What is the best approach to manage burning mouth syndrome in a middle-aged to elderly woman?

Management of Burning Mouth Syndrome

Start with gabapentin as first-line pharmacological therapy combined with cognitive behavioral therapy, as this combination approach outperforms monotherapy and addresses both neuropathic and psychological components of the condition. 1

Initial Diagnostic Workup

Before initiating treatment, you must exclude secondary causes through targeted evaluation:

• Order complete blood count, vitamin B12, iron studies (ferritin, serum iron, TIBC), and thyroid function tests to identify nutritional deficiencies and systemic disorders that commonly cause oral burning 2
• Perform oral examination specifically looking for candidiasis (confirm with KOH preparation), mucosal lesions, traumatic ulceration from dental work, and signs of autoimmune conditions like Sjögren's syndrome 2
• Review all medications for pharmacological side effects that may cause oral burning 2
• Assess for post-traumatic trigeminal neuropathy or post-herpetic neuralgia if there is relevant history 2

First-Line Treatment Algorithm

Non-Pharmacological Management (Start Immediately)

• Refer for cognitive behavioral therapy as primary intervention to address psychological components that contribute to or exacerbate symptoms 1
• Provide reassurance and education emphasizing that the condition won't worsen—inadequate reassurance is a critical pitfall that increases patient anxiety 1
• Implement dietary modifications: avoid crunchy, spicy, acidic, or hot foods and drinks 1
• Optimize oral hygiene with bland rinses (salt and sodium bicarbonate solution) and avoid products containing alcohol or strong flavoring agents 1

Pharmacological Management (Start Concurrently)

• Initiate gabapentin as first-line medication, which reduces burning sensation in 50% of patients 1
• Consider alpha lipoic acid combined with gabapentin for enhanced outcomes, as this combination demonstrates superior results compared to monotherapy 1

Second-Line Options (If Inadequate Response After 4-6 Weeks)

• Switch to amitriptyline if gabapentin is ineffective or not tolerated 1
• Add topical treatments: high-potency topical steroids, viscous lidocaine, or topical clonazepam for temporary symptom relief 1
• Consider topical capsaicin (apply thin film 3-4 times daily to affected areas), though this is supported by older evidence 3, 4

Management of Associated Symptoms

For Dry Mouth (Common Comorbidity)

Mild symptoms:

• Increase water intake and limit caffeine consumption 1
• Use saliva substitutes (moisture-preserving mouth rinses, sprays, or gels with neutral pH and electrolytes) 1
• Employ sugar-free chewing gum or lozenges to mechanically stimulate saliva production 1

Moderate to severe symptoms:

• Prescribe systemic sialagogues: cevimeline or pilocarpine (5 mg orally four times daily), though monitor carefully for side effects including excessive sweating, nausea, and bronchoconstriction 1

For Taste Disturbances

• Maintain regular oral hygiene with bland rinses 1

Refractory Cases

• Refer to pain specialist or neurologist if inadequate response after 4-6 weeks of initial therapy 1
• Evaluate and treat comorbid depression or anxiety appropriately, as these significantly impact outcomes 1
• Consider combination therapy with multiple agents, as CBT plus pharmacotherapy generally outperforms monotherapy 1

Critical Pitfalls to Avoid

• Do not fail to inform patients about the chronic nature and high treatment failure rates—setting realistic expectations is essential 1
• Do not overlook secondary causes before diagnosing primary BMS, as treating underlying conditions (nutritional deficiencies, candidiasis, autoimmune disorders) often resolves symptoms 2
• Do not use irritating oral care products containing alcohol or strong flavoring agents, which worsen symptoms 1

Key Clinical Pearls

The condition primarily affects peri- and post-menopausal women and typically involves the tongue tip bilaterally, lips, palate, and buccal mucosa with normal-appearing oral mucosa on examination 2. The multidisciplinary approach combining CBT with pharmacotherapy is superior to either intervention alone 1. Treatment failures are common, requiring patience and often multiple therapeutic adjustments 1.