What is the workup for burning mouth syndrome (BMS)?

From the Guidelines

The workup for burning mouth syndrome (BMS) should begin with a thorough medical history and physical examination to rule out potential underlying causes, as suggested by the guidelines for management of facial pain 1. The initial step in evaluating BMS involves a comprehensive medical history and physical examination to identify any potential underlying causes.

• Initial laboratory tests should include:
  • Complete blood count
  • Comprehensive metabolic panel
  • Thyroid function tests
  • Vitamin B12, folate, zinc, and iron levels with ferritin to identify nutritional deficiencies
  • Fasting blood glucose or HbA1c to rule out diabetes
• Additional testing may include:
  • Oral cultures for candidiasis
  • Patch testing for contact allergies
  • Salivary flow rate measurement to assess for xerostomia
• Medication review is essential as certain drugs like ACE inhibitors can cause oral burning sensations, as noted in the differential diagnosis of facial pain 1. A referral to an oral medicine specialist or neurologist may be warranted if initial investigations are unrevealing, and psychological assessment may be beneficial as anxiety and depression can contribute to BMS 1. Imaging studies are typically not necessary unless specific pathology is suspected.
• Treatment options depend on findings but may include:
  • Topical clonazepam (0.5-1mg dissolved in mouth 3 times daily)
  • Alpha-lipoic acid (600mg daily)
  • Low-dose tricyclic antidepressants like amitriptyline (10-25mg at bedtime) This comprehensive approach is important because BMS is a diagnosis of exclusion, and identifying treatable underlying causes can lead to symptom resolution, as emphasized in the guidelines for management of facial pain 1.

From the Research

Workup for Burning Mouth Syndrome

The workup for burning mouth syndrome (BMS) involves a comprehensive evaluation to rule out underlying causes of the condition. The following are some of the key components of the workup:

• Laboratory tests:
  • Screening for vitamin and mineral deficiencies, such as vitamin D, vitamin B6, zinc, and vitamin B1 2
  • Thyroid function tests, including thyrotropin (TSH) levels 2, 3, 4
  • Fasting blood glucose levels 2
  • Complete blood count, iron, vitamin B12, and folic acid levels 5
• Diagnostic tests:
  • Thyroid echography to evaluate thyroid function and structure 3, 4
  • Taste sensation evaluation to assess for ageusia or other taste abnormalities 4
• Medical history and physical examination:
  • Meticulous history and physical examination to rule out underlying medical conditions that may be causing the burning mouth symptom 6
  • Evaluation for psychogenic disorders, such as depression, which may be associated with BMS 6, 4
• Referral to specialists:
  • Referral to an endocrinologist or other specialists as necessary to evaluate and manage underlying conditions, such as hypothyroidism 3

Key Findings

Some key findings from the studies include:

• Vitamin and mineral deficiencies are common in patients with BMS, with vitamin D, vitamin B2, and vitamin B6 being the most frequently deficient 2
• Thyroid dysfunction, particularly hypothyroidism, is a common underlying condition in patients with BMS 3, 4
• Taste abnormalities, such as ageusia, are common in patients with BMS 4
• Anemia, hematinic deficiencies, and hyperhomocysteinemia are common in patients with BMS, particularly those with thyroglobulin antibody or thyroid microsomal antibody positivity 5