How Do I Manage a Patient with Burning Mouth Syndrome?

Burning Mouth Syndrome

Idiopathic burning sensation of the oral mucosa with no apparent underlying cause. Etiology and pathogenesis is unknown (appears to be multifactorial) with a possible neuropathic basis.

Presentation

Population

• Middle-aged and elderly adults
• Predominantly in perimenopausal and postmenopausal women

Signs

• Onset is usually spontaneous, but previous trauma or dental treatment may be precipitating factors
• Most commonly a bilateral burning sensation of the tongue, lips, and/or palate
• Often presents with xerostomia
• Can be associated with anxiety, depression, and/or poor “quality of life”

Symptoms

• Continuous burning sensation of the tongue, hard palate, and/or lips
• Sensations may be described as dry, sandy, or numb; may be associated with other dysethetic changes
• Pain is sometimes reported to be mitigated by eating or gum chewing
• Often associated with loss of taste or changes in taste (e.g., phantom taste)

Investigation

• Thoroughly review the patient’s medical history for diseases and disorders with related oral symptoms
• Perform an oral examination that may include adjunctive laboratory studies when indicated (i.e., biopsy, fungal smear, blood test, etc.) to diagnose mucosal changes and assess and rule out systemic conditions which may cause a burning sensation of the oral mucosa

Diagnosis

Based on clinical examination and adjunctive laboratory assessments, if all local and systemic causes for burning pain can be excluded, a diagnosis of idiopathic burning mouth syndrome may be determined.

Differential Diagnosis

• Mucosal irritation due to:
  • Rough restoration or rough/ill-fitting prosthesis, parafunctional habits (e.g., cheek biting or tongue rubbing/biting)
  • Contact hypersensitivity to oral hygiene product, food, or dental material
  • Smoking
• Hyposalivation due to:
  • Autoimmune disease (e.g., Sjögren syndrome)
  • Radiation treatment to the head and neck
  • Medication-related side effects
• Mucocutaneous conditions (e.g., lichen planus, benign mucous membrane pemphigoid, pemphigus)
• Migratory glossitis (geographic tongue)
• Candidiasis
• Deficiency in vitamins and minerals (e.g., vitamin B₁₂, folic acid, iron, zinc)
• Endocrine issues (e.g., diabetes, hypothyroidism)

Treatment

Common Initial Treatments

• Sucking on ice chips
• Drinking cold water frequently
• Avoiding alcohol, food, oral products, or habits which may exacerbate symptoms

Alternate Treatments

• Cognitive behavioural therapy (CBT), clonazepam, and possibly alpha-lipoic acid have shown to be effective in reducing symptoms.
• Antidepressants and anticonvulsants are commonly prescribed; however, there is a lack of experimental evidence to support their effectiveness in the treatment of idiopathic burning mouth. They are nonetheless established in other neuropathic pain conditions.

Advice

• Acknowledge and reassure the patient, as patient frustration and dissatisfaction is very common.
• Treatment is difficult and challenging. Referral to a clinically-active specialist in oral medicine/oral pathology is recommended, with further medical management if the patient has other complex issues which may be contributing to the pain complaints.
• Realistic treatment goals should be set. Management is primarily supportive and aimed at symptom reduction rather than symptom elimination.

THE AUTHORS

	Dr. Chugh is assistant professor, department of oral pathology and oral medicine, faculty of dentistry, University of Toronto, Toronto.
	Dr. Mock is professor, department of oral pathology and oral medicine, faculty of dentistry, and department of pathobiology and laboratory medicine, faculty of medicine, University of Toronto, Toronto.

Correspondence to: Dr. Deepika Chugh, University of Toronto, Faculty of Dentistry, 124 Edward Street, Room 515A, Toronto ON  M5G 1G6. Email: deepika.chugh@dentistry.utoronto.ca

The authors have no declared financial interests.

This article has been peer reviewed.

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