How is burning mouth syndrome managed?

Management of Burning Mouth Syndrome

Burning mouth syndrome (BMS) is best managed through a combination of pharmacological and non-pharmacological approaches, with cognitive behavioral therapy, topical medications, and neuropathic pain medications showing the most promising results for symptom relief.

Diagnostic Considerations

• BMS is characterized by burning sensation of the oral mucosa without clinically apparent mucosal alterations, commonly affecting the tongue tip, lateral borders, lips, and palate, primarily in peri- and post-menopausal women 1, 2
• Diagnosis requires exclusion of secondary causes, including:
  • Local factors: oral candidiasis, mucosal lesions 1, 2
  • Systemic factors: hematological disorders, auto-immune disorders 1, 2
  • Pharmacological side effects 1, 2

First-Line Management Approaches

Non-Pharmacological Interventions

• Cognitive behavioral therapy (CBT) is recommended as a primary intervention for BMS, addressing psychological components that may contribute to symptoms 1, 2
• Patient reassurance is crucial - emphasizing that the condition will not worsen often provides significant psychological relief 1, 2
• Education about the nature of the condition helps reduce anxiety and improves coping 2

Pharmacological Management

• Gabapentin has demonstrated efficacy in reducing burning sensation in approximately 50% of patients 2
• Clonazepam (topical or systemic) shows favorable outcomes in both short and long-term assessment 3
• Topical capsaicin (0.02% oral rinse) can significantly reduce pain/burning levels 4
• Amitriptyline has shown some benefit in open-label studies 2, 5

Second-Line and Adjunctive Treatments

• Alpha-lipoic acid supplements may provide modest short-term benefits with increased positive effects in long-term assessment 3, 5
• Low-level laser therapy has demonstrated favorable outcomes in both short and long-term assessments 3
• For associated dry mouth:
  • Improve hydration and limit caffeine intake 2
  • Use saliva substitutes and moisture-preserving mouth rinses/sprays 2
  • Consider systemic sialagogues like pilocarpine for moderate to severe symptoms 6
• Vitamin B complex and zinc supplements have shown statistically significant reduction in pain/burning levels 4

Management Algorithm

1. Rule out secondary causes of oral burning sensation 1, 2
2. Initiate first-line therapy:
   • Cognitive behavioral therapy 1, 2
   • Topical clonazepam or capsaicin 3, 4
3. If inadequate response, add or switch to:
   • Gabapentin or amitriptyline 2, 5
   • Alpha-lipoic acid supplements 3, 5
4. For persistent symptoms, consider:
   • Low-level laser therapy 3
   • Vitamin B and zinc supplementation 4
5. Manage associated symptoms (dry mouth, taste disturbances) 2, 6

Important Considerations and Pitfalls

• Treatment failures are common in BMS management - set realistic expectations with patients 1, 2
• Avoid spicy, acidic, or hot foods and drinks that may exacerbate discomfort 2
• The prognosis is generally poor with only a small number of cases resolving fully 1
• Inadequate reassurance about the benign nature of the condition can increase patient anxiety 2
• Multiple concurrent causes of BMS may be present in more than a third of patients, requiring comprehensive evaluation 7