Neuropathic Pain in Lower Lip after Guided Tissue Regeneration: A Case Report.

Post-traumatic trigeminal neuropathic pain is mainly caused by the extraction of third molars or the placement of dental implants. This report describes the treatment of neuropathic pain arising after guided tissue regeneration (GTR). The patient was a 55-year-old woman who had to undergo GTR due to severe periodontitis in the distal aspect of the right mandibular second molar. Postoperatively, the patient had been prescribed mecobalamin for hypesthesia and allodynia in the right lower lip. No improvement was observed in these symptoms after 4 months, however, so she was referred to our Orofacial Pain Center. Preoperative and postoperative cone-beam computed tomography revealed a cyst-like lesion (radiolucent area) close to the right mandibular second molar and canal. Although the results of quantitative sensory examination were normal, rubbing the right lower lip with a cotton swab elicited mechanical allodynia. The diagnosis was post-traumatic trigeminal neuropathic pain for which the patient was given pregabalin and Neurotropin®. The symptoms improved within approximately 32 weeks, with the medication being terminated at 64 weeks. Although hypoesthesia due to nerve injury may suddenly go into remission, allodynia is often intractable. If symptoms show no improvement after 3 months, possible nerve injury should be investigated. Additionally, the distal root of the mandibular molar may be close to the inferior alveolar nerve, necessitating appropriate diagnostic imaging of the operative field. If the lesion or distal root is close to the inferior alveolar nerve, postoperative hypesthesia or neuropathic pain may occur, even without direct trauma.

Usefulness of lateral cephalometric radiography for successful blind nasal intubation: a prospective study.

Background: This study aimed to investigate the relationship between pharyngeal morphology and the success or failure of blind nasotracheal intubation using standard lateral cephalometric radiography and to analyze the measurement items affecting the difficulty of blind nasotracheal intubation. Methods: Assuming a line perpendicular to the Frankfort horizontal (FH) plane, the reference point (O) was selected 1 cm above the posterior-most end of the hard palate. A line passing through the reference point and parallel to the FH plane is defined as the X-axis, and a line passing through the reference point and perpendicular to the X-axis is defined as the Y-axis. The shortest length between the tip of the uvula and posterior pharyngeal wall (AW), shortest length between the base of the tongue and posterior pharyngeal wall (BW), and width of the glottis (CW) were measured. The midpoints of the lines representing each width are defined as points A, B, and C, and the X and Y coordinates of each point are obtained (AX, BX, CX, AY, BY, and CY). For each measurement, a t-test was performed to compare the tracheal intubation success and failure groups. A binomial logistic regression analysis was performed using clinically relevant items. Results: The items significantly affecting the success rate of blind nasotracheal intubation included the difference in X coordinates at points A and C (Odds ratio, 0.714; P-value, 0.024) and the ∠ABC (Odds ratio, 1.178; P-value, 0.016). Conclusion: Using binomial logistic regression analysis, we observed statistically significant differences in AX-CX and ∠ABC between the success group and the failure group.

Acupuncture Combined with Trigger Point Injection in Patient with Chronic Myofascial and Referred Pain.

Here, we report a case in which acupuncture combined with trigger point injection was effective in a patient with chronic myofascial pain with referred pain in the masticatory muscles. The patient was a 46-year-old woman with the chief complaint of chronic persistent pain in the region of the left mandibular first molar, which had been extracted 5 months earlier. Stellate ganglion block was performed and amitriptyline administered at another hospital, but were ineffective. At her initial visit to our hospital, her primary complaint was chronic persistent pain in the region of the bilateral mandibular first molars. Several tender points were found on the masseter, temporalis, and sternocleidomastoid muscles, with bilateral referred pain. The pain score according to the visual analogue scale was 85. No significant psychological factors were found, however. Based on these findings, the diagnosis was chronic myofascial pain with referred pain in the masticatory muscles. Therefore, stretching of masticatory muscle and trigger point injection were performed. Two months later, the patient requested trigger point injections to be performed at all tender points, as the previous injections had been effective. The total volume of local anesthetic that this would require was considered to be excessive as there was a large number of tender points, however, and it was feared that a toxic reaction might occur. Therefore, acupuncture in combination with trigger point injection was selected instead. The symptoms disappeared within 9 months after commencement of this therapy, and treatment was completed within 1 year. The present results suggest that acupuncture therapy is effective when used in combination with trigger point injection.

Comparison of Risk Factors in Patients With Acute and Chronic Orofacial Pain.

Management of patients with orofacial pain may benefit from a better understanding about patient factors that may lead pain chronicity. In this study, we retrospectively compared physical and psychological factors in patients with acute and chronic orofacial pain. We analyzed data from 854 patients presenting to the Orofacial Pain Center, Department of Dental Anesthesiology, Tokyo Dental College, Suidobashi Hospital between April 2010 and March 2014. We categorized patients into the acute group if their condition had persisted <6 months and the chronic group if their condition had lasted 6 months or longer, based on the classification by the International Association for the Study of Pain. The retrospective data were analyzed by using univariate analysis on background factors from a health questionnaire, pain evaluation sheet, and psychological test completed at the time of presentation. Multiple logistic regression was applied on these factors. Our results suggest that female gender and high trait anxiety may be involved in orofacial pain becoming chronic.

A Comparative Study of Oral Analgesics for Postoperative Pain After Minor Oral Surgery.

We compared the effects of preoperative administration of diclofenac sodium, celecoxib, and acetaminophen on postoperative pain in patients undergoing minor oral surgery under general anesthesia. One hundred twenty-eight patients were randomly divided into 4 groups preoperatively treated with diclofenac sodium 50 mg, celecoxib 400 mg, acetaminophen 1000 mg, or placebo. Postoperative pain was managed using intravenous patient-controlled infusion of fentanyl. Assessments included levels of postoperative pain by using visual analog scale (VAS) scores at 4, 5, and 6 hours after administration of the test drug; consumption of fentanyl up to each time point; and time to first requirement for fentanyl. Our study demonstrated that, for diclofenac sodium and celecoxib in comparison with placebo, there were significantly lower VAS scores at 4, 5, and 6 hours after oral administration of the study drug; a longer period of time to first requirement for fentanyl after surgery; and less consumption of postoperative fentanyl. A similar analgesic effect versus placebo was noted for acetaminophen but only at the 5- and 6-hour time points. In contrast, no significant differences in VAS scores at 4 hours after administration or time to first requirement for fentanyl were observed between acetaminophen and placebo. Furthermore, no significant differences in measurements were observed between the study drugs at any time point. These findings suggest that oral administration of celecoxib 400 mg is suitable for controlling postoperative pain, and as effective as diclofenac sodium 50 mg. Acetaminophen 1000 mg also exerts analgesic effect with slower onset for postoperative pain.

Propofol-remifentanil is More Effective than Propofol-fentanyl in Decreasing Intraoperative Blood Loss during Sagittal Split Ramus Osteotomy.

This study retrospectively compared blood loss during sagittal split ramus osteotomy in patients receiving propofol-remifentanil (R group) and those receiving propofol-fentanyl (F group). All patients underwent sagittal split ramus osteotomy under general anesthesia during the 3-year 4-month period between October 2007 and February 2011 in an operating room at Tokyo Dental College Suidobashi Hospital. Blood loss in the R group was significantly less than that in the F group. Mean arterial pressure and heart rate, measured at 20 and 15 min after tracheal intubation, respectively, were both lower in the R group. No marked change was observed in blood pressure in the R group under general anesthesia, however. Volume of urine was also larger in the R group. The results of this study suggest that remifentanil is effective in reducing intraoperative blood loss during sagittal split ramus osteotomy.

Effect of combination of trigger point injection and stellate ganglion block on non-odontogenic mandibular molar pain referred from masseter muscle: a case report.

We report a case of myofascial pain syndrome (MPS), manifested as nonodontogenic mandibular molar pain referred from the masseter muscle, relieved by a combination of trigger point injection (TPI) and stellate ganglion block (SGB). The patient was a 32-year-old woman who had experienced cold hypersensitivity in the right third mandibular molar 2 months prior to visiting our department. Subsequently, she had visited a family dentist and undergone pulpectomy under local anesthesia. She eventually visited our clinic because there was no marked change in her symptoms. On the first visit, no tooth abnormality was found and the patient was neither anxious nor depressive. Tender points were found in the right masseter and temporal muscles during muscle palpation. Referred pain radiating to the right mandibular molars was observed when pressure was applied to the central portion of the right masseter muscle. As a result, we diagnosed MPS based on evidence of nonodontogenic tooth pain caused by referred pain from the masseter muscle. We performed TPI with 2% lidocaine hydrochloride to the tender point in the masseter muscle. Although the visual analog scale (VAS) pain score dropped from 97 to 36, complete pain relief was not achieved. The TPI was effective for approximately 7 hrs, after which severe throbbing pain returned. The sustained nature of the tooth pain suggested that it was sympathetic nerve-dependent. Subsequently, we performed SGB, resulting in a reduction in the VAS pain score from 90 to 32. Therefore, we performed another TPI and the VAS pain score dropped to 0. We continued SGB and TPI for the next 3 days and the symptoms disappeared. Thus, a combination of TPI and SGB controlled MPS manifested as masseter muscle-mediated nonodontogenic tooth pain.

Midazolam more effectively suppresses sympathetic activations and reduces stress feelings during mental arithmetic task than propofol.

PURPOSE: The aim of the present study was to examine the effect of intravenous midazolam and propofol sedation on autonomic nervous activities during psychological stress, and whether these results are associated with changes in subjective stress feelings. MATERIALS AND METHODS: Seven healthy male volunteers were included in a randomized crossover manner. The heart rate (HR), HR variability, arterial oxygen saturation, and bispectral index value were continuously monitored. A mental arithmetic task for 7 minutes was given with or without intravenous sedation with midazolam or propofol. A bispectral index value of 75 to 85 and an Observer's Assessment of Alertness/Sedation score of 4 were the targeted sedation level in both groups. HR variability was assessed using the power spectral analysis (low-frequency [LF] and high-frequency [HF] components and LF/HF ratio). The faces anxiety scale was used to grade their stress feelings after each mental arithmetic task. RESULTS: During the mental arithmetic task with intravenous sedation, no differences were found in the bispectral index values, arterial oxygen saturation, or the results of the mental arithmetic task between the 2 groups. The HR, LF/HF ratio, and normalized unit LF increased, and the normalized unit HF decreased in both groups. However, the percentage of changes in LF/HF ratio, normalized unit LF, and normalized unit HF were smaller in the midazolam group. In addition, the reduction in faces anxiety scale was greater in the midazolam group. CONCLUSIONS: These results suggest that midazolam more effectively suppresses sympathetic nervous activation and reduces subjective stress feelings during a mental arithmetic task than propofol.

Effects of intravenous adenosine 5'-triphosphate on intraoperative hemodynamics and postoperative pain in patients undergoing major orofacial surgery: a double-blind placebo-controlled study.

PURPOSE: We conducted a double-blind placebo-controlled study to investigate the effects of the intraoperative intravenous infusion of adenosine 5'-triphosphate (ATP) on intraoperative hemodynamics and postoperative pain in patients undergoing major orofacial surgery. METHODS: Thirty patients (age, 16-42 years; 16 males/14 females) scheduled for sagittal split ramus osteotomy were assigned in a double-blind fashion to receive intraoperative intravenous infusion of ATP (n = 15) or saline (n = 15). Anesthesia was induced and maintained with propofol, fentanyl, and vecuronium. Local anesthesia was added for intraoperative analgesia. In the ATP group, ATP was infused at a rate of 160 microg.kg(-1).min(-1) throughout surgery. Postoperative pain was managed with intravenous patient-controlled analgesia (PCA) with morphine. The intensity of postoperative pain was assessed with a verbal numeric rating scale (NRS). Morphine consumption was also assessed. RESULTS: There were no differences in demographic, anesthetic, and surgical data between the ATP and placebo groups. Intraoperatively, ATP effectively suppressed responses of blood pressure and heart rate to painful surgical stimuli. There were no differences in postoperative NRS scores between the two groups. However, postoperative morphine consumption was significantly less in the ATP group, compared with the placebo group, throughout the 72-h postoperative observation period. Cumulative morphine consumption for 72 h postoperatively was 47% less with ATP, compared with placebo. No adverse effect of ATP was observed. CONCLUSION: Our data suggest that intraoperative ATP infusion can blunt hemodynamic responses to surgical stimuli and produce prolonged analgesia in patients undergoing major orofacial surgery.