What is the best approach to manage burning mouth syndrome in a middle-aged to elderly woman with no clear underlying cause?

Management of Burning Mouth Syndrome

For a middle-aged to elderly woman with burning mouth syndrome and no clear underlying cause, initiate gabapentin as first-line pharmacological therapy combined with cognitive behavioral therapy, after excluding secondary causes through targeted laboratory testing. 1

Diagnostic Approach: Exclude Secondary Causes First

Before diagnosing primary BMS, systematically rule out secondary causes through:

Essential Laboratory Workup

• Complete blood count with differential to identify anemia 2
• Vitamin B12 levels (deficiency is a well-established cause) 2
• Iron studies (ferritin, serum iron, TIBC) as iron deficiency frequently presents with burning tongue 2
• Fasting glucose and HbA1c to evaluate for diabetes 3
• Thyroid function tests (TSH, free T4) as hyperthyroidism can cause tongue erythema and burning 2, 3
• Vitamin D 25(OH) levels 3

Clinical Examination Focus

• Perform thorough oral examination looking specifically for oral candidiasis (diagnosed by scraping and KOH preparation), mucosal lesions, traumatic ulceration from sharp tooth edges or ill-fitting dentures, and thermal/chemical injury 2, 3
• Document pain characteristics: onset timing, location (tongue tip and anterior two-thirds most commonly affected), duration, and severity 3
• Review medication history for pharmacological side effects causing oral burning 2
• Assess for autoimmune conditions including Sjögren's syndrome and sicca syndrome 2

Primary BMS: Understanding the Condition

Primary BMS is a disorder of peripheral nerve fibers with central nervous system changes, confirmed through neurophysiological testing, biopsies, and functional MRI, affecting predominantly peri- and post-menopausal women 2. The condition manifests as continuous burning, stinging, or itchy sensation most commonly affecting the tongue tip bilaterally, lips, palate, and buccal mucosa, with normal-appearing oral mucosa on examination 2.

Treatment Algorithm for Primary BMS

First-Line Management

Pharmacological therapy:

• Gabapentin is the first-line pharmacological option, demonstrating efficacy in reducing burning sensation in 50% of patients in randomized controlled trials 1
• Alpha-lipoic acid combined with gabapentin shows superior outcomes compared to monotherapy 1

Non-pharmacological therapy:

• Cognitive behavioral therapy (CBT) is a primary intervention to address psychological components that contribute to or exacerbate symptoms 1
• Combination approaches (CBT plus pharmacotherapy) generally outperform monotherapy 1

Patient Education and Reassurance

• Provide adequate reassurance emphasizing that the condition won't worsen—inadequate reassurance increases patient anxiety and should be avoided 1
• Inform patients about the chronic nature of the condition and that treatment failures are common 1

Management of Associated Symptoms

For dry mouth:

• Improve hydration and limit caffeine intake 1
• Use saliva substitutes and moisture-preserving mouth rinses/sprays for mild symptoms 1
• Consider systemic sialagogues (cevimeline or pilocarpine) for moderate to severe symptoms 1

For taste disturbances:

• Regular oral hygiene with bland rinses (salt and sodium bicarbonate solution) 1
• Avoid irritating oral care products containing alcohol or strong flavoring agents 1

Dietary modifications:

• Avoid crunchy, spicy, acidic, or hot food and drinks that may exacerbate discomfort 1

Second-Line Options

If inadequate response after 4-6 weeks:

• Consider amitriptyline when gabapentin is ineffective or not tolerated 1
• Topical treatments including high-potency topical steroids, viscous lidocaine, topical clonazepam, diazepam, or capsaicin may provide temporary relief 1, 3
• Refer to pain specialist or neurologist for refractory cases 1

Refractory Cases

• Evaluate for comorbid depression or anxiety and treat appropriately 1
• Consider combination therapy with multiple agents 1
• Ensure regular follow-up during symptomatic periods 1

Common Pitfalls to Avoid

• Do not diagnose primary BMS without excluding secondary causes—oral candidiasis, nutritional deficiencies, thyroid disorders, and autoimmune conditions must be ruled out first 2, 3
• Avoid inadequate reassurance—failing to emphasize that the condition won't worsen is crucial for managing patient anxiety 1
• Do not use irritating oral care products containing alcohol or strong flavoring agents 1
• Recognize that treatment failures are common—set realistic expectations with patients about the chronic nature of BMS 1