Gritty feeling in mouth

Dental procedures make many people feel uneasy. They worry not just about the procedure itself, but the potential for side effects. While most people recover without issue from their dental procedures, occasionally worrying sensations linger. Discover more about numb tongue and other problems some patients face after dental procedures.

Numb Tongue

Your tongue will usually feel numb after a dental procedure while the anaesthetic wears off. The typical unaesthetic causes numbness around the mouth for approximately four hours. The effects of strong unaesthetic used for more invasive procedures, including wisdom teeth extraction, last between eight and nine hours.

Losing sensation in your tongue after the anaesthetic wears off is incredibly rare. However, it can occur after some procedures. For example, your tongue might go numb after we extract a wisdom tooth, as these teeth sit very close to the nerve that runs to the tongue. The extraction process can traumatise the nerve, causing a lingering numb sensation.

Numbness may also persist if the anaesthetic needle touches or penetrates the nerve that connects the tongue to the mouth. The anaesthetic solution can also inflame the mouth’s nerves, causing lingering numbness in the tongue. Again, this kind of numbness after a dental procedure is very rare.

In the unlikely event your tongue loses sensation for an extended period after a dental procedure, it’ll probably return within two weeks of treatment after your nerves regenerate. By six months after treatment, full sensation is restored in between 95-99% of cases. Patients rarely experience permanent numbness in their tongue after a dental procedure.

Permanent tongue numbness only occurs when something severs the nerve. This is unlikely to happen, as the nerve to the tongue is very large. Modern CT scanners create three-dimensional pictures which help dentists see how close to wisdom tooth is to the nerve so they can plan the best course of attack and avoid nerve damage. If there is a very high risk of nerve damage, which may occur if the nerve wraps around the wisdom tooth, for example, we inform our patients of this. They can then make informed decisions about whether they want to leave their wisdom tooth or accept the risks and forge ahead with the extraction.

Call your dentist if your tongue feels numb the day after a dental procedure. We’ll typically arrange a follow-up appointment where we’ll perform a procedure called mapping. During this simple procedure, you’ll close your eyes and wait for us to touch different parts of your tongue. You’ll tell us what you can feel and what you can’t so we get a better idea of the numbness you’re experiencing.

Anti-inflammatory medications can reduce swelling in the mouth which can improve sensations for affected patients. However, medications can’t speed up the regeneration of the nerve endings. The problem usually resolves itself in due time without treatment.

Burning and Tingling Sensations

Occasionally, patients say they feel burning or tingling sensations in their mouth after dental procedures. These may be symptoms of nerve damage or irritation. They can also be symptoms of the mouth and its nerves healing itself after receiving dental treatment. Usually, your mouth will feel normal again within two weeks. As with numb tongue, anti-inflammatory medications may provide some relief.

Nausea

Some patients feel nauseous after dental procedures. Nausea is a common by-product of anxiety. If you’re nervous about your procedure, nausea can linger even after it’s done. You may also feel nauseous if you sit up too quickly after your procedure as the blood rushes from your head. No matter the cause, this nausea should pass quickly.

Pain and Sensitivity

Some pain and sensitivity are quite common after dental procedures, including fillings. These unpleasant sensations may be exacerbated with exposure to hot or cold foods and drinks or simply biting down. The deeper the work, the closer it is to the nerve and the more likely that nerve is to become inflamed. The chemicals used for dental procedures, such as fillings, can also cause inflammation.

The inflammation and the pain associated with it usually subsides within two weeks. However, if your bite feels different after two to three days, call your dentist for a follow-up appointment. We can make any adjustments necessary to improve your bite and reduce your pain.

How to Get Your Mouth Back to Normal Faster

Most patients who complain of numb tongue and other worrying sensations in their mouth simply don’t like the way their body feels under the influence of anaesthetic. Doing activities that get your heart pumping to increase circulation can help your body recover from the anaesthetic faster and start feeling normal sooner.

If you’re really concerned, we can also give you a reversing agent for the anaesthetic. This injection causes the blood vessels to dilate, counteracting the epinephrine in the anaesthetic.

It’s common for your mouth to feel different after a dental procedure as your anaesthetic wears off. Tongue numbness and other unusual sensations rarely persist beyond 24 hours, but it does happen. Usually, these side effects too will resolve themselves in time. However, if you’re concerned about any sensations in your mouth after a dental procedure, feel free to contact your 123Dentist practice for a follow-up appointment.

We’ve all had burnt mouth syndrome too

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Burning Mouth Syndrome: Symptoms, Causes and Treatment

Burning mouth syndrome is a chronic, painful condition characterized by burning sensations in the tongue, lips, palate (roof of the mouth), gums, inside of the cheeks and the back of the mouth or throat. The discomfort cannot be easily attributed to any physical abnormalities in the mouth or any underlying medical disorders.

A complicated and poorly understood condition, it appears to affect women seven times more often than men. Most sufferers are middle aged, but younger individuals also have been affected by the condition.

Burning mouth syndrome may also be called burning tongue syndrome, burning lips syndrome, glossodynia, stomatodynia and scalded mouth syndrome.

Symptoms

There are a number of symptoms associated with burning mouth syndrome, most notably the sensation of pain or burning. This sensation is typically mild in the mornings, becoming progressively more intense throughout the day, peaking in the evening and subsiding at night. Some sufferers feel continuous pain while others experience intermittent burning sensations. The pain can last for several months or years.

Other symptoms include dry lips, a sore or dry mouth, tingling or numbness on the tip of the tongue or in the mouth and bitter or metallic changes in taste.

Causes

The exact cause of the condition is still not clearly understood. A burning sensation or symptom in the mouth can result from, or be a symptom of, a number of oral and systemic conditions. These problems must be ruled out before a diagnosis can be made.

Some of the factors contributing to the condition include:

Nutritional deficiencies: Deficiencies of iron, folate and vitamin B complex have been associated with a burning sensation in the mouth. As a result, some treatment approaches have included supplements of B vitamins and minerals like zinc and iron.

Dry Mouth (xerostomia): Medications, Sjogren’s syndrome and any number of other causes can lead to dry mouth and its related burning sensation. Sipping liquids throughout the day, using artificial saliva and/or eliminating the cause of the dry mouth may reduce or eliminate the uncomfortable sensation.

Oral Candidiasis (Oral Thrush): A symptom of this oral fungal infection is a burning sensation in the mouth, particularly when consuming acidic or spicy foods, or when the cottage-cheese like lesions are scraped from the inside of the mouth. The plan that your dentist recommends to treat oral thrush can help end the sensations.

Diabetes: Diabetics are more susceptible to oral infections (including oral thrush) that produce burning mouth sensations. Additionally, diabetics are prone to vascular changes that affect the small blood vessels in the mouth, creating a lower threshold for pain. A better control of blood sugar levels in diabetic patients may prevent onset or help improve symptoms.

Menopause: Hormonal changes have been associated with a burning sensation in the mouth in middle-aged women. Burning mouth is among the most common oral manifestations of menopause. However, hormone replacement therapy has only been effective in relieving symptoms in certain patients.

Anxiety/Depression: Psychological problems do not directly cause burning mouth but could aggravate these symptoms or even result from the frustration patients experience dealing with their chronic pain. Anxiety or depression may have a role in initiation of destructive oral habits such as tooth grinding (bruxism) or tongue thrusting which can further irritate the lips and mouth. Stress may also lead to alteration of the flow or composition of the saliva, exacerbating the oral burning.

Other: Additional causes could be physical irritation from dentures, contact allergy to denture components (contact stomatitis) or oral hygiene products (Sodium Lauryl sulfate in toothpastes), gastroesophageal reflux disease, low levels of thyroid hormones, certain antihypertensive medications, changes in salivary composition, tongue thrusting and cancer therapy.

If you are experiencing burning sensations in your mouth, it is important that you visit your dentist as soon as possible to discuss your symptoms and undergo an examination. Your dentist will likely review your complete medical history and perform a thorough oral examination in order to help identify the local cause of these sensations in your mouth. If oral thrush (oral fungal infection), dry mouth, oral sores or other oral/dental issues are ruled out as the cause, you may be referred to a physician or an oral medicine practitioner for further evaluation and treatment.

Blood work and other diagnostic tests may be necessary to look for infection, nutritional deficiencies, diabetes or thyroid problems, Sjogren’s syndrome and allergy. Once identified, treatment is directed against the cause of burning mouth symptoms.

In the absence of local or systemic causes for oral burning sensations, the condition is diagnosed as burning mouth syndrome thought to be caused by neuropathy or dysfunction of the nerves involved in the perception of pain and taste sensations from the oral cavity.

Treatments

Treatments include different medications traditionally used to relieve the underlying causes of other conditions, such as depression and chronic pain. Tricyclic antidepressants (amitriptyline/Elavil), antipsychotics (chlordiazepoxide/Librium), anticonvulsants (gabapentin/Neurontin), analgesics, benzodiazepines (clonazepam/Klonopin) and mucosal protectors have provided effective relief for some patients.

In addition, topical capsaicin (the natural chemical in cayenne pepper) has been used to desensitize patients suffering from burning mouth syndrome.

However, despite the success of these approaches in certain situations, there is no universal treatment that is effective in all cases. Treatment is planned to meet the specific needs of each patient. The cost of treatment varies depending upon the medications prescribed (if any), how long they will be needed and whether or not medical and/or dental insurance will cover all or some of the costs.

Additional relief may be achieved by making some simple changes:

  • Stop using mouthwash that contains alcohol.
  • Stop using toothpaste that contains sodium lauryl sulfate.
  • Chew sugarless gum, preferably sweetened with xylitol.
  • Avoid alcoholic beverages.
  • Use baking soda and water when brushing your teeth.
  • Refrain from drinking beverages with high acidity (fruit juices, coffee, soft drinks).
  • Abstain from tobacco use.
  • Sip water or suck on ice chips.

Dry Mouth

What is dry mouth?

Dry mouth or ‘xerostomia’ is a condition which affects the flow of saliva and is something that some patients with RA experience. Your mouth needs saliva to be able to work properly. Saliva is important as it:

  • Keeps your mouth comfortably moist.
  • Helps you to speak.
  • Helps you to swallow.
  • Helps to break down your food.
  • Acts as a cleanser – it is constantly washing around your mouth and teeth, fighting decay, gum disease and infections by helping to keep your mouth clean.
  • Helps keep in (complete) dentures.

Dry mouth symptoms

  • You may notice a change in taste and dry foods feeling gritty within the mouth.
  • You may notice an increase in cuts/grazes/burns/ulcers.
  • Lack of moisture will lead to plaque and food debris being more stagnant as the protective washing effect of saliva is diminished.
  • Some people feel that their saliva has become thick and sticky, making it difficult to speak or swallow. Some people also have a ‘prickly’ or burning sensation in their mouth.
  • Certain foods may cause greater sensitivity, e.g. spicy foods, dry crumbly foods and acidic foods/drinks.
  • The mouth can become sore and there is a higher risk of tooth decay, gum disease and infections. In some cases, the mouth can also become red and shiny.

If you are suffering from any of these symptoms it doesn’t necessarily mean that you have dry mouth, but it may be best to talk to your dentist or doctor about it.

Causes of dry mouth

Dry mouth may be caused by Sjögren’s syndrome or be a side-effect of medication (see ‘RA medication and the mouth’).

Sjögren’s syndrome is a chronic autoimmune disease in which a person’s immune system attacks glands that secrete fluid e.g. tear and salivary glands. This results in less fluid being produced by the glands. Patients with Sjögren’s syndrome therefore commonly have dry eyes and a dry mouth.

Sjögren’s syndrome is usually classified by a clinician as either primary or secondary. Primary Sjögren’s syndrome develops by itself (i.e. not as a result of another condition) and secondary Sjögren’s syndrome develops in combination with another autoimmune disease such as RA.

However, this classification does not always correlate with the severity of symptoms or complications. Primary Sjögren’s and Secondary Sjögren’s patients can all experience the same level of discomfort, complications and severity of their disease.

If you become aware of any symptoms of dry mouth and/or eyes, please discuss it with your dentist (mouth only), GP or rheumatologist. If it is as a result of your RA medication, your rheumatologist may be able to adjust your medication, though this may not be always be possible.

Please be aware that it is normal to have a dry mouth first thing in the morning and that dry mouth can also be part of the natural aging process.

What can I do about my dry mouth?

Your dentist, dental therapist or hygienist won’t be able to help with the cause of your dry mouth but will be able to help keep your mouth clean and help prevent tooth decay and gum concerns. They will also be able to give dietary advice such as cutting down on sugar and acid intake to reduce the risk of tooth decay and erosion. Sugar substitutes such as xylitol can be used, for example.

Try the following tips:

  • Keeping hydrated – sip (not gulp!) water or sugar-free drinks frequently during the day.
  • Avoid drinks which dry the mouth, such as caffeine-containing drinks (tea, coffee, some soft drinks) and alcohol.
  • Avoid tobacco as this has a drying effect.
  • Use a humidifier (or a wide bowl of water) in your bedroom at night to keep the air full of moisture.
  • Chew sugar-free gum or sugar-free sweets to stimulate saliva flow (though this may not be possible if you also suffer with jaw joint pain).
  • Try using a toothpaste without the foaming ingredient sodium lauryl sulphate as it can cause irritation to an already dry mouth. However, do make sure the toothpaste still contains fluoride to help keep teeth strong.

Your dentist or GP may be able to prescribe certain saliva replacement products such as artificial saliva, which can provide useful relief from dry mouth; the gel will have a neutral pH (the scale used to measure levels of acidity) and contain electrolytes (including fluoride). Normal NHS prescription charges apply.

Some large pharmacies also carry a range of over-the-counter dry mouth products including artificial saliva, gels, chewing gum and toothpastes. The two main brands are BioXtra and Biotène.

How can I keep my dentures in if I have a dry mouth?

Saliva is required as a lubricant to maintain the hold of dentures in the mouth. It helps create suction between the base of your denture and the ridge of gum tissue on which your denture sits. Therefore, with a dry mouth maintaining the position of dentures can become difficult. The use of artificial saliva will help to increase hold as well as using denture fixatives.

It is important to see your dentist to check the fitting surface of the denture, as an ill-fitting denture will not help with natural hold in the mouth. It may be possible to reline your current denture or it may be a better solution to make a new set with an improved design where possible.

How to Manage Burning Mouth Syndrome

Everyone has sipped a too-hot cup of coffee or dug into a bowl of soup too soon and scalded the mouth and tongue. Unpleasant, yes, but fortunately temporary. However, if you feel that sensation all day every day, you might be living with a condition called burning mouth syndrome.

Affecting close to 5 percent of Americans, burning mouth syndrome, or BMS, most often strikes the top of the tongue, lower lip, and roof of the mouth. Besides the burn, you may also experience a dry, gritty feeling in your mouth and changes in your taste buds.

Burning Mouth Syndrome: Looking for the Source

“The cause of burning mouth syndrome is currently unknown, but research has shown that this is a neuropathic condition,” says Eugene Antenucci, DDS, a spokesman for the Academy of General Dentistry. “It seems that the patient’s nerves are not sending or processing information correctly – there’s a short circuit in the nervous system and the brain can’t turn off the pain receptors.”

Besides general damage to the nerves, other possible culprits behind this ailment include:

  • Nutritional deficiencies, specifically a lack of iron, zinc, and vitamin B12
  • A dry mouth, which can be the result of another medical condition, such as diabetes or Sjögren’s syndrome, or a side effect of various medications
  • Hormonal changes (women in menopause and postmenopause are much more likely to get it)
  • An oral fungal infection called oral candidiasis
  • Acid reflux
  • Sensitivity or an allergy to dentures or ingredients in certain toothpastes and mouthwashes

There may also be a link between anxiety and depression and burning mouth syndrome, though more research is needed to determine whether these conditions can cause the mouth burn or whether the physical symptoms themselves lead to difficulty sleeping, depression, and anxiety.

Burning Mouth Syndrome: Treatment Options

First steps toward finding a reason for your mouth burn include a physical exam and a review of your medical history by your primary care physician. Tests may include blood work to check for nutritional issues such as vitamin deficiencies, infections, and conditions like diabetes or thyroid issues; a mouth swab to rule out oral candidiasis; and allergy testing.

“The treatments mainly depend on the cause,” says Kenneth Magid, DDS, a clinical associate professor of international esthetic and high technology at the New York University College of Dentistry and a dentist at Advanced Dentistry of Westchester in Harrison, N.Y. “If the cause is dry mouth, either locally acting medications for the dry mouth or systemic medications can serve as treatments. If the cause is vitamin deficiency, treatment can include vitamin supplements. If the burning mouth started when changing toothpaste or mouthwash, discontinue them.”

Addressing any underlying disorder your doctor finds, like diabetes or a thyroid problem, or switching medications if the burn is a side effect should help. For some people, medications to treat anxiety, depression, or oral candidiasis or simply to help relieve pain from nerve damage can also be beneficial.

Finally, there are easy self-care steps you can try. Drinking water regularly and chewing sugarless gum may alleviate symptoms. Avoid tobacco (always a good idea) and alcohol as well as spicy, hot, or acidic foods.

“Burning mouth syndrome is not a matter of life or death, but it is a matter of quality of life,” says Dr. Antenucci. If you think you might have BMS symptoms, he suggests talking with your general dentist and seeing a health practitioner who has experience with the condition.

Burning Mouth Syndrome: Putting Out the Fire

When you have burning mouth syndrome, it is as if someone has ignited a fire in your mouth. Many years ago, I struggled with this condition myself, so I know how frustrating and uncomfortable it can be. Even though I was a dental hygienist, I was baffled about what was causing my problem. I felt like a fire-eater in the circus. I couldn’t think of anything I had done to cause such an annoying ailment. As I longed for a normal mouth and tongue, looking for relief soon became my obsession. I am going to share with you now what I wish I had known then.

What Are the Signs and Symptoms?

Just as the name suggests, when you have this condition, a burning sensation affects all or parts of your mouth, including your tongue, gums, the inside of your cheeks, the roof of your mouth and even the back of your throat. According to the National Institute of Dental and Craniofacial Research, symptoms include a tingling or numbness on the tip of your tongue, a dry and sore mouth and a bitter or metallic taste in your mouth.

For me, the burning was mostly on my tongue, but it also traveled around different areas of my mouth. Carbonated sodas made my tongue feel prickly, and spicy foods sent me through the roof — especially the chili that I ordered in Santa Fe. What was I thinking? Even toothpaste and mouthwash irritated my mouth.

What Are the Causes?

There is no simple answer. There are numerous possible causes, according to the American Dental Association. Both men and women are affected, but the syndrome is more common in women during or after menopause. Other conditions associated with burning mouth syndrome are diabetes, nutritional deficiencies, oral fungal infections, tongue thrusting, cancer treatment and acid reflux. Damage to the nerves that serve the tongue and mouth, ill-fitting dentures, allergies to denture materials and an abnormal thyroid condition are other possible causes.

I attributed my fiery mouth to menopause. After about a year, routine blood work showed that I had a thyroid deficiency. After I took thyroid medicine for a time, the burning disappeared as mysteriously as it had arrived. My situation was probably due to the thyroid, but it also could have been caused by menopause.

What Is the Treatment?

The first step of treatment is to diagnose the cause of the symptoms. Start by consulting your dentist. He can determine whether your problem is oral, such as a fungal infection, irritation due to sharp or broken teeth or an improperly fitting denture or partial.

If your dentist cannot find any obvious reason for your symptoms, he may suggest that you try some simple steps to get relief. Changing to an alcohol-free mouthwash, such as Colgate Total® Advanced Pro-Shield™ Mouthwash, or switching brands of toothpaste may help. You may also try eliminating gum, tobacco, soft drinks and coffee for 2 weeks. When you take medications, you should check the side effects in case any of them is known to cause a burning sensation in your mouth.

If nothing is helping your burning mouth syndrome, the next step is to visit your doctor. He may order blood tests to look for other disorders or nutritional deficiencies that could be the underlying cause.

Living every day feeling as though your mouth is on fire can cause anxiety. Some individuals become depressed. This is why I urge you not to wait to find answers or get relief. See your dentist or doctor right away.

Burning Mouth Syndrome

Treatment

Treatment triggers improvement in symptoms for most people with burning mouth syndrome. But the type of treatment depends on the underlying cause.

  • Dry mouth (xerostomia). Treating the cause of your dry mouth — Sjogren’s syndrome, use of medications or some other cause — may relieve burning mouth symptoms. In addition, drinking more fluids or taking a medication that promotes flow of saliva may help.
  • Other oral conditions. If the cause is oral thrush, treatment is with oral antifungal medications such as nystatin (Mycostatin) or fluconazole (Diflucan). If you wear dentures, your dentures may also need to be treated.
  • Psychological factors. For a burning mouth that may be caused by or associated with psychological factors such as anxiety and depression, your doctor may recommend antidepressant therapy or psychiatric therapy or both together. Selective serotonin reuptake inhibitors (Prozac, Zoloft, others) may cause less dry mouth than other antidepressant medications.
  • Nutritional deficiencies. You may be able to correct nutritional deficiencies by taking supplements of B vitamins and minerals such as zinc and iron.
  • Irritating dentures. Your dentist may be able to adjust your dentures so they are less irritating to your mouth. If your dentures contain substances that irritate your oral tissues, you may need different dentures. You may also improve symptoms by practicing good denture care, such as removing dentures at night and cleaning them properly.
  • Nerve disturbance or damage (neuropathy). Your doctor may suggest medications that affect your nervous system and control pain, including benzodiazepines such as clonazepam (Klonopin), tricyclic antidepressants such as amitriptyline or nortriptyline (Pamelor, Aventyl), or anticonvulsants such as gabapentin (Neurontin). For pain relief, your doctor may also suggest rinsing your mouth with water and capsaicin — the active ingredient in hot peppers, which also is called capsicum.
  • Allergies. Avoiding foods that contain allergens that may irritate the tissues of your mouth may help.
  • Certain medications. If a medication you’re taking is causing a burning mouth, using a substitute medication, if possible, may help.
  • Oral habits. Tongue thrusting and teeth grinding (bruxism) can be helped with mouth guards, medications and relaxation techniques.
  • Endocrine disorders. If a burning mouth is associated with conditions such as diabetes or hypothyroidism, treating those conditions may improve your symptoms.

If doctors can’t identify the cause of your symptoms, they may still recommend trying oral thrush medications, B vitamins or antidepressants. These medications have proved effective in treating burning mouth syndrome.

Coping skills

Burning mouth syndrome can be painful and frustrating. The good news is that it’s a treatable condition. Although it may take time, with the help of a team of health professionals, you can usually find a treatment plan that’s right for you.

In the short term, you may gain some relief by avoiding irritating substances, such as alcohol-based mouthwashes, cinnamon or mint products, and cigarette smoke. Chewing on ice chips or sugar-free gum also may help. So can keeping your dentures out all night and brushing your teeth with baking soda instead of toothpaste. Ask your doctor for other tips to manage your pain and discomfort.

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Q: What is the prognosis of BMS?
A: One-half to two-thirds of patients will experience at least a partial improvement in symptoms within a few weeks to a few months of treatment. For those with long-term symptoms (that may last 6-7 years or longer), the intensity of burning tends to remain fairly stable at a manageable level, although some patients will return to normal without any residual burning. Patients who experience improvement with treatment can expect good control for years. There is no association of BMS with development of oral cancer.

Q: How is BMS treated?
A: There is no cure for BMS. Some, if not most, of the discomfort can be alleviated using a variety of medications, many of which are used to treat anxiety, depression, and other neurologic disorders although at lower doses. The medications help to reduce the activity of nerve fibers. Since many patients also have difficulty sleeping and experience anxiety, these medications may help you to sleep and rest better, and feel less anxious. These drugs are sometimes used as individual agents or in combination to achieve the desired benefit.

These medications include clonazepam either as a mouth rinse or in dissolvable wafer or pill form. Others include amitriptyline, nortriptyline doxepin and gabapentin. These medications can cause drowsiness and dry mouth but they are usually taken at night and this may help you to sleep. However, be careful because you may run the risk of falling, especially if you are already taking other medications with a similar side effect. Please do not drink alcohol or drive after taking these medications. Over-the-counter medications such as alpha lipoic acid may be useful as well as topical capsaicin.

Because BMS is a chronic problem, non-pharmacologic approaches to management used alone or in addition to the above medications may be helpful. These include stress management/reduction, meditation, yoga, exercise, psychotherapy and cognitive behavioral therapy.. If stress, anxiety and/or depression are contributing to BMS, regular use of these techniques or regular counseling may help to reduce symptoms and keep drug dosages low. With any therapy for BMS, it may take several weeks or even months before maximum benefits are achieved.

Prepared by N. Treister, SB Woo and the AAOM Web Writing Group
Updated 22 January 2015

Spanish Translation – Traducción Español

The information contained in this monograph is for educational purposes only. This information is not a substitute for professional medical advice, diagnosis, or treatment. If you have or suspect you may have a health concern, consult your professional health care provider. Reliance on any information provided in this monograph is solely at your own risk.

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