What is the treatment for burning mouth syndrome?

Treatment of Burning Mouth Syndrome

Gabapentin is the first-line pharmacological treatment for burning mouth syndrome, with 50% of patients experiencing reduction in burning sensation, combined with cognitive behavioral therapy for optimal outcomes. 1

Initial Diagnostic Requirement

Before initiating treatment, you must exclude secondary causes through targeted workup 1, 2:

• Complete blood count to identify anemia 2
• Vitamin B12 and iron studies (ferritin, serum iron, TIBC) as deficiencies commonly cause oral burning 2
• Oral examination to rule out candidiasis (diagnosed by scraping and KOH preparation), mucosal lesions, or traumatic factors 2
• Medication review for pharmacological side effects 2
• Thyroid function and autoimmune screening (particularly Sjögren's syndrome) 2

Primary Treatment Algorithm

First-Line Therapy

Gabapentin is the recommended initial pharmacological agent, demonstrating efficacy in randomized controlled trials with 50% response rate 1. This should be combined with cognitive behavioral therapy, as combination approaches outperform monotherapy 1.

Second-Line Options

If gabapentin is ineffective or not tolerated after 4-6 weeks 1:

• Amitriptyline has shown benefit in open-label studies 1
• Alpha-lipoic acid combined with gabapentin demonstrates superior outcomes compared to monotherapy 1

Topical Treatments for Symptomatic Relief

• High-potency topical steroids (clobetasol 0.05% gel) or viscous lidocaine provide temporary relief 3, 1
• Topical clonazepam, diazepam, or capsaicin have shown some effect 1
• Magic mouthwash (equal parts diphenhydramine, antacid, and viscous lidocaine) for acute symptom management 3

Management of Associated Symptoms

Dry Mouth (Sicca Syndrome)

For mild symptoms 3, 1:

• Improve hydration and limit caffeine intake
• Saliva substitutes and moisture-preserving mouth rinses/sprays
• Dietary modifications: avoid crunchy, spicy, acidic, or hot foods/drinks 3

For moderate to severe symptoms 3, 1:

• Systemic sialagogues: cevimeline or pilocarpine to increase saliva flow
• Prednisone may provide partial improvement but usually requires chronic management
• Referral to rheumatology and dentistry (severe sicca can cause dental caries and tooth loss) 3

Taste Disturbances

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

Non-Pharmacological Interventions

Cognitive behavioral therapy is a primary intervention to address psychological components that contribute to or exacerbate symptoms 1. This is particularly important as BMS commonly occurs with depression and poor quality of life 1.

Additional options for refractory cases 4:

• Laser therapy
• Acupuncture and auriculotherapy
• Transcranial magnetic stimulation
• Nerve blocks

Critical Management Considerations

Treatment failures are common in BMS management 1. When approaching patients:

• Provide adequate reassurance and emphasize that the condition won't worsen (inadequate reassurance increases patient anxiety) 1
• Educate patients about the chronic nature of the condition 1
• If inadequate response after 4-6 weeks, refer to pain specialist or neurologist 1
• For refractory cases, evaluate for comorbid depression or anxiety and treat appropriately 1
• Consider combination therapy with multiple agents rather than sequential monotherapy 1

Special Population: Immunotherapy-Related Oral Dysesthesia

In patients receiving immune checkpoint inhibitors who develop oral dysesthesia 3:

• Continue immunotherapy for mild symptoms (Grade 1)
• Hold immunotherapy for moderate to severe symptoms; rechallenge can be considered after symptoms become Grade 1
• Gabapentin has shown efficacy (10 of 20 patients experienced reduction in burning sensation in controlled trials)
• Topical steroids (liquid dexamethasone 0.5 mg/5 mL elixir or fluocinonide 0.05% gel) may provide relief