The use of magnetic-laser therapy of patients with post-dental implant neuropathy

Objective: The aim of this study was to assess the effectiveness of magnetic-laser therapy in complex treatment of neuropathy after dental implantation Materials and methods: The present study is based on the results of the analysis of clinical, instrumental and radiation studies of 27 patients, with post-traumatic neuropathy inferior alveolar nerve. Diagnosis of damage to the inferior alveolar nerve was based on the clinical manifestations of neuropathy (pain, paresthesia, loss of sensation, etc.). The study of the sensitivity of the skin of the lower lip and chin in the segment of the inferior alveolar nerve dysfunction and in the symmetrical segment performed using sensory tests. Conservative treatment included: Anti-infl ammatory, analgesics, antioxidants, B complex of the vitamins group. Magnetic-laser therapy included in a conservative treatment complex for patients. To conduct a comparative analysis of effectiveness of magnetic-laser therapy, two groups were formed: Patients fi rst group (n= 14), whose treatment complex included magneticlaser therapy, Patients second group (n= 13), whose treatment complex did not include magnetic-laser therapy. Results: Most patients after implant placement complained of pain of varying degrees, a decrease or lack of sensitivity of the lower lip, chin skin, and the mucous membrane of the alveolar process of the lower jaw, paresthesia or hyperesthesia. Some patients did not have pain, however noted that sensitivity disorders have a negative effect on general well-being and interfere with work. When comparing 2 group the best pain relief was patients fi rst group. The average area of skins sensory impairment in patients was mean 9.4cm2. Patients fi rst group complete recovered function of inferior alveolar nerve within mild 1 month, patients in the second group, whose treatment complex did not include magnetic laser therapy, fully recovered function of inferior alveolar nerve within mild 2 months. Conclusion: Thus, the inclusion of magnetic laser therapy in the post-implantation traumatic neuropathy treatment complex allows to reduce the recovery time of functional disorders of the inferior alveolar nerve, to reduce the area of skins sensory impairment and increase the effectiveness of treatment. Research Article The use of magnetic-laser therapy of patients with postdental implant neuropathy Hakobyan Gagik1*, Lazar Yesayan2, Arman Seyranyan3 and Davit Matevosyan4 1Professor, Head of Department of Oral and maxillofacial surgery, Yerevan State Medical University after M. Heratsi, Armenia 2Professor, Head of Department of Therapeutic Dentistry, Yerevan State Medical University after M. Heratsi, Armenia 3,4Assistant professor Department of Oral and maxillofacial surgery, Yerevan State Medical University after M. Heratsi, Armenia Received: 14 April, 2019 Accepted: 22 April, 2020 Published: 23 April, 2020 *Corresponding author: Gagik Hakobyan DMSc,PhD, Professor, Head of Department of Oral and maxillofacial surgery, Yerevan State Medical University after M. Heratsi, 0028 Kievyan str. 10 ap. 65 Yerevan, Armenia, Tel: (+37410)271146; E-mail:


Introduction
Dental implantation, which is now widely used, is a fairly popular type of orthopedic care with partial or complete adentia. At the same time, it is known that 5%-26% of patients after dental implantation develop complications, accompanied by a complex of functional and structural disorders [1][2][3][4][5][6].
One of the surgical complications of dental implantation is damage to the mandibular canal during the dental implant site osteotomy or placement and postoperative indirect trauma due to hematoma, secondary ischemia and thermal stimuli [7][8][9][10].
It is manifested by post-traumatic neuropathy, a characteristic clinic of pain syndrome, from mild paresthesia to complete anaesthesia, accompanied by emotional-stress disorders, and signifi cantly worsens the patient's quality of life. The most common result of nerve damage is loss of lip, chin sensitivity [14][15][16]. As a result of nerve injury, many functions disturbance, such as speech, eating, and drinking, etc. Different degrees of nerve injury are available.
For assessment of the severity of inferior alveolar nerve injury, Jalbout and Tabourian classifi ed three categories of neurosensory alterations during the implant placement (neuropraxia, axonotmesis and neurotmes) based on the dynamics of time and the completeness of restoration of sensitivity [17].
Diagnosis of IAN sensory disturbances is based on subjective clinical sensory testing and objective sensory tests. The loss sensation of the lip and chin can be measured by clinical testing [18]. Various methods of testing are used to assess neurosensory function: from patient questioning to hightech tests, however, the patient's report is the most sensitive indicator of sensory disturbances [19,22].
Clinical sensory testing is still the most popular in everyday practice based upon the stimulated through cutaneous contact and includes pin tactile discrimination and thermal discrimination (war, cold).
Currently there are different treatment methods inferior alveolar nerve injury, the use of medication (vitamins B, steroidal anti-infl ammatory substances), acupuncture, local physiotherapy [23][24][25][26][27]. However, there is no universal therapy that contributes to the full normalization of the function of damaged nerve.
Magnetic therapy is considered a relatively safe alternative, without signifi cant side effects. There are few scientifi c publications that evaluate the effects of magnetic-laser therapy for treatment neuropathy after implant surgery. Therefore, the effectiveness of magnetic-laser therapy in the treatment of neuropathy needs to be studied.
The aim of this study was to assess the effectiveness of magnetic-laser therapy in complex treatment of traumatic neuropathy after dental implantation.

Materials and methods
The work is based on the results of the analysis of clinical, instrumental and radiation studies of 27 patients (16 women and 11 men, The average age was 41.7 years), with post-traumatic neuropathy inferior alveolar nerve (axonotmesis) [17]. Patients who presented with a complaint of pain were asked to record pain scores via a paper VAS to indicate pain intensity. Patients were instructed that a score of 1 to 3was indicative of mild pain, 4 to 6 was indicative of moderate pain, and 7 to 10 was indicative of severe pain ( Figure 2).
The study of the sensitivity of the skin of the lower lip and chin in the segment of the mandibular nerve dysfunction and in the symmetrical segment performed using sensory tests.  The nature, location, prevalence, intensity, duration and frequency of pain were evaluated. The response to pain (needle puncture), thermal (hot water tube) was assessed, quantitative assessment of the area of paresthesia of the skin (Figures 3,4).
For monitoring of the IAN sensory function recovery neurosensory disorder surface area was mapping and photographing to compare with the dynamics of treatment     In 6 patients fi rst group with mild pain (1 to 3 VAS score) pain decreased and disappeared after mean 8,2 day, in 3 patients fi rst group, with moderate pain (4 to 6 VAS score) pain decreased and disappeared after mean 12,4 day. In 5 patients second group with mild pain (1 to 3 VAS score) pain decreased and disappeared after mean 13,6 day, in 4 patients second group, with moderate pain (4 to 6 VAS score) pain decreased and disappeared after mean 18,3 day. When comparing 2 group the best pain relief was patients fi rst group.
The average area of skins sensory impairment in patients was mean 9.4cm 2 . Analysis of the results showed that the timing of the restoration of sensitivity correlated with the use of magneto-laser therapy. Patients fi rst group complete recovered function of inferior alveolar nerve within mean 1 month, in patients second group, whose treatment complex did not include magnetic laser therapy,fully recovered function of inferior alveolar nerve within mean 2 months (diagram 1).

Discussions
The Inferior Alveolar Nerve (IAN) carries general sensation for the mouth, teeth, lip and chin and serve important function for oral health and general functions such as eating, chewing, tasting, and phonation [33].
Inferior alveolar nerve damage can occur during various dental surgical procedures (wisdom tooth extraction, reconstructive surgery on the lower jaw, orthognathic surgery, surgical removal of cysts, inferior alveolar nerve lateralization, dental implant placement) [34][35][36][37][38]. The development of these complications can be an important factor in reducing the quality of life. One of the problems dental implantology is prevention complications, development of effective methods complications.
During implant insertion different function of the inferior alveolar nerve degree disorders are caused by: direct perforation of the inferior alveolar canal, intraosseous hematoma or nerve pressure with implant. Due to a hematoma, minor injury to the IAN may develop, edema will develop later, and the injury will worsen.
In cases where the patient reports permanent numbness on the side of implant placement, including the lower lip and chin (3 hours after surgery when the effect of local anesthesia weakens), this will be the fi rst sign of nerve damage [12].
Patient with post-traumatic trigeminal neuropathy can manifest as neuropathic pain, anesthesia, hypesthesia or hyperesthesia and the resulting stress disorder [39].
There are many possible assessment tools that are used for the assessment of nerve injury severity [40,41]. Clinical neurosensory tests (pinprick sensation, thermal sensation) were the most common reported diagnostic tests undertaken.
Any damage (penetration or compression), as well as hemorrhages in the mandibular canal lead to intraoperative pain of the neuralgic type. Ischemia itself, even without direct damage to the nerve, will cause suffi cient infl ammation and damage to the nerve, which can lead to permanent damage to the nerve. The degree of pain relief is individual and depends on each patient.
The issue of regeneration of nerve tissue and pathomorphological changes in the nerve fi ber when it is damaged during dental implantation is discussed in research publications.
The variety of proposed treatment methods and the lack of universal tactics indicate the need to develop new methods of treatment post-traumatic neuropathy of inferior alveolar nerve.
The conservative therapies for Inferior Alveolar Nerve (IAN) neuropathy include the use of corticosteroids and nonsteroidal anti-infl ammatories [41]. In the absence of effective methods to resolve post-traumatic neuropathy inferior alveolar nerve has been a recommended alternative treatment method, including physiotherapy [42][43][44][45][46][47][48].  Magneto-laser therapy is among the methods of physiotherapy accelerates the healing and regeneration of tissues after damage, eliminates pain and swelling. Мagnetolaser fi eld act on the molecules of cell structures, to activate the processes of metabolism of cells and the activity of enzymatic systems, stimulation of nerve cell and lymphocyte respiration. At the tissue level, there is observed: improved microcirculation, accelerated revascularization and reinnervation, decreased intracellular and intercellular edema, increased blood oxygen saturation at the microcirculatory level.
The early diagnosis and treatment of this pathology, which causes suffering to patients, seems to be an important task in implantology, in connection with the foregoing, the further development of treatment methods is reasonable and relevant.
Based on this, for the treatment of 27 patients with postimplantation neuropathy inferior alveolar nerve (axonotmesis) we included magnetic-laser therapy in the treatment complex and evaluated the results of treatment.
The Visual Snalogue Scale (VAS) pain scores for each group at each time were analyzed. Results from the study indicate that pain was reduced in both treatment groups. A reduction in the duration of pain and the terms of the restored function of the lower alveolar nerve in patients of the fi rst group compared to patients second group shows the effectiveness of magneticlaser therapy. Еffectiveness of magnetic-laser therapy on pain reduction can be explained by the fact that laser light absorbed by nociceptors, exert an inhibitory effect on A and C pain fi bers, which slows conduction velocity, and suppresses neurogenic infl ammation.
The results of the treatment showed that, сomplex treatment using magnetic-laser therapy reduced the time of restoration of sensitivity of the lips and skin of the chin also facilitated pain sensitivity and decreases increase the effectiveness of treatment. Magnetic-laser therapy promote to increase blood fl ow by vasodilation and also reduces edema. Thus, the inclusion of magnetic-laser therapy in the post-implantation traumatic neuropathy treatment complex allows to reduce the recovery time of functional disorders of the inferior alveolar nerve, to reduce the area of skins sensory impairment.
If the nerve is damaged, evaluation and treatment should be started immediately after the damage to get a good prognosis. Magnetic-laser therapy can be recommended as a non-pharmacological alternative in patients presenting with mild to moderate pain on the day after nerve injury, the effects related to the degree of nerve injury. Moreover, the use of magnetic laser therapy does not cause side effects and allows you to achieve a lasting long-term result.

Conclusions
Based on the developed data, it can be concluded that magnetic-laser therapy can have a positive effect on the restoration of disorders of the sensitivity of the lower alveolar nerve, accelerating the improvement of the regeneration of the affected nerves after dental implantation, increase the effectiveness of treatment.

Confl ict of interest and fi nancial disclosure
The author declares that he has no confl ict of interest and there was no external source of funding for the present study. None of the authors have any relevant fi nancial relationship(s) with a commercial interest.

Funding
This research did not receive any specifi c grant from funding agencies in the public, commercial, or not-for-profi t sectors.