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Lingual and Inferior Alveolar Nerve Damage Discussion Site

Subject: "Injectional Injury Protocol"     Previous Topic | Next Topic
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MaverickDMD
Member since Dec-14-07
142 posts
Apr-25-08, 02:45 AM (CST)
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"Injectional Injury Protocol"
 
   LAST EDITED ON Aug-23-08 AT 11:35 PM (CST)
 
This thread is devoted to the development of a global protocol to be enacted in the event of an injectional injury to the lingual and/or inferior alveolar nerve, or any other nerves as they pertain to needle injection during dental, oral and maxillofacial, or facial surgery.

This post marks a time in the evolution of a protocol that can be accessed and enacted based on the current scientific literature and the anecdotal and circumstantial evidence created here by posters on this site. Any poster is welcome to add to this protocol as he sees fit and I will alter this document as needed should there by merit to the claim. Ultimately, a technique to minimize the chance of lingual nerve injury is needed during the IAN block technique. Currently there is no iron-clad way to fully prevent a lingual or inferior alveolar nerve injury given the time-honoured injection method. A newer approach to this nerve block that hopefully minimizes this risk will be addressed shortly as a website of this nature is being constructed (6/08).

NERVE INJURY PROTOCOL

1) Report signs of continued numbness in excess of 24 hours of your appointment to your treating practitioner at once. Referral to an oral and maxillofacial surgeon at this point as a second opinion. A delay here by the patient may preclude the window where steroid anti-inflammatory medications can be employed. Steroid anti-inflammatory drugs such as dexamethasone or prednisone are given by phone or personally.

2) Next day or first clinical follow up: evaluation of the nerve(s) involved; assessment of injectional or extraction causation or both to allow localization of the site of injury. Steroid anti-inflammatory drugs such as Decadron 4mg bid or Medrol for up to 7 days (medical history permitting) should be initiated. Additionally, although there is no good evidence to support the following, sublingual methyl cobalamin at 1000 mcg/day (better absorbed than oral route) or Nerve Fx as a standby.

3) 5 day clinical follow up: mapping of the extent of neural deficit should be initially recorded and cross-referenced with the medications used, the needle diameters used, the injection type and number of administrations and the volume of anesthetic used. This information should be in the patient chart. This is done either by the treating practitioner or the oral and maxillofacial surgeon. Preferential follow up with oral and maxillofacial surgeon for evaluation. Two way sensation and pain sensation should be mapped out or preferably photographed.

4) STEPS 4-8 SHOULD HAPPEN CONCURRENTLY At this visit, 2-way touch with Von Frey hairs and pain reception to the affected area should be assessed and clinically mapped or photographed. Subjective description of deficit should be included.

5) If significant trauma to IA or lingual nerve is suspected by early and complete anesthesia of these nerves, a prompt referral to a neuromicrosurgeon should also be arranged -- given that the wait list for treatment by these specialists is long, early referral is recommended; a false alarm can always be cancelled. Many newer studies show that early surgical intervention in nerve transection is preferred as a stretching anastomosis is more efficacious than transneuronal bridging. Surgical correction, even with a 50% success rate is advocated by some researchers within the first 3 months of nerve injury; success rates fall with time thereafter.

6) While surgical referral is progress, patients should be seen biweekly in the first month and second month, monthly in the 3rd month and bimonthly until the 1st year. Evaluations, mapping and photographs should be taken to monitor the progression of sensation. Patients with sensations of tingling or gripping of the lower jaw have a better chance and encouragement in these cases is indicated. Complete anesthesia has a poorer prognosis at this time but recovery is not impossible.

7) During this period, medications such as Tegretol (carbamazepine), Trileptal (oxcarbazepine), Neurontin (gabapentin), low dose Elavil (amitriptyline) or Lyrica (pregabalin), and their may be others such as Tramadol, should be considered to modulate neural side effects and dysesthesias. Clonazepam is also indicated with a lesser degree of success. The general practitioner physician and dentist/oral surgeon and ideally a neurologist should act as a team in applying these meds. Pain medication is often needed, often involving opiates (Tyl 3, Percocet, Vicodin), but the addiction potential should be weighed against the need for pain resolution. Naproxen is a good anti-inflammatory that can be used for some duration without any addiction. Some studies suggest high doses (1-5 mg) of the methylcobalamin form of vitamin B12 are helpful and no prescription is required for this. These medications can be administered by the oral and maxillofacial surgeon or the referred neurologist as early on as the symptoms suggest.

8) At the 3 month interval if there is no improvement to tests with 2-way or pain tests, the consideration of microneurosurgical repair gains traction. The low success rate and the high magnitude of recovery from this surgery should be weighed by the symptoms and candidacy of surgery with the microneurosurgeon (oral and maxillofacial surgeon or neurologist).

9) The alternate option at 3 months is to wait. Thirty percent of patients go on to majority recovery in the next years; recoveries up to 5 years have been recorded. Recovery is a mixed equation of gender and age but the younger the patient the better the prognosis.

10) Nerve injury does rise with age, particularly in women. Early extraction of foreseeably mencacing third molars is still, despite its comparatively small risks, is the best choice. Injectional injuries, being in their relative infancy of active treatment, are unconfirmed in their incidence, however, it would seem likely that their current gender predilection follows the same distribution as third molar extraction.

11) YOUR COMMENTS ARE WELCOME HERE. Add to the above as anyone would see fit. I can be reached at drgmc@shaw.ca if needed.


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  Subject     Author     Message Date     ID  
  RE: Injectional Injury Protocol bowho Apr-28-08 1
     RE: Injectional Injury Protocol MaverickDMD May-17-08 2
         RE: Injectional Injury Protocol bowho May-22-08 3
             RE: Injectional Injury Protocol MaverickDMD May-22-08 4
                 RE: Injectional Injury Protocol bowho May-22-08 5
                     RE: Injectional Injury Protocol MaverickDMD May-23-08 6
                         RE: Injectional Injury Protocol Bob May-23-08 7
                             RE: Injectional Injury Protocol bowho Jul-27-08 11
                         RE: Injectional Injury Protocol bowho May-23-08 8
                         RE: Injectional Injury Protocol redrosen1961 Jul-05-08 9
                             RE: Injectional Injury Protocol bowho Jul-14-08 10

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bowho
Member since Nov-26-07
565 posts
Apr-28-08, 10:28 PM (CST)
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1. "RE: Injectional Injury Protocol"
In response to message #0
 
   LAST EDITED ON Jul-14-08 AT 05:47 PM (CST)
 
12) when you find that all of the above isnt working, seek psychiatric advice ASAP to keep yourself from jumping off a bridge, it may help.

13) in the event you think you may have encountered a negligent dentist seek the advice of a good malpractice attorney.

14) if 1 thru 11 doesnt help..shitt happened and your basically screwed for many years to come...ADJUST


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MaverickDMD
Member since Dec-14-07
142 posts
May-17-08, 01:29 AM (CST)
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2. "RE: Injectional Injury Protocol"
In response to message #1
 
   I am a little disappointed here.

In my view, the very genesis of this site was to pool all those suffering nerve injuries together and then review all the causes of injury and then to alter the cause of injury where possible and then where needed come up with a protocol to enact when unavoidable injuries continued to occur.

Any participant to this site, one would figure, would be right on top of this, tweeking this thread daily until it was ready to be applied to the next patient and perhaps even to have an internationally approved protocol to apply to anyone within the world if they suffered a nerve injury.

Granted, some people come on here just to vent their frustrations, but I think for the greater good of mankind, wouldn't the piecing together of a protocol to help address the nerve injured patient be a better focus of this energy? In my view a prevention of injury as well as a treatment of the injury are equally important. Just a thought.


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bowho
Member since Nov-26-07
565 posts
May-22-08, 01:28 PM (CST)
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3. "RE: Injectional Injury Protocol"
In response to message #2
 
   Could you explain this in layman terms and back it up with proof ?
Many newer studies show that early surgical intervention in nerve transection is preferred as a stretching anastomosis is more efficacious than transneuroal bridging.


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MaverickDMD
Member since Dec-14-07
142 posts
May-22-08, 06:41 PM (CST)
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4. "RE: Injectional Injury Protocol"
In response to message #3
 
   A recent study in Japan found that early intervention by stretching the loose ends of the nerve trunk and joining them together at or before the 3 month period was better than waiting a longer period. After 3 months, the loose nerve ends have healed with scar tissue and have shrunken in size so stretching them to join is not possible later on. The catch 22 is that it takes 3 months in many cases to discover whether nature will heal the injury. Statistically, I think it's only 25% or so go on towards significant healing after 3 months if complete anesthesia was present at the 3 month mark. By doing surgery prior to giving nature a chance, it may be subjecting the patient to another surgical insult. If it were me I'd follow the protocol I listed above -- I'd wait 4 months rather than 3 as I'd want to give nature every chance to heal but have the process for referral for surgery in place and ready to pounce once the natural process is abandoned.


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bowho
Member since Nov-26-07
565 posts
May-22-08, 08:24 PM (CST)
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5. "RE: Injectional Injury Protocol"
In response to message #4
 
   LAST EDITED ON May-22-08 AT 08:25 PM (CST)
 
The Japanese study must have done on subjects with severed nerves ? Is this a study on the LN or the IAN ? I would think if either nerve was completely cut in half the chance of recovery would be 0 FOREVER..
I suppose i should consider myself one of the lucky ones who regained some feeling after a year with a 6 1/2 month nature healing of my LN with added repair surgery.. Maybe if my surgery was done at 3 months i would of regained total feeling ? Who knows.....


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MaverickDMD
Member since Dec-14-07
142 posts
May-23-08, 00:42 AM (CST)
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6. "RE: Injectional Injury Protocol"
In response to message #5
 
   LAST EDITED ON May-23-08 AT 00:44 AM (CST)
 
As with any surgical procedure, time adds to the collective knowledge, and 7 years can be a quantum leap from the understanding of that time. As you know, this surgery can still be considered in its infancy although it is not a new discovery by any means. Although the Japanese study is promising it may be misleading as it is advocated during a time when hope is still alive. Who knows; successes in this case may have been due to natural healing after all as it was still too early in the recovery period. The key is not give false hope to a surgical repair. And more importantly, although lingual nerve or IA nerve injury may be absolutely unavoidable during molar extraction, I think injectional injuries can be avoided in most cases.


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Bob
Member since Aug-6-07
156 posts
May-23-08, 07:28 AM (CST)
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7. "RE: Injectional Injury Protocol"
In response to message #6
 
   "Injectional injuries can be avoided in most cases". That is a very bold statement, and it implies that my dentist was neglegent for not avoiding my injectional injury. Just how would a dentist avoid this injury?


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bowho
Member since Nov-26-07
565 posts
Jul-27-08, 08:28 PM (CST)
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11. "RE: Injectional Injury Protocol"
In response to message #7
 
   Really Mav , could you expound on this for us ? Bob asked you this 2 months ago ...


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bowho
Member since Nov-26-07
565 posts
May-23-08, 02:08 PM (CST)
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8. "RE: Injectional Injury Protocol"
In response to message #6
 
   LAST EDITED ON May-23-08 AT 02:09 PM (CST)
 
Are you saying success in my case could have been due to natural healing after a half of a year ? I would tend to reckon that 26 weeks of natural healing would have resulted in a tiny glimmer of relief from the agony of the nerve injury ? I know for a fact in my case 3 weeks after the repair surgery my tongue miraculously snapped out its cramped like feeling !! I certainly would have preferred not having that feeling for and extra 4 months .. And thank god that part of the injury never returned .... I somehow dont think that part would be better today had i not had the surgery ? I am certainly not giving false hope to surgical repair !! As far as i see whats going on here its only if you complain enough to the right kind of DOCTOR that you might end up with the kind of help you need... Luckily for me i dont live in bum fuk and was lead to a jaw surgeon who had experience with these injuries ... And i suppose what your saying is that the molar extraction causes a more severe injury than an injectional injury ? That must be where nerves are more likely to be severed rather than just traumatized or do the nerves become severed from the injection too ? its a wonder i got any feeling back after the killer shot on top of the killer extraction.. Be careful with them dam shots our mouths are not a dart board !! And if the dentist didnt have his mind wandering off in lala land during the procedure maybe only 1/4 of the injuries would occur anyways.. Of course thats just my opinion.. :-)


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redrosen1961
Member since Jul-5-08
25 posts
Jul-05-08, 08:10 PM (CST)
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9. "RE: Injectional Injury Protocol"
In response to message #6
 
   Maverick, I recently (ll days ago) became injured. Dentist said it was from the injection that was given for me to get numb so that I could have a lower left molar pulled. My symptoms are extremely painful burning numb tongue and lips. Iam also experiencing sore throat and difficulty swallowing. Infection of my throat and tonsils has been rulled out. I also experinceing increase in allergy like symptoms. Increase nasal drip and conjestion. I recently prescribed predisone pack for another condition I have with my temporal styloid process. I have both of these problems going on at once. Iam at witts end and its just been 11 days. I dont know how anyone can or could live with this pain for years. I dont know where to go for help. My dentist office assures me that it will all go away on its own. They seem to think my symptoms arnt bad as Iam telling them. WHY ARNT PATIENTS WORNED OF THESE POSSIBLE SIDE AFFECTS FROM INJECTIONS??? My gosh I have to sign release forms for way less procedures than this. No one I know has ever heard of this happening from an dental injection. COULD THERE BE LEAGAL ISSUE HERE??? This is quite debiltating. Ian not very educated but I think dental patients should be warned. Why isnt the dentist responsible for this??? I have so many question running thru my mind. Just now fair. If I had know that conditions like these could happen I would have given much thought about getting my tooth pulled in the beginning. Any help you could give or advice would be greatley appreciated. I just joined this forum, but what I have reviewed I havent heard of anyone seeking legal advice. Is there any?? Please help. Thank you so much!! redrose

Redrose


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bowho
Member since Nov-26-07
565 posts
Jul-14-08, 05:44 PM (CST)
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10. "RE: Injectional Injury Protocol"
In response to message #9
 
   Sorry Redrose that you are being ignored by the DMD here especially when you are in dire straights !! Here is something for you to consider ..


http://www.associatedcontent.com/article/34828/dental_malpractice_cases_should_you.html
Dental Malpractice Cases: Should You Consult an Attorney? - Associated Content


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