Autor: Dra. Delwyn Dyall-Smith FACD, Dermatology, 2010.
what is burning mouthsyndrome?
Burning mouth syndrome is achronicpain syndrome strictly defined as a painful burning sensation in the mouthdysesthesia) with normal clinical examination and no obvious organic cause. Therefore, it is a diagnosis that is only made after excluding recognized organic causes of mouth pain.
It is currently thought to beneurologicalof origin and notpsychogenicas previously believed. Many other names have been given to this condition, including orodynia (burning mouth) and glossodynia (burning tongue).
Who gets burning mouth syndrome?
Burning mouth syndrome is seen predominantly, but not exclusively, in perimenopausal and postmenopausal women. Males can be affected. Heincidenceincreases with advancing age. It is rarely seen before age 30. No racial or ethnic differences were reported. It probably affects approximately 1% of the general population, increasing to 30% in selected populations such as postmenopausal women.
Burning mouth syndrome may be associated with personality or mood disorders, particularlyanxiety and depression. It is not clear whether they are due to the oral symptoms or whether they contribute to thedevelopmentof the problem. Teeth grinding, tongue hanging out and jaw clenching are also commonly associated and can only be identified by asking family members.
What are the clinical features or burning mouth syndrome?
History and symptoms
A careful history is important, as underlying organic causes must be sought and excluded to make this diagnosis. Questions should cover the following points.
- Medications: Some dry out the mouth.
- Dental care - denture hygiene
- General health, especially diabetes risk.
- Skin Conditions: May affect the mouth.
- Diet: Iron and vitamins are necessary for good oral health.
- Hormonal status: burning mouth can start around menopause
The three main symptoms of burning mouth syndrome are:
- mouth pain
- abnormal taste
- Dry mouth sensation.
| mouth pain | Oral pain is the greatestsymptomand is most commonly described as a burning sensation in the mouth, like a burn from a hot drink, or as tingling or numbness. The tongue is the most affected site, followed by the inner part of the lower lip and hard bone.palate. Pain rarely causes awakening from sleep. Three patterns of oral pain have been identified:
|
| abnormal taste | abnormal taste (dysgeusia, parageusia) is a metallic or bitter taste in the mouth or an altered perception of taste, particularly of salty or sweet and sour foods. |
| dry mouth feeling | Although the patient may perceive dry mouth, the reductionsalivaproduction is not confirmed in tests. |
In burning mouth syndrome, symptomspersistfor many months and often years. Not all people with this condition describe all three main symptoms, and the absence of any one of them does not exclude the diagnosis.
Many other symptoms can also be described and can include:
- Complaint that the dentures do not fit properly even though the dentist thinks they fit well
- Worsening or relief of symptoms with specific foods
- Bad breath (halitosis): must be confirmed by questioning family members as it can be socially disabling
- Difficulty swallowing (dysphagia)
- Lumpy feeling in the throat when there is nothing
- Jaw clenching or teeth grinding symptoms can present as a headache, earache, pain in the muscles or joints around the jaw, face and neck.
- Languageulcersare usually related to swollen tonguepapillae.
the mouth exam
A thorough clinical examination should be performed, including the oral cavity where there are local organic causes such asoral thrush(thrush) andoral cancer, must be deleted. The upper part of the tongue must have a complex architecture (i.e., it must not be smooth as seen inanemia). All surfaces of the mouth should be checked forulcerationwhich may represent a spectrum of causes oftrauma,idiopathic recurrent aphthous stomatitis,autoimmunediseases such as pemphigus to oral cancer.
skin exam andnailsmust seeksystemicCauses of oral pain, including nutritional deficiencies,common planhormonal disorders (for example,diabetes mellitus,thyroid disease).
o oralmucosaseems normal in burning mouth syndrome. Clues may be seen on the scan that can help confirm the diagnosis.
- Worn teeth or damaged tooth enamel can indicate teeth grinding and clenching.
- Scalloping along the sides of the tongue caused by tongue thrust
- Protruding teeth or malocclusion may indicate tongue propulsion
- Tenderness in the muscles around the jaw and neck due to jaw clenching
- Foamy saliva accumulated on the floor of the mouth, indicating excess mucoid submandibular saliva that is not easily eliminated by swallowing
- Mild redness in symptomatic areas such as the tongue, hard palate, inner lower lip near the incisors
- exposition offiliformpapillae (taste buds) on the tongue due totraumaticteeth abrasion
How is burning mouth syndrome diagnosed?
Burning mouth syndrome is a diagnosis of exclusion, so the history, clinical examination, and tests are aimed at finding an organic explanation for the symptoms.
Testing may be necessary based on history and exam results. However, in burning mouth syndrome, all are normal/negative.
Investigations may include:
- Detection of nutritional deficiencies (folate,hierro, vitamina B12,zinc)
- Hormone levels (especially for thyroid and menopause), autoimmune conditions
- Blood sugar: diabetes mellitus
- mucosascraping throughsincere
- patch testsforcontact allergy
- Sialometry for saliva production
- mucosabiopsy, but this is rarely indicated.
What is the treatment for burning mouth syndrome?
In a small number of patients (3%) the condition resolves spontaneously. Over 6-7 years, between half and two-thirds of patients experience some improvement. There is no definitive cure.
A list of burning mouth syndrome symptoms and signs can help the patient to accept the diagnosis, as this is an important step to take.progress. For some, only recognition and explanation are needed.
For many, the condition is disabling and requires active treatment. Realistic expectations of treatment response are important. often the firstsignalresponse is an improvement in altered taste. However, improvement is unpredictable: it can be incomplete and slow, and for some it can take several years. The feeling of dryness (xerostomia) is often resistant to therapy. Referral to a specialistmultidisciplinaryoral medicine unit may offer the best chance of medium to long term relief.
Few studies have been conducted on treatment and only cognitive-behavioral therapy,realclonazepam, via oralcapsaicinand alpha-lipoic acid (+/- cognitive behavioral therapy) have been shown to have a positive impact in well-conducted trials. Oral capsaicin causes significant abdominal pain that may outweigh any benefit. Cognitive-behavioral therapy may exert its effect through improved pain coping mechanisms.
PlaceboControlled studies have failed to show any benefit usingtopical steroids, benzydamine hydrochloride mouthwashes or trazodone (serotonergic antidepressant), the latter causing most patients to drop out of the study due to side effects, mainly dizziness.
Reported treatments include:
- Other medications
- Antidepressants, particularly tricyclics, are the most commonly used treatment and should be started at low doses, as dry mouth is a common side effect, e.g.amitriptylinestarting with 10 mg at bedtime, slowly increasing to a maximum of 150 mg as tolerated or needed.
- Anxiolytic drugs such as benzodiazepines at low doses may be helpful in confirming the diagnosis, as mild improvement is usually seen, eg clonazepam starting at 0.25 mg at bedtime, increasing to a maximum of 2 mg as tolerated or needed.
- Anticonvulsants, for examplegabapentinstarting with 100 mg at bedtime and increasing as tolerated or needed.
- hormone replacement therapy
- Reallocal anesthetics
- topical capsaicin
- Behavioral therapies, including relaxation therapies and exercise.
- Physical therapies, including massage, acupuncture andlaser
- Empirical treatment for known causes of mouth pain, such as nystatin for candidiasis
These treatments can be used alone or in combination, particularly with cognitive behavioral therapy.