Burning mouth syndrome (glossodynia)

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Burning mouth syndrome (glossodynia)

Cooper C. Wriston, Ashley B. Wentworth and Rochelle R. Torgerson

Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Primary burning mouth syndrome (BMS) is a chronic and debilitating condition characterized by intraoral burning in the absence of systemic disease or identifiable abnormalities on physical examination and laboratory testing. Current evidence suggests that altered neurophysiology of the central or peripheral nervous systems may play an etiopathogenic role. The diagnosis of primary BMS is a clinical diagnosis of exclusion. Various medical conditions and medications can induce oral burning, a condition referred to as secondary BMS.

Management strategies

A detailed history and physical examination should be completed to identify all alternative or correctable causes of oral burning. Several associated factors may be simultaneously present requiring treatment. Correctable, associated factors may be local, systemic or psychological.

Specific investigations

Table 33.1

Specific investigations

History
Oral symptoms	Timing, quality, duration, location, alleviating/exacerbating factors
Medications	Efavirenz, clonazepam, fluoxetine, sertraline, venlafaxine, enalapril, captopril, lisinopril, candesartan, eprosartan, omeprazole, topiramate, hormone replacement therapy
Dental	Prostheses, recent procedures, dentifrices, topical medicaments
Parafunctional habits	Bruxism, tongue thrusting
Review of symptoms	Weakness, headache, fatigue, concentration, sleep disturbance, arthralgia
Physical examination
Oral	Complete oral exam, including head and neck (remove any dental prostheses)
Nodal	Adenopathy
Musculoskeletal	Temporomandibular joint

Table 33.2

Laboratory evaluation

Hematologic	Complete blood count; ferritin; serum folate, cobalamin (+ methylmalonic acid, homocysteine)
Metabolic	Serum thiamine, riboflavin, pyridoxine, zinc (+ alkaline phosphatase), magnesium
Endocrinologic	Glycosylated hemoglobin, thyrotropin (+ free thyroxine)
Immunologic	Antinuclear factor, ( +Ro/SSA, La/SSB)
Dermatologic	Biopsy (+ direct immunofluorescence) if visible abnormality on oral exam
Microbiology testing	Herpes simplex (PCR); varicella zoster (PCR); candidosis (swab from site of pain for direct examination and culture); human immunodeficiency virus screening

Table 33.3

Consultations

Otolaryngology	Nasopharyngoscopy
Gastroenterology	Esophagogastroduodenoscopy
Oral/maxillofacial	Periapical radiographs, magnetic resonance imaging
Mental health	Psychiatry consultation
Neurology	Neurologic examination, magnetic resonance imaging
Hypersensitivity testing	Epicutaneous patch testing (preservatives, oral flavors, metals, adhesives)

Pathophysiology of primary burning mouth syndrome.

Jaaskelainen SK. Clin Neurophysiol 2012; 123: 71–7.

A review of the evidence for neurophysiologic alterations in the peripheral or central nervous systems in the etiopathogenesis of BMS. A neurophysiologic evaluation is suggested to characterize the neuropathology in individual patients and target treatments.

Psychiatric comorbidity in patients with burning mouth syndrome.

Bogetto F, Maina G, et al. Psychosom Med 1998; 60: 378–85.

In a case–control study of 102 patients with BMS, 59.8% had concomitant psychiatric disorders.

Interventions for the treatment of burning mouth syndrome.

Zakrzewska JM, Forssell H, et al. Cochrane Database Syst Rev 2005; CD002779.

In nine comparative trials identified for BMS, only α-lipoic acid, clonazepam, and cognitive behavior therapy were effective. Therapeutic efficacy for painkillers, hormones, and antidepressants was not found.

Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth symptoms.

Drage LA and Rogers RS, 3rd. Mayo Clin Proc 1999; 74: 223–8.

Seventy patients with a burning or sore mouth were reviewed retrospectively. Associated conditions included psychiatric disease (30%), xerostomia (24%), geographic tongue (24%), nutritional deficiency (21%), and allergic stomatitis (13%).

Burning mouth syndrome: an update.

Lopez-Jornet P, Camacho-Alonso F, et al. Med Oral Patol Oral Cir Bucal 2010; 15: e562–8.

BMS is reviewed as a chronic orofacial pain disorder. Serotonin reuptake inhibitors, clonazepam, and capsaicin may be effective treatments.

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 psychologic illness are reviewed. Recommendations for evaluation and management are given.

First-line therapies

Acknowledge and validate patient symptoms and experience; reassure	E
Avoid contact irritants (alcohol-based oral rinses, caustic mouthwashes, flavored dentrifices, acidic foods, carbonated beverages)	E
Treat xerostomia (sialogogues, artificial oral lubricants)	D
Discontinue or change causative medications (ACE inhibitor, ARB, SSRI, SNRI, benzodiazepine, NNRTI, PPI, anticonvulsant, anticholinergics)	E
Replace thiamine, riboflavin, pyridoxine, folate, cobalamin, iron, zinc, ascorbic acid, magnesium	C
Manage concomitant psychiatric illness	C
Assess and address parafunctional habits (bruxism, tongue thrusting)	E
Assess oral prostheses and dental work	C
Imidazole/azole therapy (presence of functional pain)	C

Patients complaining of a burning mouth. Further experience in clinical assessment and management.

Main DM and Basker RM. Br Dent J 1983; 154: 206–11.

A high rate of intraoral burning attributable to shortcomings in denture design.

Glossodynia from Candida-associated lesions, burning mouth syndrome, or mixed causes.

Terai H and Shimahara M. Pain Med 2010; 11: 856–60.

Ninety-five glossodynia patients with no objective tongue findings were assessed for functional pain (significant increase in tongue pain while eating or no tongue pain at rest). Seventy-two (75.7%) of the patients with functional glossodynia improved with imidazole therapy (25 mg of gel four times a day for 2 to 4 weeks).

Drug-induced burning mouth syndrome: a new etiological diagnosis.

Salort-Llorca C, Minguez-Serra MP, et al. Med Oral Patol Oral Cir Bucal 2008; 13: E167–70.

Antihypertensive medications that interact with the renin-angiotensin system are the most frequent cause of drug-associated BMS. Efavirenz, clonazepam, venlafaxine, fluoxetine and sertraline were also associated.

Proton pump inhibitors.

Scully C. Br Dent J 2010; 208: 147.

A case report of BMS-like symptoms that resolved after discontinuing omeprazole.

Topirimate-induced burning mouth syndrome.

Friedman DI. Headache 2010; 50: 1383–5.

A case report of BMS that resolved after discontinuing topiramate. Symptoms recurred upon rechallenge.

Zinc deficiency may be a cause of burning mouth syndrome as zinc replacement therapy has therapeutic effects.

Cho GS, Han MW, et al. J Oral Pathol Med 2010; 39: 722–7.

In a series of 276 patients with BMS, 55 zinc-deficient patients who received zinc supplementation reported a greater reduction of oral pain compared to patients without supplementation (p=0.004).

Second-line therapies

Topical capsaicin	A
Topical clonazepam	B
Low-dose clonazepam	A
Low-dose tricyclic antidepressant (doxepin)	C
Paroxetine	D
Milnacipran	D
Low-dose pregabalin	E
Duloxetine	E
Low-dose olanzapine	E
Cognitive behavioral therapy	B