Burning Mouth Syndrome

Aka: Burning Mouth Syndrome, Oral Dysesthesia, Orodynia, Stomatopyrosis

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II. Epidemiology

  1. Patients are generally older
  2. More common in women by ratio of 7:1
  3. Prevalence: 1 million in U.S. affected

III. Pathophysiology

  1. No clear cause identified
  2. Postulated causes
    1. Nutritional Deficiency
      1. Vitamin B Deficiency
      2. Iron Deficiency Anemia
    2. Major Depresion
    3. Increased Taste Sensation
    4. Xerostomia
    5. Menopause (90% of women are postmenopausal)
    6. Trigeminal Nerve (CN V) Neuropathy
    7. Candidiasis
    8. Dentures
    9. Diabetes Mellitus

IV. Symptoms

  1. Characteristics of pain
    1. Burning pain affecting oropharynx
    2. Pain may be severe Toothache-like pain
  2. Timing
    1. Onset in mid-morning
    2. Progression over course of day
    3. Peaks in late afternoon
    4. Subsides at night (may interfere with going to sleep)
  3. Multiple pain sites often affected
    1. Anterior two-thirds of Tongue
    2. Oral Mucosa (especially anterior Hard Palate)
    3. Lower lip mucosa
  4. Palliative
    1. Pain may be relieved with eating
  5. Provocative
    1. Worse with emotion, speech
  6. Associated symptoms
    1. Dry Mouth (Xerostomia)
    2. Taste disturbance (bitter or Metallic Taste)

V. Signs

  1. No lesions present

VI. Labs

  1. Complete Blood Count
  2. Serum Iron or Ferritin
  3. Serum Vitamin B12
  4. Zinc
  5. KOH and Fungal Culture
  6. Serum Glucose or Hemoglobin A1C

VII. Differential Diagnosis

  1. See Tongue Pain

VIII. Associated Conditions

  1. Mood disturbance including Major Depression

IX. Diagnosis: ICHD-3 Criteria

  1. Oral Pain
    1. Burning quality
    2. Superficially felt in the Oral Mucosa
  2. Timing
    1. Recurrs daily for >3 months
    2. Present for >2 hours/day
  3. Exam
    1. Normally appearing Oral Mucosa
    2. Clinical examination is normal including Sensory Exam
  4. Exclusions
    1. Not explained better by another ICHD-3 diagnosis
  5. References
    1. (2018) Cephalalgia 38(1):1-211 +PMID: 29368949 [PubMed]

X. Course

  1. Spontaneous onset with persistence for years

XI. Management

  1. Treat potential causes of differential diagnosis
    1. Antifungal agent for Oral Candidiasis (Thrush)
    2. Estrogen Replacement for Menopause
    3. B Vitamin Supplementation for B Vitamin Deficiency
    4. Increase Saliva in Xerostomia
    5. Alpha-lipoic acid
    6. Cognitive Behavioral Therapy
  2. Neuropathic Pain Medications
    1. Amitriptyline (Elavil) at bedtime
    2. Clonazepam (Klonopin) at bedtime
    3. Gabapentin (Neurontin) at bedtime
    4. Capsaicin
      1. Start with hot pepper diluted 1:2 with water
      2. Rinse mouth with 1 teaspoon
      3. May decrease dilution to 1:1 as tolerated

XII. References

  1. Muzyka (1999) Cutis 64(1):29-35 [PubMed]
  2. Grushka (2002) Am Fam Physician 65(4):615-20 [PubMed]
  3. Tan (2022) Cephalalgia 42(2):128-61 +PMID: 34404247 [PubMed]
  4. McMillan (2016) Cochrane Database Syst Rev 11(11):CD002779 +PMID: 27855478 [PubMed]

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