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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 25-29

Burning mouth syndrome: A review


Department of Oral Medicine and Radiology, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India

Date of Submission24-Sep-2015
Date of Acceptance25-Jun-2017
Date of Web Publication04-Aug-2017

Correspondence Address:
Rajendra G Patil
Department of Oral Medicine and Radiology, Kothiwal Dental College and Research Centre, Moradabad - 244 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_184_15

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   Abstract 

Burning mouth syndrome is a condition characterized by chronic orofacial pain without any mucosal abnormalities or other organic disease. There are numerous synonyms for this ailment such as stomatodynia, stomatopyrosis, glossodynia, glossopyrosis, sore mouth, sore tongue, oral dysesthesia, and scalding mouth syndrome. Patients usually present with burning, stinging, or numbness on the tongue or other areas of oral mucosa. The complex etiology and lack of characteristic signs and symptoms makes the diagnosis difficult. As a result of which managing such patients become a herculean task. Moreover, lack of understanding of the disease leads to misdiagnosis and unnecessary referral of patients. In this article, the authors have described the etiopathogenesis, diagnostic algorithm and management of this confusing ailment.

Keywords: Burning mouth syndrome, scalding mouth syndrome, stomatodynia


How to cite this article:
Patil RG, Singh U, Moger G, Thankappan S. Burning mouth syndrome: A review. J Indian Acad Oral Med Radiol 2017;29:25-9

How to cite this URL:
Patil RG, Singh U, Moger G, Thankappan S. Burning mouth syndrome: A review. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2018 Aug 18];29:25-9. Available from: http://www.jiaomr.in/text.asp?2017/29/1/25/212083


   Introduction Top


International Association of Pain and Headache Society defines burning mouth syndrome (BMS) as a “distinctive nosological entity, including all forms of burning sensation of mouth, including complaints described as stinging sensation or pain in association with oral mucosa that appears clinically normal in the absence of local or systemic diseases or alterations.”[1]

Although a lot has been said and published on BMS, still there are many conflicting issues. The major confusion is due to the fact that BMS is defined by symptoms which co-exist with many other local or systemic pathologies or psychologic disorders. The lack of clarity in the diagnostic algorithm is the root cause for the difficulties in its management.[2] It is usually observed in middle aged and elderly population aged 38–78 years.[3] Females are seven times more commonly affected than males, and the prevalence is more in the postmenopausal population.[4],[5]

Etiopathogenesis

BMS is defined by multifactorial etiology many of which are often contradictory. The etiological factors can be broadly classified into primary and secondary causes. [Table 1] includes various primary causes of BMS. Apart from primary causes there are secondary causes which can be further divided into localised, generalized and psychogenic causes.[17],[18],[19],[20]
Table 1: Primary causes of burning mouth syndrome

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Clinical features

The term BMS refers to chronic pain condition in absence of any visible mucosal abnormality or organic disease. It is defined by symptoms that persist for a long time. The pain episodes usually occur continuously for about 4–6 months and may last for 10–12 years or more with an average duration of 3.4 years. The most common complaint is unremitting oral mucosal pain in association with dysgeusia and xerostomia. No signs of lesions or other detectable changes in the oral mucosa even in painful areas are seen.[21],[22] The type of pain experienced by majority of BMS patients is a prolonged “burning” sensation. Scalding, tingling, or numbness of the oral mucosa are other common complaints. Burning sensation is most frequently reported on the tip of the tongue (71%) followed by lips (50%), lateral borer of tongue (46%), dorsum of tongue (46%), and palate (46%).[7] The upper lip and anterior mandible region may also be affected whereas buccal mucosa and the floor of mouth are rarely involved. BMS patients may suffer from headache and pain in the temporomandibular joint areas, suprahyoid muscles, neck, shoulder, and upper back. The onset of oral pain is generally spontaneous, but triggering factors may be positive in some cases.[23],[24]

In 1994, Lamey & Lamb divided the syndrome into three types:[25]

Type 1: defined by daily pain where symptoms are absent upon awakening but gradually increase in severity as the day progresses. Positive association is seen with systemic disorders such as hyperglycemia and nutritional deficiencies. It is not related to psychiatric conditions.

Type 2: defined by constant pain day and night. The anxiety levels are raised in patients. These patients often report mood changes, depression, decreased desire to socialize, and altered eating and sleeping habits.

Type 3: defined by intermittent symptoms with pain free periods during the day. Pain occurs in unusual sites such as floor of mouth and posterior oropharynx. There is positive correlation between pain and type of food taken as well as allergens.[26]

Dysgeusia is another common complaint in BMS patients. Patients complain of bitter or metallic taste. Disorder in sense of taste occurs due to disturbance of sensory modalities in small-diameter afferent fibers. Majority of BMS patients complain of dry mouth which may be due to extensive abuse of anticholinergics, antihistamines and diuretics.[7],[24] Salivary flow is reduced with changes in salivary composition. Thus, due to lack of natural flushing action, these patients are more likely to develop opportunistic infections. Studies have reported significantly higher protein, potassium, and phosphate concentrations in unstimulated saliva of BMS patients.[23],[24]

Diagnosis

Diagnosing BMS is a challenging task even for experienced clinicians because there are no visible mucosal or organic abnormalities. It is defined only by symptoms, and the symptomatic triad rarely occurs simultaneously in one patient and due to overlapping stomatitis. Symptomatically, chronic pain conditions such as traumatic/inflammatory/immune-mediated stomatitis or orofacial pain disorders present similar to BMS. Foremost it is essential to discriminate between primary and secondary BMS. Thus, a thorough case history and a careful examination are the key to successful diagnosis. Systematic evaluation of masticatory system including clinical assessment of occlusion, dentition, temporomandibular joint status, and masticatory muscles is essential to rule out possible joint disorders. Salivary flow rate below 0.1 ml/min for unstimulated whole saliva or 0.7 ml/min for stimulated whole saliva is suggestive of hyposalivation. Sialochemistry can be helpful to assess specific qualitative alterations in saliva. Nutritional deficiencies, diabetes mellitus, and menopausal disorders are diagnosed through hematological tests, blood glucose levels, and estrogen/progesterone concentrations, respectively. The presence of underlying psychological disorders can be revealed by appropriate structured interviews and/or psychometric instruments. If clinical or laboratory examination reveals the presence of any these factors, speculation of secondary BMS should be made. While in absence of these, a final diagnosis of primary BMS can be made. [Table 2] shows the diagnostic algorithm for BMS.
Table 2: Key features of burning mouth syndrome

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The most common conditions that may mimic BMS are atypical facial pain, atypical odontalgia, lingual nerve neuropathy, post-herpetic neuralgia, secondary trigeminal neuralgia, and idiopathic facial arthromyalgia.[26] Atypical facial pain is a condition characterized by a burning, aching, or cramping sensation occurring on one side of the face, usually in the region of trigeminal nerve. Facial trauma, basal skull fracture with resultant injuries of any peripheral, or proximal branch of trigeminal nerve may cause this disorder. Atypical odontalgia is a painful toothache in a perfectly healthy tooth. The pain is continuous, usually burning, aching, or throbbing and most often occurs in maxillary molars.[27] Diagnosis is based primarily on exclusion of other possible disorders. If a nerve block does not result in pain reduction, a diagnosis of atypical odontalgia should be considered.

Lingual nerve neuropathy may be due to complication of third molar extraction or dental anesthetic injection. It can result in anesthesia, paresthesia, or dysesthesia in the tongue and inner mucosa of lower lip, jaw, or chin.[28] Neuralgias also present with burning pain that is similar to that perceived in BMS. Post-herpetic neuralgia (PHN) is the pain that lingers for 3 months after resolution of herpes zoster. It is caused by varicella zoster virus and is typically confined to a same dermatome. Differentiating PHN in cases of zoster sine herpete and BMS is further cumbersome.[29] Trigeminal neuropathic pain that mimics BMS pain can be secondary to various other pathologies such as brainstem neoplasms, viral rhombocephalitis, cerebellopontine angle neoplasms, acoustic neuromas, meningiomas, arachnoid cysts, and granulomatous diseases such as neurosarcoids.

Management

The wide variety of associated factors and their complex presentation in patients highlights the obvious challenge in BMS management. Despite extensive research, the management has been quiet disappointing. Correct diagnosis is of utmost importance in the management. First, the primary or secondary BMS should be determined. In case of secondary BMS, the underlying condition needs to be managed. The management of primary BMS is based entirely on the patient’s symptoms.

Initially, it is important to inform patients about the nature and course of their condition. Reassurance is a must because these patients keep consulting many healthcare providers. Patient’s assumptions, phobias, and anxiety need to be addressed. Precautionary measures such as abstaining from smoking and specific food allergens should be suggested. Drugs causing xerostomia should be avoided as well.[30],[31]

There are various pharmacological agents which when administered topically or systemically are useful to treat BMS pain. Antidepressants used for BMS treatment are broadly classified into tricyclic antidepressants (amitriptyline, imipramine, desimipramine, clomipramine, and doxepin), selective serotonin reuptake inhibitors (fluoxetine, paroxetine, and sertraline), and atypical antidepressants (trazodone).[32] Amitriptyline blocks the neuronal reuptake of noradrenaline and thus exerts its antidepressant action. However, due to its anticholinergic it may cause delirium in elderly patients. Desipramine and nortriptyline are equally efficacious substitutes due to their least anticholinergic activity. Dosage for adults is initially 25 mg thrice daily which can be increased up to 150 mg daily in divided doses; 10 mg three times a day for geriatric population. Imipramine inhibits noradrenaline reuptake to a lesser extent and is thus less sedative than amitryptiline. Dosage is 25 mg thrice daily up to 100 mg thrice daily. Doxepin inhibits reuptake of monoamines at central synapse. Dosage is 25 mg thrice daily which can be increased to 50 mg/day. Selective serotonin reuptake inhibitors inhibit drug metabolizing isoenzymes CYP2D6 and CYP3A4. Dosage for fluoxetine is 20 mg once daily which can be increased up to 80 mg in two divided doses. Sertraline is started as 50 mg once daily and increased up to 200mg/day. Atypical antidepressant such as trazodone selectively blocks 5HT reuptake and has prominent alfa blocking and weak 5HT2 antagonistic action.[33] In adults, starting dose is 50 mg/day at bedtime for 3 days and maintenance dose is 100 mg. Maximum daily dose is 400 mg. Salonen et al. evaluated the efficacy of trazodone in placebo controlled trial for 8 weeks and concluded that no difference was noticed between trazodone and placebo.[34]

Antipsychotic drugs such as amisulpride (50 mg/day) have also been tried in BMS. Maina et al. compared the efficacy and tolerability of amisulpride 50 mg/day, paroxetine 20 mg/day, and sertraline 50 mg/day for 8 weeks and concluded that amisulpride manifested earlier within first week of therapy. Ueda reported two case reports of BMS wherein he prescribed 2.5 mg/day olanzapine and noted a reduction in symptoms without any recurrence.[35]

Antiepileptic drugs such as clonazepam and gabapentin (300–600 mg thrice daily) have been tried in BMS. Heckman et al. conducted a study where gabapentin was used to treat 15 BMS patients. They reported that gabapentin exerts little effect upon BMS. Grushka et al. tested clonazepam (0.25–3 mg/day) via oral route in 30 BMS patients. Forty-three percent experienced slight improvement; 27% experienced improvement but abandoned because of the adverse effects; and 30% reported no benefit.[36] Woda et al. evaluated topical clonazepam in an open label study with 25 patients. The patients were instructed to open the clonazepam tablet and retain saliva in the mouth for 3 min without swallowing followed by expulsion; 24% showed no improvement; 36% reported partial improvement but continued with the treatment; and 40% reported complete symptom remission.[37]

Capsaicin desensitizes the c-fiber nociceptors, thereby exciting noticeable effects on painful disorders arising out of these afferents. Dosage is 0.25% orally and or 2–16 drops of capsaicin in 60 ml of water for topical application. It is a highly irritant material requiring protective goggles, respirators, and proper handling procedures.[38] Petruzzi et al. conducted a randomized, triple-blind placebo controlled study wherein they evaluated efficacy of 0.25% capsaicin via oral route and concluded it to be highly efficacious.[39] Sardella et al. conducted a study to determine the efficacy and safety of benzidamine hydrochloride 0.15% in BMS patients and found no improvement in 90% patients.[40] Antioxidants have also been used as a treatment modality with varying success rates. Femiano et al. reported improvement in 81% patients using alfa lipoic acid at a dose of 600 mg/day.[41]

Studies conducted in the last decade have shown a positive relation between BMS and alteration in gonadal and adrenal steroid level. In postmenopausal women, there is dramatic reduction in gonadal hormones which in turn reduce the production of neuroactive steroids.[42] Hormone replacement therapy seems to be a promising treatment modality in postmenopausal women. Volpe et al. conducted a clinical study to assess estradiol-based treatment in postmenopausal women and reported improvement in 55% cases.[43] Electroconvulsive and cognitive behavioral therapy have also been tried in BMS, however, the results were not satisfactory. Alternative therapy can serve as an adjunct along with mainstay treatment. These include acupuncture, ayurveda, naturopathy, aroma therapy, bachflower therapy, biofeedback, and dietary and lifestyle changes.[44],[45]


   Conclusion Top


Correct diagnosis is of paramount importance which serves as the foundation for successful management of BMS. A collaborative teamwork between oral physicians, appropriate specialists, and psychologists is essential to offer better care to ailing patents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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