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

Management and Treatment of Burning Mouth Syndrome

Burning mouth syndrome (BMS) should be managed with a multimodal approach including patient education, topical treatments, systemic medications, and supportive therapies, with gabapentin being a first-line pharmacological intervention for symptom relief. 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 with tobacco/alcohol history or younger with HPV) require careful evaluation for malignancy 1

• Consider MRI of face and neck for persistent unexplained pain to evaluate cranial nerves, particularly glossopharyngeal nerve (CN IX) 1

Treatment Algorithm

First-line Treatments

1. Patient Education and Reassurance

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

2. Topical Treatments

   • Clonazepam (dissolved in mouth) - provides temporary relief of severe symptoms
   • Topical steroids
   • Viscous lidocaine for acute symptom management 1
   • Topical antifungals for localized infections 1

3. Systemic Medications

   • Gabapentin - start at 300 mg daily with gradual titration
   • Can be used in combination with other treatments 1
   • Alternative medications include alpha-lipoic acid, duloxetine, amitriptyline, and pregabalin 2

Management of Associated Symptoms

1. For Dry Mouth

   • Systemic sialagogues: cevimeline or pilocarpine
   • Salivary stimulants: sugar-free gum, lozenges, candy
   • Pilocarpine 5 mg three to four times daily
   • Saliva substitutes: moisture-preserving mouth rinses, sprays, or gels with neutral pH and fluoride 1

2. For Taste Disturbances

   • Manage underlying causes
   • Zinc supplementation if deficient 3

Lifestyle and Supportive Therapies

• Dietary modifications:

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

• Cognitive behavioral therapy (CBT):

  • Particularly effective for patients with psychological factors
  • Provides both short-term and long-term benefits 1

Treatment for Refractory Cases

For patients who don't respond to first-line treatments:

1. Alternative Pharmacological Options

   • Low-dose aripiprazole 2
   • Capsaicin (topical) 4
   • Carbamazepine (especially for neuropathic pain) 1

2. Non-pharmacological Therapies

   • Laser therapy
   • Acupuncture
   • Transcranial Magnetic Stimulation (rTMS) 2, 4
   • Psychological/psychiatric intervention 5

Special Considerations

• Secondary BMS: If local, systemic, or psychological factors are identified, treating these underlying causes often results in significant clinical improvement 3

• Vitamin or Hormone Deficiencies: Replacement therapy (vitamins, zinc, hormones) can be effective for reducing symptoms in patients with corresponding deficiencies 3

• Glossopharyngeal Neuralgia: If BMS is accompanied by severe pain in the oropharyngeal region triggered by swallowing, consider carbamazepine as primary treatment, with alternatives including oxcarbazepine, lamotrigine, and baclofen 1

Treatment Efficacy

Recent systematic reviews indicate that cognitive behavior therapy, topical capsaicin, topical clonazepam, and laser therapy demonstrate favorable outcomes in both short-term (≤3 months) and long-term (>3 months) assessments 4.

Common Pitfalls to Avoid

• Failing to rule out organic causes of oral burning sensation
• Overlooking psychological factors that may contribute to or exacerbate symptoms
• Expecting immediate resolution of symptoms with treatment
• Not providing adequate patient education about the chronic nature of the condition
• Using single-modality treatment instead of a comprehensive approach

BMS management remains challenging due to its complex etiology, and treatment outcomes may vary significantly between patients. The most recent evidence supports a combination of pharmacological and non-pharmacological approaches tailored to address the specific symptoms and contributing factors in each case.