今日の臨床サポート

舌痛症

著者: 豊福 明 東京医科歯科大学大学院 医歯学総合研究科歯科心身医学分野

監修: 近津大地 東京医科大学

著者校正/監修レビュー済:2022/05/25
患者向け説明資料

概要・推奨   

  1. 高齢患者が増加しており、効果的かつ薬剤相互作用が少ない処方が推奨される[1]
  1. 口腔症状の部分寛解や症候移動も少なくないので、柔軟な対応が求められる。
  1. 高齢者では稀に悪性腫瘍が潜んでいる症例もあり、慎重な経過観察が必要である。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
豊福 明 : 特に申告事項無し[2022年]
監修:近津大地 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、高齢者の鑑別診断について追記した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 舌の慢性の「ピリピリ」「ヒリヒリ」感を訴える
  1. 50歳代以降の女性が80%程度
  1. 器質的異常所見は認められず、食事には支障が少ない
  1. ステロイド軟膏やビタミン剤などは無効
  1. 抗うつ薬が奏効する
  1. 舌痛症の患者の20%程度にうつ病の合併があるので注意
  1. 内科的疾患との因果関係は否定的な例がほとんどである[2]
  1. 約60%で味覚障害や口腔乾燥症を伴うとされ、痛みよりそれらが前景に立つこともある。
  1. 本症の自然治癒率は5年間で3%である[3]
問診・診察のポイント  
  1. 舌癌や口底癌を見逃さないよう、口腔内の視診と触診、特に口庭部の双指診は必須[4]
  1. 精神科的既往歴(特にうつ病や双極性障害)の有無を聴取

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

Takayuki Suga, Takeshi Watanabe, Yuma Aota, Takahiko Nagamine, Akira Toyofuku
Burning mouth syndrome: The challenge of an aging population.
Geriatr Gerontol Int. 2018 Dec;18(12):1649-1650. doi: 10.1111/ggi.13548.
Abstract/Text
PMID 30548780
Takayuki Suga, Miho Takenoshita, Akira Toyofuku
Medical comorbidities of patients with burning mouth syndrome.
Oral Dis. 2020 Jan;26(1):238-239. doi: 10.1111/odi.13186. Epub 2019 Oct 10.
Abstract/Text
PMID 31466124
A Sardella, G Lodi, F Demarosi, C Bez, S Cassano, A Carrassi
Burning mouth syndrome: a retrospective study investigating spontaneous remission and response to treatments.
Oral Dis. 2006 Mar;12(2):152-5. doi: 10.1111/j.1601-0825.2005.01174.x.
Abstract/Text OBJECTIVE: The aim of this investigation was to evaluate the spontaneous remission rate of burning mouth syndrome (BMS) in a group of subjects suffering from this syndrome.
SUBJECTS AND METHODS: The medical records of BMS patients attending the Unit of Oral Medicine (1995-2002) were reviewed. The patients with a follow-up period of at least 18 months were then contacted over phone and interviewed using a structured ad hoc questionnaire to record their current symptoms and data about their treatment responses to the therapies.
RESULTS: Forty-eight women and five men with a mean age of 67.7 years (range 33-82 years) were included in the study (mean duration of BMS 5.5 years, s.d. +/-1.9 years, mean follow-up period of 56 months). As a consequence of different treatments, 26 patients (49.0%) reported no change in oral symptoms, 15 (28.3%) moderate improvement and 10 (18.9%) a worsening of oral complaints. Only two patients (3.7%) reported a complete spontaneous remission of oral symptoms without any treatment.
CONCLUSIONS: In this study, a complete spontaneous remission was observed in 3% of the patients within 5 years after the onset of BMS. A moderate improvement was obtained in <30% of the subjects.

PMID 16476036
Takayuki Suga, Trang Thi Huyen Tu, Miho Takenoshita, Lou Mikuzuki, Yojiro Umezaki, Hiroaki Shimamoto, Yasuyuki Michi, Chaoli Hong, Yoshihiro Abiko, Tohru Ikeda, Narikazu Uzawa, Hiroyuki Harada, Akira Toyofuku
Case Report: Hidden Oral Squamous Cell Carcinoma in Oral Somatic Symptom Disorder.
Front Psychiatry. 2021;12:651871. doi: 10.3389/fpsyt.2021.651871. Epub 2021 Apr 1.
Abstract/Text Background: Burning mouth syndrome (BMS) is a common condition of predominant oral pain without evident cause, that maxillofacial surgeons and otolaryngologists often refer to psychiatrists as somatic symptom disorder. In very rare cases, its typical burning symptom mimics those of other diseases in which serious fatal comorbidities may be missed. We encountered three rare cases of oral squamous cell carcinoma (OSCC) with the first symptom of burning tongue. Case Presentation: Case 1: A 68-year-old woman had burning pain on the left lingual margin for 8 years. Antidepressant treatment was not efficacious. Cytology and biopsy revealed OSCC. Case 2: A 70-year-old man had burning sensation and paralysis of the tongue for 6 months. Magnetic resonance imaging (MRI) revealed a 37 × 23-mm mass under the floor of the mouth and enlargement of lymph nodes on both sides. Case 3: A 90-year-old man had burning sensation of the tongue for 1 year. MRI revealed a 12 × 12-mm mass on the mandible with bone absorption. Conclusion: This case series suggests that psychiatrists must always be careful in regarding BMS as somatic symptom disorder and be cautious of the possibility of OSCC, especially in elderly patients.

Copyright © 2021 Suga, Tu, Takenoshita, Mikuzuki, Umezaki, Shimamoto, Michi, Hong, Abiko, Ikeda, Uzawa, Harada and Toyofuku.
PMID 33868058
Trang T H Tu, Miho Takenoshita, Hirofumi Matsuoka, Takeshi Watanabe, Takayuki Suga, Yuma Aota, Yoshihiro Abiko, Akira Toyofuku
Current management strategies for the pain of elderly patients with burning mouth syndrome: a critical review.
Biopsychosoc Med. 2019;13:1. doi: 10.1186/s13030-019-0142-7. Epub 2019 Jan 31.
Abstract/Text Burning Mouth Syndrome (BMS), a chronic intraoral burning sensation or dysesthesia without clinically evident causes, is one of the most common medically unexplained oral symptoms/syndromes. Even though the clinical features of BMS have been astonishingly common and consistent throughout the world for hundreds of years, BMS remains an enigma and has evolved to more intractable condition. In fact, there is a large and growing number of elderly BMS patients for whom the disease is accompanied by systemic diseases, in addition to aging physical change, which makes the diagnosis and treatment of BMS more difficult. Because the biggest barrier preventing us from finding the core pathophysiology and best therapy for BMS seems to be its heterogeneity, this syndrome remains challenging for clinicians. In this review, we discuss currently hopeful management strategies, including central neuromodulators (Tricyclic Antidepressants - TCAs, Serotonin, and Norepinephrine Reuptake Inhibitors - SNRIs, Selective Serotonin Reuptake Inhibitors - SSRIs, Clonazepam) and solutions for applying non-pharmacology approaches. Moreover, we also emphasize the important role of patient education and anxiety management to improve the patients' quality of life. A combination of optimized medication with a short-term supportive psychotherapeutic approach might be a useful solution.

PMID 30733824
Takayuki Suga, Trang T H Tu, Takahiko Nagamine, Akira Toyofuku
Careful use of clonazepam and alpha lipoid acid in burning mouth syndrome treatment.
Oral Dis. 2022 Apr;28(3):846-847. doi: 10.1111/odi.13776. Epub 2021 Jan 26.
Abstract/Text
PMID 33440037
Takayuki Suga, Miho Takenoshita, Takeshi Watanabe, Trang Th Tu, Lou Mikuzuki, Chaoli Hong, Kazuhito Miura, Tatsuya Yoshikawa, Takahiko Nagamine, Akira Toyofuku
Therapeutic Dose of Amitriptyline for Older Patients with Burning Mouth Syndrome.
Neuropsychiatr Dis Treat. 2019;15:3599-3607. doi: 10.2147/NDT.S235669. Epub 2019 Dec 30.
Abstract/Text OBJECTIVE: To assess the therapeutic dose and safety of amitriptyline and the outcome following treatment with amitriptyline among older patients with burning mouth syndrome (BMS).
METHODS: 187 consecutive patients were prescribed amitriptyline as a first-line medication from April 2016 to September 2018 and followed-up for >1 month. Patients were divided into 3 groups: group 1, 113 patients aged <65 years; group 2, 52 patients aged between 65 and 74 years; and group 3, 22 patients aged 75 years or older. The visual analog scale (VAS), Pain Catastrophizing Scale (PCS), Somatic Symptom Scale-8 (SSS-8), Patient Global Impression of Change (PGIC), and Short-form McGill Pain Questionnaire (SF-MPQ) were used for analysis.
RESULTS: Thirty-two patients (17 in group 1, 10 in group 2, and 5 in group 3) stopped taking amitriptyline due to side effects. There were no differences among the groups with respect to sex; scores of VAS, PCS, and SSS-8; and drop-out ratio. There were no significant differences in the VAS, PCS, and PGIC scores among the groups after 1 month. The mean daily dose after 1 month was 20.4 ± 8.6 mg in group 1, 17.3 ± 8.7 mg in group 2, and 13.2 ± 5.8 mg in group 3; this difference was significant (p value = 0.003). About 76% of patients showed improvements in their symptoms (PGIC ≥ 3). About 90% of patients reported side effects. No serious side effects occurred.
CONCLUSION: The therapeutic dose of amitriptyline may be lower for older BMS patients than for younger patients.

© 2019 Suga et al.
PMID 31920319
Motoko Watanabe, Miho Takenoshita, Trang T H Tu, Akira Toyofuku
Real-world Discontinuation of Antidepressant Treatment in Patients with Burning Mouth Syndrome: A Chart Review.
Pain Med. 2020 Sep 1;21(9):2009-2010. doi: 10.1093/pm/pnz324.
Abstract/Text
PMID 31841160
Motoko Watanabe, Chihiro Takao, Zhenyan Liu, Gayatri Nayanar, Takayuki Suga, Chaoli Hong, Trang Thi Huyen Tu, Tatsuya Yoshikawa, Miho Takenoshita, Haruhiko Motomura, Takahiko Nagamine, Akira Toyofuku
The Effectiveness and Adverse Events of Amitriptyline and Aripiprazole in Very Elderly Patients With BMS.
Front Pain Res (Lausanne). 2022;3:809207. doi: 10.3389/fpain.2022.809207. Epub 2022 Mar 4.
Abstract/Text Burning mouth syndrome (BMS) is defined by chronic oral burning sensations without any corresponding abnormalities. Besides amitriptyline, aripiprazole has been reported as a possible medication to manage BMS. However, especially for elderly patients, the adverse events of these medications would be a problem. The aim of the present study was to investigate the differences in the effectiveness and adverse events of amitriptyline and aripiprazole in very elderly patients with BMS. This is a retrospective comparative study of 80 years old and older patients with BMS who were initially treated with amitriptyline or aripiprazole and who were new outpatients of our department from April 2017 to March 2020. All clinical data, including sex, age, comorbid physical diseases, comorbid psychiatric disorders, the prescribed doses (initial, maximum, and effective dose), prognosis, and adverse events, were collected from their medical charts. Each medication was selected considering their medical history. Amitriptyline was prescribed in 13 patients (11 women, 82.3 ± 2.1 years old) and aripiprazole was prescribed in 27 patients (26 women, 84.2 ± 3.8 years old). There were no significant between-group differences in sex, age, duration of illness, pain intensity, salivation, and psychiatric comorbidity at the first examination. Amitriptyline clinically improved more patients (7 patients, 53.8%) with the effective dose of 10 (7.5, 15.0) mg than aripiprazole (11 patients, 40.7%) of which the effective dose was 1.0 (0.5, 1.5) mg, although there were no significant between-group differences. The adverse events of amitriptyline were found in 9 patients (69.2%) and most patients had constipation (46.2%). For aripiprazole, 7 patients (25.9%) showed adverse events, most of them reported sleep disorder (11.1%). Amitriptyline had significantly longer duration taking medication (p = 0.021) and lower discontinuation (p = 0.043) despite of higher occurrence rate of adverse events (p = 0.015) compared to aripiprazole. These results suggest that both psychopharmacotherapies with a low dose of amitriptyline and aripiprazole are effective for the very elderly patients with BMS. Furthermore, aripiprazole may have some advantages in the adverse events compared to amitriptyline; however, the low dose amitriptyline monotherapy may have more benefit in the effectiveness and tolerability over prudent collaboration with primary physicians.

Copyright © 2022 Watanabe, Takao, Liu, Nayanar, Suga, Hong, Tu, Yoshikawa, Takenoshita, Motomura, Nagamine and Toyofuku.
PMID 35295804
Durga Paudel, Masafumi Utsunomiya, Koki Yoshida, Sarita Giri, Osamu Uehara, Hirofumi Matsuoka, Itsuo Chiba, Akira Toyofuku, Yoshihiro Abiko
Pharmacotherapy in relieving the symptoms of burning mouth syndrome: A 1-year follow-up study.
Oral Dis. 2020 Jan;26(1):193-199. doi: 10.1111/odi.13226. Epub 2019 Nov 26.
Abstract/Text OBJECTIVE: Burning mouth syndrome (BMS) is a chronic intraoral burning sensation with no identifiable causes. In this study, we aim to demonstrate the effectiveness of treatment strategy using ethyl loflazepate monotherapy or in combination with milnacipran or amitriptyline.
METHOD: A hospital-based, retrospective study was conducted in 86 patients. The patients were divided into remission group and non-remission group. The remission group comprised patients who were satisfied with their pain relief within a year of treatment initiation and did not require any follow-up treatment. The treatment was considered effective if the patient got remission within 1 year or was able to reduce the visual analogue scale (VAS) score to <20, in the absence of remission.
RESULTS: The treatment strategy was effective in 76.7% of the patients. Significant reductions (p < .05) in VAS scores from 73.5 ± 14.2 at first visit to 14.7 ± 8.7 at last visit in the remission group, and from 79.7 ± 14.3 at first visit to 33.4 ± 23.7 after 1 year of treatment in the non-remission group were noted.
CONCLUSION: The treatment strategy using ethyl loflazepate monotherapy or in combination with milnacipran or amitriptyline can be very effective in reducing pain in BMS patients.

© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved.
PMID 31705718
Miho Takenoshita, Haruhiko Motomura, Akira Toyofuku
Low-Dose Aripiprazole Augmentation in Amitriptyline-Resistant Burning Mouth Syndrome: Results from Two Cases.
Pain Med. 2017 Apr 1;18(4):814-815. doi: 10.1093/pm/pnw200.
Abstract/Text
PMID 27558854
Takayuki Suga, Miho Takenoshita, Trang T H Tu, Takashi Sugawara, Susumu Kirimura, Akira Toyofuku
A case of vestibular schwannoma mimicking burning mouth syndrome.
Biopsychosoc Med. 2021 Mar 21;15(1):7. doi: 10.1186/s13030-021-00209-y. Epub 2021 Mar 21.
Abstract/Text BACKGROUND: An oral burning sensation with unidentified cause in patients with preexisting psychosocial conditions is usually diagnosed as burning mouth syndrome. However, unexpected organic lesions may be detected in rare cases.
CASE PRESENTATION: A 35-year-old woman had chief complaints of a burning sensation and numbness of the right side of the lip and tongue, as well as a dry sensation of the mouth with a taste disturbance of the right side of the tongue. The symptoms were continuous and did not show any daily fluctuations. The symptoms started without any recognizable triggering factor six months before her first visit to our clinic,. No abnormality was detected in her mouth. MRI images revealed an approximately 30 × 30 mm well-defined mass localized in the right cerebropontine angle compressing the trigeminal nerve, which was diagnosed as schwannoma of the right auditory nerve.
CONCLUSIONS: It is important for clinicians to consider the possibility of brain tumors in their differential diagnosis of BMS. Although it is not always easy to eliminate all diseases that may cause an oral burning sensation in patients with BMS-like symptoms, more attention and careful examination based on the patient's psychosomatic background features and other possible causes are needed to rule out organic diseases.

PMID 33743774
Takayuki Suga, Trang T H Tu, Junichiro Sakamoto, Akira Toyofuku
A case of vestibular schwannoma with oral burning sensation: surgical complication or burning mouth syndrome?
Biopsychosoc Med. 2021 Aug 23;15(1):13. doi: 10.1186/s13030-021-00215-0. Epub 2021 Aug 23.
Abstract/Text BACKGROUND: Despite improvements in surgical techniques, the removal of vestibular schwannoma is related to some complications. Recovery from surgical complications of vestibular schwannoma is often difficult and complications sometimes lead to permanent deficits. However, treatable trigeminal symptoms may be missed in atypical cases.
CASE PRESENTATION: A 46-year-old woman complained about burning sensation on her tongue and maxilla for four years before her first visit to our clinic. She visited the neurosurgery department in a university hospital because her facial pain and burning sensation of her tongue were suddenly aggravated. She was diagnosed with vestibular schwannoma and tumour resection was performed. However, her oral pain persisted after surgery. Two months before the initial visit to our clinic, the oral pain became more severe than ever before. When the patient visited a psychiatrist due to a panic attack, the psychiatrist diagnosed her as having somatic symptom disorder and depression and referred her to our clinic. Based on the characteristics of the pain, she was diagnosed as burning mouth syndrome and treated for the same. Within 1.5 months, the pain and burning sensation of the tongue and maxilla almost completely remitted with low dose amitriptyline.
CONCLUSIONS: Our case suggests that there are exceptional cases in which burning mouth syndrome and vestibular schwannoma occur simultaneously. Burning pain after vestibular schwannoma surgery cannot always be considered a complication of surgery.

© 2021. The Author(s).
PMID 34425849

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