The number of patients with psychosomatic dental problems is potentially large. The onset of such symptoms is mostly associated with psychosocial problems. This paper reviews the “Introduction to Psychosomatic Dentistry” which was presented at a seminar on psychosomatic dentistry for dental hygienists. Psychosomatic dentistry has been poorly defined thus far. The medically unexplained symptom, which is defined as physical symptoms without any physical, biomedical or psychiatric problems, is consistent with psychosomatic dentistry. When a dental professional sees a patient who may have psychosomatic dental problems, it is necessary to determine whether the patient should be referred to psychiatrics. Patients without psychiatric problems require intervention by dental professionals. Dental hygienists are expected to intervene in such psychological problems in the dental setting.

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Dental fear is a crucial clinical issue in dental practice. It occasionally presents as dental phobia, causing long-term avoidance of dental treatment. The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition （DSM-5） of the American Psychiatric Association defines dental phobia as a subtype of specific phobias in the category of anxiety disorders. According to previous epidemiological studies on dental fear, the proportion of individuals with severe dental fear in the general population ranged from 7.3％ to 24.3％ （average: approximately 12％）. In dental fear, some people fear the whole concept of dentistry, but some are only afraid of certain aspects of dentistry. The etiology of dental fear can be divided into two types: （1） specific situations, instruments, and procedures, and （2） factors associated with the dentist. Previous studies revealed that the most feared stimuli in dentistry were dental surgery, the “drill,” and “injection” or “needle.” It should be noted that these rankings are generally true for most people. In a previous study, 50％ of patients with dental fear reported the dentist as the major cause, and among them, 81％ did not report pain as the cause. Some patients reported the fear of becoming embarrassed or being belittled by dental professionals. The possibility of accidents during a dental procedure is a major concern in fearful dental patients. Therefore, dental professionals should be well aware of the common causes of dental fear. Procedures that are less stressful for both patients and dental professionals should be performed.

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It is not unusual to see patients with chronic oral pain or occlusal discomfort. Such patients often have several medically unexplained symptoms such as headache, low back pain, tinnitus, dizziness and gastrointestinal disorders. No medical specialist prefers patients with such burdens. Oral（dental）hygienists are expected to play an important role in caring for such patients properly. This article describes how to assess and care for these dental patients with psychosomatic problems.

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In daily dental practice, we sometimes treat patients with complicated complaints that are difficult to manage with ordinary procedures. Reversible prosthetic treatment such as the double casting technique for a fixed partial denture and fitting a fixed partial denture on an existing removable partial denture could help to manage patients safely, especially in prosthetic practice. Some tips for prosthetic practice procedures are introduced through four cases of patients who underwent reversible prosthetic treatment with the help of brief psychotherapy.

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Cognitive behavioral therapy is one of the psychotherapies that are widely used in the world and its efficacy for various problems has been confirmed. In cognitive behavioral therapy, the relations among the symptoms and problems of patients are understood based on behavioral and cognitive theories. This article examines how to understand and deal with problems based on cognitive behavioral therapy using psychosomatic problems in dental settings as an example.

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In 1999, a liaison outpatient clinic was established in the Department of Oral and Maxillofacial Surgery, Aichi Gakuin University Hospital（AGUH）to provide services on mainly chronic orofacial pain（including burning mouth syndrome and persistent idiopathic facial pain）. Our clinic has invited psychiatrists and formed a medical care team based on the concept of consultation-liaison psychiatry to evaluate the psychosocial and psychiatry aspects of a patient’s life to enhance the medical treatment.
The aim of this study was to comprehend our medical team’s present situation, and to apply the results to our activities in the future. We performed a series of analyses by comparing the clinical statistics between calendar year（CY）2018 to the 20th anniversary of its inauguration, and fiscal year（FY）2004. The statistics for FY2004 were published earlier.
The number of first-visit patients was 53（FY2004）and 92（CY2018）which is an approximately 1.7-fold increase. The proportion of referral patients was 96％（FY2004）and 92％（CY2018）. The most common referral source was other departments of our outpatient clinic both in FY2004 and CY2018. However, the number of referrals from dental and oral surgery departments of the hospital was higher in CY2018 compared with FY2004. As referral sources, medical institutions other than dentistry have diversified（comprehensive medical care, psychiatry, internal medicine and pain clinic）, and the number of referral patients has increased. The illness period of first-visit patients was not significantly shorter in CY2018 compared with FY2004（P＝0.22）, but showed such a trend（median 12 months in CY2018 and 18 months in FY2004）. Moreover, the number of patients with an illness period of more than 36 months decreased. From this study, it is suggested that awareness of our team in this region has increased.

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Somatoform disorders are psychological disorders characterized by complaints such as body pain and discomfort in the absence of organic abnormalities. In the dental field, pain of the tongue/teeth is frequently observed. At the time of the first visit to a dental clinic, patients with somatoform disorders cannot connect symptoms with stress, although dentists explain about their cause, and the disorder sometimes becomes intractable. We encountered a patient with various oral complaints who began to recover relatively early after psychiatric treatment. The patient’s understanding and awareness are necessary for early healing.
A 68-year-old female complained of pain due to contact between the lingual margin and teeth/gingiva, tightening pain in the mandibular teeth, and viscous fluid discharged from the left inferior gingiva. In the dental clinic, we performed minimal treatment, and referred her to the Department of Psychiatry soon after establishing a rapport with her. Liaison psychiatry services were provided, and she has mostly recovered from the disorder after drug administration and counseling.

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For patients with severe oral psychosomatic symptoms who struggle in their daily lives, hospitalization with sufficient treatment duration could be useful. However, due to recent changes in the Japanese health insurance system, it is becoming more difficult to receive long hospitalization. In addition, the change in environment might worsen the symptoms of burning mouth syndrome（BMS）, especially in elderly patients. A strategy to manage patients with severe symptoms in the outpatient setting is therefore required. With careful observation of side effects, support from the family, patient education and careful dose adjustment, patients with severe BMS symptoms could be managed successfully without hospitalization. A 68-year-old female presented burning tongue sensation, dry mouth sensation and dysgeusia for 3 months before her first visit. The severe oral symptoms caused insomnia, loss of appetite and fatigue. She could not do any housework and lay on a bed all day. We diagnosed her pain as BMS. We started treatment with 10mg of amitriptyline. Amitriptyline was titrated carefully and quickly up to a single bedtime dose of 40mg. The burning pain of the tongue almost resolved within 1month and she recovered to her normal life by 5 months from the initial visit. Regarding side effects, drowsiness, dry mouth, weight gain of 2kg and constipation were reported, but there were no serious side effects.

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