Burning Mouth Syndrome

By Jeanne Barss, DDS, MS

BMS has gained recognition due to growing interest in neuropathic pain and its prevalence in older adults.

Burning mouth syndrome commonly affects a person’s ability to swallow, eat, speak, and sleep well – making it of wide concern. Many people in the United States may have heard Burning Mouth Syndrome called by different names, like “oral burning,” “tongue pain,” and “burning mouth condition.”

Medical professionals also have their own terminology:

• Glossodynia (mainly on the tongue).
• Stomatodynia (academic term for burning mouth syndrome).
• Glossopyrosis (possible systemic cause).
• Syndrome of oral complaints.
• Scalded mouth syndrome.

What is Burning Mouth Syndrome?

Burning Mouth Syndrome (BMS) is an orofacial pain disorder that is characterized by burning in the intraoral and perioral tissues without relevant clinical signs at the time of the examination or laboratory findings to suggest an organic cause. It is a complex chronic neuropathic orofacial pain disorder identified by a generalized or localized burning within the mouth, abnormal sensation, or pain of the oral mucosa. According to the National Institute of Health (NIH), BMS is identified when pain is “recurring daily for more than 2 h per day for more than 3 months, without any evidence of specific mucosal lesions and/or laboratory findings.” The December 30, 2022, Burning Mouth Syndrome: An Overview and Future Perspectives article by Daniela Adamo states that the main symptom reported by the patients is “burning” pain, as the name implies. BMS also goes by various names based on what triggers this medical condition.

What Causes Burning Mouth Syndrome?

Multiple factors may contribute to BMS, and addressing each one can improve treatment effectiveness. However, some factors play a more significant role than others. For instance, nutritional deficiencies and systemic diseases rarely contribute to BMS. The cause is unknown.

Commonly known triggers of BMS:

• Anxiety.
• Menopause.
• Gastro-oesophageal reflux.
• Thyroid problems.
• Vitamin deficiencies.
• Type 2 diabetes.
• Irritation from toothpaste, mouthwash, or acidic foods and beverages.
• Oral inflammatory conditions (lichen planus, geographic tongue, and yeast infections). ^[1]

While a general screening is often performed, positive findings are uncommon. Nevertheless, any identified irregularities should be addressed, even if they seem to have minimal impact on symptoms. Similarly, many BMS patients experience xerostomia or mechanical trauma, both of which can be managed.

What are Common Symptoms of Burning Mouth Syndrome?

Most patients experience good days and bad days. This fluctuation in symptoms seems to relate most to stress levels, among other factors.

Oral manifestations of BMS typically include the following:

• A person may feel sensations that include a feeling of “roughness,” “sandiness,” dry mucosa, and other phantom sensations.
• Patients often report dry mouth even in cases where salivary flows are observed to be normal.
• Loss of taste can be quantified by spatial taste testing but is rarely perceived by the patient.
• Ongoing bitter, foul, and metallic tastes in the mouth. Taste changes are often as disturbing as the burning pain.

BMS often coexists with a host of persistent changes to oral somatosensory and taste perception. These sets of sensory disturbances and the burning pain appear to be connected since they usually both respond to similar treatments, including anticonvulsant analgesics for pain.

Burning mouth syndrome subtypes based on cause:

• Trauma BMS.
• Candidiasis.
• Vitamin deficiency BMS.
• Neuropathic BMS.
• Medication-induced BMS.
• Xerostomia BMS.

Often, BMS pain begins suddenly, with intermittent and then constant pain in the oral mucosa. Patients often report the pain is precipitated by antibiotic therapy or dental surgery. Every patient can be unique, with different medical occurrences accompanying their symptoms.

Common parts of the mouth that feel burning mouth pain:

1. The dorsal tongue.
2. A person’s lips.
3. A person’s hard palate.

The above NIH study also reports that the tongue appears to be the most frequently involved site. The pain may be at one or several of these sites and is frequently bilateral. It is usually not detectable during sleep and on waking but progressively increases throughout the day to a maximal level in the evening. Eating often reduces the pain – although certain foods may exacerbate it.

Common foods that may make BMS worse:

• Acidic foods.
• Spicy foods.
• Carbonated.
• Mint.
• Tobacco.
• At times, caffeine and chocolate.

Can anxiety cause burning mouth syndrome?

Psychological factors are known to be directly associated with BMS; anxiety is the foremost of these factors. Given the complex connection sometimes found between anxiety, BMS, and facial pain, a treatment approach guided by a multidisciplinary team is often best. When one or more dentists, psychiatrists, orofacial pain specialists, and psychologists evaluate multimorbidity, BMS subjects can gain the best-personalized pain treatment plan.

How is Burning Mouth Syndrome Diagnosed?

During diagnosis and diagnostic criteria for BMS the following are typical: ^[2]

• Comprehensive patient history review.
• Cognitive behavioral therapy.
• Psychological assessment.
• Thyroid function tests.
• MRI.
• CT.
• Absence of clinical findings during examination.

The diagnosis of Burning Mouth Syndrome is often based on history and the absence of clinical findings on examination. Typically, patients complain of burning pain affecting their tongue, anterior palate, lips, and gingival tissue, which is often, but not always, bilateral. Occasionally, patients will complain of burning pain extending from the area of the foliate papillae to the tip of the tongue, or complain of pain localized almost exclusively to the anterior palate behind the upper incisors. In almost all of these instances, no clinical lesions explain the burning pain. MRI and CT imaging studies of the cranial nerves and brain are almost always negative, although central changes compatible with aging may be found in older patients. Unlike most dental pains, oral burning, taste changes, and dryness are typically decreased by chewing gum, candy, food, and sleep. An additional hallmark of this disorder appears to be the pattern of pain and sensory disturbances, which progressively increases over the day until late afternoon or early evening, when it then decreases. The pain and other associated disturbances usually remit during sleep and are at their lowest level each morning.

How common is burning mouth syndrome?

NIH’s September 28, 2022 Worldwide prevalence estimates of burning mouth syndrome: A systematic review and meta-analysis reports the prevalence of burning mouth syndrome was 1.73% in the general population, and 7.72% in clinical patients.

• In Europe, it is 5.58%, and in North America, the prevalence of BMS is only 1.10%.
• Analysis by gender showed the prevalence for females is 1.15%, which is considerably higher than for males, 0.38% in the general population.
• Subgroup analysis by age reports the prevalence was higher for people over 50 (3.31%) than under people under 50 (1.92%).

The percentage of individuals suffering from BMS depends on the definition used in specific studies and the purpose of the study (e.g. General practice, tertiary care, medical practice, etc.). With the increase of our aging population, BMS will present with increasing frequency.

What are Common Treatments for Burning Mouth Syndrome?

Treatment depends on whether you have primary or secondary burning mouth syndrome. ^[2]

The Minnesota Head & Neck Pain Clinics have found cevimeline or pilocarpine have been very effective in correcting dryness of the mouth.

Burning mouth syndrome treatment options may include:

• Trauma-related BMS: stress management/reduction
• Reduce tongue thrust and oral habits: cognitive behavioral therapy
• Smarting symptoms in the oral mucosa: oral splints
• Neuropathic BMS: balancing the decrease in neuroprotective gonadal hormones and increase in stress hormone levels ^[3]
• Hormonal changes caused by diabetes-related BMS – glucose test (either fasting or random)
• Regular counseling or physical therapy can reduce pain symptoms and keep drug dosages at a minimum.

Rationale for BMS treatment due to the disorder’s pathophysiology

As some BMS subtypes are also considered psychophysiologic disorders, psychoanalytic therapy may be recommended.

• Use of medications (particularly gabapentin and dexamethasone elixir) that restore inhibition to cranial nerves IX and V and are consistent with the treatment of neuropathic pain.
• Low-dose clonazepam taken by mouth or applied to the skin, gabapentin added to clonazepam, and low-dose Lamotrigine or Keppra have all been found to help some patients with BMS.
• Other drugs and drug classes, like major tranquilizers, have been reported to help with BMS, but there are limited case studies to support their use.

A 2023 Jan 18 NIH report found thatpsychotropics, gastroprotectors and gastrointestinal tract (GI)-associated drugs, and antihypertensives were the three most commonly used drugs among the BMS patients studied. Most BMS patients (82.5%) take at least one medicine. ^[4]

“Medications, especially multiple medications, may play an important role in the development of BMS, especially for the older female BMS patients.” – Association of medications with burning mouth syndrome ^[4]

 

Pearls of Wisdom: thoroughness in identifying and addressing BMS

It is possible that several underlying mechanisms may be related to the development of BMS. The thoroughness in identifying and addressing each contributing factor will improve the overall effectiveness of treatment. However, some factors play a more significant role in clinical practice than others. For example, very few patients with oral burning who have had problems with nutritional deficiency or other systemic disease that contributes to their condition. While a general screening is often done for systemic causes, the expectation of positive findings appears to be very low. Any irregularity should be treated, although it appears to make little difference in symptom presentation. Likewise, many patients with BMS experience xerostomia or mechanical trauma, both of which are common factors that contribute to BMS and can be treated.

SUMMARY: Prognosis and Treatment of Burning Mouth Syndrome Patients

People suffering from BMS benefit from improved educational materials to ensure an early diagnosis. We trust this article helps explain when to call and make an appointment and what to expect. If you have additional questions or want to schedule an appointment with one of our clinic’s BMS pain specialists, we are eager to make a difference in your daily life.

Call today!

Plymouth: (763) 577-2484 St. Paul: (651) 332-7474 Burnsville: (952) 892-6222 St. Cloud: 763-233-7252    

About the Author

Jeanne Barss, DDS, MS is a specialist in Periodontics and practices Oral Medicine. She has had BMS herself and is very aware of the quality of life challenges it presents. References: [1] N. Treister, SB Woo and the AAOM Web Writing Group, “Burning Mouth Syndrome by the American Academy of Oral Medicine,” Updated 2022, https://maaom.memberclicks.net/index.php?option=com_content&view=article&id=81:burning-mouth-syndrome&catid=22:patient-condition-information&Itemid=120 [2] Mayo Clinic research dept, “Burning mouth syndrome – Diagnosis and treatment,” Feb 2023, https://www.mayoclinic.org/diseases-conditions/burning-mouth-syndrome/diagnosis-treatment/drc-20350917 [3] Jääskeläinen, Satu K, “Is burning mouth syndrome a neuropathic pain condition?”, March 2018, https://journals.lww.com/pain/abstract/2018/03000/is_burning_mouth_syndrome_a_neuropathic_pain.25.aspx [4] Yu-Hsueh Wua, and Chun-Pin Chiangc, “Association of medications with burning mouth syndrome in Taiwanese aged patients,” Jan 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10068492/