Burning Mouth Syndrome: How to Put Out the Fire

My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled. She underwent coronary artery bypass grafting 11years ago. Recently, burning mouth syndrome (BMS) developed. I have tried avariety of strategies--from stopping her angiotensin-converting enzyme (ACE)inhibitor for short periods to prescribing oral preparations--but nothing seemsto help. She obtains relief only by eating Popsicles, but these increase her sugarintake. I have heard that the condition may persist for 7 to 8 years. What elsecan I offer this patient to alleviate her symptoms?-- Morton Krakow, PA-C
   Homewood, IllThe diagnosis and management of BMS can bechallenging. However, improved understandingof the pathogenesis of the condition offers hopeto affected patients.BMS is a type of neuropathic pain that developsin clinically normal mucosa. It rarely has an underlyingsystemic cause. Developing theories link BMSto disinhibition that results from altered taste function.The tongue and lips are the most commonly involvedsites, and symptoms are bilateral. If symptomsare unilateral, conditions that may cause unilateralnerve damage--including tumor--must be ruled out.BMS is most commonly seen in perimenopausal orpostmenopausal women. In addition to her age and sex,your patient has 2 other potential risk factors for thecondition: diabetes and use of ACE inhibitors. (Hypersensitivityto dental materials, including acrylics, doesnot seem to play a role in the development of BMS.)However, in most patients with BMS, no risk factors areidentified--and in your patient, discontinuation of ACEinhibitors did not mitigate her symptoms.A thorough oral examination is necessary to rule outpotential local causes of burning, such as:

• Candidiasis.
• Oral mucosal changes, such as those that result frominfections.
• Dry mouth.
• Tongue habits (eg, pressing the tongue against theteeth).

BMS can be very troubling to the patient. If localcauses have been ruled out, and underlying, potentiallyaggravating conditions have been eliminated or cannot bealtered, symptomatic management is indicated. Topicaltherapies provide limited benefit in some patients. Topicalcapsaicin has been associated with modest relief of symptomswhen applied to isolated sites up to 4 times daily.Although the evidence supporting treatment ofBMS with centrally acting medications is limited, youmay want to try low-dose clonazepam as an initial strategy.If clonazepam is not effective or side effects areexcessive, other centrally acting medications--such asneurontin, lamotrigine, or a tricyclic antidepressant--may be tried at a low dosage. No studies have assessedcombination therapy with these agents.In addition--as with any chronic symptom--considerthat psychological factors may be the cause of thepain of BMS or may at least play a role in the experienceand presentation of pain. A recent study found that varioustypes of neuroticism--including anxiety, depression,anger, hostility, impulsiveness, and vulnerability--correlatedwith BMS; moreover, these findings differentiatedaffected patients from controls. Review the patient's psychologicalprofile and any known DSM diagnoses; insome instances, counseling may be an important part ofmanagement.

-- Joel Epstein, DMD, MSD, FRCD(C)
   Professor and Head, Department of Oral Medicineand Diagnostic Sciences
   College of Dentistry
   University of Illinois
   Chicago

References:

FOR MORE INFORMATION:Al Quran FA. Psychological profile in burning mouth syndrome. Oral SurgOral Med Oral Pathol Oral Radiol Endod. 2004;97:339-344.Grushka M, Epstein JB, Gorsky M. Burning mouth syndrome and other oralsensory disorders: a unifying hypothesis. Pain Res Manag. 2003;8:133-135.Grushka M, Epstein JB, Gorsky M. Burning mouth syndrome. Am FamPhysician. 2002;65:615-622.