Lecturer, Department of Oral Medicine and Diagnostic Sciences, Oral Biology / Pathology and Microbiology Division. College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545,Saudi Arabia.
Correspondence: Dr. Ahmed Qannam
How to CITE:
J Pak Dent Assoc 2010;19(1):.42 - 44
Burning mouth syndrome (BMS) is a chronic oral pain or burning sensation affecting the oral mucosa in the absence of apparent mucosal abnormalities. This disorder is one of the most common disorders encountered in the clinical practice of oral and maxillofacial pathology. This condition is probably of multifactorial origin, however the exact underlying etiology remains uncertain. BMS occurs most often among women and may be accompanied by xerostomia and altered taste. This article discusses several aspects of BMS, updates current knowledge about the pathogenesis and describes the clinical features as well as the management of BMS patients.
burning mouth syndrome, xerostomia, dysgeusia.
Burning mouth syndrome is defined as burning sensation and chronic pain in the oral mucosa without any visible mucosal alterations.1 Tongue is usually the primary site for burning sensations2 in addition to other intraoral site such as lips and palate,3 The syndrome has been termed by various names such as somatodynia, somatopyrosis, oral dysesthesia, glossopyrosis, glossodynia, sore mouth and sore tongue, these terms reflect either the type or location of pain in the oral cavity.4Reported prevalence rate of BMS in general populations vary from 0.7% to 4.5%, this variability was
likely due to various criteria used to diagnose BMS. 4
BMS may be present as an idiopathic condition (primary BMS) when local oral factors or relative systemic conditions can not be identified, and as (secondary BMS) when relative local or systemic abnormalities are observed.4
A variety of conditions may lead to secondary BMS, local oral factors known to induce secondary BMS include: oral mucosal diseases (such as lichen planus, candidiasis), xerostomia, galvanism, contact hypersensitivity, and para-functional habits.5-8 Systemic
disorders known to induce secondary BMS include diabetes mellitus, vitamin or nutritional deficiency, hormonal changes and medications side effects.5, 6, 9, 10
Diagnosis of BMS should be limited to only patients with apparently normal mucosa.1 The initial approach in the management of this disorder is differentiating primary from secondary BMS based on the identification of possible etiological factors, consequently treatment of Secondary BMS is aimed at correcting the underlying cause, while cases of primary BMS undergo proper pain control and supportive therapy4
BMS predominantly occurs in the postmenopausal women;12 the mean age of BMS patients is between 55-60 years, with occurrence under 30 being rare.13 Women are seven times more likely to have this syndrome than men.4,
Oral pain represents the cardinal symptoms of BMS, the type of pain experienced by BMS is continuous burning sensation in the oral mucosa that often increases at the end of each day and seldom interferes with sleep.12,16some patients with BMS may relate the onset of pain to previous dental procedures, stressful life events or recent illnesses.17The location of burning sensation is most commonly bilateral and may occur at any site or combination of sites within the mouth, 3,18 burning sensations in other body sites such as anogenital region is also reported.4 The principle site of the burning sensation is the tongue, particularly the anterior two thirds, other sites such as hard palate, labial mucosa, alveolar ridges, buccal mucosa, orophayrnx and floor of the mouth are also reported.2, 3In addition to burning sensation, other symptoms such as xerostomia and dysgeusia (altered taste) are frequent findings in BMS patients.12,19approximately 46-67% of patients with BMS complain of dry mouth.12, 19 The feeling of oral dryness in these patients generally reflects a subjective sensations rather than salivary gland dysfunction.2 Moreover in almost 70% of BMS patients, taste disorder is also evident with dysgeusic taste frequently presenting as bitter, metallic or both.15, 20, 21
Several mechanisms have been suggested in the etiology of BMS; however the etiopathogenesis of BMS is unclear and probably in majority of patient involves interactions between several biological and psychological factors.22Despite the evidence suggesting that BMS may reflect a dysfunction involving peripheral and or central nervous system, psychological factors may also predispose to BMS.23 In a recent case control study by Gao and coworkers24, the scores of depression and anxiety were significantly higher in BMS patients than those of the control group. They suggested that BMS may be of a psychogenic origin. A study conducted by Miziara et al25 showed that emotional life events such as family and personal losses may generate symptoms of BMS. Despite the growing knowledge about pathogenesis of BMS, further well planned studies are needed to clarify the nature of BMS. Recently, evidence of neuropathic abnormalities has been identified in BMS.26 In addition salivary gland dysfunction has been suggested as causative factor in BMS27. Oral dryness (xerostomia) is a frequent compliant of patients with BMS, Lamey and coworkers28 found evidence of reduced parotid gland function in BMS patients who had burning symptoms every day and that were present throughout the day
in the etiology of BMS.4, 26, 31 The role of peripheral neuropathy has been recently highlighted, Lauria and colleagues26 showed that patients with BMS had significantly lower density of the epithelial nerve fibers in the biopsy specimens of the anterior two thirds of the tongue as compared with normal controls, in addition epithelial and sub-papillary nerve fibers showed diffuse morphological changes reflecting axonal degeneration. They concluded that BMS is caused by trigeminal small fiber sensory neuropathy. In addition to changes in the peripheral level, accumulated data demonstrate involvement of central nervous system and its interaction with peripheral nervous system in BMS.4 Grushka and colleagues32 suggested that BMS might be related to hyperactivity of both sensory and motor components of the trigeminal nerve following the loss of central inhibition as a result of taste damage of chorda tympani nerve.Eliav33 recently demonstrated chorda tympani hypofunction in 82% of 22 patients with BMS. They proposed that chorda tympani may play an important role in the pathology of BMS. The mechanism is related to central nerve processing.32, 33Taste sensations of the anterior two thirds of the tongue are supplied by chorda tympani nerve, a branch of facial nerve. Other sensory sensations are supplied by the lingual nerve, a branch of the mandibular division of the trigeminal nerve. Inhibitory influences between the two systems are thought to maintain a state of sensory balance in the tongue32, 33. When there is disruption of this balance induced by chorda tympani dysfunction, this will result in lingual nerve hyperfunction.32, 33 This may generate central sensitization with resultant burning sensation spreading beyond the a ff e c t e d n e r v e d i s t r i b u t i o n . 3 2 , 3 3 R e c e n t l y, neurophysiologic and imaging studies have suggested that dysfunction of dopaminergic pathway may play a role in the pathophysiology of BMS.34 Hagelbreg and colleagues34 using positron emission tomography (PET scan) demonstrated a decline in the dopamine levels in the putamen of BMS patients as compared with healthy controls. This findings support the presumption of nigrostriatal dopaminergic hypofunction in the pathophysiology of burning mouth syndrome.
MANAGEMENT AND PROGNOSIS
Successful management of BMS demands cooperation among the dentist, the patients and the other health professionals. An effective approach for BMS patients should be based on a detailed clinical history and careful clinical examination. The history should include a review of major illnesses, systemic diseases and medications usage as well as other conditions associated with BMS. A review of chief compliant of burning pain should focus on onset, duration, intensity, anatomic location as well as factors that improve or worsen the pain. Physical examination should screen for soft tissue lesions, damaged or irritated mucosa and signs of salivary glands dysfunction as well as any signs of parafunctional habits such as teeth wear. The next step after detailed history and intraoral examination is the differential diagnosis for BMS and the discrimination between primary BMS and secondary BMS based on the identification of possible etiological factors for the syndrome.4, 27, 35 Patients with secondary BMS should be treated for the precipitating factors of this disorder, local factors such as lichen planus, candidiasis, xerostomia, galvanism, contact hypersensitivity, and parafunctional habits should be addressed, predisposing systemic abnormalities should be also corrected.4, 27, 35 Patient with primary BMS should receive supportive therapy to provide a better control and improve the quality of life.4, 27Although a large variety of medications and several treatment modalities have been proposed, the treatment of primary BMS is unsatisfactory and there is no definitive cure for primary BMS.36-38 The pharmacological therapy of primary BMS involves the use of sedatives, anxiolytics, antidepressants, local anesthetic solutions and other psychoactive substances.39, 40
Different therapies were used to treat primary BMS such as clonazepam either topically or systemically, alpha lipoic acid, topical and Systemic capsaicin, amitriptyline, selective serotonin repeutake inhibitors and analgesics.40-45
However, none of these treatments have been proven to be effective in a double blind controlled trial.41, 46
Patients who do not respond to pharmacological therapy, should undergo cognitive behavior therapy by psychotherapists, since they probably have in their BMS spectrum, a complex and strong psychogenic component of pain.47, 48 The purpose of this treatment is allow each patients to understand the cause of his/here symptoms and this may serve as form of defense against emotional distress.48 Successful treatment of primary BMS with combined psychotherapy and psycho-pharmacotherapy has also been reported. 49 The long term prognosis for primary BMS is variable, few patients may have spontaneous remission months or years after the onsets of symptoms, others may continue to experience the symptoms throughout the rest of their lives.41, 50other patients with BMS have become accustomed to symptoms and no longer sought treatment. 3
Our knowledge of BMS has increased over the last few years, future studies about the different pathogenic mechanisms including the possible neuropathic origin of BMS are needed. Even though this syndrome is chronic and may not always respond to therapy, patients should be reassured about the benign nature of this syndrome
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