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Managing Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a condition characterized by severe, chronic pain in the oral cavity affecting the tongue and the mucosal tissue of the mouth lips and/or the palate.

Burning mouth syndrome (BMS) is a condition characterized by severe, chronic pain in the oral cavity affecting the tongue and the mucosal tissue of the mouth lips and/or the palate. BMS can be considered a diagnosis of exclusion because there are numerous conditions—local or systemic—to which a burning sensation may be attributed. Conducting a comprehensive clinical examination is important to rule out all secondary causes to diagnose true idiopathic BMS. Local factors include parafunctional habits, candidiasis, geographic tongue, and xerostomia, the most common complaint associated with BMS. Systemic factors include but are not limited to gastroesophageal reflux, diabetes, and nutritional deficiencies.

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Manifestation of Symptoms

Manifestation of BMS varies, but, in most cases, the symptoms are not physical changes but changes in sensation. The sensations associated with BMS are described as burning, scalding, tingling, numb, or itching. The affected tissues, including oral mucosa, lip, and tongue, usually appear healthy with no lesions or physical changes in appearance; however, there are cases identified where patients present with a geographic tongue. The pain is typically bilateral occurring on the anterior two-thirds of the tongue with the tip and lateral borders being the most commonly affected sites. The lips, palate, buccal mucosa, and floor of the mouth are also areas reported by patients with BMS but less common than the tongue.

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Etiology

The exact etiology of BMS is not clear. Scientific evidence suggests that the hormonal fluctuations associated with stress and anxiety may cause neurodegenerative alterations in the small nerve fibers of the oral mucosa, triggering pain in the mouth and manifesting as a burning sensation, dysgeusia, and xerostomia. There are many conditions, both locally and systemically, in which BMS is a secondary condition. Local factors within the oral cavity include but are not limited to: localized allergic reaction; mucosal diseases; oral lesions; mechanical or chemical irritation; poorly fitting oral prosthesis that causes microtrauma or erythema; parafunctional habits, such as tongue thrust; continual rubbing of the tongue over the teeth or an oral prosthesis; buccal, labial, and lingual biting; and compulsive movements of the tongue. Various oral infections have been associated with BMS, most frequently Candida albicans infection. Oral infections with Klebsiella, Enterobacter, and Streptococcus aureus also frequently occur in patients with BMS.

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Medical History Review

If a patient presents with symptoms of BMS, oral health professionals should look at patients’ dental histories to see if they were exposed to dental materials that may cause an allergic reaction, evaluate the oral mucosa and look for erythema, or identify an oral prosthesis in areas affected. It is crucial to check for and rule out all possible factors within the oral cavity that may cause BMS. If a potential local factor is identified, treating the patient for that condition may provide relief. A thorough review of his or her medical history may reveal systemic conditions known to be associated with BMS. Oral health professionals should discuss this information with patients and provide a referral to see a physician for further evaluation and treatment.

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Medications

Some medications may be potentially effective, but, more research in this area is still needed. Clonazepam, a benzodiazepine with an inhibitory effect on the central nervous system, shows promise in treating BMS symptoms by relaxing the muscles and providing pain relief. However, clonazepam can result in dependence and can cause xerostomia, lethargy, and fatigue; symptoms will return once use of this medication is discontinued. Capsaicin, a component of peppermint, is another medication used for management of BMS. Capsaicin is an analgesic that can desensitize peripheral nociceptors and control neuropathic pain; it has been reported to significantly reduce the burning sensation of BMS. Side effects are an increase in the burning sensation after topical application and gastric pain when taken systemically after long-term use.

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Enzyme Approach

Research has been conducted to evaluate the effectiveness of alpha lipoic acid (ALA) for treating BMS. ALA is a mitochondrial enzyme with neuroprotective properties that could assist with repair of neural damage. Further research is needed; some studies conclude that it is not effective, while others show promise in its ability to manage BMS. When used with ALA, the anticonvulsant medication gabapentin, was found to reduce pain in 70% of patients. The antidepressant amitriptyline has also shown promise in managing BMS due to its analgesic properties. Side effects include drowsiness and xerostomia.

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Psychological Approach

When medications are ineffective, some evidence suggests psychological/psychiatric intervention may be needed. Cognitive behavioral therapy (CBT) is an effective method for the management of BMS. CBT is traditionally used for treatment of depression and anxiety; in reference to BMS, CBT focuses on education, distraction, evaluation of harmful automatic thoughts, and the replacement of those thoughts with more beneficial ones. Ritchie et al reported that several studies demonstrated that CBT was effective in reducing pain after 12 sessions to 15 sessions and that CBT used in combination with ALA may be more effective than using either treatment alone, but further research in needed to explore their efficacy.

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