What is the treatment for burning mouth syndrome?

Treatment of Burning Mouth Syndrome

The treatment of burning mouth syndrome should focus on a combination of reassurance, education, cognitive behavioral therapy (CBT), and neuropathic pain medications, with topical clonazepam and systemic gabapentin showing the most promising results for symptom relief. 1, 2

Understanding Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a chronic condition characterized by:

• Burning sensation primarily affecting the tongue (especially the tip and lateral borders), lips, palate, and buccal mucosa
• Normal-appearing oral mucosa with no clinically evident lesions
• Predominantly affects peri- and post-menopausal women
• Often accompanied by dry mouth, abnormal taste, and depression
• Can be primary (idiopathic) or secondary (due to identifiable causes)

Diagnostic Approach

Before initiating treatment:

1. Rule out secondary causes:

   • Oral candidiasis
   • Mucosal lesions
   • Hematological disorders
   • Autoimmune conditions
   • Medication side effects

2. Assess characteristics:

   • Location and pattern of burning sensation
   • Continuous vs. intermittent symptoms
   • Severity and impact on quality of life
   • Associated symptoms (xerostomia, dysgeusia)

Treatment Algorithm

First-Line Approach

1. Patient education and reassurance:

   • Explain the chronic nature of the condition
   • Reassure that while prognosis for complete resolution is limited, symptoms typically won't worsen 1
   • Discuss the neuropathological basis of the condition

2. Dietary modifications:

   • Avoid spicy, acidic, hot foods/drinks
   • Limit caffeine intake
   • Maintain adequate hydration

3. Topical treatments:

   • Topical clonazepam: Dissolve tablet in mouth for 3 minutes before spitting out 2, 3
   • Topical capsaicin: Applied to affected areas (caution: initial burning sensation) 2
   • Topical steroids: High-potency topical corticosteroid gel or dental paste 1
   • Viscous lidocaine: For temporary relief of severe symptoms 1

Second-Line Approach (Moderate to Severe Cases)

1. Systemic medications:

   • Gabapentin: Starting at 300 mg daily with gradual titration 1
   • Alpha-lipoic acid: Antioxidant supplement (mixed evidence but may provide long-term benefit) 2
   • Antidepressants: Amitriptyline or duloxetine for patients with comorbid depression 4

2. Cognitive Behavioral Therapy (CBT):

   • Particularly effective for patients with psychological factors 1, 2
   • Shown to provide both short-term and long-term benefits

For Patients with Concurrent Dry Mouth

1. Salivary stimulants:

   • Sugar-free chewing gum, lozenges, or candy
   • Pilocarpine: 5 mg three to four times daily (if no contraindications) 5, 6
   • Cevimeline: For patients who cannot tolerate pilocarpine 5

2. Saliva substitutes:

   • Moisture-preserving mouth rinses, sprays, or gels
   • Products with neutral pH and containing fluoride 5

Monitoring and Follow-up

• Regular follow-up every 4-6 weeks initially to assess treatment response
• Adjust medications based on symptom improvement and side effects
• Consider combination therapy for refractory cases

Special Considerations

Treatment Challenges

• High percentage of treatment failures with standard neuropathic pain medications 1
• Limited evidence from high-quality randomized controlled trials
• Need for individualized approach based on symptom severity and comorbidities

Important Caveats

• Avoid overmedication with systemic agents due to potential side effects
• Be aware that topical treatments may provide only temporary relief
• Consider psychological support for patients with significant impact on quality of life
• Recognize that complete resolution is uncommon, but symptom control is achievable

By following this structured approach to BMS management, clinicians can help patients achieve better symptom control and improved quality of life despite the challenging nature of this condition.