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

Management of Burning Mouth Syndrome

The management of burning mouth syndrome (BMS) requires a multimodal approach with gabapentin as a primary pharmacological intervention, combined with topical treatments, lifestyle modifications, and supportive therapies. 1

Diagnosis and Assessment

• Thorough oral examination is essential to rule out other conditions, including:
  • Examination of tongue mobility
  • Presence of ulcers or masses
  • Palpation of floor of mouth and tongue
  • Assessment of oropharynx 1
• High-risk patients (older patients with tobacco/alcohol history or younger patients with HPV) require careful evaluation for malignancy
• Assess for referred pain from TMJ syndrome, dental pathologies, or upper aerodigestive tract cancer
• MRI of face and neck is recommended for persistent unexplained pain to evaluate cranial nerves, particularly the glossopharyngeal nerve (CN IX) 1

Pharmacological Management

First-line Treatments:

• Systemic medications:

  • Gabapentin: Start at 300 mg daily with gradual titration for symptom relief 1
  • Can be used in combination with other treatments

• Topical treatments:

  • Clonazepam: Provides temporary relief of severe symptoms 1
  • Topical steroids: For symptom management
  • Viscous lidocaine: For acute symptom relief
  • Capsaicin: May be effective but can cause initial burning sensation 2, 3
    • Important caution: Test on small area first, avoid use on damaged skin, and wash hands thoroughly after application unless treating hands 2
    • Apply 3-4 times daily for best results 2
    • Stop use if severe burning persists or blistering occurs 2

For Associated Symptoms:

• Dry mouth management:

  • Systemic sialagogues: Cevimeline or pilocarpine (5 mg three to four times daily) 1
  • Salivary stimulants: Sugar-free chewing gum, lozenges, or candy
  • Saliva substitutes: Moisture-preserving mouth rinses, sprays, or gels with neutral pH containing fluoride 1

• For glossopharyngeal neuralgia (if present):

  • Carbamazepine: Primary drug of choice
  • Alternatives: Oxcarbazepine, lamotrigine, and baclofen 1

Non-Pharmacological Approaches

• Patient education and reassurance:

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

• Dietary modifications:

  • Avoid spicy, acidic, or hot foods
  • Improve hydration
  • Limit caffeine intake 1

• Psychological interventions:

  • Cognitive behavioral therapy (CBT): Particularly effective for patients with psychological factors 1
  • Provides both short-term and long-term benefits 4

• Alternative therapies with some evidence:

  • Low-level laser therapy
  • Alpha-lipoic acid supplements (may show increased benefit with long-term use) 3, 4

Treatment Algorithm

1. Rule out secondary causes (local, systemic, psychological factors)
2. Begin with:
   • Patient education and reassurance
   • Topical treatments (clonazepam or capsaicin) for immediate symptom relief
   • Dietary modifications
3. If insufficient response, add:
   • Systemic medication (gabapentin starting at 300 mg daily)
   • Management of associated symptoms (dry mouth, taste alterations)
4. For persistent symptoms:
   • Consider cognitive behavioral therapy
   • Evaluate for psychological factors
   • Consider alternative therapies (laser therapy, alpha-lipoic acid)

Common Pitfalls and Caveats

• BMS is often misdiagnosed or undertreated due to its complex and poorly understood pathophysiology 5, 6
• No single treatment works for all patients; combination therapy is often necessary 7
• Treatment outcomes may be modest; set realistic expectations with patients 1
• Regular follow-up is essential to adjust treatment as needed
• Capsaicin can cause initial worsening of symptoms before improvement 2
• Avoid applying heat to areas treated with topical medications 2
• Psychological factors should not be overlooked, as they can significantly impact treatment outcomes 1