近年心身症的な症状に悩む患者数は増加しているが, 歯科領域における心身症患者の数も増え続けている.患者はさまざまな口腔内の愁訴を訴えて歯科医院を訪れるが, 歯科医師もはっきりした器質的病因をみつけられず, その治療は一時的なものとなることが多い.歯科心身症のなかでもしばしばみられる舌痛症は, その病因がはっきりしておらず, 心理学的な原因について指摘する論文も多々見受けられる.心理検査等を用いて舌痛症患者の心理的特性を把握しようとする試みは今までもいくつか見受けられるが, 本稿では精神分析理論を用いて舌痛症患者の精神病理の解釈と, 心理療法における精神分析的治療の有効性への可能性を考察した.
心身症における精神分析学的な解釈は, Freudの神経症における研究に端を発しているが, 抑圧された欲望が身体化表現されたという説から発展してきている.Abraham (1877-1925) はFreudの説を発展させ, 自我の発達におけるそれぞれの相の重要性と性格形成に及ぼす影響を論じている.その後, Iqein (1882-1960), Fairbairn (18892-1964) らが早期口唇期における心的構造の発達に重要性をおいた対象関係論を展開していった.
今回, エセックス大学にて学んだ英国派精神分析理論を軸として, 東京医科歯科大学歯学部附属病院頭頸部心療外来を受診した舌痛症患者3名の精神病理について, 対象関係論を中心とした考察を行った.共通して観察された事項として, 対象喪失に関する経験を持ち, 抑圧された感情を言語化する機会を失っているということが挙げられる.また, 口腔に関わる嗜好を持ち, 口唇期的な依存的な性格を残している.口腔に現れた症状は口唇期における葛藤に根ざした, 分離・個別化の過程で生じた何らかの未解決な問題に根ざしているという解釈が成り立つのではと考えられた.また, これらの症状は患者の抑圧された攻撃性と同一化への願望を無意識のうちに呈出しているものとも考えられた.

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Objective: To present the clinical experience of the use of a Kampo medicine, Sai-boku-to, in the treatment of 25 glossodynia patients.
Study design: The patients consisted of 3 males and 22 females, 25 patients in total, with a mean age of 63.1±2.0 years. CMI testing was performed. Sai-boku-to was administered to each of the 25 patients orally for 12 weeks. The clinical examination evaluated oral stimulatory, neuropsychological and somatic symptoms.
Results: In the CMI test, 29%(6/21) of patients were diagnosed as either provisionally neurotic or neurotic. Tongue pain recovery rates were high 2 and 4 weeks after completion of the administration of Sai-boku-to, with the symptoms reduced in more than 70% of patients. Oral stimulatory symptom recovery rates were also high in other categories, besides tongue pain, 2 and 4 weeks after the completion of administration, with improvement observed in more than 60% of cases. The recovery rates were high for neuropsychological symptoms after 12 weeks of administration and 2 and 4 weeks after the completion of administration, with the symptoms reduced in more than 70% of cases. Concerning somatic symptoms, the rates were fairly high with recovery rates of more than 50% after 12 weeks of administration and 2 and 4 weeks after the completion of administration. Liver dysfunction (4%: 1/25) was the only significant side effect.
Conclusions: The results suggest that Sai-boku-to may be clinically useful and safe for the longterm treatment of glossodynia patients.

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Excessive clenching of the teeth due to physical or psychological tension or stress can result in excessive air swallowing.This study sought to investigate and evaluate the characteristics of such patients in terms of both their physical condition in the head and neck region and relevant psychological and social factors.
The subjects consisted of 187 patients (57males and130females) having chief complaints of aerophagia symptoms who visited the psychosomatic medicine clinic at the head and neck department of the Tokyo Medical and Dental University.52.4%were in their twenties and thirties and 69.5%were female.
The principal psychological and social stress factors tended to be study and work related among younger patients, and family problems among female patients.Most of the patients exhibited depression, anxiety, neurosis and a tendency towards autonomic imbalance, and also tended to complain of neck or shoulder pain, headache, oral or pharynx paresthesia and symptoms of quasi-temporomandibular arthrosis in the head and neck region.
The degree of improvement of aerophagia symptoms and a tendency to change doctors too frequently in order to find more appropriate treatment were both considered to be related to depression.
The explanation of habitual teeth clenching, the existence of psychological and social stress factors, the mechanism of air swallowing, and ways to control clenching was useful in helping patients to reduce their aerophagia symptoms.

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Background: It can be difficult to treat glossodynia in the elderly due to various restrictions on the use of pharmaceutical therapy. We report two cases in which elderly patients with glossodynia recovered with the use of sertraline, which in July 2006 became the third SSRI approved for use in Japan.
Case 1: Female, 81 years old.
Chief complaint: Burning glossal pain.
Medical history: Ischemic cardiac disease, hyperpiesia. History of present disease: She had suffered burning glossal pain persistently for approximately 20 years. She had visited various medical facilities prior to referral to our clinic but the pain had not been alleviated. Milnacipran did reduce the pain by approximately 70% but this had to be stopped due to constipation and drug eruption. Sertraline (25mg/day) was then prescribed, and the pain disappeared immediately.
Case 2: Female, 88 years old.
Chief complaint: Prolonged burning glossal pain.
Medical history: Cerebral infarction, colorectal carcinoma.
History of present disease: A tingling proglossal pain had been persisting for several months. No anemia or minor element deficiency was detected in the medical examination, and steroid ointment and vitamin preparation were ineffectual. She visited our clinic for fear of oral cancer. The pain was almost entirely relieved by the use of sertraline (12.5mg/day).
Discussion & Conclusion:
The treatment of glossodynia in the elderly can be complicated by coexisting diseases. The sideeffects of anti-depressants often also appear due to their lowered immune systems. In addition, antidepressants are reported to be ineffective for elderly patients with organic cerebral lesions. We did find, however, that sertraline was effective and produced no particular side effects even under the conditions of these two cases. It is suggested that sertraline may be an effective treatment for glossodynia in the elderly.

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A patient with dental phobia, who visited our dental clinic with the chief complaint of anterior tooth esthetic disorders, was motivated to receive treatment through the design of a provisional restoration and a combination of dental treatment with behavioral therapy. A summary of this case is presented. The patient was a 26-year-old male who hyperventilated with anxiety in response to the sound generated by a machine during dental treatment. To treat the chief complaint of progressive caries in the maxillary front tooth region, we performed a sufficient inquiry and prepared a provisional restoration to motivate the patient to receive further treatment. Application of the provisional restoration at the initial stage enabled the patient to understand the aim of the treatment more fully and this enhanced his confidence during subsequent treatment, leading to the establishment of a good rapport. It was found that his dental phobia could be overcome by means of behavioral therapy consisting of systematic desensitization and exposure techniques. The patient currently continues to receive dental treatment at our hospital.

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In clinical dentistry, we occasionally encounter patients in whom there is no objective finding that corresponds to their subjective complaints. Oral cenesthopathy is a typical condition of this kind. This report presents the case of a patient who was diagnosed with oral cenesthopathy at departments of psychiatry and neurology, and came to our department for a close examination of the oral cavity. The patient was a 64-year-old female. Her primary complaint was a sensation that she described as being like “a metal-like object” sticking into her mouth.
History of present illness: After having received periodontal surgical treatment in May June, 1998, she complained of the sensation of “a metal-like object sticking out from the side of the tongue.” Radiography and periodontal examination were performed but no finding in the oral cavity explained the complaint. Cerebral MRI disclosed an old infarction in the right caudate nucleus. In dental treatment, a radical approach was avoided and the patient was given sufficient time to describe her complaint. To help her visualize her subjective symptoms, she was asked to reproduce them three-dimensionally with the help of a dentition model and utility wax^®. This allowed us to understand the patient's complaint in detail and satisfied the patient that she had conveyed her sensation accurately. Antidepressants prescribed by the psychiatric department produced a mild improvement in the symptoms. The characteristics of this case are (1) The stress of periodontal surgical treatment may have been involved, (2) Mirnaciplan was effective, and (3) Cerebral infarction was recognized. The involvement of a dentist and a specialist in disorders of the oral cavity, the sympathetic attitude toward the patient's complaint, and the act of having the patient reproduce her symptoms, which were difficult to explain in words, with the assistance of a model may have helped to alleviate her psychological burden.

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