Burning mouth syndrome (glossodynia)

Burning mouth syndrome (glossodynia)

Cooper C. Wriston, Ashley B. Wentworth and Rochelle R. Torgerson

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 chronic and debilitating condition 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 systems 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.

Management strategies

A detailed history and physical examination should be completed to identify all alternative or correctable causes of oral burning. Several associated factors may be simultaneously present requiring treatment. 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 contact stomatitis (flavorings, food additives, dental materials).

Systemic factors

Systemic factors include: deficiency states (iron, zinc, folate, cobalamin, thiamin, riboflavin, pyridoxine, ascorbic acid, magnesium); autoimmune disease (Sjögren syndrome); gastrointestinal disease (gastroesophageal reflux); neurologic disease (trigeminal neuralgia, acoustic neuroma, Parkinson disease, glossopharyngeal neuralgia); medication-related (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, antidepressants, antihistamines, antiretrovirals, benzodiazepines, proton pump inhibitors, anticonvulsants, radiochemotherapy) and endocrinopathies (hypothyroidism, diabetes).

Psychological factors

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

Laboratory evaluation and empiric treatment 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 some degree of success with multi-modal approaches resembling those used for the treatment of chronic, neuropathic pain.

Specific investigations

Table 33.1

Specific investigations

History
Oral symptoms	Timing, quality, duration, location, alleviating/exacerbating factors
Medications	Efavirenz, clonazepam, fluoxetine, sertraline, venlafaxine, enalapril, captopril, lisinopril, candesartan, eprosartan, omeprazole, topiramate, hormone replacement therapy
Dental	Prostheses, recent procedures, dentifrices, topical medicaments
Parafunctional habits	Bruxism, tongue thrusting
Review of symptoms	Weakness, headache, fatigue, concentration, sleep disturbance, arthralgia
Physical examination
Oral	Complete oral exam, including head and neck (remove any dental prostheses)
Nodal	Adenopathy
Musculoskeletal	Temporomandibular joint

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 exam
Microbiology testing	Herpes simplex (PCR); varicella zoster (PCR); candidosis (swab from site of pain for direct examination and culture); human immunodeficiency virus screening

Table 33.3

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)

Pathophysiology of primary burning mouth syndrome.

Jaaskelainen SK. Clin Neurophysiol 2012; 123: 71–7.

A review of the evidence for neurophysiologic alterations in the peripheral or central nervous systems in the etiopathogenesis of BMS. A neurophysiologic evaluation is suggested to characterize the neuropathology in individual patients and target treatments.

Psychiatric comorbidity in patients with burning mouth syndrome.

Bogetto F, Maina 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.

Interventions for the treatment of burning mouth syndrome.

Zakrzewska JM, Forssell H, et al. Cochrane Database Syst Rev 2005; CD002779.

In nine comparative trials identified for BMS, only α-lipoic acid, clonazepam, and cognitive behavior therapy were effective. Therapeutic efficacy for painkillers, hormones, and antidepressants was not found.

Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth symptoms.

Drage LA and Rogers RS, 3rd. Mayo Clin Proc 1999; 74: 223–8.

Seventy patients with a burning or sore mouth were reviewed retrospectively. Associated conditions included psychiatric disease (30%), xerostomia (24%), geographic tongue (24%), nutritional deficiency (21%), and allergic stomatitis (13%).

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