What are the management options for burning tongue syndrome?

Management of Burning Mouth Syndrome

For patients with burning mouth syndrome, a systematic approach starting with gabapentin as first-line pharmacological treatment for moderate to severe symptoms is recommended, while mild symptoms can be managed with patient education, reassurance, and dietary modifications. 1

Diagnosis and Assessment

• Burning mouth syndrome (BMS) is characterized by a burning sensation primarily affecting the tongue, lips, palate, and buccal mucosa, with normal-appearing oral mucosa and no clinically evident lesions 1
• Predominantly affects peri- and post-menopausal women 1
• Can be primary (idiopathic) or secondary (due to identifiable causes) 1

Before initiating treatment:

• Rule out secondary causes:
  • Medication side effects
  • Nutritional deficiencies (vitamin B complex, zinc, iron)
  • Endocrine disorders (diabetes, hypothyroidism)
  • Oral infections (candidiasis)
  • Sjögren's syndrome
  • Post-herpetic neuralgia
  • Trigeminal neuropathic pain
  • Glossopharyngeal neuralgia 1

Management Algorithm

Step 1: For Mild Symptoms

• Patient education and reassurance about the chronic nature of the condition 1
• Dietary modifications:
  • Avoid spicy, acidic, and hot foods
  • Improve hydration
  • Limit caffeine intake 1

Step 2: For Moderate to Severe Symptoms (First-line Pharmacological Treatment)

• Gabapentin: Start at 300 mg daily with gradual titration 1
• Consider combining with alpha-lipoic acid for better outcomes 1

Step 3: Topical Treatments

• Clonazepam: Dissolve in mouth for 3 minutes then spit out 1
• High-potency topical steroids for inflammatory component 1
• Viscous lidocaine for temporary relief of severe symptoms 1

Step 4: For Persistent Symptoms or Specific Presentations

• Tricyclic antidepressants (e.g., amitriptyline) for patients with comorbid depression 1, 2
• Salivary stimulants or systemic sialagogues (cevimeline or pilocarpine) for associated dry mouth 1
• Duloxetine for central type BMS 2
• Pregabalin as an alternative to gabapentin 3

Step 5: Non-Pharmacological Approaches

• Cognitive behavioral therapy for patients with significant psychological factors 1
• Consider referral to mental health professionals for structured psychotherapy 1
• Laser therapy, acupuncture, or transcranial magnetic stimulation may be considered in refractory cases 3

Special Considerations

• Menopausal women: Consider hormone replacement therapy if appropriate 1
• Sjögren's syndrome: Management should follow a two-stage sequential regimen with induction and maintenance therapy 4
• Oral hygiene: Clean the mouth daily with warm saline mouthwashes 4
• Candidal infection: If suspected, treat with nystatin oral suspension or miconazole oral gel 4

Monitoring and Follow-up

• Regular assessment of symptom severity
• Evaluate effectiveness of treatment
• Adjust medications as needed
• Reassure patients that while prognosis for complete resolution is limited, symptoms typically won't worsen 1

Pitfalls and Caveats

• Avoid misdiagnosing BMS as psychogenic without proper exclusion of organic causes
• Be aware that BMS may have multiple contributing factors requiring combination therapy
• Medications may take weeks to show effectiveness; counsel patients about realistic expectations
• Recognize that BMS is often a chronic condition requiring long-term management
• Avoid excessive use of topical anesthetics which may mask symptoms without addressing underlying causes

By following this structured approach to BMS management, clinicians can provide effective symptom relief while addressing the multifactorial nature of this challenging condition.