What are the management options for burning mouth syndrome?

Burning Mouth Syndrome: Workup and Management

Burning mouth syndrome (BMS) should be managed with a combination of reassurance, education, cognitive behavioral therapy, and neuropathic pain medications, with gabapentin being a first-line pharmacological option showing efficacy in reducing burning sensation in 50% of patients. 1

Diagnostic Workup

• BMS is characterized by burning sensation of the oral mucosa (commonly tongue tip, lateral borders, lips, palate, buccal mucosa) without clinically apparent mucosal alterations 1
• Primarily affects peri- and post-menopausal women 1
• Diagnostic process requires exclusion of secondary causes:
  • Local factors: oral candidiasis, mucosal lesions 1
  • Systemic factors: hematological disorders, auto-immune disorders 1
  • Pharmacological side effects 1
  • Nutritional deficiencies (vitamin, zinc) 2

Clinical Presentation

• Burning sensation is typically continuous but may increase in intensity during evening and night 3
• Often presents as a triad: mouth pain, altered taste, and altered salivation 3
• May be accompanied by dry mouth, abnormal taste, depression, and poor quality of life 1
• Pain severity ranges from mild to severe 1

Management Approach

First-Line Interventions

1. Reassurance and Education

   • Inform patients that while prognosis for complete resolution is poor, the condition will not worsen 1
   • This reassurance is often crucial for patient well-being 1

2. Cognitive Behavioral Therapy (CBT)

   • Recommended as a primary intervention for BMS 1
   • Helps address psychological components that may contribute to or exacerbate symptoms 4

Pharmacological Management

1. Neuropathic Pain Medications

   • Gabapentin: Demonstrated efficacy in randomized controlled trials with 50% of patients experiencing reduction in burning sensation 1
   • Alpha-lipoic acid: May provide relief of oral burning symptoms 2
   • Clonazepam: Shown efficacy in controlled clinical trials 2
   • Amitriptyline: Open-label studies show some benefit 1

2. Topical Treatments

   • High-potency topical steroids (gel or dental paste preferred) 1
   • Viscous lidocaine for temporary relief 1

Management of Associated Symptoms

1. For Dry Mouth (if present)

   • Mild symptoms: Improve hydration, limit caffeine intake, use saliva substitutes, moisture-preserving mouth rinses/sprays 1
   • Moderate/severe symptoms: Consider systemic sialagogues (cevimeline or pilocarpine) 1
   • Salivary stimulants: Sugar-free chewing gum, lozenges, or candy 1

2. Dietary Modifications

   • Avoid crunchy, spicy, acidic, or hot food/drinks that may exacerbate discomfort 1

Special Considerations

• Treatment failures are common - BMS management has a high percentage of failures 1
• Multidisciplinary approach may be required for refractory cases, including dental, pain management, and psychiatric specialists 4
• Regular follow-up during symptomatic periods is essential 4
• Psychological support is important for addressing the psychogenic component of pain 4

Common Pitfalls to Avoid

• Misdiagnosis: Failing to rule out secondary causes of burning mouth sensation 2
• Inadequate reassurance: Not emphasizing that the condition won't worsen, which is crucial for patient anxiety 1
• Monotherapy approach: Relying solely on medications without addressing psychological factors 4
• Premature treatment termination: Not providing adequate follow-up during symptomatic periods 4

Treatment Algorithm

1. Rule out secondary causes through appropriate investigations
2. Begin with non-pharmacological approaches: Reassurance, education, and CBT
3. Add pharmacological therapy if symptoms persist:
   • First-line: Gabapentin
   • Alternative options: Alpha-lipoic acid, clonazepam, or amitriptyline
4. Address associated symptoms (dry mouth, taste alterations)
5. Consider psychiatric referral for refractory cases with significant psychological component