Journal reading

報告者： PGY2 曾智皇報告日期 : 103.07.08指導老師 : 林立民 醫師 陳玉昆 醫師

Introduction

• Burning mouth syndrome (BMS) is typically described by the patients as a burning sensation of the oral mucosa

absence of clinically apparent mucosal alterations

• Overall prevalence ranging from 0.7% to 7% • Prevalence up to 12% to 18% for post-

menopausal women with BMS

• BMS often affects the tongue (particularly the tip and lateral borders), lips, and hard and soft palate

• Unremitting oral mucosal pain, dysgeusia, and xerostomia

Diagnostic criteria

• Oral burning or painUnremitting for at least 4–6 monthsContinuous throughout almost all the daySeldom interferes with sleep and never

worsensMay be relieved, by eating and drinking

• Other oral symptoms: DysgeusiaXerostomiaPresence of sensory/chemo-sensory

anomaliesMood changesDisruptions in patient personality traits

• Can not have any signs of oral mucosal pathology !!

• Detailed review of patient’s medical and dental histories

• Careful analysis of data obtained from physical and laboratory examinations

Classification and subtypes

Lopez-Jorne et al

Type 1 BMS:• Pain-free waking gradually increasing

reaching its peak intensity by evening• 35%• Linked to systemic disorders such as

nutritional deficiency, diabetes mellitus

Type 2 BMS:• Continuous symptoms throughout the day• 55%• Usually associated with psychological

disorders

Type 3 BMS:• Intermittent symptoms• 10%• Show allergic reactions

• Scala et al. classified BMS into 2 clinical forms

1. Primary BMS:a. Essential or idiopathicb. Peripheral and central neuropathological

pathways are involved

2. Secondary BMS:c. Caused by local, systemic or psychological

factors

Primary BMS• 1st subgroup: Peripheral small-diameter fiber neuropathy of

intraoral mucosa (50–65%)

• 2nd subgroup: Subclinical lingual, mandibular, or trigeminal

system pathology (20–25%)

• 3rd subgroup: Hypofunction of dopaminergic neurons in the

basal ganglia (20–40%)

• Lauria et al Significantly lower density of epithelial nerve fibers in patients with BMS than in control subjects

• Just et al Patients with BMS exhibit a decreased somatosensory and gustatory perception

• Albuquerque et al Patients with BMS had less volumetric activation throughout the entire brain

Secondary BMS• Local factors: poorly fitting prostheses,

parafunctional habits, dental anomalies, allergic reactions, infection, chemical factors, galvanism, taste alterations, and xerostomia

• Systemic factors: endocrine alterations (hypothyroidism, diabetes, and menopause), vitamin B complex, iron and zinc deficiencies, anemia, gastrointestinal anomalies, medication, Sjogren’s syndrome, and esophageal reflux

• Psychological factors: anxiety, depression, compulsive disorders, psychosocial stress, and cancerphobia

• Netto et alSignificant association of the presence of

gastrointestinal diseases and urogenital diseases with BMS

Significant correlation between the intake of H-2 receptor antagonist or proton-pump inhibitor and BMS

• Gao et al87(BMS) and 82

No statistical difference in blood analyses (including white blood cell count, red blood cell count, hemoglobin (Hb), and

platelet count ) between the BMS and control groups

Significantly higher serum follicle-stimulating hormone level and a significantly lower serum estradiol level in the menopausal or post-menopausal women with BMS

Anxiety and depression scores in patients with BMS are higher

Habit of tongue thrusting, lip sucking, periodontitis, smoking, outcome of recent medication, and depression are the principal risk factors for the BMS

• Lin et alPatients with BMS had a significantly higher

frequency of Hb, iron, or vitamin B12 deficiency

Abnormally elevated blood homocysteine level

Serum GPCA (gastric parietal cell antibody) positivity

• Boras et alSignificantly lower serum neurokinin A is

found in patients with BMS

Indicating an inefficient dopaminergic system in patients with BMS

• Pekiner et alSignificantly lower serum IL-2 and TNF-a levels

in patients with BMS

Significantly lower mean salivary Mg level in patients with BMS

• Maragou and Ivanyi, Cho et alSignificantly lower mean serum zinc level in

patients with BMS

• Pokupec-Gruden et alAnxiety and depression are most common in

patients with BMS

General consideration for treatment of BMS

• Detailed review of patient’s medical and dental histories and a careful analysis of patient’s data

setting up a therapeutic regimen

• Treatment or elimination of these factors (local, systemic, psychological) usually results

in a significant clinical improvement

• If patients still have the symptoms drug therapy should be instituted

• The custom-made or combination therapy for each patient with BMS

the greatest benefit to the patient and lessen the treatment duration

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

Vitamin supplement treatment• Sun et al

• Vitamin BC capsules plus relatively high doses of corresponding deficient hematinics

a. reduce the abnormally higher mean serum homocysteine levels

b. raise the corresponding lower mean deficient hematinic and Hb levels

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

Zinc replacement treatment• Cho et al

• Evaluated the serum zinc level in 276 patients with BMS

• Zinc replacement therapy in BMS patients with zinc deficiency is effective

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

Hormone replacement treatment• Wardrop et al prevalence of oral discomfort is significantly

higher in perimenopausal and post-menopausal women

43% <-> 6%

• Forabosco et al

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

Topical drug treatment• Epstein and Marcoe

• Gremeau-Richard et al

• Peripheral nervous system dysfunctions in patients with BMS

• Sardella et al

• Lopez-Jornet et al

• Topical Aloe vera has been shown to promote the healing process in the treatment of burns, psoriasis, and oral lichen planus

1. Vitamin supplement treatment2. Zinc replacement treatment3. Hormone replacement treatment4. Topical drug treatment5. Systemic drug treatment

Systemic drug treatment• Petruzzi et al

• Its use is not recommended for extended treatment

• Grushka et al

• Heckmann et al

• Ko et al

• Investigated outcome predictors of clonazepam therapy

• Amos et al

• Combined topical and systemic clonazepam administration is an effective regimen for treatment of BMS

• Femiano et al

• Antioxidant mitochondrial coenzyme neuroprotective effect

• Marino et al

• prolonged therapy in chronically affected patients with BMS is needed for maintaining a more permanent effect

• Maina et al

• No serious adverse effects are referred in any of the three groups

• Rodriguez-Cerdeira and Sanchez-Blanco

• Amisulpride seems to be effective and well tolerated

• Yamazaki et al

• A tricyclic antidepressant• The side effects are minor and transient and no

serious safety issues are observed

• Bergdahl et al

Summary

• BMS is probably of multifactorial origin and may be idiopathic

• Clinicians should first try to identify the precise causative factors for the BMS

• If patients still have the symptoms after the removal of potential causes, drug therapy should be instituted

• Previous clinical trials have found that drug therapy with capsaicin, alpha-lipoic acid, clonazepam, and antidepressants

relief of oral burning or pain symptom

• Psychotherapy and behavioral feedback may also help eliminate the BMS symptoms

Thank you for your attention