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Case Report
Combination therapy of atypical odontalgia with fluoxetine and clonazepam: Report of an effective prescription Hamed Mortazavi1, Maryam Baharvand1, Amin Khodadoustan2, Zahra Mansouri1 Department of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, 2Department of Periodontology and Implantology, Dental School, Hamadan University of Medical Sciences, Hamadan, Iran 1
A B S T R A C T Introduction: Atypical odontalgia (AO) is a subgroup of persistent idiopathic facial pain. We introduced a combination therapy of fluoxetine and clonazepam to treat AO. Case Report: A 30-year-old female with the chief complaint of severe pain (#8 based on Visual Analogue Scale( VAS)) in the site of extracted tooth #3 since 2 months ago was referred to the Department of Oral Medicine. The pain was of sharp quality continuing all day long and radiated to cervical muscles, forehead, and mandible of the ipsilateral side and contra lateral structures. The patient was treated with fluoxetine 20 mg/d and clonazepam 0.5 mg/d. The pain intensity was reported almost #0 when the patient was re evaluated 1 month after the first visit. An 8-month follow up revealed no sign of pain and discomfort on the affected site. Discussion: Combination therapy with clonazepam and fluoxetine has a positive effect in the treatment of AO. Key words: Atypical odontalgia, clonazepam, fluoxetine
Introduction
We introduced a combination therapy of fluoxetine and clonazepam to treat AO.
Atypical odontalgia (AO) is a subgroup of persistent idiopathic facial pain as defined by International Headache Society (IHS),[1] which was first described in 1947 by McElin and Horton.[2] This entity was also called phantom tooth pain and idiopathic periodontalgia.[3] Characteristically, AO presents as prolonged periods of constant burning or throbbing pain in the teeth following pulp extirpations, apicoectomy, or tooth extraction in the absence of any identifiable etiology.[4] The incidence of AO has been estimated to be between 2.1 and 12%.[1,5,6] Except for children, all ages can be affected, especially women in their mid-40s.[4] Molar and premolar regions are most commonly affected sites.[1,4,5] Access this article online Quick Response Code:
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DOI: 10.4103/2155-8213.133438
Case Report A 30-year-old female with the chief complaint of severe pain in the site of extracted tooth #2 was referred to the Department of Oral Medicine. Caries and severe pain since 2 months ago, which had negative impact on patient’s personal and social life, prompted her to extract the tooth. The pain was of sharp quality continuing all day long and radiated to cervical muscles, forehead, and mandible of the ipsilateral side and contra lateral structures as well. On the first visit, the intensity of pain was reported so severe (#8 based on VAS) that it interfered with patent’s sleep and eating. Clinical examination revealed normally healed socket of #2. Meanwhile, neither panoramic view nor periapical radiographs showed pathologic lesions in the site of right maxillary second molar [Figures 1 and 2]. For more elaborate examinations of the maxillary sinus and ears, the patient was referred to an ear, nose and throat (ENT) specialist whose report was not contributory. It is noteworthy that the patient
Corresponding Author: Dr. Maryam Baharvand, Department of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Daneshjoo Blvd, Tabnak St, Chamran Highway, Tehran, Iran. E-mail:
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[Downloaded free from http://www.dentalhypotheses.com on Sunday, July 27, 2014, IP: 188.245.224.36] || Click here to download free Android application for this journal Mortazavi, et al.: Fluoxetine and clonazepam to treat atypical odontalgia
Figure 1: Panoramic view shows site of the extracted tooth
had referred to several dental practitioners, but the prescriptions including acetaminophen, ibuprofen, mefenamic acid, and a variety of antibiotics did not relieve the pain. In regard with the nature of the pain and lack of any evidence in favor of pathologic process in clinical and imaging investigations, the diagnosis of AO was established. The patient was treated with fluoxetine (Dr Abidi Pharm. Co. Tehran, Iran) 10 mg/bid (twice a day) after breakfast and lunch and clonazepam (Sobhan Daru Pharm, Co. Rasht, Iran) 0.5 mg half an hour before sleep. On the second visit after 2 weeks, the pain intensity was reduced 50% (VAS #4), so the treatment protocol was continued 2 weeks afterwards. The pain intensity was reported almost #0 when the patient was re evaluated 1 month after the first visit, and she felt better spiritually as well. The patient was instructed to continue fluoxetine up to 2 weeks later with the same dosage and then decrease it to 10 mg daily after breakfast. Finally, clonazepam was continued until 2 weeks and then decreased to 0.25 mg (one-fourth of tablet) before sleep. When the patient was examined after 2 months since the first visit, she reported no pain; therefore clonazepam and fluoxetine was tapered during 2 weeks and discontinued afterwards. An 8-month follow up revealed no sign of pain and discomfort on the affected site.
Discussion The pathophysiology of AO remains unclear. However, possible mechanisms for AO include those with neuropathic, vascular, and psychogenic origin.[1,5,7] Abiko demonstrated that there is a strong correlation between AO and psychological conditions.[1] It is also noted that about 70% of AO patients have a history of depression, so that depression and somatization scores were moderate to high in patients with 76
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Figure 2: Periapical radiograph shows normal healing and trabeculation pattern in site of the extracted tooth
AO. [1] Therefore, it is rational to choose tricyclic antidepressants (TCAs) as the standard treatment for psychogenic pains such as AO.[1,4] However, the adverse effects of TCAs, e. g. dry mouth, tachycardia, constipation, orthostasis, and blurred vision, can limit their utility.[8] Schreiber showed that fluoxetine has similar analgesic effect to that of amitriptylin in management of chronic pain and can be considered as an alternative therapy in patients unable to tolerate the side effects of TCAs.[9] Several diagnostic criteria have been proposed for AO including a dull and continuous toothache, no clinical or radiographic abnormality, infrequent trigger areas, female predominance, precipitation by traumatic events, difficulty to localize the pain, and pain spreading to adjacent areas (unilaterally or bilaterally).[1,4] The risk factors leading to the development of AO after a dental procedure are the intensity and duration of preoperative tooth pain, female gender, history of a previously painful treatment in the orofacial region, and previous chronic pain problems.[1] Albeit the features of orofacial pain can be quite diverse, general characteristics of odontogenic and neuropathic conditions help establish the correct diagnosis.[4] In accordance to our case, it is noted that 80–90% of AO patients are female.[1,3] It is also reported that 56% of patients complained of pain in the upper jaw.[1] In addition, molar and premolar regions in the maxilla are most often affected.[4,6,7] Review of literature showed that in 83% of cases, AO presented after an invasive dental or surgical procedure.[1-5] Our case was treated using fluoxetine and clonazepam on the basis of a successful experience by the author Apr-Jun 2014 / Vol 5 | Issue 2
[Downloaded free from http://www.dentalhypotheses.com on Sunday, July 27, 2014, IP: 188.245.224.36] || Click here to download free Android application for this journal Mortazavi, et al.: Fluoxetine and clonazepam to treat atypical odontalgia
in the management of chronic masticatory myalgia with these medications.[10] Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant. Clonazepam is a benzodiazepine derivative with anticonvulsant, muscle relaxant, analgesic, and very potent anxiolytic properties. Clonazepam and fluoxetine facilitate the inhibitory effects of gammaaminobutyric acid (GABA), affect levels of serotonin and adrenaline in synapses, and inhibit spinal multisynaptic afferent pathways.[9,10] Antidepressants can produce analgesia faster and at lower doses than those required for their antidepressant effect. Activation of norepinephrine (NE) and serotonin (5-HT (5-hydroxytryptamine)) within descending pain pathways are mediated by antidepressants, which produces analgesia. These substances reduce the synthesis and release of pain-promoting neurotransmitters, e. g. substance P and glutamate in the spinal cord. On the other hand, antidepressants decrease the extent of limbic output within the brain, which may contribute to depression and anxiety that exacerbate underlying pain.[9] In conclusion, combination therapy with clonazepam and fluoxetine has a positive effect in the treatment of AO. However, further controlled studies are mandatory to clarify our findings.
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References 1.
Abiko Y, Matsuoka H, Chiba I, Toyofuku A. Current evidence on atypical odontalgia: Diagnosis and clinical management. Int J Dent 2012;2012:518548. 2. McELIN TW, Horton DT. Atypical facial pain: A statistical consideration of 65 cases. Ann Intern Med 1947;27:749-53. 3. Marbach JJ. Is phantom tooth pain a deafferentation (neuropathic) syndrome? Part II: Psychosocial considerations. Oral Surg Oral Med Oral Pathol 1993;75:225-32. 4. Matwychuk MJ. Diagnostic challenges of neuropathic tooth pain. J Can Dent Assoc 2004;70:542-6. 5. Ram S, Teruel A, Kumar SK, Clark G. Clinical characteristics and diagnosis of atypical odontalgia: Implications for dentists. J Am Dent Assoc 2009;140:223-8. 6. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT. Frequency of persistent tooth pain after root canal therapy: A systematic review and meta-analysis. J Endod 2010;36:224-30. 7. Marbach JJ. Phantom tooth pain. J Endod 1978;4:362-72. 8. Leo RJ, Barkin RL. Antidepressant use in chronic pain management: Is there evidence of a role for duloxetine? Prim Care Companion J Clin Psychiatry 2003;5:118-23. 9. Schreiber S, Vinokur S, Shavelzon V, Pick CG, Zahavi E, Shir Y. A randomized trial of fluoxetine versus amitriptyline in musculoskeletal pain. Isr J Psychiatry Relat Sci 2001;38:88-94. 10. Javadzadeh Bolouri A, Delavarian Z, Mortazavi H, ToufaniAsl HR, Falaki A, Falaki F. The effect of combination therapy with fluoxetine and clonazepam in myofascial pain dysfunction syndrome. Aust J Basic Appl Sci 2011;5:520-5. Cite this article as: Mortazavi H, Baharvand M, Khodadoustan A, Mansouri Z. Combination therapy of atypical odontalgia with fluoxetine and clonazepam: Report of an effective prescription. Dent Hypotheses 2014;5:75-7. Source of Support: Nil, Conflict of Interest: None declared.
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