What is the basic treatment for burning tongue?

Basic Treatment for Burning Tongue (Burning Mouth Syndrome)

The basic treatment for burning tongue involves first excluding secondary causes through targeted laboratory testing, then initiating cognitive behavioral therapy as the primary intervention, with topical clonazepam or gabapentin as first-line pharmacological options if psychological therapy alone is insufficient. 1

Initial Diagnostic Exclusion

Before treating burning tongue as primary burning mouth syndrome, you must exclude secondary causes that require different management:

• Order complete blood count to identify anemia, which commonly causes oral burning 2
• Check vitamin B12 levels as deficiency is a well-established cause of secondary burning mouth syndrome 2
• Obtain iron studies (ferritin, serum iron, TIBC) since iron deficiency anemia frequently presents with burning tongue 2
• Examine for oral candidiasis by scraping and KOH preparation, as fungal infection can cause burning symptoms 2
• Review medications for pharmacological side effects that can cause oral burning 2
• Assess for autoimmune diseases such as Sjögren's syndrome and sicca syndrome 2

Non-Pharmacological First-Line Treatment

Cognitive behavioral therapy is the primary intervention for burning mouth syndrome, addressing psychological components that contribute to or exacerbate symptoms. 3, 1

Supportive Oral Care Measures

• Clean the mouth daily with warm saline mouthwashes or bland rinses (salt and sodium bicarbonate solution) 3, 1
• Apply white soft paraffin ointment to lips every 2 hours during acute symptoms 3
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, for anti-inflammatory effect 3
• Apply chlorhexidine oral rinse twice daily as antiseptic 3
• Avoid irritating oral care products containing alcohol or strong flavoring agents 1
• Avoid crunchy, spicy, acidic, or hot foods and drinks that exacerbate discomfort 1

Pharmacological Treatment Options

First-Line Pharmacological Therapy

Gabapentin is the first-line pharmacological option, showing efficacy in reducing burning sensation in 50% of patients in randomized controlled trials. 1 The American College of Physicians recommends this as the primary medication for neuropathic pain in BMS. 1

Topical clonazepam demonstrates the most consistent evidence across multiple studies, with significant pain reduction after both topical and systemic application. 4, 5, 6 This benzodiazepine can be used as mouthwash, holding the solution in the mouth for about 5 minutes. 3

Alternative Pharmacological Options

• Alpha lipoic acid combined with gabapentin has demonstrated good outcomes in reducing burning sensation 3
• Amitriptyline has shown some benefit in open-label studies 1
• Topical capsaicin showed evident pain reduction in controlled studies, though systemic capsaicin causes significant gastric toxicity (32% gastric pain) limiting its use 4, 7, 5

Topical Corticosteroid Therapy

Use betamethasone sodium phosphate mouthwash (0.5 mg tablet dissolved in 10 mL water) four times daily, holding the solution in the mouth for about 5 minutes. 3 This may help reduce symptoms, though evidence is primarily from pemphigus management guidelines. 3

Management of Associated Symptoms

Dry Mouth Management

• 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 dry mouth 1

Taste Disturbance Management

• Maintain regular oral hygiene with bland rinses (salt and sodium bicarbonate solution) 1

Treatment Algorithm

1. Exclude secondary causes through laboratory testing and oral examination 2
2. Initiate cognitive behavioral therapy as primary intervention 1
3. Add supportive oral care measures (benzydamine rinse, chlorhexidine, paraffin ointment) 3
4. If inadequate response after 4-6 weeks, add gabapentin or topical clonazepam 1, 4
5. If still inadequate response, consider referral to pain specialist or neurologist 1
6. For refractory cases, evaluate for comorbid depression or anxiety and treat appropriately, consider combination therapy 1

Critical Caveats

• Treatment failures are common in BMS management, and patients should be informed about the chronic nature of the condition 1
• Provide adequate reassurance and emphasize that the condition won't worsen, as inadequate reassurance increases patient anxiety 1
• Alpha lipoic acid increases headache (in 2 studies with 118 participants) and gastrointestinal complaints (in 3 studies with 138 participants) 5
• Antidepressants increase dizziness and drowsiness 5
• Systemic capsaicin causes significant gastric toxicity (32% gastric pain) threatening its long-term use 7