Burning mouth syndrome

Gayathri Devi Kumaresan; M Subha

doi:10.4103/ijofb.ijofb_12_17

REVIEW ARTICLE

Year : 2017 | Volume : 1 | Issue : 2 | Page : 53-58

Burning mouth syndrome

Gayathri Devi Kumaresan, M Subha
Department of Oral Medicine, Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Web Publication

23-Jan-2018

Correspondence Address:
Gayathri Devi Kumaresan
Department of Oral Medicine, Saveetha Dental College, Chennai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ijofb.ijofb_12_17

Abstract

Burning mouth syndrome (BMS), a chronic orofacial pain syndrome is characterized by the presence of burning, stinging, and/or itching of the oral cavity in the absence of specific oral lesion. This condition affects chiefly of middle-aged and elderly woman with hormonal changes or psychological disorders. In addition to burning sensation, patient with BMS can be accompanied by gustatory disturbances such as dysgeusia (distortion in the sense of taste), parageusia, and subjective xerostomia (dry mouth) also complains of oral mucosal pain. This condition is probably of multifactorial origin, involving various local, systemic, and/or psychogenic causes, often idiopathic and its exact etiopathogenesis remains unclear. Female gender, premenopausal, depression and anxiety, Parkinson's disease, and chronic medical conditions including gastrointestinal and urogenital diseases are risk factors for developing BMS. BMS most often involves the tongue with or without extension to the lips and oral mucosa. The present paper discusses several aspects of BMS, updates current knowledge, and provides guidelines for patient management. The aim of this study is to review the current concepts regarding pathogenesis, classification, diagnosis, and treatment for this disorder. A literature review was carried out on Google Scholar and PubMed/Medline about the BMS and the related articles was selected and reviewed. BMS is a painful and often frustrating condition to the patients. There is no universal opinion regarding etiology, diagnosis, and treatment of BMS. BMS is a diagnosis of ejection which plausibly has multifactorial origin. A thorough understanding of the etiology and psychological impact of this disorder is required for better management. Diverse pharmacological and nonpharmacological therapies are available, but it is unmanageable to achieve curative treatment. Compounding of cognitive behavioral therapy, alpha-lipoic acid, and/or clonazepam had shown promising results.

Keywords: Burning mouth syndrome, glossopyrosis, neuropathic pain stomatodynia, oral dysesthesia, sore tongue, stomatopyrosis

How to cite this article:
Kumaresan GD, Subha M. Burning mouth syndrome. Int J Orofac Biol 2017;1:53-8

How to cite this URL:
Kumaresan GD, Subha M. Burning mouth syndrome. Int J Orofac Biol [serial online] 2017 [cited 2023 Jun 3];1:53-8. Available from: https://www.ijofb.org/text.asp?2017/1/2/53/223816

Introduction

Burning mouth syndrome (BMS) “A pain of at least 4–6 months duration located on the tongue or other oral mucosal membranes associated with normal clinical or laboratory findings” defined by the International Association for the Study of Pain.^[1] In the past, this condition has been referred by variety of names that include scalded mouth syndrome, stomatodynia, sore tongue, burning lips syndrome, glossodynia, glossalgia, stomatopyrosis, oral dysesthesia, burning mouth condition, glossopyrosis, sore mouth, and BMS (the most widely accepted).^[2],[3] There are many systemic and local disorders causing a burning sensation of the oral cavity. However, psychogenic and neurological conditions may be responsible for this symptom. As its name implies, BMS is one of the conditions causing burning sensation of the oral cavity which has various synonyms such as stomatodynia, glossodynia, glossopyrosis, and oral dysesthesia. It is a diagnosis of exclusion having the prevalence ranging from 0.7% to 4.6%.^[3] BMS is more common in premenopausal or postmenopausal women which may also be associated with other chronic pain disorders, depression, anxiety or somatization; so the patient usually has poor quality of life.^{[4],[5],[6],[7]} So far, there is no definitive cure for this condition and most of the treatment approaches; medications remain unsatisfactory.

Various attempts to classify BMS based on etiology and symptoms have been made.

In a classification by etiology or cause

“Primary BMS” (or “true BMS”) idiopathic BMS
“Secondary BMS” has an identifiable cause.

Another classification of BMS is based on symptoms, stratifying cases into 3 types, as follows:^[8]

Type 1 BMS: Patients have no symptoms on waking, with progression throughout the day. Nighttime symptoms are variable. Nutritional deficiency and diabetes may produce a similar pattern
Type 2 BMS: Patients have continuous symptoms throughout the day and are frequently asymptomatic at night. This type is associated with chronic anxiety
Type 3 BMS: Patients have intermittent symptoms throughout the day and symptom-free days. Food allergy is suggested as a potential mechanism.

BMS is likely more than one disease process, and the etiology may be multifactorial. The ambiguous definition of BMS makes evaluation of prognosis and treatment difficult.

Epidemiology

It is extremely difficult to establish the true preponderance of BMS due to the lack of appropriate, uniform and reproducible classification system, determinate diagnostic criteria and their awareness among the oral health-care professionals. Many authors fail to differentiate between the syndrome and the symptom as such. The preponderance of BMS reported from different international studies ranges from 0.6% to 15%, respectively.^[9] BMS is basically a disorder of middle-aged and elderly individuals with an age range of 38–78 years.^[3] It seems that their preponderance increases with age in both males and females. BMS exhibits substantial female predilection and the ratio between females and males varies from 3:1 to 16:1 in different literature studies.^[10] Even though it is not yet outlined, these gender differences were explained in the context of biological, psychological, and sociocultural factors. Epidemiological studies reveal that this condition is especially common among pre- and post-menopausal women where their prevalence increases up to 12%–18%.^[11] This condition is exceedingly rare in patients under 30 years and never been reported in children and adolescence.^[12]

Etiopathogenesis

The pathophysiology of BMS is not yet fully understood, and different hypotheses have been projected to explain its etiopathogenic mechanism. BMS being a diagnosis of exclusion, burning sensation in the mouth caused by various systemic and local disorders has to be ruled out. Burning sensation inside mouth caused by various local conditions includes smoking, dental conditions such as ill-fitting denture, contact hypersensitivity to dental materials, alkaline oral rinses, or acidic foods.

Local causes

Clinical examination followed by biopsy will usually exclude mucocutaneous diseases such as oral candidiasis, lichen planus, lichenoid reactions, pemphigus, and glossitis. Similarly, viral infections such as herpes simplex or zoster may cause burning sensation.

Systemic causes

Endocrine

Menopause is associated with a higher occurrence of BMS, whereas the mechanism is unknown, hormonal (Estrogen) alterations have documented effects on oral mucosa, and deprivation may lead to atrophic changes within the epithelium.^[13] Alternatively, atrophic epithelia may be more prone to inflammation. Peripheral neuropathy occurs in diabetes mellitus is a cause of secondary BMS.^[14]

Immunologic

An immunologic mechanism for BMS has been suggested by the observation of increased serum erythrocyte sedimentation rate and salivary IgA in BMS patients compared with controls.^{[10],[15],[16]}

Nutritional

Deficiencies of B vitamins 1, 2, 6, and 12, zinc,^[17] folate, and iron, have been suggested as causes of secondary BMS, either from direct neurologic damage or in relation to anemia.

Infectious

Oral infections have been explored, and a few microbes had been identified to be possibly more prevalent in BMS patients without visible mucosal lesions: Candida, Enterobacter, Fusospirochetals, Helicobacter pylori, and Klebsiella.^[18],[19]

Iatrogenic

Various cases of drug-associated BMS have been reported. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), antiretrovirals nevirapine, efavirenz, L-thyroxine, and topiramate are the most commonly noted in case reports.^{[20],[21],[22]}

Allergic

Allergies are not frequently identified in patients with BMS but have been proposed as a cause of Type 3 BMS (intermittent symptoms). However, they are typically associated with signs of mucosal irritation. Proposed irritants include dental materials such as mercury (present in amalgam), methyl methacrylate, cobalt chloride, zinc, and benzoyl peroxide.^[16] Components of lotions such as petrolatum cadmium sulfate, octyl gallate, benzoic acid, and propylene glycol have been concerned. Food allergens include peanuts, chestnuts, cinnamon, and sorbic acid.^[8] Nicotinic acid also been suggested as allergen.

The exact etiology of BMS is not clearly understood. Therefore, it is thought to be of multifactorial in origin.^[23] Local and systemic factors have been projected as the possible etiological agents from different studies.^{[23],[24],[25],[26],[27],[28],[29],[30]}

Psychological causes

Anxiety, hypochondriasis, depression, stress, life events, personality disorders, cancerophobia, and neuropathy.^{[31],[32],[33]} It has also been suggested that BMS occurs due to damage to the taste pathways, for example, Chorda tympani nerve; and axonal degeneration of the trigeminal sensory nerve fiber has been demonstrated as well.^{[34],[35],[36],[37]}

Clinical Features

The term BMS inculpates to an individual who complains of variety of chronic oral symptoms that admits oral mucosal pain, altered taste sensation, xerostomia, and others that often increases in intensity at the end of each day that seldom interfere with sleep.^[4] The clinical display may vary as some patients can be oligosymptomatic (pain and dysgeusia or xerostomia) or monosymptomatic (pain only).^[3] In general, 63% of patients describe BMS accompanying dry mouth, 60% bitter/metallic taste, and 35% altered taste perception. The pain is represented as burning, scalding, tingling, or numbness. It is of moderate-to-severe intensity and can decrease during eating. It is commonly bilateral and most often involves the tongue succeeded by the palate and lower lip. In contrast, the buccal mucosa and floor of the mouth are rarely involved.^[10] The onset is spontaneous, though some BMS patients report ascendant dental procedures, initiation of medications, or other illnesses.^[3],[38] Xerostomia may be immanent; however, some patients have demonstrated alterations in saliva quantity and quality.^[3] Vertical visual analog scale (VAS, 0-10 cm)^[39] is commonly used to describe pain intensity in BMS.

Diagnosis

The diagnosis of BMS remains intriguing as diagnostic criteria are not sufficiently defined or universally accepted, several contradictory diagnoses exist, and the clinical display is often variable. Scala et al.^[3] projected the following fundamental criteria:

Daily and deep bilateral burning sensation of the oral mucosa
Burning sensation for at least 4–6 months
Constant intensity or increasing intensity during the day
No worsening but possible improvement on eating or drinking; and
No interference with sleep.

Additional supportive criteria are ^[1] dysgeusia and/or xerostomia;^[2] sensory or chemosensory alterations; and ^[3] mood changes or psychopathological alterations.

It is wise for the clinician to obtain a clear and elaborate medical/dental history as well as execute a thorough oral clinical examination including any laboratory studies indicated. A neurological examination can be useful although, unless there is marked inadequacy, the lack of baseline data can present a trouble. If all other causes of oral burning symptom are excluded and/or the patient fails to respond to a normal course of treatment, then a diagnosis of primary BMS is reasonable.^[40]

Differential Diagnosis

Differentiating primary BMS from secondary BMS is important. The following conditions may produce BMS-like symptoms:^{[19],[41],[42],[43],[44]}

Anemia
Anxiety
Alcohol-based mouthwash
Aphthous stomatitis
Areca nut extract exposure
Bacterial infection
Candidiasis
Ciguatera neurotoxin exposure
Chewing tobacco use
Contact stomatitis
Diabetes
Dehydration
Erosive lichen planus
Gastroesophageal reflux disease
Geographic tongue
Impacted teeth
Infections of bone, teeth, or implants
Leukoplakia
Multiple sclerosis
Mouth breathing/nasal obstruction
Medication reaction (e.g., ACE inhibitors, ARBs, antiretrovirals, psychotropic, anticholinergic, clonazepam, and chemotherapeutic agents)
Mandibular fracture
Neoplasia
Pemphigoid
Pemphigus
Radiation-induced stomatitis
Sjögren Syndrome
Scleroderma
Vitamin deficiency (B1, B2, B6, B12, folate, iron)
Hypothyroidism.

Management

A thorough clinical examination of the oral mucosa is crucial in these patients. The lack of oral mucosal pathology is mandatory for the diagnosis of BMS. Details regarding the quality, onset, persistence, intensity, occurrence, duration, relieving factors, evolution, site(s) involved in pain symptoms are essential. This information will give a vital clue in differentiating the BMS from other chronic orofacial pain disorders. Management of BMS can be broadly discussed under three topics, namely, topical medications [Table 1], systemic medications [Table 2], and behavioral interactions. Medications used for BMS include antidepressants, analgesics, antiepileptics, antifungals, antibacterials, sialagogues, antihistamines, anxiolytics, antipsychotics and vitamin, mineral, and hormonal replacements.

Table 1: Topical medications

Click here to view

Table 2: Systemic medications

Click here to view

Successful treatment of BMS patients with combined psychotherapy and psychopharmacotherapy has also been reported in [Table 2].^[51],[52]

Conclusion

BMS is a painful and often frustrating condition to the patients. There is no universal opinion regarding etiology, diagnosis, and treatment of BMS. BMS is a diagnosis of ejection which plausibly has multifactorial origin. A thorough understanding of the etiology and psychological impact of this disorder, combined with novel pharmacological interventions is required for better management. Diverse pharmacological and nonpharmacological therapies are available, but it is unmanageable to achieve curative treatment. Compounding of cognitive behavioral therapy, alpha-lipoic acid, and/or clonazepam had shown promising results.^[57]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Pia LJ, Fabio CA, Paz AM, Mariano SS, Francisco GG. Burning mouth syndrome: Update. Med Oral Patol Oral Cir Bucal 2010;15:e562-8.
2.	Lamey PJ. Burning mouth syndrome. Dermatol Clin 1996;14:339-54.
3.	Scala A, Checchi L, Montevecchi M, Marini I, Giamberardino MA. Update on burning mouth syndrome: Overview and patient management. Crit Rev Oral Biol Med 2003;14:275-91.
4.	Gorsky M, Silverman S Jr, Chinn H. Clinical characteristics and management outcome in the burning mouth syndrome. An open study of 130 patients. Oral Surg Oral Med Oral Pathol 1991;72:192-5.
5.	Zakrzewska JM. The burning mouth syndrome remains an enigma. Pain1995;62:253–7.
6.	Lipton JA, Ship JA, Larach-Robinson D. Esti-mated prevalence and distribution or reported orofacial pain in the United States. J Amer Dent Assoc 1993;124:115–21.
7.	Wessely S, Nimnuan C, Sharpe M. Function-al somatic syndromes: one or many? Lancet 1999;354:936–9.
8.	Huang W, Rothe MJ, Grant-Kels JM. The burning mouth syndrome. J Am Acad Dermatol 1996;34:91-8.
9.	Zakrzewska JM, Hamlyn PJ. Facial pain. In: Crombie IK, editor. Epidemiology of Pain. Seattle, WA: IASP Press; 1999. p. 175-82.
10.	Grushka M. Clinical features of burning mouth syndrome. Oral Surg Oral Med Oral Pathol 1987;63:30-6.
11.	Sun A, Wu KM, Wang YP, Lin HP, Chen HM, Chiang CP. Burning mouth syndrome: A review and update. J Oral Pathol Med 2013;42:649-55.
12.	Lopez-Jornet P, Camacho-Alonso F, Andujar-Mateos P, Sanchez-Siles M, Gomez-Garcia F. Burning mouth syndrome: An update. Med Oral Patol Oral Cir Bucal 2010;15:e562-8.
13.	Välimaa H, Savolainen S, Soukka T, Silvoniemi P, Mäkelä S, Kujari H, et al. Estrogen receptor-beta is the predominant estrogen receptor subtype in human oral epithelium and salivary glands. J Endocrinol 2004;180:55-62.
14.	Moore PA, Guggenheimer J, Orchard T. Burning mouth syndrome and peripheral neuropathy in patients with type 1 diabetes mellitus. J Diabetes Complications 2007;21:397-402.
15.	Granot M, Nagler RM. Association between regional idiopathic neuropathy and salivary involvement as the possible mechanism for oral sensory complaints. J Pain 2005;6:581-7.
16.	Koike M. A case of burning mouth associated with dental metal allergy. Nihon Hotetsu Shika Gakkai Zasshi 2005;49:498-501.
17.	Cho GS, Han MW, Lee B, Roh JL, Choi SH, Cho KJ, et al. Zinc deficiency may be a cause of burning mouth syndrome as zinc replacement therapy has therapeutic effects. J Oral Pathol Med 2010;39:722-7.
18.	Jääskeläinen SK, Rinne JO, Forssell H, Tenovuo O, Kaasinen V, Sonninen P, et al. Role of the dopaminergic system in chronic pain – A fluorodopa-PET study. Pain 2001;90:257-60.
19.	Terai H, Shimahara M. Glossodynia from Candida-associated lesions, burning mouth syndrome, or mixed causes. Pain Med 2010;11:856-60.
20.	Castells X, Rodoreda I, Pedrós C, Cereza G, Laporte JR. Drug points: Dysgeusia and burning mouth syndrome by eprosartan. BMJ 2002;325:1277.
21.	Triantos D, Kanakis P. Stomatodynia (burning mouth) as a complication of enalapril therapy. Oral Dis 2004;10:244-5.
22.	Savino LB, Haushalter NM. Lisinopril-induced “scalded mouth syndrome”. Ann Pharmacother 1992;26:1381-2.
23.	Grushka M, Epstein JB, Gorsky M. Burning mouth syndrome. Am Fam Physician 2002;65:615-20.
24.	Bergdahl M, Bergdahl J. Burning mouth syndrome: Prevalence and associated factors. J Oral Pathol Med 1999;28:350-4.
25.	Mock D, Chugh D. Burning mouth syndrome. Int J Oral Sci 2010;2:1-4.
26.	Oh R, Brown DL. Vitamin B12 deficiency. Am Fam Physician 2003;67:979-86.
27.	Hagelberg N, Forssell H, Rinne JO, Scheinin H, Taiminen T, Aalto S, et al. Striatal dopamine D1 and D2 receptors in burning mouth syndrome. Pain 2003;101:149-54.
28.	Maragou P, Ivanyi L. Serum zinc levels in patients with burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1991;71:447-50.
29.	Lamey PJ, Allam BF. Vitamin status of patients with burning mouth syndrome and the response to replacement therapy. Br Dent J 1986;168:81-4.
30.	Hugoson A, Thorstensson B. Vitamin B status and response to replacement therapy in patients with burning mouth syndrome. Acta Odontol Scand 1991;49:367-75.
31.	Basker RM, Sturdee DW, Davenport JC. Patients with burning mouths. A clinical in-vestigation of causative factors, including the climacteric and diabetes. Br Dent J 1978;145:9-16.
32.	Wardrop RW, Hailes J, Burger H. Oral dis-comfort at the menopause. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1989;67:535-40.
33.	Rojo L, Silvestre FJ, Bagan JV. Psychiatric morbidity in burning mouth syndrome. Psychiatric interview versus depression and anxiety scales. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1993;75:308-11.
34.	Yilmaz Z, Renton T, Yiangou Y, Zakrzewska J, Chessell IP, Bountra C, et al. Burning mouth syndrome as a trigeminal small fibre neuropathy: Increased heat and capsaicin receptor TRPV1 in nerve fibres correlates with pain score. J Clin Neurosci 2007;14:864-71.
35.	Lauria G, Majorana A, Borgna M, Lombardi R, Penza P, Padovani A, et al. Tregiminal small-fiber sensory neuropathy causes burning mouth syndrome. Pain 2005;115:332-7.
36.	Groushka M, Bartoshuk LM. Burning mouth syndrome and oral dysaesthesia: Taste injury is a piece of puzzle. Can J Diagnosis 2000;17:99-109.
37.	Gao S, Wang Y, Wang Z. Assessment of trigeminal somatosensory evoked potentials in burning mouth syndrome. Chin J Dent Res 2000;3:40-6.
38.	Speciali JG, Stuginski-Barbosa J. Burning mouth syndrome. Curr Pain Headache Rep 2008;12:279-84.
39.	Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175-84.
40.	Ambaldhage VK, Puttabuddi JH, Nunsavath PN. Burning mouth syndrome: An update. Indian J Pain 2015;29:2-8. [Full text]
41.	Culhane NS, Hodle AD. Burning mouth syndrome after taking clonazepam. Ann Pharmacother 2001;35:874-6.
42.	Heir GM. Ciguatera neurotoxin poisoning mimicking burning mouth syndrome. Quintessence Int 2005;36:547-50.
43.	Parmar G, Sangwan P, Vashi P, Kulkarni P, Kumar S. Effect of chewing a mixture of areca nut and tobacco on periodontal tissues and oral hygiene status. J Oral Sci 2008;50:57-62.
44.	Ozkan BT, Celik S, Durmus E. Paresthesia of the mental nerve stem from periapical infection of mandibular canine tooth: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e28-31.
45.	Buchanan J, Zakrzewska J. Burning mouth syndrome. Clin Evid 2004;12:1899-905.
46.	Moreno Gimenez J. Glosodynia before and after diagnosis. Piel 2005;20:524-9.
47.	Brufau-Redondo C, Martin-Brufau R, Corbalan-Velez R, de Concepcion-Salesa A. Burning mouth syndrome. Actas Dermosifiliogr 2008;99:431-40.
48.	Gremeau-Richard C, Woda A, Navez ML, Attal N, Bouhassira D, Gagnieu MC, et al. Topical clonazepam in stomatodynia: A randomized placebo-controlled study. Pain 2004;108:51-7.
49.	Lopez-Jornet P, Camacho-Alonso F, Molino-Pagan D. Prospective, randomized, double-blind, clinical evaluation of Aloe vera Barbadensis, applied in combination with a tongue protector to treat burning mouth syndrome. J Oral Pathol Med 2013;42:295-301.
50.	Femiano F. Burning mouth syndrome (BMS): An open trial of comparative efficacy of alpha-lipoic acid (thioctic acid) with other therapies. Minerva Stomatol 2002;51:405-9.
51.	Aravindhan R, Vidyalakshmi S, Kumar MS, Satheesh C, Balasubramanium AM, Prasad VS, et al. Burning mouth syndrome: A review on its diagnostic and therapeutic approach. Dent Sci 2016;6:S21-5.
52.	Van Houdenhove B, Joostens P. Burning mouth syndrome. Successful treatment with combined psychotherapy and psychopharmacotherapy. Gen Hosp Psychiatry 1995;17:385-8.
53.	Buchanan J, Zakrzewska J. Burning mouth syndrome. Clin Evid 2005;14:1685-90.
54.	Nagler RM, Hershkovich O. Sialochemical and gustatory analysis in patients with oral sensory complaints. J Pain 2004;5:56-63.
55.	Sun A, Lin HP, Wang YP, Chen HM, Cheng SJ, Chiang CP, et al. Significant reduction of serum homocysteine level and oral symptoms after different vitamin-supplement treatments in patients with burning mouth syndrome. J Oral Pathol Med 2013;42:474-9.
56.	Forabosco A, Criscuolo M, Coukos G, Uccelli E, Weinstein R, Spinato S, et al. Efficacy of hormone replacement therapy in postmenopausal women with oral discomfort. Oral Surg Oral Med Oral Pathol 1992;73:570-4.
57.	Bergdahl J, Anneroth G, Perris H. Personality characteristics of patients with resistant burning mouth syndrome. Acta Odontol Scand 1995;53:7-11.