Purpose: In response to the public's heightened awareness of the existence of non-odontogenic toothache, the number of patients who consult an orofacial pain (OFP) specialty clinic with unexplained intra-oral pain may be increasing. The purpose of this study was to investigate the clinical characteristics of patients with unexplained intra-oral pain.
Methods: The subjects were 95 individuals with intra-oral pain who consulted the OFP clinic of Keio University Hospital, Department of Dentistry and Oral Surgery, from January 2012 to December 2012. We performed a retrospective review of the following clinical characteristics of the candidates: the male-to-female ratio, age distribution, location of the chief ion of the chief complaints, pathological diagnosis, and the method and effectiveness of the treatment.
Results: The study candidates included 19 males and 76 females. The age distribution ranged from the 30s to the 60s, with approximately the same frequency. The main pathological diagnoses were myofascial pain (MFP) (48%) and neuropathic pain (NP) (26%), which accounted for approximately 80% of all cases. Odontogenic lesion represented 8% of cases. Moreover, MFP coexisted with NP in one-third of NP cases. The main treatment methods for MFP were cognitive behavior therapy and physical therapy, while the main treatment method for NP was medication therapy. The symptoms tended to improve in about 70% of cases.
Conclusions: Based on the medical treatment of unexplained intra-oral pain patients in an OFP specialty clinic, we conclude that a pathological diagnosis, including the differential diagnosis of non-odontogenic pain, is important.

View full abstract

Purpose: To define the response of the sympathetic nerve activity that caused by psychological or physical stress in myofascial pain syndrome (MPS) patients.
Methods: This study examined 10 Japanese MPS patients suffering from chronic pain for over 6 months (MPS group) and 10 adult volunteers who served as the controls. In separate sessions conducted over one-week interval, subjects were exposed to psychological stress, visual stress, which was produced by the International Affective Picture System, or physical stress, which consisted of the active standing test. Changes of the sympathetic nerve activity were estimated by a spectral analysis of the heartbeat fluctuation using the Relax Meijin computer software (Crosswell Inc., Tokyo). The spectral components analyzed included low frequency power (L: power between 0.04 and 0.15 Hz), high frequency power (H: power between 0.15 and 0.4 Hz) and L/H, which is a tool that is used to assess autonomic cardiovascular regulation.
Results: In both groups, L/H during physical stress loading was significantly higher compared with baseline (P < 0.05). There were no differences between the control and MPS groups. During psychological stress loading, the L/H was significantly higher in the MPS versus the control group (P < 0.05).
Conclusions: There found psychological stress increases the sympathetic nerve activity responsible for the manifestation and continuation of MPS.

View full abstract

Purpose: This article describes the diagnosis of a patient exhibiting tooth pain using structured pain interview sheets and the TMD*+OFP** diagnostic protocol (including cranial nerves test. The diagnosis of tooth pain is a constant challenge to the dental practitioner. Moreover, only a dentist can diagnose tooth pain. Therefore, the dentist must diagnose the patient based on the accurate information regarding his or her current medical state and history, while taking into account other information and knowledge about disease mechanisms and treatment. The accurate diagnosis helps concerted efforts to treat the patient with the help of other departments, as well. However, dentists with little clinical experience or even dentists with considerable clinical experience when faced with complex cases often face difficulties. This study examined the efficacy of using structured pain interview sheets for hypothetico-deductive clinical diagnostic reasoning methods and data gathering and the TMD+OFP diagnostic protocol (including cranial nerves test) for diagnosis.
Study selection: We used the following five steps to diagnose pain in a patient who complained of tooth pain in the left mandibular molar region. Step 1: comprehensive history taking; Step 2: enumeration of diagnostic hypotheses; Step 3: revision of diagnostic hypotheses; Step 4: confirmation of diagnostic hypothesis; Step 5: final diagnosis. We used structured pain interview sheets and the TMD+OFP diagnostic protocol (including cranial nerves test) in Steps 1 and 3, respectively.
Result: A definitive diagnosis was reached for the patient. Treatment was selected based on the diagnoses, and the patient was completely cured.
Conclusions: We confirmed the efficacy of the clinical diagnostic reasoning using the structured pain interview sheet and the TMD+OFP diagnostic protocol (including cranial nerves test) for diagnosis of tooth pain in a patient.

View full abstract

Patients: Case 1) A 70-year-old female had received the surgery in our department to remove a black lesion on the premolar buccal gingiva of the left mandible, X years back. Although the wound healed after the surgery completely, the patient has hypoesthesia of left mental nerve innervation. Moreover, because unpleasantness around the wound has also remained, she visited the Chronic Pain Clinic at the Department of Oral and Maxillofacial Surgery, Tokyo Medical University. Case 2) A 61-year-old female was treated for peri-implantitis and temporomandibular disorder in our department. Because the patient began to perceive the persistent tongue pain during the treatment period, she visited the Chronic Pain Clinic of our department. As a result of the medical interviews which performed for these patients many times, we diagnosed that psychosomatic treatments are needed in these case. Thus, these patients were referred to the Oral Pain Clinic of the Psychiatric department in our university. Although they were prescribed mirtazapine and milnacipran, neither medication was effective. Further, the patient of Case 2 reported some side effects. The medication was subsequently changed to duloxetine, thereby the reduction of symptoms in both patients were obtained.
Discussion: Although Tricyclic antidepressants (TCAs) have been used for chronic pain in the orofacial area, TCAs have various side effects, such as dry mouth, urinary retention, and abnormalities on electrocardiogram. Because the use of a safer drug is needed occasionally, we have worked on using antidepressants other than TCAs in our clinic proactively so far. As a consequence, we believe that it is important to follow the Guidelines for chronic pain of treatment, whereas considering side effects of drugs carefully, and providing the treatment that is specifically tailored to each patient.
Conclusions: We performed psychosomatic medical approach to the chronic pain of orofacial area, and reported the case which duloxetine was effective for the pain relief.

View full abstract

Patient: A 48-year-old woman presented with persistent pain in the left upper and lower molars and numbness in the left arm. The pain began about five years ago and the patient was referred to our pain center after having received medication and endodontic treatment at many medical institutions. The pain was spontaneous and fluctuated daily. The patient had poor oral hygiene and had abandoned dental treatment of many teeth. Our treatment at each visit was as follows: we listened to her complaints, explained the pathophysiology of her pain, and instructed her through psychological intervention to recognize oral parafunctional activities as pain behaviors and to relax masticatory organs. The patient experienced a change in pain intensity and decided to restart dental treatment. Approximately 12 months after both dental treatment, in which her teeth had been fixed with crowns and bridges, and our treatment, the patient could now eat without pain.
Considerations: It is better to avoid invasive dental procedures for idiopathic toothache. It could cause aggravation of the oral environment and an increase in patient anxiety, leading to discontinuation of endodontic treatment until the pain improves. We postulate that the patient's awareness of the pain changed through exercise therapy, including psychological intervention, and therefore she could receive treatment at the dental clinic, which lead to a reduction in pain.
Conclusion: Jaw exercise therapy, including psychoeducation about pain, in cooperation with a dental clinic may be a useful procedure to treat persistent dentoalveolar pain.

View full abstract

Patients: Evaluation was used Numerical rating scale (NRS) and The Evaluation form that we had created.
Case1: The patient was 20's men. Tooth extraction of right upper and lower wisdom tooth was performed under local anesthesia. After 3weeks, pain of temporal muscle, medial pterygoid muscle, buccinator muscle and limited mouth opening had remained. Pain was improved by as a result of the conducted 4 times Post Isometric Relaxation (PIR) in 7weeks. In addition, mouth opening was 36mm prior to treatment and 50mm after treatment. before and after PIR.
Case2: The patient was 30's men. Suddenly, right temporomandibuler joint pain appeared. Pain of masseter muscle, buccinator muscle and limited mouth opening was exhibited. Pain was improved by as a result of the conducted 2times PIR in 5weeks. In addition, mouth opening was 24mm prior to treatment and 50mm after treatment.
Discussion: Both cases was suggested that Taut band, Trigger point and Referred pain. For that reason, It is reasonable to support that Myofascial pain (Simmons et al 1989). Lewit proposed that effectiveness of the PIR for Myofacial pain (Lewit et al 1984). Both cases suggested that effectiveness of the PIR for Myofacial pain.
Conclusions: Nowadays, Treatment for Myofascial pain of Orofacial by Physiotherapist has little currency in Japan. Physiotherapist has ability to treatment and evaluation of the skeletal muscle of the whole body. A need for intervention of Physiotherapist in a dental field is required.

View full abstract

Patients: A 60-year-old female complained of pain in the anterior tongue tip. After clinical examination, geographic tongue was only found. Based on a thorough history and diagnostic test including blood tests and microbial tests, any local factors (candidiasis, herpes, hyposalivation, allergy, or mucosal lesions) or systemic factors (vitamin deficiencies, diabetes, hypothyroidism, medications such as ACE inhibitors, or autoimmune disorders), causes of symptoms were not found. Consequently, we diagnosed glossodynia with geographic tongue. Psychotherapy, topical pharmachological management (local anesthetic) and reassurance relieved her symptoms in several months.
Discussion: Burning mouth syndrome is chronic oral mucosal pain or discomfort, involving the anterior tongue in most cases, and sometimes also the lips, palate, and pharynx. If the symptoms are confined to the tongue only, it is called glossodynia. It has no identifiable causative lesions and is not caused by any other condition or disease. In this case, geographic tongue was found, but we didn't consider it as a cause of symptoms. If we could not find objective finding which explains the subjective symptoms, we should just explain the patients' clinical conditions and/or conservative treatment instead of invasive surgical treatment.
Conclusion: In this case, we could manage a patient by psychotherapy and using local anesthetic. Topical lidocaine may be useful for the management of glossodynia from the viewpoints based on efficacy, lack of systemic side effects and convenience of use as one of conservative treatment.

View full abstract

Patients: A 50-year-old woman experienced discomfort in the root of the tongue on the right side 16 months prior to her first visit. After visiting an internal medicine clinic, a mouthwash was prescribed, but her discomfort did not improve. She subsequently visited another internal medicine clinic and was suspected to have connective tissue disease, but a blood test did not show any abnormal findings. Her discomfort gradually spread to the edge of the right side of the tongue. Two months prior to her first visit to our clinic, a dental clinic recommended she consulted the Oral Surgery Department of our hospital. A fungal test did not reveal presence of Candida. However, she was treated with an ointment and a mouthwash, but her symptom did not improve. Thereafter, she visited our clinic, presenting with a spontaneous burning sensation on the right side of her tongue. She experienced gastric distress and was also visiting the internal medicine clinic. Therefore, we prescribed Rikkosan 7.5g/day as a mouthwash. After gargling, she experienced temporarily relief. After using Rikkosan for 7 weeks, the frequency of her symptoms decreased, and after 11 weeks, the duration of symptom-free periods increased. Thereafter, she used Rikkosan only when she felt her symptom. Over 7 weeks, she experienced tongue discomfort only two times. Therefore, 5 months after the initial prescription, she was asked to gargle with Rikkosan only when she felt discomfort. Eight months after the initial prescription, her symptom resolved, and the treatment was thus discontinued.
Discussion: In this case, the patient's symptom did not improve after gargling with a mouthwash but improved after gargling with Rikkosan. Therefore, some components of Rikkosan might effectively relieve discomfort associated with the tongue mucosa.
Conclusions: This case suggests that gargling with Rikkosan can treat burning mouth syndrome when oral intake of medications is difficult.

View full abstract