A 70 year old woman complains of dry mouth the most frequent cause of this problem is

FOLLOW-UP OF PATIENTS

Long-term follow-up in primary care, or as shared care is usually appropriate.

PATIENT INFORMATION SHEET

Burning mouth syndrome

▼ Please read this information sheet. If you have any questions, particularly about the treatment or potential side-effects, please ask your doctor.

This is a common condition.

The cause is not usually known, but it may be a nerve hypersensitivity.

It is not inherited.

It is not infectious.

It may occasionally be caused by some mouth conditions, dry mouth, deficiencies, diabetes or drugs.

It has no long-term consequences.

Blood tests or biopsy may be required.

Burning mouth syndrome may be controlled by some nerve-calming drugs.

The Clinical Syndrome

Burning mouth syndrome is an infrequent but serious cause of oral pain. Although mouth pain has many causes with readily demonstrable pathological conditions, such as herpes simplex infections and aphthous ulcers, burning mouth syndrome is the diagnosis given to patients who complain of mouth and tongue pain in the presence of a completely normal physical examination. Therefore burning mouth syndrome is by definition a diagnosis of exclusion. Included in the diagnosis of burning mouth syndrome are the clinical syndromes of burning tongue syndrome, glossalgia, glossodynia, stomatodynia, and oral dysesthesia syndrome. Affecting females 7 to 8 times more frequently than men, burning mouth syndrome is a disease of the fifth decade and beyond. The pain of burning mouth syndrome is characterized as a burning, hot, or scalded sensation of the mouth and tongue that may be accompanied by tingling. Most commonly the anterior two thirds of the tongue, palate, gingiva of the upper and lower alveolar region, and lips are involved, with the sublingual region less commonly affected. The exact pathophysiology responsible for burning mouth syndrome remains elusive, and the putative causes in most cases are multifactorial. Underlying nutritional disorders, psychiatric illness, allergic stomatitis, xerostomia, diabetes mellitus, menopause, and other endocrinopathies are often identified in patients with burning mouth syndrome, even though the oral examination is completely negative.

5.61.1.2.3.(i) Burning mouth syndrome

Burning mouth syndrome (BMS) is a putative centrally mediated pain that is poorly understood and treated. BMS is diagnosed only when the burning sensation is not associated with a local or systemic pathology. In contrast, burning mouth symptoms (BMST) is diagnosed in the presence of a known etiology for the altered sensation. BMS is an intraoral disorder most prevalent in postmenopausal women (Grushka, M., 1987; Grushka, M. et al., 2002), characterized by a burning mucosal pain without major visible physical signs. Altered taste sensations have long been associated with BMS and nearly 70% of the patients complain of accompanying dysguesia (altered taste sensation) (Ship, J. A. et al., 1995). Conventional QST in BMS patients identified defects in pain tolerance, altered chemosensory function, increased pain threshold to laser stimulation, and hypoesthesia of large and small nerves (Grushka, M. and Sessle, B., 1988; Grushka, M. and Sessle, B. J., 1991; Mott, A. E. et al., 1993; Formaker, B. K. and Frank, M. E., 2000). Accumulating evidence suggests that BMS involves central and peripheral nervous system pathologies induced by the damage to the taste system at the level of the chorda tympani nerve. This damage results in reduced trigeminal inhibition that in turn leads to an intensified response to oral irritants and eventually to oral phantom pain (i.e., BMS) (Grushka, M. et al., 2003).

Recent studies of BMS show how electrical tests can enhance a QST examination. Electrical stimulation of the tongue can provoke two different sensations; one is described as itch (tingling) and the other as an electrical taste (Bujas, Z. et al., 1979; Lindemann, B., 1996). The electrical taste threshold in the tongue is easily recognized as a sensation usually described as a battery-like or sour taste. The taste sensation is assumed to be conducted via the chorda tympani nerve and the itch sensation via the lingual nerve. Thus electrical detection thresholds of the anterior two thirds of the tongue likely evaluate the role of chorda tympani and lingual nerve function in BMS.

Eliav E. et al. (2007) found no difference between electrical taste and electrical detection thresholds among 23 BMS patients, 14 BMS patients, or 10 asymptomatic controls at extraoral nerve mental and infraorbital control sites. In the control and BMST patients, the ratio between the electrical taste and the itch sensation on the tongue was <0.7, while this ratio was significantly higher (1.4) in the BMS patients. This result is consistent with the hypothesis that BMS is an oral phantom-type pain induced by damage to the taste system (Grushka, M. et al., 2003), and suggests that the electrical taste and itch ratio may be a useful diagnostic test for BMS.

Burning Mouth Syndrome

Burning mouth syndrome (BMS) is an idiopathic and multifactorial syndrome characterized by burning and painful sensations in the hard and soft tissues in the oral cavity, in the absence of physical abnormalities. The most prevalent site for BMS is the anterior two thirds of the tongue.91 Diagnosis is often made on the basis of patient complaints of burning, dysgeusia (often bitter, metallic, or both), xerostomia, intensification of symptoms as the day progresses, nonexistence of symptoms at night, and decrease in symptoms while eating. Allergic reactions to dental materials have resulted in symptoms of BMS. The onset of pain is typically spontaneous and may persist for years.

The etiologies of BMS are complex and not fully understood. The prevalence is significant in postmenopausal women.91 Xerostomia (and diseases and conditions that cause xerostomia), diabetes, candidiasis, geographic tongue, dental treatment, allergic reactions, depression and anxiety, and malnutrition are also associated with BMS. This condition is sometimes a symptom of physical or psychological stress, and requires referral to the physician.

Treatment depends on the symptoms presented. For example, a patient experiencing xerostomia will be provided with methods to stimulate saliva flow to minimize oral changes. Low doses of benzodiazepines and tricyclic antidepressants are considered to reduce the symptoms of BMS.92 Additionally, topical capsaicin has been used as a desensitizing agent. Hormone replacement therapy has been recommended for postmenopausal women experiencing BMS and an antifungal agent has been prescribed for candidiasis. Lifestyle changes such as smoking cessation and avoidance of alcohol can be helpful.

Nutrient deficiencies have been identified as a factor for BMS. Insufficient dietary intake of iron, zinc, and B complex vitamins is a possible culprit. A dietitian's consultation can identify nutritional deficiencies and provide counseling focused on appropriate food and beverage choices. Appropriate dietary supplementation to alleviate the symptoms of BMS can be explored.

Burning Mouth Syndrome

Burning mouth syndrome (BMS) is also known as stomatodynia, glossodynia, oral dysesthesia, or stomatopyrosis. Diagnostic criteria for BMS are presented in Box 101-5. It is an enigmatic pain condition whereby the pathophysiology is largely unknown. Data from several experimental models support the hypothesis that BMS is most probably neuropathic in origin.71 The role of the peripheral and/or central nervous system(s) is supported by studies involving quantitative sensory testing and functional imaging methods.71 BMS most commonly presents in postmenopausal females with reported prevalence rates in the general population varying from 0.7% to 15% and is rather rare in individuals younger than 30 years old.72-74 For clinical purposes, BMS may be categorized into “primary BMS” or essential/idiopathic BMS for which a neuropathological cause is likely and “secondary BMS” resulting from local or systemic pathological conditions.75 Primary BMS is a diagnosis of exclusion because it is not attributable to any underlying systemic or local factors.76 Furthermore, typical characteristics manifested by the condition are a mild to severe burning sensation in the mucosa, dysgeusia, and xerostomia accompanied by a lack of clinical findings and normal results from laboratory testing and/or imaging studies. The subjective burning is routinely observed bilaterally, most frequently involving the anterior two-thirds of the tongue, the dorsum and lateral borders of the tongue, the anterior hard palate, and the mucosa of the lower lip, and often presenting in multiple oral sites.77 Typically, BMS has a spontaneous onset lasting months to several years.76 Spontaneous remission has been reported in only 3% of patients after 5 years of onset.78 Burning symptoms are common upon awakening with intensification as the day progresses and climaxing in the evening. Aggravating factors responsible for burning intensification are personal stressors and fatigue and eating acidic/hot/spicy foods. Paradoxically, in about 50% of patients, oral intake/stimulation and distraction reduce or alleviate the symptoms.79 An association with anxiety, depression, and personality disorders has been reported especially in postmenopausal women, but it is unknown if pain initiated the psychological disorder or vice versa.74,80

Management includes three strategies, which may be employed as monotherapy or in combination: (1) behavioral strategies involving cognitive behavioral approaches and/or group psychotherapy; (2) topical therapies utilizing anxiolytics (clonazepam), anesthetics (lidocaine), antidepressants (doxepin), atypical analgesics (capsaicin), nonsteroidal antiinflammatories (benzydamine—not FDA approved for use in the US), antimicrobials (lysozyme-lactoperoxidase), mucosal protectants (sucralfate, aloe vera, lycopene virgin oil), artificial sweeteners (sucralose), and low level laser therapy; and (3) systemic approaches employing various medications, such as antidepressants (amitriptyline, imipramine, nortriptyline, desipramine, trazodone, paroxetine, sertraline, duloxetine, milnacipran), anxiolytics (clonazepam, diazepam, chlordiazepoxide), anticonvulsants (gabapentin, pregabalin, topiramate), antioxidants (alpha lipoic acid), atypical analgesics/antipsychotics (capsaicin, olanzapine: amisulpride, levosulpride—both medications are not FDA approved), histamine receptor antagonists (lafutidine—not FDA approved), monoamine oxidase inhibitors (moclobemide—not FDA approved), salivary stimulants (pilocarpine), dopamine agonists (pramipexole), herbal supplements (Hypericum perforatum or St. John's wort), vitamin supplementation (B and C), and acupuncture. A recent randomized controlled trial indicated that systemic use of clonazepam should be considered as a first-line treatment.81

What Not To Do:

Discussion

Burning mouth syndrome is the occurrence of oral pain in a patient with a normal oral mucosal examination.

Psychiatric disease is a common underlying factor in patients with BMS. At least one third of patients may have an underlying psychiatric diagnosis, most commonly depression or anxiety disorders. A phobic concern regarding cancer is also prominent in 20% of patients. Remember that depression and psychologic disturbance are common in chronic pain populations and may be secondary to the chronic pain, rather than the cause of BMS. In addition, many of the medications that are used to treat psychiatric disease can cause xerostomia and exacerbate BMS.

Dry mouth is a frequent complaint among BMS patients. Drug-related xerostomia is common and can occur with many medications, including tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, antihypertensives, and antihistamines. Connective tissue diseases, such as Sjögren syndrome, or sicca syndrome, can cause xerostomia, as can a history of local irradiation or diabetes mellitus. Even stress and anxiety can lead to a dry mouth.

Because of rapid cell turnover and trauma, the oral cavity is especially sensitive to nutritional deficiencies and may be the first indicator of such a problem. Iron-deficiency anemia, pernicious anemia (an autoimmune B12 deficiency), zinc deficiency, and B-complex vitamin deficiency have all been reported to cause BMS.

Flavoring or food additives have been implicated as possible allergens in BMS. Cinnamon aldehyde (cinnamon), sorbic acid, tartrazine, benzoic acid, propylene glycol, menthol, and peppermint have all been identified as potential causes of mouth pain.

Denture-related pain is usually caused by faulty design, irritation, or parafunctional behavior. Candidiasis can also contribute to denture-related pain. Most BMS patients with dentures or significant dental work benefit from referral for a formal dental consultation to assess dental work, dentures, occlusion, and the need for modification or replacement.

Candidiasis is reported as a causative factor in 6% to 30% of patients with BMS. The mucosal alterations typically seen with candidiasis (thrush) may be minimal or absent. Candidal overgrowth occurs with xerostomia, corticosteroid treatment, antibiotic treatment, denture use, and diabetes mellitus. Empiric treatment for oral candidiasis is often prescribed to patients with BMS.

Approximately 5% of BMS patients have diabetes mellitus. BMS is the second most common oral complaint after xerostomia in a study of diabetic patients. Improved control of their diabetes mellitus may lead to improvement or cure of BMS.

The angiotensin-converting enzyme inhibitors enalapril, captopril, and lisinopril can cause scalded mouth or BMS. There is often improvement with reduction or discontinuation of the medication.

Although they are often regarded as asymptomatic variants of normal, multiple studies have shown geographic, fissured, or scalloped tongues more frequently in patients with tongue pain. When these patients complain of pain, technically they do not fit under the rubric of BMS but can be treated as such and should be reassured about their possibly increased fear of cancer.

Identification of correctable causes of BMS should be emphasized, and psychiatric causes should not be invoked without thorough evaluation of the patient. Such a thoughtful and structured evaluation has been associated with improvement in approximately 70% of these patients.

Burning-mouth syndrome

Burning-mouth syndrome is characterized by a burning sensation in one or several oral structures (Tourne and Fricton, 1992). Although no obvious cause has been established, numerous possibilities exist. The pathogenesis may be summarized into local, systemic, and psychological etiologies. Local factors include contact allergy, denture irritation, oral habits, infection, and possible reflux esophagitis. The systemic factors include menopause, vitamin and mineral deficiency, diabetes, oral infection, and chemotherapy. Psychogenic factors have often been cited but are mostly anecdotal. An essential component to rule out is Candida infection. Patients with fungal infection respond quickly to antifungal preparations such as clotrimazole or fluconazole. Topical clonazepam (0.5 –1.0 mg three times per day) has been effective at reducing a burning oral pain (Woda et al., 1998). Patients are instructed to suck a tablet for 3 min (and then spit it out) three times per day for at least 10 days. Serum concentrations are minimal (3.3 ng/ml) 1 and 3 h after application. Woda hypothesized that clonazepam produced a peripheral, not central, action, disrupting the neuropathological mechanism. Additional treatments for burning-mouth syndrome include medications ranging from tricyclic antidepressants, antiepileptic drugs, benzodiazepines, to folic acid and oral rinses. Treatment outcome is varied.

Oral dysaesthesias

A complaint of a burning tongue or mouth is the common type of oral dysaesthesia. Dry mouth, disturbed taste sensations and delusions of halitosis are other dysaesthesias. These are often manifestations of monosymptomatic hypochondriasis, somatization pain disorder or a depressive neurosis. There is sometimes cancer phobia, or anxiety about the possibility, for example, of venereal disease or human immunodeficiency virus (HIV) infection.

Burning Mouth Syndrome

This relatively common “nonlesion” clinical problem is included in this section because the symptoms associated with burning mouth also appear in patients with vitamin B deficiency, pernicious anemia, iron deficiency anemia, and chronic atrophic candidiasis. Patients with burning mouth, or burning tongue, syndrome usually exhibit no clinically detectable lesions, although symptoms of pain and burning can be intense. This is a particularly frustrating problem for both patient and clinician, because usually no clear-cut cause is evident once the previously stated conditions are ruled out, and no uniformly successful treatment is present.

Burning mouth syndrome

Torgerson RR. Dermatol Ther 2010; 23: 291–8.

Multiple possible etiologies of BMS, including neuropathic, exocrine dysfunction, taste disturbance, mucosal atrophy, and psychological illness, are reviewed. Recommendations for evaluation and management are given.

First-Line Therapies