What are the treatment options for Burning Mouth Syndrome (BMS)?

Treatment Options for Burning Mouth Syndrome

Burning mouth syndrome (BMS) should be managed with a combination of pharmacological and non-pharmacological approaches, with gabapentin being the first-line medication option due to its demonstrated efficacy in reducing burning sensation in 50% of patients. 1

Diagnostic Considerations

• BMS is characterized by burning sensations of the oral mucosa without clinically apparent mucosal alterations, commonly affecting the tongue tip, lateral borders, lips, palate, and buccal mucosa 2, 1
• Primarily affects peri- and post-menopausal women 2, 3
• Diagnosis requires exclusion of secondary causes including oral candidiasis, mucosal lesions, hematological disorders, auto-immune disorders, and medication side effects 1

First-Line Treatment Options

Pharmacological Approaches

• Gabapentin has demonstrated efficacy in randomized controlled trials, with 50% of patients experiencing reduction in burning sensation 1, 3
• Alpha-lipoic acid shows modest evidence of decreasing pain/burning and may work synergistically with gabapentin 3
• Topical clonazepam (applied directly to affected areas) has shown effectiveness in reducing symptoms 3, 4
• Amitriptyline has demonstrated some benefit in open-label studies for managing BMS symptoms 1, 5

Non-Pharmacological Approaches

• Cognitive behavioral therapy is recommended as a primary intervention to address psychological components that may contribute to or exacerbate symptoms 2, 1
• Patient education and reassurance that the condition will not worsen is crucial for reducing anxiety 1
• Topical treatments including high-potency topical steroids and viscous lidocaine may provide temporary relief 1, 6

Second-Line Treatment Options

• Capsaicin (topical) has shown efficacy but is limited by side effects 3
• Duloxetine or other SNRIs may be beneficial, particularly when depression is a comorbidity 4
• Low-level laser therapy has shown some evidence of effectiveness 7
• Clonazepam (oral) may be considered when topical application is insufficient 5

Management of Associated Symptoms

• For dry mouth:
  • Improve hydration and limit caffeine intake 6
  • Use saliva substitutes and moisture-preserving mouth rinses/sprays 6
  • Consider systemic sialagogues (cevimeline or pilocarpine) for moderate to severe symptoms 1
• For taste disturbances:
  • Avoid foods that exacerbate symptoms (spicy, acidic, hot) 6
  • Regular oral hygiene with bland rinses (salt and sodium bicarbonate solution) 2

Treatment Algorithm

1. Initial management:

   • Exclude secondary causes of burning mouth symptoms 1
   • Start with gabapentin at low dose and titrate up as needed 1, 3
   • Implement cognitive behavioral therapy concurrently 1
   • Apply topical agents (lidocaine, clonazepam) before meals to facilitate eating 6

2. If inadequate response after 4-6 weeks:

   • Consider adding alpha-lipoic acid to gabapentin for synergistic effect 3
   • Try alternative medications such as amitriptyline or duloxetine 1, 4
   • Consider referral to pain specialist or neurologist 2

3. For refractory cases:

   • Evaluate for comorbid depression or anxiety and treat appropriately 4
   • Consider combination therapy with multiple agents 3
   • Explore experimental options such as transcranial magnetic stimulation 5

Important Considerations

• Treatment failures are common in BMS management, and patients should be informed about the chronic nature of the condition 2, 1
• Regular follow-up is essential to monitor treatment efficacy and adjust management as needed 1
• A multidisciplinary approach involving dental specialists, pain management, and mental health professionals may be beneficial for complex cases 7
• Avoid irritating oral care products containing alcohol or strong flavoring agents 2