What is burning mouth syndrome and how is it worked up and managed?

Burning Mouth Syndrome: Diagnosis and Management

Burning mouth syndrome (BMS) is a chronic condition characterized by burning sensation of the oral mucosa without clinically apparent mucosal alterations, predominantly affecting peri- and post-menopausal women, with a poor prognosis where only a small number of patients resolve fully. 1, 2

Definition and Clinical Presentation

• BMS commonly affects the tongue tip, lateral borders, lips, palate, and buccal mucosa, presenting as continuous burning, stinging, or itchy sensations ranging from mild to severe 1
• Associated symptoms include dry mouth, abnormal taste, depression, and poor quality of life 2
• Pain may be aggravated or relieved by eating, depending on the individual 1
• The condition is seen predominantly in middle-aged and elderly women, particularly during or after menopause 1, 3

Classification

• Primary (idiopathic) BMS: No identifiable local or systemic causes can be found; likely neuropathological in origin 3
• Secondary BMS: Caused by identifiable local, systemic, and/or psychological factors 3

Diagnostic Approach

• Diagnosis is primarily one of exclusion, as the oral mucosa appears normal on examination 1
• Secondary causes that must be ruled out include:
  • Local factors: Oral candidiasis, mucosal lesions 1, 2
  • Systemic factors: Hematological disorders, autoimmune disorders 1, 2
  • Pharmacological side effects: Certain medications may cause similar symptoms 1, 2
• Neurophysiological testing, biopsies, and functional MRI suggest BMS involves peripheral nerve fiber disorder with central brain changes 1

Management Algorithm

Step 1: Rule Out Secondary Causes

• Complete oral examination to exclude mucosal lesions 2
• Laboratory tests to exclude hematological disorders, autoimmune conditions 2
• Medication review to identify potential pharmacological causes 2

Step 2: Patient Education and Reassurance

• Reassure patients that while prognosis for complete resolution is poor, the condition will not worsen - this reassurance is crucial for reducing anxiety 1
• Educate about the nature of the condition and its chronic course 2

Step 3: First-Line Management

• Cognitive behavioral therapy (CBT) to address psychological components 1, 2
• Neuropathic pain medications:
  • Gabapentin has shown efficacy in reducing burning sensation in 50% of patients 2
  • Alpha-lipoic acid combined with gabapentin 300mg has shown the best outcomes in some studies 1

Step 4: Second-Line Management

• Topical treatments:
  • Topical clonazepam 1
  • Topical diazepam 1
  • Topical capsaicin 1, 3
• Antidepressants may provide relief for some patients 2, 3

Step 5: Management of Associated Symptoms

• For dry mouth:
  • Improve hydration and limit caffeine intake 2
  • Use saliva substitutes and moisture-preserving mouth rinses/sprays 2
  • Consider systemic sialagogues for moderate to severe symptoms 2
• Dietary modifications:
  • Avoid crunchy, spicy, acidic, or hot foods and drinks that may exacerbate discomfort 2

Common Pitfalls and Caveats

• Treatment failures are common in BMS management 1, 2
• Inadequate reassurance about the non-progressive nature of the condition can increase patient anxiety 2
• Overlooking psychological factors (stress, anxiety, depression) that may contribute to or exacerbate symptoms 4
• Failure to recognize that BMS may coexist with other oral conditions, creating diagnostic challenges ("complicated BMS") 5
• Expecting complete resolution rather than symptom control can lead to patient and provider frustration 6

Special Considerations

• A multidisciplinary approach involving dental professionals, pain specialists, and psychological support is often necessary 2, 5
• Regular follow-up during symptomatic periods is important for monitoring and adjusting treatment 5
• Patient acceptance of possible psychological components can be challenging but is essential for effective management 4