Burning Mouth Syndrome

Nurdiana, drg., Sp.PM

“Burning Mouth Syndrome” (BMS)

oral burning in tongue or other oral mucous membranes no detectable

cause, do not follow anatomic pathways, no mucosal lesions or known neurologic disorders & no laboratory abnormalities

*BMS burn ing lips syndrome

scalded mouth syndrome

stomatodynia

glossodynia

glossopyrosis

*Prevalence rates in epidemiologic studies 0.7 - 2.6%

*Typically affects middle-aged women

*Women 7 times >> men recent epidemiologic data equal male : female

*Men affected at a later age than women

*Rare in children & teenagers, very uncommon in young adults

*Most prevalent in postmenopausal women in mid- to late fifties 10 - 15%

*Most prevalent 3 – 12 yrs after menopause

Cause unknown

local, systemic & psychological

Lokal

*Pseudomembranous & erythematous candidiasis BMS

*Gorsky et al patients BMS no clinical signs of candidiasis 86% improved after using antifungal lozenges & 13% complete elimination of symptoms

*Bacteria (staphylococci, streptococci, anaerobes)

*Carcinomas of the oral cavity itching or burning premonitory symptom

*Premalignant entities leukoplakia or erythroplakia burning or painful sensation

*Faulty denture design promote burning sensation increased level of functional stress to the circum oral or lingual musculature

*Main & Basker ill-fitting dentures single greatest contributor

*Majority patients denture abnormalities adequately corrected BMS persisted

*Chemical irritation & allergic reactions no evidence result of allergic reactions to food, oral hygiene products, or dental materials (methyl-methacrylate monomer & mecury)

*Contact allergy affect the oral mucosa burning sensations inflammatory, lichenoid, or ulcerative lesions

*Mechanical irritation/trauma oral habit, dentures (errors in denture design) & sharp teeth

*Dry mouth higher incidence in BMS patients no clear association between BMS & decreased salivary flow rate

*Glass xerostomia local contributing factor, other authors higher or lower prevalence of xerostomia in BMS patients

*No significant decrease in salivary flow unstimulated or stimulated subjective complaints of mouth dryness & thirst

*Studies significant alterations in salivary components mucin, IgA, phosphates, pH, buffering capacity, proteins & electrical resistance

*Relationship of changes salivary composition to BMS unknown altered sympa thetic output related to stress or from alter ations in interactions between cranial nerves & pain sensation

Systemic

Various systemic factors BMS many of these conditions require further study to verify the correlation

*Increased incidence in menopause women hormonal changes hypoestrogenemia

*Its mechanism remains unclear not usually reversible with hormone replacement therapy

*BMS symptoms of deficiency iron, Vitamin B & folic acid

*Lamey et al replacement therapy of vitamin B1, B2 & B6 effective in treating BMS in 88% patients

*Laboratory results abnormal management & correction do not lessen BMS

*BMS symptoms of diabetes associated with xerostomia & candidiasis

*Diabetic neuropathies in the head & neck region contributing BMS

*Symptoms in diabetic patients did not decrease after glucose control  others found diabetic treatment resolved the oral symptoms

*Burning characteristic of post-traumatic nerve injuries alterations in perception to touch, temperature, two-point discrimination, & threshold pain BMS infrequent

*Recently secondary to the use of angiotensinconverting enzyme (ACE) inhibitors (captopril, enalapril, & lisinopril) remitted following discontinuation of the medication

Psychological

*Personality & mood changes psychogenic problem

*Psychologic dysfunction common in patients with chronic pain result of the pain rather than its cause

*Lamb et al 60% BMS patients psychological factors & anxiety was most difficult to control

*BMS symptom of cancer-phobia reassuring after a proper diagnosis often helpful in relieving symptoms

*Strong psychological component chronic low-grade trauma parafunctional oral habits rubbing the tongue across the teeth or pressing it on the palate

*In some patients, more than one of these factors may be contributing to the problem in others, no specific cause can be identified

*> 50% patients BMS onset spontaneous, no identifiable precipitat ing factor

*± 1/3 patients relate time of onset dental procedure, recent illness or medication course

*Pain intensity & other symptoms commonly develop gradually over time

*Persist for many years

*Most common sites anterior tongue, anterior hard palate, & lower lip

*Burning often occurs in more than one oral site

*Burning intermittent or constant eating, drinking, or placing candy/chewing gum relieves the symptoms

*Patients with lesions or neuralgias increased oral burning during eating

*Pain moderate - severe intensity gradually increases throughout the day max intensity by late evening difficulty falling asleep at night & experiencing interrupted sleep

*Reported mood changes irritability & decreased desire to socialize related to altered sleep patterns

*Personality characteristics depression & anxiety may affect the pain or be secondary to the chronic pain

*Frequently accompanied by dry mouth & thirst despite lack of evidence of decreased salivary flow

*Altered taste (dysgeusia)

*Additional pain complaints facial pain & pain at other sites

*Local anesthetic elixir increases burning but decreases dysgeusia

*Mechanism by which factors can causes symptoms completely unknown

*Morphologic alterations in peripheral tissue injury/disease biochemical & pathophysiologic changes in nociceptive neurons in CNS to previously non-noxious stimuli

*These conditions occur as a result of common systemic/local disorders nerve damage occurs to either the trigeminal nerve directly or other cranial nerves inhibit oral nociceptive activity

*History taking key to diagnosis

*Diagnosis detailed history, clinical examination, laboratory studies & exclusion of all other possible oral problems

*Even patient reports typical features of BMS other potential causes should be ruled out

*Patients complaining xerostomia & burning evaluated for the possibility of a salivary gland disorder mucosa dry & difficulty swallowing dry foods without sipping liquids

*Patients with unilateral symptoms thorough evaluation of trigeminal & other cranial nerves eliminate neurologic source of pain

*Clinical characteristics sudden or intermittent onset of pain, bilateral presentation, progressive increase during the day & remission with eating

*Burning persists after management of sys temic or local oral conditions diagnosis of BMS can be considered

*Making clinical diagnosis not difficult determining the subtle factor difficult

*C. albicans culture, Sjogren's syndrome antibodies serum tests, complete blood count, serum iron, total iron-binding capacity, serum B12 & folic acid levels

*Tests individual consideration depend on clinical history & clinical suspicion

*Biopsy not indicated no typical clinical lesion is associated

*First exclude other disease

*Sources of pain must be dealt with not too much expectation

*Reassured benign nature of the symptoms & frightening possibilities such as cancer can be excluded

*If suggests psychogenic factors explain to the patient that depression & other emotional disturbances can cause physical diseases & emotional disturbances affect almost everyone

*Counseling & reassurance adequate for mild BMS more severe symptoms drug therapy

*Drug therapies low doses tricyclic antidepressants (TCA) amitriptyline, desipramine, nortriptyline, imipramine, clomipramine, or doxepin

*Should be stressed drugs not to manage psychiatric illness analgesic effect

*Clinicians should be familiar potential serious & annoying side effects

*Benzodiazepines clonazepam (benzodia-zepine derivative) GABA (gamma-aminobutyric acid) receptor agonist effective for various orofacial pain disorder

*Grushka et al clonazepam effective in relieving taste dysgeusias & oral dryness along with the oral burning

*Other medications & treatments neuropathic pain conditions :

*Topical capsaicin the monoamine oxidase inhibitor tranylcypromine sulphate in combination with diazepam

*Systemic anesthetic mexiletine use-dependent sodium channel blocker

*Parafunctional oral habits splint covering the teeth and/or the palate

*Partial remissions occur in approx 2/3 patients in 6 – 7 years after onset

*No studies investigated whether earlier intervention or earlier & better pain control lead to earlier disease remission