We present the case of a 53-year-old man, who until 1992, when he was 41 years old, had a small hiatus hernia as his only personal history of interest. Since that date and as a consequence of a traffic accident, he began to experience discomfort in both the cervical and lumbar spine, with the pain radiating to the shoulders, arms and legs. The painful symptomatology increased in intensity, and under the diagnosis of lumbar disc herniation L4-L5, a lumbar discectomy and laminectomy were performed, with a worsening of her symptoms appearing after the operation. Months later, due to lumbar instability, he underwent a new operation to fix the lumbar vertebrae, and as a consequence of this operation his symptoms worsened even more, with the appearance of paraesthesia and neuropathic pain accompanied by urination disorders, constipation and erectile difficulties, which led to the diagnosis of post-surgical epidural fibrosis or post-laminectomy syndrome.
In 1997 he underwent two further operations. The first time, to remove the osteosynthesis material; and the second time, to perform a cervical discectomy with laminectomy at C3-C4, which also failed, as the pain increased in intensity and acquired neuropathic characteristics.
Given the severity of the condition and the poor evolution of the patient, he was referred to the Pain Unit of our hospital where, after the initial assessment, it was decided to opt for the placement of a spinal neurostimulator, which also failed to achieve satisfactory results. On the other hand, as a consequence of the continuous analgesic and anti-inflammatory treatments used to try to control the pain, the patient developed a duodenal ulcer which aggravated the pre-existing hiatus hernia, and anxiety and depression.
Recently, after an accidental fall, he fractured both calcaneus, adding a new component of pain to those already reflected, and which has ended up plunging the patient into moderate depression. The calcaneal fracture is leading to a sympathetic-reflex dystrophy of both legs.
He is currently diagnosed with cervical and lumbar postlaminectomy syndrome, and presents continuous pain, of moderate-severe intensity, with frequent exacerbations that increases with sitting and throughout the day, and becomes unbearable in the afternoon, being forced to use crutches due to the degree of disability, and due to the marked limitation of mobility, especially in the cervical and lumbar regions. Examination revealed a positive bilateral Lasegue's sign at 30 degrees; severe sensory impairment, which, in addition to the pain, caused hypoaesthetic and spastic areas in both lower limbs; and marked motor and sphincteric difficulties that significantly limited the patient's daily life.
The pain has been treated with numerous drugs, ranging from non-steroidal anti-inflammatory drugs to morphine, anti-competitive drugs, anxiolytics and antidepressants. Since three years ago, oral fentanyl citrate therapy was introduced to accompany the use of transdermal fentanyl. Since then, his pain and quality of life have improved substantially, although the results are still far from optimal, as he needs two 400 µg tablets almost every day to control his painful exacerbations.
As the most significant fact to be highlighted, the patient states that months after starting continuous treatment with oral fentanyl citrate, he has developed multiple caries, which have caused the loss of a total of ten teeth, and he blames this on the use of this drug. His dental hygiene is defective but existing, and he performs it occasionally, almost every day.
In the group of 77 patients who also receive chronic oral treatment with fentanyl citrate for various pathologies in our Pain Unit, and whom we reviewed as a result of the case in question, no other cases of significant dental disorders were found. The mean age of these patients was 63 ± 8.2 years and the duration of fentanyl treatment was 36 ± 8 months. Dental hygiene behaviour in this group has not changed with the introduction of the new drug, and the prevalence of caries can be extrapolated to that of the general adult population, where it is around 85-99%, depending on age and different studies (5).
