Management of Burning Mouth Syndrome

December 15, 2011

ABSTRACT

Burning mouth syndrome is a challenging condition in terms of both diagnosis and management. These challenges lead to frustration for patients and difficulties for dental practitioners. Unfortunately, delays are common between initial presentation and definitive diagnosis, and also between diagnosis and appropriate management. Furthermore, interventions are often undertaken without a working diagnosis, knowledge of the underlying condition or knowledge of best management strategies for this form of chronic orofacial pain. This article discusses potential reasons for diagnostic delays. It also presents current strategies for managing burning mouth syndrome, to assist the dental practitioner in making prudent therapeutic choices.

Introduction

The diagnosis and management of burning mouth syndrome are challenging. Major delays may occur between initial presentation and definitive diagnosis, and also between diagnosis and appropriate management. Furthermore, when interventions are employed, they are often undertaken in the absence of a working diagnosis, knowledge of the underlying condition or knowledge of best management for this form of chronic orofacial pain. Clearly, this enigmatic condition presents a challenge for both patients and practitioners.

As described in an accompanying article,1 we conducted a retrospective analysis of 49 consecutive adult patients (43 women and 6 men, mean age 56.4 years, age range 33 to 68 years) who presented to an oral medicine/orofacial pain clinic with a sensation of oral burning. The mean duration of the sensation of oral burning was 41 months (standard deviation [SD] 73.5, range 2 to 360 months, median 20 months) before a definitive diagnosis of burning mouth syndrome was made. Thirty-eight of the patients reported that they had received some form of treatment for the oral burning before referral to the pain clinic (mean 1.9 [SD 1.2] treatments per patient, range 1 to 6 treatments), whereas 11 reported not receiving any treatment. Interestingly, of the 38 patients who received treatment, only 18 had received some form of monotherapy. The other 20 patients had received more than one form of therapy. Altogether, these 38 patients had undergone a total of 71 treatments before an accurate diagnosis was reached. The 5 most frequently reported medication categories (in descending order) were salivary stimulants, antifungals, anticonvulsants, anxiolytics and topical anesthetics (Table 1). This retrospective study confirmed that a delay in diagnosis of burning mouth syndrome is common. It also confirmed the uncertainty among health care practitioners as to the appropriate management strategies for patients with this condition.

Table 1  Treatments prescribed before definitive diagnosis of burning mouth syndromea

Category
Specific medication or therapy
No. (%) of treatmentsa
Salivary stimulants Topical (rinse, gel, paste) or systemic sialogogue (pilocarpaine, cevimeline) 21 (30)
Antifungal Topical (nystatin cream or gel, clotrimazole troche) or systemic (fluconazole) 13 (18)
Anticonvulsant Carbamazepine, gabapentin, oxcarbazepine 8 (11)
Anxiolytic Topical or systemic (clonazepam) 7 (10)
Topical anesthetic Topical (xylocaine or lidocaine gel or rinse) 6 (8)
Otherb Narcotics, corticosteroids, antioxidants, vitamins, minerals, antidepressants, mechanical approaches (including oral appliances) 16 (23)
Total   71 (100)

aSome patients reported undergoing more than one form of therapy.

bFor therapies reported by 3 patients or fewer.

Discussion

To date, the literature on burning mouth syndrome has not yielded a clear consensus on recommendations for management. In general, 3 approaches (or combinations thereof) can be considered: behavioural interventions, topical medications and systemic medications (Table 2).

Table 2 Summary of interventions for management of burning mouth syndrome that have been investigated in published trials

Behavioural therapy

  • Cognitive behavioural therapy
  • Group psychotherapy
  • Electroconvulsive therapya

Topical medication

  • Benzodiazepine: clonazepam (swish and expectorate)
  • Anesthetic: lidocaine (viscous gel)
  • Atypical analgesic: capsaicin (cream)
  • Antidepressant: doxepin (cream)
  • Nonsteroidal anti-inflammatory: benzydamine (oral rinse)
  • Antimicrobial: lactoperoxidase (oral rinse)
  • Mucosal protectant: sucralfate (oral rinse)

Systemic medication

  • Benzodiazepine (low dose): clonazepam, chlordiazepoxide
  • Anticonvulsants: gabapentin, pregabalin, topiramate
  • Atypical analgesic: capsaicin
  • Antidepressants (low dose): amitriptyline, imipramine, nortriptyline, desipramine, trazodone
  • Selective serotonin reuptake inhibitors: paroxetine, sertraline, trazodone
  • Selective norepinepherine reuptake inhibitors: milnacipran, duloxetine
  • Antioxidant: α-lipoic acid
  • Antipsychotics: amisulpride, levosulpride
  • Atypical antipsychotic: olanzipine
  • Dopamine agonist: pramipexole
  • Histamine2 receptor antagonist: lafutidine
  • Herbal supplement: Hypericum perforatum (St. John's wort)
  • Salivary stimulants: pilocarpaine, sialor, cevimiline, bethanechol

aStudy performed outside North America.

Several studies have suggested that the health care practitioner consider involving a behavioural medicine practitioner (e.g., cognitive psychologist or psychotherapist) as part of a multidisciplinary approach in managing patients with burning mouth syndrome.2-4 Notably, the success rates in these studies have been variable.

Other studies have investigated a variety of topical medications in the management of burning mouth syndrome.5-8 Currently, clonazepam appears to be the most efficacious topical agent, with other topical agents not yielding positive outcomes.9

Numerous systemic therapies have also been assessed for the management of burning mouth syndrome, including antidepressants, anticonvulsants, anxiolytics, -aminobutyric acid receptor agonists, atypical analgesics, H2 receptor antagonists, atypical antipsychotics, herbal supplements and vitamin complexes.10-23 Currently, systemic clonazepam appears to be the most widely recommended first-line therapeutic agent for burning mouth syndrome.9,24,25 Individual studies using various doses of this drug have reported a reduction of oral burning in at least 70% of patients.13,26 A well-studied nonpharmacologic systemic alternative in the management of this condition is -lipoic acid, the trometamol salt of thioctic acid. Initial studies of this agent as a treatment for burning mouth syndrome reported significant improvements,3,8,27-29 but more recent controlled studies have not confirmed these beneficial results.30-33

Despite the existence of these generally accepted management strategies, the definitive diagnosis is usually delayed, as indicated by both our retrospective study1 and an earlier European study, in which the average delay from onset of symptoms to definitive diagnosis was 34 months (range 1 to 348 months, median 13 months).34

The findings of our retrospective study (based on data from 38 patients) regarding the number of prescriptions that each patient received before attending the pain clinic (about 2 prescriptions per patient) and the many treatments prescribed (a total of 71 treatments) are of interest. These findings indicate that practitioners may be using multiple pharmacological approaches to treat oral burning, or they may indicate possible misdiagnosis of burning mouth syndrome. Another possibility is that practitioners have prescribed some of these pharmaceutical agents to treat other symptoms or comorbidities associated with burning mouth syndrome, such as dry mouth and altered sensations. Alternatively, patients may have sought treatment from several health care practitioners because of persistence of the problem, despite prior interventions; as a result, individual patients may have received multiple medications. This situation is not unusual, as patients with unexplained pain are more likely to consult multiple practitioners.35 Also, it has been reported that patients whose burning mouth syndrome was initially misdiagnosed consulted approximately 3 (range 0 to 12) health care practitioners before receiving the definitive diagnosis.34

In our retrospective study, 11 patients reported no previous prescribed treatment for their oral burning, despite presentation to various health care practitioners. This lack of treatment may have been due to practitioners' uncertainty about the diagnosis or appropriate therapy and hence a reluctance to prescribe treatment before referral.36-38

The patients in this retrospective study received prescriptions for various medications before burning mouth syndrome was definitively diagnosed. Salivary stimulants (sialogogues) or salivary substitutes may have been prescribed because symptoms of dry mouth (xerostomia, which is determined subjectively, or hyposalivation, which can be measured objectively) are commonly reported by patients with burning mouth syndrome.39-41 Antifungals may have been prescribed because of an association between oral burning and clinical or subclinical candidiasis. In addition, hyposalivation may be associated with an increased risk of fungal infection.42 Practitioners commonly prescribe antifungals for patients who report oral burning and/or taste alteration without visible lesions, as may have occurred in these patients. Anticonvulsants may have been prescribed because practitioners presumed that the oral burning represented a neurological disorder such as neuropathy or neuralgia. Intriguingly, burning mouth syndrome has been theorized to be a neuropathic condition,43-49 with some patients experiencing associated symptoms such as sensory and taste alteration (dysgeusia).39,40,50 Anxiolytics may have been prescribed if health care practitioners perceived that patients' complaints of oral burning were caused by anxiety disorders or neuropathic pain. Certainly, burning mouth syndrome has been associated with psychological disorders, including anxiety.51-53 However, other studies comparing patients with burning mouth syndrome with the general population have found a lack of evidence for significant clinical elevations on any psychological subscales, including anxiety.54-56 Practitioners may have prescribed topical anesthetics on the assumption that oral burning was due to an underlying mucosal lesion. However, topical anesthetics have not been reported to have any utility in the management of this condition.

As evidenced by our retrospective study1 and others, burning mouth syndrome may present diagnostic and management challenges. Given the possible need for diagnostic testing and management with systemic medications not commonly used in dentistry, appropriate referral may be a reasonable approach in caring for dental patients who present with oral burning sensation.

THE AUTHOR

Dr. Klasser is associate professor at the Louisiana State University School of Dentistry, New Orleans, Louisiana.

Dr. Epstein is professor, University of Illinois at Chicago, College of Dentistry, department of oral medicine and diagnostic sciences; director, interdisciplinary program in oral cancer biology, prevention and treatment, College of Medicine, Chicago Cancer Center, Chicago, IL.

Ms. Villines is research coordinator, Advocate Lutheran General, Park Ridge, IL.

Correspondence to: Dr. Gary D. Klasser, Louisiana State University School of Dentistry, division of diagnostic sciences, 1100 Florida Ave., New Orleans, LA 70119, USA. Email: gklass@lsuhsc.edu.

The authors have no declared financial interests.

This article has been peer reviewed.

References

  1. Klasser GD, Epstein JB, Villines D. Diagnostic dilemma: the enigma of an oral burning sensation. J Can Dent Assoc. 2011;77:b146.
  2. Bergdahl J, Anneroth G, Perris H. Cognitive therapy in the treatment of patients with resistant burning mouth syndrome: a controlled study. J Oral Pathol Med 1995;24(5):213-5.
  3. Femiano F, Gombos F, Scully C. Burning Mouth Syndrome: open trial of psychotherapy alone, medication with alpha-lipoic acid (thioctic acid), and combination therapy. Med Oral 2004;9(1):8-13.
  4. Miziara ID, Filho BC, Oliveira R, Rodrigues dos Santos RM. Group psychotherapy: an additional approach to burning mouth syndrome. J Psychosom Res 2009;67(5):443-8. Epub 2009 Feb 28.
  5. Grushka M, Epstein JB, Gorsky M. Burning mouth syndrome. Am Fam Physician. 2002;65(4):615-20.
  6. Gremeau-Richard C, Woda A, Navez ML, Attal N, Bouhassira D, Gagnieu MC, et al. Topical clonazepam in stomatodynia: a randomised placebo-controlled study. Pain 2004;108(1-2):51-7.
  7. Sardella A, Uglietti D, Demarosi F, Lodi G, Bez C, Carrassi A. Benzydamine hydrochloride oral rinses in management of burning mouth syndrome. A clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(6):683-6.
  8. Femiano F. Burning mouth syndrome (BMS): an open trial of comparative efficacy of alpha-lipoic acid (thioctic acid) with other therapies. Minerva Stomatol 2002;51(9):405-9.
  9. Patton LL, Siegel MA, Benoliel R, De Laat A. Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103 Suppl:S39 e1-13.
  10. Maina G, Vitalucci A, Gandolfo S, Bogetto F. Comparative efficacy of SSRIs and amisulpride in burning mouth syndrome: a single-blind study. J Clin Psychiatry 2002;63(1):38-43.
  11. Demarosi F, Tarozzi M, Lodi G, Canegallo L, Rimondini L, Sardella A. The effect of levosulpiride in burning mouth syndrome. Minerva Stomatol 2007;56(1-2):21-6.
  12. Tammiala-Salonen T, Forssell H. Trazodone in burning mouth pain: a placebo-controlled, double-blind study. J Orofac Pain 1999;13(2):83-8.
  13. Grushka M, Epstein J, Mott A. An open-label, dose escalation pilot study of the effect of clonazepam in burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86(5):557-61.
  14. Heckmann SM, Heckmann JG, Ungethum A, Hujoel P, Hummel T. Gabapentin has little or no effect in the treatment of burning mouth syndrome - results of an open-label pilot study. Eur J Neurol 2006;13(7):e6-7.
  15. Petruzzi M, Lauritano D, De Benedittis M, Baldoni M, Serpico R. Systemic capsaicin for burning mouth syndrome: short-term results of a pilot study. J Oral Pathol Med 2004;33(2):111-4.
  16. Lopez V, Alonso V, Marti N, Calduch L, Jorda E. Marked response of burning mouth syndrome to pregabalin treatment. Clin Exp Dermatol 2009;34(7):e449-50.
  17. Siniscalchi A, Gallelli L, Marigliano NM, Orlando P, De Sarro G. Use of topiramate for glossodynia. Pain Med 2007;8(6):531-4.
  18. Sardella A, Lodi G, Demarosi F, Tarozzi M, Canegallo L, Carrassi A. Hypericum perforatum extract in burning mouth syndrome: a randomized placebo-controlled study. J Oral Pathol Med 2008;37(7):395-401. Epub 2008 Mar 6.
  19. Toida M, Kato K, Makita H, Long NK, Takeda T, Hatakeyama D, et al. Palliative effect of lafutidine on oral burning sensation. J Oral Pathol Med 2009;38(3):262-8. Epub 2009 Jan 23.
  20. Ueda N, Kodama Y, Hori H, Umene W, Sugita A, Nakano H, et al. Two cases of burning mouth syndrome treated with olanzapine. Psychiatry Clin Neurosci 2008;62(3):359-61.
  21. White TL, Kent PF, Kurtz DB, Emko P. Effectiveness of gabapentin for treatment of burning mouth syndrome. Arch Otolaryngol Head Neck Surg 2004;130(6):786-8.
  22. Toyofuku A. Efficacy of milnacipran for glossodynia patients. Int J Psychiatry Clin Pract. 2003;7(Suppl 1):23-24.
  23. Ito M, Kimura H, Yoshida K, Kimura Y, Ozaki N, Kurita K. Effectiveness of milnacipran for the treatment of chronic pain in the orofacial region. Clin Neuropharmacol 2010;33(2):79-83.
  24. Grushka M, Ching V, Epstein J. Burning mouth syndrome. Adv Otorhinolaryngol 2006;63:278-87.
  25. Suarez P, Clark GT. Burning mouth syndrome: an update on diagnosis and treatment methods. J Calif Dent Assoc 2006;34(8):611-22.
  26. Barker KE, Batstone MD, Savage NW. Comparison of treatment modalities in burning mouth syndrome. Aust Dent J 2009;54(4):300-5; quiz 396.
  27. Femiano F, Gombos F, Scully C, Busciolano M, De Luca P. Burning mouth syndrome (BMS): controlled open trial of the efficacy of alpha-lipoic acid (thioctic acid) on symptomatology. Oral Dis 2000;6(5):274-7.
  28. Femiano F, Scully C. Burning mouth syndrome (BMS): double blind controlled study of alpha-lipoic acid (thioctic acid) therapy. J Oral Pathol Med 2002;31(5):267-9.
  29. Femiano F, Gombos F, Scully C. Burning mouth syndrome: the efficacy of lipoic acid on subgroups. J Eur Acad Dermatol Venereol 2004;18(6):676-8.
  30. Steele JC, Bruce AJ, Drage LA, Rogers RS. Alpha-lipoic acid treatment of 31 patients with sore, burning mouth. Oral Dis 2008;14(6):529-32.
  31. Lopez-Jornet P, Camacho-Alonso F, Leon-Espinosa S. Efficacy of alpha lipoic acid in burning mouth syndrome: a randomized, placebo-treatment study. J Oral Rehabil 2009;36(1):52-7. Epub 2008 Oct 18.
  32. Carbone M, Pentenero M, Carrozzo M, Ippolito A, Gandolfo S. Lack of efficacy of alpha-lipoic acid in burning mouth syndrome: a double-blind, randomized, placebo-controlled study. Eur J Pain 2009;13(5):492-6. Epub 2008 Dec 9.
  33. Cavalcanti DR, da Silveira FR. Alpha lipoic acid in burning mouth syndrome--a randomized double-blind placebo-controlled trial. J Oral Pathol Med 2009;38(3):254-61. Epub 2009 Jan 23.
  34. Mignogna MD, Fedele S, Lo Russo L, Leuci S, Lo Muzio L. The diagnosis of burning mouth syndrome represents a challenge for clinicians. J Orofac Pain 2005;19(2):168-73.
  35. Aggarwal VR, McBeth J, Zakrzewska JM, Macfarlane GJ. Unexplained orofacial pain - is an early diagnosis possible? Br Dent J 2008;205(3):E6; discussion 140-1. Epub 2008 Jul 4.
  36. Haberland CM, Allen CM, Beck FM. Referral patterns, lesion prevalence, and patient care parameters in a clinical oral pathology practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87(5):583-8.
  37. Suarez P, Clark G. Oral conditions of 1,049 patients referred to a university-based oral medicine and orofacial pain center. Spec Care Dentist 2007;27(5):191-5.
  38. Farah CS, Simanovic B, Savage NW. Scope of practice, referral patterns and lesion occurrence of an oral medicine service in Australia. Oral Dis 2008;14(4):367-75.
  39. Woda A, Navez ML, Picard P, Gremeau C, Pichard-Leandri E. A possible therapeutic solution for stomatodynia (burning mouth syndrome). J Orofac Pain. 1998;12(4):272-8.
  40. Grushka M. Clinical features of burning mouth syndrome. Oral Surg Oral Med Oral Pathol. 1987;63(1):30-6.
  41. Ship JA, Grushka M, Lipton JA, Mott AE, Sessle BJ, Dionne RA. Burning mouth syndrome: an update. J Am Dent Assoc 1995;126(7):842-53.
  42. Osaki T, Yoneda K, Yamamoto T, Ueta E, Kimura T. Candidiasis may induce glossodynia without objective manifestation. Am J Med Sci 2000;319(2):100-5.
  43. Lauria G, Majorana A, Borgna M, Lombardi R, Penza P, Padovani A, et al. Trigeminal small-fiber sensory neuropathy causes burning mouth syndrome. Pain. 2005;115(3):332-7.
  44. Jaaskelainen SK. Clinical neurophysiology and quantitative sensory testing in the investigation of orofacial pain and sensory function. J Orofac Pain. 2004;18(2):85-107.
  45. Hagelberg N, Forssell H, Aalto S, Rinne JO, Scheinin H, Taiminen T, et al. Altered dopamine D2 receptor binding in atypical facial pain. Pain. 2003;106(1-2):43-8.
  46. Forssell H, Jaaskelainen S, Tenovuo O, Hinkka S. Sensory dysfunction in burning mouth syndrome. Pain. 2002;99(1-2):41-7.
  47. Heckmann SM, Heckmann JG, HiIz MJ, Popp M, Marthol H, Neundorfer B, et al. Oral mucosal blood flow in patients with burning mouth syndrome. Pain. 2001;90(3):281-6.
  48. Formaker BK, Mott AE, Frank ME. The effects of topical anesthesia on oral burning in burning mouth syndrome. Ann N Y Acad Sci. 1998;855:776-80.
  49. Nagler RM, Hershkovich O. Sialochemical and gustatory analysis in patients with oral sensory complaints. J Pain. 2004;5(1):56-63.
  50. 50. Eguia Del Valle A, Aguirre-Urizar JM, Martinez-Conde R, Echebarria-Goikouria MA, Sagasta-Pujana O. Burning mouth syndrome in the Basque Country: a preliminary study of 30 cases. Med Oral. 2003;8(2):84-90.
  51. Eli I, Baht R, Littner MM, Kleinhauz M. Detection of psychopathologic trends in glossodynia patients. Psychosom Med 1994;56(5):389-94.
  52. Buljan D, Savic I, Karlovic D. Correlation between anxiety, depression and burning mouth syndrome. Acta Clin Croat 2008;47(4):211-6.
  53. Abetz LM, Savage NW. Burning mouth syndrome and psychological disorders. Aust Dent J 2009;54(2):84-93.
  54. Carlson CR, Miller CS, Reid KI. Psychosocial profiles of patients with burning mouth syndrome. J Orofac Pain 2000;14(1):59-64.
  55. Danhauer SC, Miller CS, Rhodus NL, Carlson CR. Impact of criteria-based diagnosis of burning mouth syndrome on treatment outcome. J Orofac Pain 2002;16(4):305-11.
  56. Merigo E, Manfredi M, Zanetti MR, Miazza D, Pedrazzi G, Vescovi P. Burning mouth syndrome and personality profiles. Minerva Stomatol 2007;56(4):159-67.

Add new comment