Burning mouth syndrome (glossodynia)

Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Primary burning mouth syndrome (BMS) is a rare, chronic, debilitating disease characterized by intraoral burning in the absence of systemic disease or identifiable abnormalities on physical examination and laboratory testing. Current evidence suggests that altered neurophysiology of the central or peripheral nervous system as well as immune-mediated, hormonal, and psychological factors may play an etiopathogenic role. The diagnosis of primary BMS is a clinical diagnosis of exclusion. Various medical conditions and medications can induce oral burning, a condition referred to as secondary BMS. Secondary BMS improves with treatment of the underlying condition(s).

Management Strategy

A detailed history and physical examination should be completed to identify all alternative or correctable causes of oral burning. Correctable, associated factors may be local, systemic, or psychological.

Local Factors

Local factors include xerostomia (age, medication, radiotherapy); direct irritation (oral care products, tobacco); mechanical trauma (rough dental restorations, poorly fitting dental prostheses); parafunctional habits (bruxism, tongue thrusting); microbial infection or colonization (candidiasis, herpetic, fusospirochetal); geographic or fissured tongue; mucocutaneous diseases (lichen planus, pemphigus, pemphigoid); and allergic or irritant contact stomatitis (flavorings, food additives, dental materials, cosmetic products).

Systemic Factors

Systemic factors include nutritional deficiency states; autoimmune disease (Sjögren syndrome); gastrointestinal disease (gastroesophageal reflux); neurologic disease (trigeminal neuralgia, acoustic neuroma, Parkinson disease, glossopharyngeal neuralgia); medication(s); and endocrinopathies (hypothyroidism, diabetes).

Psychological Factors

Psychological factors include anxiety (including cancerophobia), depression, adjustment disorder, and psychosocial stressors.

Specific Investigations

Laboratory evaluation should be directed by the history and physical examination findings. If burning persists after eliminating or treating potential local, systemic, and psychological factors, a working diagnosis of primary BMS is adopted. Although consensus on treatment for primary BMS is lacking, many have found success with multimodal approaches resembling those used for the treatment of chronic, neuropathic pain.

A population-based study of the incidence of burning mouth syndrome

Kohorst JJ, Bruce AJ, Torgerson RR, et al. Mayo Clin Proc 2014; 89(11): 1545–52.

Annual age- and sex-adjusted incidence of BMS of 11.4 per 100,000 person-years.

Burning mouth syndrome

Jaaskelainen SK, Woda A. Cephalalgia 2017; 37: 627–47.

A review of BMS including evidence of neurophysiologic alterations in the peripheral or central nervous system.

Psychiatric comorbidity in patients with burning mouth syndrome

Bogetto F, Maina G, Ferro G, et al. Psychosom Med 1998; 60: 378–85.

In a case-control study of 102 patients with BMS, 59.8% had concomitant psychiatric disorders.

Burning mouth syndrome

Torgerson RR. Dermatol Ther 2010; 23: 291–8.

Multiple possible etiologies of BMS, including neuropathic, exocrine dysfunction, taste disturbance, mucosal atrophy, and psychological illness are reviewed ( Tables 33.1–33.3 ).

Table 33.1

Specific investigations

History
Oral symptoms	Timing, quality, duration, location, alleviating/exacerbating factors
Medications	Causative: efavirenz, ACE inhibitors, ARBs, omeprazole, topiramate, TNF-α inhibitors
Dental	Prostheses, recent procedures, dentifrices, topical medicaments, oral care products
Parafunctional habits	Bruxism, tongue thrusting
Review of symptoms	Weakness, headache, fatigue, concentration, sleep disturbance, arthralgia
Physical examination
Oral	Complete oral examination, including head and neck (remove any dental prostheses)
Nodal	Adenopathy
Musculoskeletal	Temporomandibular joint
Neurologic	Cranial nerve exam

Table 33.2

Laboratory evaluation

Hematologic	Complete blood count, ferritin, serum folate, cobalamin (+ methylmalonic acid, homocysteine)
Metabolic	Serum thiamine, riboflavin, pyridoxine, zinc (+ alkaline phosphatase), magnesium
Endocrinologic	Glycosylated hemoglobin, thyrotropin (+ free thyroxine)
Immunologic	Antinuclear factor (+ Ro/SSA, La/SSB)
Dermatologic	Biopsy (+ direct immunofluorescence) if visible abnormality on oral examination
Microbiology testing	Herpes simplex (polymerase chain reaction [PCR]); varicella zoster (PCR); candidiasis (swab from site of pain for direct examination and culture); human immunodeficiency virus screening

Table 33.3

Consultations

Otolaryngology	Nasopharyngoscopy
Gastroenterology	Esophagogastroduodenoscopy
Oral/maxillofacial	Periapical radiographs, magnetic resonance imaging
Mental health	Psychiatry consultation
Neurology	Neurologic examination, magnetic resonance imaging
Hypersensitivity testing	Epicutaneous patch testing (preservatives, oral flavors, metals, adhesives, food-related allergens)

Burning mouth syndrome: a comparative cross-sectional study

Rabiei M, Leili EK, Alizadeh L. Contemp Clin Dent 2018; 9: S256–60.

Age and sex are significant risk factors for development of BMS. Menopause, candidiasis, psychological disorders, job status, dentures, and dry mouth were more common in patients with BMS.

Burning mouth syndrome

Bender SD. Dent Clin North Am 2018; 62: 585–96.

BMS is a multifactorial condition, including interaction of psychological and neurophysiologic factors.

First-Line Therapies

Acknowledge and validate patient symptoms and experience; reassure	E
Avoid contact irritants (alcohol-based oral rinses, caustic mouthwashes, flavored dentifrices, acidic foods, carbonated beverages)	E
Treat xerostomia (sialagogues, artificial oral lubricants)	D
Discontinue or change causative medications (ACE inhibitor, ARB, selective serotonin reuptake inhibitor [SSRI], serotonin-norepinephrine reuptake inhibitor, benzodiazepine, non-nucleoside reverse-transcriptase inhibitor, PPI, anticonvulsant, anticholinergics, TNF-α inhibitors)	E
Replace thiamine, riboflavin, pyridoxine, folate, cobalamin, iron, zinc, ascorbic acid, magnesium	C
Manage concomitant psychiatric illness	C
Assess and address parafunctional habits (bruxism, tongue thrusting)	E
Assess oral prostheses and dental work	C
Imidazole/azole therapy (presence of functional pain)	C
Assess and address oral hygiene	E
Address sleep quality	B

Patients complaining of a burning mouth. Further experience in clinical assessment and management

Main DM, Basker RM. Br Dent J 1983; 154: 206–11.

A high rate of intraoral burning attributable to shortcomings in denture design.

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