What are the management options for burning mouth syndrome?

Burning Mouth Syndrome Management

For burning mouth syndrome, initiate gabapentin as first-line pharmacological therapy after excluding secondary causes, combined with cognitive behavioral therapy to address both neuropathic and psychological components. 1

Diagnostic Workup Required Before Treatment

Before diagnosing primary BMS, you must systematically exclude secondary causes through:

• Oral examination to identify candidiasis (diagnosed by scraping and KOH preparation), mucosal lesions, traumatic ulceration from sharp dental edges, or thermal/chemical injury 2
• Laboratory testing including CBC with differential, thyroid function tests (hyperthyroidism causes tongue erythema and burning), vitamin B12, folate, iron studies, and zinc levels 2, 3
• Medication review to identify pharmacological side effects causing oral burning 2
• Autoimmune screening for Sjögren's syndrome and sicca syndrome if dry mouth is prominent 2
• History focused on timing of onset, recent dental procedures, systemic diseases, and hormonal status (primarily affects peri- and post-menopausal women) 2

First-Line Pharmacological Management

Gabapentin is the recommended first-line agent, demonstrating efficacy in reducing burning sensation in 50% of patients in randomized controlled trials 1

• Start gabapentin and titrate to therapeutic dose over 4-6 weeks 1
• If inadequate response after 4-6 weeks, consider referral to pain specialist or neurologist 1

Alternative and Adjunctive Pharmacological Options

• Alpha lipoic acid combined with gabapentin has demonstrated good outcomes in reducing burning sensation 1
• Topical clonazepam has shown favorable outcomes in both short- and long-term assessment 4
• Topical capsaicin demonstrated favorable outcomes in both short- and long-term assessment, though patients should be warned about initial burning sensation that generally disappears after several days 4, 5
• Amitriptyline has shown benefit in open-label studies for managing BMS symptoms 1
• High-potency topical steroids and viscous lidocaine may provide temporary symptomatic relief 1

Non-Pharmacological Management (Essential Component)

Cognitive behavioral therapy is a primary intervention and should be initiated alongside pharmacological treatment to address psychological components that contribute to or exacerbate symptoms 1

• CBT helps manage the chronic pain syndrome aspects and improves quality of life 1
• Provide adequate reassurance and emphasize that the condition won't worsen—inadequate reassurance is a critical pitfall that increases patient anxiety 1

Management of Associated Symptoms

For dry mouth (xerostomia):

• Improve hydration and limit caffeine intake 1
• Use saliva substitutes and moisture-preserving mouth rinses/sprays for mild symptoms 1
• Consider systemic sialagogues (cevimeline or pilocarpine) for moderate to severe symptoms 1

For taste disturbances:

• Regular oral hygiene with bland rinses using salt and sodium bicarbonate solution 1
• Avoid oral care products containing alcohol or strong flavoring agents 1

Dietary modifications:

• Avoid crunchy, spicy, acidic, or hot foods and drinks that exacerbate discomfort 1

Treatment Algorithm for Refractory Cases

If symptoms persist despite initial management:

• Evaluate for comorbid depression or anxiety and treat appropriately 1
• Consider combination therapy with multiple agents (e.g., gabapentin plus alpha lipoic acid) 1
• Refer to pain specialist or neurologist if inadequate response after 4-6 weeks 1

Critical Pitfalls to Avoid

• Failing to exclude secondary causes before diagnosing primary BMS—this is the most common diagnostic error 2
• Inadequate patient education about the chronic nature of the condition—treatment failures are common, and patients need realistic expectations 1
• Not providing adequate reassurance that the condition won't worsen, which significantly increases patient anxiety 1
• Using irritating oral care products containing alcohol or strong flavoring agents that worsen symptoms 1

Important Caveats

• Primary BMS is a disorder of peripheral nerve fibers with central nervous system changes, confirmed through neurophysiological testing, biopsies, and functional MRI 2
• The condition predominantly affects peri- and post-menopausal women and manifests as continuous burning, stinging, or itchy sensation most commonly affecting the tongue tip bilaterally, lips, palate, and buccal mucosa 2
• Treatment failures are common in BMS management, requiring a multidisciplinary approach and regular follow-up during symptomatic periods 1, 6