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Burning Mouth: an Initial Examination of a Potential Role of Herpes Virus Infection

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Burning Mouth: an Initial Examination of a Potential Role of Herpes Virus Infection Oral Med Pathol 11 (2006) 45 Burning Mouth: An Initial Examination of a Potential Role of Herpes Virus Infection Joel B. Epstein1, Miriam Grushka2, Christopher Sherlock3, Matthew S. Epstein4 and Meir Gorsky5 1Department of Dentistry, Vancouver Hospital and Health Sciences Center,Vancouver British Columbia, Canada; currently Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois, Chicago, Illinois, USA 2Department of Dentistry,Vancouver Hospital and Health Sciences Center, Vancouver British Columbia, Canada; currently Private Practice, Toronto, Ontario, Canada 3Department of Pathology & Laboratory Medicine, University of British Columbia/St. Paul’s Hospital, Department of Virology, University of British Columbia, Vancouver British Columbia, Canada 4Department of Dentistry, Vancouver Hospital and Health Sciences Center, Vancouver British Columbia, Canada; currently School of Dentistry, University of Washington, Seattle, Washington, USA 5Department of Dentistry, Vancouver Hospital and Hearth Science Center, Vncouver British Columbia, Canada; currentry, Department of Oral Pathology and Oral Medicine, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel Epstein JB, Grushka M, Sherlock C, Epstein MS and Gorsky M. Burning mouth: an initial examination of a potential role of herpes virus infection. Oral Med Pathol 2006; 11: 45-48, ISSN 1342-0984 Burning Mouth Syndrome (BMS) is a burning sensation of the oral mucosa that occurs in the absence of a clinical or laboratory finding. Since herpes virus infections are common in the oropharynx, a possible association between BMS and post-herpetic neuralgia was speculated. The purpose of the present study was to evaluate a potential viral role in the etiology of BMS. Materials and Methods: Viral serology (HSV, CMV, VZV IgM and IgG) obtained from 9 patients with BMS was compared to that of 13 patients with other oral mucosal conditions. Results and Discussion: The general profile of the BMS patients in this trial fits the profile of these patients reported in the literature. No IgM seropositivity for any of the 3 viruses was recorded in the BMS patients. Although most subjects in the two groups were positive for HSV, CMV, and HZV IgG, no difference in the prevalence was noted between burning mouth and the control groups. The positive IgG findings indicate past exposure to the viruses as expected in the general population. Although no evidence was found that would support the presence of an active viral infection in BMS subjects, the possibility of a “hit and run” role for viral damage in BMS could not be ruled out based on the present sample. Key words: herpes simplex virus, varicella-zoster virus, cytomegalovirus, burning mouth syndrome, oral neuropathic pain Correspondence: Joel B. Epstein, Department of Oral Medicine and Diagnestic Sciences, College of Dentistry, 801 S. Paulina St, Chicago, Illinois, USA Phone: +312-996-7480, Fax: +312-355-2688, E-mail: [email protected] Introduction The pain is usually described as burning with as- Burning Mouth Syndrome (BMS) is defined as a sociated dysesthetic qualities similar to those present in burning sensation in the tongue and/or other oral mu- other neuropathic pain conditions. Although psychologi- cous membranes not associated with any identified clini- cal factors are often prominent in BMS, no clear evidence cal signs and laboratory findings (1, 2). There is no clear of a close causal relationship between psychogenic fac- understanding of its etiology or pathogenesis (3, 4) and tors and burning mouth has been reported (7). The pain diagnosis remains essentially clinical by exclusion of other often begins spontaneously (2) and increases in intensity diseases. BMS is considered a chronic disorder and in over a short period of time before it plateaus. Approxi- the few studies that have looked at spontaneous remis- mately one third of the subjects attribute the onset of sion in BMS, at least a partial remission may occur within their oral burning to a dental procedure or illness, such 6 to 7 years after onset in up to two-thirds of subjects (5, as an upper respiratory infection (2). 6). In view of the relatively rapid onset, as well as the 46 Epstein et al. Herpes viruses and burning mouth syndrome relatively high prevalence of BMS in more than 1.0% in the BMS patients, a subjective sensation of oral dryness the general population [higher in post-menopausal women was reported by 75%, and taste changes were reported (7)] and the quality of pain, the possibility that BMS fol- by 22% of the subjects. The onset of the burning sensa- lows a viral infection can be considered. Herpes virus tion of BMS was described as gradual by 71.4% of the infections are common in the oropharynx and it is pos- patients and as sudden by 28.6%. The 13 subjects who sible that neuropathic effects may follow oropharyngeal had identifiable oral lesions associated with their oral infection associated with nerve infection (8). Since the burning served as control subjects, of these 11 had evi- possible association between BMS and Herpes virus as- dence of erosive lichen planus and two suffered from post- sociated nerve damage as in post-herpetic neuralgia fol- radiation therapy mucosal sensitivity. None of this group lowing Herpes zoster infections, has not been investigated, reported taste alterations and 6 patients (46.1%) reported the purpose of this preliminary study was to evaluate the oral dryness. No patients in either group demonstrated potential viral role of Herpes viruses in patients with decreased salivary flows on salivary collection. burning mouth symptoms. The severity of the discomfort on a visual analog scale ranging from 0 to 10 with the following anchors “no Material and methods discomfort” to “extremely painful” was assessed. In the Patients with complaints of oral burning were en- BMS subjects VAS pain was a mean of 6.3. In addition rolled following completion of institutional informed con- to burning of the lips and the cheeks, tongue involvement sent. A standard history was acquired and oral examina- was reported by 5 patients (55.6%) with BMS. Taste tion completed. BMS was diagnosed when there was an changes were reported by 2 male subjects (22.2%). absence of oral changes, and standard screening blood Table 2 shows medication use of the 22 individuals tests for blood glucose, anemia, iron deficiency, folate, B12 with oral pain. Pain control medications were used mostly were negative (9). Consecutive patients with oral burn- by individuals in the control group and only 23% of this ing had viral serology completed (HSV, CMV, VZV, IgM group of patients used antidepressant medications; how- and IgG), using the appropriate ELISA tests (Dade ever, a majority of the BMS patients (78%) used antide- Behring Inc; Newark DE). Whole resting salivary flow pressants. was assessed by having patients collect saliva for 5 min- The results of the serologic tests for HSV, CMV and utes while at rest and while stimulated by chewing VZV are shown in Table 3. All but one subject in both the unflavored chewing gum base for 5 minutes, after which study and control groups were negative for IgM antibody the collections were weighed (4). Controls were consecu- to the Herpes viruses tested. However, one patient of the tive patients with identified oral mucosal conditions in control group, a 64 year old woman with oral and left whom oral discomfort was present. facial pain compatible with the diagnosis of Herpes zoster, was found to be positive for VZV IgM antibody. Most sub- Results jects in the two groups were positive for HSV, CMV and The characteristics of the 22 subjects in the study HZV IgG and no difference was found in the prevalence group are presented in Table 1. The mean ages of the male of the positive findings between the two groups. and female study subjects was not significantly differ- ent. Tobacco use was low: 14.2% of men and 7.1% of women Discussion smoked. Approximately 62% of the study group reported Although there is strong evidence from clinical some alcohol consumption, which was limited to beer or studies to suggest that people who present with BMS are wine and was for most individuals only on social occa- mostly post-menopausal women (2, 7), some recent epi- sions; however, for one man and three women (23% of demiological data suggests a more equal male to female study subjects) daily alcohol consumption was reported. ratio (10, 11). We identified an approximately equal male Mouthwashes were used by 10 subjects (47.6%); almost to female ratio in our small series of consecutive clinical half of these subjects reported using rinses more than cases. The distribution of oral sites most often involved once daily. were the anterior tongue, anterior hard palate and the Even though all patients complained of discomfort lower lip (2), consistent with the subjects identified in and pain in the oral cavity, exclusion of any clinically iden- this study as experiencing BMS. tified etiology resulted in 9 patients with a clinical diag- The general profile of the BMS patients in the nosis of BMS. The mean age of the patients diagnosed present study fits the profile of BMS as reported in the with BMS was 56.6 years (57.6 years for women and 55.5 literature (12). We identified an almost equal sex distri- years for men). Of the nine BMS patients, 4 were males bution in our clinic cases, comparable to the epidemiol- and 5 females, who suffered oral burning for a mean of ogy studies of BMS, but in contrast to most clinical trials 30.8 months (36.5 months for men and 26.4 months for which reported a preponderance of female patients. The women). Only 1 of these patients (11.1%) was a prior mean age of our BMS patients was 57 years and the com- smoker and 44.4% used alcohol on social occasions.
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