Recent advances in the understanding of the aetiology and therapeutic strategies in burning mouth syndrome: Focus on the actions of cannabinoids.

Burning mouth syndrome (BMS) is a neuropathic pain disorder associated with a burning sensation on oral mucosal surfaces with frequently reported xerostomia, dysgeusia and tingling or paraesthetic sensations. However, patients present no clinically evident causative lesions. The poor classification of the disorder has resulted in a diagnostic challenge, particularly for the clinician/dentist evaluating these individuals. Major research developments have been made in the BMS field in recent years to address this concern, principally in terms of the pathophysiological mechanisms underlying the disorder, in addition to therapeutic advancements. For the purpose of this review, an update on the pathophysiological mechanisms will be discussed from a neuropathic, immunological, hormonal and psychological perspective. This review will also focus on the many therapeutic strategies that have been explored for BMS, including antidepressants/antipsychotics, non-steroidal anti-inflammatories, hormone replacement therapies, phytotherapeutic compounds and non-pharmacological interventions, overall highlighting the lack of controlled clinical studies to support the effectiveness of such therapeutic avenues. Particular focus is given to the cannabinoid system and the potential of cannabis-based therapeutics in managing BMS patients.

Efficacy and safety of a novel mucoadhesive clobetasol patch for treatment of erosive oral lichen planus: A phase 2 randomized clinical trial.

BACKGROUND: Oral lichen planus (OLP) is a chronic inflammatory disorder of the oral mucosa. Currently there is no approved treatment for OLP. We report on the efficacy and safety of a novel mucoadhesive clobetasol patch (Rivelin® -CLO) for the treatment of OLP. METHODS: Patients with confirmed OLP and measurable symptomatic ulcer(s) participated in a randomized, double-blind, placebo-controlled, multicenter clinical trial testing a novel mucoadhesive clobetasol patch (Rivelin® -CLO) in OLP across Europe, Canada, and the United States. Patients were randomized to placebo (nonmedicated), 1, 5, 20 µg Clobetasol/patch, twice daily, for 4 weeks. The primary endpoint was change in total ulcer area compared to baseline. Secondary endpoints included improvement from baseline in pain, disease activity, and quality of life. RESULTS: Data were analyzed and expressed as mean [SD]. One hundred thirty-eight patients were included in the study; 99 females and 39 males, mean age was 61.1 [11.6] years. Statistical analyses revealed that treatment with 20-µg Rivelin® -CLO patches demonstrated significant improvement with ulcer area (p = 0.047), symptom severity (p = 0.001), disease activity (p = 0.022), pain (p = 0.012), and quality of life (p = 0.003) as compared with placebo. Improvement in OLP symptoms from beginning to the end of the study was reported as very much better (best rating) in the 20-µg group (25/32) patients compared to the placebo group (11/30), (p = 0.012). Adverse events were mild/moderate. Candidiasis incidence was low (2%). CONCLUSIONS: Rivelin® -CLO patches were superior to placebo demonstrating statistically significant, clinically relevant efficacy in objective and subjective improvement and, with a favorable safety profile.

Plasma IL-8 signature correlates with pain and depressive symptomatology in patients with burning mouth syndrome: Results from a pilot study.

BACKGROUND: Burning mouth syndrome (BMS) is a neuropathic orofacial pain condition of unknown aetiology that encompasses intra-oral burning pain without abnormal clinical findings. Psychological, neural and inflammatory processes are associated with BMS pathogenesis. Currently, studies characterising plasma cytokine/chemokine profiles with pain and depression in patients with BMS are lacking. Considering that inflammation is associated with the pathophysiology of BMS, and that inflammation is closely associated with pain and depression, we aimed to correlate depressive symptomatology and oral cavity pain with plasma cytokine/chemokine signatures in a cohort of patients with BMS. METHODS: In this study, plasma protein levels of Th1 cytokines (IFN-γ, IL-2, IL-12p70, TNF-α), Th2 cytokines (IL-4, IL-10, IL-6, IL-13) and the chemokine IL-8 were assessed in patients with BMS (n = 10) and healthy volunteers (n = 10), using pro-inflammatory-10-plex assays. Clinical histories, alongside self-rated oral cavity pain intensities and depressive symptomatology were assessed using a visual analogue scale and the 16-item Quick Inventory of Depressive Symptomatology questionnaires, respectively. RESULTS: We present evidence that BMS is associated with increased depressive symptomatology and enhanced oral cavity pain. Plasma isolated from BMS patients display enhanced expression of the pro-inflammatory chemokine IL-8, when compared to plasma from healthy individuals. Plasma IL-8 signature correlates with pain and depressive symptomatology in the study cohort. CONCLUSIONS: Overall, these findings indicate that plasma IL-8 profiles are dysregulated in BMS and that modulation of IL-8 production in the disorder may be a tool in the management of BMS symptomatology.

Plasma N-acylethanolamine and endocannabinoid levels in burning mouth syndrome: Potential role in disease pathogenesis.

OBJECTIVE: The objective was to measure endocannabinoid (eCB) ligands and non-cannabinoid N-acylethanolamine (NAE) molecules in plasma from individuals with burning mouth syndrome (BMS) and to determine whether plasma eCB/NAE levels correlated with pain, inflammation and depressive symptomatology in this cohort. STUDY DESIGN: Plasma content of the eCBs, anandamide (AEA) and 2-arachidonoyl-glycerol (2-AG), and the NAE molecules, palmitoylethanolamide (PEA) and oleoylethanolamide (OEA) were assessed in healthy subjects (n = 8) and in a cohort of newly diagnosed BMS patients (n = 9) using liquid chromatography-tandem mass spectrometry. Plasma eCBs and NAE profiles were correlated with self-rated oral cavity pain intensities, depressive symptomatology and plasma IL-8 levels. RESULTS: Plasma levels of PEA, but not OEA, AEA or 2-AG, were significantly elevated in patients with BMS, when compared to plasma from healthy individuals. Plasma PEA, OEA and AEA levels correlated with depressive symptomatology. CONCLUSIONS: This is the first evidence to indicate that circulating eCB/NAE levels are altered in BMS.

What's new in... Capnography Monitoring for Dental Conscious Sedation: A Clinical Review.

Capnography monitoring during conscious sedation is not currently required for dentistry in Britain and Ireland. Other countries have introduced guidelines and standards requiring capnography monitoring for procedural sedation. This review highlights the variability of procedural sedation including the setting, the position on the sedation continuum, and the routine use of supplemental oxygen. Specific research is required for conscious sedation in a dental setting to support standards and guidelines with regard to capnography monitoring. The Academy of Medical Royal Colleges and their Faculties emphasise that each specialty must produce its own guidance for the use of sedative techniques.1 Clinical practice guidelines for the monitoring and safe practice of sedation vary by specialty and institution. Standards are generally set from the best available evidence based research. There is a growing body of literature that recognises the potential additional value of capnography (ETCO2) monitoring during procedural sedation in different settings and for different sedation techniques.2-5 In these studies, capnography reduced the incidence of hypoxaemia during procedural sedation. A meta-analysis published by Waugh et al. (2010) concluded that end-tidal carbon dioxide monitoring is an important addition in detecting respiratory depression during procedural sedation.6 A more recent systematic review by Conway et al. (2016) concluded that patients monitored with capnography in addition to standard monitoring had a reduced risk of hypoxaemia compared to those with only standard monitoring.7 However, it has to be noted that both the Waugh and Conway reviews contained substantial statistical heterogenicity which is likely to affect the quality of the evidence. As research evidence for capnography monitoring from the medical settings studied became available, new standards for capnography monitoring were introduced in several countries (Table 1).

Squamous Papilloma Causing Airway Obstruction During Conscious Sedation.

Monitoring for respiratory depression is essential during conscious sedation. We report a case of a squamous papilloma as an unusual cause of intermittent partial airway obstruction in a 43-year-old man undergoing intravenous conscious sedation with midazolam. The Integrated Pulmonary Index (IPI) is an algorithm included in some commercially available monitors that constitutes a representation of 4 parameters: end-tidal carbon dioxide, respiratory rate, oxygen saturation, and pulse rate. We discuss the potential of the IPI as a monitoring tool during sedation.

Tetany During Intravenous Conscious Sedation in Dentistry Resulting From Hyperventilation-Induced Hypocapnia.

Hyperventilation can be a manifestation of anxiety that involves abnormally fast breathing (tachypnea) and an elevated minute ventilation that exceeds metabolic demand. This report describes a case of hyperventilation-induced hypocapnia resulting in tetany in a 16-year-old girl undergoing orthodontic extractions under intravenous conscious sedation. Pulse oximetry is the gold standard respiratory-related index in conscious sedation. Although the parameter has great utility in determining oxygen desaturation, it provides no additional information on respiratory function, including, for example, respiratory rate. In this case, we found capnography to be a very useful aid to monitor respiration in this patient and also to treat the hypocapnia.

Adverse reactions to facial dermal fillers: a case report.

AIM: To describe an early-onset adverse reaction following the injection of facial fillers, and to summarise the current legislation and research regarding cosmetic dermal fillers. To emphasise that dermal fillers should be considered as part of a general dental practitioner's differential diagnosis for lower lip swelling. OBJECTIVES: (1) To describe the types of adverse reactions associated with dermal fillers in the literature; (2) to summarise the current European and Irish legislation and guidance regarding the use of these products; and, (3) to present a case study of an early-onset adverse reaction. CONCLUSION: Dentists should question patients regarding the use of cosmetic dermal fillers as part of the differential diagnosis of any intra-oral painless swelling where other pathology cannot be identified.

Smartphone technology for communications between clinicians - A scoping review.

OBJECTIVES: This scoping review aims to review explore, assess, and map the literature to inform clinical practice regarding communication between clinicians. Specific Apps/channels used were identified and assessed with a focus on data security with key concepts and knowledge gaps identified. DATA: The Joanna Briggs Institute framework is followed, with search results reported as per the PRISMA ScR for scoping reviews guidelines. SOURCES: A systematic search strategy encompassing EBSCO and OneSearch databases was conducted - two identical searches, (June and October 2020) limited to English language articles published 2016-2020. A narrative synthesis was used to integrate and report the findings. STUDY SELECTION: Sixty-six publications were selected. Twelve from EBSCO, thirty-five from OneSearch, nineteen were hand searched. Sixteen of the publications were research studies, nine were literature reviews, twenty-six were editorial, one was a newspaper article and fourteen were grey literature. Instant Messaging (40%, n = 23), image sharing (41%, n = 24), and video conferencing (19%, n = 11) were functions most popular with clinicians. WhatsApp, generic instant messaging, Facebook messenger, ZOOM, and Skype are evidenced as channels for communication between clinicians within the EU. A sizeable proportion of the publications (38%; n = 25) failed to identify or adequately address technical security concerns and requirements around privacy and data protection. CONCLUSIONS: Clinicians use smartphones /Apps to communicate clinical information with each other. The security and privacy issues arising from their communication of sensitive data is absent or only superficially acknowledged within the literature. CLINICAL SIGNIFICANCE: Clinician's need clearer guidance on the use of smartphone technology for clinical communications.

Validity and reliability of a newly developed quality of life questionnaire for patients with chronic oral mucosal diseases.

INTRODUCTION: The aims of this study were to test the validity and reliability of a newly developed discipline-specific questionnaire, the Chronic Oral Mucosal Diseases Questionnaire (COMDQ), to measure quality of life in patients with chronic oral mucosal conditions. MATERIALS AND METHODS: Two patient samples were recruited for the purposes of this study. First, a random sample of 160 patients attending the Oral Medicine Unit of Cork University Dental School and Hospital with the following chronic oral mucosal conditions, recurrent aphthous stomatitis, oral lichen planus, the more common vesiculobullous conditions (mucous membrane pemphigoid and pemphigus vulgaris) and orofacial granulomatosis. Second, the COMDQ was randomly distributed to a sample of 100 patients without a chronic oral mucosal condition. Convergent and discriminative validity and internal consistency of the newly developed questionnaire were assessed. RESULTS: This study has demonstrated that the newly developed questionnaire has good convergent validity with Pearson correlation coefficient of 0.819 with Oral Health Impact Profile-14 and 0.883 with Visual Analogue Scale for pain scores. The discriminative validity was also good with statistically significant differences between patients with chronic oral mucosal conditions and without chronic oral mucosal conditions. The new instrument has also demonstrated excellent reliability with Cronbach's alpha of 0.929. CONCLUSIONS: In conclusion, this study has demonstrated that the COMDQ is a valid and reliable measure to assess quality of life in patients with chronic oral mucosal diseases and therefore will be a valuable instrument in the management of these conditions.

Patch testing for food-associated allergies in orofacial granulomatosis.

BACKGROUND: Food-associated allergies, especially to benzoates and cinnamon-related compounds, have been associated with orofacial granulomatosis and both standard and urticarial patch testing have been used to detect such allergies. Elimination diets have also been shown to be effective in some patients. OBJECTIVES: To compare the results of standard and urticarial patch testing in a cohort of patients with orofacial granulomatosis. MATERIALS AND METHODS: Records of 120 cases seen in two hospitals were retrieved and examined for patch test details. RESULTS: Standard patch testing was much less likely to detect allergy to benzoates and cinnamon compounds (7%) than urticarial tests (55%). All urticarial tests that were positive had shown a reaction by 60 min. CONCLUSIONS: Both standard and urticarial patch tests are required to detect food allergies in orofacial granulomatosis. The difficulties of patient self-recording of urticarial tests can be eliminated by retaining patients in the testing unit for professional reading of patches at 60 min.

Oral medicine and the elderly.

UNLABELLED: A focus often exists in dental practice on the maintenance and management of the dentition and the periodontium, however, conditions of the oral mucosa and orofacial pain can cause significant problems for older patients. Oral mucosal conditions are more prevalent in older patients and many orofacial pain disorders, such as burning mouth syndrome and trigeminal neuralgia, are more common in patients over the age of 50 years. Although these conditions may not be routinely managed in general practice, identification of these patients in primary care and appropriate referral will lead to more prompt and effective treatment. CLINICAL RELEVANCE: Dental practitioners need to be able to identify what is considered to be within the normal physiological limits of the ageing oral tissue and hence what is abnormal and requires further investigation to facilitate appropriate referral.

Systemic diseases and the elderly.

UNLABELLED: Although systemic diseases can occur at any age, they are more common in older patients. Accurate and detailed medical and drug histories are important in dental practice as many conditions and medications can influence oral health and dental care in patients. Not only can these conditions influence patient care in the surgery and oral hygiene at home, but access to dental services may also be adversely affected. CLINICAL RELEVANCE: The systemic diseases can impact upon oral care or can have oral manifestations. Many of the pharmacological interventions prescribed for chronic conditions can have multiple and diverse adverse effects on the oral environment.

Burning mouth syndrome-a diagnostic dilemma.

BACKGROUND: Burning mouth syndrome (BMS) is a chronic pain disorder, more common in peri and postmenopausal females, with a varied symptomatology. Symptoms include a burning or stinging sensation of the tongue, lips or other oral mucosal surfaces, subjectively dry mouth or excess saliva, altered taste or loss of taste and paraesthetic sensations. These are usually present daily for more than 3 months. AIMS: The aims of this study were to highlight the symptomatic manifestations of BMS along with the need for prompt diagnosis and onward referral when necessary. METHODS: A cross-sectional study of patients with idiopathic BMS was conducted. The presenting symptoms, time to diagnosis and number of clinicians seen in advance of a diagnosis of BMS and anxiety and depression as determined by the Hospital Anxiety and Depression Scale (HADS) was recorded. Correlations were explored. RESULTS: Fifty patients were enrolled in this study (38, F:12, M). The average time from onset of symptoms to diagnosis was 13 months. Commonly reported symptoms included burning (n = 44) and altered taste (n = 14). The median anxiety score was 13 and the median depression score was 10. No statistically significant correlations were found between the anxiety and depression scores generated and the number of clinicians seen or the time to diagnosis. CONCLUSION: The results of this study indicate that there is a need for an increased awareness of the symptoms reported in BMS, particularly in peri and postmenopausal women. This should aid prompt diagnosis and may alleviate some of the anxiety that patients may experience.

Microstream capnography during conscious sedation with midazolam for oral surgery: a randomised controlled trial.

OBJECTIVES/AIMS: There has been no dentistry-specific published data supporting the use of monitoring with capnography for dental sedation. Our aim was to determine if adding capnography to standard monitoring during conscious sedation with midazolam would decrease the incidence of hypoxaemia. MATERIALS AND METHODS: A randomised controlled trial was conducted in which all patients (ASA I and II) received standard monitoring and capnography, but were randomised to whether staff could view the capnography (intervention) or were blinded to it (control). The primary outcome was the incidence of hypoxaemia (SpO2⩽94%). RESULTS: We enrolled 190 patients, mean age 31 years (range, 14-62 years). There were 93 patients in the capnography group and 97 in the control group. The mean cumulative dose of midazolam titrated was 6.94 mg (s.d., 2.31; range, 3-20 mg). Six (3%) patients, three in each group, required temporary supplemental oxygen. There was no statistically significant difference between the capnography and control groups for the incidence of hypoxaemia: 34.4 vs 39.2% (P=0.4962, OR=0.81, 95% CI: 0.45-1.47). CONCLUSIONS: We were unable to confirm an additive role for capnography to prevent hypoxaemia during conscious sedation with midazolam for patients not routinely administered supplemental oxygen.

World Workshop on Oral Medicine VI: Patient-reported outcome measures and oral mucosal disease: current status and future direction.

OBJECTIVE: This systematic review aimed to (1) explore the patient-reported outcome measures (PROMs) currently used in the oral mucosal disease literature and report on the type and context of the use of these instruments and (2) provide a future direction for PROMs in Oral Medicine practice and research. STUDY DESIGN: A systematic review of published English-language articles relating to the use of PROMs in the oral mucosal diseases literature was performed in November 2013. RESULTS: In total, 131 articles met the inclusion criteria; these articles addressed the following oral mucosal conditions: lichen planus (75); recurrent aphthous stomatitis (30); mucous membrane pemphigoid/pemphigus vulgaris (14); orofacial granulomatosis (1); and multiple oral mucosal diseases (11). The most commonly used instruments were visual analog scales (VAS) and the oral health impact profile (OHIP). CONCLUSIONS: Limited progress has been achieved with use of PROMs in Oral Medicine in the last few decades in both clinical practice and a research setting. With the engagement of allied medical disciplines in PROM usage and the promotion of PROMs by national health care bodies globally, advancement of PROMs is imperative for Oral Medicine. Exposure through the World Workshop on Oral Medicine (WWOM), along with potential involvement in the Core Outcome Measures in Effectiveness Trials (COMET) or other such initiatives, will enable worldwide collaboration to promote the development and utilization of valid and reliable PROMs in oral medicine, and improve patient care.