Medical Management of Common

Home , Aphthous stomatitis, Cyclic neutropenia, Lichen planus, Osteonecrosis of the jaw, Overjet, Stomatitis

5/16/2018

Case-based scenarios Medical Management of Common Oral mucosal disorders ▫ Oral candidiasis Orofacial Conditions in Dental Practice ▫ Lichenoid mucositis (OLP, GVHD, desquamative gingivitis) ▫ Recurrent aphthous stomatitis David Dean, DDS, MSD, DABOM, FDS RCSEd Graduate Program Director & Acting Assistant Professor TMD with limited opening Department of Oral Medicine ▫ Myofascial pain with limited opening University of Washington School of Dentistry Seattle Cancer Care Alliance ▫ Disc displacement without reduction

Case-based scenarios Declarations Medication-related osteonecrosis of the jaw (MRONJ) • I am not a physician  Oral burning disorders • I have no conflicts of interest to disclose ▫ Burning mouth syndrome • Medication recommendations include “off label” uses ▫ Hyposalivation/xerostomia ▫ Oral burning related to other causes (systemic disease, • Recommendations are consistent with current literature parafunctional habits, etc.) & standard of care within Oral Medicine/Orofacial Pain

Disclaimer • All opinions expressed are my own • They do not reflect official policies of the University of Washington, UWSOD, the department of Oral Medicine, Oral mucosal disorders (Stomatitis) or esteemed Husky football coach Chris Petersen

1 5/16/2018

CASE 1 CASE 1

• Sensitivity began approximately 4 weeks ago Case • Increased by orange juice, spicy foods, & mouthwash ▫ 58-year-old Filipino female • Sensitivity is absent (or “very low”) at rest ▫ Referred to Oral Medicine clinic at SCCA by heme- • Dexamethasone rinse was initially helpful, but not burns oncology for management of Graft-versus-Host disease when applied (GVHD) • Concurrent symptoms: ▫ Chief concern: Mucosal sensitivity & increasing “lichenoid” changes while tapering immunosuppressive ▫ Xerostomia (“My mouth is very dry all the time”) medications

CASE 1 CASE 1

• Past medical history • Social history • Medications • Adverse medication reactions ▫ AML ▫ Originally from the • Acyclovir ▫ None ▫ DM2 Philippines ▫ 800mg BID ▫ HTN ▫ Immigrated to US 10 • Bactrim DS ▫ 2x/wk (Monday & Tuesday) ▫ History of pulmonary years ago • Dexamethasone elixir embolism ▫ Primary language is ▫ 0.5mg/5mL rinse for 5 min QID Tagalog • Family history • Prednisone (5 day “pulse” dose) ▫ Non-contributory • Tacrolimus ▫ 0.5mg BID • Warfarin ▫ 2mg QD

CASE 1 Mucosal symptoms What are the key symptoms? Patients develop sensitivity due to thinning of mucosa • Sensitivity to acids, spices, & mouthwash (mint, alcohol?) Common triggers: ▫ Acids • Xerostomia ▫ Spices • Lack of improvement with dexamethasone rinse & pulse ▫ Carbonated beverages prednisone ▫ Strong flavors (ex. mint in toothpaste) ▫ Rough textures

2 5/16/2018

CASE 1 CASE 1

Head & neck exam Key questions ▫ (-) extraoral swelling or asymmetry • If her symptoms are related to GVHD, why isn’t she ▫ (-) lymphadenopathy improving with topical & systemic steroids? ▫ (-) sinus pain (maxillary or frontal) ▫ (-) thyromegaly ▫ Is she using the medication as prescribed? ▫ (-) TMJ dysfunction ▫ Are there other factors that would make the medications ▫ (-) pain in muscles of mastication or cervical muscles less effect? ▫ (+) skin dryness ▫ Do we have the correct diagnosis?...

CASE 1 CASE 1

What tests should be performed next? 1) Inspection of the oral cavity ▫ Oral mucosa, salivary expression, etc. 2) Additional tests based on clinical findings ▫ Biopsy(?), culture, salivary flow testing, etc.

CASE 1 CASE 1

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CASE 1 CASE 1

• Plan of Care – Manage contributing factors What are the key factors in treatment? ▫ Dry mouth • Establish correct diagnosis ▫ Immunosuppression ▫ What condition are we treating? ▫ Topical & systemic steroids ▫ Are their multiple co-occurring conditions the need to be ▫ Endocrine dysfunction (DM2) addressed simultaneously? ▫ Antibiotic therapy (change in normal flora) ▫ Dentures • Address contributing factors ▫ Others: steroid inhalers, smoking ▫ Factors increasing risk for infection/re-infection

Deal with the dry mouth! Consider objective salivary measurement • Adequate hydration (frequent sips of water) before starting a sialagogue • Salivary stimulants (sugar-free candies, mints, gum, etc.) • Stimulated & unstimulated salivary flow • Normal saline rinses (¾ TSP salt in 32 oz. water) ▫ No food/drink for 2 hours prior to exam • Coating agents (Aquoral, Biotene, Xerostom, Xylimelts, ▫ Unstimulated (WNL >0.5ml/min) OraMoist, MouthKote, etc.) ▫ Stimulated (WNL = 1-1.5ml/min)

Medications to increase salivary flow Sialagogue therapy

• Sialagogues • Contraindications ▫ Cevimeline (Evoxac®) – 3omg TID* ▫ Narrow angle glaucoma ▫ Pilocarpine (Salagen®) – 5mg TID ▫ Uncontrolled asthma

*FDA approved for Sjögren’s Syndrome only

4 5/16/2018

Sialagogue therapy Sialagogue hacks… • Cautions • Warn patients about potential flushing & sweating ▫ Arrhythmia, Beta blocker use, &/or other significant cardiac ▫ Titrate up to minimize side effects disease (e.g. MI, angina) ▫ Sample instructions: ▫ Respiratory illnesses (controlled asthma, mod/severe COPD) ▫ Begin with 30mg dose before bed, after 5 days add a ▫ Gallstones/Kidney stones second dose in the morning. After an additional 5 days increase to recommended 30mg TID ▫ Severe hepatic impairment • 3-month trial required for maximum effect ▫ Anti-cholinergic meds (diphenhydramine, bupropion oxybutynin, etc.)

CASE 1 CASE 1

• Plan of Care – Candidiasis • Plan of Care – Treating the denture • Clotrimazole Troches (10 mg) • Nystatin ointment (100,000 IU/g) ▫ Dissolve slowly in mouth 5x/day ▫ Apply liberally to all surfaces of denture TID ▫ If dry, rinse mouth with water first • Remove denture at night  soak in denture cleaner • Nystatin oral suspension (100,000 IU/mL) ▫ 5 mL swish & hold for 2 minutes 4x/day ▫ 33-50% sucrose (caries risk with chronic use)

CASE 1 CASE 1

• Plan of Care – Treating the denture (alternative) • Plan of Care – Angular cheilitis • Bleach (1 TSP in 32 oz of water) ▫ May bleach denture • Clotrimazole cream (1%) • Zephiram 1:770 (cold sterile solution) ▫ Available OTC (Lotrimin AF ®) • Nystatin ointment (100,000 IU/g) RINSE THOROUGHLY AFTER USE (!) ▫ Yellow color may impact compliance • Apply to corners of mouth TID • Continue for 4 days after © SCCA resolution of redness/cracking

5 5/16/2018

CASE 1 CASE 1

• Plan of Care – Angular cheilitis (alternative) • Plan of Care – Systemic therapy (alternative) ▫ Fluconazole • Bacterial co-infection is possible • Sample instructions: • Yellow crusting = Staph 200mg on day 1 & 100mg for next 6 days Treat with: ▫ 2% Ketoconazole What is a disadvantage to a systemic ▫ 2% Mupirocin azole antifungal in this case?

Fluconazole – Drug interactions • In this case the most significant interaction is with warfarin Azoles have MANY drug interactions (!) • Elevated bleeding risk ▫ 39-44% increase in PT w/ 7 day dosing(1,2) ▫ 34% with single 150mg dose(3) ▫ 2x risk of hospitalization for GI bleed(4) • Contact physician (possible dose adjustment?)

1 Crussell-Porter L et al. (Arch Intern Med, 1993) 2 Black D et al. (Clin Pharmacol Ther, 1992) 3 Turrentin M (Obstet Gynecol, 2006) 4 Schelleman H, et al. (Clin Pharmacol Ther, 2008)

Fluconazole – Drug interactions (cont.) • See: Hersch & Moore, “Drug Interactions in Dentistry: The Oral mucosal GVHD is a lichenoid condition Importance of Knowing your CYPs” (JADA, 2004) that is diagnosed clinically. ▫ Statins ▫ Anti-psychotics How would this case differ if this was ▫ Benzodiazepines ▫ Calcium channel blockers oral lichen planus? ▫ HIV medications ▫ Etc., etc., etc. • Pregnancy Category X

6 5/16/2018

Oral Lichen Planus Differential Diagnosis (Oral lichen planus) • Primary lichen planus (oral +/- mucocutenous involvement) • Lichenoid mucositis ▫ Medication-induced (NSAIDs, anti-hypertensive, anti-diabetes medications) ▫ Hypersensitivity reactions (dental materials, OH products) ▫ Graft-versus-Host disease (allogeneic transplants only) • Autoimmune/Vesicullobullous disorders (PV, MMP, Lupus, etc.) • Trauma (Mechanical – e.g. cheek biting; Thermal - e.g. burn; Chemical - e.g. cinnamon oil, SLS-toothpaste, etc.) • Candidiasis • Oral dysplasia/carcinoma © OMCS

Oral lichen planus - Management Diagnostic tests (Oral lichen planus) • Oral lichenoid lesions should be treated if: • Mucosal biopsy (H&E + Direct immunofluorescence) ▫ Symptoms are affecting quality of life (e.g. general comfort, • Elimination trials (medications, dietary factors, etc.) food choice, etc.) ▫ Tissues are ulcerated • Patch testing (dental materials) • Laboratory testing (Hepatitis C, thyroid disease?) Patients with non-oral signs/symptoms should be evaluated & treated by an appropriate physician

Oral lichen planus - Management • Remove potential irritants Topical steroid therapy – Whole mouth ▫ Smooth potentially traumatic teeth & appliances • Dexamethasone elixir (0.5mg/5mL) ▫ Avoid potentially traumatic habits ▫ Rinse with 5-10mL for 5 minutes, QID. ▫ Discontinue tobacco ▫ Taper down to lowest effective dose ▫ Decrease foods/beverages that increase symptoms ▫ Preferably alcohol-free (though hard to find!) ▫ Practice good oral hygiene • Compounded rinses Goals = improve comfort & decrease • Clobetasol 0.05%, rinse with 5 mL BID-TID general inflammation • Triamcinolone acetonide 0.1% (micronized), rinse with 5 mL QID

Adapted from Mirowski et al. (UpToDate, 3.2018)

7 5/16/2018

Topical steroid therapy - Instructions Topical steroid therapy – Localized • Spit out after use • Fluocinonide gel (0.05%) • Do not eat, drink, rinse for 30 minutes ▫ Dry lesion. Apply a thin film of gel. Cover with gauze. Leave for 10 minutes. Repeat TID-QID. • Clobetasol gel (0.05%) ▫ Dry lesion. Apply “bb-sized” amount of gel. Cover with gauze. Leave for 10 minutes. Repeat BID.

Can also be used in combination with a rinse

Mini-case Mini-case

Topical steroid considerations • Custom trays can be helpful for direct application of corticosteroid gels to gingival tissues

8 5/16/2018

Topical steroid considerations • Ultrapotent steroids (clobetasol, halobetasol) ▫ Not meant for continuous use (2 weeks on, 1+ week off) ▫ Limit use on external lip due to risk of permanent atrophy  Desonide ointment is a good alternative ▫ Cost has dramatically increased in the last 2 years; Ointments may be more cost effective

Topical steroid considerations Topical steroid considerations • Kenalog (triamcinolone) in Orabase is irritating to tissues • Increased risk for secondary candidiasis ▫ Not recommended in OLP ▫ Especially in pts with other risk factors for yeast infection ▫ Also very expensive: $80(!) for 5 grams ▫ Risk factors: hyposalivation, broad-spectrum antibiotic use, steroid inhalers, poor glycemic control, other causes • Rivelin (clobetasol) patch of immunosuppression, etc. ▫ Direct application to lesion site ▫ FDA/EMA approved • Consider prophylactic anti-fungal ▫ Currently in phase II trials in Europe ▫ e.g. Clotrimazole troches (10mg, 1-2x daily)

Oral lichen planus - Management

• Indications for referral ▫ Concern for malignancy or OLP subtype with higher risk for transformation (e.g. erosive & hyperplasic) ▫ Poor or incomplete response to therapy ▫ Unclear diagnosis • Other treatments are available, but carry higher risk for adverse effects ▫ Topical tacrolimus, injectable & systemic corticosteroids, systemic immunomodulators (e.g. azathioprine, MMF, etc.)

Photos: © OMCS

9 5/16/2018

Oral lichen planus – Malignant transformation Oral lichen planus – Follow-up • Lifetime transformation rate • Patient education is crucial due to low (but significant) ▫ OLP = 1.09%; OLL = 3.2%(1) risk for malignant transformation (2,3) ▫ Other studies (OLP) = 0.4-5.3% • Recommend follow-up every 3-4 months • Annual transformation rate = 0.2-0.5%(4) ▫ Photos • Mean age at transformation = 60.8 yo(1) ▫ Adjunctive diagnostic testing (?) ▫ Biopsy/Re-Biopsy (?)

1 Fitzpatrick et al. (JADA, 2014) 3 Farah et al. (J Int Dent, 2014) 2 Holmstrump et al. (J Oral Med Pathol, 1998) 4 World Workshop of Oral Medicine (2007)

Photos help to monitor lesions over time

Photos: © OMCS

10 5/16/2018

Adjunctive diagnostic testing Adjunctive diagnostic testing • Disadvantages • Advantages ▫ Adjunctive tests do not provide a diagnosis ▫ Less invasive (useful when biopsy contraindicated) • Biopsy remains the “gold standard” ▫ May be accepted when biopsy refused ▫ Sensitivity/specificity considerations (e.g. anxious patients, those requiring multiple biopsies over time) ▪ False(+) may lead to unnecessary therapy, anxiety, & expense ▪ False(-) may provide a false sense of security to pt & provider ▫ May help in evaluation of large areas (e.g. choosing the best site to biopsy)

Adjunctive diagnostics (Autofluorescence) Toluidine blue

CASEMini-case 3 Squamous cell carcinoma transformed from OLP Toluidine blue • 70-year-old male with a long history of lichen planus • 5 previous biopsy of the lateral tongue (all benign) • Chief concern: “changes” on right tongue beginning 6mo ago

11 5/16/2018

Mini-case Mini-case

21-year-old female (12 years post-transplant) Case • 21-year-old Caucasian female • 12 yrs post-allogeneic HCT for ALL ▫ Chief concern: “GVHD” under my tongue that has been there “as long as I can remember” ▫ 6 months ago, intermittent stinging/burning progressed to continuous soreness ▫ Has not seen a dentist in several years ▫ Sees orthodontist regularly (provider unsure of etiology) © SCCA

Mini-case

Oral mucosal lesions (Recurrent Aphthous Stomatitis)

T2N0M0  Partial glossectomy + selective neck dissection

Mini-case Mini-case

Case • 34-year-old Vietnamese female • Referred to the Oral Dysplasia clinic (UW Otolaryngology) • Chief concern: recurrent, painful mucosal ulcers since

immigrating to the US five years ago © EL Truleove

12 5/16/2018

Mini-case Mini-case

Differential Diagnosis (Aphthous Stomatitis) Aphthous management • Stress (!) • Rule out contributing factors (previous slide) • (including loss of mucin layer) Trauma • Avoid irritants & maintain salivary coating • Hypersensitivity (OH products, cinnamon oil, chocolate, ▫ Foaming (SLS) & anti-tartar (pyrophosphate) additives strawberries, tomatoes, nuts, coffee, dairy/lactose, wheat/celiac) cause dose-dependent desquamation • Medication reaction (NSAIDs, beta blockers, birth control, sulfa) • GI disease (Crohn’s, ulcerative colitis, celiac disease, H. pylori) ▫ Alternatives: • Hematologic diseases (leukemia, cyclic neutropenia, HIV) • Prevident Gel • Biotene Gentle Mint (original or new formulas) • Syndromes (Behcet’s, Sweet’s, PFAPA, MAGIC) • Squiggle Enamel Saver (online)

Mini-case Mini-case

Aphthous management Aphthous management

• Topical steroids (see previous slides) • Minor aphthous usually resolves within 7-14 days and • Mucosal protectents (Orabase®, Zilactin-B®) may not require management ® ® • Canker-melts (Glycyrrhiza extract) or B12-melts • Major aphthous may require additional systemic • H2 blockers (e.g. Cimetidine 600mg TID) interventions (under the guidance of a specialist) • Tetracycline rinse (short-term only) • Cautery/caustic agents (e.g. laser, silver nitrate, etc.) and • Stress management antibiotics (e.g. tetracycline) aren’t recommended in chronic therapy

Recommended resource

TMD with limited opening

13 5/16/2018

CASE 2 CASE 2

Case History of chief concern • 46-year-old Caucasian female • Initial symptoms • Referred to SCCA Oral Medicine by Oncology to “rule out ▫ “Sharp” pain near maxillary left first molar (#14) emerging Medication-related Osteonecrosis of the Jaw” ▫ Onset immediately after eating a Milk Dud while driving ▫ History of Multiple Myeloma with 13 doses of pamidronate to Portland in a “torrential downpour” (Aredia) ▫ Intensity rated as moderate (6 out of 10) ▫ Autologous PBSCT (January 2015) • Chief concern: Left-sided jaw pain with limited opening

CASE 2 CASE 2

• Chief concern (current) History of chief concern ▫ Constant “aching” pain in the left jaw which has been • Evaluated by dentist  No clinical or radiographic present for the past 6 weeks evidence of odontogenic infection ▫ Intensity = 3 to 7 out of 10 ▫ Aggravated by jaw function, clenching, stress, & poor sleep • Sharp pain has not recurred since her initial episode • Secondary concerns ▫ Difficulty eating a cheeseburger last week • “I couldn’t open enough. It was too painful.” ▫ Audible clicking (bilateral TMJs)

CASE 2 CASE 2

• Past medical history • Social history • Medications • Adverse medication reactions • Multiple myeloma • Part-time teaching • Lorazepam ▫ Nausea with dental • Anxiety assistant at a University ▫ 0.5 mg TID anesthetic • Insomnia • Married (x20 years), • Zolpidem husband attends • Family history ▫ 5 mg daily medical visits • Calcium • Parents + 5 siblings are • 12 year old daughter • alive and in good health Multivitamin without iron • Vitamin D ▫ 2000 IU daily

14 5/16/2018

CASE 2 CASE 2

What are the key symptoms? Differential Diagnosis

• Constant “aching” pain that is aggravated by jaw • Myofascial pain (with limited opening) function, clenching, & stressors • Disc displacement with reduction • Limited opening due to pain • Daytime parafunction (clenching +/- nocturnal bruxism?) • Audible clicking (bilateral TMJs) • Occult dental pathology (e.g. “cracked tooth syndrome”) • Initial episode of sharp pain that has not recurred • Referred pain (?)

CASE 2 CASE 2

• Head & neck exam ▫ (-) extraoral swelling or asymmetry What tests should be performed next? ▫ (-) lymphadenopathy 1) TMD examination (range of motion, muscle & joint ▫ (-) sinus pain (maxillary or frontal) palpation) ▫ (-) salivary gland abnormality 2) Inspection of the oral cavity (mucosa, gingiva, dentition) ▫ (-) thyromegaly ▫ (+) visible distress related to CC 3) Dental testing (radiographs, endodontic testing, percussion, palpation, perio probing, etc.)

CASE 2

• TMD exam Functional measurements ▫ Maximum opening without pain = 19mm • Maximum Opening ▫ Maximum opening with pain = 37mm 1) Unassisted without pain Maximum opening produced: 2) Unassisted with pain • Pain in bilateral masseters 3) Assisted with pain • Spasm in left masseter • Decrease in maximum opening (37mm  34mm) ▫ Normal: >40mm ▫ Abnormal: <30mm

15 5/16/2018

CASE 2

• TMD exam (cont.) Joint sounds Audible clicking (R/L) TMJs • Click/pop ▫ Maximum opening • Crepitus (audible, soft) ▫ Lateral excursions ▫ Maximum opening ▫ Right & left lateral ▫ Click eliminated in protrusion ▫ Protrude jaw  open/close in protrusion • Does click go away?  disc reducing normally

CASE 2 Muscles palpation = 2 pounds of pressure Q: Are any structures painful to standardized palpation?

Frontalis Temporalis

Orbicularis oculi Zygomaticus

Masseter Buccinator

Orbicularis oris Sternocleidomastoid Trapezius

CASE 2 CASE 2 Q: Are any structures painful to standardized palpation?

TMJ palpation = Frontalis • 1 lbs lateral pole • 2 lbs around pole Temporalis

Orbicularis oculi TRIGGER Zygomaticus POINT

Masseter

Masseter Buccinator Sternocleidomastoid Orbicularis oris Trapezius

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CASE 2 CASE 2 • Intraoral exam

Muscle examination increased baseline pain from 3 to 7 (out of 10)

CASE 2 CASE 2

• Intraoral exam • Fractured amalgam (Tooth#14) Problem Differential Diagnosis • Teeth painful to percussion in multiple quadrants Constant, aching pain 1) Myofascial pain with (UR, UL, LR) (Left jaw) referral • No evidence of exposed bone (i.e. no MRONJ) . Daytime parafunction . Nocturnal bruxism 2) Left TMJ arthralgia 3) Occlusal traumatism 4) Odontogenic pain (referred)

TMD – Diagnostic categories Problem Differential Diagnosis • Group 1: Muscle Disorders Sharp pain 1) Myofascial pain with • Group 2: Disc Displacements (region of tooth #14) referral (left masseter) • Group 3: Other Disorders (Joint & Bone) 2) Occlusal traumatism 3) Cracked tooth #14 4) Maxillary sinusitis

17 5/16/2018

RDC-TMD TMD – Muscle disorders (RDC for TMD) Myalgia, Myofascial Pain, Myofascial pain w/ limited opening

No Dx Muscle 1) Pain No Dx Muscle Disc 2) ≥3 painful muscle sites

Joint Muscle, Disc, Disc & Joint Myofascial pain Muscle & Muscle, Disc, Joint Joint & Joint Muscle & 3) Maximum opening Joint <40mm Myofascial pain Seeking Care Not Seeking Care w/ limited opening Clinic TMD Cases n=247 Community TMD Cases n=120

TMD – Muscle disorders (DC for TMD) TMD – Disc displacements Disc displacement with & without reduction Familiar pain with: 1) Local Myalgia 1) Jaw opening OR ▫ Pain at site only 2) Muscle palpation 2) Myofascial pain + confirmation of site Reciprocal click = ▫ aka “MFP w/ spreading” DD w/ reduction Myalgia ▫ Pain beyond area of • Muscle pain stimulation

TMD – Other disorders (Joint & bone) TMD pain – Prevalence in last 6mo Arthralgia, Osteoarthritis, Osteoarthosis 20 1) Joint pain N = 1016 N = 1016 Males 1) Ongoing Females 2) On palpation 15 3) On opening or excursion 10 Arthralgia 5 TMD-RELATED PAIN Coarse Crepitus DECREASES WITH AGE Osteoarthritis 0 18-24yo 25-44yo 45-64yo >65yo

Van Korpff, 1988

18 5/16/2018

Conservative TMD protocol • Most patients with TMD improve over time • Conservative management is usually effective in decreasing pain & increasing function • Avoid irreversible treatment if possible ▫ Surgery is reserved for very select cases

CASE 2

• Plan of Care – Conservative TMD protocol Key questions • What are you trying to treat with recommended/prescribed medications? ▫ General pain?

10 10 3 ▫ Muscle pain? 10 3 ▫ Inflammatory pain? ▫ Contributing factors? • Bruxism/Parafunction • Axis II factors (depression, anxiety, somatization, stressors)

CASE 2

• Plan of Care – Pharmacotherapy Tricyclic antidepressants (TCAs) ▫ Low-dose Amitriptyline (10mg before bed) • Amitriptyline & nortriptyline • Short-term effect in myalgia & arthralgia ▫ Starting doses 10 (to 30) mg before bed ▫ Up to 3-month trial for maximum effect • Especially useful in cases with: • Bruxism • Sleep dysfunction • Concurrent, depression, anxiety, somatization

19 5/16/2018

CASE 2

• Plan of Care – Pharmacotherapy (alternative) TCA considerations ▫ Short-term muscle relaxant • Hyposalivation (dose dependent)  Effective in management of acute Myalgia & MFP, ▫ Increased caries risk at higher doses & in patients taking but less effective in chronic TMD* multiple xerogenic medications • Sedation *May still be used as part of a chronic ▫ Increased fall risk in elderly patients (esp. those taking other management protocol CNS depressants) • Arrhythmia ▫ Increased risk in elderly patients (don’t prescribe over age 65) ▫ Off-label use / Within scope of practice (?)

Muscle relaxant considerations Muscle relaxants • Only effective if the patient has muscle pain • Cyclobenzaprine (Flexeril) • Metaxalone (Skelaxin) ▫ 5-10mg (up to TID) • Carisoprodol (Soma) • Tizanidine (Zanaflex) ▫ 2mg (up to) TID • Methocarbamol (Robaxin) ▫ 500-1500mg (up to) QID • Diazepam (Valium) ▫ 2-4mg (up to) TID

Muscle relaxant considerations Muscle relaxant considerations • Cyclobenzaprine (Flexeril) • Tizanidine (Zanaflex) ▫ “Hangover” effect ▫ Alpha-2 adrenergic antagonist ▫ Can minimize SEs by starting at low dose ▫ Generally well-tolerated (e.g. 5-10 mg before bed) on a “weekend” • SE: sedation, hypotension, hepatic effects ▫ Drug interactions with TCAs & SSRIs due to ▫ Caution with beta blockers & in elderly patients serotonin effects ▫ Always check drug interactions • Methocarbamol (Robaxin) ▫ Less potent (OTC in Canada) ▫ Titration advantage in pts sensitive to sedating meds

20 5/16/2018

Muscle relaxant considerations Muscle relaxant considerations • Diazepam (Valium) • Drug interactions ▫ Especially helpful in short-term management of patients ▫ Sedating & centrally-acting medications with muscle-based pain & concurrent anxiety ▫ Narcotics ▫ All benzodiazepine considerations apply (e.g. caution ▫ Anti-depressants with driving, dependence, cognitive decline) ▫ Anti-psychotics • Carisoprodol (Soma) ▫ Barbiturates ▫ Dependence/addiction risk ▫ MAO inhibitors ▫ H2 blockers

CASE 2

• Plan of Care – “Boil & bite” soft nightguard Occlusal guards • May decrease clenching (do not stop it) • Protect teeth & decrease force on joint • Most useful in patients waking with pain ▫ E.g. myalgia, arthralgia, pain in teeth, headache • Avoid in cases of open bite if attempting to regain contact

Soft guards Both custom acrylic • Buy the least expensive guard & soft “sports guards” are that covers all the teeth effective(1) • Expensive soft guards are too bulky & may increase pain • Soft guards do not fit as well ▫ Some patients report ↑clenching ▫ D/C guard if pain increases

1 Truelove (JADA, 2006) Photo: Truelove (JADA, 2006)

21 5/16/2018

Custom guards 1) Acrylic exterior with thermoplastic intaglio 2) Flat plane 3) Balanced occlusion 4) Avoid indexing of opposing teeth • “locking in” may increase pain 5) Avoid heavy anterior contact • “Masseteric reflex”

CASE 3

Case How would this case look different if limited opening was caused by • 31-year-old Caucasian female disc displacement? • Referred by her dentist to UW Oral Medicine due to acute onset limited opening. • Chief concern: “My jaw locked last week, now I can’t open wide”

CASE 3 CASE 3

History of chief concern • Past medical history • Social history • Asymptomatic “popping” in the jaw for many years ▫ Depression ▫ College student at ▫ Situational anxiety Seattle Pacific • No history of pain or locking University • Family history ▫ Studying psychology • Went skiing with friends (after final exams) ▫ Breast cancer (mother) ▫ Very active (running, • She was laughing while riding the chairlift skiing, outdoor ▫ Immediate sharp pain in front of right ear activities) ▫ Unable to open wide since that time • Current pain with yawning, laughing, & chewing

22 5/16/2018

CASE 3 CASE 3

• Medications • Adverse medication reactions • Fluoxetine ▫ Penicillin (rash) What are the key symptoms? ▫ 20mg daily • Acute onset pre-auricular pain • Multivitamin • Acute onset, persistent limited opening • Pain with function (e.g. opening wide, chewing) • Loss of clicking (?)

CASE 3 CASE 3

Head & neck exam • (-) extraoral swelling or asymmetry What tests should be performed next? • (-) lymphadenopathy 1) TMD examination • (-) sinus pain (maxillary or frontal) 2) Advanced imaging - MRI (TMJ series) • (-) salivary gland abnormality • (-) thyromegaly

CASE 3

• TMD exam TMD exam ▫ Open & close (x3) • Opening pattern  Non-corrected deviation toward the right ▫ Straight ▫ Joint sounds ▫ Corrected deviation (DD w/ reduction)  None (i.e. no clicking or crepitus) ▫ Uncorrected deviation (DD w/o reduction)

23 5/16/2018

CASE 3 CASE 3

• TMD exam • TMD exam ▫ Maximum opening without pain = 20 mm ▫ Right lateral = 10 mm ▫ Left lateral = 4 mm ▫ Maximum opening with pain = 21 mm • WNL = ≥6 mm (including midline discrepancy) Maximum opening produced: ▫ Protrusion = 4 mm . Pain in right pre-auricular region • WNL = 8-11 mm (including overjet)

Left lateral & protrusion produced: • Pain in right pre-auricular region

CASE 3 CASE 3

What are the key signs? What are the key signs?

• Limited opening (<30mm) • Deviation on opening (to the right) • History of clicking/popping which stopped w/ onset ▫ In disc displacement w/o reduction the jaw deviates TOWARD the side of displacement ▫ The opposite condyle is still able to translate normally • Limited contralateral excursion (to the left) ▫ The condyle on the side of displacement CANNOT translate

CASE 3

Disc displacements Problem(s) Differential Diagnosis Acute onset: 1) Disc displacement without Have you ever had your jaw lock • Right preauricular pain reduction with limited so that it won’t open all the • Limited opening opening (right) way, • Limited left excusive 2) TMJ arthralgia (right) and was this limitation in jaw movement opening severe enough to interfere with your ability to eat?

Disc Displacement w/o reduction

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Key differences between cases Key differences between cases • Maximum Opening • Pain location ▫ Muscle (Myofascial pain w/ limited opening) ▫ Muscle (Myofascial pain w/ limited opening)  Assisted >> Unassisted  Bilateral muscles of mastication (e.g. masseters)  No physical blockage ▫ Disc (Disc displacement w/o reduction) ▫ Disc (Disc displacement w/o reduction)  Preauricular area, side of displacement (e.g. right TMJ)  Assisted = Unassisted & <35mm  Displaced disc prevents further opening

CASE 3

Key differences between cases • Joint noise IMMEDIATE GOAL: ▫ Present in ~1/3 of general population Resolve inflammatory pain ▫ Muscle (Myofascial pain w/ limited opening)  May or may not be present ▫ Disc (Disc displacement w/o reduction)  Loss of click with onset of limited opening

CASE 3 CASE 3

• Plan of Care – Conservative TMD protocol • Plan of Care – Pharmacotherapy ▫ Piroxicam, 10mg daily for 7-10 days

10 3

25 5/16/2018

Anti-inflammatory medications NSAID considerations

• Very effective in managing Arthralgia, DJD, & pain related to • Piroxicam • Lowest GI side effects acute trauma ▫ 10mg daily • Celebrex (Cox-2 selective) • E.g. sprain/strain, trauma, post-dental work ▫ Once daily dosing aids in • Etodolac compliance Muscle pain is usually NOT inflammatory • Relative risk of GI side effects1 ▫ NSAID serving as analgesic only ▫ Ibuprofen (low dose) = 1.0 ▫ ASA = 1.6 • Corticosteroids severe arthralgia ▫ Naproxen = 2.2 • E.g. disc displacement w/0 reduction, DJD ▫ Piroxcam = 3.8

1 Henry et al. (Brit Med J, 1996)

NSAIDs (Rx) NSAIDs (OTC)

• Piroxicam (Feldene)* • Etodolac (Lodine) • Ibuprofen • Advantages ▫ 10mg daily ▫ 200mg TID-QID ▫ 400-800 mg TID-QID ▫ “Familiar” • Meloxicam (Mobic)* • Diclofenac (Voltaren) ▫ MAX doses ▫ Easy to find (OTC) ▫ 7.5mg tab ▫ 50mg TID (max) • Analgesic (1200 mg/d) ▫ Lower side effects ▫ 5mg cap • Anti-inflammatory (3200 mg/d) • Naproxen *Once daily dosing improves ▫ 220-440 mg BID compliance ▫ MAX dose (660 mg)

NSAID considerations Anti-inflammatory considerations

GI side effects generally take • NSAID cautions/contraindications 1 ▫ Active GI ulcers/bleeding 84 days (!) to develop ▫ Bleeding disorders or anticoagulants ▫ Kidney dysfunction (dose adjustment) ▫ Elderly (dose adjustment) ▫ Aspirin triad (asthma, chronic urticarial, nasal polyps) ▫ Pregnancy (avoid in 1st/3rd trimester; very short-term use ibuprofen/naproxen in 2nd)

1 Richy et al. (Ann Rheum Dis, 2004)

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CASE 3

• Plan of Care – Pharmacotherapy (alternative) Systemic corticosteroid considerations ▫ Medrol dosepak (6 day taper) ▫ Especially helpful in cases of severe arthralgia • Adrenal suppression • Immunosuppression ▫ DOSE IN THE AM (do not follow package instructions) • Elevated blood glucose • GI bleeding • Increased BP • Decreased bone • Insomnia density* • Mood lability • Cataracts ▫ Do not use in patients with bipolar disorder, schizophrenia, severe *Ask about bisphosphonates in patients taking depression, suicide risk long-term corticosteroids

CASE 3 CASE 3

• Plan of Care – Patient education Encourage patient that opening will improve over time

SECONDARY GOALS: 1) Disc will reduce in normal position • Improve Range of Motion OR • Minimize risk for recurrence 2) Posterior ligaments will remodel

CASE 3 CASE 3

• Plan of Care – Stretching exercises • Begin stretching AFTER joint pain has improved • Passive ▫ Maximum opening without pain OTHER CONSIDERATIONS:  Hold 10 secs  close halfway • Predisposing factors?  Repeat 10x • Factors influencing prognosis? • Active ▫ Evenly distributed, sustained pressure on chin/incisors ▫ Tongue depressors/Popsicle sticks

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CASE 3 CASE 3

Anti-Depressants Problem(s) Differential Diagnosis Parafunction habits 1) Stress-related (daytime) • SSRIs have been linked to parafunctional habits (e.g. clenching & parafunction grinding)(1,2) 2) Nocturnal bruxism • Paroxetine (Paxil) & Fluoxetine (Prozac) appear to be the main 3) Medication side effect(?) offenders Axis II considerations 1) Depression 2) Situational anxiety 3) Stress (school-related)

1 Lobbezoo et al. (J Orofac Pain, 2001 2 Romanelli F et al. (Ann Pharmacother, 1996)

Axis I Axis II (Physical) (Psychosocial) Axis I vs. Axis II

Muscle Maladaptive Myalgia/MPD Both Axis I & II must be effectively Thinking Disc Disturbed managed or treatment will be Disc Displacement w/ or w/o reduction Emotions ineffective Bone/Joint Dysfunctional DJD/OA Behavior

Dworkin, 1998

CASE 3 • Plan of Care – Contributing factors • Address Axis II factors • Consult with psych about alternative to SSRI

TMD resources

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TMD - Risk factors TMD - Risk factors 1) Level 1 studies Other traditional risk factors have lower association/levels • Female Gender of evidence 2) Level 2 studies • Nocturnal bruxism • Other Chronic Pains • Occlusal interferences ▫ Migraines, Back Pain, TTHA, FMS, IBS • Class II/III occlusion • “Axis II” Disorders • Joint hypermobility ▫ Depression, Somatization • Sleep dysfunction ▫ High perceived stress • Sexual/Physical/Emotional abuse • History of Trauma Drangsholt and LeResche (Epidemiology of TMD, 2012) Drangsholt and LeResche (Epidemiology of TMD, 2012)

Protocols for minimizing TMD flare related to dental care

TMD - Indications for referral Intervention Dose Freq. Duration 1) Moderate-to-severe psychological dysfunction or 24hrs before Ice 15min BID disability along with chronic pain + 2d after 24hrs before 2) Moderate-to-severe unremitting pain Ibuprofen 400mg QID + 2d after 3) Multiple failed surgical inventions with continued Night before Diazepam 2-5mg chronic pain + 1 hr prior Frequent Q5min comfort Breaks or PRN Pediatric PRN Handpiece

Medication-related osteonecrosis of the jaw (MRONJ) http://www.rdc-tmdinternational.org/

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Medication-related osteonecrosis of the jaw (MRONJ)

1) Current or previous treatment with anti- • Zoledronic acid (Zometa®) resorptive or antiangiogenic agents; 2) Exposed bone (or bone that can be ▫ IV Bisphosphonate probed through a fistula) in the ▫ Inhibits osteoclast activity maxillofacial region that has persisted for ▫ Used to prevent hypercalcemia & decrease risk for fracture more than 8 weeks; and in patients with Multiple Myeloma 3) No history of radiation therapy or © SCCA obvious metastatic disease to the jaws. © SCCA

• Denosumab (Xgeva®) • MRONJ risk in cancer patients exposed to Zometa® ▫ RANK-L inhibitor used in the setting of bony metastasis (e.g. = 50-100X higher than placebo(1) breast cancer, prostate cancer) & Multiple Myeloma ▫ Incidence ranges from 0.7% - 6.7% (2,3) (approved 1/2018) ▫ ~1% when limited to Level 1 studies(2, 4-6) ▫ MRONJ risk = comparable to Zometa®

1 AAOMS Position Paper (2014) 4 Qi et al. (Int J Clin Oncol, 2013) 1 Fizazi et al. (Lancet, 2011) 2 Coleman et al. (Breast Cancer Res Treat, 2011) 5 Mauri et al. (Breast Cancer Res Treat, 2009) 2 Stopeck et al (EJC supplements, 2009) 3 Vahtsevanos et al. (J Clin Oncol, 2009) 6 Scagliotti et al, (J Thorac Oncol, 2012) 3 Henry (J Clin Oncol, 2011)

Don’t let the name fool you… Remember…

• There are two different forms of both zoledronic acid • Lower dose = Lower risk for MRONJ (Zometa® & Reclast®) & denosumab (Xgeva® & Prolia®) ▫ “The risk for ONJ among patients [with osteoporosis] treated ▫ Cancer = Zometa® & Xgeva® with either zolendronate or denosumab (0.017 – 0.04%) ▫ Osteoporosis = Reclast® & Prolia® approximates the risk for ONJ of patients enrolled in placebo groups (0%-0.02%)

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Don’t forget to ask… Other medications associated with MRONJ Zometa® & denosumab are usually given every 3-4 weeks in cancer patients • VEGF inhibitors Patients may not report on ▫ Bevacizumab (aka Avastin®) current med list if not taking daily ▫ Lung, colorectal, metastatic renal cancers • Multiple tyrosine kinase inhibitors ▫ Solid tumors with bony metastasis ▫ Sunitinib (aka Sutent®) (esp. breast & prostate cancer) ▫ Renal cell carcinoma ▫ Multiple Myeloma

AAOMS Position Paper (2014)

CASE 4 CASE 4

Case MRONJ - Management

• 78-year-old Caucasian male • Keep area as clean as possible • Stage IV metastatic prostate cancer ▫ Decreases infection risk • 3 years of denosumab therapy ▫ Promotes “re-growth” of gingiva beneath area of exposed bone  promotes sequestration • Assess bone mobility  remove mobile sequestrae • Avoid invasive surgery (unless stage 3) ▫ Conservative bony re-contouring is OK ▫ Re-countouring is recommended in cases of trauma, excess plaque build-up, etc.

CASE 4

MRONJ – Follow-up MRONJ – Stage 1 Monitor for: Clinical characteristics Symptoms Signs • Exposed & necrotic bone • Pain • Local inflammation • No signs of infection • Drainage and/or bad (erythema, edema) • Asymptomatic taste/bad breath • Bleeding and/or purulence Management • Neurologic symptoms on probing • OHI (keep bone clean) ▫ Dysesthesia, paresthesia, • Signs of progressive infection © SCCA numbness ▫ Fever, lymphadenopathy, • Chlorhexidine 0.12% swelling, limited opening (dip & brush + rinse) Mawardi et al. (UpToDate, 3.2018)

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MRONJ – Stage 2 MRONJ – Stage 2 Clinical characteristics Management • Exposed & necrotic bone • Stage 1 interventions • Evidence of infection • Systemic antibiotic therapy • Symptomatic ▫ Amoxicillin (500mg TID) ▫ Clindamycin (300mg QID) ▫ Metronidazole (500mg TID-QID) © SCCA © SCCA © SCCA • Consider culture + sensitivity

MRONJ – Stage 3 MRONJ – Stage 3 (or “what you see if you google osteonecrosis of the jaw”) • Clinical characteristics • Management ▫ Evidence of infection ▫ Antibiotic therapy (Beyond region of alveolar bone) ▫ Surgical intervention ▫ Osteomyelitis  Resection (to inferior border of Mn/Mx sinus)  Debridement ▫ Oro-antral communication ▫ Extraoral fistula ▫ Pathologic fracture

Photo: Eckardt A et al. (Anticancer Research, 2011)

CASE 4

Drug holidays • Limited evidence for drug holidays in cancer therapy prior to EXTs • May be considered in active MRONJ in consultation with oncologist(1) • More likely to be effective in patient’s taking denosumab Half-life = 6 months vs. 10-15 years

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CASE 4 CASE 4

• Plan of Care ▫ Consult with Oncologist • “Will the patient’s systemic health support a drug holiday? • Oncologist elected to hold denosumab due to active MRONJ

▫ Follow-up/assessment every 4-12 weeks based on signs & symptoms

CASE 4 CASE 4

CASE 5

Case ▫ 52-year-old Caucasian male ▫ Referred to UW Oral Medicine by Otolaryngology for Oral burning disorders evaluation & management of oral burning ▫ Chief concern: Continuous burning sensation, primarily in the tongue

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CASE 5 CASE 5

• Primarily affects “tip and sides” of tongue, anterior History of chief concern palate, & lips • Oral burning developed 2 months after left thumb surgery • Minimal intensity on waking; “ramps up” during the day ▫ After surgery, he was prescribed oxycodone for post-op • Symptoms are increased with coffee, strawberries, & pain, which led to full body pruritus work stress ▫ Itching had a significant negative impact on sleep (total duration decreased to 1.5 hours per night) • Concurrent symptoms: ▫ Oral burning developed first noticed during late ▫ Dysguesia (“metallic”) night/early morning hours ▫ Xerostomia (“mild”)

CASE 5 CASE 5

• Evaluated by his PCP who prescribed Nystatin • Past medical history • Social history suspension for presumed candidiasis ▫ Benign paroxysmal ▫ Married w/o children ▫ Minimal benefit with the rinse positional vertigo ▫ Recycling truck driver ▫ Anxiety • Referred to ENT to rule out GERD ▫ High work stress ▫ Depression (applying for union position) ▫ Sleep Dysfunction ▫ Healthy lifestyle  ▫ Bilateral thumb distressed by recent surgeries health problems • Family history ▫ Non-contributory

CASE 5 CASE 5

• Medications • Adverse medication reactions What are the key symptoms? • Nexium ▫ None ▫ 20mg daily ▫ Environmental sensitivities • Oral burning with well-defined, bilateral distribution • Nystatin suspension (cats, dust) ▫ 1oo,ooo IU/mL • Symptoms that are absent in the morning, but increase as ▫ 5mL “swish & spit” QID the day goes on • B complex • Acute onset during a time of high stress • No response to topical antifungal/anti-yeast therapy

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CASE 5 CASE 5

Head & neck exam What tests should be performed next? ▫ (-) extraoral swelling or asymmetry 1) Inspection of the oral cavity (mucosa, gingiva, dentition) ▫ (-) lymphadenopathy 2) Cranial nerve assessment including qualitative sensory ▫ (-) sinus pain (maxillary or frontal) testing of the Trigeminal nerve (Q-tip, pin prick, ▫ (-) salivary gland abnormality temperature) ▫ (-) thyromegaly 3) Laboratory testing ▫ (-) TMJ dysfunction 4) Advance imaging ▫ (-) pain in muscles of mastication or cervical muscles

CASE 5 CASE 5

• Intraoral exam ▫ Decreased tissue wetting & salivary expression Problem Differential Diagnosis ▫ Tongue hyperactivity (involuntary movement) Continuous burning pain 1) Primary Burning Mouth ▫ Subtle atrophy at the tip of tongue -Sides & “tip” of Tongue Syndrome -Anterior hard palate 2) Hyposalivation -Upper & Lower lip 3) Atrophic Candidiasis 4) Lingual parafunction 5) Systemic condition (e.g. GERD, DM, hypothyroidism, nutritional deficiency)

CASE 5 Clinical descriptors

Problem Differential Diagnosis Burning Scalded Psychosocial factors impacting CC 1) Work stress 2) Health concerns Tingling Numb 3) Anxiety (suspected) 4) Sleep dysfunction • Primary insomnia • Depression (suspected) 1° BMS • Sleep apnea Unremitting Annoying Distressing Spontaneous

Grushka, et al. (Am Fam Physician, 2002) Patton, et al. (OOOOE, 2007)

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Location

• Bilateral & symmetric Primary Care Provider distribution ▫ “Tip” & sides of ENT tongue ▫ Anterior palate Dentist GI SpecialistPsych ▫ Lower lip Neurologist Dermatologist

Bergdahl et al. (J Oral Pathol Med, 1999) DaSilva et al. (Orofac Pain Rounds, 2005) Ward, R. (UW Master’s Thesis, 2014) Grushka, et al. (Am Fam Physician, 2002) Mignogna, et al. (J Orofac Pain, 2005)

CASE 5

• Plan of Care ▫ Avoid irritating substances* • Hot, spicy foods AVG 14 months & 3.1 misdiagnoses • Acidic foods/drinks before reaching diagnosis of primary BMS • Oral hygiene products ▫ Toothpaste (SLS, Pyrophosphates, flavoring agents) • Alcohol (including mouthwash) • Tobacco ▫ Rule out other potential causes of oral burning *These interventions are also helpful in all mucosal diseases

Mignogna, et al. (J Orofac Pain, 2005)

Scala et al. (Crit Rev Oral Biol Med 2003)

Differential Diagnosis – Hyposalivation

Systemic Parafunctional Mucosal Burning “Dry Mouth” Conditions Habits Disorders Mouth Syndrome Secondary BMS Primary

Rule out other potential cause of oral burning

Treister et al. (Blood, 2012)

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Differential Diagnosis – Hyposalivation Differential Diagnosis – Atrophic Candidiasis

Differential Diagnosis – Atrophic Candidiasis Differential Diagnosis – Migratory Glossitis

Will see signs of mucosal disease Atrophy Erythema Striae Ulcerations

Differential Diagnosis – Systemic Disorders Differential Diagnosis – Systemic Disorders

(1) Nutritional • Diabetes mellitus Deficiencies(1) • Hypothyroidism • Anemia (1,2) • GI problems ▫ Iron ▫ GERD, H. pylori infection ▫ B vitamins • Neurologic disease(1) • B9 ▫ Multiple sclerosis • B12 ▫ Trigeminal neuropathies • Other ▫ Zinc © C.D. Johnson © J.E. Bouquot 1 Brailo, et al. (Med Oral Patol Oral Cir Bucal, 2006) UT Houston West Virginia Univ. 2 Netto, et al. (Clin Oral Investig, 2011) 1 Klasser, et al. (JCDA, 2011)

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Differential Diagnosis – Systemic Disorders Differential Diagnosis – Medical Therapies • Laboratory tests • Medications(1) ▫ Diabetes: Blood glucose, HbA1c ▫ Anti-Hypertensives ▫ Thyroid: T3, T4, TSH • ACE inhibitors (“-prils”) ▫ Vitamins: Iron, B vitamins, Zinc • Angiotensin receptor blockers (“-sartans”) • Diuretics • Smoking cessation(2)

www.cbslaboratories.com 1 Salort-Llorca, et al. (Med Oral Patol Oral Cir Bucal, 2008) 2 Gao, et al. (J Oral Pathol Med, 2009)

Differential Diagnosis – Parafunction/Habits Differential Diagnosis – Parafunction/Habits • Clinical exam • Denture issues(1,2) ▫ Witnessed tongue habits ▫ Irritation of anterior tongue ▫ Poor fit or poor design ▫ “Truelove mirror test” • Tongue habits ▫ Dyskinesia • “Stent” trial ▫ “Checking” behaviors

1 Brown, et al. (Gen Dent, 2006) 2 Svensson, et al. (J Oral Rehab, 1995)

CASE 5 CASE 5

• Plan of Care – Pharmacotherapy • Plan of Care – Cognitive behavioral therapy ▫ Topical clonazepam (dissolve 0.5mg BID) ▫ Randomized trial (Sweden) • Randomized trial (France) ▫ 1 hour of CBT per week of 12-15 weeks • Dissolve 1 mg in mouth TID (spit out excess) Intensity = 1 (endurable) to 7 (unendurable) Pre-Tx Post-Tx 6mo f/u CBT 5.0±0.8 2.2±1.0 1.4±1.1 (N = 15) Placebo 4.3±1.7 4.6±1.7 4.7±1.2 (N =15)

Gremeau-Richard (Pain, 2004) Bergdahl et al. (J Oral Pathol Med, 1995)

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Prognosis Recommended resource

2/3s of patients experience • Clonazepam spontaneous, partial recovery • Cognitive Behavioral within 6-7 years(1,2) Therapy • Alpha-lipoic acid Oral Surg Oral Med Oral Pathol Oral Radiol Endod • Capsaicin Constant  episodic  pain-free(1,2) 2007;103(suppl 1):S39.e1-S39.e13) World Workshop of Oral Medicine IV

1 Ship, et al. (JADA, 1995) 2 Grushka, et al. (Am Fam Physician, 2002)

Thank You

David Dean Email: [email protected]