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Review Article

Burning mouth syndrome: An update

Vijay Kumar Ambaldhage, Jaishankar Homberhalli Puttabuddi1, Purnachandrarao Naik Nunsavath2
Departments of Oral Medicine and Radiology, P M Nadagouda Memorial (PMNM) Dental College and Hospital, Bagalkot, 1Oral Medicine and
Radiology, Jagadguru Sri Shivarathreeswara Dental College and Hospital, Mysore, Karnataka, 2Oral Medicine and Radiology, SIBAR Institute of
Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh, India

ABSTRACT
Burning mouth syndrome (BMS) is characterized by an oral burning sensation in the absence of any organic disorders of the oral cavity.
Although the cause of BMS is not known, a complex association of biological and psychological factors has been identified, suggesting the
existence of a multifactorial etiology. It is observed principally in middle-aged patients and postmenopausal women and is characterized
by an intense burning type of pain, preferably on the tongue and in other areas of the oral mucosa. As the symptom of oral burning is seen
in various pathological conditions, it is essential for a clinician to be aware of how to differentiate between symptom of oral burning and
BMS. This article provides an overview of the literature on this syndrome with special reference to the etiological factors, clinical aspects,
diagnostic criteria that should be followed and the therapeutic management with reference to the most recent studies.
Key words: Glossodynia, glossopyrosis, glossalgia, stomatodynia

Definition

Introduction
Burning mouth syndrome (BMS) is a chronic orofacial pain
condition characterized by deep burning pain of the oral
mucosa in absence of identifiable local or systemic pathology,
lasting at least 4-6 months.[1] It is associated with burning,
stinging, and/or itching of the oral cavity in the absence of any
organic disease and most often involves the tongue with or
without extension to the lips and other parts of oral mucosa.[2]
It can be accompanied by dysgeusia (distortion in sense of
taste) and subjective xerostomia (dry mouth). It is observed
principally in middle-aged patients and postmenopausal
women.[3] Probably of multifactorial origin, and often
idiopathic, with a still indefinite etio-pathogenesis in which
local, systemic and psychological factors are implicated.
Currently there is no consensus on the specific treatment
of the condition.[3] This article provides an overview of the
literature on this syndrome with special reference to the
etiological factors, clinical aspects, diagnostic criteria that
should be followed and the therapeutic management with
reference to the most recent studies.

The BMS has been defined principally by the quality or location

of the pain. The International Association for the study of Pain
(IASP) defines BMS as A pain of at least 4-6 months duration
located on the tongue or other oral mucosal membranes
associated with normal clinical or laboratory findings.[3]
The International Headache Society (IHS) in the
International Classification of Headache Disorders-II
classifies BMS in the category of cranial neuralgias and
central causes of facial pain within the subcategory of
central causes of facial pain. According to the IHS, burning
mouth syndrome is an intraoral burning sensation for
which NO dental or medical cause is found.[1]
Synonyms
The BMS is also called as Stomatodynia, Stomatopyrosis,
Oral dysesthesia, Sore mouth and Sore tongue. The most
aected area is the tongue (tip and lateral borders) thus
denominated the terms Glossodynia (painful tongue),
Glossopyrosis (burning tongue) and Glossalgia.[3,4]

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DOI:
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Address for correspondence:

Dr. Vijay A. Kumar,
Department of Oral Medicine and Radiology,
PMNM Dental College and Hospital,
Bagalkot - 587 101, Karnataka, India.
E-mail: vijaykumarcoorg@gmail.com
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Ambaldhage, et al.: Burning mouth syndrome: An update

Authors prefer to use the term syndrome to refer to this

entity due to the frequent association of burning sensation
in oral cavity with other symptoms like xerostomia and
taste alterations in the absence of any organic disease and
the complexity surrounding the condition of the patient.[5]
Epidemiology
Burning mouth syndrome is a debilitating medical
condition aecting nearly 1.3 million of Americans. The
true prevalence of BMS is dicult to establish due to the
lack of accurate diagnostic criteria in many of the published
series that do not distinguish between the symptom of oral
burning and the BMS. Thus the prevalence varies between
0.6-15% in general population.[2] The female/male ratio of
occurrence of BMS is 7:1. The prevalence of BMS increases
with age in both males and females, mainly aecting the
middle aged females in the fifth to seventh decade of life.[3]
Its prevalence is estimated 18-33% in postmenopausal
women.[1]
The condition aects multiple sites in the oral cavity, but
the tip of the tongue is the most common location (71%)
followed by lips (50%), lateral border of tongue, (46%)
and palate (46%).[6]
Clinical presentation
A typical patient with BMS is postmenopausal woman of age
fourth to sixth decade with various medical comorbidities.
Patients usually complains of the classic triad of chronic
oral mucosal burning pain associated with dysgeusia and
xerostomia with no visible disease in the oral mucosa for
4-6 months duration.[6] Clinical presentations may vary as
some patients can be oligosymptomatic (pain and dysgeusia
or xerostomia) or monosymptomatic (pain only).[5] In
general, 63% of patients report accompanying dry mouth,
60% of patients may report bitter/metallic taste, and 35%
may complain of altered taste perception.[7]
Pain characteristics in BMS
The patients usually complaint of chronic pain of 4-6
month duration, burning or scalding type, sometimes
itching sensation or numbness of the tongue and other
oral mucosal surfaces.[3] The onset of pain can be either
gradual and spontaneous or sudden and related to a
precipitating event such as any dental procedure. Typically
pain is localized to tongue and sometimes involving other
mucosal surfaces also like palate, lip, buccal mucosa and
floor of mouth. The pain will be continuous or intermittent,
mild to moderate in intensity, localized to the oral cavity
and does not radiate to other regions of face. The pain
typically relieves on intake of food or liquids, which is in
Indian Journal of Pain | January-April 2015 | Vol 29 | Issue 1

contrast to burning symptom in other diseases; in which

the pain aggravates. Patients do not normally wake up
during the night, but do find it dicult to get to sleep.[1,7]
Review of systems may be remarkable for headache,
chronic fatigue, gastrointestinal and urogenital symptoms,
insomnia, mood changes, irritability, anxiety and
depression. Physical examination and laboratory analysis
are classically unremarkable in primary BMS. However,
they can be abnormal in secondary BMS.[4]
Classification
According to Scala A et al., BMS classified into two types:[5]
Primary BMS/idiopathic BMS: for which NO organic
local/systemic causes are identified.
Secondary BMS: resulting from local/systemic
pathological conditions and thus this form responds
well to the etiology-directed therapy.
According to Lamey and Lamb (1994) the BMS can
be divided into three clinical types depending on the
diurnal fluctuations of symptoms.[8]
Type 1: it is characterized by progressive burning
type of pain. Patients wake up without pain, which
then increases gradually throughout the day. Aects
approximately 35% of patients. This type may be
associated with systemic diseases, such as nutritional
deficiencies.
Type 2: in this the symptoms are constant throughout
the day and patients find it difficult to get sleep.
Aects 55% of patients. These patients usually present
associated psychological disorders.
Type 3: symptoms are intermittent, with atypical
location and pain. Constitutes 10% of patients. It seems
that contact with oral allergens could play an important
etiologic role in this group.
Diagnostic criteria
The BMS is a primary diagnosis. Several factors are reported
as being associated with burning mouth symptoms,
including xerostomia, allergies to dental restorative
materials, oral candidiasis, systemic nutritional deficiency
(e.g. vitaminB1, B2, B12, folic acid and zinc), diabetes,
hormonal disturbances, oral ulcer and periodontitis.
Nonetheless, diagnosis of BMS requires the exclusion of
secondary causes.
Diagnosis of BMS may be complex for three main reasons[5]:
BMS is positively defined only by symptom(s) without
regard to signs or etiologies.
The symptomatic triad rarely occurs simultaneously in
same patient.
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Ambaldhage, et al.: Burning mouth syndrome: An update

Overlapping or overwhelming stomatitis may confuse

the clinical presentation.

As a result, clinicians can arrive at a diagnosis of BMS

by matching specific details of the main complaint with
clinical oral findings that exclude oral mucosal changes,
the only exception being the presence of stomatitis, which
requires proper and prompt management.
The diagnostic Criteria developed by Scala for the diagnosis
of burning mouth syndrome are as follows[5]:
Fundamental criteria:
Daily deep burning sensation of the bilateral oral
mucosa.
Burning sensation for at least 4-6 months.
Constant intensity or increasing intensity during the
day.
No worsening on eating or drinking. Instead the
burning sensation may reduce.
No interference with sleep.
Additional criteria:
Dysgeusia and/or xerostomia.
Sensory or chemosensory alterations.
Mood changes or psychopathological alterations.
Etiological factors
The symptom of oral burning sensation might be
associated with a large number of local and systemic
factors. But, the term burning mouth syndrome or a
true BMS should be applied only if burning sensation
occurs in clinically healthy oral tissues in the absence of
all aforementioned known local and systemic factors. The
various conditions in which patients feels the symptom of
oral burning are summarized in Table 1.
Xerostomia is a concomitant symptom in patients with
BMS, prevalence varying between 34 and 39%, while
Grushka et al., found that this is equal to or greater
than 60%. In contrast, some authors consider that the
composition (increased concentrations of K+, Na+, Cl-,
Ca+2, immunoglobulin A, amylase) of the saliva could play
a major role in the pathogenesis of BMS.[9]
A study was done to assess the ecacy of anti-xerostomic
topical medication (urea 10%) in patients with BMS by
Luciana A da Silva et al. The patients were evaluated before
and after treatment with the xerostomia questionnaire
and quantitative sensory testing. The results showed no
dierences between control and BMS groups and both
exhibited an association between reported improvement
4

Table 1: various etiological factors for oral burning

Local conditions:
Xerostomia
Poorly fitting prostheses
Dental anomalies
Allergic reactions like lichenoid reactions, stomatitis
medicamentosa etc
Infections (Bacterial, Viral, Fungal)
Diseases of oral mucosa like apthous stomatitis, migratory glossitis,
Fissured tongue, OSMF etc
Autoimmune diseases like lichen planus, DLE, oral pemphigus etc.
Chemical burns
Galvanism etc
Systemic factors:
Endocrine diseases like diabetes, hypothyroidism, menopause etc
Nutritional deficiencies like Iron, vit B complex, zinc, copper etc
Anemias
GIT anomalies like crohns disease, ulcerative colitis
Peripheral neuropathies
Sjgrens syndrome
Renal stomatitis
Psychological factors
Anxiety
Depression
Compulsive disorders
Psychological stress
Cancer phobia

and salivation. There was an improvement in chewing and

generalized pain complaints, supporting the role of saliva
in oral health and the patho-physiological eects of local
chronic pain.[9]
Cavalcanti et al., found no dierence in the presence of
Candida albicans between BMS and control patients.
Thus, candidiasis has not been confirmed as an associate
etiological factor for BMS.[10]
Some authors have pointed out a possible relationship
between diabetes mellitus and BMS, since this syndrome
is found in 2-10% of diabetic patients. Although Sardella
et al., did not found this relationship; burning sensation
could be a symptom of an undiagnosed diabetes
mellitus and perhaps the control of diabetes leads to the
improvement or cure of burning sensation.[5,11]
Deficiency disorders have always been referred as cause
of burning symptom. Nutritional deficiencies have been
claimed to cause oral mucosal burning in 2-33% of patients.
Zinc deficiency may cause organic eects such as lingual
papillary atrophy, resulting in dysgeusia and glossodynia.[8]
Tanaka et al., noted improvement in symptoms following
zinc intake and further clinical improvement when zinc
was associated with B12 vitamin and iron.[12]
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Ambaldhage, et al.: Burning mouth syndrome: An update

BMS may change the individuals general and psychological

well being, reducing the quality of life, even though it is
not clear if psychopathologic distress is related to this
syndrome or it is a result of the chronic oral burning
symptoms that these patients suer. Some studies have
reported that people with BMS experience adverse life
events more frequently than people without BMS, which
may be a risk factor for developing BMS. Hakeberg et al.,
focusing on psychological aspects of women with BMS,
observed that all patients in their study had gone through
situations of great stress or disappointment in their lives
leading to chronic oral pain.[13]
A study by Bakhtiari S et al., to correlate between BMS
and anxiety in the elderly inmates of sanitaria in Tehran
showed that highly significant dierences in anxiety scores
between the case and control groups. They evaluated the
state and trait anxiety using Cattell Anxiety Scale. The trait
anxiety scores or anxiety were significantly higher in BMS
patients than the controls.[14]
An clinical study by Tatullo M et al., to assess the
correlation between the BMS and oxidative stress, in which
Oxidative stress assessment was performed by means of
an integrated analytical system. Study results indicated
that female patients aected by BMS show significantly
different oxidant capacity and biological antioxidant
potential as iron-reducing activity levels, similar to those
present in oxidative stress condition with respect to the
general population. Thus confirming the eectiveness
of antioxidant treatments in these patients to prevent or
decrease the onset of oxidative stress.[7]
There is evidence of a possible relationship between BMS
and psychogenic factors, as shown by Sardella et al. More
recently several authors have investigated the trigeminal
somatosensory system in order to detect neurogenic
abnormalities. These studies suggest peripheral alterations
in the function of this system with the presence of
abnormal reflex.[15]
Calcitonin gene-related peptide (CGRP) is one of the
neurotransmitters found in the nerve fibers of the
nervous system that is involved in salivary secretion and
plays an important role in the development of pain and
hyperalgesia. Supporting this interpretation, some studies
showed that the use of neuroprotective/neurotropic
drugs improved the symptoms in patients with BMS.
However, Zidverc-Trajkovic et al., found no elevated levels
of CGRP in the saliva of patients with BMS, which seems
to demonstrate the trigeminal nerve degeneration in this
syndrome.[16]
Indian Journal of Pain | January-April 2015 | Vol 29 | Issue 1

Gao et al., found anxiety, depression and somatization

symptoms to be the most common psychological
problems in BMS.[15] Bergdahl et al., demonstrated that
patients with BMS exhibited low levels of socialization
and high levels of anxiety and health status concern
when compared to a Control Group.[17] It has been shown
that BMS exerts a negative impact on the quality of life
of aected individuals. According Lpez-Jornet et al.,
patients with BMS have poorer scores on all scales that
measure quality of life.[13]
More recently, a beguiling hypothesis has been proposed
that burning mouth syndrome is associated with an
alteration of gonadal, adrenal and neuroactive steroid
levels. Woda et al., suggested that chronic anxiety or stress
results in a dysregulation of adrenal steroids. A reduction
in adrenal steroids may lead to an altered production of
neuroactive steroids in skin, mucosa and the nervous
system.[18] The relationship with menopause is proven by
the suggestion that the dramatic fall in gonadal steroids
that occurs at that time further alters the production of
neuroactive steroids.[19]
Since both BMS and vulvodynia occur more frequently
in menopausal women, estrogen deficiency could be
considered as a common pathological mechanism of these
clinical conditions. Estrogen receptors are also identified
in both the tongue and the vaginal mucosa besides having
microscopic similarity. However, hormone replacement
therapy (HRT) has not been majorly found to be useful
and thus estrogen deficiency is generally not accepted as
underlying etiology of BMS.[20]
According to Bergdahl and Bergdah, the chronic use of
systemic drugs may be a significant factor for BMS.[17]
Hugosson and Thorstensson, in a study involving patients
with BMS and a control group, have observed that 87.5%
of the patients with the syndrome were taking one or more
drugs; 44% were psychotropic drugs, 25% were digestive
disorder drugs, 25% were lung disorder drugs and 6.2%
were supplemental vitamins.[21]
In a study by Cavalcanti et al., found that 80.6% of the
patients with BMS were chronic users of systemic drugs,
among which 35.5% were benzodiazepines, 19.35% were
other antidepressants and 38.7% were antihypertensive
drugs. Some drugs, like antihypertensive agents, are
frequently associated with the beginning of symptoms
compatible with BMS.[10]
Although the relationship between BMS and Parkinsons
disease (PD) is not universally accepted, the comorbidity
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Ambaldhage, et al.: Burning mouth syndrome: An update

has been suggested. BMS is frequent among patients with

PD. In a study of 115 patients with PD, burning mouth
happened in 24% of them, incidence prevalence 30 times
greater than expected by chance only.[22] It is hypothesized
that Levodopa may play a role in the development of BMS
in patients with PD.[23]
Diagnosis
It is judicious for the clinician to obtain a clear and detailed
medical/dental history as well as perform a thorough oral
clinical examination including any laboratory studies
indicated. A neurological examination can be useful
although, unless there are marked deficiencies, the lack
of baseline data can present a problem. If all other causes
of oral burning symptom are ruled out and/or the patient
fails to respond to a normal course of treatment then a
diagnosis of primary BMS is reasonable.
Management
The initial step in management is to identify primary
versus secondary BMS. The objective of management for
secondary BMS should initially be directed at treating the
causative local or systemic disease and withdrawing the use
of oending medications (such as ACE inhibitors). This
etiology-directed therapy typically gives a good response.
The cure for primary BMS, however, remains obscure
despite attempts with wide variety of medications.[1]
There is no universally accepted management protocol
for primary BMS due to unknown specific mechanisms
underlying the syndrome. Researchers have tried wide
variety of drugs including antidepressants, anxiolytics,
anticonvulsants, antioxidants, local anesthetics, NSAIDs,
hormone replacement therapy, antimicrobials, mucosal
protectants, salivary stimulants (sialogogues) and herbal
supplements.[24] Various alternative treatment modalities
have also been implicated, which includes: lasers,
acupuncture, behavioral therapies, yoga, relaxation therapy,
meditation, group psychotherapy, electroconvulsive
therapy etc.[25] [Table 2].
Alpha lipoic acid (ALA) is a powerful neuroprotector
that prevents damage to nerve cells by free radicals. It
regenerates other antioxidants such as vitamins C and E,
thus increasing levels of intracellular glutathione. Due
to its antioxidant properties ALA significantly reduces
the symptoms in the majority of patients with idiopathic
dysgeusia and reduces the symptoms of peripheral
neuropathy in diabetics. Several studies suggest ALA can
improve the symptoms in BMS.[3] Recent randomized
double blind placebo controlled trial by Lopez D et al.,
6

Table 2: Different treatment modalities used in the management

of BMS
Psychological therapy
Cognitive behavioral therapy
Group psychotherapy
Electroconvulsive therapy
Yoga
Meditation
Relaxation therapies
Topical medication
Benzodiazepine: clonazepam at dose of 0.25 to 2mg swish
and expectorate
Local anesthetic: lignocaine or benzocaine viscous gel
Atypical analgesic: capsaicin cream
Antidepressant: doxepin cream
Nonsteroidal anti-inflammatory drugs: benzydamine hydrochloride
oral rinse
Antimicrobial: lactoperoxidase oral rinse
Mucosal protectant: sucralfate oral rinse, artificial saliva
Systemic medication
Benzodiazepine (low dose): chlordiazepoxide at dose of 10-30mg a day
Anticonvulsants: gabapentin 300-1500 mg per day, pregabalin,
topiramate
Antidepressants (low dose): amitriptyline (10-150 mg per day),
imipramine, nortriptyline, desipramine, trazodone
Selective serotonin reuptake inhibitors: paroxetine, sertraline,
trazodone
Selective norepinepherine reuptake inhibitors: milnacipran,
duloxetine
Antioxidant: alpha lipoic acid, zinc supplements
Antipsychotics: amisulpride, levosulpride
Dopamine agonist: pramipexole
Histamine receptor antagonist: lafutidine
Salivary stimulants: pilocarpaine, cevimiline

showed that use of gabapentin alone (300 mg daily) or in

combination with ALA (600 mg daily) was beneficial in
reducing symptoms in 50% and 70% of patients with BMS,
respectively, compared to placebo (15%).[11,26]
Clonazepam lozenges (oral dissolution of 1 mg tablets for 3
min with subsequent expectoration three times a day) are
beneficial in patients with predominantly primary BMS.
A randomized controlled study of topical clonazepam
reported a reduction in pain intensity in 66% of patients
after 2 week and 29% after 6 months.[18,27]
Ecacy of capsaicin, a desensitizer of neural receptors
for inflammation, has been evaluated in several studies.
Systemic capsaicin 0.25% capsules three times daily
showed dramatic improvement (93%) in patients with
severe BMS in duration of 1 month. Side eects includes
gastric pains in 32% of the patients and thus may long
term use of this medication is not possible.[28] Capsaicin
oral rinse may be beneficial in treating primary BMS with
reported reduction of burning sensation in over 75% of
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Ambaldhage, et al.: Burning mouth syndrome: An update

the patients after 2 months of therapy without significant

side eects.[29]

treatment eectively carried out by a multi professional

team in order to manage all symptoms related to BMS.

Capsaicin receptors have both efferent and sensory

activities. These receptors are found in the C-polymodal
nociceptors, which regulates the events associated with
neurogenic inflammation. These receptors are activated
by receiving aerent signals and simultaneous release
of neuropeptides from the same nerve endings. Thus,
capsaicin acts by depletion of substance P.[2,19]

References

Pramipexol is a non-ergotic dopaminergic agonist,

with predilection to dopaminergic D-2 receptors. The
dopaminergic and nigrostriatal pathways are important
on pain modulation. Non-specific disturbances on
the dopaminergic system have been documented in
patients with BMS. The association of BMS with PD
and the improvement with amisulpiride suggests that
dopaminergic dysfunction in BMS. All these facts support
the use dopaminergic agonists such as pramipexol in
treating BMS.[22,25]
Psychiatric interventions show great promise in treating
patients with BMS. In an study by Bergdahl J et al., Weekly
one-hour sessions of cognitive behavioral therapy lasting
for 12-15 weeks significantly reduced oral burning symptom
in all study patients compared to placebo control group,
with an estimated 27% of patients remaining symptom-free
at 6 month follow-up.[17]
There is no consensus in the literature concerning the
best treatment approach. Conservative management
such as low doses of antidepressants, benzodiazepines
and topical clonazepam or capsaicin application are
some of the modalities that have been evaluated. There
is insucient evidence to understand the real cause and
to provide accepted guidance for an eective treatment
of BMS. Furthermore, it is important that in most of the
patients the disease is self-limiting, not exceeding three
years, regardless of the treatment modality used.[30]

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Conclusion
The symptom of oral burning is a very frequent complaint
a dental clinician can come across in daily clinical practice
and is seen in wide variety of oral and systemic disorders.
The BMS diagnosis will be defined only after excluding
all possibilities of oral mucosa diseases, contact allergy
reactions and all other possible causes of referred pain
or burning sensation. Due to the multifactorial etiology
of this condition (local, systemic, psychogenic and
neuropathic), clinicians should better opt for an integrated
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How to cite this article: Ambaldhage VK, Puttabuddi JH, Nunsavath

PN. Burning mouth syndrome: An update. Indian J Pain 2015;29:2-8.
Source of Support: Nil. Conflict of Interest: None declared.

Indian Journal of Pain | January-April 2015 | Vol 29 | Issue 1