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Burning Mouth Syndrome: Diagnostic appraisal and management strategies.

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128 REVIEW ARTICLE SAUDI DENTAL JOURNAL SAUDI DENTAL JOURNAL

Burning Mouth Syndrome: Diagnostic appraisal and

management strategies
Sukumaran Anil, BDS, MDS, PhD, FICD, FPFA *
Mohammed Nasser Alsqah, BDS **
R. Rajendran, BDS, MDS, PhD ***

Burning mouth syndrome (BMS) is a disorder that is characterized by a burning sensation of the oral cavity in the absence
of visible local or systemic abnormalities. Affected patients often present with multiple oral complaints, including burning,
dryness and taste alterations. The exact cause of burning mouth syndrome often is difficult to pinpoint. Conditions that
have been reported in association with burning mouth syndrome include chronic anxiety or depression, various nutritional
deficiencies, type 2 diabetes and changes in salivary function. Studies have pointed to dysfunction of the cranial nerves
associated with taste sensation as a possible cause of burning mouth syndrome. Since burning mouth symptoms may
arise as the result of a number of etiologic factors, diagnosis and management of the patient with BMS should involve
consideration of all possible causative factors. Hormone replacement therapy, benzodiazepines/ anti-convulsants, anti-
depressants, analgesics, capsaicin, alpha-lipoic acid and cognitive behavioral therapy etc. have all been used in the
management of BMS. The present review outlines various aspects of BMS, updates current knowledge on the disease,
and provides guidelines for successful patient management.

INTRODUCTION a significant emotional impact on these

Burning mouth syndrome (BMS) has
been defined as pain of a burning nature
in the tongue or oral mucous membrane,
usually without accompanying clinical
and laboratory findings.1,2 Other terms
that are applied to this condition include
burning lips syndrome, scalded mouth
syndrome, stomatodynia, glossodynia,
and glossopyrosis.3,4 There has also
been no clear consensus on the etiology,
pathogenesis or treatment of burning
mouth syndrome.5 As a result, patients
with inexplicable oral complaints are often
referred from one health care professional
to another without effective management
strategies. This situation not only adds
to the health care burden but also has
*Associate Professor, Division of Periodontics
**Intern
***Professor, Division of Oral Pathology
College of Dentistry, King Saud University
P.O. Box 60169, Riyadh 11545, Saudi Arabia
patients, who are sometime suspected
of deducting or exaggerating their
symptoms.
Epidemiology
Based on the data accrued so far, oral
burning appears to be most prevalent
in postmenopausal women.6 It has been
noted in 10 to 40 percent of women reported
for treatment of menopausal symptoms.7
These percentages are in contrast to the
much lower prevalence rates reported
for oral burning in epidemiologic studies
(0.7 to 2.6 percent),8,11 The Incidence
and prevalence of BMS vary according
to diagnostic criteria, and many studies
Address reprint request to
Dr. S. Anil
Associate Professor and Consultant
College of Dentistry, King Saud University
P.O. Box 60169, Riyadh 11545, Saudi Arabia
E mail: anil@graduate.hku.hk
Web: www.perio.in

Saudi Dental Journal, Volume 19, No. 3, September - December 2007

Anil et al. 129

included people with the symptom of mouth syndrome and its complex
burning mouth rather than with burning clinical picture, a number of etiologies
mouth syndrome.9 have been suggested. However, each of
these postulated causes explains the
Pain Characteristics pain in isolated groups of patients. With
In more than one half of patients with the recently increased understanding
burning mouth syndrome, the onset of of the role that taste damage plays in
pain is spontaneous, with no identifiable the pathogenesis of burning mouth syn-
precipitating factor. Approximately one drome, many of these etiologies can now
third of patients relate the time of onset be viewed as part of a larger spectrum of
to a dental procedure, recent illness or disease.
medication course. Regardless of the Etiological factors can be divided
nature of pain onset, once the oral burning into local, systemic and psychological
starts, it often persists for many years.10 (Table 1).
The burning sensation often occurs
in more than one oral site, with the Local Causes of Burning Mouth
anterior two thirds of the tongue, the Syndrome
anterior hard palate and the mucosa of Although many predisposing factors
the lower lip most frequently involved.6 In have been attributed to BMS, none are
many patients with the syndrome, pain is free from controversies.
absent during the night but occurs at a Table 1. Common conditions associated with burning
mild to moderate level by middle to late mouth syndrome
morning. The burning may progressively Local
increase throughout the day, reaching its Candidiasis Lichen planus
greatest intensity by late afternoon and Erythema migrans Parafunctional habits
into early evening.10 Patients often report Gastro-oesophageal
Denture problems
that the pain interferes with their ability reflux disease
to fall asleep. Perhaps because of sleep Systemic Conditions
disturbances, constant pain, or both, Medications
Diabetes mellitus
patients with oral burning pain often (such as captopril)
have mood changes, including irritability, Dry mouth -Xerostomia Menopause
anxiety and depression.2 Deficiency States
Little information is available on Vitamin B Folate
the natural course of burning mouth Iron
Psychogenic
syndrome. Spontaneous partial recovery
Cancerophobia Depression
within six to seven years after onset
Anxiety Hypochondriasis
has been reported in up to two thirds of
Stress
patients, with recovery often preceded
by a change from constant to episodic Candidiasis
burning.6 Most studies have found that Pseudomembranous and erythematous
oral burning is frequently accompanied candidiasis have been associated with
by other symptoms, including dry mouth BMS.5 The pseudomembranous type
and altered taste.6 is easily recognized by white, slightly
elevated plaques that have a milky
Etiologic Factors - Systemic and Local appearance and can be rubbed off, it
Factors is most commonly found on the cheeks
Because of a long-standing difficulty and palate. The erythematous type is
in understanding the pain of burning characterized by flat, red changes of the

Saudi Dental Journal, Volume 19, No. 3, September - December 2007

130
mucosa, tongue, and palate. The diagnosis
of candidiasis is often presumptive, made
on the response to antifungal therapy
and rarely based on cytologic or histologic
studies. Gorsky et al.11 reported that in
patients with BMS having no clinical
signs of candidiasis, 86% improved after
using antifungal lozenges and 13% had
complete elimination of their symptoms.
Oral Cancer
Glossodynia may be caused by oral
cancer, which is normally present on
the lateral borders of the tongue or the
oropharynx. Carcinomas of the oral
cavity can also present with itching or
burning as the premonitory symptom.
Premalignant entities such as leukoplakia
or erythroplakia may also present with
burning or painful sensation.12
Dental Causes
A faulty denture design may promote
the burning sensation due to an increased
level of functional stress to the circum
oral or lingual musculature. Main and
Basker 13 found ill-fitting dentures to
be the single greatest contributor to
BMS in their patient population. BMS
patients were found to have significantly
less daily denture use, reduced tongue
space, incorrect placement of the
denture occlusal table, and increased
denture vertical dimension.14 However,
in the majority of patients in whom
denture abnormalities were adequately
corrected, the burning mouth symptoms
persisted.15
A similar controversy attributes the
cause of burning mouth to an allergic
response to the denture materials.
Methyl-methacrylate monomer and other
products used in denture fabrication
have been shown to produce positive skin
reactions to patch testing.16 If erythema
of the mucosa exists, the construction of
new dentures using different material,
such as metal alloys, has been shown to
Saudi Dental Journal, Volume 19, No. 3, September - December 2007
BURNING MOUTH SYNDROME
result in a partial or even total relief of
symptoms. However, in the absence of
oral lesions which could indicate contact
dermatitis, the substitution of materials
in general has not been shown to alleviate
BMS.17
Hypersensitivity to mercury was found
to be one of the most common medical
diagnoses concomitant with BMS.18
In addition to mercury, other metals
used in dental restorations are gold,
palladium, zinc, tin, gallium, indium,
cobalt, chrome, nickel, iron, and silicon.
Although hypersensitivity to these
materials has been reported, their precise
role in the causation of symptoms of BMS
is not absolutely clear. The symptoms
of galvanism may resemble those of
BMS, and they require consideration.12
Treatment would involve the elimination
of one of the metallic restorations or
using synthetic nonconductive materials
wherever applicable.
Lichen Planus
The symptoms of burning and pain
occur most often with erosive lichen
planus.19 The diagnosis is made by
histological examination. Local or
systemic corticosteroid therapy is
frequently helpful in the acute phase
of erosive lichen planus. The incidence
of malignant transformation of erosive
lichen planus varies from 0% to 10%.
Systemic Causes of Burning Mouth
Syndrome
Various systemic factors have been
associated with BMS, although many of
these conditions require further study to
verify the correlation. There is a predilection
for BMS to occur in menopausal and
postmenopausal women,7 however, there
have been varied opinions regarding the
hormonal role in BMS. Oral discomfort,
including burning mouth, is one of the
two most common oral manifestations of
menopause.20 Basker et al.21 reported that
Anil et al.
26% of patients evaluated for menopause
experienced some oral symptoms, one-
third of these describing BMS. Yet in
early studies, neither topical nor systemic
hormonal replacement therapy has been
shown to be effective.22,23 In a recent study,
hormone-replacement therapy was found
to be efficacious in BMS patients who had
demonstrated nuclear estrogen receptors
on immunohistochemical assay, and
ineffective in those patients who did not
have the receptors.24 Therefore, hormone
modifications may have a role in selected
patients with BMS.
Iron and Vitamin B Complex Deficiency
Glossodynia may be one of the
symptoms of deficiency states especially
iron, Vitamin B and folic acid. The diagnosis
can be made by estimation of hemoglobin
content, serum iron, ferritin level and iron
binding capacity. The treatment is by iron
replacement therapy. Lamey et al.25 found
replacement therapy of vitamin B1, B2
and B6 effective in treating BMS in 88%
of patients. However, in another study of
therapy-resistant BMS patients, vitamin B
replacement therapy was unsuccessful.26
The definitive role of B complex vitamins
in the etiology of BMS remains unclear.
A deficiency of folic acid may lead to
burning mouth associated with angular
cheilitis and glossodynia.27 The tongue
shows varying degrees of papillary
atrophy which progresses until the
surface of tongue is smooth and shiny.
The diagnosis is done by RBC morphology
and serum folate level. Likewise, niacin
deficiency causes generalized erythema
of the oral mucosa along with papillary
atrophy. A proper diagnosis can be made
by the measurement of niacin level. It is
treated with niacin and vitamin B-complex
vitamins.27
Diabetes Mellitus
Glossodynia may be one of the
symptoms of diabetes, which is often
Saudi Dental Journal, Volume 19, No. 3, September - December 2007
131
associated with xerostomia and
candidiasis. There also may be diabetic
neuropathies, which manifest in the
head and neck region contributing
glossodynia.21,28
It has been suggested that diabetics
are more susceptible to the Candida
infections which may cause the burning
mouth.5 While some found that the
symptoms of BMS in diabetic patients
did not decrease after glucose control,12
others found that in many cases, diabetic
treatment resolved the oral symptoms.28
Psychologic Dysfunction
Personality and mood changes have
been consistently demonstrated in
patients with burning mouth syndrome
and have been used to suggest that the
disorder is a psychogenic problem.29 How-
ever, psychologic dysfunction is common
in patients with chronic pain and may
be the result of the pain rather than its
cause. Browning et al.30 concluded that
44% of burning mouth patients had an
associated psychiatric disorder. Lamb
et al.31 indicated that 60% of burning
mouth patients has had psychological
factors and anxiety was most difficult to
control. Glossodynia may be a symptom
of cancer-phobia. Reassuring the patients
after a proper diagnosis is often helpful
in relieving the symptoms. The treatment
of psychogenic Glossodynia is anxiolytic/
antidepressant drugs or by referring
the patient for psychiatric consultation.
The reported success of bio-behavioral
techniques in the treatment of burning
mouth syndrome may be related more to
an improvement in pain-coping strategies
than to a “cure” of the disorder.32 Similarly,
the usefulness of tricyclic antidepressants
and some benzodiazepines may be more
closely related to their analgesic and
anticonvulsant properties, and to the
possible effect of benzo-diazepines on
taste-pain pathways.33
132
Hormonal Changes
Hormonal changes are still
considered to be important in burning
mouth syndrome,6 although there is
little convincing evidence of the efficacy
of hormone replacement therapy in
postmenopausal women with the
disorder.24 Approximately 90 percent of
the women in studies of the syndrome
have been postmenopausal, with the
greatest frequency of onset reported
from three years before to 12 years after
menopause.10
Dry Mouth (Xerostomia)
Dry mouth has been suggested as
an etiologic factor, in view of its higher
incidence in patients with burning mouth
syndrome.10,14 Glass34 suggests that
xerostomia is a local contributing factor
in the development of BMS, and other
authors also found a higher or lower
percentage prevalence of xerostomia in
burning mouth syndrome patients.35,36
However, most salivary flow rate studies
in affected patients have shown no
decrease in unstimulated or stimulated
salivary flow.6 Studies have demonstrated
alterations in various salivary components,
such as mucin, IgA, phosphates, pH and
electrical resistance.6 The relationship of
these changes in salivary composition to
burning mouth syndrome is unknown,
but the changes may result from altered
sympathetic output related to stress, or
from alterations in interactions between
the cranial nerves serving taste and pain
sensation.7 Although there is no effective
treatment, saliva substitute and fluoride
gel should be prescribed for the relief of
these oral symptoms.
Taste Function
The role of taste in burning mouth
syndrome is not straightforward,
although recent studies by one set of
investigators demonstrated a possible
relationship between taste activity and
the disorder.37,38
Saudi Dental Journal, Volume 19, No. 3, September - December 2007
BURNING MOUTH SYNDROME
Diagnosis of BMS
History taking is the key to diagnosis
of BMS. Both diagnosis and management
may be difficult because patients often
present with multiple oral complaints, may
be focused on their symptoms and may be
anxious or depressed, which intensifies
the pain experience. The diagnosis
is based on clinical characteristics,
including either a sudden or intermittent
onset of pain, bilateral presentation, a
progressive increase in pain during the
day and the remission of pain with eating
and sleeping.
The clinical history is helpful in
diagnosing burning mouth syndrome.
Most patients with the disorder report an
increase in pain intensity from morning
to night, decreased pain while eating, oral
dryness that waxes and wanes with the
burning, and the frequent presence of
taste disturbances.39 Even when a patient
reports typical features of burning mouth
syndrome, other potential causes should
be ruled out (Table 2).
Table 2. Investigations and assessment which might
currently be considered in patients with symptoms of a
burning mouth
 Detailed history and clinical examination
 Blood test- to exclude anaemia
 Iron, vitamin B12 and red cell folate levels – to
exclude deficiency
 Random blood glucose levels – to exclude diabetes
mellitus
 Measurement of salivary flow – to exclude dry mouth
 Autoantibody assay-to exclude Sjogren’s syndrome
 Oral biopsy – for definitive oral diagnosis
 Assessment of denture fitness and function
 Psychological assessment – to investigate possible
roles of depression or anxiety
If burning persists after management
of systemic or local oral conditions, a
diagnosis of burning mouth syndrome
can be considered, and empiric treatment
for sensory neuropathy may be offered.
Although not widely available, specific
techniques can be used to test for taste
disturbances and salivary function.
Referral to a specialist with expertise in
Anil et al.
this area may be beneficial in particularly
difficult cases.
Management of BMS
Owing to the large variety of
associated factors, the protocol for BMS
management is complex. Although many
drugs, medications, and miscellaneous
treatments have been proposed in BMS,40
the management of this syndrome is
still not satisfactory, and there is no
definitive cure.41,42 In the absence of
any identifiable cause(s) of the burning
sensation, pharmacologic therapy has
been suggested. Medications used for
BMS include antifungals, antibacterials,
corticosteroids, analgesics, sialagogues,
vitamin and mineral replacements,
hormone replacements, benzodiazepines,
antidepressants and antihistamines.43
BMS patients have shown a good
response to long-term therapy with
systemic regimens of anti-depressants44
and anxiolytics.45 In addition, some
patients undergoing topical capsaicin
administration have experienced a partial
or even complete remission of their
pain.46
Information for Patients and Psychological
Support
Patients with BMS often feel that
they have insufficient information about
the condition and verbal reassurance
should be reinforced with well-supported
documents. Patients must be made
aware, instead, that their pain is “real”,
the syndrome is common in middle-aged/
elderly individuals, and is often linked to
some identified conditions. Precautionary
measures, such as abstaining from
smoking and specific food allergens,
should also be suggested. Drugs able
to induce either BMS 47,48 or xerostomia
49
should be avoided as well. Some
explanatory leaflets or booklets may be
helpful for this purpose. When evidence
of a psychogenic pain component is
Saudi Dental Journal, Volume 19, No. 3, September - December 2007
133
detected, specialists should also provide
patients with adequate psychological
support. This preliminary counseling,
in fact, can have a great impact on the
patients’ attitude and may often result in
long-term beneficial effects.50
Causative Therapy in BMS
Subjects with BMS should be treated
for the precipitating factors of this
disorder. Depending on the type of salivary
dysfunction, xerostomia is controlled with
saliva substitutes or saliva-stimulating
agents.51,52 Saliva substitutes have some
properties similar to those of the salivary
glycoproteins.53 Active stimulation of
salivation may be obtained by means
of chewing gums or sweets, whereas
passive stimulation is achieved through
specific cholinergic drugs (sialagogues),
such as pilocarpine.33,52 Pyridostigmine
is of greater benefit, since it is longer-
acting and associated with fewer side-
effects. Parafunctional habits are treated
by a biofeedback technique 54 and/or
restoration of proper bite. Muscular
tension/pain and temporomandibular
joint mobilization are managed by means
of physical relaxation training and
physical therapy, respectively.55 Peri-/
post-menopausal women with BMS should
be referred to a gynecologist for proper
administration of conjugated estrogens
and medroxyprogesterone acetate, which
in fact, may relieve oral symptoms in this
subgroup of BMS patients.24 Vitamin B
complex replacement therapy (pyridoxine,
riboflavin, thiamine, etc.) may yield a good
response 25 in very few cases of patients
with nutritional deficiency.26
As mentioned previously, the different
types of responses to etiology-directed
therapy in BMS might be related to the
type(s) of neuropathic change(s) underlying
the syndrome. In non-responding cases,
local and/or systemic predisposing
factors may have caused an irreversible
134 BURNING MOUTH SYNDROME

neuropathic damage/defect, and thus Table 3. Supportive therapy of Burning Mouth Syndrome
patients should be additionally treated Medications (Dosage) Prescription
with a therapy targeted to the neuropathic 10 mg at bedtime; increase
Tricyclic antidepressants
dosage by 10 mg every 4 to
damage. Recently, a three- to four-week Amitriptyline (Elavil)
7 days until oral burning is
regimen of alpha-lipoic acid (ALA) has Nortriptyline (Pamelor)
relieved or side effects occur
been claimed to provide a slight to decisive 0.25 mg at bedtime; increase
pain reduction in BMS patients.56,57 Based dosage by 0.25 mg every 4
on the currently reported efficacy of ALA to 7 days until oral burning
is relieved or side effects
in treating neuronal damage,58 especially Benzodiazepines occur; as dosage increases,
in diabetic neuropathy,59 this drug might Clonazepam (Klonopin) medication is taken as full
be particularly indicated in BMS subjects dose or in three divided
who show lack of response to etiology- Chlordiazepoxide doses
(Librium) 5 mg at bedtime; increase
directed therapy. Further investigation,
dosage by 5 mg every 4
however, is mandatory for better defini- to 7 days until oral burning
tion of the role of this drug in BMS. is relieved or side effects
occur; as dosage increases,
Supportive Care in BMS: The Control of medication is taken in three
divided doses
Pain and Associated Symptoms
100 mg at bedtime; increase
The supportive treatment of burning dosage by 100 mg every 4
mouth syndrome is usually directed at to 7 days until oral burning
Anticonvulsants
its symptoms and is the same as the is relieved or side effects
Gabapentin (Neurontin)
management of other neuropathic pain occur; as dosage increases,
medication is taken in three
conditions (Table 3). Studies generally
divided doses
support the use of low dosages of
Rinse mouth with 1 teaspoon
clonazepam (Klonopin),3 chlordiazepoxide of a 1:2 dilution (or higher)
(Librium) 33 and tricyclic antidepressants of hot pepper and water;
Capsaicin
(e.g., amitriptyline [Elavil]) 60 . Evidence increase strength of capsaicin
also supports the utility of a low dosage as tolerated to a maximum of
1:1 dilution.
of gabapentin (Neurontin).39 Studies have
not shown any benefit from treatment with
Antidepressants: For many years, low
selective serotonin reuptake inhibitors or
dose tricyclic antidepressants (TCA’s)
other serotoninergic antidepressants (e.g.
including amitriptyline, desipramine,
trazodone [Desyrel].61
nortriptyline, imipramine and
Although benzodiazepines might exert
clomipramine remained the treatment of
their effect on oral burning by acting as a
choice in the management of BMS.60,61
sedative-hypnotic, this possibility appears The choice of these medications was
to be unlikely because the maximal effect based on the effectiveness of the tricyclic
of clonazepam is usually observed at lower antidepressants as analgesics.
dosages.45 The beneficial effects of tricyclic
antidepressants in decreasing chronic Benzodiazepines: There are several
pain indicate that, in low dosages, these published reports that both
agents may act as analgesics. Topical chlordiazepoxide and clonazepam,
capsaicin has been used as a desen- GABA (gamma-amino butyric acid)
sitizing agent in patients with burning receptor agonists, may be effective for
mouth syndrome.46 However, capsaicin some orofacial pain conditions including
may not be palatable or useful adjunct in BMS.3,33 These drugs are believed to
many patients. facilitate the inhibitory actions of GABA.

Saudi Dental Journal, Volume 19, No. 3, September - December 2007

Anil et al.
Woda et al.3 additionally demonstrated
the possibility of a topical effect of
clonazepam in reducing oral burning in
approximately 2/3 of their BMS patients.
These studies also suggest no particular
benefit to increasing doses of clonazepam
beyond what appears to be its “window” of
activity in BMS.
Capsaicin: Capsaicin desensitization is
an effective oral analgesia when painful
lesions are present.46 According to our
hypothetical model, capsaicin would not
be expected to be effective in reducing
BMS since the burning is a central and
not a peripheral sensation. This is in
contrast to atypical odontalgia, in which
peripheral triggers in the periodontal
membranes of the affected teeth do appear
to respond to capsaicin desensitization
and/or topical anesthetic with temporary
relief of pain.62,63
Alpha-Lipoic Acid
Alpha-lipoic acid (ALA) significantly
reduces symptoms of burning mouth
syndrome (BMS).57 The improvement in
symptoms was maintained for at least
ten months after discontinuing treatment
with ALA in the majority of cases. ALA
is a potent antioxidant that protects the
body against damage from free radicals. It
has been used to treat radiation sickness
and complications of diabetes, and has
been investigated as a possible anti-HIV
medicine. ALA helps to conserve other
antioxidants, such as vitamins E and C,
and increases cellular levels of glutathione,
another potent antioxidant. The benefits of
ALA may be due to its ability to neutralize
free radicals and prevent damage to nerve
cells. However, more research is needed
to clarify its mechanism of action in the
treatment of BMS.
Cognitive behaviour therapy (CBT) has
been shown to have some benefit in this
condition but is complex and clinically
intensive. This involves the identification
Saudi Dental Journal, Volume 19, No. 3, September - December 2007
135
of maladaptive thought processing and
its attempts to change this in a positive
way.50,64 Successful treatment of BMS
patients with combined psychotherapy
and psycho-pharmacotherapy has also
been reported.65
SUMMARY
Burning mouth syndrome is a painful
and often frustrating condition. The
burning sensation may affect the tongue,
the roof of the mouth, the gums, the inside
of the cheeks and the back of the mouth or
throat. The exact cause of burning mouth
syndrome often is difficult to pinpoint. The
disorder has long been linked to a variety
of other conditions: menopause, diabetes,
nutritional deficiencies, tongue thrusting,
disorders of the mouth (oral thrush and
dry mouth), acid reflux, cancer therapy
(irradiation and chemotherapy) and
psychological problems.
Burning mouth syndrome remains a
fascinating, though poorly understood,
condition in the field of oral medicine.
New evidence for the neuropathic basis
of this syndrome is emerging. As a
result, a subgroup of BMS cases may
fall into the category of nigrostriatal
dopaminergic disorder. In the remaining
group of patients, in whom there are clear
precipitating local factors, BMS might be
considered as a consequence of selective
damage (trauma/ chemo-mechanical
irritation) to the nerve fibers of the
trigeminal nervous system.
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