Burning Mouth Syndrome

Scalded mouth syndrome, stomatodynia, sore tongue, burning lips syndrome, glossodynia, glossalgia, stomatopyrosis, oral dysesthesia, burning mouth condition, glossopyrosis, sore mouth... All of these terms have been used to identify the same painful syndrome known as burning mouth syndrome (BMS), a chronic disease state characterized by a painful sensation in the oral mucosa. However, no obvious signs of pathology are associated with this condition. This presents a challenge for the long-term care healthcare professional because without a diagnostic test to confirm either a positive or negative result, they must rely heavily on the patient’s history. An accurate and timely diagnosis of BMS requires, at minimum, a clear and comprehensive medical history from the patient. A team of researchers based in India recently published a review of BMS in the Journal of Pharmacy & Bioallied Sciences, including a discussion of diagnosis and management.

According to the authors, the prevalence of this condition is not really known. Several studies show the rate of occurrence ranges from 0.6% to 15%, with middle-aged to elderly women being most affected. The prevalence among menopausal or post-menopausal women tends to be higher than in non-menopausal women, at 12% to 18%. Those afflicted with this condition experience continuous pain deep within the oral mucosa (lips, tongue, hard palate). The pain has been described as “burning, tingling, scalding, annoying, tender, or numb,” and can last for months, with varying intensity on a daily basis. It has been suggested that BMS be classified into three subtypes based upon pain characteristics and intensity level: subtype 1 = pain-free upon waking and pain developing with gradual increasing intensity throughout the day; subtype 2 = continuous pain throughout the day, upon waking and into the night; and subtype 3 = intermittent pain with no regular pattern.  There is a higher prevalence of cases having subtype 2 characteristics.  Persons enduring the constant discomfort experience a diminished quality of life and are at high risk for depression and anxiety, the authors noted.

BMS usually lacks evident signs of pathology and may be idiopathic, as reported by the authors. The exact cause is unknown and most likely due to multiple factors. There are several theories on the pathogenesis of this condition, but none have yet been proven. It is not uncommon for the following comorbid conditions to be associated with BMS: headache, temporal mandibular joint pain, dizziness, musculoskeletal disorders, irritable bowel syndrome, dermatological, and psychiatric disorders. Although these are not likely to be etiological factors, they should be eliminated to remove any unnecessary stressors on the patient, the authors reported.

Making an accurate diagnosis of BMS essentially means first ruling out every other condition known to give similar symptoms.  The authors mention that some of the conditions to consider are xerostomia, degenerative nerve diseases, infection (viral, bacterial, fungal), allergies, and psychiatric disorders (anxiety, pyschosocial stressors).  By dismissing all other possibilities, the physician is left with BMS as a likely diagnosis.

There is neither a cure for BMS nor a gold standard treatment to quickly alleviate the unpleasant symptoms. The authors report that there are topical, systemic, and behavioral treatment options available. Topical treatments include capsaicin cream, diluted solution of Tabasco sauce, benzydamine hydrochloride mouthwash, and aloe vera gel. The systemic therapies that have demonstrated efficacy are tricyclic antidepressants and selective serotonin reuptake inhibitor (SSRI) antidepressants, benzodiazepines, atypical antipsychotics, alpha-lipoic acid (ALA), and vitamin/mineral supplementation. For peri- and post-menopausal women experiencing this painful syndrome, hormone-replacement therapy has been found to relieve symptoms in some cases.  Cognitive behavior therapy may also benefit those patients whose BMS symptoms are associated with psychosomatic disorders.

Due to the multifactorial nature of BMS, one treatment modality that has shown efficacy in one patient may not be effective for another. As such, appropriate management of BMS involves a multidisciplinary and systematic approach with a therapeutic plan customized for the individual. A person diagnosed with BMS endures relentless physical pain and psychological stress, and is therefore in a fragile state. A trusting relationship between the healthcare professional and patient is essential to ensuring successful management of this condition. As part of the management plan, the patient should have a full understanding of their condition and a realistic perspective on the prospect of being cured. And the oral health care professional must choose treatment options that make the most sense for the individual patient. Diagnosing and managing BMS can be challenging, but the healthcare professional who is not fully aware of this disease will find the tasks most difficult. 

-Greg Whaley