- Email: [email protected]
Facial palsy after inferior alveolar nerve block: case report and review of the literature
Facial nerve palsy after dental anaesthesia
1139
Case Report Oral Medicine
Facial palsy after inferior alveolar nerve block: case report and review of the literature
V. Chevalier1, R. Arbab-Chirani1,2, S. H. Tea3, M. Roux1 1 Centre Hospitalier Universitaire-Service d’Odontologie, Universite´ Europe´enne de Bretagne-Faculte´ d’Odontologie, Brest, France; 2LAIM-INSERM U650, Brest, France; 3 Centre Hospitalier Universitaire-Service d’Explorations Fonctionnelles Neurologiques, Brest, France
V. Chevalier, R. Arbab-Chirani, S. H. Tea, M. Roux: Facial palsy after inferior alveolar nerve block: case report and review of the literature. Int. J. Oral Maxillofac. Surg. 2010; 39: 1139–1142. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Bell’s palsy is an idiopathic and acute, peripheral nerve palsy resulting in inability to control facial muscles on the affected side because of the involvement of the facial nerve. This study describes a case of Bell’s palsy that developed after dental anaesthesia. A 34-year-old pregnant woman at 35 weeks of amenorrhea, with no history of systemic disease, was referred by her dentist for treatment of a mandibular left molar in pulpitis. An inferior alveolar nerve block was made prior to the access cavity preparation. 2 h later, the patient felt the onset of a complete paralysis of the left-sided facial muscles. The medical history, the physical examination and the complementary exams led neurologists to the diagnosis of Bell’s palsy. The treatment and results of the 1-year follow-up are presented and discussed. Bell’s palsy is a rare complication of maxillofacial surgery or dental procedures, the mechanisms of which remain uncertain.
Accepted for publication 27 April 2010 Available online 3 June 2010
Bell’s palsy is an idiopathic and acute, peripheral nerve palsy resulting in inability to control facial muscles on the affected side because of the involvement of the facial nerve, which supplies motor response for the muscles of facial expression11. The annual incidence of Bell’s palsy is about 20–30 per 100,000 people4. It has been described in patients of all ages, with a peak incidence around the age of 40 years11. Association between this disease and pregnancy was first described by CHARLES BELL1,13 but its increased incidence during pregnancy is still controversial in the literature13. As the origin of Bell’s palsy is still unclear, aetiologies such as viral infection, vascular ischaemia, autoimmune inflammatory disorders and familial susceptibility have been proposed as underlying causes in the general population7, of these, the reactiva-
methylphloroglucinol and Macrogol 4000. The patient complained of the recent onset of spontaneous pain, increased by the decubitus position. The history, and clinical and radiological examinations revealed the loss of a prosthetic crown on this tooth (#37), and its replacement by a temporary metal crown. The X-ray examination showed no periradicular change (Fig. 1). No panoramic radiograph was available. The diagnosis was irreversible pulpitis in the mandibular left second molar. An inferior alveolar nerve block (IANB), a technique of choice in case of irreversible pulpits, was made with an injection of 1.8 ml of chlorydrate of mepivacaine without epinephrine (Scandicaı¨ne1, Septodont, Saint-Maur-desfosse´s, France). A disposable needle, 25G, 0.50 35 mm, mounted on a dental syringe was used. The injection of the
tion of herpes simplex virus (HSV) has become the most likely hypothesis. Thanks to the development of molecular biology and animal models, several reports of herpes virus infection have been recorded4. In pregnant women, the most frequent physiologic and pathologic processes could be viral infection, hypertension and immunosuppression1. The authors present a case of complete unilateral Bell’s palsy. Case report
A 34-year-old pregnant woman at 35 weeks of amenorrhea was referred by her dentist for a severe pain in her mandibular left second molar in October 2008. She had no history of systemic disease but reported recurrent labial herpetic vesicles. Her medication was Phloroglucinol/Tri-
1140
Chevalier et al.
Fig. 1. Preoperative radiography of tooth #37 with temporary metal crown (black arrow).
anaesthetic solution was uneventful. A pulpotomy was carried out as emergency treatment. Analgesic treatment with acetaminophen was prescribed, and a second appointment was made to terminate the endodontic treatment. 2 h later, the patient felt the onset of a fast and complete paralysis of all of the left-sided facial muscles. She went to the general emergency unit of Brest hospital and was referred immediately to the neurology department. Her medical history excluded recent arthralgia, ear pain, fever, influenza or exposure to ticks and the enquiry into family history yielded no history of a similar disorder. Physical examination revealed the disappearance of the left facial and forehead creases, the left naso-labial fold, the asymmetry of the mouth left corner and drooping of the lower left eyelid (Fig. 2). The patient was unable to close her left eyelid, and her eye rolled upward when she attempted to close it. She appeared unable to smile properly (Fig. 2c,f) and reported a feeling of a discomfort on eating. Her mouth, pharynx and ears showed no signs of disease. No herpetic vesicles were found. To evaluate eventual neurological lesions, brain magnetic resonance imaging and computed tomo-
graphy scans were acquired, and were found to be normal. After ruling out Lyme disease, Guillain-Barre´ syndrome, otitis media, Ramsay Hunt syndrome, sarcoidosis and tumour, the neurologists diagnosed a complete Bell’s palsy (grade VI using the House–Brackman grading system). To eliminate any risk to the foetus, the obstetrician, neurologist, consulting physician and patient decided not to prescribe corticosteroids or antiviral drugs. No ophthalmic intervention was undertaken because of the neurological aetiology of the patient’s palsy. To prevent ophthalmic damage, an eye lubricant was prescribed for the first months of patient’s palsy. A clinical follow-up was organized and 1 week after the onset of the paralysis, the first electromyography was performed to evaluate the nervous lesion. The patient gave birth in November 2008, 5 weeks after the first appointment. The facial nerve palsy did not change immediately after giving birth. 3 months after the onset, a progressive and partial recovery was observed with recovery of the left naso-labial fold and symmetry of the mouth corners. The slight dissymmetry between the eyes remained, probably resulting from a drooping of the lower left eyelid, which indicates incomplete recovery. The patient was able to close both her eyes correctly. 4 months after the onset of the disease, evidence of good re-innervation in all the areas of the left facial nerve by electromyography justified the continuation of the clinical and electrical follow-up. The patient was examined in June 2009, 8 months after the onset. There was still very slight dissymmetry between the eyes, but the patient showed good recovery to
grade II of the House–Brackman grading system (Fig. 3). She was examined 1 year after the onset and presented a subtotal recovery with persistent slight muscular stiffness (grade I/grade II) (Fig. 4). 1-year follow-up was carried out in October 2009. The patient is still under follow-up.
Discussion
Bell’s palsy is a rare, but well-documented, complication of maxillofacial surgery or dental procedures and anaesthesia6,9,12. Several mechanisms have been suggested for cases of Bell’s palsy related to IANB anaesthesia8. Relationships have been established between two types of facial nerve paralysis and dental anaesthesia: the immediate palsies that start just after the injection and which recover a few hours later; and delayed palsies, in which the onset of symptoms is delayed for a few hours to a few days, and the course is more protracted9. The present case belongs to the latter category. In the immediate type, either the aberrant facial nerve trunk in the retromandibular space or the facial nerve within the parotid fascia is anaesthetized9. According to some authors, the difficulty of anaesthetizing the facial nerve via the oral cavity makes this mechanism unlikely. It fails to explain the involvement of the upper divisions of the facial nerve and the corda tympani12. The delayed form may result from stimulation, by the anaesthetic solution, of the sympathetic plexus connected to the external carotid artery, which communicates with the plexus-covering stylomastoid artery. By causing reflex vasospasm, this leads to ischaemia of the facial nerve12. Another hypothesis suggests that an ascending viral infection triggers delayed Bell’s palsy9. Dental
Fig. 2. Initial photographs showing ocular trouble (a) in closed eyes, (b) in completely opened eyes, (c) patient trying to smile and the loss of the left naso-labial fold (black arrows), (d) in closed eyes, (e) in completely opened eyes, (f) patient trying to smile. (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
Facial nerve palsy after dental anaesthesia
Fig. 3. The 8-month follow-up showing good recovery (non total), (a, c) in closed eyes, (b, d) in completely opened eyes. (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
Fig. 4. The 1-year follow-up showing a subtotal recovery (a) in closed eyes, (b, c) in opened eyes, (d) patient smiling, with normal left naso-labial fold (black arrows). (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
anaesthesia could act as a precipitating factor, reactivating the latent HSV. It is uncertain whether pregnancy may influence the aetiology of facial palsy1. In pregnant women, the most frequent physiologic and/or pathologic processes could be viral infection (HSV), immunosuppression, hypercoagulopathy, hypertension, an increase in total body water and the influence of ovarian hormones1. During pregnancy, Bell’s palsy mainly occurs in the third trimester or immediately post partum1,13. The proposed explanations for this are a low susceptibility to HSV reactivation during early pregnancy and an increased susceptibility to HSV reactivation in late pregnancy and in the anaesthetic management of delivery13. There are conflicting reports about prescribing corticosteroids to pregnant women with Bell’s palsy. According to COHEN et al.1, a supply of exogenous steroids during the last half of pregnancy is superfluous in the treatment of Bell’s palsy: indeed, recovery would be enhanced by the production of endogenous steroids. Another argu-
ment rests on the controversial, but possible, adverse effects of prednisone during pregnancy1. Given the young age of most pregnant patients and the good prognosis of untreated Bell’s palsy in these patients compared with non-pregnant patients, corticosteroid treatment is generally only supportive1. Other authors3 note that the prognosis for a satisfactory recovery for women who develop complete Bell’s palsy during pregnancy is lower than that for the non-pregnant population. The prognosis during pregnancy remains unclear because of the lack of homogeneity in methodologies between studies13. Given that the possible adverse effects of corticosteroids exist only in the first trimester, and that the onset of Bell’s palsy is rare in early pregnancy, these authors are in favor of the use of such medications (prednisone 1 mg/kg for 5 days, or prednisolone) in the late stage of pregnancy to speed recovery13. Some antiviral medications, such as acyclovir or its prodrug valacyclovir, have been prescribed in the general population
1141
because of the possible role of HSV I in the aetiology of Bell’s palsy; their efficacy is controversial. According to HATO et al., the recovery rates of patients treated with acyclovir and prednisolone in combination or valacyclovir and prednisolone were both better than those for patients treated with prednisolone alone4. Other investigations showed no significant difference in recovery rates between patients treated with steroids plus (val)acyclovir and those treated with steroids alone. A large-scale, randomized, placebo-controlled, doubleblind study was recently carried out by ENGSTRO¨M et al. to gain more insight into the impact of these treatments2. The recovery rates of groups of patients treated with either prednisolone and valacyclovir, or prednisolone, or valacyclovir, or none of them were studied. This study provided conclusive evidence that prednisolone shortened the time needed for complete recovery and that antiviral drugs did not significantly enhance recovery. The authors conclude that this may lead to the reduction or discontinuation of antiviral drugs to treat this palsy, based on evidence-based medicine. In the present case, the obstetrician, neurologist and consulting physician, in agreement with the patient, decided not to prescribe corticosteroids or antiviral drugs, even though the risk to the pregnant women and the developing foetus is very limited. Concerning other treatments, such as acupuncture, the quality of the studies in the literature seems to be inadequate to allow any conclusion about the efficacy of these treatments5. More randomized controlled trials (RCTs) are needed. According to other reviews, the small number of RCTs available can not demonstrate a high level of evidence of significant benefit or harm from any physical therapy10. That is why, in this case, it was decided not to prescribe any of these therapies. In conclusion, Bell’s palsy constitutes a rare local complication of maxillofacial surgery or dental procedures, particularly after IANB anaesthesia. It is important that clinicians are aware of it and understand the treatment. Patients must be referred systematically to a specialist for a complete neurological examination. The recovery is often total but slow and progressive. Competing interests
None declared. Funding
None.
1142
Chevalier et al.
Ethical approval
Not required.
Acknowledgement. The authors would like to thank Ms. Marie-Paule Friocourt for her assistance.
References 1. Cohen Y, Lavie O, Granovsky-Grisaru S, Aboulafia Y, Diamant Y. Bell palsy complicating pregnancy: a review. Obstet Gynecol Surv 2000: 55: 184–188. 2. Engstro¨m M, Berg T, StjernquistDesatnik A, Axelsson S, Pitka¨ranta A, Hultcrantz M, Kanerva M, Hanner P, Jonsson L. Prednisolone and valaciclovir in Bell’s palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008: 7: 993–1000. 3. Gillman GS, Schaitkin BM, May M, Klein SR. Bell’s palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg 2002: 126: 26–30.
4. Hato N, Sawai N, Teraoka M, Wakisaka H, Takahashi H, Hinohira Y, Gyo K. Valacyclovir for the treatment of Bell’s palsy. Expert Opin Pharmacother 2008: 9: 2531–2536. 5. He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, Zhang DP, Li QF, Yang J, Zhang X. Acupuncture for Bell’s palsy. Cochrane Database Syst Rev 2007: 17(4):CD002914 Review. P. 8. 6. Newlands C, Dixon A, Altman K. Ocular palsy following Le Fort 1 osteotomy: a case report. Int J Oral Maxillofac Surg 2004: 33: 101–104. 7. Savadi-Oskouei D, Abedi A, SadeghiBazargani H. Independent role of hypertension in Bell’s Palsy: a case–control study. Eur Neurol 2008: 60: 253–257. 8. Shenkman Z, Findler M, Lossos A, Barak S, Katz J. Permanent neurologic deficit after inferior alveolar nerve block: a case report. Int J Oral Maxillofac Surg 1996: 25: 381–382. 9. Tazi M, Soichot P, Perrin D. Facial palsy following dental extraction: report of 2 cases. J Oral Maxillofac Surg 2003: 61: 840–844. 10. Teixeira LJ, Soares BGDO, Vieira VP, Prado GF. Physical therapy for Bell’s
palsy (idiopathic facial paralysis) (Review). Cochrane Database Syst Rev 2008: 16 CD006283. Review. 11. Tiemstra JD, Khatkhate N. Bell’s palsy: diagnosis and management. Am Fam Physician 2007: 76: 997–1002. 12. Vasconcelos BC, Bessa-Nogueira RV, Maurette PE, Carneiro SC. Facial nerve paralysis after impacted lower third molar surgery: a literature review and case report. Med Oral Pathol Oral Cir Bucal 2006: 11: E175–E178. 13. Vrabec JT, Isaacson B, Van Hook JW. Bell’s palsy and pregnancy. Otolaryngol Head Neck Surg 2007: 137: 858– 861. Address: Reza Arbab-Chirani UFR d’Odontologie de Brest 22 rue Camille Desmoulins 29238 Brest Cedex 3 France Tel.: +33 298223330 fax: +33 298016932 E-mail: [email protected] doi:10.1016/j.ijom.2010.04.049
Case Report Oral Medicine
Temporary eyelash loss following dental treatment
S. Nezafati1, S. Rahimi2, H. Mohseni1 1 Oral and Maxillofacial Surgery, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran; 2Dental Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
S. Nezafati, S. Rahimi, H. Mohseni: Temporary eyelash loss following dental treatment. Int. J. Oral Maxillofac. Surg. 2010; 39: 1142–1144. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The isolated absence or loss of eyelashes (madarosis) is associated with many processes including systemic and local diseases. Madarosis of dental origin has not been reported. This paper is a report of the successful treatment of unilateral eyelash loss following root canal therapy of an upper posterior tooth.
Loss of eyelashes, known as madarosis, may be the presenting feature of a number of vision and life threatening conditions, including endocrinopathy (hypothyroidism), bacterial infections (leprosy), viral infections (HIV/herpes zoster), autoimmune disease (scleroderma, discoid lupus)
and malignant tumors4,9. It is divided into scaring and non-scaring types, which indicate the potential for lash re-growth4. Loss of eyelashes following dental treatment has never been reported in the English medical literature. This article presents a case of unilateral eyelash loss following
Keywords: eyelash loss; dental treatment; madarosis. Accepted for publication 27 April 2010 Available online 3 July 2010
endodontic treatment of a posterior maxillary tooth. Case report
A 25-year-old man was referred with the chief complaint of eyelash loss in the right
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Case Report Oral Medicine
Facial palsy after inferior alveolar nerve block: case report and review of the literature
V. Chevalier1, R. Arbab-Chirani1,2, S. H. Tea3, M. Roux1 1 Centre Hospitalier Universitaire-Service d’Odontologie, Universite´ Europe´enne de Bretagne-Faculte´ d’Odontologie, Brest, France; 2LAIM-INSERM U650, Brest, France; 3 Centre Hospitalier Universitaire-Service d’Explorations Fonctionnelles Neurologiques, Brest, France
V. Chevalier, R. Arbab-Chirani, S. H. Tea, M. Roux: Facial palsy after inferior alveolar nerve block: case report and review of the literature. Int. J. Oral Maxillofac. Surg. 2010; 39: 1139–1142. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Bell’s palsy is an idiopathic and acute, peripheral nerve palsy resulting in inability to control facial muscles on the affected side because of the involvement of the facial nerve. This study describes a case of Bell’s palsy that developed after dental anaesthesia. A 34-year-old pregnant woman at 35 weeks of amenorrhea, with no history of systemic disease, was referred by her dentist for treatment of a mandibular left molar in pulpitis. An inferior alveolar nerve block was made prior to the access cavity preparation. 2 h later, the patient felt the onset of a complete paralysis of the left-sided facial muscles. The medical history, the physical examination and the complementary exams led neurologists to the diagnosis of Bell’s palsy. The treatment and results of the 1-year follow-up are presented and discussed. Bell’s palsy is a rare complication of maxillofacial surgery or dental procedures, the mechanisms of which remain uncertain.
Accepted for publication 27 April 2010 Available online 3 June 2010
Bell’s palsy is an idiopathic and acute, peripheral nerve palsy resulting in inability to control facial muscles on the affected side because of the involvement of the facial nerve, which supplies motor response for the muscles of facial expression11. The annual incidence of Bell’s palsy is about 20–30 per 100,000 people4. It has been described in patients of all ages, with a peak incidence around the age of 40 years11. Association between this disease and pregnancy was first described by CHARLES BELL1,13 but its increased incidence during pregnancy is still controversial in the literature13. As the origin of Bell’s palsy is still unclear, aetiologies such as viral infection, vascular ischaemia, autoimmune inflammatory disorders and familial susceptibility have been proposed as underlying causes in the general population7, of these, the reactiva-
methylphloroglucinol and Macrogol 4000. The patient complained of the recent onset of spontaneous pain, increased by the decubitus position. The history, and clinical and radiological examinations revealed the loss of a prosthetic crown on this tooth (#37), and its replacement by a temporary metal crown. The X-ray examination showed no periradicular change (Fig. 1). No panoramic radiograph was available. The diagnosis was irreversible pulpitis in the mandibular left second molar. An inferior alveolar nerve block (IANB), a technique of choice in case of irreversible pulpits, was made with an injection of 1.8 ml of chlorydrate of mepivacaine without epinephrine (Scandicaı¨ne1, Septodont, Saint-Maur-desfosse´s, France). A disposable needle, 25G, 0.50 35 mm, mounted on a dental syringe was used. The injection of the
tion of herpes simplex virus (HSV) has become the most likely hypothesis. Thanks to the development of molecular biology and animal models, several reports of herpes virus infection have been recorded4. In pregnant women, the most frequent physiologic and pathologic processes could be viral infection, hypertension and immunosuppression1. The authors present a case of complete unilateral Bell’s palsy. Case report
A 34-year-old pregnant woman at 35 weeks of amenorrhea was referred by her dentist for a severe pain in her mandibular left second molar in October 2008. She had no history of systemic disease but reported recurrent labial herpetic vesicles. Her medication was Phloroglucinol/Tri-
1140
Chevalier et al.
Fig. 1. Preoperative radiography of tooth #37 with temporary metal crown (black arrow).
anaesthetic solution was uneventful. A pulpotomy was carried out as emergency treatment. Analgesic treatment with acetaminophen was prescribed, and a second appointment was made to terminate the endodontic treatment. 2 h later, the patient felt the onset of a fast and complete paralysis of all of the left-sided facial muscles. She went to the general emergency unit of Brest hospital and was referred immediately to the neurology department. Her medical history excluded recent arthralgia, ear pain, fever, influenza or exposure to ticks and the enquiry into family history yielded no history of a similar disorder. Physical examination revealed the disappearance of the left facial and forehead creases, the left naso-labial fold, the asymmetry of the mouth left corner and drooping of the lower left eyelid (Fig. 2). The patient was unable to close her left eyelid, and her eye rolled upward when she attempted to close it. She appeared unable to smile properly (Fig. 2c,f) and reported a feeling of a discomfort on eating. Her mouth, pharynx and ears showed no signs of disease. No herpetic vesicles were found. To evaluate eventual neurological lesions, brain magnetic resonance imaging and computed tomo-
graphy scans were acquired, and were found to be normal. After ruling out Lyme disease, Guillain-Barre´ syndrome, otitis media, Ramsay Hunt syndrome, sarcoidosis and tumour, the neurologists diagnosed a complete Bell’s palsy (grade VI using the House–Brackman grading system). To eliminate any risk to the foetus, the obstetrician, neurologist, consulting physician and patient decided not to prescribe corticosteroids or antiviral drugs. No ophthalmic intervention was undertaken because of the neurological aetiology of the patient’s palsy. To prevent ophthalmic damage, an eye lubricant was prescribed for the first months of patient’s palsy. A clinical follow-up was organized and 1 week after the onset of the paralysis, the first electromyography was performed to evaluate the nervous lesion. The patient gave birth in November 2008, 5 weeks after the first appointment. The facial nerve palsy did not change immediately after giving birth. 3 months after the onset, a progressive and partial recovery was observed with recovery of the left naso-labial fold and symmetry of the mouth corners. The slight dissymmetry between the eyes remained, probably resulting from a drooping of the lower left eyelid, which indicates incomplete recovery. The patient was able to close both her eyes correctly. 4 months after the onset of the disease, evidence of good re-innervation in all the areas of the left facial nerve by electromyography justified the continuation of the clinical and electrical follow-up. The patient was examined in June 2009, 8 months after the onset. There was still very slight dissymmetry between the eyes, but the patient showed good recovery to
grade II of the House–Brackman grading system (Fig. 3). She was examined 1 year after the onset and presented a subtotal recovery with persistent slight muscular stiffness (grade I/grade II) (Fig. 4). 1-year follow-up was carried out in October 2009. The patient is still under follow-up.
Discussion
Bell’s palsy is a rare, but well-documented, complication of maxillofacial surgery or dental procedures and anaesthesia6,9,12. Several mechanisms have been suggested for cases of Bell’s palsy related to IANB anaesthesia8. Relationships have been established between two types of facial nerve paralysis and dental anaesthesia: the immediate palsies that start just after the injection and which recover a few hours later; and delayed palsies, in which the onset of symptoms is delayed for a few hours to a few days, and the course is more protracted9. The present case belongs to the latter category. In the immediate type, either the aberrant facial nerve trunk in the retromandibular space or the facial nerve within the parotid fascia is anaesthetized9. According to some authors, the difficulty of anaesthetizing the facial nerve via the oral cavity makes this mechanism unlikely. It fails to explain the involvement of the upper divisions of the facial nerve and the corda tympani12. The delayed form may result from stimulation, by the anaesthetic solution, of the sympathetic plexus connected to the external carotid artery, which communicates with the plexus-covering stylomastoid artery. By causing reflex vasospasm, this leads to ischaemia of the facial nerve12. Another hypothesis suggests that an ascending viral infection triggers delayed Bell’s palsy9. Dental
Fig. 2. Initial photographs showing ocular trouble (a) in closed eyes, (b) in completely opened eyes, (c) patient trying to smile and the loss of the left naso-labial fold (black arrows), (d) in closed eyes, (e) in completely opened eyes, (f) patient trying to smile. (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
Facial nerve palsy after dental anaesthesia
Fig. 3. The 8-month follow-up showing good recovery (non total), (a, c) in closed eyes, (b, d) in completely opened eyes. (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
Fig. 4. The 1-year follow-up showing a subtotal recovery (a) in closed eyes, (b, c) in opened eyes, (d) patient smiling, with normal left naso-labial fold (black arrows). (The informed consent of the patient with approval for publishing as a case report, including pictures of the face, on a medical journal had been obtained before submitting the manuscript.)
anaesthesia could act as a precipitating factor, reactivating the latent HSV. It is uncertain whether pregnancy may influence the aetiology of facial palsy1. In pregnant women, the most frequent physiologic and/or pathologic processes could be viral infection (HSV), immunosuppression, hypercoagulopathy, hypertension, an increase in total body water and the influence of ovarian hormones1. During pregnancy, Bell’s palsy mainly occurs in the third trimester or immediately post partum1,13. The proposed explanations for this are a low susceptibility to HSV reactivation during early pregnancy and an increased susceptibility to HSV reactivation in late pregnancy and in the anaesthetic management of delivery13. There are conflicting reports about prescribing corticosteroids to pregnant women with Bell’s palsy. According to COHEN et al.1, a supply of exogenous steroids during the last half of pregnancy is superfluous in the treatment of Bell’s palsy: indeed, recovery would be enhanced by the production of endogenous steroids. Another argu-
ment rests on the controversial, but possible, adverse effects of prednisone during pregnancy1. Given the young age of most pregnant patients and the good prognosis of untreated Bell’s palsy in these patients compared with non-pregnant patients, corticosteroid treatment is generally only supportive1. Other authors3 note that the prognosis for a satisfactory recovery for women who develop complete Bell’s palsy during pregnancy is lower than that for the non-pregnant population. The prognosis during pregnancy remains unclear because of the lack of homogeneity in methodologies between studies13. Given that the possible adverse effects of corticosteroids exist only in the first trimester, and that the onset of Bell’s palsy is rare in early pregnancy, these authors are in favor of the use of such medications (prednisone 1 mg/kg for 5 days, or prednisolone) in the late stage of pregnancy to speed recovery13. Some antiviral medications, such as acyclovir or its prodrug valacyclovir, have been prescribed in the general population
1141
because of the possible role of HSV I in the aetiology of Bell’s palsy; their efficacy is controversial. According to HATO et al., the recovery rates of patients treated with acyclovir and prednisolone in combination or valacyclovir and prednisolone were both better than those for patients treated with prednisolone alone4. Other investigations showed no significant difference in recovery rates between patients treated with steroids plus (val)acyclovir and those treated with steroids alone. A large-scale, randomized, placebo-controlled, doubleblind study was recently carried out by ENGSTRO¨M et al. to gain more insight into the impact of these treatments2. The recovery rates of groups of patients treated with either prednisolone and valacyclovir, or prednisolone, or valacyclovir, or none of them were studied. This study provided conclusive evidence that prednisolone shortened the time needed for complete recovery and that antiviral drugs did not significantly enhance recovery. The authors conclude that this may lead to the reduction or discontinuation of antiviral drugs to treat this palsy, based on evidence-based medicine. In the present case, the obstetrician, neurologist and consulting physician, in agreement with the patient, decided not to prescribe corticosteroids or antiviral drugs, even though the risk to the pregnant women and the developing foetus is very limited. Concerning other treatments, such as acupuncture, the quality of the studies in the literature seems to be inadequate to allow any conclusion about the efficacy of these treatments5. More randomized controlled trials (RCTs) are needed. According to other reviews, the small number of RCTs available can not demonstrate a high level of evidence of significant benefit or harm from any physical therapy10. That is why, in this case, it was decided not to prescribe any of these therapies. In conclusion, Bell’s palsy constitutes a rare local complication of maxillofacial surgery or dental procedures, particularly after IANB anaesthesia. It is important that clinicians are aware of it and understand the treatment. Patients must be referred systematically to a specialist for a complete neurological examination. The recovery is often total but slow and progressive. Competing interests
None declared. Funding
None.
1142
Chevalier et al.
Ethical approval
Not required.
Acknowledgement. The authors would like to thank Ms. Marie-Paule Friocourt for her assistance.
References 1. Cohen Y, Lavie O, Granovsky-Grisaru S, Aboulafia Y, Diamant Y. Bell palsy complicating pregnancy: a review. Obstet Gynecol Surv 2000: 55: 184–188. 2. Engstro¨m M, Berg T, StjernquistDesatnik A, Axelsson S, Pitka¨ranta A, Hultcrantz M, Kanerva M, Hanner P, Jonsson L. Prednisolone and valaciclovir in Bell’s palsy: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Neurol 2008: 7: 993–1000. 3. Gillman GS, Schaitkin BM, May M, Klein SR. Bell’s palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Neck Surg 2002: 126: 26–30.
4. Hato N, Sawai N, Teraoka M, Wakisaka H, Takahashi H, Hinohira Y, Gyo K. Valacyclovir for the treatment of Bell’s palsy. Expert Opin Pharmacother 2008: 9: 2531–2536. 5. He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, Zhang DP, Li QF, Yang J, Zhang X. Acupuncture for Bell’s palsy. Cochrane Database Syst Rev 2007: 17(4):CD002914 Review. P. 8. 6. Newlands C, Dixon A, Altman K. Ocular palsy following Le Fort 1 osteotomy: a case report. Int J Oral Maxillofac Surg 2004: 33: 101–104. 7. Savadi-Oskouei D, Abedi A, SadeghiBazargani H. Independent role of hypertension in Bell’s Palsy: a case–control study. Eur Neurol 2008: 60: 253–257. 8. Shenkman Z, Findler M, Lossos A, Barak S, Katz J. Permanent neurologic deficit after inferior alveolar nerve block: a case report. Int J Oral Maxillofac Surg 1996: 25: 381–382. 9. Tazi M, Soichot P, Perrin D. Facial palsy following dental extraction: report of 2 cases. J Oral Maxillofac Surg 2003: 61: 840–844. 10. Teixeira LJ, Soares BGDO, Vieira VP, Prado GF. Physical therapy for Bell’s
palsy (idiopathic facial paralysis) (Review). Cochrane Database Syst Rev 2008: 16 CD006283. Review. 11. Tiemstra JD, Khatkhate N. Bell’s palsy: diagnosis and management. Am Fam Physician 2007: 76: 997–1002. 12. Vasconcelos BC, Bessa-Nogueira RV, Maurette PE, Carneiro SC. Facial nerve paralysis after impacted lower third molar surgery: a literature review and case report. Med Oral Pathol Oral Cir Bucal 2006: 11: E175–E178. 13. Vrabec JT, Isaacson B, Van Hook JW. Bell’s palsy and pregnancy. Otolaryngol Head Neck Surg 2007: 137: 858– 861. Address: Reza Arbab-Chirani UFR d’Odontologie de Brest 22 rue Camille Desmoulins 29238 Brest Cedex 3 France Tel.: +33 298223330 fax: +33 298016932 E-mail: [email protected] doi:10.1016/j.ijom.2010.04.049
Case Report Oral Medicine
Temporary eyelash loss following dental treatment
S. Nezafati1, S. Rahimi2, H. Mohseni1 1 Oral and Maxillofacial Surgery, Emam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran; 2Dental Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
S. Nezafati, S. Rahimi, H. Mohseni: Temporary eyelash loss following dental treatment. Int. J. Oral Maxillofac. Surg. 2010; 39: 1142–1144. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The isolated absence or loss of eyelashes (madarosis) is associated with many processes including systemic and local diseases. Madarosis of dental origin has not been reported. This paper is a report of the successful treatment of unilateral eyelash loss following root canal therapy of an upper posterior tooth.
Loss of eyelashes, known as madarosis, may be the presenting feature of a number of vision and life threatening conditions, including endocrinopathy (hypothyroidism), bacterial infections (leprosy), viral infections (HIV/herpes zoster), autoimmune disease (scleroderma, discoid lupus)
and malignant tumors4,9. It is divided into scaring and non-scaring types, which indicate the potential for lash re-growth4. Loss of eyelashes following dental treatment has never been reported in the English medical literature. This article presents a case of unilateral eyelash loss following
Keywords: eyelash loss; dental treatment; madarosis. Accepted for publication 27 April 2010 Available online 3 July 2010
endodontic treatment of a posterior maxillary tooth. Case report
A 25-year-old man was referred with the chief complaint of eyelash loss in the right