CE Course 5

Burning Mouth Syndrome

Credit: Continuing Education Hours: 2
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Table of Contents

  • Course Goals
  • Learning Outcomes
  • Abstract
  • Introduction
  • Prevalence and Symptoms
  • Diagnosis
  • General Sex/Gender Differences
  • Definitions
  • Treatment
  • Treatment Plannind Model
  • Symptoms of Idiopathic Burning Mouth Syndrome
  • Location of Orofacial Pain Sites
  • Somatic Complaints
  • Case History and Application of Spectrum of Care Model
  • Conclusion
  • Supplemental Activities
  • Author

  • Course Goals

    The purpose of this continuing education course is to review the etiology, prevalence, assessment, and treatment of burning mouth syndrome (BMS). The role of the oral health care professional in the assessment, treatment, and referral of clients with this syndrome will be reviewed.


    Learning Outcomes

    Upon completion of this course, the learner will be able to:

    • Define the etiology of BMS
    • Describe the prevalence of BMS
    • Identify the symptoms of BMS
    • Describe the sex/gender differences related to BMS
    • Describe the treatment regimes used to treat BMS
    • Describe various dental hygiene interventions for clients with BMS

    Assessment Method: Post-test only


    Abstract

    A critical component of the dental hygiene process of care is assessment of the oral and general health conditions of clients. Some clients present with burning and painful sensations in the oral cavity in the absence of any noticeable disease. This condition has been referred to as burning mouth syndrome (BMS), an often complicated condition.

    Various local, systemic, and psychological factors have been linked with BMS, but its etiology is not fully understood. Yet as many as one million people are affected by it in the United States, and it is an increasingly common problem in the aging population. Middle-aged women, mostly postmenopausal, are diagnosed with symptoms seven times more frequently than men. Careful diagnosis and treatment are necessary to alleviate the symptoms of this condition. Referral to a physician is warranted in some cases.

    The purposes of this course are to review the etiologic factors and clinical implications related to this condition and to discuss appropriate dental hygiene interventions. Collaboration among the client, dental hygienist, dentist, and physician provides for interdisciplinary actions that can lead to palliation of symptoms and evaluation of the possible underlying factors contributing to the condition.


    Introduction

    Oral health care providers may have clients with a chief complaint of burning and painful sensations in the oral cavity. In many cases, the mucosa is absent of any noticeable disease. This situation has been referred to as burning mouth syndrome (BMS), a multifactorial syndrome.1 It is also known as glossodynia, stomatodynia, glossopyrosis, stomatopyrosis, or oral dysesthesia.2 Since its etiology is not fully understood, identification of symptoms, rather than objective clinical or laboratory findings, is often used to assess this condition. Therefore, attempts to treat the condition have had limited success and more study is needed.2


    Prevalence and Symptoms

    BMS is a complicated oral condition that affects more than one million people in the United States.3 Complaint of a burning mouth is an increasingly common problem in the older population.4 This has remained a puzzle for health care professionals, as visible pathologic lesions are not usually evident. Dental treatment, candidiasis, contact allergies, food allergies or sensitiv-ities, geographic tongue, lichen planus, xerostomia, lip licking and sucking, and mouth breathing have all been associated with BMS. Symptoms of oral burning are also associated with systemic disorders, such as anemia, diabetes, vitamin B and folic acid deficiencies, depression, anxiety, and other endocrine and immunologic disorders.5 Middle- aged women are particularly affected by the condition and report symptoms seven times more frequently than men.3

    BMS is characterized by a burning sensation in the oral cavity, although the oral mucosa appears clinically normal. The most prevalent site for burning sensations is the anterior tongue.6 The pain is chronic (at least six months), continuous, and progressive throughout the day, with no apparent cause.3 Clients with BMS are often evaluated by physicians, so it is imperative for both physicians and oral health care professionals to recognize the condition.3

    Hyposalivation or alterations in the composition of saliva have been associated with BMS, as have temporomandibular joint (TMJ) pain, face pain, oral sores, and burning mouth. Radiation of the head and neck, Sjogren’s syndrome, and certain medications that cause xerostomia also have been linked to BMS. Bergdahl studied oral complaints and salivary flow in men and women. Subjective indicators, such as oral dryness, age, medication, taste disturbances, intake of L-thyroxines, illness, stimulated salivary flow rate, depression, and anxiety were factors associated with BMS. The study concluded that BMS should be seen as a marker of illness and/or distress and suggested that the complex etiology of BMS demands treatment by a specialist.6

    Another study investigated gender differences in orofacial pain symptoms—including burning mouth—in a sample of elderly adults. Findings were consistent with other epidemiological and clinical studies—females were more likely to report TMJ pain and face pain than males.7

    Those affected by BMS experience a great deal of discomfort and pain. It is associated with varying symptoms and conditions and may be indicative of systemic disease. Careful assessment and diagnosis is necessary to alleviate pain and restore the client to a state of oral health and comfort.


    Diagnosis

    BMS has been classified as an underdiagnosed and often poorly managed oral sensory disturbance.8 Recognition of the condition and clinical approaches to ensure a correct diagnosis and appropriate management are vital for client comfort. One study reviewed the expansion of the traditional role of oral health care professionals in the context of overall oral and general health and concluded that BMS demands intensive assessment, open discussions with the affected client, and a carefully planned long-term management strategy.8 Identification of this condition is often through a default diagnosis, or one of exclusion. It has been defined as a neuropathic condition perpetuated by systemic medical, local oral, and psychological con-tributing factors.2 Therefore, local, systemic, and environmental factors must be assessed to identify the predisposing influences.


    General Sex/Gender Differences

    BMS is a condition that affects more women than men.3 There is increasing awareness of the sex/gender differences that affect both health and disease. For example, it is now commonly known that pregnancy, the menstrual cycle, and menopause affect not only a woman’s reproductive system, but also her oral soft tissues and alveolar bone. There are also sex/gender differences in dental patterns, perhaps because women access oral health care differently than men.9 Women also react to health promotion actions in a more positive manner than men. Because women live longer, they are more likely to take medications for chronic conditions that may complicate oral health treatment and contribute to BMS.9

    Although facial pain and arthromyalgia (tempromandibular joint dysfunction) pain are common in both women and men, women seek treatment much more frequently.9 BMS is especially common among postmenopausal and elderly women.11

    The purpose of a study by Ben Aryeh et al. was to evaluate oral complaints related to menopause, including BMS. The intent was to correlate oral and systemic symptoms of menopause and the oral health and salivary composition and flow rate in a group of women in menopause before initiation of hormone replacement therapy.11 Two groups of women participated in the study, one without any systemic disease or treatments and another with diseases for which they were taking various medications. The salivary composition and flow rates did not differ significantly between the groups. However, the salivary total protein and IgA concentrations of both were significantly higher in comparison to healthy young controls. The conclusion was that a high prevalence of oral discomfort was present in this group of women who attended a menopause clinic.11 The altered salivary composition in these women may be attributed to sympathetic activation related to psychological stress.11


    Other Contributing Factors for BMS

    Subclinical Candida infection has been suggested as one of the etiological factors in patients with BMS. In order to investigate the possible factors that contribute to the relatively high isolation rate of Candida in people with BMS, a study analyzing parotid saliva sam-ples from clients with this condition were collected, and the growth of Candida in each sample was observed.13 The results showed no significant growth disparity within the test and control saliva samples with Candida albicans and Candida tropicalis. However, a single isolate of Candida glabrata tende to grow better in the saliva from BMS patients than in saliva from the controls. The results indicate that the composition of saliva may be a contributing factor for the high isolation rate of Candida in saliva of patients with BMS.12

    Salivary gland hypofunction (xerostomia), caused by salivary gland disease, medication, or radiation, may predispose a person for secondary oral mucosal diseases, and has been thought to be a cause of BMS.12 In clients with salivary hypofunction the protective coating of saliva is reduced or absent, leaving the oral mucosa more vulnerable to opportunistic infections. Candidiasis, BMS, and white lesions of the oral mucosa increase in frequency in these clients.13 However, if treating the underlying causes of pain alleviates the burning mouth symptoms, it is not classified as true BMS. The goal of management in clients with xerostomia is to prevent oral pathological changes. Dental hygiene interventions will be reviewed in the treatment section.

    Clients may be misdiagnosed with BMS when other conditions actually exist. There is a report of a female denture wearer who presented with burning of the lips and tongue, with no visible oral lesions. She appeared to be suffering from BMS. Her biochemical data, complete blood cell count, sedimentation rate, thyroid, and sex hormones were assessed as normal, and a tongue culture produced negative results. Patch tests were then performed with a panel of 20 potential denture allergens and yielded positive results only to a 2% petrolatum cadmium sulfate that was present in the denture material. Removal of the denture led to resolution of her oral symptoms in three days. The study by Purello-D’Ambrosio highlights the need for careful diagnosis and for performing tests for the possible allergens present in denture materials.14 In this case, what appeared to be BMS was identified as a metal allergy after differential diagnosis, and a new denture was indicated.


    Definitions

    Burning mouth syndrome—
    A term used only in idiopathic cases. Symptoms are described as a burning, painful, or itching sensation located in the oral mucosa, with or without involvement of the tongue and with or without associated symptoms in the oral cavity or elsewhere in the body.

    Denture sore mouth—
    A condition of burning or itching sensation in the mucosa underneath the denture. Frequently located under the upper denture and with no inflammation. Other sites may be the tongue or the lips.

    Denture stomatitis—
    Clinically observed, symptomatic, inflammatory changes in the oral mucosa underneath the dentures. Symptoms regress or disappear after removal of the dentures. Micro flora of the palatal mucosa and the inner surface of the denture is a part of the pathogenesis of this condition. Candida albicans is frequently the microflora.

    Glossalgia—
    A painful tongue.

    Glossodynia—
    A painful tongue.

    Glossopyrosis—
    A burning sensation in the tongue.

    Lingual dyesthesia—
    A discomfort sensation in the tongue.

    Stomatitis prothetica—
    Another term for denture stomatitis.

    References
    Boucher C: Current Clinical Dental Terminology: A Glossary of Accepted Terms in All Disciplines
    of Dentistry.
    St. Louis: Mosby, 1963.

    Waal van der I: The Burning Mouth Syndrome, 1st ed. Copenhagen: Munksgaard, 1990.

    WHO: Application of the International Classification of Disease to Dentistry and Stomatology, 2nd ed. Geneva, Switzerland, 1978.


    Treatment

    Current treatment for BMS is usually either empiric or directed at correcting detected organic causes. It often involves the use of tricyclic antidepressants, which have been used for many years to treat depression.15

    Recently, there has been renewed interest in the use of benzodi-azepines (anticonvulsants) for burning mouth syndrome. One study assessed the effect of clonazepam (a benzodiazepine approved by the Food and Drug Administration to treat seizures and panic disorder) on burning mouth syndrome in clients with a chief complaint of mouth burning without oral mucosal lesions or evident pathology.16 Clonazepam (commonly known as Klonopin) was approved by the Food and Drug Administration (FDA) in 1975. It is also one of the top 200 drugs prescribed in the United States, and is used to treat conditions such as epilepsy and Lennox-Gastaut syndrome (a severe form of epilepsy).

    A pilot study by Grushka et al. suggests that clonazepam may be helpful in treating BMS, as 70% of the subjects experienced pain reduction with low doses of the drug.17 This included 43% of participants who achieved total or partial relief, and 27% who achieved relief but withdrew from the study because of the side effect of drowsiness.16

    BMS and the resulting stomatodynia (pain in the mouth) are difficult for both clients and clinicians. In the past, clients have often been offered poorly effective treatment for pain. This has prompted studies, such as one by Woda, to investigate therapeutic agents for pain relief. The study examined the local application of clonazepam (0.5 or 1.0 mg two or three times daily) in clients who suffered from idio-pathic stomatodynia. The conclusion was that clonazepam was a possible therapeutic solution for stomatodynia resulting from BMS.17 The antidepressant trazodone was evaluated in another study in the treatment of chronic burning mouth pain. An eight-week parallel placebo- controlled, double-blind trial was conducted, but trazodone failed to relieve burning mouth pain.18

    Since BMS is an oral pain disorder of uncertain origin, it has been proposed that central or peripheral pain mechanisms may play a role in the oral burning. One study tested the effect of a topical anesthetic (dyclonine HCl) on clients’ intensity ratings for oral burning, taste dysgeusia (impairment), and the taste of two chemical stimuli (1.0 M NaCl and 1.0 M sucrose). The anesthetic reduced the perceptual intensity of both chemicals in most of the study clients post-anesthesia, suggesting BMS dysgeusia is related to the activation of peripheral taste mechanisms. It also implies that BMS oral burning may be a disorder of peripheral pain pathways in some clients.20

    For clients with no identified causative factor, antifungal, nutritional, and estrogen replacement therapy can be initiated. If these fail, long-term therapy with anti-depressants, benzodiazepines, and clonazepam can be considered. Topical capsaicin and laser therapy have been reported to be beneficial in a few clients.22

    According to one researcher, BMS is a common condition.21 Its management is successful in about 70% of cases if a structured protocol based on scientific evidence is adopted. Specialist advice must be sought in some cases, but many clients can be successfully treated in the primary care environment.

    Dental hygiene interventions may include instruction in proper oral hygiene, saliva-stimulating agents such as pilocarpine HCI, saliva substitutes, or dietary recommendations, depending on the severity of the salivary dysfunction. Treatment may include antifungal therapy if candidiasis is diagnosed. In severely distressed clients, local or systemic corticosteroids may be indicated. Life style changes, such as refraining from tobacco and alcohol use, should be initiated. Avoiding toothpastes containing sodium lauryl sulfate may also be considered. Research shows that future treatment might include agents with combined antibacterial and anti-inflammatory actions, such as triclosan, which show promising effects in clients with oral mucosal diseases secondary to salivary hypofunction.13


    Treatment Planning Model

    A “Spectrum of Care” treatment-planning model is one that can be employed for BMS.21 The highlights of the model are as follows:

    • client concerns/needs
    • dentist/dental hygienist assessment
    • dentist/dental hygienist identification of optimal levels of care
    • presentation of options and prognoses to client
    • plan of care determined by client and dentist/dental hygienist
    • plan implementation.

    Client concerns and needs:
    Good communication skills are needed to discern perceived needs and client concerns. The domains of need that should be explored are:

    • Function—ask about the ability to masticate and speak.
    • Symptoms and Pathology—ask open ended questions to elicit the most accurate information about pain, quality of life, etc.
    • Esthetics—ask clients to elaborate on their concerns about their appearance.

    Assessment:

    • Discern the type and severity of the clients’ needs and ability to tolerate potential treatment.
    • Evaluate the client’s capacity to function in a way that can maintain oral health. Take into account the client’s resources and any physical or psychological limitations.
    • Develop a treatment plan based on objective clinical data, focusing on the domains of need already identified.
    • Assess the client’s ability to chew and speak. Reviewing the client’s eating habits or asking the client to maintain a food diary are examples of methods to identify problems relating to this need.
    • Perform clinical and diagnostic tests as indicated.
    • Perform a complete head and neck examination, including an intraoral examination.
    • Assess general health status and possible oral relationships.
    • Evaluate the client’s ability to tolerate the stress of potential treatment by taking into account age and health status.

    Identification of optimal levels of care and treatment options:

    • An interdisciplinary approach including the dental hygienist, dentist, physician, and any other health care provider pertinent to the condition identified.
    • Present options to client.
    • Implement plan.21


    Symptoms of Idiopathic Burning Mouth Syndrome

    The following have been described as symptoms:
    (Primary symptoms in order of frequency)

    • Xerostomia Altered taste
    • Dryness, thirst
    • Burning pain of tongue
    • Burning pain of lips


    Location of Orofacial Pain Sites

    • Tip of tongue
    • Lateral borders of tongue
    • Dorsum of tongue
    • Lips
    • Buccal Mucosa
    • Palate
    • Throat
    • Upper denture site
    • Lower denture site
    • Oral cavity


    Somatic Complaints

    • Gastrointestinal
    • Constipation
    • Heartburn
    • Nausea
    • Vomiting
    • Colitis
    • Headaches
    • Migraines
    • Back aches/neck aches
    • Skin disorders


    Case History and Application of Spectrum of Care Model

    A 55-year-old female client in good general health arrives at the office for preventive maintenance. She is postmenopausal, with intact ovaries, and takes no prescribed medications. She has not had a physical examination for two years. She takes an over-the-counter product called Remefemin, which contains the herb black cohosh. This is widely used to treat hot flashes in Germany. She complains of burning mouth and tongue on a continual basis, but does not have xerostomia. A thorough medical and dental history is taken, blood pressure is measured, and an extra oral and intraoral examination is performed. No lesions or swellings are noted, and blood pressure is 110/75 mm Hg. The client wears a partial upper denture to replace tooth No. 3, No. 12, and No. 13. Periodontal pockets measure 3–4 mm, and tissue is pink and firm.

    Client concerns and perceived needs:

    • Function: Unable to enjoy spicy or hot foods, but chewing is adequate.
    • Symptoms and Pathology: Unpleasant taste and burning sensation in mouth and on tongue.
    • Esthetics: Client considers upper partial denture unattractive.

    Dental hygiene assessment:

    • Function: Partial denture is functional.
    • Symptoms and Pathology: Upper partial denture, replacing tooth No. 3, No. 12, and No. 8.
    • Esthetics: Partial denture appearance could be better.

    Client’s ability to tolerate stress of treatment:

    • Consultation with physician may be necessary to evaluate BMS.

    Client’s functional capacity and resources for maintaining oral health:

    • Excellent.

    Identifying optimal level(s) of care and treatment options:

    • Option A: Proceed with preventive maintenance and monitor symptoms of discomfort in mouth.
    • Option B: Proceed with preventive maintenance and consult with physician for medical testing.
    • Option C: Either A or B, and replacement of missing teeth with dental implants or fixed partial dentures.

    • Client decided on option C, with dental implants.

    Plan of care:

    • Preventive maintenance performed by the dental hygienist, including self-care instructions and demonstrations.
    • Client is referred to oral surgeon and prosthodontist for dental implants.
    • Client is referred to physician to rule out possible causes for her burning mouth symptoms, such as anemias, iron deficiency, diabetes, anxiety or depression, and hormonal imbalance.

    Reevaluation:

    • Client returns in three months, with symptoms greatly relieved. Her medical examination was unremarkable, with the exception of initiation of hormone replacement therapy. This was not a true case of BMS, rather a symptom of low estrogen levels.


    Conclusion

    The diagnosis of BMS is a difficult task and is usually based on the exclusion of certain diseases. Its diagnosis and treatment may require collaboration between health care professionals, including the dental hygienist, dentist, nurse practitioner, and physician. The dental hygienist can assist in assessing and treating clients with this disorder by taking a very thorough medical history and asking open-ended questions. An oral examination, along with a comprehensive diagnostic evaluation, are necessary, since oral and systemic complicating factors must be identified.

    The client’s physician should treat any systemic conditions present, such as diabetes; anemia; or vitamin B12 , folic acid, or estrogen deficiencies.2 Response to therapy for those contributory factors should be considered and evaluated. If the therapy is partially successful, or not successful, the next stage is to treat the local oral factors, such as inflammatory conditions and xerostomia. Infections should be treated with appropriate antibiotic, antifungal, or antiviral medications. If the client responds to treatment, then true BMS does not exist. If the client does not respond, and BMS is suspected, drugs such as Clonazepam can be used. A combination of treatment modalities may be employed to alleviate the pain or the underlying causes of pain.

    Most importantly, the client should be educated in preventive oral health techniques and lifestyle changes that may alleviate the symptoms of BMS. However, clients should be informed that treatment might result in only partial relief of pain and that immediate or complete relief of pain is unlikely. Clients should be monitored and reevaluated for several months after treatment.


    Resources

    NIH/National Oral Health Information Clearinghouse
    1 NOHIC Way
    Bethesda, Maryland 20892-3500
    Tel: 301/402-7364
    Fax: 301/907-8830
    TDD: 301/656-7581
    Email: nidr@aerie.com
    Web site: www.aerie.com/nohicweb/

    NIH/National Institute of Diabetes, Digestive and Kidney Diseases
    Building 31 Rm 9A04
    31 Center Drive
    Bethesda, Maryland 20892-2560
    Tel: 301/496-3583
    Fax: 301/496-7422

    Burning Mouth Syndrome Network
    2035 Molleye Brown Drive
    Corydon, Indiana 47112-9136


    Supplemental Activities

    View the following Web sites for additional information
    on this and related topics.

    American Association of Dental Research
    www.iadr.org

    American Autoimmune Related Disease Association, Inc.
    www.aarda.org

    American Diabetes Association
    www.diabetes.org

    Federation of Special Care of Dentistry
    www.foscod.org

    International Association of Dental Research
    www.iadr.org

    International Association for Disability and Oral Health
    www.iadh.org

    Lupus Foundation of America
    www.lupus.org

    National Association of Rare Disorders, Inc.
    www.rarediseases.org

    National Institute of Dental and Craniofacial Research
    www.nidcr.nih.gov

    National Institute of Health
    www.nih.gov

    National Oral Health Information Clearinghouse
    www.nohic.nidce.nih.gov

    Scleroderma Foundation
    www.sjogrens.org

    Sjogren’s Syndrome Foundation
    www.sjogrens.org


    Key Terms

    benzodiazepines—
    anticonvulsants

    dysgeusia—
    impairment of the sense of taste

    glossodynia—
    pain of the tongue

    glossopyrosis—
    burning tongue

    Lennox-Gastaut syndrome—
    a severe form of epilepsy

    L-thyroxines—
    thyroid hormones

    oral dysesthesia—
    abnormality of sensation in the oral cavity

    stomatodynia—
    pain in the mouth

    stomatopyrosis—
    burning mouth


    Author

    Maria Perno, RDH, BA, MS, is a researcher, author, and speaker based in San Carlos, California. She presents seminars internationally on various topics, including women's health issues.