What is the recommended approach to using steroids, such as prednisolone, in an older adult patient with burning mouth syndrome and potential risk factors for steroid-induced side effects like osteoporosis, diabetes, and hypertension?

Steroids Are Not Recommended for Burning Mouth Syndrome

Systemic corticosteroids should not be used for burning mouth syndrome (BMS), as there is no evidence supporting their efficacy for this condition, and they carry substantial risks—particularly in older adults with pre-existing risk factors for osteoporosis, diabetes, and hypertension. 1

Why Steroids Are Inappropriate for BMS

Lack of Evidence for Efficacy

• No randomized controlled trials or systematic reviews demonstrate benefit of corticosteroids for burning mouth syndrome 2, 3
• BMS is a chronic neuropathic pain condition, not primarily an inflammatory disorder, making anti-inflammatory steroids mechanistically inappropriate 4, 5
• The condition requires treatments targeting neuropathic pain mechanisms rather than inflammation 3

Substantial Risk Profile in Older Adults

The risks of systemic corticosteroids are particularly concerning in elderly patients with BMS:

Cardiovascular and Metabolic Complications:

• Steroids cause sodium retention and can precipitate or worsen hypertension and heart failure 6
• They induce insulin resistance, increasing risk of diabetes onset and progression 1
• Cardiovascular disease risk increases with steroid exposure 1

Bone Health Deterioration:

• Fracture risk increases within 3 months of starting corticosteroids, with greatest bone loss occurring early in treatment 1, 6
• Doses ≥7.5 mg/day prednisolone are associated with increased vertebral and nonvertebral fractures 7
• Elderly patients have higher baseline osteoporosis risk, making steroid-induced bone loss particularly dangerous 7

Other Serious Adverse Effects:

• Mood disorders, insomnia, and psychosis 1
• Increased infection risk 1, 6
• Peptic ulcers, cataracts, myopathy 1
• Adrenal suppression with prolonged use 1

Evidence-Based Alternatives for BMS

The systematic review literature identifies several treatments with demonstrated efficacy:

First-Line Pharmacological Options:

• Topical clonazepam shows favorable outcomes in both short- and long-term assessment 3
• Topical capsaicin demonstrates benefit with sustained effect 4, 3
• Alpha-lipoic acid provides increasing positive effects with long-term use 4, 3
• Gabapentin or pregabalin for neuropathic pain management 2, 4

Alternative Pharmacological Approaches:

• Antidepressants (duloxetine, amitriptyline) for neuropathic pain 2, 4
• Pramipexole (dopamine agonist) showed clear improvement in a case series with 4-year sustained benefit 5

Non-Pharmacological Therapies:

• Cognitive behavioral therapy demonstrates favorable short- and long-term outcomes 3
• Low-level laser therapy shows benefit in multiple studies 2, 3
• Acupuncture, transcranial magnetic stimulation as adjunctive options 2

Critical Clinical Pitfall

The most important pitfall is prescribing systemic corticosteroids empirically for oral burning symptoms without proper diagnosis. 1 This practice:

• Exposes patients to serious adverse effects without potential benefit
• Delays appropriate neuropathic pain management
• Is particularly dangerous in elderly patients with multiple comorbidities 6, 7

If Steroids Were Absolutely Necessary (They Are Not for BMS)

Should systemic corticosteroids ever be considered for a different oral condition in an elderly patient with similar risk factors, mandatory precautions would include:

• Calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation from day one 1, 6
• Immediate bisphosphonate therapy for doses ≥30 mg/day prednisolone for ≥30 days 6, 8
• Proton pump inhibitor for gastrointestinal protection 6
• Pneumocystis jirovecii prophylaxis with trimethoprim-sulfamethoxazole for doses ≥20 mg/day for ≥4 weeks 6, 8
• Baseline and ongoing monitoring of blood pressure, glucose, and bone mineral density 6, 7

However, these precautions are irrelevant for BMS because steroids should never be prescribed for this condition in the first place. 1