Case 1

Initial Presentation: A 65-year-old female presents with erosive lichen planus that was initially diagnosed 15 years prior and is associated with remitting and relapsing intraoral pain. She states she is currently having a “flare-up.” She reports a medical history significant for hypertension, insomnia, anxiety, and gastro-esophageal reflux disorder (GERD). She is partially edentulous and reports tooth loss due to decay and tooth fracture. She also reports a history of nocturnal bruxism. When PDMP data are queried, it demonstrates that she has had 44 prescriptions for controlled substances in the past year, including 20 opioids and 24 benzodiazepenes. The prescriptions were written by 5 different healthcare providers and filled at 3 pharmacies.

Action Plan: Further assess potential for misuse/abuse by identifying prescribers and area of practice and underlying control of her health conditions. Assess the patient for risk of self-harm and utilize motivational interviewing techniques to discuss her plans of action regarding her overall health and opioid use.

Conclusion: It was determined that all prescribers were in the same primary care practice and the pharmacies were close to this practice, her work, and her home. During discussion, patient stated that she was using alcohol and opioids to treat underlying anxiety and depression and that she desired improved intervention, including pharmacological and behavioral therapy. Treatment of intraoral lesions with topical steroid therapy and local anesthetic medication as well as an intake diary to identify triggers was initiated and occlusal analysis and fabrication of an occlusal guard to reduce the incidence and harm from nocturnal bruxism was treatment planned.