Pain Management Case Studies

CLINICAL FEATURES

The term BMS refers to chronic pain condition in absence of any visible mucosal abnormality or organic disease. It is defined by symptoms that persist for a long time. The pain episodes usually occur continuously for at least 4-6months and may last for 12 years or more with an average duration of 3.4years. The most common complaint is unremitting oral mucosal pain in association with dysgeusia and xerostomia. And no signs of lesions or other detectable changes in the oral mucosa even in painful areas.[21] The type of pain experienced by majority of BMS patients is a prolonged “burning” sensation. However, scalding, tingling or numb feelings of the oral mucosa have also been reported. Burning sensation is most frequently reported

It is defined only by symptoms and the symptomatic triad rarely occurs simultaneously in one patient and due to overlapping stomatitis. Symptomatically, chronic pain conditions like traumatic/inflammatory/immune-mediated stomatitis or orofacial pain disorders present similar to BMS. Foremost it is essential to discriminate between primary and secondary BMS. Thus a thorough case history and a careful examination are the key to successful diagnosis. Systematic evaluation of masticatory system including clinical assessment of occlusion, dentition, temporomandibular joint status and masticatory muscles is essential to rule out possible joint disorders. Salivary flow rate below 0.1ml/min for unstimulated whole saliva or 0.7ml/min for stimulated whole saliva is suggestive of hyposalivation. Sialochemistry can be helpful to assess specific qualitative alterations in saliva. Nutritional deficiencies, diabetes mellitus and menopausal disorders are diagnosed through haematological assessment of nutritional status, blood glucose and estrogen/progesterone concentrations respectively. The presence of underlying psychological disorders can be revealed by appropriate structured interviews and/or psychometric instruments. If clinical or laboratory examination reveals the presence of any these factors, then speculation of secondary BMS should be made. While

Antidepressants used for BMS treatment are broadly classified into tricyclic antidepressants (amitriptyline, imipramine, desimipramine, clomipramine, doxepin) selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline) and atypical antidepressants (trazodone).[32]Amitriptyline exerts its antidepressant action by blocking the neuronal reuptake of noradrenaline and serotonin. But due to its anticholinergic it may cause delirium in elderly patients. Desipramine and nortriptyline, which have least anticholinergic activity, are equally efficacious substitutes. Dosage for adults is initially 25mg thrice daily which can be increased upto 150mg daily in divided doses. For elderly population, 10mg three times a day is sufficient. Imipramine inhibits noradrenaline reuptake to a lesser extent and thus is less sedative than amitryptiline. Dosage is 25mg thrice daily upto 100mg thrice daily. Doxepin inhibits reuptake of monoamines at central synapse. Dosage is 25mg thrice daily which can be gradually increased to 50mg. Selective serotonin reuptake inhibitors inhibit drug metabolizing isoenzymes CYP2D6 and CYP3A4. Dosage for Fluoxetine is 20 mg once daily which can be increased upto 80mg in two divided doses. Sertraline is started as 50mg once daily and increased upto 200mg/day. Atypical antidepressant like trazodone selectively blocks 5HT reuptake and has