bms - burning mouth syndrome

By Dr. Javed A. Qazi, BDS, MSc.

AN INDEPENDENT CE STUDY COURSEFOR DENTAL PROFESSIONALS

GLOSSODYNIA(BURNING MOUTH SYNDROME)

File Name: amelogo and usage.epsAs of Date: 04/2004

www.arcmesa.com

GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORSwww.arcmesa.com

ABOUT THE AUTHOR

Dr. Qazi a graduate of Khyber Medical College and received a BDS degree fromUniversity of Peshawar in 1980. In 1982, he was appointed as Lecturer. He obtaineda Master of Science degree in Oral Medicine & Periodontia in 1991 from KhyberCollege of Dentistry, Peshawar. He worked as a periodontist at Royal DentalHospital; KSA from 2001-2003. Dr. Qazi is active in several national dentalorganizations and has written numerous dental journal articles. He maintains aprivate practice of generalized & specialized dentistry.

Presently, he is working as Senior Lecturer at Khyber Medical College and beenawarded exemption in Membership in Oral Medicine of Royal College of Surgeonsof Edinburgh, UK (Part 1). He is also an Examiner of BSc in dental technology andBDS examinations. Dr. Qazi is member of IADR and is actively involved in researchof glossodynia.

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© 2006 – ArcMesa Educators, LLC/Dr. Javed A. QaziAll rights reserved. This CE/CME course, or any part thereof, may not be duplicated

or reproduced without the permission of the authors.

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COURSE OBJECTIVES

Upon successful completion of this course, the participant will:

1. Comprehend the local, systemic and psychogenic causes of glossodynia

2. Understand the various symptoms of glossodynia

3. Know the significance of the multiple causes in relation to other possiblechronic diseases

Target Audience This course was developed to provide an overview of glossodynia for dental professionals.

Accreditation ArcMesa Educators, LLC is an ADA CERP Recognized Provider

for Dental Continuing Education, an Academy of General

Dentistry Accepted National Sponsor (#90564) for

FAGD/MAGD Credit, a Florida Board of Dentistry Provider (#BP-00246), and a registered provider

with the Dental Board of California (RP 4365).

Credit DesignationBy reviewing the course content and completing the post test at the end of this continuing medical

education activity, you are entitled to receive one credit hour if you achieve a score of 70% or greater.

Estimated time to complete this activity is one hour.

DisclosureIt is the policy of ArcMesa Educators, LLC to ensure balance, independence, objectivity, and

scientific rigor in all its educational activities. All faculty/authors are expected to disclose any

relevant financial relationships they may have with commercial interests in relation to this activity.

These relationships, along with the educational content of this program, have been reviewed and

any potential conflicts of interest have been resolved to the satisfaction of ArcMesa Educators.

Dr. Javed Qazi has indicated he has nothing to disclose relative to this activity.

ArcMesa Educators, LLC staff has nothing to disclose relative to this activity.

Date of original release: June 2006 Date of most recent review/approval: N/A

Medium used: Monograph / Internet Expiration Date: June 2009


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TABLE OF CONTENTS

ABOUT THE AUTHOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

COURSE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii

COURSE INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

ETIOLOGIC FACTORS OF GLOSSODYNIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

LOCAL FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

SYSTEMIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

PSYCHOGENIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

MULTIPLE ETIOLOGIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

COURSE EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20


COURSE INSTRUCTIONS

FOR INTERNET AND HOME STUDY PARTICIPANTS!

• Read the course material carefully. Internet participants may study online or print a copy

of the course for off-line study. Start when you are fresh and take your time.

• This course includes an "open book" exam. You may review the text at any time as a learning

aid or to check the accuracy of your responses before submitting your completed exam.

• Be sure to answer each exam question; blanks are counted as incorrect answers.

A minimum score of 70% is required for successful completion of this exam.

• The processing fee for this course entitles only one person to receive a certification of com-

pletion. A history of courses taken and certificates earned can be found in your "Member

History" section of our online program and/or available traditionally by contacting our cus-

tomer services department.

• After successful completion of the course exam, Internet users are returned to their

"Member History" page where you may view and/or print your Certificate of Completion.

Please note that each certificate is uniquely identified with an ArcMesa "Certificate ID

Number". Numbers may be used for certificate validation by various authorized organiza-

tions. Mailed or faxed exams and evaluations are processed within 48 hours of receipt.

Certificates are posted for return by 1st Class U.S. Mail the next day.

• If you fail an on-line exam, you may retest immediately by selecting the "Repurchase Exam"

link found directly across from the course title within your "Member History" page.

Note: Traditional users will be notified by ArcMesa and may retest upon purchasing a

new exam.

• Please complete the brief course evaluation form at the end of the exam. Your responses

and suggestions will allow us to upgrade our procedures and course materials to serve you

more effectively in the future.

PROBLEMS OR QUESTIONS?

If you have any questions about your examination or your Certificate of Completion, please callArcMesa at 1-800-597-6372

Your Certificate of Completion will reflect the following data:

Date of completion, name, profession/occupation, license number (if provided), course title,CE/CME hours awarded, provider name and approval number (if applicable). Internet users receivean online grade report. Home study users may request a grade report.

Thank you for choosing ArcMesa Educators!

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INTRODUCTION

GLOSSODYNIA, is also known as burning mouth syndrome (BMS), Glossalgia,Glossopyrosis, Stomatodynia or oral dysphasia. It has been recognized worldwideand affects 2.6 percent of the general population and more than 1 million people inthe United States.1

Glossodynia is characterized by intra oral pain disorder with burning or alteredsensation in the tongue, gingiva, lips or denture bearing areas. The burning may beunilateral or bilateral and tends to be relieved by eating or drinking. Othersymptoms commonly associated with this disorder include dry mouth, headache,sleep disturbances and severe postmenopausal symptoms in women.

Traditionally it has been described as a chronic syndrome without specific organicetiology and those diagnosed with BMS are often emotionally disturbedpostmenopausal women. Women are particularly affected by the condition; they arediagnosed with symptoms seven times more frequently than males.

Schoenberg et al reported that the symptoms occur in men as well as in womenand are not necessarily confined to old age.2

Glossodynia can be divided into two types:3

1. With observable alterations of the tongue and

2. Without any observable alterations of the tongue

The common observable signs of BMS are inflamed fungi form papillae, a localizedreddening due to trauma or atrophy of the filiform papillae, localized or generalizedlobulations and generalized redness. These symptoms may alter an individual’ssense of taste.

In the second type of BMS with no observable alterations of the tongue, there isno evidence of tissue abnormalities and both the filiform and fungi form papillae ofthe tongue are without any atrophic changes.

Although the burning sensations are readily recognizable symptoms, theunderlying cause is always obscure. The clinician must consider various etiologicalfactors with careful and thorough clinical examination plus laboratoryinvestigations before diagnosing a case of glossodynia. The purpose of this courseis to present a systemic approach to the differential diagnosis of glossodynia.

Etiologic factors of glossodynia include: local, systemic and psychogenic causes.


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ETIOLOGIC FACTORS OF GLOSSODYNIA

LOCAL FACTORS• Candidiasis

• Migratory Glossitis

• Lichen Planus

• Trauma

• Oral Cancer

• Denture faults

• Impression surface

• Polished surface

• Occlusal surface

• Denture Plaque

• Residual monomer

• Sensitivity to dental materials

• Radiation therapy (xerostomia)

• Periodontal diseases

• Electro galvanic discharge

CANDIDIASISOne of the most common causes of glossodynia is candidiasis or moniliasis. It is

caused by candida albican, a fungal organism that exists in the oral cavity as a partof normal flora. There is a competitive inhibition with other organisms in the oralflora. The host immune defenses maintain the candida population low numbers.When there is a disruption of the ecosystem or the host defense mechanism islowered, the candida proliferate and as a result candidiasis develops. Candidiasis canalso occur from the prolonged use of antibiotics, corticosteroids and cancerchemotherapy. Those with debilitating diseases like diabetes mellitus, often havecandidiasis as well. Trauma from ill-fitting dentures along with poor oral hygieneallows candida organisms to penetrate the oral tissues, thus resulting in candidiasis.

Oral manifestations of candidiasis range from erythema to creamy whiter coloniesthat may be associated with angular cheilosis. There is burning sensation of entireoral mucosa rather than only the tongue. The treatment consists of rinsing themouth with Nystatin oral suspension or clotrimazol troches.


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LICHEN PLANUSLichen Planus is a dermatological disease with oral manifestations. Recent studies

indicate that oral lesions are present without skin lesions in 65% of Lichen Planuscases. Lichen Planus represents 9% of all oral white lesions and appear in threeforms (as atrophic and bullous subtype):4

• Striated

• Plaque like &

• Erosive

The exact etiology of Lichen Planus is unknown but it is presumed to be anautoimmune or psychosomatic disease. The predisposing factors for Lichen Planusare emotional stress, trauma, viral or bacterial infection, hypersensitivity, or drugtherapy.

Oral manifestations of Lichen Planus include: wickhams striae (lacy whiteconfiguration), erosions, ulcers or white plaques (which may or may not bepresent). The buccal mucosa is the most common site but the tongue and gingivalarea may also be affected. About 50% patients with oral Lichen Planus also haveraised purple, itchy papules with white lacy striae on the skin.5

The symptoms of burning and pain occur most often with erosive Lichen Planus.The diagnosis is made by a histological examination and biopsy. Local or systemiccorticosteroid therapy is frequently helpful in the acute phase of erosive LichenPlanus. The incidence of malignant transformation of erosive Lichen Planus variesfrom 0% to 10%. Therefore, careful monitoring is recommended, as chronic oralulcerative might represent a cofactor in the development of malignancy in certainpeople.5

TRAUMALow incidence of trauma may be on the list of causes for oral burning. Trauma

may be in the form of physical, chemical or thermal injury. Biopsy and surgicalrepair of tongue can also result in Glossodynia.

ORAL CANCERGlossodynia may be caused by oral cancer, which is normally present on the lateral

borders of the tongue or the oropharynx. The incidence of oral cancer varies indifferent parts of the world. In 1980, oral and pharyngeal cancer ranked the sixthmost common form of cancer worldwide. In India, for example, 40% of all cancersoccur in the mouth while in England there is incidence of 2% oral cancer. Binnie etal reported a rate of 1.9% for oral cancers compared to all cancers in England and


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Wales. Whenever leukoplakia or erythroplakia persist with accompanying burningsymptoms, the biopsy is mandatory.6

The incidence of the oral cavity and oropharynx cancers represent approximatelythree percent of all malignancies in men and two percent of all malignancies inwomen in the United States. Over 90 percent of these tumors are squamous cellcarcinomas, which arise from the oral mucosal lining. Approximately 2,000patients a year are diagnosed with oral cancer in New York State alone. GovernorGeorge Pataki has taken a leadership role in the United States by mandating andfunding training for dentists in the prevention and early detection of oral cancer.Dental surgeons because of its continual association with the oral cavity have thegreatest opportunity to detect early oral cancer and can educate prevention amongtheir patients. Patients with persistent leukoplakia and accompanying burningsymptoms need to have a biopsy in order to test for oral cancer.

MIGRATORY GLOSSITISMigratory Glossitis (Geographic tongue) is an asymptomatic inflammatory

condition that can be painful. A patient with migratory glossitis will often go to thedentist because of the unusual appearance of the tongue, rather than complaints ofpain.

Migratory Glossitis is a common idiopathic recurring condition, which manifestsas an area of depapillation of the filiform papillae of the tongue with whitehypertrophic borders. The patient may complain of a burning sensation of thetongue in the depapillated area after eating hot or spicy foods. The treatment issymptomatic and patient is assured of its benign condition.

The treatment for Migratory Glossitis is given as a symptomatic treatment,according to each symptom. As there is no helpful therapy, most patients arerelieved to know that the disease is not contagious, life-threatening, and not a signof any serious internal problem. In patients who experience pain, analgesics areprescribed. Patients with a history of anxiety are often prescribed anxiolytic drugsto relieve their anxious symptoms.

DENTAL CAUSESA faulty denture design in any three surfaces (Impression, polished or occlusal

surface) may promote the burning sensation due to an increased level of functionalstress to the circum oral or lingual musculature. The presence of dental plaque canalso cause glossodynia.

A patient, who has an allergy to the denture base material such as monomericmethyl methacrylate, is a potent tissue irritant that can cause glossodynia. The


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allergy is an infrequent cause of burning mouth syndrome because once the denturedesign is modified the symptoms are alleviated. Other allergens, which causeburning mouth syndrome, include propylene glycol, sorbic acid, benzoates andcinnamon aldehyde.

XEROSTOMIAXerostomia is a subjective condition in which there is less than the normal

amount of saliva present in the mouth. The relation between burning and drymouth has been recognized since the 1930’s and present literature also providesstatistical support for this inter relationship. Xerostomia may be reversible orirreversible. The patients with severe xerostomia will often complain of dry, burningmouth, which can be very painful and interfere with functions.

Xerostomia is normally caused by a local factor, radiation therapy. Ionizingradiation causes pronounced changes in salivary glands, and the degeneration ofacini. Replacement of resultant fibrous or fatty may be necessary depending on theeffects from the amount of radiation therapy. Saliva substitute and fluoride gelshould be used to reduce the risk caries from radiation therapy.

SYSTEMIC FACTORS• Climacteric as postmenopausal hypoestrogenism

• Diabetes

• Sjogren’s syndrome (Xerostomia)

• Drug reactions (Xerostomia)

• Deficiency states

• Anemias (Iron, Vitamin B12, Folic Acid deficiencies)

• Lingual artery atherosclerosis

• Rheumatoid arthritis

• Gastric disturbances such as hyperacidity

• Xerostomia

• Hypothyroidism

DIABETESDiabetes mellitus is the most common of the endocrine disorders. Its prevalence

in Britain is over 1% although 50% of those affected remain undiagnosed. The oralmanifestations of diabetes comprise of painless swelling of the parotid, increased


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amounts of glucose in serous saliva, increased risk of periodontal disease and caries.Glossodynia may be one of the symptoms of diabetes, which is often associatedwith xerostomia and candidiasis. There also may be diabetic neuropathies, whichmanifest in the head and neck region contributing glossodynia.

Basker et al reported that diabetes might not be an important etiological factor inglossodynia as the association between diabetes and burning mouth syndrome issmall. Recently Zegarelli reported that he did not find any case of hyperglycemiaamong the 57 patients with burning mouth syndrome.9

The treatment of diabetic glossodynia is achieved by the correct management ofdiabetes as directed by the patient’s physician for such treatment. A saliva substituteand fluoride gel should be used in the cases of xerostomia and the other infections.

SJOGREN’S SYNDROMESjogren’s Syndrome is a chronic disease in which the body’s white blood cells

attack the moisture-producing glands causing various symptoms, one being drymouth. It is one of the most prevalent autoimmune disorders, striking as many asfour million Americans. Glossodynia may appear early in the course of the disease,before other symptoms appear. The oral symptoms of Sjogren’s syndrome are due toxerostomia. The diagnosis is made by histological and hematological examinationswith serologic findings. Although there is no effective treatment, saliva substituteand fluoride gel should be prescribed for the relief of these oral symptoms.

DRUG REACTIONS (XEROSTOMIA)Many drugs used to treat a variety of systemic disorders produce varying degrees

of xerostomia, such as pharmacologically induced xerostomia and Iatrogenicxerostomia. Drugs that are frequently used for long periods of time can causeprolonged decrease in salivary flow and eventually xerostomia occurs. Short-termxerostomia itself often does not cause oral discomfort and dental problems ratherthe prolonged use of certain drugs that lead to xerostomia may produce oraldiscomfort with an increased incidence of caries.

The primary neural control of salivary flow is exerted through the parasympatheticdivision of the autonomic nervous system. An increase in cholinergic activity willincrease the salivary flow where as the decrease in nerve activity results in thedecrease of flow. Likewise drugs that alter cholinergic activity either at sites in thecentral nervous system or in the periphery will alter salivary flow rate. The moststriking example of the cholinergic drugs on salvation is the profound decrease inflow seen after administration of cholinergic (muscarinic) blocking drugs such asatropine propantheline and glycopyrrolate. These drugs block the action of


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acetylcholine, a neurotransmitter, at peripheral muscarinic receptors. Other drugssuch as antihypertensive agents (CLONIDINE) act on the central nervous system todecrease cholinergic nerve output to peripheral sites such as salivary gland.Xerostomia can also be caused by opium and its derivatives, bronchodilators(ephedrine), central nervous system stimulants, Tricyclic anti-depressant(Imipramine) and diuretics.

NUTRITIONAL DEFICIENCIES (ANEMIAS)Glossodynia may be one of the symptoms of deficiency states especially iron,

Vitamin B12 and folic acid reported as early as in 1922 by Beal.10

Iron deficiency can cause oral discomfort with glossodynia and angular cheilitis.There are atrophic changes in the epithelium of any part of oral mucosa, which mayresult in non-specific ulceration. These atrophic changes in the oral pharyngealmucosa may lead to wide spread soreness and dysphasia. The diagnosis can be madeby estimation of hemoglobin content, serum iron, ferritin level and iron bindingcapacity. The treatment is by iron replacement therapy. The recent data indicatesthat the burning sensation may also result from the deficiency of vitamin B1 andB6 also produces greasy dermatitis of the face.

In pernicious anemia, there may be generalized atrophy of the oral mucosa withulceration as in iron deficiency anemia. The soreness of tongue is due to atrophicchanges in the lingual papillae termed as “Beefy red tongue“. The tongue oftenshows a shiny smooth appearance and may be painful and tender to hot or spicyfoods. Glossodynia is a common symptom. The diagnosis can be made by RBCmorphology and serum vitamin B12 parental therapy.

Complex vitaminsIron deficiency is not a disease but a sign of disease and associated with

glossodynia. The high incidence of iron deficiency anemia in women often occursin the second half of pregnancy due to the increased demand for iron. Inpostmenopausal women and adult males, the common cause of iron deficiency isgastrointestinal bleeding by non-steroidal anti-inflammatory drugs and hookworms infection.11

Patients suffering from iron deficiency states are also particularly susceptible tocandida albican infection, a skin infection caused by a yeast-like fungus. With thisinfection, there is an atrophy of tongue epithelium with resulting disturbance ofunderlying nerve that causes taste disturbance and pain in the tongue. This changein sensitivity of tongue can be of diagnostic value in determining possible vitamindeficiency states.


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Iron deficiency anemia has insidious onset with gradual fatigue, irritability,dizziness, palpitation, breathlessness and headache. These changes in metabolism oforal epithelial cells are due to minor variations in the overall quality of the bloodsupply. The changes in the blood supply give rise to abnormalities of cell structureand keratosis pattern of the oral epithelium resulting in the atrophy and possibleelimination of the filiform papillae of the tongue. The atrophic changes in thetongue may lead to ulceration and soreness, and in many cases affect the whole oralmucosa and lead to ulceration.

In a small group of patients, the atrophic changes in the oral and pharyngealmucosa may lead to wide spread soreness and dysphasia. This is known asPlymmer-Vinson syndrome or achlorhydria. The patient may experience angularcheilitis, thrush and complain of taste disturbance due to atrophy of the tongueepithelium (from the disturbance of underlying nerve endings).

Folic acid like vitamin B12 is involved with RNA and DNA metabolism. Adeficiency of folic acid may lead to burning mouth angular cheilitis andglossodynia. The tongue shows varying degrees of papillary atrophy whichprogresses until the surface of tongue is smooth and shiny. The diagnosis is done byRBC morphology and serum folate level. Likewise, niacin deficiency causesgeneralized erythema of the oral mucosa along with papillary atrophy. A properdiagnosis can be made by the measurement of niacin level. It is treated with niacinand vitamin B-complex vitamins.12

PSYCHOGENIC FACTORS• Anxiety

• Depression

• A cancer phobia

Psychogenic factors are often implicated as being etiologic in burning mouthsyndrome and are the most frequent factor in many patients. Engman firstrecognized the psychogenesis of burning mouth in 1920 that studied elevenpatients suffering from burning mouth syndrome who were mostly women havingthe fear of cancer.13

It is reported that Glossodynia is one of classic symptoms of anxiety anddepression precipitated by psychological stress. The specific psychological stress is areal or threatened loss of love, person, valuable object or bodily function. Chronicillness of psychosomatic origin can be traced to dental operation, proper fittingdentures and the failure of the patients to adjust to these procedures. Losing a tooth


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according to an old adage means, “losing a friend” but it also means in theunconscious loss of strength and virility. Thus the patients suffering from burningmouth syndrome often associate the onset of symptoms as correlating with a timeseveral weeks after exodontias, periodontal surgery or extensive restorative dentaltreatment.

Ewalt noted that a common complaint in depression is a peculiar taste, stinging orburning sensation around teeth, gingival or tongue.14 The diagnosis ofpsychologically induced glossodynia is established after all local and systemicfactors are excluded by a negative clinical picture, negative laboratory findings andpositive historical data regarding emotional factors. The burning sensation isconfined to tongue but the palate and lips are frequently involved. Pain could beaggravated by hot and/or spicy foods and relieved by local anesthetics. Main andBasker claim that 20% patients complaining of burning mouth syndrome have ordo not have anxiety towards a cancer-phobia.15 Browning et al concluded that 44%of burning mouth patients had an associated psychiatric disorder.16 Recently, Lambet al indicated that 60% of burning mouth patients has had psychological factorsand anxiety was most difficult to cure.17

Glossodynia may be symptom of cancer-phobia. Reassuring the patients after acomplete diagnosis is often helpful in relieving the symptoms. The treatment ofpsychogenic Glossodynia is anxiolytic/antidepressant drugs or by referring thepatients for psychiatric consultation.


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MULTIPLE ETIOLOGIC FACTORS

Occasionally, some patients are diagnosed with glossodynia from the presence ofmultiple etiologic factors. The exact amount of burning sensation from each causeis unknown but it is evident that more than one can exist in such patients. Zegarellireported that multiple etiologic factors for glossodynia exist in 12.3% of the cases in57 patients he studied with burning mouth syndrome.9

In 1984, a study conducted at the Division of Stomotology at ColumbiaPresbyterian Medical Center concluded that out of 57 patients, 7 patients with BMShad multiple co existent causes (12.5%). Psychogenesis moniliasis was found in 4of patients, 2 male and 2 female. All four had history of a psychiatric disorder(depression) and were taking anti depressive therapy with demonstrable xerostomiaand candidiasis. Treatment for these patients included anti fungal and antidepressant drugs.

In the same study two female patients had psychogenesis and geographic tonguewhile one was having geographic tongue and moniliasis. In this case, anti fungaltherapy was given and within 9 days there was 75% improvement. When multiplecauses of glossodynia exist, treatment is provided for each cause.9


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CONCLUSION

A systematic approach to the diagnosis of burning mouth syndrome is suggestedfor the successful management of this condition. The following diagnostic protocolis recommended.

HISTORYA detailed history for each patient must be taken with reference to his complaint.

The emphasis should be placed on the following points; exact site of burningsensation, duration, and severity and in case of edentulous patients, any associationwith denture must be assessed. The relationship of symptoms with chemotherapyor dental procedure should be noted. For the denture wearer, specific questioningabout the age of present denture, length of denture wearing experience, associationof symptoms with previous denture, whether denture worn at night, any repair andrelining done. The patient’s prescription or non-prescription drug history should betaken in order to determine potential systemic factors that can cause xerostomia orhypersensitivity reactions.

CLINICAL EXAMINATIONRoutine extra and intra oral examination should also be performed. Any

abnormality in color texture of oral mucosa particularly at the site of burning mustbe noted. When erythema presents its precise relationship to adjacent natural teethor dentures, this must be noted. All dentures should be examined with regard tomaterial, plaque formation and design of impression occlusal or polished surfaces.

SPECIAL LABORATORY INVESTIGATIONSEvery patient should be advised for a complete blood, urine and stool

examination. Patients having xerostomia must have their blood glucose levelchecked in order to prevent xerostomia from becoming worse. A smear should betaken for cytological examination from dorsal surface of tongue for the presence ofcandida infection. Whenever necessary, panoramic x-rays and biopsy should beperformed.

If inconclusive results are obtained after all efforts mentioned above, then apsychiatric consultation should be considered. Whenever diagnosis is confirmedthen appropriate treatment should be given with necessary periodic follow up.


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REFERENCES

1. Grushka M, Sessle BJ. Burning mouth syndrome, a historical review. ClinicalJournal of Pain 1987; 2:245-252.

2. Schoenberg B, Carr AC, Kutscher AH., Zegarelli EN. Chronic idiopathicorolingual pain: psychogenesis of burning mouth NY state J Med 1971; 71:1932-7.

3. Glass BJ, Kuhel RF, Langlais RP. Treatment of common orofacial condition.Dent clinic of N. America 1986; 30: 3, 443-445.

4. Shklar G, Mccarthy PL. The oral manifestations of systemic diseases. Ist EdPP 74-75 Boston and London, Butterworths, 1976.

5. Kaplan B and Barnes. Oral Lichen Planus and squamous cell carcinoma: casereport and update of the literature. Arch Otolaryngol. III (8): 543-547, 1985.

6. Fowler CB, Rees TD, Smith BR, Squamous cell carcinoma on the dorsum ofthe tongue arinsin in a long standing lesion of erosive Lichen Planus. JADA1987; 115: 707-709.

7. Binnie WJ, Cawson RA, Hill GB, Soaper AE. Oral Cancer in England andWales. A national study of morbidity, mortality, Curability and relatedfactors. Office of population censuses and surveys studies on medical andpopulation subjects. No. 23 London, HMSO, 1972.

8. Basker RM, Sturdee DW, Davenport JC. Patients with burning mouth. Aclinical investigation of causative factors including the climacteric anddiabetes. Br Dent J 1978; 145: 9-16.

9. Zegarelli DJ. Burning mouth. An analysis of 57 patient’s oral surg 1984; 58:34-38.

10. Beal H. Glossopyrosis. Dent Cosmos 1922: 64: 474.

11. Qazi JA. Glossodynia associated with iron deficiency anemia; case report.Pak Oral and Dental J 1989; 9: 2; 56-59.

12. Gallagher FJ, Baxter DL, Denobile J, Taybos GM. Glossodynia, irondeficiency anemia and gastrointestinal malignancy report of a case. Oralsurg oral Med oral Path 1988; 65: 1, 130-133.

13. Engman MF. Buring tongue. Arch dermatol syphilol 1920; 6: 137-8.

14. Ewalt J. Somatic manifestations of depression. Hosp. Med 1966; 2:6.

15. Main DMG, Basker Rm. Patients complaining of burning mouth Br Dent J1983; 154: 206-211.


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16. Browning S, Hislop S, Scully S, Shirlan P. The associated between burningmouth syndrome and psychological disorders. Oral surg oral Med oral Path1978; 64, 171-74.

17. Lamb AB, Lamey PJ, Reeve PE. Burning mouth syndrome psychologicaldisorders. Br Dent J 1988; 165: 256-260.

18. Zegarelli DJ, Schmidt ECZ. Oral fungal infection. Journal of Oral Med 1987;42: 2, 76-79.

19. Harris M. Psychosomatic disorders of mouth and face. Practioner1975:214:372-379.

20. Grushka M, Epstein JB, Gorsky M.Burning mouth syndrome. Am FamPhysician. 2002 Feb 15; 65(4): 615-20. Review.

21. Muzyka BC, De Rossi SS. A review of burning mouth syndrome. Cutis. 1999Jul; 64(1): 29-35. Review.

22. Savage NW, Boras VV, Barker K.Burning mouth syndrome: clinicalpresentation, diagnosis and treatment. Australas J Dermatol. 2006 May;47(2): 77-81

23. Kugu N, Akyuz G, Dogan O.Burning mouth syndrome and depression: a casereport] Turk Psikiyatri Derg. 2002 Autumn; 13(3): 232-7

24. Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin.2002 Jul-Aug; 52(4): 195-215

25. WHO. World health statistics Annual Geneva. WHO 1967.

26. Tyldesley Wr. Oral Medicine for Dental Practitioner. Brit Dent J 1974, 136:111.

27. Lamey PJ AB. Prospective study of aetiological factors in burning mouthsyndrome. Brit Dent J 1988; 296: 1243-46

28. Chimenos-Kustner E, Marques-Soares MS.Burning mouth and saliva. MedOral. 2002 Jul-Oct; 7(4): 244-53. Review. English, Spanish.

29. Lamey PJ, Lewis MAO. Oral Medicine in practice: Orofacial allergic reactions.Br Dent J 1990; 168: 59-63

30. Gruskha M., Clinical features of burning mouth syndrome. Oral Surg OralMed Oral Path 1987; 62: 30-6

31. Macleod J, Edwards C, Bouchier I. Davidson’s Principles and practice ofMedicine. 15th Ed PP 461-62 ELBS, 1987.

32. Taybos Gm and Terezhalmy GT. Glossodynia: Diagnosis and Treatment. USNavy MED Sept-Oct 1983; 74: 18-19.


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33. Gilman AG, Goodman LS, Rall TW, Murad F. Goodman and Gilman’s ThePharmacological Basis of Therapeutics, 7th Ed, PP 135, New York; MacmillanPublishing Company, 1985.

34. Tyldesley Wr. Oral Medicine, the oral mucosa in generalized disease (2) 1sted. PP 133-34 Oxford E I B S, Oxford University Press, 1985.

35. Lamey PJ, Allam BF. Vitamin status of patients with burning mouthsyndrome and the response to replacement therapy. Br Dent J 1986; 160; 81.

36. Vander Pleog HM, vander waal N, Eijkman MAJ, vander waal I.Psychological aspects of the patients with burning mouth syndrome. Oralsurg 1987; 63: 664-668.

37. Dworkin SF, Burgess JA. Orofacial pain of psychologenic origin. Currentconcepts and classification. JADA 1987; 115: 565-571.

38. Kutscher AH, Schoenberg B, Carr AC. Death, grief and dental thanatology asrelated to dentistry. JADA 1970; 81: 1373-7.

39. Forabosco A, Negro C. Burning mouth syndrome. Minerva Stomatol. 2003Dec; 52(11-12): 507-21. Review.

40. Domb GH and Chole RA. The burning mouth and tongue. Ear nose throat J1981; 60: 310-314

41. Kaaber S, Crames M, Jespen Fl. The role of cadmium as a skin sensitizingagent n denture and non-denture wearers. Contact Dermatitis 1982, 8: 308-313

42. Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment ofburning mouth syndrome. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD002779. Review.

43. Hammaren M, Hugoson A. Clinical psychiatric assessment of patients withburning mouth syndrome resisting oral treatment. Swed Dent J. 1989; 13(3):77-88.

44. Grushka M. Clinical features of burning mouth syndrome. Oral surg OralMed Oral Path 1987; 63: 30-36.

45. Pinto A, Stoopler ET, DeRossi SS, Sollecito TP, Popovic R.Burning mouthsyndrome: a guide for the general practitioner. Gen Dent. 2003 Sep-Oct;51(5): 458-61

46. Kerr AR Cruz GD Oral cancer. Practical prevention and early detection forthe dental team. : N Y State Dent J. 2002 Aug-Sep; 68(7): 44-54.


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COURSE EXAMINATION

Traditional Completion: To complete the examination, please circle the appropriate answer for

each question on the “Examination Answer Sheet” provided and return to ArcMesa customer service.

Online Completion: We suggest using this page to prepare for the online examination. If you have

purchased the program, and are ready to complete the online examination, select the “Take Exam” link

located directly across from the program title within your online ArcMesa “Member History” section.

1. Glossodynia has been reported worldwide and affects what percentage of thegeneral population?

a. 2.6%b. 5%c. 10%d. 25%

2. One of the local causes of glossodynia is:

a. Diabetesb. Drug reactionsc. Oral Cancerd. Deficiency states

3. Glossodynia is classified into:

a. Two typesb. Four typesc. Five typesd. Six types

4. The glossodynia and oral symptoms of Sjogren’s syndrome are due to:

a. Bacterial Infectionb. Xerostomiac. Thermal Injuryd. Salivary Gland enlargement

5. The treatment of diabetic Glossodynia is:

a. Steroid therapyb. Analgesic drugsc. Topical application of Betnovet Creamd. Referral to physician for diabetic management


v21

6. The administration of cholinergic drugs such as atropine, propatheline andglycopyrrolate effect on salivation is:

a. Increase in salivationb. Profound decrease in viscosity/flow c. Stops the salivationd. Has no effect

7. “Beefy Red tongue” is a symptom of:

a. Iron deficiency anemiab. Blood loss anemiac. Pernicious anemiad. Hereditary Spherocytosis

8. Migratory Glossitis is a benign condition:

True False

9. Oral Lichen Planus is present without lesions in:

a. 25% of casesb. 65% of casesc. 75% of casesd. 100% of cases

10. The psychogenesis of the mouth was first recognized in:

a. 1920b. 1930c. 1950d. 1975

11. Glossodynia may occur in an individual who has a fear of developingcancer:

True False

12. Losing a tooth according to old age means “Losing an enemy”.

True False

13. Erosive Lichen Planus has symptoms of burning and pain.

True False

14. Candida albican does not exist in the oral cavity as a part of normal flora.

True False


v22

15. The relationship between burning and dry mouth has been recognized since:

a. 1930sb. 1980sc. 1990sd. 2005

16. Common complaint in depression is:

a. Peculiar taste, stinging or burning sensationb. Xerostomia, candidiasis and altered tastec. Glossodynia, Xerostomia and excessive salivationd. Halitosis, burning of mouth & caries

17. Anxiety is not an etiological factor of glossodynia.

True False

18. Glossodynia may be present in postmenopausal women as one of thesystemic causes.

True False

19. A deficiency of folic acid in a glossodynia patient’s diet causes greasydermatitis of the face.

True False

20. The primary cause of glossodynia in recent studies is denture defects.

True False


1. (A) (B) (C) (D)

2. (A) (B) (C) (D)

3. (A) (B) (C) (D)

4. (A) (B) (C) (D)

5. (A) (B) (C) (D)

6. (A) (B) (C) (D)

7. (A) (B) (C) (D)

8. True False

9. (A) (B) (C) (D)

10. (A) (B) (C) (D)

11. True False

12. True False

13. True False

14. True False

15. (A) (B) (C) (D)

16. (A) (B) (C) (D)

17. True False

18. True False

19. True False

20. True False

Examination Answer SheetIf completing the exam traditionally, please remove the Examination Answer Sheet and Evaluation page andreturn to ArcMesa when completed.

Important Note: Please retain a copy or be sure to mark your answers on the examination page(s) for your own records.

GLOSSODYNIA (BURNING MOUTH SYNDROME)Use a dark pen or pencil to circle the appropriate answer for each of the questions from the examination.

If you wish to FAX your answer sheet back to ArcMesa, it is best to use a dark pen.

ARCMESA EDUCATORSwww.arcmesa.com

Credit Card Information (For online users completing traditionally):If you have not yet purchased this course, and would like to complete the course traditionally, Mail or Fax boththe Answer Sheet and Evaluation form with your credit card information to: ArcMesa Educators, 615 Hope Road, Bldg 1, Eatontown, NJ 07724 or Fax to: 732-380-1104.

ONLINE USERS PLEASE NOTE: Your account will be charged an additional $5.00 processing and grading feefor traditional completion, and a certificate of completion will be mailed upon receipt of a passing grade.

ArcMesa Educators • 615 Hope Road, Building One, Eatontown, NJ 07724 • Voice: 732-380-1101 Fax: 732-380-1104

Method of Payment:q VISA q Mastercard q American Express q Discover Total Payment: $ _______.____

Card Number: Expiration Date:

Signature: Date:

Please add any other comments about this course or your suggestions for future courses:__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

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Course EvaluationCOURSE TITLE: GLOSSODYNIA (BURNING MOUTH SYNDROME)

1. After participating in this course do you feel that

A. the learning objectives were met? q Yes q No ____________________________

B. your knowledge has been enhanced? q Yes q No ____________________________

C. your skills have been improved? q Yes q No ____________________________

D. the course was effective in meeting identified needs? q Yes q No ____________________________

E. you are satisfied with the course content? q Yes q No ____________________________

F. the information gained applies to your profession? q Yes q No ____________________________

G. the information gained will assist in improving

your professional performance? q Yes q No ____________________________

2. Your overall rating of this course ("A" being the best): A B C D

3. Please estimate the number of hours spent to complete the course and examination. No. of hrs? ________

Please provide us with your candid evaluation so that we can continue to improve these continuing education materials. We thank you for your comments and appreciate your suggestionsfor future courses.

Comments

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Validation: I certify that I have studied the course materials and have personally completed the course examination.

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Mail or fax back to: ArcMesa Educators • 615 Hope Road, Building One, Eatontown, NJ 07724 • Fax: 732-380-1104

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