Yojiro Umezaki

The Efficacy of Daily Prefrontal Repetitive Transcranial Magnetic Stimulation (rTMS) for Burning Mouth Syndrome (BMS): A Randomized Controlled Single-blind Study

BACKGROUND Burning mouth syndrome (BMS) is a burning oral sensation without any corresponding abnormal findings. In some cases, BMS is refractory to pharmacologic treatments. Repetitive transcranial magnetic stimulation (rTMS) over left prefrontal cortex induces analgesic effect in both acute and chronic pain. However, its effect for BMS has not been evaluated. OBJECTIVE The aim of this randomized, controlled, single-blind study was to assess the efficacy of prefrontal rTMS for BMS. METHOD Twenty patients with BMS were recruited and randomized to receive 30,000 pulses in total at 10 Hz TMS (n = 12) or sham TMS (n = 8). We assessed the change of BMS pain condition, functional status and mood until 2 months after the beginning of treatment. RESULTS In the real group, the BMS pain intensity decreased 67%, and 75% of the patients reported >50% pain decrease on final assessment compared to baseline, without heavy side effects. There was significant pain reduction in subjects in the real group immediately after 1 week of treatment, whereas there was none in those in the sham group. Similar tendency was confirmed in change of functional status. Mood and the affective aspect of pain were not changed in this study. CONCLUSION BMS pain was significantly improved with 2 weeks of treatment of high frequency rTMS over left DLPFC compared to sham stimulation. Further study is needed to refine and improve TMS as a potential treatment of BMS.

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.

Oral Dysesthesia Rating Scale: a tool for assessing psychosomatic symptoms in oral regions

BackgroundThe concept of cenesthopathy was first introduced by Dupré and Camus in 1907 to describe clinically unexplainable bodily sensations mainly attributed to psychiatric pathology. If it occurs in oral regions, it is termed oral cenesthopathy and it has been of special interest to psychiatrists and dentists. While there is no independently defined criteria for this condition, which is classified as either a delusional or a somatoform disorder, clinical practice and research require a standard scale to measure and rate its symptoms. In this study, we included any types of psychosomatic symptoms in oral regions as oral dysesthesia, and developed an Oral Dysesthesia Rating Scale (Oral DRS) and evaluated its validity and reliability as an assessment tool.MethodsThe scale was developed based on literature review and extensive clinical experience. Twelve reviewers assessed relevancy of each item to oral dysesthesia symptoms by 1–4 scoring scale and item content validity index was computed. To evaluate the inter-rater reliability of Oral DRS, pairs of raters administered the scale to 40 randomly selected patients with complaints of oral dysesthesia symptoms and Cohen’s weighted kappa coefficient was determined for each item.ResultsThe scale assesses the severity of feelings of foreign body [A1], exudation [A2], squeezing-pulling [A3], movement [A4], misalignment [A5], pain [A6], and spontaneous thermal sensation or tastes [A7], and the degree of impairment in eating [B1], articulation [B2], work [B3], and social activities [B4] on a scale of 0–5. Items A1, A2, A3, A4, B3, and B4 demonstrated acceptable content validity. Inter-rater reliabilities were good or excellent for all items evaluated.ConclusionThe Oral DRS can help define the nosography of clinically unexplainable oral dysesthesia through further case evaluation and clinical research and facilitate devising of treatment modalities.

Two Cases of Oral Somatic Delusions Ameliorated With Brain Perfusion Asymmetry: A Case Report

Background Oral cenesthopathy is the complaint of abnormal oral sensation where no underlying organic cause can be identified. It is also called oral dysesthesia or oral somatic delusion and classified as delusional disorder, somatic type. The patients with oral cenesthopathy show right > left asymmetric regional cerebral blood flow (rCBF) in the broad brain region. However, the studies scrutinizing the rCBF change before and after the successful treatment are still a few so far. Case We present 2 cases of oral cenesthopathy, who responded well to aripiprazole. The asymmetric rCBF patterns were attenuated after successful treatment in both cases. Conclusions We found a marked improvement of oral cenesthopathy with aripiprazole. It is suggested that right > left rCBF asymmetry in the frontal and temporal lobes and thalamus, and the dopaminergic and serotonergic dysfunctions are involved in the pathology of oral cenesthopathy.

Daily left prefrontal repetitive transcranial magnetic stimulation for medication-resistant burning mouth syndrome

Burning mouth syndrome (BMS) is a persistent and chronic burning sensation in the mouth in the absence of any abnormal organic findings. The pathophysiology of BMS is unclear and its treatment is not fully established. Although antidepressant medication is commonly used for treatment, there are some medication-resistant patients, and a new treatment for medication-resistant BMS is needed. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technology approved by the US Food and Drug Administration (FDA) for the treatment of depression. Recent studies have found beneficial effects of TMS for the treatment of pain. A case of BMS treated successfully with daily left prefrontal rTMS over a 2-week period is reported here. Based on this patients clinical course and a recent pain study, the mechanism by which TMS may act to decrease the burning pain is discussed.

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.