B An Overview of Burning Mouth ...

clinical practice
An Overview of Burning Mouth Syndrome
Anuradha Sunil*, Archana Mukunda**, Merwyn Nitin Gonsalves†, Ashik Bin Basheer‡, Deepthi K‡
Abstract
Burning mouth syndrome (BMS) is an idiopathic condition characterized by a chronic continuous burning sensation of intraoral
soft tissues, typically involving the tongue, with or without extension to the lips and oral mucosa. It is classically accompanied
by gustatory disturbances like dysgeusia and parageusia and subjective xerostomia. This syndrome commonly affects people
all over the world without racial or socioeconomic predilection. Some patients may develop a single episode of burning
sensation while some may show recurrent episodes that last for months or years. It commonly affects perimenopausal and
postmenopausal women. The etiology remains obscure and multifactorial, hence the treatment is complicated with multiple
approaches involving drugs, psychotherapy along with latest techniques like acupuncture and low level laser therapy being
used to treat BMS effectively.
Keywords: Orofacial pain, stomatodynia, glossodynia, neuropathic pain, glossopyrosis, scalded mouth syndrome
B
urning mouth syndrome (BMS) refers to chronic
orofacial pain without any visible mucosal
changes or lesions and laboratory findings.
It is also known by various terminologies such as
orofacial pain, stomatodynia, glossodynia, neuropathic
pain, glossopyrosis and scalded mouth syndrome.
It is characterized by an intense burning or stinging
sensation, preferably on the tongue or in other areas
of the oral mucosa.1 The etiology has remained unclear
and numerous local, systemic and psychological
factors have been implicated in the etiology and
current knowledge throws light on the underlying
neurological disorder. The International Association
for the Study of Pain and International Headache
Society defines it as a “distinctive nosological entity,
including ‘all forms of burning sensation in the mouth
with stinging sensation or pain, in association with
an oral mucosa that appears clinically normal in the
absence of local or systemic diseases or alterations.’’2
BMS is seen more commonly in postmenopausal
females.3 There is no single accepted treatment for
BMS and hence there are a variety of therapeutic
approaches available. This present article focuses on
updated knowledge on etiology, classification of BMS
and also adds a note on latest treatment modalities,
home remedies and techniques to cope with BMS
successfully.
CLASSIFICATION
BMS is classified as follows:


Based on etiology as

Primary, where etiology is unknown

Secondary, where the etiology is known3,4
Based on symptoms as

*Professor and Head
**Reader
Dept. of Oral and Maxillofacial Pathology
Royal Dental College (KUHS), Chalissery, Kerala
†Reader
Dept. of Oral and Maxillofacial Pathology
AJ Institute of Dental Science, Mangalore
‡Senior Lecturer
Dept. of Oral and Maxillofacial Pathology, Royal Dental College (KUHS)
Chalissery, Kerala
Address for correspondence
Dr Anuradha Sunil
Professor and Head
Dept. of Oral and Maxillofacial Pathology, Royal Dental College (KUHS)
Chalissery, Kerala
E-mail: anuradhasunil@hotmail.com

Type 1 BMS: Patients have no symptoms upon
waking but symptoms progress throughout
the day reaching its peak intensity by evening.
Night-time symptoms are variable. It is linked
to systemic disorders like nutritional deficiency
and diabetes.
Type 2 BMS: Patients have continuous
symptoms throughout the day and are
symptomatic at night resulting in sleepless
nights. This type is associated with chronic
anxiety due to altered sleep pattern and is
related to use of antidepressant drugs, which
cause xerostomia.
Indian Journal of Clinical Practice, Vol. 23, No. 3, August 2012
145
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
Type 3 BMS: Patients have intermittent
symptoms throughout the day with symptomfree periods. Usually seen due to anxiety or
allergic reactions especially to food allergens.3
Etiologies
Different factors have been proposed for secondary
BMS as follows:
implicated. Food allergens include peanuts, chestnuts,
cinnamon, nicotinic acid and sorbic acid.8
Psychological Factors
Patients with BMS show increase in salivary cortisol
level indicating higher levels of stress.9 However,
anxiety and depression are considered as exacerbating
factors rather than the cause of BMS as the symptoms
disappear following their remission.

Local factors

Systemic factors
Iatrogenic Factors

Nutritional factors

Allergic or immunological factors

Psychological factors

Iatrogenic factors

Infections

Hormonal imbalances

Neurological disturbances3,5,6
Drug-associated BMS have been observed with use
of angiotensin-converting enzyme (ACE) inhibitors
and angiotensin receptor blockers (ARBs).10 The
product of inflammatory reaction generates increased
bradykinin. The mechanism is clearly not understood
but kallikrein, a molecule active in the kinin pathway,
is increased in the saliva of BMS patients, resulting in
increased inflammation. Other drugs like antiretrovirals
nevirapine and efavirenz may also result in BMS.
However, the mechanism is not clearly understood.
Local Factors

Oral conditions: Lichen planus, geographic tongue
Infections

Oral habits: Tongue thrusting, bruxism
Few
microbes
like
Candida,
Enterobacter,
Fusospirochetes, Helicobacter pylori and Klebsiella are
prevalent in patients with BMS without visible mucosal
lesions.3,11

Excessive
mouth
irritation:
Overbrushing,
overuse of mouth washes, overingestion of acidic
drinks.3,5,6
Systemic Factors


Xerostomia caused by various health problems like
Sjogren’s syndrome and radiation therapy.
Gastroesophageal reflux disease (GRED)3,5,6
Nutritional Factors
Deficiencies of B vitamins 1, 2, 6 and 12, as well as
zinc, folate and iron, have been suggested as causes
of secondary BMS, occurring from direct neurologic
damage or in relation to anemia.3,5,6
Allergic or Immunological Factors
Elevated erythrocyte sedimentation rate (ESR) and
salivary IgA levels is seen in BMS patients suggestive
of immunologic or allergic phenomenon. Allergies
are seen in type 3 BMS as intermittent symptoms,
associated with signs of mucosal irritation. Suggested
irritants include dental materials such as mercury
(present in amalgam), methyl methacrylate, cobalt
chloride, zinc and benzoyl peroxide.7 Components
of lotions such as petrolatum cadmium sulfate, octyl
gallate, benzoic acid and propylene glycol have been
146
Indian Journal of Clinical Practice, Vol. 23, No. 3, August 2012
Endocrine Disorders
Menopause, whether surgical or physiological, is
associated with higher prevalence of BMS. The
mechanism is unclear but hormonal alterations
may possibly affect the oral mucosa. Estrogen has
documented effects on oral mucosa, and deprivation
may lead to atrophic changes thereby altering
stimulation of the nerve endings within the epithelium.
Alternatively, atrophic epithelia may be more prone to
inflammation.12
Thyroid hormones are involved in maturation and
specialization of taste buds and recent studies have
shown that thyroid hypofunction may be responsible
for hypogeusia, for bitter taste and for the release of
inhibitions for sensitive trigeminal sensation.13
Neurological Disorders
Sensory testing has revealed taste deficits and heat/pain
intolerance among BMS patients due to an abnormal
interplay between the sensory function of chorda
tympani and lingual nerve either in the peripheral or
central nervous systems resulting in BMS.
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PATHOPHYSIOLOGY

BMS was originally described as a psychogenic illness,
however, a neuropathic mechanism is currently
favored. This is based on objectively measured
abnormalities of physiologic responses of the trigeminal
nerve in BMS patients.14 Taste to the anterior twothird of the tongue is by the chorda tympani branch of
facial nerve and somatosensory is supplied by lingual
nerve branch of trigeminal nerve. Chorda tympani
hypofunction results in lingual nerve hyperfunction by
disrupting the centrally-mediated equilibrium between
the two.15 Individuals with high density of fungiform
papillae present on the anterior aspect of the tongue
are known as supertasters and are more at risk for
developing BMS. Supertasters are mainly females who
are able to perceive the bitter taste of a substance called
PROP (6-n-propylthiouracil) and also experience a more
intense burning sensation in the oral cavity, especially
when stimulated with chili peppers.
Unilateral anesthesia of the chorda tympani nerve
intensifies the perception of burning pain on the
contralateral anterior portion of the tongue, suggesting
the presence of central inhibitory interactions between
taste and oral pain.5 Damage to the chorda tympani
or any alteration in the gustative papillae releases
this inhibition, and may lead to an intensification of
normal trigeminal sensations leading to spontaneous
pain, altered sensations of touch, subjective sensations,
of oral dryness and taste alterations (dysgeusia and
phantom tastes). Xerostomia seen in BMS is more due
to neuropathy than glandular dysfunction. It is noted
that salivary content shows differences but there is no
change in salivary quantity or flow.16
Clinical Features








Symptoms may vary from mild-to-severe but
moderate pain is seen frequently.
Symptoms may appear early in the morning or
develop later in the day.
Altered taste sensation such as bitter or metallic
taste
Oral mucosa appears apparently normal without
any visible changes.

Xerostomia

Geographic and fissured tongue

Painful teeth, jaw and temporomadibular joint

Loss of a comfortable jaw position and uncontrollable
jaw tightness

Headache, neck and shoulder pain

Increased parafunctional activity

Difficulty in speaking, nausea, gagging and
dysphagia

Usually bilateral but can be unilateral as well

Multiple mood and emotional disturbances1,3,5,17,18
Investigations





Blood tests: Complete blood cell count, glucose
level, thyroid function, nutritional factors and
immune function
Oral cultures: For bacterial, viral and fungal
infections
Imaging: Magnetic resonance imaging (MRI),
computed tomography (CT) scan or other imaging
test to check for other health problems.
Patch tests: To check allergy to certain foods,
additives or even denture materials.
Sialometric analysis to measure and check salivary
flow.
Occurs most commonly, but not exclusively in
females though occurs in men as well.

Seen in
women

Gastric reflux tests: To determine GERD.

Biopsy of tongue or oral mucosa.
perimenopausal
or
postmenopausal
Unexplained, usually persistent burning sensation
or pain of the oral soft tissues.
The diagnostic criteria for BMS are that pain
episodes must occur continuously for at least
4-6 months. They may last for 12 years or more
with an average duration of 3.4 years.3
Commonly affects the tongue presenting as
glossodynia (painful tongue) and glossopyrosis
(burning tongue).
Psychological questionnaires: To check symptoms
of depression, anxiety, etc.
Treatment and Management
The goal of treating BMS is to first identify the
underlying etiology, then to try to reduce or eliminate
the etiology thoroughly. Attempting combinations of
therapies may be appropriate as there is no definitive
cure. The treatment can thus comprise of medical
management, home remedies and self help measures.
Indian Journal of Clinical Practice, Vol. 23, No. 3, August 2012
149
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antidepressants may act as analgesics thereby
decreasing chronic pain.24
Medical Management
Primary BMS


Topical therapy:





Clonazepam, a benzodiazepine, when applied
as 0.5-1 mg 2-3 times daily, acts by locally
disrupting the neuropathologic mechanism
that underlies stomatodynia. But it decreases
the density and/or ligand affinity of peripheral
benzodiazepine receptors. This, in turn, could
cause spontaneous pain from the tissues
concerned.19,20 Low doses of clonazepam
dissolvable wafers available commercially are
better than tablets.21



Chlordiazepoxide, a benzodiazepine, works by
slowing down the movement of chemicals in
the brain. This results in a reduction in nervous
tension (anxiety) and muscle spasm, and also
causes sedation. These effects are unlikely
as maximum effect of benzodiazepine is not
observed at lower dosage.19
Capsaicin induces desensitization to thermal,
chemical and mechanical stimuli by inducing
selective and reversible desensitization of the
afferent sensory C fiber endings. It is used as
mouth rinse one teaspoon of a 1:2 dilution or
higher of hot pepper and water. The strength of
capsaicin can be increased if it can be tolerated
by the patient to a maximum of 1:1 dilution.
But the restrictions are limited effect over time
and magnitude of improvement. Moreover,
the use of capsaicin rinse itself produces
burning sensation thus limiting the use among
patients.22,23


Chlordiazepoxide, a benzodiazepine, is advised
10-30 mg/day, to start with 5 mg at bedtime
and increase the dose to 5 mg every 4-7 days
until oral burning is relieved. Medication is
taken in divided doses as side effects increase
as the dosage is increased.20
Gabapentin, an anticonvulsant drug, is advised
300-1,600 mg/day; 100 mg at bedtime. The
dosage is increased by 100 mg every 4-7 days
until oral burning is relieved or side effects
occur. As the dosage increases, the medication
should be taken in three divided doses.25
Alpha lipoic acid is a mitochondrial coenzyme,
trometamol salt of thioctic acid. It has
antioxidant effect that eliminates the toxic
free radicals produced in stress. It has neuroprotective property; hence, used to manage
these patients.26 Usually administered in doses
of 400 mg twice-daily for a month.
Acupuncture appears to be the current
valid therapeutic choice as it influences oral
microcirculation, resulting in a significant
variation of the vascular pattern associated
with significant reduction of the burning
sensation as long as 18 months.27
Low level laser therapy may be an alternative
treatment for the relief of oral burning in
patients with BMS.28
Secondary BMS
Secondary BMS is treated depending on the perceived
etiological factor

Oral thrush: Topical and oral antifungal are used

Nutritional deficiency: Oral supplements

Xerostomia: High fluid intake, sialagogues
Clonazepam, a benzodiazepines, exert
its effect by acting as a sedative hypnotic
0.25-2 mg dosage/day, 0.25 mg at bedtime,
increase dosage by 0.25 every 4-7 days until
oral burning is relieved or side effects occur.
As the dosage is increased, medication is taken
in three divided doses.19

Menopause: Hormone replacement therapy
Amitriptyline, a tricyclic antidepressant, is
given in doses of 10-150 mg/day, to start
with 10 mg at bedtime and increase the dose
by 10 mg until oral burning is relieved or
side effects occur. It is noted that in low doses
Oral lidocaine has also been used topically for
relieving the burning sensation.
Systemic therapy:

150

Behavioral interventions: Cognitive behavioral
therapy by a clinical psychologist.
Indian Journal of Clinical Practice, Vol. 23, No. 3, August 2012

Cranial nerve injury: Central pain control with
benzodiazepines,
tricyclic
antidepressants,
gabapentin, topical capsaicin

Drug allergy: Change the medication

Specific oral rinses and mouth washes

Oral lidocaine and topical steroids can be used
BMS can be managed with medical approaches and
variety of drugs. In addition, self help measures
and simple home remedies may also be of great help to
the patients.
clinical practice
Many patients with BMS show reduction or
disappearance of symptoms during meals or when
chewing gum or confectionary is used. So the following
measures may be taken

Sip water frequently

Chew sugarless gum
Symptoms of BMS can be reduced and also prevented
from becoming worse by

Avoidance of tobacco products

Avoidance of products with cinnamon or mint

Avoidance of spicy and hot foods

Avoidance of acidic foods and liquids

Using different brands of toothpastes

Take steps to reduce excessive stress
Some of these adjunct techniques may help patients in
coping up with BMS.

Practice of relaxation exercise such as yoga

Joining a pain support group


Engaging in pleasurable activities such as exercise
and hobbies.
Making an effort to stay socially active by
connecting with understanding family members
and friends.
Conclusion
BMS is a difficult and challenging problem for the
dental practitioner. It is a clinical diagnosis made
via the exclusion of all other causes. No universally
accepted diagnostic criteria, laboratory tests, imaging
studies or other modalities definitively diagnose or
exclude BMS. The key to successful management is a
good diagnostic work-up and coordination between
the dental practitioners and appropriate physicians and
psychologists.
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