Pain Update

Diagnosis and management of persistent

posttraumatic trigeminal neuropathic pain
secondary to implant therapy
A review
Divya Kohli, BDS, MDS; Giannina Katzmann, DDS; Rafael Benoliel, BDS;
Olga A. Korczeniewska, PhD
JADA 2021:n(n):n-n
https://doi.org/10.1016/j.adaj.2020.08.017

D
ental implants are used to replace missing teeth for restoration of function and esthetics.
Implant dentistry is practiced around the world. In the United States, the prevalence of
dental implants has increased from 0.7% in 1999 through 2000 to over 5% in 2015 through
2016, with the predicted increase in implant placement approaching 23% in 2026.1 As the place-
ment of dental implants increases, it is imperative to consider the possible complications. Surgical
complications such as hemorrhage (z24%) and neurosensory disturbances (z7%) are possible, with
a combined incidence of 30%.2 Chronic pain, such as posttraumatic trigeminal neuropathic pain
(PTNP) secondary to implant placement, has been reported; however, the prevalence is unclear.3
The patients have variable clinical manifestations, routinely reporting symptoms of persistent pain
secondary to implant therapy. This is accompanied with positive or negative sensory abnormalities,
which interfere with routine activities like mastication, eating, and speaking. These complications
can jeopardize the success of the implant and potentially impact the patient’s life.
According to the International Association for the Study of Pain, pain lasting more than 3
months is classified as chronic. Chronic pain is defined as pain occurring for more than 15 days per
month and lasting over 2 hours daily for at least 3 months.4 Chronic pain serves no biological
purpose. It affects the patient’s quality of life, and up through 85% of patients with chronic pain are
affected by severe depression.5,6 Dental treatments, including dental implants, may result in PTNP;
therefore, an awareness of these complications among dental clinicians is critical. In addition, the
role of informed consent is crucial, as patients must be provided with adequate information
regarding potential complications. Early recognition, accurate diagnosis, and adequate management
are imperative in preventing the development of PTNP.

EPIDEMIOLOGY
The exact epidemiology of PTNP secondary to implant placement is not clear. The prevalence of
neuronal injury secondary to implant placement has been reported as ranging from 0.5% to as
high as 37%.2,7-9 This wide range in prevalence can be owing to the fact that both transient and
permanent neurosensory disturbances secondary to implant placement have been included in the
data over a wide range of time, not accounting for clinician expertise and techniques. The re-
ported prevalence of permanent neurosensory disturbances as a result of trigeminal nerve (TN)
injury associated with implant placement is reported at approximately 8%.10 TN neurosensory
disturbance secondary to an injury can manifest as pain, numbness, tingling, or altered sensa-
tion.11 There is a lack of epidemiologic data, particularly in relation to chronic pain secondary to
implants. Some studies suggest an incidence of 8%.3,12 One of the reasons for the lack of
agreement on the prevalence of chronic pain secondary to implants is a lack of common
nomenclature and universally accepted diagnostic criteria. Chronic pain after dental treatments
Copyright ª 2021
has been classified in numerous terms including atypical odontalgia, atypical facial pain,
American Dental
phantom tooth pain, anesthesia dolorosa, painful posttraumatic trigeminal neuropathy, and Association. All rights
PTNP.13-16 reserved.

JADA n(n) n http://jada.ada.org n n 2021 1

 Figure 1. Possible nerve injuries secondary to implant placement. A. Healthy tooth. B. Dental implant placed too close
to a canal may cause nerve compression. C. Injury to the nerve due to partial intrusion of an implant drill or an implant
into a canal. Direct: mechanical injury to a nerve through the encroachment or laceration. Indirect: trauma due to
hematoma or bone debris and secondary ischemia. D. Full implant drill or an implant intrusion into a canal can cause
direct injury to the nerve (transection or compression). E. Heat generated from the drill can lead to primary nerve
damage or peri-implant bone necrosis and postoperative secondary nerve damage.

DIAGNOSIS
According to the 2020 International Classification of Orofacial Pain, the diagnostic criteria for
PTNP require the following characteristics: the presence of persisting or recurring pain within
trigeminal nerve distribution for more than 3 months duration with onset within 6 months of injury
and associated with somatosensory symptoms and, signs, or both. The injury to the trigeminal
nerve’s peripheral branches can be mechanical, thermal, radiation, or chemical with a confirmatory
diagnostic test for a lesion to the nerve.16 The International Classification of Orofacial Pain states
that the severity of nerve injury can vary, ranging from mild to severe, with dental implants as 1 of
the many possible dental treatmenteinduced iatrogenic injuries.

ETIOLOGY
Iatrogenic nerve injuries due to dental implants may result from direct or indirect trauma. The
preparation or osteotomy is more commonly associated with injury than placement. The prepara-
tion bur (during osteotomy) or the placement of the implant can cause direct trauma to the
nerve.17-19 Indirect trauma is secondary to mechanical or chemical causes including extrusion of
debris into the inferior alveolar canal, hemorrhage, and inflammation.17,18 The prevalence of
hemorrhage-induced nerve injury is approximately 24%, in which persistent ischemia of the nerve
occurs owing to hemorrhage caused during placement.2,20 Iron or hemoglobin from the blood can result
in a chemical injury, and hemorrhage can result in direct mechanical damage to the nerve.21-23 Nerve
injury is also possible while administering a local anesthetic (LA).24 Pain can also occur during the
restoration of the implant, rendering the implant nonrestorable.25 The innervation of peri-implant
tissue reportedly increases with postimplant loading, possibly explaining pain associated with placement
of a restoration in some patients.26 In a minority of patients, pain may develop in a well-placed implant
in the absence of complications even with adequate postoperative care. Figure 1 depicts potential nerve
injuries secondary to implant placement.

CLINICAL FEATURES
A combination of environmental, genetic, and psychosocial factors are implicated in the high
variability in the clinical manifestations after identical injuries.12 The type of nerve fibers involved
also determines the clinical phenotype exhibited. An injury to A beta nerve fibers, normally
responsible for light touch sensation, may result in positive (allodynia) and negative (numbness)
changes to light touch, whereas an injury to A delta and C type fibers, normally responsible for the
transmission of noxious stimuli, may manifest as an exaggerated response to painful stimuli
(hyperalgesia).12 The clinical features of pain are variable and mostly described as continuous,
unilateral pain (occurring most of the day and on most days) in the dermatome of the affected
nerve.27 Involvement of both intraoral and extraoral trigeminal dermatomes has been reported.28
Radiation of pain or spreading beyond the dermatome has also been reported,27,29 as have parox-
ysms of pain, which can be spontaneous or evoked by function or touch.30 The onset of pain
typically is reported immediately after implant placement but can occur on the loading of the
implant as well.25 The intensity is moderate to severe, with a quality most often described as

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burning, shooting, or stabbing.30,31 In relation to implant-induced PTNP, the quality of pain also
has been described as sharp, dull, aching, throbbing, discomforting, or tingling in nature.25 Stress,
cold weather, illness including comorbid pain conditions, depression, anxiety, and fatigue are
among the aggravating factors of PTNP.25
Numbness is reported frequently with an implant-induced nerve injury.32 Patients can perceive
swelling or a foreign-body sensation.27,30 Sensory distortions in the orofacial region can interfere
with daily activities such as speaking, chewing, eating, kissing, shaving, and drinking.20 Sensory
changes outside the trigeminal sites may be indicative of central changes.33,34 Patients with PTNP
exhibit a higher prevalence of anxiety, depression, pain catastrophizing, and diminished quality of
life and coping efficacy posing as a psychosocial burden.35,36 The prognosis of PTNP usually is
considered poor, with only about 30% of patients showing improvements in the long term.12,37
The presence of somatosensory signs and symptoms is crucial in diagnosis. Sensory abnormalities
can vary greatly in manifestation, ranging from positive (increased sensation) to negative (dimin-
ished) neurologic symptoms.38,39 Dysfunctions of sensations include unpleasant abnormal sensations
described as pins and needles; painful burning or an aching feeling (dysesthesia); painless abnormal
sensations such as tingling, numbness, skin crawling, or itching (paresthesia); normally nonpainful
stimuli causing pain (allodynia); increased sensitivity to stimuli (hyperesthesia); reduced perception
of stimuli (hypoesthesia); or an absence of sensation (numbness or anesthesia).32,40,41

ASSESSMENT
A detailed history with specific emphasis on characteristics of pain and other symptoms is impor-
tant. The diagnosis of PTNP is accomplished via a thorough history and clinical examination. The
sensory examination plays a critical role in the evaluation and quantification of the sensory changes
associated with PTNP. Sensory symptoms must be recorded in acceptable terms such as allodynia,
dysesthesia, and paresthesia, as we have described previously.42 Patients with PTNP report thermal
and mechanical allodynia.43,44 Some of the methods used to detect somatosensory changes include
patient self-reports, questionnaires, nerve conduction studies, clinical neurosensory tests, and
thermal and electrical quantitative sensory testing (QST).45 Diminished perception of thermal
stimuli, in particular warm stimuli, has been associated with increased risk of developing chronic
pain and more severe sensory symptoms.46 Abnormality in thermal QST has been reported to persist
years after the injury, which represents long-standing sensory alterations.47
Sensory assessment tests (QST and neurosensory tests) may be considered impractical and
difficult to perform in a routine dental practice owing to their complexity and time and financial
constraints. These testing modalities are, therefore, limited to a research setting. Modifications of
these tests suitable for a dental setting have been suggested.12 Chairside neurosensory testing in-
cludes the use of commonly available instruments in a dental practice such as a cotton swab or
monofilament (von Frey, if available) to test for changes in light touch sensation (allodynia), a
dental probe to test for pinprick sensation (hypersensitivity to a noxious stimulus), and warm and
cool instruments for thermal sensation.12,45 It is suggested that clinicians perform the tests bilat-
erally, noting sensation as normal, increased, or reduced on affected and unaffected sides on the
basis of patients response. Regions of abnormal sensations must be mapped, marked, and photo-
graphed for maintaining proper records.12 These data can be used during follow-up visits to evaluate
the progress and patient motivation. The role of imaging is variable. Imaging can provide access to
the extent of nerve damage but can be historic if the offending implant has been removed.45

PREVENTION
Implant-related nerve injuries are avoidable, and hence PTNP is preventable. Dentists must give
adequate importance to preventive measures, which can be divided on the basis of the sequence of
events for the operative or causative procedure into preoperative, intraoperative, and postoperative
procedures. Prevention is of utmost importance as the available management modalities typically do
not offer complete pain relief and may have unpleasant adverse effects.

Preoperative
Recognition of Risk Factors
Age, sex, anxiety, depression, pain catastrophizing, preexisting chronic pain conditions, systemic
illness, and presence of preoperative pain in the site are some of the known factors associated with

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 higher levels of postoperative pain.48-50 Higher levels of anxiety preoperatively also has been linked
to intraoperative resistance to anesthesia, making patients with anxiety at higher risk of experi-
encing postoperative pain.51
In addition to evaluating the patients’ biopsychosocial profile, presurgical planning of the type of
incision and flap and the type of surgery and implant technique to be used is recommended to
minimize the risk of causing nerve injury.49,52,53 Evaluation of the site radiographically plays a major
role in avoiding nerve injury and deciding on the site of placement. The type of available imaging
ranges from conventional panoramic radiograph to cone-beam computed tomography. The
American Academy of Oral and Maxillofacial Radiology recommends cross-sectional cone-beam
computed tomographic imaging as the imaging of choice to assess the site of implant placement.54
Vital anatomic structures and their likely variations should be considered when deciding on the
ideal imaging and site of implant placement.55 Clinical and radiographic assessment is essential in
assessing the overall preoperative risk. It has been reported that 30% of dentists do not conduct a
risk assessment before implant placement and that deficient radiographic evaluation is the most
common cause of nerve injury.20
General predictors of postsurgical pain, such as the patient’s biopsychosocial profile and careful
assessment of the surgical site and the type of surgery and implant technique to be used, should be
considered to minimize the risk of experiencing chronic postsurgical pain.56
It is crucial to educate patients about possible complications, to prepare them in case compli-
cations happen. When treatment planning for the implant is done, it is imperative to obtain
informed consent based on individualized, patient-specific risk assessment. Significant lack of un-
derstanding of potential risks with regard to implant placement has been reported with approxi-
mately 70% of patients who signed the consent form but were unaware of potential nerve injury.28

Intraoperative
Clinicians must pay specific attention to guidelines for an adequate safety zone (2-4 millimeters) and
the use of shorter implants is recommended to minimize the risk of experiencing injury.28,57,58 The
extent of the required safety zone is determined individually on the basis of the operator’s skill and
radiographic interpretation.28 However, it is imperative to emphasize that even a 4-mm safety zone
is not always preventive, and in the presence of significant inflammation, the onset of symptoms
might be slow and eventually result in PTNP. In addition, perineural inflammation secondary to a
well-placed implant may result in PTNP. Intraoperative radiographs are suggested during implant
bed preparation.59 It is important for clinicians to remember that certain preparation drills are
longer than the implant. If a sudden give is encountered during preparation, this may indicate
penetration of the buccal or lingual cortical plate or inferior alveolar nerve canal roof fracture.60
The procedure must be stopped, and prompt action must be taken when bleeding, severe pain,
or sudden drop is encountered. In such cases, the patient should be informed about the possibility of
nerve damage. Immediate referral to an appropriate specialist in TN injuries is recommended in
cases in which nerve injury is suspected. It is recommended not to place the implant in the presence
of intraoperative bleeding. Some reports suggest that the placement should be delayed for 3 days
when intraoperative bleeding occurs.60 Severe pain during preparation is another factor to be
considered. The use of LA infiltrations over nerve blocks has been suggested, so that the patient can
feel pain symptoms if damage to a nerve occurs.28,61 Adequate analgesia is important, particularly
when performing high-risk procedures in susceptible patients; therefore, adequate preventive pre-
and postoperative analgesia is indicated.62,63

Postoperative
Early follow-up is critical in the prevention of chronic pain development. The dental practitioner
must contact the patient routinely within 6 through 12 hours postoperatively to detect any
symptoms of potential nerve damage. In case nerve damage is suspected, this home check is crucial
to ensure LA effect has been reversed and no symptoms have developed. In the event that the
patient reports symptoms of neuropathy, immediate appropriate referral and implant removal is
indicated.64 If numbness persists after LA has worn off, the implant must be removed within a 24-
through 36-hour window to facilitate recovery and prevent development of chronic pain.60,65,66
Delayed removal of implant, wait and watch, and conservative modalities are futile in alleviating
neuropathy and pain.30 If severe pain occurred on administration of LA, then implant removal is

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 Posttraumatic Trigeminal Neuropathic Pain

Pharmacologic Nonpharmacologic Surgical

Systemic drugs:
• Tricyclic antidepressants and • Cognitive-behavioral therapy
• Limited evidence
Serotonin norepinephrine • Psychosocial interventions
reuptake inhibitors • Some cases
• Massage therapy
• Pregabalin microneurosurgey
• Gabapentin • Intergrative and physical therapy
• Topical medications

Figure 2. Summary of modalities indicated in the management of posttraumatic trigeminal neuropathic pain secondary
to implant therapy.

not indicated, and the diagnosis of the cause of injury is LA.67 Steroids and nonsteroidal antiin-
flammatory drugs must be considered in such cases.64,68 Immediate steroid therapy has been shown
to aid in recovery by reducing perineural inflammation and swelling around the nerve.69 When the
nerve injury is confirmed, it is important to inform the patient and describe management options
and prognosis.

MANAGEMENT
The treatment of PTNP remains challenging, and the evidence of the efficacy of available in-
terventions is inconclusive; therefore, an interdisciplinary approach is indicated.70,71 Several mo-
dalities, summarized in Figure 2, with variable evidence have been indicated in the management of
PTNP. These include pharmacotherapy, surgical interventions, and complimentary therapies.72
The first step in management is patient education. Communication with the patient, clarification
regarding the condition, and support are part of initial psychological treatment, which begins with
the dental practitioner.19 The patient expectation is critical for successful management of PTNP;
therefore, patients should be educated regarding prognosis and treatment and should understand
that partial pain relief is a good and expected outcome. Many times, the dentist does not
communicate with the patient, and this increases the uncertainty of the disease in the patient’s
mind, adding to anxiety and stress. The number of required analgesics has been shown to decrease
when the patient education program was integrated with pharmacotherapy.73 Combination ther-
apies are recommended to lower pain, enhance the patient’s coping skills, restore function, and
potentially reduce adverse effects.74 A paradigm for prevention and management of PTNP is
summarized in the Figure 3 flowchart.

Pharmacologic interventions
Pharmacologic interventions are the most frequently used modalities in the management of PTNP
and include a wide variety of drug categories. Antiepileptic drugs and antidepressants, including
tricyclic antidepressants and selective serotonin norepinephrine reuptake inhibitors, are 2
commonly used drug classes.75,76 The first-line drug therapy includes tricyclic antidepressants and
serotonin norepinephrine reuptake inhibitors or gabapentinoids.77 To improve efficacy and reduce
adverse effects, a combination of 2 different drugs is suggested.78 The choice of drug depends on
patient factors, such as presence of systemic comorbidities, age, and drug adverse effect profile.79
The use of pharmacologic therapy in PTNP due to implants has been shown to reduce the pain
level better when early intervention is initiated.80 Overall, these drugs have limited efficacy and
often provide only partial pain relief. It has been reported that only 10% of patients report over 50%
reduction in pain, pointing to poor response of PTNP to pharmacotherapy.81 Topical medication
for PTNP is another possibility to avoid systemic adverse effects.82 The use of compounded topical
medications with various drug combinations, including ketamine, carbamazepine, gabapentin,
pregabalin, clonidine, lidocaine, capsaicin, and ketoprofen in variable concentrations, is also
available.83,84 In intraoral PTNP, the use of a neurostent for delivering topical medication specific
to the site of injury to increase the delivery to the site has been also reported.15

JADA n(n) n http://jada.ada.org n n 2021 5

 Pain, bleeding, or sudden drop Development of NO
High-risk patients
during placement or PTNP less likely
evidence of nerve damage
(sensory changes)
YES
YES
NO High-risk site for
Antiinflammatory:
corticosteroids and nonsteroidal implant placement
anti-inflammatory drugs
Stop bleeding: delay implant
YES
placement
NO
Alternative treatment
Favorable outcome: NO Early intervention planning or consider
pain subsides within 36 h: nonimplant therapy
implant removal

YES

YES Favorable outcome: NO Pain sensory abnormalities

Resolution of care
pain subsides persist > 3 mo

Manage as chronic pain:

PTNP

Figure 3. Summary of the decision-making process in the prevention and management of posttraumatic trigeminal neuropathy (PTNP) secondary to
implant therapy.

Nonpharmacologic interventions and complementary and alternative medicine

PTNP frequently requires long-term management and has been associated with increased risk of
experiencing depression.36 Therefore, it is important to address the psychological component
associated with PTNP. Cognitive-behavioral therapy and psychosocial interventions have been
suggested for management of PTNP, and various behavior therapies, acupuncture, massage therapy,
and integrative and physical therapies have been used as adjunctive therapies in the management of
PTNP.85

Surgical interventions
Evidence supporting the efficacy of surgical interventions in the management of PTNP is limited.
When neuropathy occurs without pain, surgery to improve sensations may be considered.86,87 As
discussed previously, timing for intervention is important because early removal of the offending
implant is suggested to reduce incidence of pain and neuropathy.68 When the implant has
osteointegrated, the evidence for implant removal to alleviate pain and prevent PTNP is limited
because permanent damage is unavoidable. Microneurosurgery has been recommended for total
resection of nerves, but no consensus on timing or a type of surgery is available to date.88 A referral
to a microneurosurgeon is recommended when no obvious pathology is seen on imaging and the
symptoms of anesthesia and hypoesthesia persist for over 3 months with no improvement or dys-
esthesia persists for over 3 months with resolution as a response to peripheral nerve blocks.87

CONCLUSIONS
Implant therapy can cause injury to branches of the TN; therefore, it is important to consider
possible complications. The dental practitioner must be aware of the risks of such injuries, discuss
them with the patient during treatment planning, and have the patient sign an informed consent
form. Fortunately, most injuries are preventable via preoperative assessment, including careful pa-
tient and implant site selection. Avoidance of nerve injuries by means of implementing appropriate
preoperative and intraoperative strategies is critical. The clinician must be aware of the signs and
symptoms of nerve injury during and immediately after a procedure and must contact the patient
the following day to ensure there are no complications. Prompt recognition is key in preventing the
transition to a chronic, irreversible neuropathy. Persistent pain and sensory distortions can be
debilitating to the patient and can negatively affect the quality of life, causing a significant

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psychological burden. Early referral to an appropriate orofacial pain or pain specialist is essential for
appropriate multidisciplinary pain management. Pharmacotherapy, surgical interventions, and
complementary alternative medicine interventions are available for management of PTNP. The key
to success rests in prevention. n

Dr. Kohli is an orofacial pain resident, Center for Orofacial Pain and
Temporomandibular Disorders, Rutgers School of Dental Medicine, Rutg-
ers, the State University of New Jersey, Newark, NJ.
Dr. Katzmann is an orofacial pain resident, Center for Orofacial Pain and
Temporomandibular Disorders, Rutgers School of Dental Medicine, Rutg-
ers, the State University of New Jersey, Newark, NJ.
Dr. Benoliel is a professor, Department of Diagnostic Sciences, Rutgers
School of Dental Medicine, Rutgers, the State University of New Jersey,
Newark, NJ.
Dr. Korczeniewska is an assistant professor, Department of Diagnostic
Sciences, Center for Orofacial Pain and Temporomandibular Disorders,
Rutgers School of Dental Medicine, Rutgers, the State University of New
Jersey, Room D-830, 110 Bergen St, Newark, NJ 07101, e-mail olga.
korczeniewska@rutgers.edu. Address correspondence to
Dr. Korczeniewska.
Disclosure. Dr. Benoliel was remunerated as editor-in-chief of Journal of
Oral & Facial Pain and Headache. None of the other authors reported any
disclosures.
Pain Update is published in collaboration with the Neuroscience Group of
the International Association for Dental Research.

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