What is the treatment for burning mouth syndrome?

Treatment for Burning Mouth Syndrome

The American College of Physicians recommends a multidisciplinary approach with gabapentin as first-line pharmacological therapy combined with cognitive behavioral therapy, after excluding secondary causes through appropriate laboratory workup. 1

Initial Diagnostic Workup Required Before Treatment

Before initiating treatment, you must exclude secondary causes through:

• Complete blood count with differential to identify anemia 2
• Vitamin B12 levels as deficiency is a well-established cause 2
• Iron studies (ferritin, serum iron, TIBC) since iron deficiency frequently presents with burning tongue 2
• Fasting glucose and HbA1c to evaluate for diabetes 3
• Thyroid function tests (TSH, free T4) as thyroid disorders can cause tongue burning 2, 3
• Vitamin D 25(OH) levels 3
• Oral examination to exclude candidiasis (diagnosed by scraping and KOH preparation), mucosal lesions, or traumatic factors 2, 3

First-Line Treatment Approach

Non-Pharmacological Management (Primary Intervention)

• Cognitive behavioral therapy is the primary intervention to address psychological components that contribute to or exacerbate symptoms 1
• Reassurance and education are crucial—emphasize that the condition won't worsen, as inadequate reassurance increases patient anxiety 1
• Combination approaches (CBT plus pharmacotherapy) generally outperform monotherapy 1

First-Line Pharmacological Treatment

• Gabapentin is the first-line pharmacological option, showing efficacy in reducing burning sensation in 50% of patients in randomized controlled trials 1
• Alpha lipoic acid combined with gabapentin demonstrates good outcomes, outperforming monotherapy in available trials 1

Second-Line Pharmacological Options

If gabapentin is ineffective or not tolerated after 4-6 weeks:

• Amitriptyline has shown benefit in open-label studies for managing BMS symptoms 1
• Topical clonazepam or diazepam have shown some effect in managing symptoms 1, 4
• Topical capsaicin demonstrated favorable outcomes in both short- and long-term assessment 4

Adjunctive Topical Treatments

For temporary symptom relief:

• High-potency topical steroids may provide temporary relief 1
• Viscous lidocaine may provide temporary relief 1

Management of Associated Symptoms

For Dry Mouth (Xerostomia)

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

For Taste Disturbances

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

Dietary Modifications

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

Treatment Algorithm for Refractory Cases

If inadequate response after 4-6 weeks:

• Consider referral to pain specialist or neurologist 1
• Evaluate for comorbid depression or anxiety and treat appropriately 1
• Consider combination therapy with multiple agents 1

Critical Pitfalls to Avoid

• Treatment failures are common in BMS management—patients should be informed about the chronic nature of the condition 1
• Do not diagnose primary BMS without excluding secondary causes including nutritional deficiencies, autoimmune diseases (Sjögren's syndrome), thyroid disorders, oral candidiasis, medication side effects, post-herpetic neuralgia, and post-traumatic trigeminal neuropathic pain 2, 3
• Failing to provide adequate reassurance that the condition won't worsen is a critical error that increases patient anxiety 1

Special Populations

• Primary BMS predominantly affects peri- and post-menopausal women and is considered a disorder of peripheral nerve fibers with central nervous system changes 2
• Unilateral pain, ulceration, or non-healing lesions warrant tongue biopsy to rule out malignancy 3