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Burn of oral cavity — Clinical Guidelines

Overview

Burning mouth syndrome (BMS) is characterized by a persistent burning sensation in the oral cavity without any visible mucosal lesions or identifiable underlying dental or medical causes. This condition significantly impacts quality of life, often leading to difficulties in eating, speaking, and sleeping. It predominantly affects middle-aged and elderly individuals, with a higher prevalence in women. Recognizing and managing BMS is crucial in day-to-day practice due to its chronic nature and the substantial psychological distress it can cause 1 3 5.

Pathophysiology

The exact pathophysiology of BMS remains elusive, but several theories propose potential mechanisms contributing to the symptomatology. One hypothesis suggests that alterations in neurotransmitter levels, particularly serotonin and noradrenaline, play a role in the neuropathic pain experienced by patients 1. Additionally, there is evidence supporting a role for nutritional deficiencies, such as deficiencies in iron, zinc, and vitamin B12, which may affect mucosal health and sensation 1 3. Psychological factors, including anxiety and depression, are also implicated, potentially modulating pain perception through central sensitization mechanisms 2. Furthermore, hormonal changes, especially in postmenopausal women, have been linked to increased susceptibility to BMS, indicating a possible influence of estrogen levels on oral mucosal sensitivity 3.

Epidemiology

Burning mouth syndrome exhibits variable prevalence rates across different populations, ranging from 0.7% to 15% in general populations 3 5. It predominantly affects middle-aged and elderly individuals, with a female-to-male ratio often exceeding 5:1 3. Geographic distribution does not show significant variations, but certain risk factors such as chronic stress, smoking, and xerostomia (dry mouth) may contribute to higher incidence rates in specific demographic groups 3. Over time, there is no clear trend indicating an increase or decrease in prevalence, though awareness and reporting may influence observed rates 5.

Clinical Presentation

Patients with BMS typically present with a persistent burning sensation affecting various sites within the oral cavity, most commonly the tongue and lips, but it can be more generalized 1 2. Symptoms often fluctuate throughout the day, with increased intensity in the evening 2. Intermittent pain patterns are common, and patients may report associated symptoms such as altered taste sensation, dryness, and sometimes mild xerostomia 2. Red-flag features include sudden onset, severe pain disproportionate to clinical findings, or signs of systemic disease, which should prompt further investigation to rule out other conditions 3.

Diagnosis

The diagnosis of BMS is primarily clinical, based on the exclusion of other oral mucosal diseases and systemic conditions. Key diagnostic criteria include:

Persistent burning sensation in the oral cavity lasting at least 2-4 weeks 3.

Absence of clinical oral lesions on examination 3.

Negative results from relevant investigations (e.g., blood tests, imaging) to rule out other causes 3.

Symptoms not attributable to local factors such as ill-fitting dentures, nutritional deficiencies, or systemic diseases 3.

Required Tests:

Complete blood count (CBC) to rule out anemia 3.

Serum vitamin B12, iron, and zinc levels to identify deficiencies 1 3.

Thyroid function tests to exclude endocrine disorders 3.

Oral swab cultures to rule out infections 3.

Differential Diagnosis:

Oral candidiasis: Presence of visible white patches or pseudomembranes 3.

Oral lichen planus: Characteristic reticular or erosive lesions 3.

Medication-induced stomatitis: History of recent medication use 3.

Diabetes mellitus: Polyuria, polydipsia, and other systemic symptoms 3.

Management

First-Line Treatment

Pharmacological Approaches:

Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-150 mg/day) or tricyclic antidepressants like amitriptyline (10-30 mg/day) 1 3.

Alpha-lipoic acid: 600-1800 mg/day, administered in divided doses 1.

Non-Pharmacological Approaches:

Behavioral Therapies: Cognitive behavioral therapy (CBT) sessions aimed at stress management and coping strategies 4.

Oral Lubricants: Saliva substitutes or sialogogues (e.g., sugar-free gum) to alleviate xerostomia 3.

Monitoring:

Regular follow-up appointments to assess symptom response and adjust dosages as needed 3.

Monitoring for side effects of pharmacological treatments, particularly with antidepressants 3.

Second-Line Treatment

Considerations:

Analgesics: Short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800 mg/day) for pain relief 3.

Vitamin Supplementation: If deficiencies are identified, specific supplementation under medical supervision 1 3.

Monitoring:

Evaluate effectiveness and adjust based on symptom improvement and patient tolerance 3.

Refractory Cases

Specialist Referral:

Pain Management Specialist: For advanced pain management strategies 3.

Psychologist: For intensive psychological support and therapy 4.

Considerations:

Evaluate for underlying psychiatric conditions requiring targeted interventions 3.

Complications

Acute Complications

Psychological Distress: Increased anxiety and depression 2.

Malnutrition: Due to altered eating habits 2.

Long-Term Complications

Chronic Pain: Persistent symptoms leading to reduced quality of life 2.

Impact on Daily Function: Difficulty in speaking, eating, and social interactions 2.

Management Triggers:

Persistent lack of symptom relief may necessitate escalation to specialist care 3.

Prognosis & Follow-up

The prognosis for BMS varies widely among individuals, with some experiencing significant improvement with appropriate management while others may have chronic symptoms 3. Prognostic indicators include the presence of psychological comorbidities and response to initial treatment strategies 2. Recommended follow-up intervals typically involve:

Initial Follow-Up: Within 4-6 weeks post-diagnosis to assess initial treatment response 3.

Subsequent Follow-Ups: Every 3-6 months to monitor symptom progression and adjust management plans accordingly 3.

Special Populations

Elderly

Increased Susceptibility: Higher prevalence and more complex comorbidities 3.

Management Considerations: Careful monitoring of polypharmacy and potential drug interactions 3.

Psychological Factors

Anxiety and Depression: Common comorbidities requiring integrated mental health support 2 3.

Key Recommendations

Exclude Underlying Causes through comprehensive clinical evaluation and relevant laboratory tests (Evidence: Strong 3).

Initiate First-Line Therapy with antidepressants (e.g., sertraline 50-150 mg/day) or alpha-lipoic acid (600-1800 mg/day) (Evidence: Moderate 1 3).

Consider Cognitive Behavioral Therapy for patients with significant psychological distress (Evidence: Moderate 4).

Monitor for Side Effects of pharmacological treatments, particularly antidepressants (Evidence: Strong 3).

Evaluate for Nutritional Deficiencies and address with appropriate supplementation (Evidence: Moderate 1 3).

Refer to Specialists for refractory cases involving pain management or psychological support (Evidence: Expert opinion 3).

Regular Follow-Up appointments every 3-6 months to reassess symptoms and adjust treatment plans (Evidence: Moderate 3).

Address Psychological Comorbidities aggressively, as they significantly impact prognosis (Evidence: Moderate 2 3).

Use Saliva Substitutes to alleviate symptoms of xerostomia (Evidence: Moderate 3).

Consider Analgesics as short-term adjuncts for pain relief (Evidence: Weak 3).

References

1 de Souza IF, Mármora BC, Rados PV, Visioli F. Treatment modalities for burning mouth syndrome: a systematic review. Clinical oral investigations 2018. link 2 Forssell H, Teerijoki-Oksa T, Kotiranta U, Kantola R, Bäck M, Vuorjoki-Ranta TR et al.. Pain and pain behavior in burning mouth syndrome: a pain diary study. Journal of orofacial pain 2012. link 3 Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome. The Cochrane database of systematic reviews 2005. link 4 Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome: a systematic review. Journal of orofacial pain 2003. link 5 Zakrzewska JM, Glenny AM, Forssell H. Interventions for the treatment of burning mouth syndrome. The Cochrane database of systematic reviews 2001. link 6 Lowry RK, Noone RB. Fires and burns during plastic surgery. Annals of plastic surgery 2001. link

Burn of oral cavity