What are the potential causes of burning mouth pain in an elderly female patient with a history of Gastroesophageal Reflux Disease (GERD) and Rheumatoid Arthritis (RA), not currently on immunosuppression?

Potential Causes of Burning Mouth Pain in an Elderly Female with GERD and RA

In an elderly female with GERD and RA not on immunosuppression, burning mouth pain is most likely secondary to nutritional deficiencies (particularly B12, iron, or folate), xerostomia from medications or Sjögren's syndrome, oral candidiasis, or GERD-related mucosal irritation, rather than primary burning mouth syndrome. 1

Primary Diagnostic Considerations

Nutritional Deficiencies

• Check complete blood count, vitamin B12, iron studies (ferritin, serum iron, TIBC), and folate levels immediately, as these deficiencies are well-established causes of secondary burning mouth syndrome and are common in elderly patients. 1
• Iron deficiency anemia and B12 deficiency frequently present with burning tongue and are readily treatable causes. 1

Autoimmune-Related Causes

• Evaluate for Sjögren's syndrome, which commonly coexists with RA and manifests with oral burning, xerostomia, and must be excluded before diagnosing primary burning mouth syndrome. 1
• Consider checking anti-SSA/Ro and anti-SSB/La antibodies, as Sjögren's syndrome affects approximately 15-20% of RA patients and causes significant xerostomia leading to burning sensations. 1

Oral Candidiasis

• Perform oral examination with scraping and KOH preparation to exclude candidiasis, which can cause burning mouth symptoms and appears as white plaques or erythematous patches. 1
• Elderly patients with chronic diseases are at higher risk for oral fungal infections. 1

GERD-Related Manifestations

• GERD can cause oral and maxillofacial manifestations including burning mouth, xerostomia, mucositis, and hyperesthesia, though the direct causal relationship remains debated. 2
• Recent evidence suggests GERD may represent a potential systemic comorbidity in burning mouth syndrome patients, with 30.95% of BMS patients showing endoscopic confirmation of GERD. 3
• Altered taste and thickened tongue coating are significantly more common in patients with GERD scores ≥8 and may be suggestive of GERD-related burning mouth symptoms. 3
• However, one study found burning mouth syndrome is not definitively a symptom of gastroesophageal reflux disease, emphasizing the need for careful clinical distinction. 4

Medication-Related Causes

• Review all current medications, as pharmacological side effects from various drugs can cause oral burning and must be excluded. 1
• Common culprits include antihypertensives, diuretics, and medications causing xerostomia. 1

Diagnostic Algorithm

Step 1: Initial Clinical Assessment

• Obtain detailed history focusing on onset timing, medication use, systemic diseases, and dental procedures. 1
• Perform thorough oral examination to identify mucosal lesions, candidiasis, traumatic factors, or signs of xerostomia. 1
• Document the specific location (tongue tip, lips, palate, buccal mucosa) and character of burning (continuous, intermittent, associated with eating). 1

Step 2: Laboratory Workup

• Complete blood count with differential 1
• Vitamin B12 level 1
• Iron studies (ferritin, serum iron, TIBC) 1
• Folate level 1
• Thyroid function tests (TSH, free T4) to exclude hyperthyroidism 1
• Consider anti-SSA/Ro and anti-SSB/La antibodies if Sjögren's syndrome suspected 1

Step 3: GERD Assessment

• If GERD symptoms are inadequately controlled, optimize PPI therapy to twice-daily dosing (e.g., omeprazole 20-40 mg twice daily before meals). 5, 6
• Consider using the Gastroesophageal Reflux Disease Questionnaire (GERDQ) as a screening tool, with scores ≥8 suggesting potential GERD contribution. 3
• Look for associated symptoms including altered taste and thickened tongue coating, which are more common in GERD-positive patients. 3

Step 4: Specific Interventions Based on Findings

If nutritional deficiencies identified:

• Supplement appropriately (B12 injections or high-dose oral, iron supplementation, folate replacement) 1

If oral candidiasis confirmed:

• Treat with antifungal therapy (nystatin suspension or fluconazole) 1

If Sjögren's syndrome suspected:

• Refer to rheumatology for confirmation and management 1
• Implement xerostomia management strategies 7

If GERD-related:

• Optimize acid suppression with twice-daily PPI therapy for 8-12 weeks 5
• Implement lifestyle modifications including avoiding late meals and maintaining upright position for 2-3 hours after eating 6

Management of Xerostomia (Common in This Population)

First-Line Interventions

• Increase water intake throughout the day and limit caffeine consumption. 7
• Use sugar-free chewing gum or lozenges to mechanically stimulate saliva production. 7
• Apply saliva substitutes (moisture-preserving mouth rinses, sprays, or gels with neutral pH and electrolytes). 7

Oral Hygiene Modifications

• Use prescription-strength fluoride toothpaste for dental protection. 7
• Rinse vigorously several times daily with bland rinse to maintain moisture and remove debris. 7
• Apply water-based lip lubricants frequently, avoiding petroleum-based products. 7

Critical Pitfalls to Avoid

• Do not diagnose primary burning mouth syndrome without excluding all secondary causes, particularly nutritional deficiencies, autoimmune conditions, candidiasis, and medication effects. 1
• Do not dismiss GERD as a potential contributor even if typical heartburn is absent, as atypical presentations are common in elderly patients. 8, 3
• Do not overlook the possibility of Sjögren's syndrome in a patient with RA, as this combination significantly increases risk of xerostomia and oral burning. 1
• Do not rely solely on patient-reported symptoms for GERD assessment; consider objective evaluation with GERDQ or endoscopy if symptoms persist despite treatment. 3

When Primary BMS is Suspected

Only after excluding all secondary causes should primary burning mouth syndrome be considered, which manifests as continuous burning affecting tongue tip bilaterally, lips, palate, and buccal mucosa with normal-appearing oral mucosa and is considered a disorder of peripheral nerve fibers with central nervous system changes. 1

Associated symptoms include dry mouth, abnormal taste, depression, and poor quality of life, with significantly lower density of epithelial nerve fibers in tongue biopsies. 1