Burning Mouth Syndrome

Burning mouth syndrome

Lisa A. Drage, MD*, Roy S. Rogers III, MD

Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

The burning mouth syndrome (BMS) is defined as

a symptom complex of those patients with mouth

pain who have a clinically normal oral mucosal

examination. BMS is a diagnosis of exclusion. Many

oral mucosal diseases present with mouth pain; a few

examples include lichen planus, recurrent herpes

simplex virus infections, and recurrent aphthous

stomatitis. A thorough oral examination must be

completed to exclude these and other oral diseases

before diagnosing BMS. Synonyms for BMS have

included glossodynia, glossopyrosis, glossalgia, sto-

matodynia, stomatopyrosis, sore tongue and mouth,

burning tongue, oral or lingual paresthesia, and

oral dysesthesia.

Burning mouth syndrome is often stereotyped as a

purely psychosomatic disorder occurring in postmen-

opausal women, which is resistant to therapy.

Although BMS can be a diagnostic and therapeutic

challenge, multiple studies have linked BMS to real

organic and psychiatric disease and show an improve-

ment in symptoms in about 70% of patients with

directed therapy [16]. Faced with a patient who has

BMS, dermatologists and other clinicians need to be

familiar with its associations and management, and

optimistic about potential outcome.

The patient variably describes a burning, tingling,

painful, hot, scalded, or numb sensation in the oral

cavity. The magnitude of BMS pain is quantitatively

similar to a toothache [7]. This sensation occurs most

commonly on the anterior two thirds and tip of the

tongue. Multiple oral sites may be involved. These

may include the upper alveolar region, palate, lips,

and lower alveolar region [1,2,5,6,8]. Less commonly

affected are the buccal mucosa, floor of the mouth,

and the throat [4]. With prevalence in the general

population of 3.7% [9], BMS affects women seven

times more frequently than men [5]. It particularly

affects the middle-aged and elderly population (mean

age 60) [2,6,10] and has not been reported in children.

The average duration of BMS is 2 to 3 years [2,11],

with rare patients suffering for decades. Most BMS

patients have consulted multiple dentists, physicians,

and other health care providers for their complaint and

may have tried a host of over-the-counter and pre-

scription medications before their presentation [2,4].

Over half state they received insufficient information

about BMS from their health care provider [12].

Burning mouth syndrome has been divided into

three subtypes based on the daily variation of the

symptoms (Table 1) [13]. Type 1 BMS (35%) is

characterized by daily pain that is not present on

awakening but progresses throughout the day with

the greatest problems occurring in the evening hours.

Type 2 BMS (55%) patients awake with a constant

daily pain, whereas Type 3 BMS (10%) patients have

intermittent pain with symptom-free intervals and the

pain occurs in unusual sites, such as the buccal

mucosa, floor of mouth, and throat. Nonpsychiatric

factors have been linked with Type 1 BMS, chronic

anxiety with Type 2, and food additives or flavoring

allergies with Type 3 BMS. The patients with Type 2

BMS tend to be most resistant to therapy [13,14].

Associated factors

Many conditions have been associated with BMS

(Table 2) [2]. It should not be surprising that oral pain

like any type of pain can have more than one cause.

The four main categories are (1) systemic, (2) local,

0733-8635/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.

PII: S0733 -8635 (02 )00063 -3

* Corresponding author.

E-mail address: [email protected] (L.A. Drage).

Dermatol Clin 21 (2003) 135145

(3) psychiatric or psychologic, and (4) idiopathic

factors. The most common associations include psy-

chiatric or psychologic disorders, xerostomia, nu-

tritional deficiencies, allergic contact stomatitis,

denture-related factors, parafunctional behavior, can-

didiasis, diabetes mellitus, and menopause or hor-

monal alterations [2].

Multifactorial

In more than a third of patients, multiple, concur-

rent causes of BMS may be identified and need to be

addressed simultaneously to achieve the best outcome

possible [15,12,15].

Psychiatric or psychologic disorders

Psychiatric disease is a common underlying factor

in patients with BMS. A psychiatric disease asso-

ciation has been reported in many series ranging from

19% to 85% [35,9,11,1325]. At least one third of

patients may have an underlying psychiatric diag-

nosis, most commonly depression or anxiety disor-

ders [2]. A phobic concern regarding cancer is also

Table 1

Lamey classification of subtypes of BMS [13]

Clinical course Association

Type 1 Daily pain, not present on awakening, increases throughout day Nonpsychiatric

Type 2 Daily pain, constant Psychiatric, especially chronic anxiety

Type 3 Intermittent pain, unusual sites (buccal mucosa, floor of mouth) Allergic contact stomatitis to flavorings, additives

From Lamey PJ, Lamb AB, Hughes A, et al. Type 3 burning mouth syndrome: psychological and allergic aspects. J Oral Pathol

Med 1994;23:2169; with permission.

Table 2

Reported etiologic agents of BMS [2]

Systemic Local Psychogenic and psychiatric Idiopathic

Deficiencies Denture factors Psychiatric

Iron Dental work Depression

Vitamin B12 Mechanical Anxiety

Folate Oral habit or parafunctional behavior Obsessive compulsive disorder

Zinc Clenching Somatoform disorder

B complex vitamins Bruxism Cancerphobia

Endocrine Tongue thrusting Psychosocial stressors

Diabetes mellitus Myofascial pain

Hypothyroidism Allergic contact stomatitis

Menopause or hormonal Dental restoration or denture materials

Foods

Xerostomia Preservative, additives, flavorings

Connective tissue disease Neurologic

Sjogrens syndrome Referred from tonsils or teeth

Sicca syndrome Lingual nerve neuropathy

Drug-related Glossopharyngeal neuropathy

Anxiety or stress Acoustic neuroma

Medication Infection

ACE inhibitor Candidiasis

Esophageal reflux Antibiotic related

Anemia Denture related

Local trauma

Corticosteroid

Diabetes mellitus

Fusospirochetal

Xerostomia

Irradiation

Local disease

From Drage LA, Rogers RS III. Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth

symptoms. Mayo Clin Proc 1999;74:2238; with permission.

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145136

prominent in 20% of patients [5]. The BMS patient

may be concerned that the symptoms are caused by

oral or systemic cancer, although the patient rarely

shares this concern spontaneously with the physician.

Repeated self-examination may be a marker for

cancerphobia [4].

Although BMS may be a somatic symptom of

depression in some cases, the association does not

always equate to a causal relationship. Depression and

psychologic disturbance are common in chronic pain

populations and may be secondary to chronic pain

rather than the cause of BMS. Studies have reported

similarities between the personality characteristics of

chronic oral pain patients and other chronic pain

populations [7]. Similar sleep disturbances have also

been documented in these populations [8]. In addition,

many of the medications used to treat psychiatric

disease can cause xerostomia and exacerbate BMS.

Although psychiatric disorders are clearly sig-

nificant for some patients with BMS, it is important

not to leap to the conclusion that all BMS is caused

by psychiatric problems. Unfortunately, psychiatric

causes are frequently postulated when no easy

answer is apparent. Each patient with BMS should

receive a careful evaluation for both psychiatric and

organic causes of pain. This thorough examination

may unveil a local or systemic cause for their

symptomatology and is often therapeutic, reassuring

the patient about concerns regarding oral cancer.

During the evaluation, direct questions about depres-

sion, anxiety, and fear of cancer and a family history

of psychiatric disorders or oral cancer should be

posed. When warranted, further evaluation and docu-

mentation of psychiatric disease by psychiatric con-

sultation should be sought. A team approach is

important; psychiatric staff may not feel as comfort-

able confirming the diagnosis of BMS because they

are less familiar with oral disease.

Xerostomia

A dry mouth is a frequent complaint among BMS

patients and can be found in up to 25% [2,5,6] of

patients with these complaints. Decreased oral lu-

brication may result in increased friction and discom-

fort leading to BMS (Fig. 1). Xerostomia itself can be

multifactorial. Drug-related xerostomia is common

[2,22] and can occur with many medications includ-

ing tricyclic antidepressants, benzodiazepines, mon-

amine oxidase inhibitors, antihypertensives, and

antihistamines. Connective tissue diseases, such as

Sjogrens syndrome or sicca syndrome, can cause

xerostomia [2,8], as can a history of local irradiation

or diabetes mellitus. Even stress and anxiety can lead

to a dry mouth. Although hypothesized, age-related

or menopausal xerostomia has not been conclusively

documented [26].

Nutritional deficiencies

Because of rapid cell turnover and trauma, the oral

cavity is especially sensitive to nutritional deficien-

cies and may be the first indicator of such a problem.

Iron deficiency anemia, pernicious anemia (an auto-

immune B12 deficiency), zinc deficiency, and B

complex vitamin deficiency [20] have all been

reported to cause BMS. Nutritional deficiencies have

been claimed to cause BMS in as few as 2% [15] and

as many as 33% [1] of patients. The mucosal alter-

ations associated with these deficiency states, such as

erythema, glossitis, loss of papillae, or atrophy, may

be absent in BMS patients (Fig. 2). Replacement

therapy may be helpful in BMS patients with docu-

mented deficiencies [2,5,6,20,27].

Allergic contact stomatitis

The role of allergens in BMS is somewhat con-

troversial. Although some studies claim a high prev-

alence of allergy to dentures and dental materials,

such as acrylates, nickel, mercury, gold, and cobalt

[2830], more recent studies [2,31] were unable to

implicate denture or denture materials as a frequent

cause of BMS. Because true allergies to denture

materials are rare, patients should not be considered

allergic to denture or dental material until controlled

patch testing has been correlated with clinical symp-

Fig. 1. Xerostomia. A dry mouth is a common complaint of

patients with burning mouth syndrome (BMS). Note the dry,

erythematous, fissured tongue plus angular cheilitis.

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145 137

toms. Patients with Type 3 BMS (intermittent pain)

are more likely to have positive patch tests [13].

Flavoring or food additives have been implicated.

This subtype clearly merits patch testing. Lamey et al

[13] noted 65% of Type 3 BMS cohort had positive

patch tests and 80% of this group improved with

avoidance of the implicated allergen. Cinnamon alde-

hyde (cinnamon), sorbic acid, tartrazine, benzoic

acid, propylene glycol, menthol, and peppermint have

all been identified as potential causes of mouth pain

[2,13,31]. Note the contribution of LeSueur and

Yiannis on contact stomatitis elsewhere in this issue.

Denture-related problems

Pain affecting only denture-bearing tissue, a tem-

poral association with denture use, or improvement

with discontinuation of dentures is a clue to denture-

related BMS. Rather than an allergic response to

denture material, denture-related pain is usually

caused by faulty design, irritation, or parafunctional

behavior. Candidiasis can also contribute to denture-

related pain. Main and Basker [6] attributed BMS to

denture design faults in 50% of patients; with replace-

ment of dentures the patients improved. Lamey and

Lamb [5] noted 60% of BMS patients had denture

design faults, but only half of these patients improved

after denture replacement. The main denture design

faults of concern are (1) restricted tongue space, (2)

lack of freeway space, and (3) underextended denture

bases [4]. These denture design faults can increase the

stress on surrounding tissues or change the normal

function of the tongue. Most BMS patients with

dentures or significant dental work benefit from

referral for a formal dental consultation to assess

dental work, dentures, occlusion, and the need for

modification or replacement. This topic is addressed

by Kupp and Sheridan elsewhere in this issue.

Parafunctional behavior

Burning mouth syndrome associated with para-

functional behavior is probably more common than is

realized and is often under appreciated by physicians.

Lamey and Lamb [5] found parafunctional activity a

concern in 13% of a group of patients with BMS.

Patients who clench or grind their teeth, thrust their

tongue repetitively (Fig. 3), run their tongue against

Fig. 2. Smooth tongue. A smooth tongue is atrophic with

loss of filiform papillae. This permits an increased sen-

sitivity to irritants causing BMS. A smooth tongue may

indicate a systemic condition, such as pernicious anemia,

iron deficiency anemia, or gluten-sensitive enteropathy.

Fig. 3. Tongue thrusting. Parafunctional habits, such as

tongue thrusting, may cause, or occur secondary to, the

symptoms of BMS. Note the crenulated or scalloped borders

to the tongue. Similar findings are seen with macroglossia.


their teeth, or try to reseat an ill-fitting denture with

their tongue may develop oral pain. These behaviors

may be unconscious or may only occur at times of

stress. Examination of the tooth surface and dentures

can sometime give clues to parafunctional behavior.

Dental consultation may be helpful in identifying and

managing these behaviors.

Candidiasis

Reported as a causative factor in 6% [5] to 30%

[15] of patients with BMS, the mucosal alterations

typically associated with candidiasis may be minimal

or absent in BMS patients. Osaki et al [32] reported

subclinical candidiasis as a cause of BMS in 25% of a

patient cohort. Glossal pain subsided with treatment

with 3% amphotericin mouthwash solution. Oral

candidiasis is an opportunistic infection. A normal

constituent of the mouth in 40% of patients, candidal

overgrowth occurs with xerostomia, corticosteroid

treatment, antibiotic treatment, denture use, and dia-

betes mellitus. Empiric treatment for oral candidiasis

is often prescribed to patients with BMS.

Diabetes mellitus

Metabolic alterations in the oral mucosae, diabetic

neuropathy, and angiopathy are all proposed mecha-

nisms behind BMS in patients with diabetes mellitus.

Xerostomia and oral candidiasis may also contribute

to the problem. About 5% of BMS patients have

diabetes mellitus [4]. BMS is the second most com-

mon oral complaint after xerostomia in a study of

diabetic patients [1]. Control of diabetes mellitus may

lead to improvement or cure of BMS.

Menopause or hormonal alterations

Most patients seen by physicians for BMS are

women. All the literature on BMS finds that this

condition is more common in women than men with a

ratio of 7 to 1 [4]. Other oral pain syndromes are also

seen more commonly in women [33]. In light of the

prevalence of BMS in postmenopausal women, a role

for a hormonal impact on BMS has long been

suspected [1,34]. In controlled clinical trials with

systemic or local estrogen treatment, however, neither

was more effective than placebo in the treatment of

BMS [10,35]. No significant differences are found

between women with mouth pain and a control group

in number of years since menopause, use of estrogen

replacement therapy, or number of years of use of

estrogen replacement therapy [8,33]. Although

clearly a significant link between BMS and this age

group of women exists and may be tied with meno-

pause, there is currently no proven benefit of hor-

mone replacement therapy in BMS.

Drug-related BMS

The ACE inhibitors enalapril, captopril, and lisi-

nopril can cause scalded mouth or BMS. There is

improvement with reduction or discontinuation of the

medication [36].

Normal mucosal findings

Often regarded as asymptomatic variants of nor-

mal, multiple studies have shown geographic (Fig. 4),

fissured (Fig. 5), or scalloped tongues more frequently

in patients with tongue pain [2,15,37,38]. Although

the patient with oral pain and these findings techni-

cally does not fit under the rubric of BMS, the

connection between these oral findings and oral pain

has been documented and should be recognized.

These findings can also increase the patients fear of

cancer. The article on glossitis by Byrd et al elsewhere

in this issue addresses this topic in greater detail.

Evaluation and work-up of the patient with BMS

The many causes and multifactorial nature of

BMS make an organized approach to evaluation

important (Table 3). Diagnosis and treatment may

Fig. 4. Geographic tongue. The geographic tongue is a

combination of an atrophic tongue with a red base caused by

diminished filiform papillae (with resultant hypersensitivity)

and a furred tongue with a white base and hyperplasia of

filiform papillae. The geographic tongue may be sympto-

matic. (From Drage LA, Rogers RS III. Clinical assessment

and outcome in 70 patients with complaints of burning or

sore mouth symptoms. Mayo Clin Proc 1999;74:2238;

with permission.)


be achieved best by a multidisciplinary approach

involving the dermatologist and the primary care

provider, dentist, psychiatrist, and otorhinolaryngol-

ogist. Simply treating the patient in a sympathetic

manner may improve the interaction and perhaps the

outcome [2,3,12].

Directed history concentrating on the medical,

dental, and psychologic or psychiatric history and

review of symptoms should occur. The description

of oral pain should include the following: duration;

character; level (scale of 1 to 10); site of involve-

ment; and subtype or pattern. Frank questions about

depression, anxiety, and fear of cancer should be

posed. Exacerbating factors, such as food and oral

preparations (mouthwash, gum, mints, toothpaste,

lip cosmetics, and smoking), should be elicited.

Relationship of pain to denture use, dental work,

and parafunctional oral behavior (tongue thrusting,

bruxism, or jaw clenching) should be documented.

All medications must be assessed for xerosto-

mic potential.

Physical examination with emphasis on a thor-

ough oral examination must be completed. Besides

identifying other diseases that could cause mouth

pain, this reassures the patient that cancer is not

present. Evaluation should include assessment for

erythema, glossitis, atrophy, candidiasis, geographic

tongue, lichen planus, and xerostomia. Clinicians with

knowledge and experience in the broad range and

presentation of oral disease are best equipped to

certify a truly normal oral mucosal examination.

Examination of dental work, dentures, denture func-

tion, and signs of parafunctional behavior may be

assessed best by a dental consultation.

Laboratory examination should include the per-

tinent tests in Table 2. Biopsy specimens are

unlikely to be beneficial if a normal clinical

examination is confirmed. Patch testing is espe-

cially important and fruitful in the patient with

Type 3 BMS and should include a standard series,

metal series, and oral flavorings and preservatives

(Box 1). The list of allergens is discussed in the

contribution by LeSueur and Yiannis elsewhere in

this issue.

Management

Burning mouth syndrome is a manageable prob-

lem with most patients responding to tailored therapy

(Box 2). Management should focus on controlling or

eliminating all potential causes of BMS, keeping in

mind that in many patients more than one factor

plays a role. Because of the number of conditions

causing oral pain, a single treatment protocol is not

appropriate. Treatment is tailored to the proposed

Table 3

Work-up of BMS

Thorough history and review of symptoms

Medications causing xerostomia

Dental or denture work

Oral care, oral products

Oral habits or parafunctional behavior

History of depression, anxiety, cancerphobia

Family history of oral cancer, psychiatric diagnoses, and

connective tissue disease

Oral examination

Erythema, candidiasis, xerostomia or other mucosal

abnormalities

Tongue disorders, such as a geographic, fissured, or

atrophic tongue

Dental work or dentures

Laboratory tests

Complete blood count

Iron, total iron binding capacity, iron saturation, ferritin

Vitamin B12, folate, zinc

Glucose, glycosylated hemoglobin

Culture for Candida

Patch testing

Include standard series, metal series, oral flavors and

preservatives

Further consultation if indicated by history and review

of systems

Psychometric testing and psychiatric consultation

Dentistry

Neurology

Otorhinolaryngology

Fig. 5. Fissured tongue. The fissured tongue is rare in

neonates and more common with age. About one sixth of

older patients have grooves and fissuring of the tongue

dorsum. Impaction of food and keratin debris can predispose

to inflammation and halitosis.


causes. Management plans for different scenarios

are reviewed.

Psychiatric disorders

A supportive environment is beneficial for con-

tinued treatment of the patient and may aid resolu-

tion of the symptoms in concert with other therapies

[2,3]. Psychiatric evaluation, medication, and psy-

chotherapy [39] may play a role in alleviating the

symptoms. Although optimally undertaken with the

guidance of a psychiatrist or psychologist; some

patients are resistant to psychiatric evaluation. Anti-

depressants and anxiolytics with less anticholinergic

impact (hence less xerostomia) are preferred. Sero-

tonin reuptake inhibitors typically cause less xero-

stomia and may be a good choice in this setting.

Reassurance that cancer is not present should be

stated clearly and repeatedly.

Denture or dental-related pain

Evaluation of dental work, dentures, denture

design faults, and parafunctional behavior by a spe-

cialist should be sought. Adaptation or replacement

may lead to relief of BMS. Removal of dentures at

night may be helpful. Avoidance of irritants, treat-

ment of dentures with anti-candidal agents, and a

review of dental hygiene should occur.

Deficiency syndromes

Replacement of iron, B12, folate, or zinc should

occur in patients with documented deficiencies. Grad-

ual improvement may follow. Evaluation into the

cause of the document deficiency must occur before

supplementation. Supplementation in absence of

documented deficiency is difficult to justify aside

from B vitamin replacement [20]. Lamey [3] recom-

mends empiric replacement of vitamins B1 (300 mg,

once a day) and vitamin B6 (50 mg, three times a day)

for 4 weeks.


Patch testing to dental and denture components,

metals, additives, preservatives, flavors and a stan-

dard series should occur under the supervision of a

dermatologist who is experienced in their proper use

and interpretation. The clinical correlation between

the patch test results and patient exposure history is

the most important component of the testing. Patient

education and training regarding the avoidance of

identified allergens is imperative.

Candidiasis

Because Candida is a normal part of the oro-

pharyngeal flora, a positive culture does not equate

to a pathologic process. Tests that quantitate Can-

dida infection are not available routinely. Typically,

empiric treatment for oral candidiasis is offered to

the patient with BMS and may benefit a subset of

patients. Treatment may include use of nystatin or

clotrimazole, which are available in multiple forms

including creams, rinses, and troche. One example

of an effective treatment regimen includes the use

of oral fluconazole, 100 mg Number 15: Day 1,

two pills; days 27, one pill; days 821, one pill

every other day. Dentures should also be treated for

Box 1. Patch testing in BMS

1. Standard series (The MayoClinic series includes 68 differentallergens)

2. Oral flavorings and preservatives3. Metal series

The allergens tested should include (butnot be limited to) the following:

Methyl methacrylateEthyl acrylateEthyleneglycol dimethacrylateTriethyleneglycol dimethacrylateBIS GMABenzoyl peroxidePropylene glycolSorbic acidBenzoic acidTartrazine yellowPeppermintSpearmintCinnamic aldehydeMentholFragrance mixBalsam of PeruCobalt chlorideNickel sulfateGold sodium thiosulfateAmalgamMercuric chlorideCadmium chloridePotassium dichromateFormaldehydep- Phenylenediamine


candidiasis and dental hygiene reviewed. Dentures

should always be removed at night. Many patients

sleep with dentures in place all night. This predis-

poses to parafunctional habits and recurrent candi-

diasis (denture stomatitis).

Diabetes mellitus

All patients with BMS need to have diabetes

mellitus excluded with fasting blood glucose levels.

Patients with abnormal findings should be referred

for management and education. Control of diabetes

mellitus many lead to decrease in BMS. Change of

the diabetic medications can sometimes be helpful.

Some patients may need oral agents or some may

need insulin therapy.

Parafunctional habits

Once identified, management many include modi-

fication of denture design; behavioral therapy consist-

ing of habit monitoring, biofeedback, and relaxation

techniques [12]; and use of sugar-free chewing gum,

mouth guards, and even hypnotherapy.

Xerostomia

A number of general measures may be instituted

to counteract xerostomia (Box 3). The discontinua-

tion or substitution of medications with potential for

Box 2. Management strategies for BMS

Tenets of treatment:1. Focus on controlling or eliminating

all potential causes of BMS2. Tailor treatment for individual pa-

tient based on suspected causes3. Resort to empiric therapy only if

no cause of BMS is found or failureof treatment

Management plans may include thefollowing:

Psychiatric and psychologic disorder

Maintain supportive environmentPsychiatric evaluation and

managementAppropriate medication or

psychotherapyReassure cancer is not present

Denture or dental work

Evaluation by dentistAdaptation or replacement as needed

Deficiency syndromes

Document deficiencyEvaluate cause of deficiencyReplacement therapy


Referral to dermatologist with experi-ence in use and interpretation ofpatch tests

Patch test to standard, metal, oralpreservatives, flavor series

Clinical correlationPatient education in avoidance of iden-

tified allergen

Candidiasis

CultureTreatment with anti-candidiasis agents

Diabetes mellitus

Referral for management and education

Parafunctional behavior

Dental evaluation

Behavioral therapySugar-free chewing gum

Xerostomia

Discontinue medications thatcause xerostomia

General measuresSaliva substituteSialogogues

Idiopathic (empiric treatment)

Avoid irritantsTrial of treatment with

anti-candidal agentB-vitamin replacementDoxepin trialLow-dose tricyclic antidepressantsLocal clonazepamConsider referral to specialist in

oral medicine


causing xerostomia should be sought. Because xero-

stomia is a very common medication side effect,

sometimes a simple reduction in the number of

drugs used may improve xerostomia. Artificial sali-

va substitutes may be helpful. Sialogogues, such as

pilocarpine, are sometimes used [32]. Note the

contribution by Parks and Lancaster on oral mani-

festations of systemic disease elsewhere in this issue

for additional discussion of xerostomia and therapy

of the dry mouth.

Idiopathic

If no underlying cause for BMS is found or

treatment targeted to a proposed etiology is not

beneficial, treatment options may follow a more

empiric approach. This may include discontinuation

of irritating substances (alcohol-based mouthwashes,

cinnamon or mint products, and smoking); a trial

treatment with anti-candidal agents; and trial treat-

ment with B complex vitamins [3]. Doxepin, famil-

iar to many dermatologists, is often prescribed in

doses up to 75 mg for its antianxiety and antide-

pressant affects. At higher doses doxepin has a

greater potential for cardiac arrhythmia, xerostomia,

and full antidepressant effect and needs to be

carefully monitored

If no response is seen, tricyclic antidepressants

may be used in a chronic pain protocol manner

[2,5,26]. Typical doses include amitriptyline, 10 to

75 mg. Low doses of tricyclic antidepressants may

have an analgesic affect that is separate from their

action as antidepressants [33]. Use of benzodiaze-

pines [40,41] including systemic clonazepam [18]

have been reported to be effective in BMS.

Although the mechanism for their action may not

rely solely on their anxiolytic effect, concerns

regarding the chronic nature of BMS and the poten-

tial for abuse of this class of medication merits

cautious use. Interestingly, Woda et al [42] reported

benefit in 52% of patients treated with local applica-

tion of clonazepam (0.5 to 1 mg) two to three times

a day. They theorized that local application of

clonazepam acts locally to disrupt the neuropatho-

logic mechanism that underlies BMS. More unusual

treatments reported have included use of capsaicin

[43] and infrared laser [44].

Burning mouth syndrome is a treatable syndrome.

Treatment is associated with improvement in about

70% of patients [16] using a directed approach. If

that fails, an empiric approach is warranted. Spon-

taneous remissions have also been noted to occur

[45,46].

Summary

Burning mouth syndrome is the occurrence of oral

pain in a patient with a normal oral mucosal exam-

ination. It can be caused by both organic and psycho-

logic or psychiatric factors, which can be broken

down into local, systemic, psychologic or psychiatric,

and idiopathic causes. The most frequently associated

conditions are psychiatric (depression, anxiety, or

cancerphobia); xerostomia; nutritional deficiency;

allergic contact dermatitis; candidiasis; denture-

related pain; and parafunctional behavior. Multiple

different factors contributing to the oral pain are

common, and a systematic approach to the evaluation

is important.

Identification of correctable causes of BMS should

be emphasized and psychiatric causes should not be

invoked without thorough evaluation of the patient. A

Box 3. Xerostomia management

General measures include the following:

Review medications and replacethose with known xerostomic po-tential. Discontinue unnecessarymedications.

Increase water intake throughoutthe day

Use humidifier in bedroomAvoid alcohol and alcohol-containing

mouthwashAvoid caffeineUse sugar-free candy, gum, and

beveragesUse petroleum jelly on lips before bed

and throughout dayFrequent dental examination. Patients

with xerostomia have increased riskof cavities and gum disease.

Commercial saliva substitutes: use asoften as needed and before bed;available without a prescription.

Examples include the following:

Mouth Kote (spray)Moi-stir-spray and swabsOptimoist (spray)

SialogoguePilocarpine, 5 mg tidCivemeline, 30 mg tid


directed history and careful oral examination must be

completed to exclude local diseases and identify clues

to potential causes. Assessment of medications, psy-

chiatric history and background, and selected labora-

tory and patch tests may help identify the etiologies of

these symptoms.

Treatment should be tailored to each patient and

may best be managed in a multidisciplinary approach

with input from dermatologists, dentists, psychiatrists,

otorhinolaryngologists, and primary care providers. A

thoughtful and structured evaluation of the patient

with BMS has been associated with improvement in

about 70% of patients. The remaining patients may

benefit from empiric therapy with a chronic pain pro-

tocol and continued supportive interactions.

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