What is the diagnosis and treatment for a patient with burning mouth syndrome?

What is "Hot Mouth" (Burning Mouth Syndrome)?

"Hot mouth" refers to Burning Mouth Syndrome (BMS), a chronic orofacial pain disorder characterized by a continuous, spontaneous burning sensation as if the mouth or tongue were scalded or on fire, typically occurring without visible mucosal lesions or clinical signs of organic disease. 1

Clinical Presentation

BMS predominantly affects postmenopausal women, with an estimated prevalence of 0.7-4.6% in the general population, affecting approximately 1.3 million American adults. 1 The condition typically presents with:

• Burning sensation most commonly affecting the tongue tip and lateral borders, lips, and hard/soft palate 2
• Progressive daily pattern: patients typically awaken without pain, but symptoms increase through the day and into evening 3
• Associated symptoms including dysgeusia (taste alterations), xerostomia (dry mouth), and unremitting oral mucosal pain 2

Diagnosis: Primary vs Secondary BMS

The diagnosis of BMS should only be established after ruling out all other possible causes. 1

Primary (Idiopathic) BMS

• No identifiable organic local or systemic causes 2
• Likely neuropathic pathogenesis involving dysfunction of cranial nerves associated with taste sensation 3
• Diagnosis based on exclusion of causative factors 2

Secondary BMS

Must rule out the following potential causes before diagnosing primary BMS 1, 2:

• Nutritional deficiencies (vitamins, zinc)
• Hormonal changes associated with menopause
• Local oral infections (candidiasis)
• Denture-related lesions or ill-fitting prostheses
• Xerostomia (dry mouth)
• Medications causing oral symptoms
• Systemic diseases including type 2 diabetes mellitus
• Hypersensitivity reactions

Important caveat: In more than one-third of patients, multiple concurrent causes may be identified. 1

Treatment Algorithm

Step 1: Address Secondary Causes (if identified)

When local, systemic, or psychological factors are present, treatment or elimination of these factors usually results in significant clinical improvement. 2

• Nutritional deficiencies: Vitamin, zinc, or hormone replacement therapy has been found effective for reducing oral burning symptoms in deficient patients 2
• Fungal infections: Empiric antifungal therapy (nystatin oral suspension or miconazole oral gel) 4, 5
• Denture problems: Eliminate sources of mechanical trauma 6
• Xerostomia management: Adequate hydration and saliva substitutes 5

Step 2: Supportive Oral Care (All Patients)

• Rinse mouth with alcohol-free, sodium bicarbonate-containing mouthwash 4-6 times daily 5
• Maintain oral hygiene with soft toothbrush after meals and before sleep 5
• Apply lip protection: White soft paraffin ointment every 2-4 hours (avoid chronic petroleum jelly use as it promotes mucosal dehydration) 7, 6
• Drink ample fluids to keep mouth moist 5

Step 3: Avoid Irritants

• Eliminate: Smoking, alcohol, hot drinks, spicy foods, acidic foods (citrus, tomatoes), and crusty/rough-textured foods 5, 6
• Avoid: Alcohol-containing mouthwashes that cause additional irritation 7

Step 4: Pharmacological Management for Primary BMS

If symptoms persist after addressing secondary causes, drug therapy should be instituted. 2

First-Line Options (based on randomized controlled trials):

• Clonazepam (benzodiazepine): Effective for symptom relief 4, 3, 2
• Alpha-lipoic acid: Provides relief of oral burning 2
• Topical capsaicin: Beneficial in some patients 4, 3, 2

Second-Line Options:

• Tricyclic antidepressants in low dosages 4, 3
• Anticonvulsants in low dosages 3

Pain Management:

• Topical anesthetics: 2% viscous lidocaine for direct pain relief 5
• Benzydamine hydrochloride oral rinses or sprays every 3 hours, particularly before eating 5, 7
• Topical NSAIDs: Amlexanox 5% oral paste for moderate pain 5

Step 5: Psychological/Psychiatric Intervention

In recalcitrant cases, psychological or psychiatric intervention may be helpful, as chronic anxiety and depression are commonly associated with BMS. 3, 8 Psychotherapy and behavioral feedback may help eliminate symptoms. 2

Common Pitfalls

• Professional delay in diagnosing, referring, and appropriately managing BMS patients occurs frequently 1
• Premature diagnosis of primary BMS without adequately ruling out secondary causes
• Inadequate pain management impacting nutrition and hydration 6
• Chronic use of petroleum-based products on lips, which promotes mucosal dehydration and increases secondary infection risk 6

Key Takeaway

Treatment should be tailored to each patient in a multidisciplinary facility. 1 Begin by systematically excluding secondary causes, implement supportive oral care measures, and progress to pharmacological management with clonazepam, alpha-lipoic acid, or topical capsaicin as first-line agents for primary BMS. 2