and is recom- mended by NICE for a wide variety of mental health and behavioral conditions [32]. CBT focuses on what people think, how those thoughts affect them emotionally, and how they ultimately behave as a result. When a patient is distressed or anxious, the manner in which they see and evalu- ate themselves can become negative. CBT thera- pists work alongside the patient to help them begin to see the link between negative thoughts and mood. This empowers patients to assert con- trol over negative emotions and to change or modify their behaviors.
CBT can be delivered at a number of levels in a stepped care model. In the lower levels of the stepped care model, techniques such as guided self-help are used, placing emphasis on the patient to maintain diary sheets and other inter- ventions with the support and guidance of a trained worker. Self-help patient resources are often CBT-based and are suitable for a range of conditions and can be carried out over the phone or face-to-face by a trained therapist.
Further up the stepped care model is pure CBT, for problems of a more complex and long- standing nature. CBT is delivered by a trained therapist, usually in a clinical setting. During CBT, the therapist will first assist in identifying the problem (along with the behavior, thoughts, and feelings that may be linked to the problem). Once the problem has been explored, the thera- pist will help to examine the thought and behav- ior patterns and help to work on ways of changing these patterns. If the patient accesses this type of therapy, they will often be provided
a set number of sessions that typically last
50 min per session. Therapists will usually set
“homework tasks” that are completed between
sessions. Homework tasks may include carrying
out activities such as thought monitoring and
entering these into a thought diary, or practicing
specific behaviors through what is known as
“behavioral exposure.”
Cognitive behavioral approaches are delivered in a number of clinical settings, with various dif- fering protocols. While the cognitive elements of the program are usually the province of psychol- ogists, other staff working alongside them, such as physiotherapists, occupational therapists, nurses, and doctors, are required to improve their psychological understanding and skills to enable them to contribute to the treatment regimen. Not surprisingly, the outcomes vary greatly between individual patients, with some subjects finding the ideas life-changing in their relevance and applicability, while others struggle to make even small changes. Studies demonstrate that although there is some diminution in effect with time, most patients never return to their previous levels of distress or disability [33].
Delivering effective CBT in the group format described above requires considerable skill, an effective team, and significant organization and resources. As a result, it is easy to administer CBT in an improper manner. Limitations of train- ing, therapist availability, and lack of resources are barriers to the penetration of these techniques into the current health-care system; therefore, it is often easier to write a prescription, or repeat an injection, than to engage the person in a compre- hensive program of CBT.
Numerous studies attest to the efficacy of CBT, but many questions remain about the essen- tial processes involved, and the most rational and effective modes of delivery. Research continues to shed light on this fascinating area of clinical medicine. In any event, it is likely that the CBT approach to pain with its humanistic emphasis, practical utility, and demonstrable efficacy is here to stay [34].
Cognitive behavioral therapy (CBT) alone, or within the context of an interdisciplinary pain rehabilitation program, has the greatest
Cognitive behavioral approaches are delivered in a number of clinical settings, with various dif- fering protocols. While the cognitive elements of the program are usually the province of psychol- ogists, other staff working alongside them, such as physiotherapists, occupational therapists, nurses, and doctors, are required to improve their psychological understanding and skills to enable them to contribute to the treatment regimen. Not surprisingly, the outcomes vary greatly between individual patients, with some subjects finding the ideas life-changing in their relevance and applicability, while others struggle to make even small changes. Studies demonstrate that although there is some diminution in effect with time, most patients never return to their previous levels of distress or disability [33].
Delivering effective CBT in the group format described above requires considerable skill, an effective team, and significant organization and resources. As a result, it is easy to administer CBT in an improper manner. Limitations of train- ing, therapist availability, and lack of resources are barriers to the penetration of these techniques into the current health-care system; therefore, it is often easier to write a prescription, or repeat an injection, than to engage the person in a compre- hensive program of CBT.
Numerous studies attest to the efficacy of CBT, but many questions remain about the essen- tial processes involved, and the most rational and effective modes of delivery. Research continues to shed light on this fascinating area of clinical medicine. In any event, it is likely that the CBT approach to pain with its humanistic emphasis, practical utility, and demonstrable efficacy is here to stay [34].
Cognitive behavioral therapy (CBT) alone, or within the context of an interdisciplinary pain rehabilitation program, has the greatest
224
T. Renton
empirical evidence for success in patients with
chronic pain conditions [34], and there is emerg-
ing evidence that CBT-based treatment methods
can improve both short-term and long-term out-
comes in patients with chronic orofacial pain
[31, 36]. However, thus far, there is no evidence
of the benefits of CBT for patients with IANI- or
LNI-induced neuropathic pain. The majority of
patients in these studies were successfully man-
aged with psychiatric support and psychological
therapies, without any additional topical analge-
sia, medical, or surgical intervention in a recent
study [16].
There are an increasing number of studies qualifying the role of CBT in the management of chronic pain; however, more recently, several novel techniques are gaining credibility in this field including ACT [35].
Acceptance and Commitment Therapy (ACT)
Acceptance and commitment therapy is a third wave behavioral therapy (along with dialectical behavior therapy and mindfulness-based cogni- tive therapy) that uses mindfulness skills to developpsychologicalflexibilityandhelpclarify and direct values-guided behavior. ACT, pro- nounced “act” and not by the initials “A-C-T,” does not attempt to directly change or stop unwanted thoughts or feelings, but aims to develop a new mindful relationship with those experiences to free a person up to be open to take action that is consistent with their chosen life values. Thus, val- ues clarification is a key component to ACT.
Evidence suggests that ACT can help to improve mental health [36]. In a comparative trial with CBT, ACT was shown to have comparable outcomes [35]. There is increasing evidence to support its use with chronic pain in both a group and individual setting [36].
Other Nonsurgical Interventions
Other nonsurgical interventions (Table 12.3) include education, TENS, peripheral nerve stim- ulation, massage, acupuncture, and exercise/ reconditioning. These strategies have mainly been explored for chronic pain management applicable to many patients with permanent trigeminal nerve injuries [31].
There are an increasing number of studies qualifying the role of CBT in the management of chronic pain; however, more recently, several novel techniques are gaining credibility in this field including ACT [35].
Acceptance and Commitment Therapy (ACT)
Acceptance and commitment therapy is a third wave behavioral therapy (along with dialectical behavior therapy and mindfulness-based cogni- tive therapy) that uses mindfulness skills to developpsychologicalflexibilityandhelpclarify and direct values-guided behavior. ACT, pro- nounced “act” and not by the initials “A-C-T,” does not attempt to directly change or stop unwanted thoughts or feelings, but aims to develop a new mindful relationship with those experiences to free a person up to be open to take action that is consistent with their chosen life values. Thus, val- ues clarification is a key component to ACT.
Evidence suggests that ACT can help to improve mental health [36]. In a comparative trial with CBT, ACT was shown to have comparable outcomes [35]. There is increasing evidence to support its use with chronic pain in both a group and individual setting [36].
Other Nonsurgical Interventions
Other nonsurgical interventions (Table 12.3) include education, TENS, peripheral nerve stim- ulation, massage, acupuncture, and exercise/ reconditioning. These strategies have mainly been explored for chronic pain management applicable to many patients with permanent trigeminal nerve injuries [31].
Combined Therapies
Combined therapies include CBT, surgery, medi- cation with 5 % lidocaine patches, and/or botuli- num toxin (Fig. 12.4) [16].
12.4 Summary
12.4.1 Improved Management of These Injuries
Commonly the patient’s anger and frustration due to the iatrogenic injury is compounded by poor immediate management by the clinician involved. After causing the injury, many patients complain that the treating clinician refuses to even communicate with the patient or remains in denial about the injury. Furthermore, particularly in secondary care, patients are seen for many months or even years, by consecutive junior staff providing them with unrealistic false hope and reassurance that their nerve injury will resolve spontaneously. Most importantly, prevention is preferable to the inadequate treatment modalities we currently possess to treat posttraumatic trigeminal neuropathy. However, if the damage occurs, earlier recognition and referral of trigem- inal injuries are fundamental to the improved treatment of these patients. A suggested strategy for management of these patients is summarized in Table 12.1.
In conclusion, the frequent incidence of pain, in patients with lingual nerve and inferior alveo- lar nerve injuries, indicates that consent should highlight the likelihood of hyperesthesia and pain, rather than numbness, prior to high-risk procedures. Attention should also be directed to the misconception that IAN injuries resolve simi- larly to LN injuries, which is not the case, and they often require more urgent management strat- egies. The pain-associated functional difficulties present in these cases explain the significant psy- chological distress seen in these cases. Possibly, the psychological distress is compounded by the iatrogenic injury, inadequate or unrecalled informed consent, and poor management in most cases. This chapter highlights several strategies that may be used to assist the practitioner in
Combined therapies include CBT, surgery, medi- cation with 5 % lidocaine patches, and/or botuli- num toxin (Fig. 12.4) [16].
12.4 Summary
12.4.1 Improved Management of These Injuries
Commonly the patient’s anger and frustration due to the iatrogenic injury is compounded by poor immediate management by the clinician involved. After causing the injury, many patients complain that the treating clinician refuses to even communicate with the patient or remains in denial about the injury. Furthermore, particularly in secondary care, patients are seen for many months or even years, by consecutive junior staff providing them with unrealistic false hope and reassurance that their nerve injury will resolve spontaneously. Most importantly, prevention is preferable to the inadequate treatment modalities we currently possess to treat posttraumatic trigeminal neuropathy. However, if the damage occurs, earlier recognition and referral of trigem- inal injuries are fundamental to the improved treatment of these patients. A suggested strategy for management of these patients is summarized in Table 12.1.
In conclusion, the frequent incidence of pain, in patients with lingual nerve and inferior alveo- lar nerve injuries, indicates that consent should highlight the likelihood of hyperesthesia and pain, rather than numbness, prior to high-risk procedures. Attention should also be directed to the misconception that IAN injuries resolve simi- larly to LN injuries, which is not the case, and they often require more urgent management strat- egies. The pain-associated functional difficulties present in these cases explain the significant psy- chological distress seen in these cases. Possibly, the psychological distress is compounded by the iatrogenic injury, inadequate or unrecalled informed consent, and poor management in most cases. This chapter highlights several strategies that may be used to assist the practitioner in
12 Nonsurgical Management of Trigeminal Nerve Injuries 225
Table 12.3 Nonsurgical (medical) interventions for chronic pain
|
Intervention
|
Definition
|
Purpose/goals
|
Examples of uses
|
|
Stretching
|
Gentle exercise to improve
flexibility
|
Improve ROM, function,
comfort
|
Arthritis, LBP, fibrmyalgia,
myofascial pain syndrome
|
|
Exercise/
reconditioning
|
Reconditioning exercises can
improve strength and endurance
as well as combat stiffness and
weakness associated with
pain-related inactivity
|
Useful in regaining muscle
and tendon strength, as well
as improving ROM,
endurance, comfort, and
function Transforms painful
activities into more easily
tolerated ones
|
Arthritis, LBP, fibromyalgia,
CRPS
|
|
Minimizes atrophy, deminer-
alization, and deconditioning
|
|||
|
Gait and posture
training
|
Appropriate attention to gait and
posture, including preventive and
therapeutic erogonomics
|
Relieve pain and restore
function; prophylax is against
further pain
|
LBP, neck pain, tension HA
|
|
Applied heat or
cold
|
Application of cold (cryotherapy)
to decrease pain and swelling and
improve function; later applica-
tion of heat (thermotherapy) to
augment performance and
diminish pain
|
Application of cold produces
local analgesia, slows nerve
conduction, and promotes
tendon flexibility
|
Acute trauma (e.g., injury,
surgery); repetitive trauma,
arthritis, muscle pain or
spasm, acute LBP
|
|
Application of heat produces
local analgesia, dilates
(widens) blood vessels, and
promotes flexibility
|
|||
|
Immobilization
|
Reduction of activity and
avidance of strain for certain
duration; may involve brace to
assist, restrict, or limit function
of joint
|
May be needed to maintain
proper alignment during
post-injury repair but is
generally harmful for patients
with CNCP
|
Some postoperative, injury
(e.g., fracture)
|
|
TENS
|
Selective stimulation of
cutaneous receptors sensitive to
mechanical stimuli (mechano-
receptors) by applying low-
intensity current via skin
electrodesa
|
TENS can reduce pain and
analgesic use and improve
physical mobility, presumably
by interfering with transmis-
sion of nociceptive impulses
in nerve fibers
|
Trauma, postoperative, labor,
abdominal pain; neuralgias,
other neuropathic pain, PVD,
angina, musculoskeletal pain
|
|
PNS
|
Electrical stimulation of selected
regions of the nervous system via
implantable devicesb
|
The goal of electrical
stimulation is to disrupt
nociceptive signaling
|
Chronic pain of the trunk and
limbs (e.g., PVD), neuro-
pathic pain (deafferentation,
poststroke pain), cancer pain
|
|
SCS
|
|||
|
IC
|
|||
|
Massage
|
Rubbing of painful or nonpainful
adjacent area
|
Facilitates relaxation and
decreases muscle tension and
pain
|
Postoperative pain, arthritis,
fibromyalgia
|
|
Acupuncture
|
Old Chinese healing technique
involves insertion of fine needles
into the skin at varying depths;
application of pressure at
acupuncture sites is called
acupressure
|
Acupuncture may cause the
secretion of endorphins and
interfere with transmission of
nociceptive information to
relieve pain
|
Postoperative, radiculopathy,
chronic LBP, fibromyalgia
|
From the American Academy of Pain
CNCP chronic noncancer pain, CRPS chronic regional pain syndrome types I and II, HA headache, IC intracerebral stimulation, LBP lower back pain, PNS peripheral nerve stimulation, PVD peripheral vascular disease, ROM range of motion, SCS spinal cord stimulation, TENS transcutaneous electrical nerve stimulation
aTENS appears to work best when applied t skin close to the pain’s site of origin and when sense of touch and pressure are preserved
bThe implanted portion of the device consists of a pulse generator and leads connected to electrodes located in fascia in close proximity to a peripheral nerve (PNS), the spinal canal (SCS), or brain (IC). The patient or clinician controls stimulation using non-implanted system components
CNCP chronic noncancer pain, CRPS chronic regional pain syndrome types I and II, HA headache, IC intracerebral stimulation, LBP lower back pain, PNS peripheral nerve stimulation, PVD peripheral vascular disease, ROM range of motion, SCS spinal cord stimulation, TENS transcutaneous electrical nerve stimulation
aTENS appears to work best when applied t skin close to the pain’s site of origin and when sense of touch and pressure are preserved
bThe implanted portion of the device consists of a pulse generator and leads connected to electrodes located in fascia in close proximity to a peripheral nerve (PNS), the spinal canal (SCS), or brain (IC). The patient or clinician controls stimulation using non-implanted system components
226
T. Renton
managing trigeminal nerve injuries while, at the
same time, reaffirming that there is no one ideal
treatment option in treating these patients.
Acknowledgements Ms Sarah Barker Lead Clinical Psychologist for Orofacial Pains services Kings College Hospital London for her assistance with interventional psychological management strategies for patients with Trigeminal nerve injuries.
References
Acknowledgements Ms Sarah Barker Lead Clinical Psychologist for Orofacial Pains services Kings College Hospital London for her assistance with interventional psychological management strategies for patients with Trigeminal nerve injuries.
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