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.
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.
|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)|
aSome patients reported undergoing more than one form of therapy.
bFor therapies reported by 3 patients or fewer.
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).
- Cognitive behavioural therapy
- Group psychotherapy
- Electroconvulsive therapya
- 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)
- 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.
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