What is the management and treatment approach for burning mouth syndrome?

Management and Treatment of Burning Mouth Syndrome

The management of burning mouth syndrome (BMS) requires a multimodal approach including topical treatments, systemic medications, and supportive therapies, with gabapentin being the most evidence-supported pharmacological intervention for symptom relief. 1

Diagnosis and Initial Assessment

• BMS is characterized by:

  • Burning sensation primarily affecting tongue, 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 1

• Before initiating treatment, rule out secondary causes:

  • Oral candidiasis
  • Mucosal lesions
  • Hematological disorders
  • Autoimmune conditions
  • Medication side effects 1

Treatment Algorithm

First-Line Approaches

1. Patient Education and Reassurance

   • Explain the chronic nature of the condition
   • Reassure that symptoms typically won't worsen
   • Discuss the neuropathological basis of the condition 1

2. Topical Treatments

   • Clonazepam (dissolved in mouth)
   • Topical steroids
   • Viscous lidocaine for temporary relief of severe symptoms 1

3. Management of Associated Dry Mouth

   • Salivary stimulants: sugar-free chewing gum, lozenges, or candy
   • Pilocarpine (5 mg three to four times daily)
   • Saliva substitutes: moisture-preserving mouth rinses, sprays, or gels with neutral pH and containing fluoride 1
   • For moderate to severe symptoms: systemic sialagogues (cevimeline or pilocarpine) 2

Second-Line Approaches

1. Systemic Medications

   • Gabapentin: Start at 300 mg daily with gradual titration 1
   • Alpha-lipoic acid: Shows some benefit in long-term assessment 3
   • Clonazepam: Effective in both short and long-term assessment 3
   • Low-dose aripiprazole 4
   • Duloxetine or Amitriptyline 4, 5
   • Pregabalin 4

2. Cognitive Behavioral Therapy (CBT)

   • Particularly effective for patients with psychological factors
   • Provides both short-term and long-term benefits
   • Can be used in combination with other treatments 1, 3

Third-Line/Refractory Cases

1. Non-pharmacological Therapies

   • Laser therapy: Demonstrated favorable outcomes in both short and long-term assessment 3
   • Acupuncture and auriculotherapy 4
   • Transcranial Magnetic Stimulation (rTMS) 4
   • Salivary mechanical stimulation 4
   • Botulinum toxin 4

2. Psychological/Psychiatric Intervention

   • For recalcitrant cases where other treatments have failed 6

Special Considerations

• Capsaicin: Effective in both short and long-term assessment, but may cause initial discomfort 3
• Dietary modifications: Avoid spicy, acidic, or hot foods that may exacerbate symptoms 2
• Hydration: Improve hydration and limit caffeine intake 2

Monitoring and Follow-up

• Regular assessment of symptom severity and impact on quality of life
• Adjustment of treatment based on response
• Long-term follow-up as BMS is often a chronic condition with limited chance of complete resolution 1

Treatment Pitfalls to Avoid

1. Failure to rule out secondary causes before diagnosing primary BMS
2. Inadequate patient education about the chronic nature of the condition
3. Monotherapy approach instead of combining multiple treatment modalities
4. Insufficient follow-up to assess treatment efficacy and make necessary adjustments
5. Overlooking psychological factors that may contribute to or exacerbate symptoms

BMS management remains challenging due to its complex etiology, but a structured approach focusing on symptom relief and improving quality of life can significantly help patients cope with this debilitating condition.