What is the best course of action for a patient with a history of GERD (Gastroesophageal Reflux Disease) and oral health issues, presenting with complaints of burning/stinging sensations bilaterally on the internal cheeks?

Management of Bilateral Burning/Stinging Sensation of the Buccal Mucosa in a Patient with GERD

This presentation is most consistent with Burning Mouth Syndrome (BMS), and you should first exclude secondary causes related to the patient's GERD and oral health issues, then initiate empirical treatment with cognitive behavioral therapy and consider gabapentin or high-potency topical steroids if symptoms are moderate to severe. 1

Diagnostic Approach

Confirm the Clinical Diagnosis

The bilateral burning/stinging sensation affecting the internal cheeks (buccal mucosa) with normal-appearing oral mucosa is characteristic of BMS, which presents as a continuous burning, stinging, or itchy sensation of mild to severe intensity. 1

Key diagnostic features to confirm:

• The oral mucosa should appear normal on examination (no visible lesions, erythema, or ulceration) 1
• Symptoms are typically continuous rather than paroxysmal 1
• Pain quality is burning or stinging, not sharp or electric shock-like 1
• Bilateral distribution involving buccal mucosa, though BMS most commonly affects the tongue tip, lips, and palate 1

Exclude Secondary Causes Before Diagnosing Primary BMS

Critical exclusions in this patient with GERD and oral health issues:

• GERD-related mucosal injury: The patient's GERD may be causing direct acid exposure to the oral mucosa, particularly if there is regurgitation. Examine for any subtle mucosal changes, erythema, or erosions that would indicate acid-related injury rather than true BMS. 1

• Oral candidiasis: Perform oral examination and consider fungal culture if any white patches or erythema are present, as candidiasis is a common secondary cause of burning sensation. 1

• Haematological disorders: Check complete blood count, iron studies, vitamin B12, and folate levels, as deficiencies can cause oral burning. 1

• Xerostomia (dry mouth): Assess for dry mouth, which is commonly associated with BMS and can be exacerbated by medications. Ask about associated dry mouth symptoms and abnormal taste. 1

• Medication side effects: Review the patient's medication list, as many drugs can cause oral burning as a side effect. 1

Treatment Algorithm

Step 1: Optimize GERD Management

Since uncontrolled GERD can directly cause oral mucosal irritation:

• Ensure the patient is on adequate PPI therapy (once-daily dosing initially, escalating to twice-daily if symptoms persist after 4-8 weeks). 1
• Any PPI can be used (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, or dexlansoprazole), dosed 30-60 minutes before meals. 1
• If the patient is already on twice-daily PPI therapy without adequate control of GERD symptoms, consider endoscopy to evaluate for complications. 1

Step 2: Initial Management for Mild Symptoms (Grade 1)

If symptoms are mild and not significantly impacting function:

• Provide reassurance that BMS will not worsen over time, which is often crucial for patient anxiety. 1
• Implement dietary modifications: avoid crunchy, spicy, acidic, or hot foods/drinks. 1
• Address xerostomia if present with topical measures (water sips, saliva substitutes, moisture-preserving mouth rinses). 1
• Initiate cognitive behavioral therapy (CBT), which has demonstrated reduction in BMS symptoms. 1, 2

Step 3: Treatment for Moderate to Severe Symptoms (Grade 2-3)

If symptoms significantly impact quality of life or function:

• First-line pharmacologic options:

  • Gabapentin: Start at low doses and titrate upward. In a randomized controlled trial, 50% of patients with oral burning experienced symptom reduction with gabapentin. 1
  • High-potency topical steroids: Use gel or dental paste formulations applied to affected areas. 1
  • Viscous lidocaine: Can provide temporary symptomatic relief, though this is for external oral use only and should not be used on large areas. 1, 3

• Alternative consideration:

  • Vitamin complexes: One trial demonstrated reduction in BMS symptoms with vitamin supplementation, though this study lacked blind outcome assessment. 2

• Avoid antidepressants as first-line: Despite theoretical benefit, trials of antidepressants for BMS have not demonstrated significant symptom reduction. 2

Step 4: Referral Considerations

Refer to appropriate specialists when:

• Dental referral: For comprehensive evaluation of oral health issues and to ensure no odontogenic source of pain. 1
• Rheumatology referral: If sicca syndrome or autoimmune disorder is suspected (though sicca syndrome typically presents with dry mouth as the primary complaint). 1
• Gastroenterology referral: If GERD symptoms are not controlled on twice-daily PPI therapy or if alarm symptoms develop (dysphagia, bleeding, anemia, weight loss, recurrent vomiting). 1

Critical Pitfalls to Avoid

Do not misdiagnose other neuropathic pain conditions:

• Post-herpetic neuralgia presents with a history of herpes zoster and is typically unilateral. 1
• Trigeminal neuralgia presents with paroxysmal, electric shock-like pain triggered by light touch, not continuous burning. 1
• Glossopharyngeal neuralgia affects the deep ear and posterior tongue, not the buccal mucosa. 1

Do not overlook GERD as a contributing factor:

• Inadequately treated GERD can cause direct mucosal irritation that mimics or exacerbates BMS. 1
• Ensure GERD is optimally managed before attributing all symptoms to primary BMS. 1

Set realistic expectations:

• The prognosis for complete resolution of primary BMS is poor, with only a small number of patients experiencing full resolution. 1
• However, reassure patients that symptoms will not worsen, which significantly improves quality of life and reduces anxiety. 1
• BMS is associated with depression and poor quality of life, so addressing psychological comorbidities is essential. 1