Homework for all OMS wannabes

[DrRob]

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Ok, why did my Oral surgeon perscribe me apo amitriptyline (10 - 50mg) after my lefort 1/palatal expansion surgery? (No I am not suffering from depression)

 

[Smilemaker100]

Ok, why did my Oral surgeon perscribe me apo amitriptyline (10 - 50mg) after my lefort 1/palatal expansion surgery? (No I am not suffering from depression)

Dear Dr Rob, (no , I am not an OMS person but I thought I would answer anyhow)

I can understand how you are perplexed in regards to that prescription. 😕 The plain and simple answer = pain management!

When I first heard of that form of treatment approach for pain management as a dental student, I didn't understand it entirely (and still don't). As a dental student, I had a few courses on atypical/myofascial/TMD pain and have read about those subjects as well. If my memory serves me correct, amitriptyline , which is a tricyclic antidepressant, given at the minimal doses (such as those prescribed to you by your OMS) is quite efficient in controlling pain ( especially chronic pain, burning mouth syndrome) as well as sleep disturbances. At higher doses, this antidepressant is more efficient at managing depression in psychiatric patients.

I never actually faced a situation in which I had to prescribe this TCA. How many dentists out there have prescribed this TCA for pain management?

 

[toothcaries]

...had a few courses on atypical/myofascial/TMD pain and have read about those subjects as well. If my memory serves me correct, amitriptyline , which is a tricyclic antidepressant, given at the minimal doses (such as those prescribed to you by your OMS) is quite efficient in controlling pain ( especially chronic pain, burning mouth syndrome) as well as sleep disturbances. At higher doses, this antidepressant is more efficient at managing depression in psychiatric patients....

we just had a tmd course last quarter.....and the brother smilemaker100 is correct..
(btw, the OS should have told u the purpose of the Rx... tisk tisk)

 

[omaralt]

guys, i think he knows why he prescribed it to him, he was just testing u guys 🙂

omar

 

[DrRob]

That may be a reason - but its not the reason why I am given it. I'll post the answer tommorrow, but heres a hint (I am to take it at bedtime).

Just a side note: I actually really had no pain with the surgery - The swelling and residual numbness (I think the to coincide) as well as not being able to chew for 4 weeks is the real PITA.

 

[toothcaries]

That may be a reason - but its not the reason why I am given it. I'll post the answer tommorrow, but heres a hint (I am to take it at bedtime).

Just a side note: I actually really had no pain with the surgery - The swelling and residual numbness (I think the to coincide) as well as not being able to chew for 4 weeks is the real PITA.

Smilemaker100's post should still be correct.
(but i am not familiar with your surgery....)

low dose tricyclics (esp amitriptyline) are great for myofascial pain associated with night bruxism.

why?
..cause they dec time in transitional sleep. (or something)

 

[badaboom]

hmmm
polyneuopathy? ur nerves got cut?

 

[Doggie]

From what our class has learned in the TMD classes, I have to agree with the previous posts about why the oral surgeon prescribed amitryptline. However, I did a quick search on micromedex, and it gave me a big list of all the possible indications......

AGITATION
AMYOTROPHIC LATERAL SCLEROSIS
ANOREXIA NERVOSA
BACKACHE
BULIMIA
BURNING MOUTH SYNDROME
CIGUATERA FISH POISONING
DEPRESSION
DYSPEPSIA
EMOTIONALISM
FIBROMYALGIA
HEADACHE
HICCUPS
HYPERHIDROSIS
IDIOPATHIC FECAL INCONTINENCE
INTERSTITIAL CYSTITIS
IRRITABLE BOWEL SYNDROME
NEUROPATHY - HIV-RELATED
NIGHT TERRORS
OPIATE-WITHDRAWAL INSOMNIA
PAIN
PANIC ATTACKS
PHANTOM LIMB PAIN
POLYNEUROPATHY
POST-HERPETIC NEURALGIA
POSTTRAUMATIC STRESS DISORDER
PREMENSTRUAL SYNDROME
RHEUMATIC PAIN CONDITIONS
SUPRANUCLEAR PALSY
TEMPOROMANDIBULAR DISORDERS
TRICHOTILLOMANIA
VULVODYNIA

I'm guessing your are taking it only in the evening cuz of the possible night terrors that you experience.....or possibly vulvodynia??????

 

[Smilemaker100]

That may be a reason - but its not the reason why I am given it. I'll post the answer tommorrow, but heres a hint (I am to take it at bedtime).

Just a side note: I actually really had no pain with the surgery - The swelling and residual numbness (I think the to coincide) as well as not being able to chew for 4 weeks is the real PITA.

Hey Dr Rob!

This is a great question. 👍 I am still sticking to my original earlier reply (in which I did mention amitr. helping the sleep disturbances ) . However, you got me thinking and I am going to take a wild educated guess.
I am assuming that part of the reason that you had the LeFort I surgery / palatal expansion was because of possible airway problems to start off with
(mouth breathing, obstructive sleep apnea). I think that the amitriptyline may help with the sleep in the post-surgical period-especially the REM phase ( the dream phase- which is an important phase of the sleep cycle). Just a wild crazy guess! 😛

Sort of aside, I think nearly all antidepressants affect the sleep cycle because depression usually has sleep disturbances as one of its main manifestations.

Interesting stuff...

 

[DrRob]

Toothcaries is correct - its to prevent parafunction and grinding by reducing the amount of REM sleep (something like that). But the main point is to prevent clenching and grinding during sleep ; thus, prevent any delay in healing. 🙂

 

[Smilemaker100]

Toothcaries is correct - its to prevent parafunction and grinding by reducing the amount of REM sleep (something like that). But the main point is to prevent clenching and grinding during sleep ; thus, prevent any delay in healing. 🙂

Hey Dr Rob!

This was an excellent question...it really got my brain grey matter working! Keep more of them coming! 😀

I actually have a pretty good book called "The Management of Temporomandibular Disorders and Occlusion" by Okeson, which unfortunately, I never managed to read in its entirety. 🙁 In any case, I feel like an idiot for saying that the amitryptiline increases REM sleep as oppose to decreasing it. I needed to revise the sleep cycle. HOWEVER...according to what I read, it isn't certain if bruxism actually occurs during REM sleep ( read below)

Here is what I found in the previously mentioned reference book:

pages 173-174

Controversy surrounds the stages of sleep during which bruxism occurs.Some studies ( refer to text for quoted articles) suggest that it takes place mainly during the REM stage, whereas others suggest that bruxism never occurs during REM sleep. Still other studies report that bruxing events occur during both REM and non-REM sleep. ...bruxing may be closely associated with the arousal phases of sleep ( non-REM).

page 388
"At this time TCAs are rarely used for depression ( that I did not know). However, they have found new value in the management of a variety of chronic pain conditions. ...The TCAs are beneficial in doses as low as 10mg in the treatment of muscle contraction headache and musculoskeletal pain. They decrease the number of awakenings, increases stage IV/delta sleep, and markedly decrease time in REM sleep. For these reasons , they may have the potential in the treatment of certain types of nocturnal bruxism and for improving the quality of sleep. Amitriptyline can be helpful in the management of certain sleep disorders associated with musculoskeletal pains."

Two conflicting views! One that states that bruxism may be more associated with non-REM and then another that implies that amitriptyline decreases REM and hence bruxism? 😕

So to make my point...this whole deal with bruxism and REM is not 100%...there doesn't seem to be an agreement amongst the researchers!

 

[DrRob]

smilemaker you may be right. I don't think that the TCA's are helping me with night clenching and I do feel less rested when I wake up - so who knows! 😴