JADA, Vol .

131, Jul y 2000 901

It has been documented that on rare occa-
si ons, an i nferi or al veol ar nerve bl ock can cause
permanent al terati on i n sensati on over the di s-
tri buti on of the l i ngual nerve, the i nferi or al veo-
l ar nerve or both nerves.
1,2
Studi es have suggest-
ed that i n the vast majori ty of cases when a
nerve i s affected abnormal l y by l ocal anestheti c,
spontaneous recovery occurs over an ei ght-week
peri od.
1,3
I t has been esti mated that between 85
percent
1
and 94 percent
2
of such i njuri es resol ve
i n thi s way. However, another study has suggest-
ed that i f recovery does not occur fai rl y qui ckl y,
then onl y about one-thi rd of these pati ents may
go on to experi ence recovery and two-thi rds of
them may have permanent i mpai rment.
3
The true i nci dence of permanent nerve i nvol ve-
ment and i ts possi bl e eti ol ogy and management
remai n controversi al . An arti cl e i n 1995 by one of
the present authors (M.A.P.) and col l eagues
3
docu-
mented 12 pati ents wi th resi dual nerve i nvol ve-
ment as a resul t of an i nferi or al veol ar nerve bl ock.
Si nce thi s arti cl e was publ i shed, the pri mary
author has recei ved many communi cati ons worl d-
wi de on thi s condi ti on and has had the opportuni ty
to exami ne many more pati ents wi th thi s probl em,
al l owi ng further concl usi ons to be drawn.
A B S T R A C T
Background. Thi s i s a prospecti ve study of
pati ents referred to a terti ary care center wi th perma-
nent al terati on i n sensati on of the i nferi or al veol ar
nerves, l i ngual nerves or both that coul d have resul t-
ed onl y from an i nferi or al veol ar nerve bl ock.
Methods. Worki ng wi th a subject pool of 83
pati ents, the researchers outl i ned and photographed
the area of al tered sensati on on each pati ent, tested i t
wi th von Freys hai rs and two-poi nt di scri mi nati on
and tested temperature sensati on and di recti on sense.
Results. Among a study popul ati on of 55
women and 28 men wi th a mean age of 41.2 years,
the l i ngual nerve was affected i n 79 percent of
pati ents and the i nferi or al veol ar nerve i n 21 percent
of pati ents. I n 47 pati ents, the causati ve i nferi or
al veol ar nerve bl ock was pai nful when admi ni stered,
but i n the other 25 pati ents, i t fel t l i ke a normal
i njecti on. Of the l ocal anestheti c agents used, pri l o-
cai ne was found to be more frequentl y l i nked to cases
of nerve i nvol vement i n thi s study.
Discussion. Occasi onal l y, an i nferi or al veo-
l ar nerve bl ock can resul t i n permanent i nvol vement
of the i nferi or al veol ar nerve, l i ngual nerve or both.
The i nci dence and exact mechani sm of i nvol vement
sti l l are unknown. By extrapol ati on from thi s study,
an i nci dence of anywhere between 1:26,762 and
1:160,571 i nferi or al veol ar nerve bl ocks can be sur-
mi sed to resul t i n thi s compl i cati on. A di fference i n
referral rates for mal e and femal e pati ents i s di ffi -
cul t to expl ai n. The 36 percent i nci dence of dysesthe-
si a i n the pati ents i n thi s study i s of concern.
Conclusion. Permanent nerve i nvol vement
after recei vi ng an i nferi or al veol ar nerve bl ock i s a
documented but very rare compl i cati on of the i nferi -
or al veol ar nerve bl ock, and the exact mechani sm
i nvol ved i s sti l l unknown.
Clinical Implications. Permanent
nerve damage can very occasi onal l y occur as a resul t
of an i nferi or al veol ar nerve bl ock. The exact mecha-
ni sm i s unknown, and there i s no means of preven-
ti on. Knowl edge of the ri sks and compl i cati ons of
l ocal anesthesi a i s essenti al .
PERMANENT NERVE INVOLVEMENT RESULTING
F R O M I N F E R I O R A LVE O L A R N E R VE B L O C K S
M . A N T H O N Y P O G R E L , D . D . S . , M . D . , F . A . C . S . , F . R . C . S . ; S R I T H A M B Y, B . D . S . , M . D . S C . , F . R . A . C . D . S .
J
A
D
A
C
O
N
T
I
N
U
I
N
G E
D
U
C
A
T
I
O
N

ARTICLE 2
Copyright 1998-2001 American Dental Association. All rights reserved.
Thi s arti cl e reports on a
study of these pati ents and oth-
ers who had experi enced what
appeared to be permanent
nerve i nvol vement after recei v-
i ng an i nferi or al veol ar nerve
bl ock.
SUBJECTS AND METHODS
The subject group consi sted of
83 consecuti ve pati ents wi th
al tered sensati on over the di s-
tri buti on of the l i ngual nerve,
i nferi or al veol ar nerve or both
nerves as a resul t of recei vi ng
an i nferi or al veol ar nerve bl ock.
The study popul ati on consi sted
of ei ght subjects from the ori gi -
nal 12 previ ousl y descri bed i n
1995
3
(the other four pati ents
recovered) and an addi ti onal 75
pati ents seen si nce 1995. Al l of
these pati ents have had al tered
sensati on for more than one
year wi th no si gns of i mprove-
mentthe cri teri on that must
be met for thi s condi ti on to be
consi dered permanent. Of the
83 pati ents, 70 were from
northern Cal i forni a, 12 were
from the Uni ted States outsi de
of northern Cal i forni a, and one
was an i nternati onal pati ent. I n
al l cases, onl y restorati ve den-
ti stry had been performed after
the admi ni strati on of the nerve
bl ock, and there was no other
possi bl e cause of the nerve
i nvol vement.
The pati ents consi sted of 55
women and 28 men. The mean
age was 41.2 years (range, 21 to
83 years).
RESULTS
The nerves i nvol ved i n the
study group are shown i n the
tabl e. The total shown i s more
than the number of pati ents
because i n seven pati ents, both
the l i p and tongue were affected
on the same si de, and i n one
pati ent, both i nferi or al veol ar
nerves and both l i ngual nerves
were permanentl y affected after
three i nferi or al veol ar nerve
bl ocks (two on one si de and one
on the other si de).
Si xty-seven pati ents were
gi ven the causati ve i njecti on by
a general dental practi ti oner,
fi ve by an endodonti st and one
by a peri odonti st. I n the cases
i n whi ch the l ocal anestheti c
was known, 33 pati ents
recei ved l i docai ne, 32 pati ents
recei ved pri l ocai ne and three
pati ents recei ved mepi vacai ne.
Twel ve pati ents recei ved mul ti -
pl e i nferi or al veol ar nerve
bl ocks wi th di fferent agents: si x
recei ved a carpul e of pri l ocai ne
fol l owed by a carpul e of l i do-
cai ne; two recei ved a carpul e of
pri l ocai ne fol l owed by a carpul e
of mepi vacai ne; one recei ved a
carpul e of pri l ocai ne fol l owed by
a carpul e of eti docai ne; one
recei ved a carpul e of mepi va-
cai ne fol l owed by a carpul e of
l i docai ne; and one recei ved
three carpul es of mepi vacai ne,
two carpul es of bupi vacai ne and
one carpul e of l i docai ne. The
reasons for these mul ti pl e i njec-
ti ons vari ed. I n some cases, i t
was the routi ne practi ce; i n oth-
ers, i t was because the fi rst
bl ock was i neffecti ve. I n three
cases, the l ocal anestheti c used
was unknown. Thi s was ei ther
because the denti st i nvol ved
had l eft the practi ce and no
i nformati on was avai l abl e, or
because more than one l ocal
anestheti c was i n routi ne use i n
the dental offi ce and the par-
ti cul ar agents had not been
recorded and coul d not be
recal l ed by the denti st.
Of the 83 pati ents, 36 coul d
not recal l anythi ng unusual
about the i njecti on and were
not aware of the el ectri c shock
sensati on that often accompa-
ni es nerve i nvol vement. The
other 47 pati ents ei ther
recei ved a very pai nful i njecti on
or fel t the el ectri c shock sensa-
ti on. From a symptomati c
standpoi nt, 28 pati ents report-
ed dysesthesi a as thei r most
troubl esome symptom, whi l e, i n
the other 55 pati ents, paresthe-
si a or anesthesi a as
predomi nant.
To date, fi ve pati ents have
undergone surgi cal expl orati on
of thei r i njuri es. The seni or
author (M.A.P.) operated on
three of these pati ents. The
902 JADA, Vol . 131, Jul y 2000
RESEARCH
TABLE
NERVE AFFECTED
NUMBER OF PATIENTS WITH
PERMANENT INVOLVEMENT
NERVES PERMANENTLY AFFECTED BY
INFERIOR ALVEOLAR NERVE BLOCK.
* Total i s more than the total number of pati ents (N = 83), as the l i p and tongue on the
same si de were permanentl y affected i n seven pati ents, and both i nferi or al veol ar
nerves and both l i ngual nerves were affected i n one pati ent.
Ri ght i nferi or al veol ar nerve
Ri ght l i ngual nerve
Left i nferi or al veol ar nerve
Left l i ngual nerve
TOTAL
13
34
14
32
93*
Copyright 1998-2001 American Dental Association. All rights reserved.
other two were treated by di f-
ferent surgeons, and we
obtai ned reports on thei r opera-
ti ons and spoke to the surgeons.
I n al l fi ve cases, there was no
obvi ous damage to the nerve
seen at surgery even when the
fasci cl es were di ssected, apart
from a sl i ght i ncrease i n adhe-
si ons around the nerve and a
sl i ghtl y whi ter appearance of
the nerve i n the area of the
i njecti ons compared wi th a
creami er appearance el sewhere.
Pati ents had not recei ved nerve
grafts or other nerve surgery,
and none of the fi ve pati ents
benefi ted symptomati cal l y from
the surgery. I n fact, two
pati ents stated that thei r pai n
was worse after the surgery. I n
fi ve pati ents, the symptoms of
dysesthesi a have taken on the
characteri sti cs of causal gi a or
sympatheti cal l y medi ated pai n
wi th a deep, bori ng, burni ng
pai n and occasi onal fl ushi ng
over the associ ated cheek,
symptoms that have been
reported previ ousl y.
4
I n si x
pati ents, the dysesthesi a
appeared to have spread proxi -
mal l y to i nvol ve other tri gemi -
nal nerve trunks, parti cul arl y
the maxi l l ary branch (Fi gure 1).
Several of the pati ents wi th
dysesthesi a have been referred
to a pai n management cl i ni c.
The seni or author exami ned al l
pati ents and tested them wi th
pi npri ck to outl i ne the area of
al tered sensati on, whi ch was
photographed. Wi thi n the
affected area, sensati on was
eval uated wi th von Freys
hai rs
5
and two-poi nt di scri mi na-
ti on, as wel l as wi th tempera-
ture sensati on (hot and col d
water) or Mi nnesota Thermal
Di scs
6
or both, and pati ents al so
were tested for di recti on sense.
Resi dual nerve i nvol vement
ranged from mi l d to compl ete
anesthesi a (i n
two cases) and,
i n al l cases,
the area out-
l i ned covered
vi rtual l y the
whol e di stri bu-
ti on of the
affected nerve.
DISCUSSION
The i nci dence
of nerve
i nvol vement
from i nferi or
al veol ar nerve
bl ock i s un-
known, but i t
can be i nfor-
mal l y cal cul at-
ed i n the
fol l owi ng
manner. Fi rst,
current sal es of
l ocal anesthet-
i cs for
denti stry i n
the Uni ted
States are
approxi matel y
161 mi l l i on
carpul es per
year (Ri chard D. Fi nkel man,
D.D.S., Ph.D., Astra-Zeneca
Corp., oral communi cati on,
1999). I n thi s study, 75 pati ents
l i vi ng i n northern Cal i forni a
(popul ati on 10.2 mi l l i on) who
had such nerve i nvol vement
were seen over a 48-month peri -
od begi nni ng i n August 1995
(an average of 18.75 pati ents
per year). Northern Cal i forni a
contai ns about 3.74 percent of
the U.S. popul ati on (approxi -
matel y 272,878,000 peopl e).
Usi ng these fi gures for the
basi s of an i nformal esti mate,
and cal cul ati ng that around
hal f of al l the l ocal anestheti c
carpul es admi ni stered duri ng
that 48-month peri od were for
i nferi or al veol ar nerve bl ocks,
thi s gi ves an esti mated i nci -
dence of permanent nerve
i nvol vement of 1:160,571 i nferi -
or al veol ar nerve bl ocks. Thi s i s
around four ti mes greater than
previ ous studi es have suggest-
ed.
2,3,7,8
Even so, i t probabl y
represents an underesti mate,
as i t i s doubtful that we i n the
Uni versi ty of Cal i forni a San
Franci sco Department of Oral
and Maxi l l ofaci al Surgery are
seei ng al l cases of thi s
condi ti on.
I n terms of anecdotal evi -
dence, the seni or author kept a
tel ephone l og of cal l s recei ved
si nce our previ ous arti cl e on
thi s subject was publ i shed.
3
For
each pati ent actual l y seen and
exami ned who have thi s prob-
JADA, Vol . 131, Jul y 2000 903
RESEARCH
Figure 1. The area of altered sensation (anesthesia
and dysesthesia) resulting from an inferior alveolar
nerve block in two patients. In each case, the area
increased over a one-year period after commencing
on the lower lip.
Copyright 1998-2001 American Dental Association. All rights reserved.
l em, tel ephone i nformati on has
been recei ved for fi ve other
pati ents who apparentl y have
the same probl em. I f al l these
other pati ents were exami ned
and found to be si mi l arl y affect-
ed, thi s woul d mean the i nci -
dence woul d be on the order of
1:26,762 i nferi or al veol ar nerve
bl ocks, whi ch i s wi thi n the
range of bl ocks that the ful l -
ti me practi ci ng denti st mi ght
admi ni ster duri ng a l i feti me of
work. Thus, perhaps every ful l -
ti me practi ti oner wi l l fi nd that
he or she has one pati ent dur-
i ng hi s or her career who has
permanent nerve i nvol vement
resul ti ng from an i nferi or al veo-
l ar nerve bl ock. However, i t i s
sti l l doubtful that we are
recei vi ng i nformati on about al l
the pati ents wi th the condi ti on,
so the true i nci dence remai ns
unknown.
I n any pati ent who has had
surgery and suffered nerve
damage, we have to assume
gi ven the present state of
knowl edgethat the damage
was caused by the surgery. I t i s
possi bl e that i n some of these
cases, the nerve i nvol vement
was caused by the i nferi or al ve-
ol ar nerve bl ock and not the
surgery, but there i s no way of
determi ni ng that.
I n terms of i nci dence, there
was no stati sti cal di fference
between the ri ght and l eft
si des. However, the l i ngual
nerve was affected 79 percent of
the ti me; thi s may be because
when the mouth i s wi de open,
the l i ngual nerve i s hel d ti ghtl y
i n the ti ssues and i s unabl e to
be defl ected by the needl e.
Taste al so was affected often,
i ndi cati ng i nvol vement of the
corda tympani . I n the current
study, when the type of l ocal
anestheti c was known and onl y
a si ngl e agent was used, 48 per-
cent of pati ents recei ved l i do-
cai ne, 47 percent recei ved pri l o-
cai ne and 5 percent recei ved
mepi vacai ne. Thi s corresponds
wi th nati onal sal es fi gures that
suggest that of al l l ocal anes-
theti cs used by denti sts i n the
Uni ted States, l i docai ne i s used
62 percent of the ti me, mepi va-
cai ne 23 percent of the ti me,
pri l ocai ne 13 percent of the
ti me and a l ong-acti ng l ocal
anestheti c such as eti docai ne or
bupi vacai ne 2 percent of the
ti me (Ri chard D. Fi nkel man,
D.D.S., Ph.D., Astra-Zeneca
Corp., oral communi cati on,
1999).
Al though the numbers i n thi s
study are smal l , i t does appear
that pri l ocai ne may be i nvol ved
more frequentl y and mepi va-
cai ne may be i nvol ved l ess often
than ei ther agents rate of use
nati onwi de (as gauged by sal es)
woul d i ndi cate, though there
may be regi onal di fferences i n
use of the di fferent anestheti cs.
Other researchers al so have
noted a hi gher i nci dence of per-
manent nerve i nvol vement wi th
pri l ocai ne.
8,9
Al l three manufac-
turers sel l i ng l ocal anestheti cs
for denti stry i n the Uni ted
States (Astra-Zeneca Corp.;
Cook-Wai te, whose product i s
manufactured by Abbott
Pharmaceuti cal s; and Novocal
of Canada, whi ch manufactures
Septodont and i ts own name
brands) were represented i n
thi s study. There were exam-
pl es of nerve damage resul ti ng
from each rel evant product; no
products were exempt.
The di fference i n referral
rates i n women as opposed to
men wi th nerve i nvol vement
caused by l ocal anestheti c i njec-
ti ons i s hard to expl ai n, when i t
woul d be assumed that the i nci -
dence of the condi ti on woul d
not have a gender bi as. I t i s
possi bl e that some of the same
eti ol ogi c factors are i nvol ved as
i n temporomandi bul ar joi nt
dysfuncti on, i n whi ch the i nci -
dence may be equal between
the sexes but women more fre-
quentl y seek care for the condi -
ti on at a referral center.
10
Al ternati vel y, however, there
have been some recent ani mal
studi es suggesti ng that nerves
may respond di fferentl y to
i njury i n femal e ani mal s than
i n mal e ani mal s.
11
The fact that several pati ents
suffered from dysesthesi a and
even causal gi a and sympatheti -
cal l y medi ated pai n i s of obvi ous
concern. The true i nci dence of
thi s i s unknown; furthermore,
thi s study may wel l represent a
sel f-sel ected group wi th a
greater preponderance of such
pati ents, as they are more l i kel y
to be referred for eval uati on.
Compari sons need to be made
wi th the dysesthesi a and
causal gi a rate associ ated wi th
nerve i nvol vement stemmi ng
from other sources, such as
thi rd-mol ar removal .
12,13
The
fact that the area affected i n al l
cases i nvol ved the whol e area
served by the nerve suggests
that whatever process i s
i nvol ved affects the whol e nerve
904 JADA, Vol . 131, Jul y 2000
RESEARCH
Perhaps every full-
time practitioner will
find that he or she
has one patient
during his or her
career who has
permanent nerve
involvement resulting
from an inferior
alveolar nerve block.
Copyright 1998-2001 American Dental Association. All rights reserved.
and not just one or two fasci cl es.
I nformati on gathered i n a
previ ous study
13
showed that
when nerve i nvol vement resul t-
ed from tooth removal , ei ght of
95 pati ents (8 percent) com-
pl ai ned pri mari l y of dysesthe-
si a, compared wi th 28 of 83
pati ents (34 percent) i n the
present study. The reasons for
thi s di fference are uncl ear.
Haas and Lennon
8
stated that
12 percent of thei r pati ents
reported experi enci ng a burni ng
feel i ng i n addi ti on to al tered
sensati on.
The eti ol ogy of thi s condi ti on
remai ns uncertai n. Di rect trau-
ma from the needl e seems
unl i kel y, because i t i s known
that most cases of trauma
resul ti ng from needl e contact
resol ve spontaneousl y.
1
I t i s di f-
fi cul t to envi si on how needl e
trauma can damage the whol e
nerve, whi ch appeared to be the
case wi th al l pati ents.
2
Addi -
ti onal l y, i n the fi ve pati ents
who underwent surgery, no evi -
dence of macrotrauma caused
by a needl e was observed.
Another prospecti ve study by
the seni or author has been car-
ri ed out i n an attempt to eval u-
ate the normal i nci dence of con-
tact between a l ocal anestheti c
needl e and the i nferi or al veol ar
or l i ngual nerve i n the course of
performi ng general denti stry.
For the present study, the
authors contacted l ocal denti sts
vi a dental soci ety meeti ngs and
personal contacts and gave
them forms to compl ete
prospecti vel y, recordi ng the
number of i nferi or al veol ar
nerve bl ocks they gave each day
and the number of presumed
contacts between the l ocal anes-
theti c needl e and the i nferi or
al veol ar l i ngual nerve. A con-
tact was presumed to have been
made when the pati ent fel t an
el ectri c shock sensati on or stat-
ed that i njecti on was parti cul ar-
l y pai nful . They were to keep
records for si x months. Forms
were returned by 42 denti sts.
The resul ts are qui te vari abl e
and to a certai n extent refl ect
the workl oad of the denti sts
i nvol ved. However, i t does
appear that the average busy
denti st admi ni sters around
ei ght to 12
i nferi or al ve-
ol ar nerve
bl ocks per
day and i s
made aware
of a needl e
contact wi th
a nerve some-
where
between once
every two
weeks and
once every
ei ght weeks
(anywhere
between one
i n 80 and one
i n 320 i nferi -
or al veol ar
nerve bl ocks).
Thi s i s a fur-
ther i ndi ca-
ti on that for
the vast
majori ty of
i nferi or al ve-
ol ar nerve
bl ocks i n
whi ch contact
i s made di rectl y wi th the nerve,
there are no subsequent l ong-
term sequel ae. Other studi es
have suggested that pati ents
may feel the el ectri c shock wi th
between 3 percent
1
and 7 per-
cent
2
of i nferi or al veol ar nerve
bl ocks.
Al though potenti al l y danger-
ous barbs can devel op on the
needl e ti p after contact wi th
bone
14
and therefore cause trau-
ma on wi thdrawal or on second
use, i t appears that most of the
nerves i n the present study
were i nvol ved before wi thdraw-
al of the needl e and on fi rst use
of the needl e.
I ntraneural hematoma
caused by the needl es stri ki ng
one of the smal l er i ntraneural
bl ood vessel s remai ns a possi bl e
hypothesi s, as i t i s known that
i ntraneural hematomas are
neurotoxi c.
15
Hematomas coul d
expl ai n the fi ndi ngs i n the fi ve
pati ents who underwent sur-
gery. There appeared to be some
i ntraneural fi brosi s among
these pati ents, as wel l as extra-
neural adhesi ons that coul d be
the resul t of l eakage of bl ood
and bl ood products through the
epi neuri um vi a the hol e or hol es
created by the needl e.
JADA, Vol . 131, Jul y 2000 905
RESEARCH
Figure 2. Axial view of the mandible at the level of the
lingula showing the relative positions of the inferior
alveolar nerve, the lingual nerve and a needle adminis-
tering an inferior alveolar nerve block. Note that the
needle passes the lingual nerve some distance before
it contacts bone.
Copyright 1998-2001 American Dental Association. All rights reserved.
Chemi cal
damage from
the l ocal anes-
theti c i tsel f
remai ns a possi bi l i ty,
16-25
though
techni cal l y i t i s di ffi cul t to
envi sage how l ocal anestheti c
coul d be i njected di rectl y i nto
the nerve. Experi mental l y, i t i s
extremel y di ffi cul t to i nject
l ocal anestheti c i nto a nerve
because the epi neuri um wi l l not
stretch, and i n thi s study, as i n
others, the l i ngual nerve i s pre-
domi nantl y affected. Al so, at
the ti me the i njecti on i s gi ven,
the needl e ti p i s wel l past the
l i ngual nerve and i s i n approxi -
mati on to the l i ngual pl ate of
the mandi bl e and cl oser to the
i nferi or al veol ar nerve (Fi gure
2). To i nject l ocal anestheti c
di rectl y i nto the l i ngual nerve
(whi ch i s the nerve affected i n
more than 70 percent of cases),
one woul d have to hol d the nee-
dl e 3 to 4 mi l l i meters beneath
the mucosa but wel l short of the
mandi bl e i tsel f. Thi s does not
happen i n practi ce. Never-
thel ess, i t coul d be envi saged
that were the needl e to have
transfi xed the l i ngual nerve
and then gone on to be i njected
normal l y adjacent to the
mandi bl e, a ti ny amount of the
l ocal anestheti c coul d come i n
contact wi th the i ntraneural
contents as the needl e i s wi th-
drawn through the l i ngual
nerve. Thi s i s because some
l ocal anestheti c woul d remai n
wi thi n the l umen of the needl e
and al so may coat the outsi de of
the needl e. However, i t appears
that i n most cases, the probl em
occurs before needl e wi thdrawal .
The number of pati ents suf-
feri ng from dysesthesi a and
causal gi a that appeared to
spread to other nerve branches
(Fi gure 1) i n some cases i s of
concern. I t i s concei vabl e that
chemi cal i njury may expl ai n
some of these symptoms, but
the mechani sms remai n obscure
and i n some respects resembl e
those of demyel i nati on. I t i s
agai n di ffi cul t to concei ve how
al l the fasci cl es of the nerve
coul d be affected, as seems to
be the case i n al l 83 pati ents
exami ned for thi s study.
Expl oratory surgery has been
unhel pful i n these pati ents and
may even have exacerbated the
symptoms. I f the cases expl ored
i n thi s study are representati ve,
then no macrotrauma i s seen,
but possi bl y some i ntraneural
fi brosi s and sl i ght i ncrease i n
extraneural adhesi ons may
occur. I t i s tempti ng to thi nk
that exci si on of the area of the
nerve showi ng i ntraneural
fi brosi s and repl acement wi th a
graft of some ki nd may be hel p-
ful . However, i n the seni or
authors experi ence, i t i s
extremel y di ffi cul t to accuratel y
del i neate the area of nerve
i nvol ved. I n addi ti on, the
nerves posi ti on i s deep to the
medi al pterygoi d muscl e (fur-
ther proxi mal than a nerve that
woul d be i nvol ved i n a thi rd-
mol ar removal ), and so i t i s vi r-
tual l y i mpossi bl e to perform a
sati sfactory grafti ng procedure
at the proxi mal anastomosi s
si te wi thout havi ng to exten-
si vel y mobi l i ze the medi al
pterygoi d muscl e and even
detach i t. Thi s i s not justi fi ed i n
l i ght of the rel ati vel y poor
resul ts that are obtai ned from
nerve-grafti ng procedures and
the morbi di ty that coul d resul t.
At the present ti me, the opti -
mum treatment i s unknown,
but i t probabl y shoul d be med-
i cal . I f dysesthesi a i s the pri me
concern, i t shoul d be managed
by a pai n management profes-
si onal .
CONCLUSION
An i nferi or al veol ar nerve bl ock
can cause occasi onal peri pheral
nerve damage. The exact mech-
ani sm i s unknown and there i s
no known preventi on or
treatment. I
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906 JADA, Vol . 131, Jul y 2000
RESEARCH
Dr. Thamby is chief
resident, Depart-
ment of Oral and
Maxillofacial
Surgery, University
of California, San
Francisco.
Dr. Pogrel is profes-
sor and chairman,
Department of Oral
and Maxillofacial
Surgery, University
of California, San
Francisco, 521
Parnassus Ave.,
C-522, San
Francisco, Calif.
94143-0440. Address
reprint requests to
Dr. Pogrel.
Exploratory surgery
has been unhelpful
in patients with
permanent nerve
involvement and
may even have
exacerbated the
symptoms.
Copyright 1998-2001 American Dental Association. All rights reserved.
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JADA, Vol . 131, Jul y 2000 907
RESEARCH
Copyright 1998-2001 American Dental Association. All rights reserved.