Firefighting: Burning Mouth Syndrome and Burning Vulva (vulvodynia)

Transcription

1 Firefighting: Burning Mouth Syndrome and Burning Vulva (vulvodynia) Rochelle Torgerson, MD, PhD Chair of Education Department of Dermatology Mayo Clinic, Rochester, MN

2 DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY I do not have any relationships with industry. I will be discussing off-label use of medications.

3 Is this you? 1) I examine vulvas and treat vulvar disease on a regular basis? 2) I examine mouths and treat oral disease on a regular basis?

4 BMS + Vulvodynia: Objectives Marvel at the similarities Note the differences Glean some ideas for treatment

5 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

6 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

7 Burning Mouth Syndrome Chronic Intraoral burning No identifiable cause No clinical abnormalities No laboratory abnormalities Torgerson. Dermatol Ther. 23:

8 Vulvodynia 2003: Chronic vulvar discomfort (mainly described as burning) occurring in the absence of visible relevant findings. 2015: Vulvar pain of at least 3 months duration, without clear identifiable cause. (which may have associated factors) Moyal-Barracco and Lynch. J Reprod Med. 49: Bornstein et al. J Low Genit Tract Dis. 20:

9 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

10 Type 1: BMS No symptoms upon waking Progression throughout the day Nighttime symptoms are variable Type 2: Continuous daytime symptoms Asymptomatic at night Type 3: Intermittent daytime symptoms Symptom-free days Huang, Rothe, Grant-Kels. J Am Acad Dermatol. 34:

11 Vulvodynia Onset: Primary Secondary Temporal pattern: Intermittent Constant Location: Localized Generalized Mixed Occurrence: Provoked Spontaneous Mixed Bornstein et al. J Low Genit Tract Dis. 20:

12 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

13 Prototypical Patient: BMS Female Postmenopausal Tongue > palate > lips Dry mouth perception Altered taste sensation Sleep not disrupted Preceding psychiatric diagnosis

14 Prototypical Patient: Vulvodynia Female patient??? Onset: secondary Temporal: constant Location: localized Occurance: mixed

15 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

16 Etiology: Multifactorial

17 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

18 Diagnosis: Exclusion Burning Mouth Xerostomia Infectious Inflammatory Neoplastic Musculoskeletal Neurologic Psychosocial Trauma/Dental Smell and taste disturbance Vulvodynia Genitourinary syndrome of M Infectious Inflammatory Neoplastic Musculoskeletal Neurologic Psychosocial Trauma Genetics

19 Diagnosis: BMS Xerostomia Infectious yeast, herpes, varicella Inflammatory geog, LP, bullous, aphthae Neoplastic SCC Musculoskeletal - TMJ Neurologic cranial nerves Psychosocial anxiety, depression Trauma/Demtal restorations, chemical Smell and taste central lesion

20 Diagnosis: Vulvodynia Genitourinary Syndrome of Menopause Infectious yeast, herpes, varicella Inflammatory LS, LP, bullous, aphthae Neoplastic SCC, Paget Musculoskeletal pelvic floor Neurologic nerve compression Psychosocial - depression Trauma obstetric, mutilation Genetics

21 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

22 Treatment Burning Mouth Decrease input Topical treatments Systemic treatments Cognitive behavioral therapy Vulvodynia Decrease input Topical treatments Systemic treatments Physical Therapy Cognitive behavioral therapy

23 Treatment Decrease input Topical treatments Systemic treatments Other therapies

24 Treatment: Decrease Input Burning Mouth Mild oral care Bland diet Lidocaine 2% viscous q 3 hours Dry mouth Vulvodynia Mild vulvar care Mild lubricants Lidocaine 5% ointment q 3 hours Genitourinary syndrome of menopause

25 Treatment Decrease input Topical treatments Systemic treatments Other therapies

26 Treatment: Topical Burning Mouth Dilute capsaicin Clonazapam suck and spit 3 min TID Vulvodynia Gabapentin 5% Amitriptyline 1%-5% Baclofen 1%-5% Ketamine 0.5%-1%

27 Treatment Decrease input Topical treatments Systemic treatments Other therapies

28 Treatment: Systemic Burning Mouth Gabapentin Pregabalin Duloxetine Nortriptyline Vulvodynia Gabapentin Pregabalin Duloxetine Nortriptyline

29 Treatment Decrease input Topical treatments Systemic treatments Other therapies

30 Treatment: Other Therapies Burning Mouth Cognitive behavioral therapy Mindfulness activities Vulvodynia Physical therapy Sexual counseling Cognitive behavioral therapy Mindfulness activities

31 Cognitive Behavioral Therapy and Mindfulness Pain clinic referral Graded exercise Mindfulness activities Yoga Meditation Art Music Gardening

32 BMS + Vulvodynia: Outline Definition Categories Prototypical patient Etiology Diagnosis Treatment Big overview

33 Cognitive changes (brain fog) Headaches Arthralgia Myalgia Restless legs Temperature dysregulation Generalized weakness Photosensitivity Depression Food/med intolerances Dizziness Fibromyalgia Pelvic pain Central Sensitization Syndrome Sleep disorder Anxiety Fatigue Irritable bowel Postural orthostasis Interstitial cystitis TMJ dysfunction Global sensory hyperresponsiveness

34 v=8defn4iibho Video: Dr. Slettin, PhD Mayo Clinic Jacksonville, Florida

35 Thank You Dr. Alison Bruce Vice Chair of Dermatology Mayo Clinic, Jacksonville, Florida Dr. Mary Marnach Department of Obstetrics and Gynecology Mayo Clinic, Rochester, Minnesota

36 Thank You

37 BMS Evaluation: The E s Exclude Empathize need to feel heard questionnaire Educate Not cancer Give it a name - placebo effect Set Expectations (no cure) Turn the volume down Move it to the back of the brain

38 BMS: Studies CBC Ferritin ANA (SSA/SSB) Folate Vitamins B1, B2, B6, B12 Vitamin D zinc, magnesium TSH, HgbA1c Swab for fungal culture (50% commensal)

39 BMS: Referrals (as symptoms dictate) ENT GI Dental Psychiatry Neurology Rheumatology Endocrinology

40 Decrease input Treatment: BMS Mild oral care Bland diet Lidocaine 2% viscous q 3 hours Dry mouth Topical treatments Systemic treatments Cognitive behavioral therapy

41 BMS: Oral Care and Diet Mild toothpaste or baking soda Non-mint SLS-free No mouthwash Dietary avoidance Spicy Acidic Carbonated Chocolate

42 BMS: Dry Mouth Assess medication side effects Sip water Reduce caffeine and alcohol Sugarless gum and candy Saliva substitutes Xylitol products

43 Treatment: BMS Decrease input Topical treatments Lidocaine Dilute capsaicin (Tabasco) Clonazapam 1 mg suck and spit 3 min TID Systemic treatments Cognitive behavioral therapy

44 Treatment: BMS Decrease input Topical treatments Systemic treatments Gabapentin (Neurontin) Pregabalin (Lyrica) Duloxetine (Cymbalta) Nortriptyline (Pamelor) Cognitive behavioral therapy

45 BMS: Systemic Treatments Gabapentin (Neurontin) 900 mg TID Pregabalin (Lyrica) 150 mg divided BID Amitriptyline (Elavil) 100 mg QHS Nortriptyline (Pamelor) 100 mg QHS Duloxetine (Cymbalta) 60 mg daily start LOW go SLOW

46 Treatment: BMS Decrease input Topical treatments Systemic treatments Cognitive behavioral therapy Pain clinic referral Mindfulness activities

47 BMS: Your Toolbox The E s Exclude, empathize, educate, expectation setting Self help Oral care, diet changes, dry mouth therapies Topical therapies Systemic therapies Cognitive behavioral therapy