CASE 16

A NUMB LIP

Dr. Areej Fatima

 SCENARIO

A 68-year-old man presents to you in general dental practice

complaining that his lower lip has become numb. How would
you investigate and manage this symptom?
 PRESENTING COMPLAINT

• He complains of sudden onset of numbness of the lower right lip

• It feels cold, as if he had had an injection for dental treatment
 HISTORY OF PRESENTING COMPLAINT

• The patient noticed the numbness immediately he woke up the previous

morning.
• His jaw has been aching for some months
• he has noticed some tingling in the lip, which he ascribes to recent dental
treatment.
 DENTAL HISTORY

• A series of appointments over the last few months have addressed pain from
the lower right quadrant.
• The tingling in the lip was noted 3 months ago.
• The lower right first molar had been considered to be the cause.
• Your colleague placed a root filling 4 months ago but the pain did not resolve
completely.
• Three weeks ago the lower right second premolar was extracted as a likely
cause of the pain.
• However, discomfort continued.
 MEDICAL HISTORY

• 50 mg atenolol for mild hypertension

• Antidepressants in the past for depression
CAUSES OF LIP NUMBNESS
 EXTRAORAL EXAMINATION

• He appears normal;
• The lip is of normal colour and shows no distortion or drooping to suggest a
motor nerve lesion.
• When you examine him you find that there is only a very mild swelling of the
posterior right lower jaw.
• There is no detectable mass, but the patient is tender in the right
sub-mandibular area.
• There is normal movement of the lip.
 TEST FOR SENSATION

• Tests of sensation may include light touch

• pain (with a sharp and blunt point),
• Vibration
• Temperature
• two-point discrimination.
• Test and retest if the results are unclear.
 INTERPRETATION

• There is mild swelling of the mandible that suggests a local mandibular cause.
• The tenderness in the right submandibular area might represent infection or
reactive lymphadenopathy
• .The fact that the area of anaesthesia is sharply delineated suggests a
peripheral nerve cause.
• The fact that lip movement is normal indicates normal facial nerve function.
• The distribution on the lower-lip skin suggests injury or compression of the
inferior alveolar nerve.
• The normal sensation under the chin is significant. This area is supplied by the
nerve to mylohyoid, given off the inferior alveolar nerve just above the lingula,
to supply a thumbprint-sized patch of skin under the chin
• . Therefore, the cause must lie between the start of the inferior dental canal
and the lip.
 INTRAORAL EXAMINATION

• The oral mucosa is healthy apart from the lower right second premolar
extraction site.
• The socket opening is swollen and filled with granulation tissue that is growing
out slightly above the alveolus.
• There are no sequestra and no sinus or pus at the socket mouth.
• The remaining teeth appear healthy and none is tender to percussion.
 APPEARANCE OF THE SOCKET

• at 3 weeks there should be an intact layer of epithelium over the granulation

tissue.
• This socket is not epithelialized.
• The granulation tissue growing out from the socket indicates a process of
frustrated healing that could have many causes.
• This socket has failed to heal.
 CAUSES OF DELAYED SOCKET
HEALING

• General causes•
• Age
• Diabetes•
• Steroids and other immunosuppressants• B
• Bisphosphonate therapy•
• Malnutrition•
• Cancer chemotherapy
• Local causes
• impacted food debris•
• Foreign bodies – bony sequestra, root fragments•
• dry socket•
• infection, including tuberculosis•
• Oroantral fistula formation•
• Previous radiotherapy to the site•
• Sarcoidosis•
• Local malignancy.
 INTERPRETATION

• There would appear to be a local cause in the body of the mandible causing
compression or injury to the inferior alveolar nerve.
• inflammation or infection from nonvital teeth or the nonhealing socket could
involve the nerve.
 INVESTIGATIONS

• The remaining teeth in the affected quadrant should be tested for vitality
• .a radiograph is required to assess the extraction socket, the adjacent teeth,
the whole height of the slightly expanded mandible and the full length of the
inferior dental canal
• . Either a dental panoramic or an oblique lateral radiograph would be an
appropriate view.
• The lower first molar is root-filled.
• The second molar is vital, but the lower right incisors, canine and first
premolar appear nonvital.
 PANORAMIC TOMOGRAPH

• Several teeth are heavily restored.

• The lower first molar is root-filled and there is a
poorly defined radiolucency about 2 cm in length
extending from the distal root of the second molar to
the premolar socket.
• The cortical bone outline of the inferior dental canal
cannot be seen in this region.
• The recent extraction socket still has the lamina dura
present, though it appears slightly more indistinct than
normal, consistent with infection or another process
causing resorption.
• No sequestra or root fragments are present in the
socket
 DIFFERENTIAL DIAGNOSIS

1. Chronic osteomyelitis

• There is a history of dental infection, extraction with a nonhealing socket and

tenderness at the site. This would be a statistically likely cause and should be
considered first. However, some features do not fit.
• Chronic osteomyelitis is usually associated with a predisposing cause. aside from this
patient’s age, none is present.
• There is no definite lymphadenopathy and no discharge of pus from the socket or
any sinuses.
• The radiological features are partly consistent, but osteomyelitis is usually a more
patchy radiolucency with zones of sclerosis. Peripheral bone sclerosis, sequestra seen
radiographically or in the socket would also be expected
• . The radiological features of osteomyelitis take several weeks to develop, but the
symptoms started several months ago. acute osteomyelitis is not suspected.
• There are no systemic symptoms of infection and the delay since extraction is
rather long. acute osteomyelitis tends to affect younger patients and the pain is deep
and throbbing. Onset is soon after extraction and there are no radiological signs.
2. Malignant neoplasms
• The patient is elderly and there is a long history of vague pain and
paraesthesia, suggesting a long-standing lesion.
• The dental extractions may have been performed for valid reasons or as a
result of the misdiagnosis of the cause of pain.
• The nonhealing socket could well be caused by malignancy and the radiological
features are suggestive; the lesion is poorly defined and purely destructive.
• POSSIBLE NEOPLASMS
• Primary
• Osteosarcoma •
• Chondrosarcoma •
• Odontogenic carcinomas sarcomas
• Secondary •
• Breast carcinoma •
• Bronchogenic carcinoma (lung) •
• Kidney carcinoma •
• Prostate carcinoma •
• Thyroid carcinoma •
 BIOPSY

• the bone curettings from the socket composed of normal

lamellar bone with several marrow spaces.

• These would normally be filled by fatty marrow in a

patient of this age.
• However, they contain rings of epithelium, recognized by
its darker staining pattern and the fact that it surrounds
duct or gland-like spaces
• . The overall pattern is that of a glandular tissue.
• No glands are present in the normal mandibular marrow –
this must be metastatic adenocarcinoma
• . Because the biopsy shows adenocarcinoma, lung, kidney
and prostate will be the most likely primary sites for the
carcinoma, because these tissues give rise to
adenocarcinomas.
• the biopsy stained with antibodies to PSa.
• Psa is an enzyme secreted by prostate cells
and expressed in their cytoplasm.
• Though not completely specific to prostate
gland, there are few other tissues that express
high levels.
• Presence of Psa is indicated by positive staining
(brown colour) around all the glands in the
bone marrow.
• Histopathology suggests strongly that this is a
metastasis from a prostate carcinoma.
• A blood test reveals a high level of circulating
PSA.
• No mass can be detected in the prostate by
clinical examination but prostate ultrasound
scanning reveals a small nodule and a needle
biopsy shows prostate carcinoma.
 DIAGNOSIS AND PROGNOSIS

• The diagnosis is metastatic prostate carcinoma.

• It usually has a poor prognosis
• patients with multiple bone metastases of myeloma, breast or prostate
carcinoma are often treated with intravenous bisphosphonates to slow
bone destruction and prevent spinal cord damage, pathological fracture
and bone pain.
• Bisphosphonate drugs prevent bone turnover and reduce bone viability.
• There is a risk of developing the unusual pattern of sterile
osteonecrosis of the jaws associated with these drugs