What is the best approach to manage burning/stinging sensations in the mouth of a patient with a history of oral health problems and no symptoms of Gastroesophageal Reflux Disease (GERD)?

Management of Burning/Stinging Mouth Sensations Without GERD Symptoms

In a patient with oral burning sensations and no GERD symptoms, focus on diagnosing and treating primary burning mouth syndrome (BMS) rather than pursuing acid suppression therapy, as this represents a neuropathic pain disorder requiring neuromodulators like gabapentin or clonazepam as first-line treatment. 1, 2

Initial Diagnostic Approach

Rule out secondary causes systematically before diagnosing primary BMS:

• Perform thorough oral examination looking specifically for candidiasis (diagnosed by scraping and KOH preparation), traumatic ulceration from sharp dental edges, mucosal lesions, or signs of chronic irritation 1, 2

• Order targeted laboratory workup including complete blood count with differential to identify anemia, vitamin B12 levels, iron studies (ferritin, serum iron, TIBC), and thyroid function tests, as these deficiencies commonly cause secondary burning mouth symptoms 1, 2

• Review medication list for pharmacological causes of oral burning 1

• Assess for autoimmune conditions including Sjögren's syndrome and sicca syndrome through clinical evaluation and autoimmune serology if dry mouth is prominent 1, 3

Distinguishing Primary from Secondary BMS

Primary BMS characteristics that confirm the diagnosis:

• Continuous burning, stinging, or itchy sensation affecting tongue tip bilaterally, lips, palate, and buccal mucosa with completely normal-appearing oral mucosa on examination 1, 2

• Symptoms typically absent upon awakening but increase through the day and into evening 4

• Predominantly affects peri- and post-menopausal women 1, 4

• Associated symptoms include dry mouth, abnormal taste (dysgeusia), depression, and significantly impaired quality of life 1, 2

This represents a disorder of peripheral nerve fibers with central nervous system changes, confirmed through neurophysiological testing showing significantly lower density of epithelial nerve fibers in tongue biopsies compared to controls. 1

Treatment Algorithm for Primary BMS

First-Line Pharmacologic Management

Initiate gabapentin as first-line therapy with a 50% response rate in controlled trials for moderate to severe BMS 5, 6

Alternative first-line options include:

• Clonazepam (benzodiazepine) in low dosages, which has demonstrated efficacy in randomized controlled trials 2, 4

• Topical clonazepam may be considered to minimize systemic side effects 6

Second-Line Options

If first-line therapy fails, consider:

• Tricyclic antidepressants in low dosages 2, 4

• Alpha-lipoic acid, which has shown benefit in randomized controlled trials 2, 6

• Topical capsaicin for localized burning 2, 4

• Low-dose naltrexone as an emerging off-label treatment 6

Non-Pharmacological Interventions

Implement cognitive behavioral therapy to address pain symptoms and enhance pain-coping skills, as this may help eliminate BMS symptoms 2, 6

Consider additional modalities:

• Behavioral feedback therapy 2

• Nerve blocks for refractory cases 6

• Transcranial magnetic stimulation in specialized centers 6

Management of Secondary BMS

When deficiencies are identified, targeted replacement therapy is curative:

• Vitamin B12, iron, or zinc replacement therapy has been found effective for reducing oral burning symptoms in patients with documented deficiency 2

• Hormone replacement therapy may benefit peri-menopausal women with documented hormonal deficiency 2

• Treatment or elimination of identified local, systemic, or psychological factors usually results in significant clinical improvement 2, 7

Critical Pitfall to Avoid

Do not pursue empiric PPI therapy in the absence of typical GERD symptoms (heartburn, regurgitation, or non-cardiac chest pain). The 2022 AGA guidelines clearly state that PPI trials are appropriate only for patients with typical reflux symptoms, and symptom improvement on PPIs may result from mechanisms other than acid suppression and should not be regarded as confirmation for GERD 8. In one case report, a patient's oral burning symptoms persisted despite resolution of GERD with omeprazole 20 mg twice daily, confirming that BMS and GERD are distinct entities 3.

Expected Outcomes and Follow-Up

Primary BMS often requires chronic management with realistic expectations that neuromodulators provide approximately 50% response rate 5, 6

Reassurance and explanation concerning the neuropathic cause of symptoms is therapeutic in itself, and some patients may choose to defer pharmacologic treatment initially 3

An interdisciplinary approach is required for optimal patient management given the multifactorial nature and chronic course of this condition 7