[in Japanese]

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Atypical odontalgia （AO）, which is toothache with no identifiable cause, is a psychosomatic disorder almost as common as burning mouth syndrome and oral dysesthesia. Antidepressants such as amitriptyline are commonly used to treat AO due to their reported effectiveness. Recently, there have been reports on the usefulness of Kampo medicines to treat AO, and we too have reported cases in which Kampo alone was as useful as antidepressants. In the present study, we compared the efficacy and safety of Kampo with antidepressants in treating AO and evaluated whether Kampo could be a useful treatment option for AO. Kampo and antidepressants both showed about 70％ efficacy. There was no significant difference in the incidence of side effects, but those of Kampo tended to be fewer. Accordingly, Kampo medicine may be a good therapeutic option to treat AO. However, when selecting a Kampo medicine, it is important to take into account the patient’s pattern as the basis of Kampo treatment.

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Extreme weight gain and loss due to anorexia, overeating, vomiting, etc. are symptoms of eating disorders and are often reported to be accompanied by swollen salivary glands as well as strong psychological factors. A 47-year-old female patient presented to our department with a chief complaint of painless swelling of the bilateral submandibular areas. Psychologically, she had been hospitalized twice at the Department of Psychiatry due to depression, vomiting, and overeating. BMI index was 15.4, and the patient was thin. Bilateral submandibular glands were elastic and soft with walnut-sized swelling, but there were no abnormal findings on ultrasonography or CT scan.
We explained to the patient that there was no obvious salivary gland disease, but she persistently appealed for surgical resection. We explained to the patient that her eating disorder was the cause of the submandibular gland swelling and that it would be difficult to improve the condition unless she stopped vomiting and overeating, and we decided to follow up the patient. The challenge for the therapist is how to avoid becoming entangled in the patient’s unrealistic demands for surgical treatment when the patient stubbornly insists on it. It is important not to begin dental treatment until the patient’s life history and medical history are fully understood, and it is important to be relaxed enough to take a step back when the patient’s psychological factors are understood to be deep-seated. However, in this case, we had the opportunity to obtain detailed information on the patient’s life history, including psychiatric hospitalization, and we were able to obtain information on the patient’s treatment history going back to the past.

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In the examination of psychosomatic dentistry, confirmation of organic findings requires particular attention. Once a diagnosis of oral psychosomatic symptoms is made, various complaints tend to be treated as mentally related, and the discovery of organic diseases could be delayed. We actively accept patients with oral psychosomatic symptoms, but there are cases of burning mouth syndrome comorbid with malignant tumors and other oral mucosal diseases, and in some cases, it is difficult to distinguish between atypical odontalgia and root fracture. This article reports our experience of four cases related to oral psychosomatic symptoms and organic oral disease for whom a favorable course was obtained.
Oral candidiasis developed during the treatment of burning mouth syndrome in case 1 and 2. Case 3 showed burning mouth syndrome comorbid with oral lichen planus. Case 4 was a patient with suspected atypical odontalgia, who was diagnosed with trigeminal neuralgia after magnetic resonance imaging.
As presented in the above cases, even after a diagnosis of psychosomatic oral symptoms has been made, there are some cases in whom mucosal diseases appear during treatment, so regular oral examinations are important. In particular, when psychosomatic treatment is successful but pain recurs amid favorable progress, careful evaluation is required as to whether it is due to an exacerbation of psychosomatic oral symptoms or an organic disease.
On the other hand, it is also necessary to consider that patients with organic abnormal findings in the orofacial area may have comorbid symptoms of psychosomatic oral symptoms. By focusing on whether or not the entire complaint can be explained by the intraoral findings, appropriate diagnosis becomes possible.

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Halitophobia is a persistent preoccupation with the conviction of bad breath although it is not perceptible to others in reality. We report a case of adolescent halitophobia that was successfully treated.
A 19-year-old female, a university student, complained of halitosis from the surface of the tongue. She noticed halitosis in the first grade as a senior high school student, then visited a dental clinic specializing in halitosis and tried many oral care instruments but her condition did not improve. In addition, she stuck to the belief of long tongue papillae and visited an oral surgeon, but no organic abnormalities were found. Gradually, she tended to withdraw, therefore her mother recommended her to visit our department.
She had no medical history except for a congenital defect of the right internal carotid artery. There was no subjective halitosis and she had kept good oral hygiene and the score on the Liebowitz Social Anxiety Scale （LSAS-J） was 56 （fear: 31/avoidance: 25）.
We explained the relationship between halitosis and anthropophobia and suggested pharmacotherapy for relieving interpersonal fear. Her mother was concerned about psychotropic drugs, so we explained the effects on pregnancy and side effects, after which informed consent was obtained. Considering the risk of activation syndrome due to selective serotonin reuptake inhibitors in youth, aripiprazole 0.5mg/day was prescribed at first. For the psychotherapy, the outpatient interview was based on “descriptions of impressions.”
Aripiprazole was increased to 1.0mg/day, and the fear part of LSAS-J decreased to 26 and avoidance decreased to 9 at 25 weeks. Her social activities with her family and friends increased, but she did not acquire confidence in meeting someone for the first time. Then, Fluvoxamine 12.5mg/day was added to aripiprazole 0.5mg/day. Off-campus practical training, which she was anxious to participate in, was accomplished. Moreover, she started a part-time job at a fast-food restaurant. At 43 weeks, the fear part of LSAS-J decreased to 14 and avoidance to 4. At 82 weeks, her complaints of halitosis have disappeared.
In this case, aripiprazole reduced avoidance, but it did not reduce fear and Fluvoxamine had a great effect. She mentioned that she had not worried about halitosis during interpersonal activities and that she had increased social activities, suggesting that supportive psychotherapy had given her confidence on interpersonal occasions with pharmacotherapy. “Descriptions of impressions” were poorer than that of previous reports and the clinical interview was preferred, therefore it is necessary to select psychotherapy appropriate for each patient.

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The efficacy of antidepressants for burning mouth syndrome is widely known. However, we often struggle with the choice of treatment for patients with psychiatric comorbidities because of their mental conditions and medications. Here we report a case of burning mouth syndrome with depression successfully treated in close collaboration with a psychiatrist. The patient was a 52-year-old female dental health worker who suffered from chronic burning pain on the right side of her tongue and was referred to our department. On a diagnosis of burning mouth syndrome, we initiated collaboration with her psychiatrist, with regular consultations approximately every three months. The treatment started with 10mg/day of amitriptyline, carefully monitored and adjusted from 25mg to 30mg/day. It was noteworthy that her pain remained in remission without serious fluctuation of psychiatric symptoms. In addition, regular oral examinations and reassurance for cancer phobia seemed to be useful for this favorable clinical outcome. Fortunately, the present case showed a good clinical course, although the situations and conditions vary widely from case to case. If additional medication is deemed necessary for burning mouth syndrome patients with psychiatric disorders, careful collaboration with the attending psychiatrist is crucial.

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key points：
・“Oral cenesthopathy” is a various and fluctuating sensation of a foreign body or discomfort in the oral area.
・Although the complaints are bizarre, “oral cenesthopathy” was originally considered to be the alterations of the common or internal sensibility, not a hallucination or delusion.
・Although the condition is described as indefinable sensation in the oral area, patients often aware of the morbid nature of their illnesses and spontaneously link their origins to disturbances in their nervous system.
・Patients are far more likely to visit a physician such as a dentist or otorhinolaryngologist than a psychiatrist, hoping for the possibility of a cure or improvement.
・There are many symptoms that overlap with burning mouth syndrome, and clear classification is often difficult.
・Many cases are intractable, and the effectiveness of any therapy is less than 50%.
・The fundamental attitude of dentists is to listen to the patient’s complaints. We should not deny the uncomfortable sensation easily. However, we also should not agree with it easily.
・An attitude of exploring the origin of the disease together with the patient is considered important.
・If abnormal sensations spread throughout the body or if psychiatric symptoms are severe, dentists should consult a psychiatrist.
・Particularly in the elderly, hidden primary diseases may become apparent later, so it is important that periodically check for cognitive function, mental status and review organic diseases, including oral cancer.

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