burning mouth syndrome

Question 1

what is the definition of BMS?

Answer 1

> An intraoral burning or dysaesthetic sensation, recurring daily for more than two hours per day over more than three months without clinically evident causative lesions

> pain is burning and is felt superficially in the oral mucosa

> clinical examination and sensory testing is normal

Question 2

how common is BMS?

Answer 2

> 0.7-18%

> incidence increases with age

Question 3

is burning mouth syndrome more common in men or women?

Answer 3

> 7F : M

> especially menopausal woman and patients with thyroid conditions

Question 4

what is the epidemiology behind BMS?

Answer 4

> spontaneous burning/ scalding sensation - can vary throughout the day

> poorly localised

> usually bilateral

> intermittent or continuous - can vary

> varies in intensity

> night wakening uncommon

Question 5

what location is burning mouth syndrome found?

Answer 5

> tongue

> lips

> palate

> buccal mucosa

> sometimes the entire oral mucosa

Question 6

what associated symptoms do some patients present with in BMS?

Answer 6

> hyperpathia - high response to low receptive stimuli

> alladinia - pain caused by a non painful stimulus

> taste disturbance

> dry mouth

Question 7

what are the excerbating symptoms that patients with BMS report?

Answer 7

> cold

> light touch

> emotional stress

> acidic foods

> spicy foods

Question 8

what is the most common sites affected by BMS?

Answer 8

1. dorsal aspect of the tongue
2. palate
3. lips
4. pharynx (bilateral)

Question 9

how do the vast majority of patients describe their BMS?

Answer 9

> onset - gradual

> character - burning, tingling, abnormal tactile sensation

> radiation - nil

> associated symptoms - xerostomia, sensation, taste

Question 10

what are the clinical features of BMS?

Answer 10

> approx. 2/3 report with altered taste (dysgeusia)

> 25% report with dry mouth

> some patients present with altered sensations (paraesthesia)

Question 11

what are the relieving factors of BMS?

Answer 11

> eating relieves symptoms

> sets it aside from geographic tongue

Question 12

what is type 1 BMS?

Answer 12

> Type 1 - pain comes on as day goes on, unremitting pain

Question 13

what is type 2 BMS?

Answer 13

> type 2 - pain on waking and throughout the day

> could be linked to chronic anxiety

> most challenging and often resistant to treatment

Question 14

what is type 3 BMS?

Answer 14

> type 3 - no regular pattern of pain, at atypical sites

> FOM or Buccal mucosa

> . evidence suggests maybe allergies causes these symptoms in patients

Question 15

what Is the cause of BMS?

Answer 15

> not fully understood

> most likely multifactorial

> Increasing evidence for a neuropathic origin

> Three hypothesis:

1. Peripheral small fibre sensory neuropathy

2. Subclinical mandibular, lingual or trigeminal neuropathy

3. Hypofunction of dopaminergic neurones (effects both mood and stress)

Question 16

what investigations would you take if a patient presents with BMS? (to exclude other symptoms)

Answer 16

> FBC (anemia)

> haematinics (iron, b12, folate)

> Glucose (blood sugar control)

> thyroid function tests

> antibody screen

> swab/ smear

> salivary flow

> psychological assessment

> patch testing

> biopsy isn’t indicated

Question 17

when carrying out a physical examination on a patient with BMS what are you looking out for? (to exclude other symptoms)

Answer 17

> massester hyperfunction

> tooth clenching

> tongue scalloping

> linea alba

> soft tissues - ulcerations, erythemia, xerostomia, denture?

Question 18

what are the local factors which could cause oral burning?

Answer 18

> dry mouth

> infections

> oral mucosal lesions

> parafunctional habits

> poor denture design

> allergic reactions

Question 19

what systemic factors could cause oral burning?

Answer 19

> blood disorders

> autoimmune disorders

> GORD

> endocrine disorders

> medication

> CNS changes

Question 20

what are the 3 main treatment categories for BMS?

Answer 20

> topical therapy

> systemic therapy

> behavioural strategies

Question 21

what topical therapy are on offer for BMS?

Answer 21

> Benzodiazepines - eg topical clonazepam (crush tablet and hold in area for 5mins)

> capsaicin - mouth rinse

> analgesics - eg difflam (mouth rinse or spray)

> laser therapy - eg low level laser therapy

Question 22

what systemic therapies are on offer for BMS?

Answer 22

> tricyclic antidepressants - eg amitriptyline/ nortriptyline

> benzodiazepines - eg clonazepam

> anticonvulsants - eg gabapentin

> food supplements - eg alpha lipoic acid

Question 23

what behavioural strategies are on offer for BMS?

Answer 23

> CBT

> Evidence based treatment

> Psychological treatment

> Biofeedback, relaxation, exposure, cognitive restructuring

Question 24

what is the prognosis for BMS?

Answer 24

> The average duration of BMS is 2 to 3 years

> Approximately 30% to 50% of patients improve spontaneously and may have complete resolution of their clinical manifestations over many years.

> 3% of the patients had a complete spontaneous clinical remission within 5 years after the onset of clinical manifestations.

> A moderate improvement was observed in 30% of the participants, with or without treatment

> In patients with a history of psychiatric illness, such as anxiety and depression, a multidisciplinary approach is needed