Burning Mouth Syndrome. Nurdiana, drg., Sp.PM

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1 Burning Mouth Syndrome Nurdiana, drg., Sp.PM

2 DEFINITION Burning Mouth Syndrome (BMS) oral burning tongue/other mucous membranes no detectable cause, anatomic pathways, mucosal lesions, neurologic disorders & lab abnormalities

3 Burn ing lips syndrome Glossopyrosis BMS Scalded mouth syndrome Glossodynia Stomatodynia

4 EPIDEMIOLOGY Prevalence % Women 7 x : men recent data male = female >>> post menopausal women mid late 50s 10-15% >>> 3 12 years after menopause Men affected at a later age than women

5 ETIOLOGY Unknown Local Systemic Psychological

6 Local Candida Bacteria Pre-Ca/Ca Denture Iritation/alergy Xerostomia

7 Candida Pseudomembranous & erythematous candidiasis BMS No clinical signs of candidiasis antifungal 86% improved & 13%

8 Streptococci Staphylococci Anaerobes Bacteria

9 Pre-Ca/Carcinoma Leukoplakia/erythroplakia burning/painful sensation Ca itching/burning premonitory symptom

10 Denture Main & Basker ill-fitting dentures single greatest contributor Faulty denture design functional stress level to circum oral/lingual muscle Denture fix BMS persist

11 Iritation/Alergy Mechanical irritation oral habit, denture design errors & sharp teeth Chemical allergy food, oral hygiene products or dental materials (methyl-methacrylate/mecury) Contact allergy inflammatory, lichenoid, or ulcerative lesions

12 Xerostomia Xerostomia BMS incidence no clear association Glass : xerostomia local contributing factor, other authors : xerostomia higher/lower??? Salivary composition changes BMS Altered sympa thetic output stress or alterations in interactions between cranial nerves & pain sensation

13 Systemic Menopause Deficiency DM Nerve injury Drugs

14 Menopause Hormonal changes incidence BMS hypoestrogenemia mechanism unclear usually not reversible with hormone replacement therapy

15 Deficiency BMS symptoms of deficiency iron, Vitamin B & folic acid Lamey et al replacement vitamin B1, B2 & B6 effective in treating 88% BMS patients Lab. abnormal management & correction BMS persist

16 Xerostomia & candidiasis Diabetes Mellitus After glucose control BMS persist, oters: diabetic treatment BMS resolved??? Diabetic neuropathy head & neck region

17 Nerve Injury Characteristic post-traumatic nerve injury alterations in perception to touch, temperature, two-point discrimination & threshold pain BMS infrequent

18 Drugs Angiotensinconverting enzyme (ACE) inhibitors (captopril, enalapril, & lisinopril) resolved after discontinuation of medication

19 Psychological Psychogenic problem personality & mood changes pain Depression & anxiety affect pain or secondary to chronic pain Lamb et al: BMS psychological factor & anxiety most difficult to control Psychological component chronic low-grade trauma parafunctional habits eg. rubbing tongue to the teeth or pressing tongue on palate BMS Symptom of cancer-phobia reassuring often helpful

20 More than one factor may be contributing BMS one another, no specific etiology can be identified

21 CLINICAL FEATURES > 50% onset spontaneous, no identifiable precipitat ing factor ± 1/3 onset with dental procedure, recent illness or medication course Most common sites : anterior tongue, anterior hard palate, & lower lip & often occurs in > one oral site Pain intensity & other symptoms gradually & persist for years Burning intermittent/constant eating, drinking, or candy/chewing gum relieves symptoms. Local anesthetic elixir burning but dysgeusia

22 Moderate - severe intensity gradually throughout the day max intensity: late evening difficulty falling asleep & experiencing interrupted sleep Mood changes irritability & decreased desire to socialize related to altered sleep patterns Frequently accompanied by dry mouth & thirst no evidence of decreased salivary flow Additional complaints facial pain & pain at other sites

23 PATHOGENESIS Completely unknown Injury/disease Biochemical & pathophysiologic changes in nociceptive neurons in CNS Morphologic alterations in peripheral tissue

24 BMS Result of common systemic/local disorders nerve damage occurs to trigeminal nerve directly or other cranial nerves inhibit oral nociceptive activity

25 Detailed history Clinical examination DIAGNOSIS Lab Exclusion of all other possible oral problems

26 DIAGNOSIS Diagnosis : detailed history, clinical examination, lab studies & exclusion of all other possible oral problems Key to diagnosis history taking Characteristics sudden or intermittent onset of pain, bilateral, progressive during the day & remission with eating Unilateral symptoms thorough evaluation of trigeminal & other cranial nerves eliminate neurologic source of pain

27 Complain xerostomia + burning evaluation of salivary gland disorder mucosa dry & difficulty swallowing dry foods Ruled out potential causes even typical features of BMS present Burning persists after management sys temic or local oral conditions diagnosis of BMS can be considered Making clinical diagnosis not difficult, determining etiology difficult

28 LABORATORY STUDIES Individual consideration depend on history & clinical suspicion Biopsy not indicated no clinical lesion is associated C. albicans culture Sjogren's syndrome antibodies serum tests complete blood count serum iron, total ironbinding capacity serum B12 & folic acid levels

29 MANAGEMENT First exclude other disease Sources of pain must be eliminate not too much expectation True BMS Education : Reassured benign nature of condition & frightening possibilities (cancer) can be excluded

30 If suggests psychogenic factors explain that depression & other emotional disturbances can cause physical diseases Instruction : Counseling & reassurance adequate for mild BMS more severe symptoms drug therapy Parafunctional oral habits eliminate splint covering teeth and/or palate Therapy : Low doses tricyclic antidepressants (TCA) : amitriptyline, desipramine, nortriptyline, imipramine, clomipramine, or doxepin

31 Should be stressed drugs not to manage psychiatric illness analgesic effect Benzodiazepines : clonazepam (benzodia-zepine derivative) & GABA (gamma-aminobutyric acid) receptor agonist effective for various orofacial pain disorder Grushka et al clonazepam effective in relieving taste dysgeusia & oral dryness along with BMS Topical capsaicin monoamine oxidase inhibitor tranylcypromine sulphate in combination with diazepam neuropathic pain conditions

32 PROGNOSIS Partial remissions occur in approximately 2/3 patients in 6 7 years after onset No studies investigated whether earlier intervention or earlier & better pain control lead to earlier disease remission