Mandibular paresthesia secondary to
cerebrovascular changes
Lyle W. Nelson, D.M.D.,* William T. Johnson, D.D.S., M.S.,** and
David A. Blaha, D.D.S.,*** Omaha and Lincoln. Neb.
UNIVERSITY

OF NEBRASKA

MEDICAL

CENTER

An unusual case of mandibular paresthesia as the only presenting symptom of a cerebrovascular
accident
is presented. The differential diagnosis of inferior alveolar nerve paresthesia is discussed. Obtaining a
definitive diagnosis depends on a thorough medical and dental history complemented by a complete clinical
and radiographic examination. The etiology of cerebral vascular accidents is reviewed, as well as risk
factors that may increase the possibility of a cerebrovascular
accident.
(ORAL SURC. ORAL MED. ORAL PATHOL. 6217-19,

P

1986)

atients with the chief complaint of inferior alveolar nerve paresthesia unrelated to a dental or surgical
procedure are rare. Paresthesia is more commonly
seen following the injection of local anesthetic
agents, endodontic procedures, mandibular fractures, and mandibular surgical procedures. Removal
of mandibular third molars, orthognathic surgery,
and excisional biopsies are common surgical procedures that may produce paresthesia. The diagnosis of
paresthesia related to the above situations is based
primarily on the dental history.
Paresthesias that are unrelated to dental procedures or trauma are more difficult to diagnose.
Possible causesof inferior alveolar nerve paresthesia
include systemic diseases, such as diabetes and
hypothyroidism,’ as well as deficiency states, such as
pellagra and pernicious anemia.’ Paresthesia is most
frequently associatedwith malignant or inflammatory lesions.‘-3A less likely explanation for the occurrence of inferior alveolar paresthesia involves cerebral ischemia and infarction involving the trigeminal
nerve fibers.
A cerebrovascular accident can result from cerebral ischemia resulting in infarction or from
intracranial hemorrhage. Cerebral ischemia and
infarction account for more than 85% of all cerebro-

*Resident, Department of Oral and Maxillofacial Surgery.
**Assistant Professor, Department of Endodontics.
***In the private practice of oral surgery, Lincoln, Neb.

vascular accidents and can be related to atherosclerotic vesselsand/or thrombus formation. Intracranial hemorrhages account for approximately 10%of all
cerebrovascular accidents and can be attributed to
aneurysms and hypertensive vascular disease.4
Cerebrovascular accidents are not uncommon in
the adult population, with 25% of the routine autopsiesdemonstrating evidenceof a previous cerebrovascular accident.4 The average age of persons at the
time of their first cerebrovascular accident is 64
years.4 Factors significantly increasing the chance
for a cerebrovascular accident include hypertension,
diabetes mellitus, cardiac enlargement, hypercholesterolemia, the use of oral contraceptives, and cigarette smoking.4
Elimination of the various possibilities from a
differential diagnosis involving paresthesia is based
on history, clinical examination, laboratory studies,
and biopsy techniques. The following case is presented as an example of a cerebrovascular accident with
mandibular paresthesia as the only presenting symptom.
CASEREPORT

A 27-year-old white woman came to the University of
Nebraska Medical Center College of Dentistry with a
chief complaint of mandibular paresthesia. The patient
had noticed “a numbness” on awakening that morning and
stated that the sensation had not been present at any time
previously. She believed the paresthesia to be secondary to
a firm mass located in the left mandibular vestibule. She
denied odontogenic pain, thermal sensitivity, tenderness to
percussion, or drainage from this region.

18

Nelson, Johnson, and Blaha

Fig. 1. Clinical photograph of left mandibular posterior
area showing mass adjacent to mandibular left first and
second molars.
The patient’s dental history revealed that she had come
to the dental college 4 months previously complaining of a
cyclic swelling in the mandibular left molar region of her
mouth. She reported that when the mass decreased in size
there would be a foul taste in her mouth. When the clinical
examination revealed no significant abnormalities, the
patient was advised to return to the clinic when the
swelling recurred.
A review of the patient’s medical history revealed an
allergy to codeine and sulfonamides and indicated that she
was currently taking oral contraceptives. The patient also
related a history of several fainting spells, lasting anywhere
from a few seconds to several minutes, with no evidence of
tonic or clonic seizures; the most recent fainting spell had
occurred 2 years previously. The patient also reported that
she had shingles in 1975. In addition, she indicated that she
smoked.
Physical examination showed a blood pressure of 130/
80 and a pulse rate of 80, which was regular. Clinical
examination of the patient’s sensory responses revealed
paresthesia in the distribution of both the left lingual and
left inferior alveolar nerves. There was a decreased
response to both pinprick and light touch. A firm, nontender, and nonmoveable mass approximately 1 cm in diameter was noted on the lateral surface of the mandible in the
buccal vestibule adjacent to the mandibular left first and
second molars (Fig. 1). The lesion was approximately 1 cm
from the crest of the ridge, with normal overlying epitheliurn. The dentition was in good repair, with occlusal
restorations in the mandibular first and second molars. a
fixed lingual retainer was present from one mandibular
cuspid to the opposite mandibular cuspid. Electrical pulp
testing of the left mandibular teeth showed all teeth to be
responsive, with no abnormal responses to heat, cold, or
percussion. Examination of the neck and the remainder of
the physical examination revealed structures within normal limits.
Panoramic and periapical radiographs of the involved
region showed a condensation of bone, approximately
5 X 5 mm, inferior to the distal root of the mandibular left

Oral Surg.
July. 1986

Fig. 2. Periapical
region.

radiograph

of mandibular

left molar

first molar (Fig. 2). The remainder of the radiographic
findings were within normal limits.
Although the lesion was thought most likely to represent
an exostosis, a biopsy was advised because of the patient’s
dental history, symptoms and concerns, and to eliminate
the possibility of malignant disease. The biopsy procedure
was scheduled for later the same week. The patient was
also referred to a neurologist because of the distribution of
the paresthesia, which involved both the left inferior
alveolar and lingual nerves.
On returning for biopsy, the patient reported that the
original mandibular paresthesia was unchanged. However,
over the intervening period of time she had noted a slurring
of speech, numbness in the left arm and hand, and the
onset of severe migrainelike headaches in the right temporofrontal and retro-orbital regions. In addition, she related
that her co-workers had noticed an asymmetry of her face
and smile.
A biopsy specimen of the mandibular
lesion was
obtained with the aid of local anesthesia. Histologic
examination revealed dense viable bone consistent with
exostosis.
In view of the patient’s additional symptoms, a consultation with the neurologist was scheduled for the same
afternoon. Upon examination of the patient, the neurologist scheduled her for a CT scan of the head and in
addition, obtained an antinuclear antibody titer, a complete blood count, and determination of prothrombin time,
partial thromboplastin time, and erythrocyte sedimentation rate. He also advised her to discontinue using the birth
control pills and to begin taking one aspirin tablet per day.
She was also given a prescription for butalbital and aspirin
(Fiorinal) for her migrainelike
headaches. While the
results of all tests performed were negative, a diagnosis of
right pontine brain-stem stroke was made on the basis of
the patient’s history, symptoms, and physical examination
findings. This was thought to be a vasospastic stroke
related to the combination of migrainelike headaches and
the use of oral contraceptives.
Three months after the initial examination the patient
reported a marked improvement in sensation on the left
side of her face and arm. In addition, the frequency of her

Volume 62
Number 1

Mandibular

migrainelike headaches had decreased significantly. The
patient was continued on her medications. She was also
advised to return if her headachesincreased in frequency
or severity or if her paresthesia or weaknessreturned.
DISCUSSION

An unusual case of inferior alveolar paresthesia
secondary to a cerebrovascular accident has been
presented. This case is unique in that paresthesia of
the trigeminal nerve was the initial presenting symptom. A review of the current literature suggests a
relationship between oral contraceptives and
strokes.5-9This relationship is further enhanced if the
patient is a smoker or has migrainelike headaches.5-9
Birth control pills alone have been reported to cause
migrainelike headaches with an associated cerebral
ischemia (either permanent or transient).6-8 This
patient exhibited several factors that placed her at
significant risk for a cerebrovascular accident. Treatment of this patient involved discontinuing the oral
contraceptives, which resulted in a decreased incidence of the headaches and an improvement in the
paresthesia.
The experience gained in this case suggests that
when a patient is seenwith a chief complaint of facial
paresthesia, a thorough medical history should be
obtained and clinical and physical examinations

paresthesia secondary to cerebrovascular

changes

19

should be performed. The patient should be questioned regarding symptoms that might suggest a
cerebrovascular accident as being the cause of the
paresthesia.
REFERENCES
I. Shafer WC. Hine, MK, Levy BM: A textbook of oral
pathology, ed. 4, Philadelphia, 1983, W.B. Saunders Company.
Lilly GE: Differential diagnosis of lesions of the jawbones. J
Oral Surg 28: 65, 1970.
Kerr DA, Ash MM, Millard HD: Oral diagnosis, ed. 5, St.
Louis, 1978, The C. V. Mosby Company.
Malamed SF: Cerebral vascular accident. In Handbook of
medical emergencies in the dental practice, ed. 2, St. Louis,
1982, The C. V. Mosby Company, pp. 210-223.
of oral
5. Beck WW: Complications and contraindications
contraception. Clin Obstet Gynecol 24: 893-901, 198 1.
6. Dale” JE, Hickler RB: Oral contraceptives and cardiovascular disease. Am Heart J 101: 626-639, I98 I.
I. Huppert LC: Vascular effects of hormonal contraception.
Clin Obstet Gynecol 24: 951-963, 1981.
8. Kelly TM: Systemic effects of oral contraceptives. West J
Med 141: 113-i 16, 1984.
9. Longstreth WT, Swanson PD: Oral contraceptives and stroke.
Stroke 15: 747-750, 1982.
Keprinr

requests

to.

Dr. Lyle W. Nelson
Department of Oral and Maxillofacial Surgery
University of Nebraska Medical Center
42nd and Dewey Ave
Omaha, NE 68105