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Eldredge RS, Ochoa B, Khoury E, Mihalcin K, Ostlie D, Lee J, McMahon L, Notrica D, Padilla BE. Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation. J Pediatr Surg 2024; 59:379-384. [PMID: 37973420 DOI: 10.1016/j.jpedsurg.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. METHODS A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. RESULTS The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. CONCLUSION In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- R Scott Eldredge
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; Division of General Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Brielle Ochoa
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Emily Khoury
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Kristin Mihalcin
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA
| | - Daniel Ostlie
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Justin Lee
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - David Notrica
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, USA; University of Arizona School of Medicine, Phoenix, AZ, USA.
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Chaar MS, Naguib AA, Abd Alsamad AM, Ahmed DF, Abdel Nabi N, Kern M. Vascular and neurosensory evaluation in relation to lingual canal anatomy after mandibular midline implant installation in edentulous patients. Clin Oral Investig 2022; 26:3311-3323. [PMID: 34985576 PMCID: PMC8898232 DOI: 10.1007/s00784-021-04312-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/20/2021] [Indexed: 11/24/2022]
Abstract
Objectives The aim of this study is to investigate vascular and neurosensory complications in edentulous patients following the installation of mandibular midline single implants in relation to lingual canals. Materials and methods After performing a cone beam computed tomography scan for the 50 recruited patients, the relationship between the potential implant site and the lingual canals was assessed, and all vascular and neurosensory complications were recorded. Results Six patients (12%) reported profuse bleeding during implant placement, and 13 (26%) reported transient neurosensory changes, which were resolved after 3 months. According to the virtual implant planning, 44 patients (88%) would have their implants touching the lingual canals, six of them reported vascular changes (14%), and 12 out of 44 patients reported neurosensory changes (27%). For the six patients who would have their implants not touching the lingual canals, one patient reported transient neurosensory changes. Conclusions The mandibular lingual canals are constant anatomic landmarks. Injury to the supra-spinosum lingual canals may occur during midline implant placement, depending on the implant length and the bone height. Clinical relevance Despite that injury to the supra-spinosum lingual canals during implant insertion does not result in permanent vascular or neurosensory complications, caution is required to avoid the perforation of the lingual cortices.
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Affiliation(s)
- Mohamed Sad Chaar
- Department of Prosthodontics, Propaedeutic and Dental Materials, School of Dentistry, Christian-Albrechts University, Kiel, Germany.
| | - Amr Ahmed Naguib
- Department of Removable Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Ahmed Mohamed Abd Alsamad
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Dina Fahim Ahmed
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Nouran Abdel Nabi
- Department of Removable Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Matthias Kern
- Department of Prosthodontics, Propaedeutic and Dental Materials, School of Dentistry, Christian-Albrechts University, Kiel, Germany
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Verma R, Vyas P, Kaur J, Javed MN, Sarafroz M, Ahmad M, Gilani SJ, Taleuzzaman M. Approaches for ear-targeted delivery systems in neurosensory disorders to avoid chronic hearing loss mediated neurological diseases. CNS Neurol Disord Drug Targets 2021; 21:479-491. [PMID: 34477535 DOI: 10.2174/1871527320666210903102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/17/2021] [Accepted: 04/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND & OBJECTIVE Hearing loss is a common audio-vestibular-related neurosensory disability of inner ears, in which patients exhibit clinical symptoms of dizziness, gait unsteadiness, and oscillopsia, at an initial stage. While, if such disorders are untreated for a prolonged duration then the progression of disease into a chronic state significantly decreases GABA level as well as an alteration in the neurotransmission of CNS systems. Hence, to control the progression of disease into a chronic state, timely and targeted delivery of the drug into the site of action in the ear is now attracting the interest of neurologists for effective and safe treatment of such disorders. Among delivery systems, owing to small dimension, better penetration, rate-controlled release, higher bioavailability; nanocarriers are preferred to overcome delivery barriers, improvement in residence time, and enhanced the performance of loaded drugs. Subsequently, these carriers also stabilize encapsulated drugs while the opportunity to modify the surface of carriers favors guided direction for site-specific targeting. Conventional routes of drug delivery such as oral. intravenous, and intramuscular are poorer in performance because of inadequate blood supply to the inner ear and limited penetration of blood-inner ear barrier. CONCLUSION This review summarized novel aspects of non-invasive and biocompatible nanoparticles-based approaches for targeted delivery of drugs into the cochlea of the ear to reduce the rate, and extent of the emergence of any hearing loss mediated neurological disorders.
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Affiliation(s)
- Rishabh Verma
- Department of Pharmacology, Faculty of Pharmacy, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
| | - Preeti Vyas
- Department of Pharmacology, Faculty of Pharmacy, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
| | - Jasmeet Kaur
- Department of Pharmacognosy, Faculty of Pharmacy, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
| | - Md Noushad Javed
- Department of Pharmaceutics, Faculty of Pharmacy, School of Pharmaceutical Education & Research, Jamia Hamdard, New Delhi-110062, India
| | - Mohammad Sarafroz
- Department of Pharmaceutical Chemistry, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, City Dammam, Saudi Arabia
| | - Makhmur Ahmad
- Department of Pharmaceutics, Buraydah College of Pharmacy and Dentistry, P.O Box- 31717, Buraydah- 51452, Al-Qassim, Saudi Arabia
| | - Sadaf Jamal Gilani
- College of Basic Health Science, Princess Nourah bint Abdulrahman University, Riyadh. Saudi Arabia
| | - Mohamad Taleuzzaman
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Maulana Azad University, Jodhpur, 342802, Rajasthan, India
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Liu PK, Chang YC, Wu WC. Management of refractory macular hole with blood and gas-assisted autologous neurosensory retinal free flap transplantation: a case report. BMC Ophthalmol 2018; 18:230. [PMID: 30176829 PMCID: PMC6122747 DOI: 10.1186/s12886-018-0909-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022] Open
Abstract
Background Macular hole (MH) may become refractory if the hole does not close after multiple surgeries. We provide a modified surgical technique for refractory MH repair with neurosensory retinal free flap transplantation. Case presentation To treat a 68-year-old female patient with refractory MH after multiple surgeries, we harvested a neurosensory retinal free flap with a 2-MH diameter area. A drop of whole blood was placed within the MH as an adhesive to fix the neurosensory retinal free flap at the MH under gas tamponade. Two months after surgery, optical coherence tomography (OCT) revealed closure of the MH. The flap was visible on OCT and had filled the MH without overlapping the neurosensory retina. The patient’s best-corrected visual acuity (BCVA) improved from 20/500 preoperatively to 20/50 at 2 months postoperatively. Conclusions Using whole blood as an adhesive to aid in the fixation of an autologous neurosensory retinal free flap under gas tamponade provides another option for patients with refractory MH due to multiple prior surgeries. Electronic supplementary material The online version of this article (10.1186/s12886-018-0909-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pei-Kang Liu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Ophthalmology, Yuan's General Hospital, No. 162 Cheng Kung 1st Road, Kaohsiung, 80249, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-Sen University, 70 Lienhai Rd, Kaohsiung, 80424, Taiwan
| | - Yo-Chen Chang
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, 100, Shih-Chuan 1st Road, Kaohsiung, 80708, Taiwan
| | - Wen-Chuan Wu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung, 807, Taiwan. .,Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, 100, Shih-Chuan 1st Road, Kaohsiung, 80708, Taiwan.
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Abstract
Although very preterm birth and very low birthweight are recognized risk factors for longer term developmental difficulties, there is a wide spectrum of outcomes for children and adolescents born preterm. Biological and social variables have the potential to explain this variability. Although current understanding of these influences and how they interact is incomplete, perinatal factors are related to permanent neurosensory impairments such as cerebral palsy, blindness, and deafness. Cognitive and academic outcomes are variably associated with biological and social variables across development, and the most robust correlates of behavior and mental health difficulties include early behavioral problems and family influences.
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Affiliation(s)
- Alice C Burnett
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria 3010, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia.
| | - Jeanie L Y Cheong
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3010, Australia; Neonatal Services, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Newborn Research, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Melbourne, Victoria 3052, Australia
| | - Lex W Doyle
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria 3010, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3010, Australia; Newborn Research, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Melbourne, Victoria 3052, Australia
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Abstract
The domain within the otic vesicle (OV) known as the neurosensory domain (NSD), contains cells that will give rise to the hair and support cells of the otic sensory organs, as well as the neurons that form the cochleovestibular ganglion (CVG). The molecular dynamics that occur at the NSD boundary relative to adjacent OV cells is not well defined. The Tbx1 transcription factor gene expression pattern is complementary to the NSD, and inactivation results in expansion of the NSD and expression of the Notch ligand, Jag1 mapping, in part of the NSD. To shed light on the role of Jag1 in NSD development, as well as to test whether Tbx1 and Jag1 might genetically interact to regulate this process, we inactivated Jag1 within the Tbx1 expression domain using a knock-in Tbx1Cre allele. We observed an enlarged neurogenic domain marked by a synergistic increase in expression of NeuroD and other proneural transcription factor genes in double Tbx1 and Jag1 conditional loss-of-function embryos. We noted that neuroblasts preferentially expanded across the medial-lateral axis and that an increase in cell proliferation could not account for this expansion, suggesting that there was a change in cell fate. We also found that inactivation of Jag1 with Tbx1Cre resulted in failed development of the cristae and semicircular canals, as well as notably fewer hair cells in the ventral epithelium of the inner ear rudiment when inactivated on a Tbx1 null background, compared to Tbx1Cre/− mutant embryos. We propose that loss of expression of Tbx1 and Jag1 within the Tbx1 expression domain tips the balance of cell fates in the NSD, resulting in an overproduction of neuroblasts at the expense of non-neural cells within the OV. Summary: Normal dosages of Tbx1 and Jag1 are required to maintain a proper balance of cell types within the neurosensory domain of the otic vesicle to form the inner ear.
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Affiliation(s)
- Stephania Macchiarulo
- Department of Genetics, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461, USA
| | - Bernice E Morrow
- Department of Genetics, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461, USA .,Departments of Obstetrics and Gynecology and Pediatrics, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461, USA
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Bashir H, Seykora JT, Lee V. Invisible Shield: Review of the Corneal Epithelium as a Barrier to UV Radiation, Pathogens, and Other Environmental Stimuli. J Ophthalmic Vis Res 2017; 12:305-311. [PMID: 28791065 PMCID: PMC5525501 DOI: 10.4103/jovr.jovr_114_17] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The ocular surface is comprised of the cornea and conjunctiva, which are structures that not only protect the eye but also enable vision. The corneal epithelium is the most superficial layer of the cornea, and therefore first line of defense against external assaults. Damage to this highly specialized structure could lead to vision loss, making it an important structure to investigate and understand. Here, we conducted a search of the current literature on the mechanisms the corneal epithelium has adapted against three frequent insults: UV-radiation, pathogens, and environmental assaults. This review systematically examines the corneal epithelium's response to each assault in order to maintain its role as an invisible shield. The goal of this review is to provide insight into some of the critical functions the corneal epithelium performs that may be valuable to current regenerative studies.
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Affiliation(s)
- Hasan Bashir
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, USA
| | - John T Seykora
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | - Vivian Lee
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, USA
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Abstract
BACKGROUND Traumatic brain injury is an increasingly prevalent injury seen in both civilian and military populations. Regardless of the mechanisms of injury, the most common sub-type of injury continues to be mild traumatic brain injury. Within the last decade, there has been tremendous growth in the literature regarding this disease entity. PURPOSE To describe the obstacles necessary to overcome in performing a rigorous and sound clinical research study investigating mild traumatic brain injury. This examination begins by a consideration of changing standards for good faith open and total reporting of any and all conflicts of interest or commitment. This issue is particularly critical in mTBI research. We next examine obstacles that include but are not limited to diagnostic criteria, inclusion/exclusion criteria, source of injury, previous history of injury, presence of comorbid conditions and proper informed consent of participants. Frequently, multi-center studies are necessary for adequate subject accrual with the added challenges of site coordination, data core management and site specific study conduct. We propose a total reversal to the traditional translational research approach where clinical studies drive new concepts for future basic science studies. CONCLUSIONS There have been few mild traumatic brain injury clinical trials in the literature with treatments/interventions that have been able to overcome many of these described obstacles. We look forward to the results of current and ongoing clinical mild traumatic brain injury studies providing the tools necessary for the next generation of basic science projects.
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Affiliation(s)
- Michael E Hoffer
- Department of Otolaryngology, University of Miami, Miller School of Medicine, United States; Department of Neurological Surgery, University of Miami, Miller School of Medicine, United States; University of Miami, Sports Performance and Wellness Institute, United States.
| | - Mikhaylo Szczupak
- Department of Otolaryngology, University of Miami, Miller School of Medicine, United States; University of Miami, Sports Performance and Wellness Institute, United States
| | - Carey Balaban
- Department of Otolaryngology, University of Pittsburgh, United States
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Al-Sabbagh M, Okeson JP, Bertoli E, Medynski DC, Khalaf MW. Persistent pain and neurosensory disturbance after dental implant surgery: prevention and treatment. Dent Clin North Am 2015; 59:143-156. [PMID: 25434563 DOI: 10.1016/j.cden.2014.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Nerve trauma caused by dental implant placement is associated with altered sensation and chronic pain. Complete or partial loss of sensation is often reported by patients who have experienced nerve trauma during implant surgery. Some patients report persistent pain and neurosurgery disturbance long after the normal healing time has passed. In addition, neuropathic pain is reported after implant surgery. Practitioners who place dental implants must be familiar with the differential diagnosis, prevention, and management of neuropathic pain. This article provides insights into the prevention and management of neurosensory deficits and chronic persistent neuropathic pain and considerations for patient referral.
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Affiliation(s)
- Mohanad Al-Sabbagh
- Division of Periodontology, Department of Oral Health Practice, University of Kentucky, College of Dentistry, 800 Rose Street, Lexington, KY 40536, USA.
| | - Jeffrey P Okeson
- Department of Oral Health Science, College of Dentistry, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Elizangela Bertoli
- Division of Restorative Dentistry, Department of Oral Health Practice, University of Kentucky, College of Dentistry, 800 Rose Street, Lexington, KY 40536, USA
| | - Denielle C Medynski
- UCSF Center for Orofacial Pain, 513 Parnassus Avenue, S-738, San Francisco, CA 94143-0476, USA
| | - Mohd W Khalaf
- Private Practice, Orofacial Pain and Oral Medicine Division, Department of Head and Neck Surgery, Kaiser Permanente, 7300 Wyndham Street, Sacramento, CA 95823, USA
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Al-Sabbagh M, Okeson JP, Khalaf MW, Bhavsar I. Persistent pain and neurosensory disturbance after dental implant surgery: pathophysiology, etiology, and diagnosis. Dent Clin North Am 2014; 59:131-42. [PMID: 25434562 DOI: 10.1016/j.cden.2014.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many studies have documented the successful outcomes of dental implants, but have also reported the association of sensory disturbances with the surgical implant procedure. Postsurgical pain is a normal response to tissue injury, and usually resolves after the tissue heals. However, some patients who receive dental implants experience persistent pain even after normal healing. This article describes the basic anatomy and pathophysiology associated with nerve injury. The incidence and diagnosis of these problems, in addition to factors that result in the development of chronic persistent neuropathic pain and sensory disturbances associated with surgical implant placement, are discussed.
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Affiliation(s)
- Mohanad Al-Sabbagh
- Division of Periodontology, Department of Oral Health Practice, University of Kentucky, College of Dentistry, 800 Rose Street, Lexington, KY 40536, USA.
| | - Jeffrey P Okeson
- Department of Oral Health Science, College of Dentistry, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Mohd W Khalaf
- Orofacial Pain and Oral Medicine Division, Department of Head and Neck Surgery, Kaiser Permanente, 7300 Wyndham Street, Sacramento, CA 95823, USA
| | - Ishita Bhavsar
- Division of Periodontology, Department of Oral Health Practice, University of Kentucky, College of Dentistry, 800 Rose Street, Lexington, KY 40536, USA
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