Burning Mouth Syndrome
Nurdiana, drg., Sp.PM DEFINITION
“Burning Mouth Syndrome” (BMS)
oral burning tongue/other mucous membranes no detectable cause, anatomic pathways, mucosal lesions, neurologic disorders & lab abnormalities Burn•ing lips syndrome
Scalded mouth Glossopyrosis syndrome BMS
Glossodynia Stomatodynia EPIDEMIOLOGY
>>> post Women 7 x : menopausal Men affected Prevalence men >>> 3 – 12 women at a later 0.7 - recent data years after mid – late age than 2.6% male = menopause 50s 10 - women female 15% ETIOLOGY
Unknown
Local Systemic Psychological
• Candida • Bacteria • Pre-Ca/Ca Local • Denture • Iritation/alergy • Xerostomia Pseudomembranous & erythematous candidiasis BMS Candida No clinical signs of candidiasis antifungal 86% improved & 13% Streptococci
Staphylococci Anaerobes
Bacteria Pre-Ca/Carcinoma
Leukoplakia/erythroplakia burning/painful sensation Ca itching/burning premonitory symptom Denture
Main & Basker ill-fitting dentures single greatest contributor
Faulty denture design functional stress level to circum oral/lingual muscle
Denture fix BMS persist Iritation/Alergy
Mechanical irritation oral habit, denture design errors & sharp teeth
Chemical allergy food, oral hygiene products or dental materials (methyl-methacrylate/mecury)
Contact allergy inflammatory, lichenoid, or ulcerative lesions Xerostomia
Altered Glass : xerostomia sympa•thetic local output stress Xerostomia BMS contributing factor, Salivary or alterations in incidence no other authors : composition interactions clear association xerostomia changes BMS between cranial higher/lower nerves & pain ??? sensation
• Menopause • Deficiency Systemic • DM • Nerve injury • Drugs
Hormonal changes incidence BMS hypoestrogenemia Menopause mechanism unclear usually not reversible with hormone replacement therapy Deficiency
BMS symptoms of deficiency iron, Vitamin B & folic acid
Lamey et al replacement vitamin B1, B2 & B6 effective in treating 88% BMS patients
Lab. abnormal management & correction BMS persist Xerostomia & candidiasis
Diabetes Mellitus After glucose control BMS Diabetic persist, oters: diabetic neuropathy treatment BMS resolved ??? head & neck region Characteristic post-traumatic nerve injury alterations in Nerve Injury perception to touch, temperature, two-point discrimination & threshold pain BMS infrequent Angiotensinconverting enzyme resolved after Drugs (ACE) inhibitors (captopril, discontinuation of enalapril, & lisinopril) medication Psychological
Psychogenic problem personality & mood changes pain
Depression & anxiety affect pain or secondary to chronic pain
Lamb et al: BMS psychological factor & anxiety most difficult to control
Psychological component chronic low-grade trauma parafunctional habits eg. rubbing tongue to the teeth or pressing tongue on palate BMS
Symptom of cancer-phobia reassuring often helpful
More than one factor may be contributing BMS one another, no specific etiology can be identified CLINICAL FEATURES
> 50% onset spontaneous, no Most common sites : anterior identifiable precipitat•ing factor ± 1/3 tongue, anterior hard palate, & onset with dental procedure, recent lower lip & often occurs in > one illness or medication course oral site
Burning intermittent/constant Pain intensity & other symptoms eating, drinking, or gradually & persist for years candy/chewing gum relieves symptoms. Local anesthetic elixir burning but dysgeusia Moderate - severe intensity gradually Mood changes irritability & throughout the day max intensity: late decreased desire to socialize evening difficulty falling asleep & related to altered sleep patterns experiencing interrupted sleep
Frequently accompanied by dry Additional complaints facial mouth & thirst no evidence of pain & pain at other sites decreased salivary flow PATHOGENESIS
• Completely unknown
Biochemical & pathophysiologic Injury/disease changes in nociceptive neurons in CNS Morphologic alterations in peripheral tissue BMS
Result of common systemic/local disorders nerve damage occurs to trigeminal nerve directly or other cranial nerves
inhibit oral nociceptive activity
Detailed history
Clinical examination DIAGNOSIS Lab
Exclusion of all other possible oral problems DIAGNOSIS
• Diagnosis : detailed history, clinical examination, lab studies & exclusion of all other possible oral problems • Key to diagnosis history taking • Characteristics sudden or intermittent onset of pain, bilateral, progressive during the day & remission with eating • Unilateral symptoms thorough evaluation of trigeminal & other cranial nerves eliminate neurologic source of pain • Complain xerostomia + burning evaluation of salivary gland disorder mucosa dry & difficulty swallowing dry foods • Ruled out potential causes even typical features of BMS present • Burning persists after management sys•temic or local oral conditions diagnosis of BMS can be considered
Making clinical diagnosis not difficult, determining etiology difficult LABORATORY STUDIES
C. albicans culture Biopsy not indicated no Sjogren's syndrome clinical lesion is antibodies serum tests Individual associated consideration complete blood count depend on history & clinical suspicion serum iron, total iron- binding capacity
serum B12 & folic acid levels MANAGEMENT
• First exclude other disease • Sources of pain must be eliminate not too much expectation
True BMS • Education : – Reassured benign nature of condition & frightening possibilities (cancer) can be excluded – If suggests psychogenic factors explain that depression & other emotional disturbances can cause physical diseases • Instruction : – Counseling & reassurance adequate for mild BMS more severe symptoms drug therapy – Parafunctional oral habits eliminate splint covering teeth and/or palate • Therapy : – Low doses tricyclic antidepressants (TCA) : amitriptyline, desipramine, nortriptyline, imipramine, clomipramine, or doxepin – Should be stressed drugs not to manage psychiatric illness analgesic effect – Benzodiazepines : clonazepam (benzodia-zepine derivative) & GABA (gamma-aminobutyric acid) receptor agonist effective for various orofacial pain disorder – Grushka et al clonazepam effective in relieving taste dysgeusia & oral dryness along with BMS – Topical capsaicin monoamine oxidase inhibitor tranylcypromine sulphate in combination with diazepam neuropathic pain conditions PROGNOSIS
• Partial remissions occur in approximately 2/3 patients in 6 – 7 years after onset • No studies investigated whether earlier intervention or earlier & better pain control lead to earlier disease remission