Miho Takenoshita

Psychiatric diagnoses in patients with burning mouth syndrome and atypical odontalgia referred from psychiatric to dental facilities

Background Burning mouth syndrome (BMS) and atypical odontalgia (AO) are two conditions involving chronic oral pain in the absence of any organic cause. Psychiatrically they can both be considered as “somatoform disorder”. From the dental point of view, however, the two disorders are quite distinct. BMS is a burning or stinging sensation in the mouth in association with a normal mucosa whereas AO is most frequently associated with a continuous pain in the teeth or in a tooth socket after extraction in the absence of any identifiable cause. Because of the absence of organic causes, BMS and AO are often regarded as psychogenic conditions, although the relationship between oral pain and psychologic factors is still unclear. Some studies have analyzed the psychiatric diagnoses of patients with chronic oral pain who have been referred from dental facilities to psychiatric facilities. No study to date has investigated patients referred from psychiatric facilities to dental facilities. Objective To analyze the psychiatric diagnoses of chronic oral pain patients, diagnosed with BMS and AO, and referred from psychiatric facilities to dental facilities. Study design Psychiatric diagnoses and disease conditions of BMS or AO were investigated in 162 patients by reviewing patients’ medical records and referral forms. Psychiatric diagnoses were categorized according to the International Statistical Classification of Disease and Related Health Problems, Tenth Revision. Results The proportion of F4 classification (neurotic, stress-related, and somatoform disorders) in AO patients was significantly higher than in BMS patients. BMS patients were more frequently given a F3 classification (mood/affective disorders). However, 50.8% of BMS patients and 33.3% of AO patients had no specific psychiatric diagnoses. Conclusion Although BMS and AO are both chronic pain disorders occurring in the absence of any organic cause, the psychiatric diagnoses of patients with BMS and AO differ substantially.

Milnacipran dose-effect study in patients with burning mouth syndrome.

Objective:The object of this study was to evaluate the dose-dependent efficacy and tolerability of milnacipran in patients with burning mouth syndrome (BMS) with inadequate response at low doses. Methods:A 12-week open-label dose-escalation study was conducted in 56 female patients (aged 20-83 years, with a mean age of 60.8 years). The initial dosage of milnacipran was 30 mg/d, and the dosage was raised up to 60 mg and 90 mg/d every 4 weeks until an improvement of at least 50% reduction of visual analog scale was achieved. Results:The mean ± SD effective daily dose of milnacipran was 63.9 ±16.7 mg. The cumulative improvement rate for the daily dose of 30 mg was 28.6%, and this rate rose (50.8%-67.9%) as the daily dose was increased (from 60 to 90 mg, respectively). The cumulative proportion of responders was significantly greater, with maximal daily doses of 60 and 90 mg, compared with that of 30 mg (P < 0.05, &khgr;2 test). Most adverse events appeared at the low dose, and there was little evidence for dose-dependence of adverse effects. No serious safety issues were observed. Conclusion:From the result of this study, dose escalation of milnacipran for patients with burning mouth syndrome with inadequate response at low doses may be helpful if the 30-mg daily dose has been tolerated well.

Psychiatric comorbidities and psychopharmacological outcomes of phantom bite syndrome

OBJECTIVE Phantom bite syndrome (PBS) is characterized by a persistent uncomfortable sensation of occlusion without an evident occlusal discrepancy. The aims of this retrospective cross-sectional study were to assess psychiatric comorbidities and evaluate psychopharmacological outcomes of PBS. METHODS The database of the Psychosomatic Dentistry Clinic of Tokyo Medical and Dental University Dental Hospital was reviewed for cases of PBS diagnosed between April 2009 and March 2012. Clinical Global Impression indices were used to assess psychopharmacological outcomes. RESULTS The review revealed 130 patients (107 women, 23 men) with a mean age of 53.0 ±13.1 years. They previously visited 4.4 ±3.4 dental clinicsand had a mean symptom duration of 5.3 ±5.4 years. Only 24 (18.5%) of 63 (48.5%) patients with psychiatric comorbidities had schizophrenia, major depressive disorder, or bipolar disorder. The frequency of psychiatric comorbidities was significantly lower in PBS with a dental trigger than that without a specific trigger. Moreover, patients without a psychiatric comorbidity showed significantly better outcomes than those with a psychiatric comorbidity. Forty patients (30.8%) showed remarkable clinical improvement after receiving amitriptyline, mirtazapine, or aripiprazole. CONCLUSION PBS is generally not associated with severe psychiatric disorders. Absence of a dental trigger predicts a psychiatric comorbidity, which affects the psychopharmacological outcome. Antidepressant or antipsychotic therapy may be effective for symptom management in PBS.

Comparison of cerebral blood flow in oral somatic delusion in patients with and without a history of depression: a comparative case series

BackgroundA significant number of patients visit dental clinics because of unusual oral sensations for which no physical cause can be found. Such patients are recognized as having oral somatic delusion (OSD). OSD may be either primary (monosymptomatic) or secondary to another disease, such as depression or cerebral infarction. Although the presenting complaints of patients with primary and secondary OSD are nearly indistinguishable, symptoms in patients with secondary OSD seem to be resistant to treatment compared with those in patients with primary OSD. Moreover, right dominant cerebral blood flow (CBF) has been reported in patients with primary OSD, but the difference in CBF between patients with primary and secondary OSD remains unclear. The aim of this study was to assess the differences in clinical characteristics and CBF distribution between patients with monosymptomatic OSD (non-depression group) and OSD in conjunction with remitted depression (depression group).MethodsParticipants were 27 patients of a psychosomatic dentistry clinic, all diagnosed with OSD. They were categorized into either the non-depression group (17 patients) or the depression group (10 patients) on the basis of assessments by their personal medical providers. CBF was examined using single-photon emission computed tomography.ResultsThere was no difference in clinical presentation between the two groups. A significant right dominant asymmetry in the temporal and posterior cerebral regions was observed in both groups. In the central region, a right dominance was seen in the non-depression group, while a left dominance was seen in the depression group. Moreover, the mean regional CBF values for patients in the depression group were significantly lower in several regions (including bilateral callosomarginal, precentral, angular, temporal, posterior cerebral, pericallosal, lenticular nucleus, thalamus, and hippocampus; and right central and cerebellum) than for patients in the non-depression group.ConclusionThese results suggest that the temporal and posterior cerebral regions are involved in in the pathophysiology of OSD, regardless of depression history, and that widespread CBF reduction is a characteristic of remitted depression.

Low-Dose Aripiprazole Augmentation in Amitriptyline-Resistant Burning Mouth Syndrome: Results from Two Cases.

Dear Editor, Despite the efficacy of antidepressants such as amitriptyline for alleviating burning mouth syndrome (BMS) [1,2], BMS may persist after antidepressant monotherapy. However, recent case reports have shown that aripiprazole (APZ) augmentation can reduce chronic pain resistant to other treatments [3]. Herein, we present two cases in which patients with BMS responded well to a very low dose of APZ in combination with amitriptyline; pain reduction was achieved within two weeks of APZ initiation and was substantial at the two-year follow-up. Case 1. A 69-year-old housewife who lived with her husband was referred to our clinic by her family doctor, complaining of tingling pain on the left edge and tip of her tongue. She had no past medical or psychiatric history, excepting hyperlipidemia, nor did her family. Her symptoms began a year earlier in the absence of any precipitating events. Although she underwent various treatments at dental, otorhinolaryngology, and oral surgery clinics, her oral symptoms persisted. The results of the laboratory tests provided by the patient’s family doctor were normal, as were those of the extra- and intraoral examinations performed at our clinic. No obvious symptoms of depression were observed at the first visit. After administering 10 mg per day of amitriptyline for pain reduction, …

Low-dose aripiprazole for refractory burning mouth syndrome

We report a case of refractory burning mouth syndrome (BMS) ameliorated with low dose of aripiprazole. The patient was a 66-year-old female who had suffered from chronic burning pain in her tongue for 13 months. No abnormality associated with the burning sensation was detected in the laboratory tests and the oral findings. Considering the clinical feature and the history together, we diagnosed the burning sensation as BMS. The BMS pain was decreased by aripiprazole (powder) 1.0 mg/d, though no other antidepressants had satisfying pain relief. It could be supposed that the efficacy of aripiprazole is caused by dopamine stabilization in this case, and BMS might have a subtype that is reactive to aripiprazole. Further studies are needed to confirm the efficacy of aripiprazole for BMS.

Clinical characteristics and course of oral somatic delusions: a retrospective chart review of 606 cases in 5 years

Objective Oral cenesthopathy is characterized by foreign body sensations without medical and dental evidence for them. It is thought to be a rare disease in psychiatry, but many patients are visiting dental clinics seeking treatment to remove a foreign body. Even though the features of oral cenesthopathy might be different between a psychiatric clinic and a dental clinic, there has been no clinic-statistical study from dentists. In this study, we report a clinico-statistical study of patients with oral cenesthopathy in dentistry. Methods This is a retrospective chart review of 606 outpatients with oral cenesthopathy in Tokyo Medical and Dental University from April 2010 through to March 2015. Results A total of 159 male and 447 female patients were included in this study. The mean age was 62.08 years, and female patients were older than male patients. The trigger of the dental treatment and the acute phase of depression at the onset were significantly related (p=0.037). Only 128 patients (36%) had clinically significant improvement after 6 months of pharmacotherapy. No history of psychiatric disorders (odds ratio [OR] 0.479 [95% confidence interval {CI}: 0.262–0.875], p=0.017) and longer duration of illness (>18 months) (OR 2.626 [95% CI: 1.437–4.799], p=0.002) were significant factors for clinical outcomes. Conclusion Patients with oral cenesthopathy in our clinic were predominantly elderly female patients. Dental treatment in the acute phase of depression might be a risk factor for oral cenesthopathy. Therefore, comprehending the situation of psychiatric disorder and obtaining adequate informed consent might be required to prevent the trouble concerning oral cenesthopathy.

An increase in salivary flow with amitriptyline may indicate treatment resistance in burning mouth syndrome

Burning mouth syndrome (BMS) is characterized by debilitating intraoral burning pain with no underlying dental or medical causes (Toyofuku, 2016). Amitriptyline is widely used as an analgesic for BMS. The objective of this study was to compare salivary flow between amitriptyline‐responders and nonresponders. Salivary flow was measured using Saxon test from 27 BMS patients before and one month after receiving amitriptyline. We defined amitriptyline‐ responders as Patient Global Impression of Change score < 5 and nonresponders as Patient Global Impression of Change score ≧ 5 after a month treatment. The statistical analysis was performed by Wilcoxon signed‐rank test. Of 27 subjects, 19 (70.4%) were responders and 8 (29.6%) were nonresponders. The average age of responders was younger than that of nonresponders, although there were no differences in female ratio, visual analogue scale score before treatment, salivary flow before treatment, and amitriptyline dosage. Nonresponders indicated a statistically significant increase in salivary flow with amitriptyline, while responders showed a significant decrease (Table 1).