Burning Mouth Syndrome

Nurdiana, drg., Sp.PM

DEFINITION

“Burning Mouth Syndrome” (BMS)

oral burning tongue/other mucous membranes no detectable cause, anatomic pathways, mucosal lesions, neurologic disorders & lab

abnormalities

BMS

Burn­ing lips syndrome

Scalded mouth syndrome

Stomatodynia Glossodynia

Glossopyrosis

EPIDEMIOLOGY

Prevalence 0.7 -

2.6%

Women 7 x : men

recent data male =

female

>>> post menopausal women mid – late

50s 10 - 15%

>>> 3 – 12 years after menopause

Men affected at a later age than women

ETIOLOGY

Unknown

Local Systemic Psychological

• Candida

• Bacteria

• Pre-Ca/Ca

• Denture

• Iritation/alergy

• Xerostomia

Local

Candida

Pseudomembranous & erythematous candidiasis BMS

No clinical signs of candidiasis antifungal 86% improved & 13%

Bacteria

Staphylococci

Streptococci

Anaerobes

Pre-Ca/Carcinoma

Leukoplakia/erythroplakia burning/painful sensation

Ca itching/burning premonitory symptom

Denture

Main & Basker ill-fitting dentures single greatest contributor

Faulty denture design functional stress level to circum oral/lingual muscle

Denture fix BMS persist

Iritation/Alergy

Mechanical irritation oral habit, denture design errors & sharp teeth

Chemical allergy food, oral hygiene products or dental materials (methyl-methacrylate/mecury)

Contact allergy inflammatory, lichenoid, or ulcerative lesions

Xerostomia

Xerostomia BMS incidence no clear association

Glass : xerostomia local

contributing factor, other authors : xerostomia

higher/lower ???

Salivary composition

changes BMS

Altered sympa­thetic

output stress or alterations in

interactions between cranial nerves & pain

sensation

• Menopause

• Deficiency

• DM

• Nerve injury

• Drugs

Systemic

Menopause

Hormonal changes incidence BMS hypoestrogenemia mechanism unclear usually not

reversible with hormone replacement therapy

Deficiency

BMS symptoms of deficiency iron, Vitamin B & folic acid

Lamey et al replacement vitamin B1, B2 & B6 effective in treating 88% BMS patients

Lab. abnormal management & correction BMS persist

Diabetes Mellitus

Xerostomia & candidiasis

Diabetic neuropathy

head & neck region

After glucose control BMS persist, oters: diabetic

treatment BMS resolved ???

Nerve Injury

Characteristic post-traumatic nerve injury alterations in

perception to touch, temperature, two-point discrimination &

threshold pain BMS infrequent

Drugs Angiotensinconverting enzyme

(ACE) inhibitors (captopril, enalapril, & lisinopril)

resolved after discontinuation of

medication

Psychological

Psychogenic problem personality & mood changes pain

Depression & anxiety affect pain or secondary to chronic pain

Lamb et al: BMS psychological factor & anxiety most difficult to control

Psychological component chronic low-grade trauma parafunctional habits eg. rubbing tongue to the teeth or pressing tongue on palate BMS

Symptom of cancer-phobia reassuring often helpful

More than one factor may be contributing BMS one

another, no specific etiology can be identified

CLINICAL FEATURES

> 50% onset spontaneous, no identifiable precipitat­ing factor ± 1/3

onset with dental procedure, recent illness or medication course

Most common sites : anterior tongue, anterior hard palate, &

lower lip & often occurs in > one oral site

Pain intensity & other symptoms gradually & persist for years

Burning intermittent/constant eating, drinking, or

candy/chewing gum relieves symptoms. Local anesthetic elixir burning but dysgeusia

Moderate - severe intensity gradually throughout the day max intensity: late

evening difficulty falling asleep & experiencing interrupted sleep

Mood changes irritability & decreased desire to socialize related to altered sleep patterns

Frequently accompanied by dry mouth & thirst no evidence of

decreased salivary flow

Additional complaints facial pain & pain at other sites

PATHOGENESIS

• Completely unknown

Morphologic alterations in peripheral tissue

Injury/disease

Biochemical & pathophysiologic changes in nociceptive neurons in CNS

inhibit oral nociceptive activity

nerve damage occurs to trigeminal nerve directly or other cranial nerves

Result of common systemic/local disorders

BMS

Detailed history

Clinical examination

Lab

Exclusion of all other possible oral problems

DIAGNOSIS

DIAGNOSIS

• Diagnosis : detailed history, clinical examination, lab studies &

exclusion of all other possible oral problems

• Key to diagnosis history taking

• Characteristics sudden or intermittent onset of pain, bilateral,

progressive during the day & remission with eating

• Unilateral symptoms thorough evaluation of trigeminal &

other cranial nerves eliminate neurologic source of pain

• Complain xerostomia + burning evaluation of salivary gland

disorder mucosa dry & difficulty swallowing dry foods

• Ruled out potential causes even typical features of BMS present

• Burning persists after management sys­temic or local oral

conditions diagnosis of BMS can be considered

Making clinical diagnosis not difficult,

determining etiology difficult

LABORATORY STUDIES

Individual consideration depend on history & clinical suspicion

C. albicans culture

Sjogren's syndrome antibodies serum tests

complete blood count

serum iron, total iron-binding capacity

serum B12 & folic acid levels

Biopsy not indicated no clinical lesion is

associated

MANAGEMENT

• First exclude other disease

• Sources of pain must be eliminate not too much expectation

True BMS

• Education :

– Reassured benign nature of condition & frightening

possibilities (cancer) can be excluded

– If suggests psychogenic factors explain that depression & other

emotional disturbances can cause physical diseases

• Instruction :

– Counseling & reassurance adequate for mild BMS more severe

symptoms drug therapy

– Parafunctional oral habits eliminate splint covering teeth and/or

palate

• Therapy :

– Low doses tricyclic antidepressants (TCA) : amitriptyline,

desipramine, nortriptyline, imipramine, clomipramine, or doxepin

– Should be stressed drugs not to manage psychiatric illness

analgesic effect

– Benzodiazepines : clonazepam (benzodia-zepine derivative) & GABA

(gamma-aminobutyric acid) receptor agonist effective for various

orofacial pain disorder

– Grushka et al clonazepam effective in relieving taste dysgeusia & oral

dryness along with BMS

– Topical capsaicin monoamine oxidase inhibitor tranylcypromine

sulphate in combination with diazepam neuropathic pain

conditions

PROGNOSIS

• Partial remissions occur in approximately 2/3 patients in 6 –

7 years after onset

• No studies investigated whether earlier intervention or earlier &

better pain control lead to earlier disease remission