Burning mouth in oncology care: a systematic review

Burning mouth, also referred to as oral dysesthesia, is an underreported condition among cancer patients that may represent an early symptom of cancer or an adverse effect of treatment. This review sought to characterize this symptom in oncology care where burning symptoms may occur. A systematic review of the literature was performed based on the PRISMA statement, and the protocol was registered at PROSPERO database. A structured search was done using eight databases. The process of study selection was conducted in two distinct phases. The JBI Critical Appraisal Tools were utilized to evaluate the risk of bias in the studies included. Of the total number of studies assessed, sixteen met the eligibility criteria. Of these studies included, 7 were case reports, 7 cross-sectional studies, and 2 non-randomized clinical trials. Most studies presented low risk of bias (n = 9), while the remaining studies were evaluated and scored as moderate (n = 5) or high (n = 2) risk of bias. Burning mouth was reported as a first symptom of cancer in three studies, and as an adverse event of radiotherapy (n = 2), chemoradiotherapy (n = 2), and chemotherapy (n = 9). Burning mouth was a first symptom in 0.62% of oral squamous cell carcinoma (OSCC), and 3.3% of patients with pain as chief complaint. Oral dysesthesia prevalence was 13.6% in patients experiencing chemotherapy-induced oral adverse events. The symptom of burning mouth should be examined in oncology care, as it may be underreported and therefore undertreated. New therapies may be related to a higher risk of oral burning and studies assessing approach to management are needed. Current management borrows from the current management of burning mouth in the non-cancer setting.

Oral dysaesthesia: a special focus on aetiopathogenesis, clinical diagnostics and treatment modalities

Oral dysaesthesia is a condition characterised by persistent alteration to oral sensation, perceived by the patient to be abnormal and/or unpleasant, in the absence of any mucosal pathology. The condition can be difficult to detect and diagnose. A possible peripheral or central neuropathic aetiology has been proposed. Burning mouth syndrome (BMS) is the most common idiopathic oral dysesthesia in which long-term suffering is often reported by patients. Recent efforts from professional organisations and study groups have provided a consensus on BMS disease definition and diagnostic criteria. Large-scale epidemiological studies are required to provide an accurate estimate for prevalence and incidence of the condition. Meticulous diagnostic investigations which may require interdisciplinary teamwork are often warranted to reach an accurate diagnosis. A combination of interventional modalities, with a holistic approach, is key for successful management and improvement in patients' quality of life.

Management of Burning Mouth Syndrome

This article provides an update for the practicing dentist and/or oral and maxillofacial surgeon on the recognition, identification, and treatment of burning mouth syndrome (BMS). We discuss the most common clinical findings and most common causes of BMS. This article provides a classification flowchart that assists the practitioner in diagnosing and classifying BMS. The article then discusses the pathophysiology and treatment of BMS updated in the literature from the latest studies and reviews. Treatment can vary from topical or systemic medication to behavioral therapy.

Burning mouth syndrome and pelvodynia: A literature review

Burning mouth syndrome (BMS) and pelvodynia are chronic pain still poorly understood and the links between them are all the more so. Health professionals therefore have few resources to understand, diagnose and treat these pains. They may consider and treat these ailments individually, which does not represent optimal care management for the patient and leads to overmedication. This article aims to highlight their contiguity from epidemiological, etiological, diagnostic, and therapeutic perspectives. This study was based on articles which were found using databases such as PubMed and Web of Science. No exclusion criteria were used. Fourteen studies were reviewed. This present work shows that the clinical presentations of these syndromes are similar, as exemplified by their strong association with anxiety and depression. The neurophysiological mechanisms involved in these conditions are similar to those in patients. The diagnosis is essentially based on visual examination and an elimination of all other possible causes. In addition, this work promotes the fact that a common therapy can be implemented when BMS and pelvodynia co-occur. However, the literature on the subject is still very limited. This can be deepened by exploring all the effective treatments in BMS and vulvodynia for penoscrotodynia. Finally, for all these pains, there is a therapeutic order to respect starting with a psychological approach, then topical treatments, systemic therapy and surgical. This therapeutic gradient assists practitioner in their patient's pain management. This article also allows health care providers to quickly find an effective systemic treatment for a patient with both BMS and pelvodynia.

Long-term prognosis of burning mouth syndrome following treatment

The purpose of this study was to evaluate the long-term prognosis of patients with burning mouth syndrome (BMS) after the termination or discontinuation of treatment and to identify the clinical characteristics that might affect that prognosis. Of 769 patients with an oral burning sensation, 202 with primary BMS who had been treated for at least 3 months were included. Among them, 28 patients who responded to the treatment and 25 patients who did not were assigned to responder and non-responder groups, respectively. Based on telephone interviews, the responders were classified into relapse and non-relapse subgroups, and the non-responder group into persistence and remission subgroups. The majority of responders reported no oral discomfort since their last visit. Compared with the non-relapse subgroup, the relapse subgroup had significantly higher levels of xerostomia at the first visit (P = 0.026) and taste disturbance at the last visit (P = 0.015). The majority of non-responders reported persistent oral discomfort since their last visit. No significant differences were found in the characteristics of oral symptoms between the persistence and remission subgroups. In conclusion, the treatment outcomes in the majority of responders and non-responders were maintained following treatment. Xerostomia and taste disturbance were associated with relapse of oral discomfort in the responders.

Effectiveness of Nonpharmacologic Treatments of Burning Mouth Syndrome: A Systematic Review

AIMS

To assess the efficacy of nonpharmacologic treatments for burning mouth syndrome (BMS).

METHODS

PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were systematically searched. Reference lists from the latest systematic reviews (2015 to 2020) on BMS treatment in the PubMed, Scopus, Web of Science, and Cochrane Library databases were also scrutinized. Randomized controlled trials (RCTs) or clinical controlled trials (CCTs) in English were considered eligible. Trials on photobiomodulation were excluded to avoid redundancy with recent publications. Risk of bias was established through the Cochrane Risk of Bias tool for RCTs and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool for CCTs.

RESULTS

This review included 27 RCTs and 6 open clinical trials (OCTs) describing 14 different nonpharmacologic interventions. Eleven trials experimented with 600 to 800 mg/day of alpha-lipoic acid for 30 to 120 days, with 7 placebo-controlled studies showing significant pain relief. Four trials tested topical and systemic capsaicin for 7 to 30 days, with 2 placebo-controlled studies revealing significant efficacy. Four of the 5 trials testing acupuncture offered favorable evidence of pain relief. Two trials reported significant pain relief after a 2- to 3-month regimen with tongue protectors and showed no difference after aloe vera addition. Short-term pain relief was reported in anecdotal placebo-controlled trials deploying tocopherol, catuama, ultramicronized palmitoylethanolamide, group psychotherapy, cognitive therapy, and repetitive transcranial magnetic stimulation of the prefrontal cortex. Most therapies were safe.

CONCLUSION

Evidence was collected from highly biased, short-term, heterogenous studies mainly focused on BMS-related pain, with scarce data on quality of life, psychologic status, dysgeusia, and xerostomia. Long-term effectiveness of nonpharmacologic treatments should be further investigated, with a more rigorous, bias-proof study design.

Prevalence and Features of Laryngopharyngeal Reflux in Patients with Primary Burning Mouth Syndrome

OBJECTIVES/HYPOTHESIS

To investigate the prevalence and features of laryngopharyngeal reflux (LPR) in patients with primary burning mouth syndrome (BMS).

STUDY DESIGN

Prospective uncontrolled study.

METHODS

Patients who visited our Departments of Otolaryngology-Head and Neck and Maxillofacial surgery with BMS were prospectively recruited from September 2018 to September 2020. Patients benefited from dental, maxillofacial, otolaryngological examinations, and hypopharyngeal-esophageal impedance pH-monitoring (HEMII-pH). Oral, pharyngeal, and laryngeal findings and symptoms were rated with Reflux Sign Assessment (RSA) and Reflux Symptom Score-12 (RSS-12). Patients were treated with a combination of diet, pantoprazole, and alginate.

RESULTS

From the 81 included patients, 76 reported >1 pharyngeal reflux events (93.8%), accounting for 35 (46.1%), 24 (31.6%), and 17 (22.3%) acid, mixed, and nonacid LPR, respectively. Thirty-two patients had both LPR and gastroesophageal reflux disease (GERD). Thirty-eight patients benefited from pepsin saliva measurement, which was positive in 86.8% of cases. The mean scores of mouth/tongue burning, RSS-12, and RSA significantly improved from pre- to post-treatment (P < .004). At 3-month post-treatment, 62.5% of patients reported an improvement of mouth/tongue burning score. Patients with both GERD and LPR reported higher baseline RSS-12 and RSA scores.

CONCLUSION

Acid, weakly acid, and nonacid LPR may be involved in the development of BMS. The use of an appropriate treatment considering the reflux features is associated with an improvement of symptoms and findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Usefulness of Psychiatric Intervention in a Joint Consultation for the Treatment of Burning Mouth Syndrome: A Monocentric Retrospective Study

Primary burning mouth syndrome is a term used for chronic oral mucosal pain with no identifiable organic cause. The aim of the study was to evaluate the usefulness of a psychiatric intervention for treating burning mouth syndrome based on a joint consultation with a psychiatrist and a dermatologist. The study was proposed to all patients who visited this consultation group between 2001 and 2017 for the treatment of primary burning mouth syndrome. The patients answered a questionnaire that was administered via mail. Of the 57 patients diagnosed with primary burning mouth syndrome, 38 were included. Seven patients (18.4%) no longer had pain; 8 (21.1%) estimated that the pain had decreased by greater than 50%; 11 (28.9%) estimated the decrease at between 30 and 50%, and 12 (31.6%) estimated a less than 30% decrease. Only 14 patients (36.8%) remained under treatment with antidepressants, as compared to 63.2% before the psychiatric intervention. This psychiatric intervention could be considered a valuable tool in the global burning mouth syndrome treatment strategy.

Burning mouth syndrome: a review of etiology, diagnosis, and management

Burning mouth syndrome (BMS) is a chronic condition characterized by a burning sensation of the oral cavity and is often associated with taste disturbances and xerostomia. It primarily affects menopausal or postmenopausal women. Idiopathic or primary BMS can occur spontaneously and without any identifiable precipitating factors. When BMS is associated with systemic factors, it is defined as secondary BMS. While the exact etiology of BMS is still unknown, the condition appears to be multifactorial, and numerous local, systemic, and psychological factors have been associated with it. Primary BMS is a diagnosis of exclusion and can only be reached after all potential causes of secondary burning pain have been eliminated. Management strategies include reassurance of the patient as well as pharmacologic agents such as clonazepam, supplements such as α-lipoic acid, and psychological therapy.

Understanding of Burning Mouth Syndrome Based on Psychological Aspects

Burning mouth syndrome (BMS) is a chronic pain condition characterised by a persistent burning sensation in clinically normal oral mucosa. BMS most commonly occurs in middleaged and elderly women. Various local and systemic factors can cause oral burning symptoms. When all possible local and systemic factors are excluded, burning mouth symptoms can be diagnosed as BMS. Psychophysical tests and histopathological data suggest the involvement of peripheral and central neuropathic mechanisms in BMS etiopathogenesis. Psychological problems are frequently observed in BMS patients. Several mechanisms, including increased parafunctional habits, steroid dysregulation, central disinhibition due to taste dysfunction, and low dopamine levels in the brain, have been proposed as an explanation for the role of psychological factors in BMS pathophysiology. However, the causal relationship between BMS and psychological problems remains controversial. Given the neuropathic nature of BMS, treatment for it is similar to other neuropathic pain conditions. Although various treatment modalities, including pharmacological intervention, behavioural therapy and psychotherapy, have been proposed, there is no definitive treatment always effective for the majority of BMS patients. In conclusion, for better understanding of the relationship between BMS and psychological factors, well-designed prospective studies are needed. In addition, the evaluation and treatment of psychological problems are essential for successful management of BMS patients.

A diagnostic and therapeutic approach to primary burning mouth syndrome

Primary burning mouth syndrome (BMS) is an oral mucosal disorder that is characterized by a chronic and often debilitating intraoral burning sensation for which no localized or systemic cause can be found. BMS most commonly affects postmenopausal women. The pathophysiology of primary BMS is not well understood. Diagnosing BMS can prove to be challenging. BMS patients can also pose a therapeutic challenge to clinicians who are consulted to evaluate these patients. Most commonly used therapies include tricyclic antidepressants, α-lipoic acid, clonazepam, and cognitive-behavioral therapy. Clinical judgment, patient counseling, and monitoring of pain are important. Further research is required to assess the effectiveness of serotonin and newer serotonin-noradrenalin reuptake inhibitors.

Interventions for treating burning mouth syndrome

BACKGROUND

Burning mouth syndrome (BMS) is a term used for oral mucosal pain (burning pain or discomfort in the tongue, lips or entire oral cavity) without identifiable cause. General population prevalence varies from 0.1% to 3.9%. Many BMS patients indicate anxiety, depression, personality disorders and impaired quality of life (QoL). This review updates the previous versions published in 2000 and 2005.

OBJECTIVES

To determine the effectiveness and safety of any intervention versus placebo for symptom relief and changes in QoL, taste, and feeling of dryness in people with BMS.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 December 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11) in the Cochrane Library (searched 31 December 2015), MEDLINE Ovid (1946 to 31 December 2015), and Embase Ovid (1980 to 31 December 2015). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any treatment against placebo in people with BMS. The primary outcomes were symptom relief (pain/burning) and change in QoL. Secondary outcomes included change in taste, feeling of dryness, and adverse effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcome data were analysed as short-term (up to three months) or long-term (three to six months).

MAIN RESULTS

We included 23 RCTs (1121 analysed participants; 83% female). Interventions were categorised as: antidepressants and antipsychotics, anticonvulsants, benzodiazepines, cholinergics, dietary supplements, electromagnetic radiation, physical barriers, psychological therapies, and topical treatments.Only one RCT was assessed at low risk of bias overall, four RCTs' risk of bias was unclear, and 18 studies were at high risk of bias. Overall quality of the evidence for effectiveness was very low for all interventions and all outcomes.Twenty-one RCTs assessed short-term symptom relief. There is very low-quality evidence of benefit from electromagnetic radiation (one RCT, 58 participants), topical benzodiazepines (two RCTs, 111 participants), physical barriers (one RCT, 50 participants), and anticonvulsants (one RCT, 100 participants). We found insufficient/contradictory evidence regarding the effectiveness of antidepressants, cholinergics, systemic benzodiazepines, dietary supplements or topical treatments. No RCT assessing psychological therapies evaluated short-term symptom relief.Four studies assessed long-term symptom relief. There is very low-quality evidence of a benefit from psychological therapies (one RCT, 30 participants), capsaicin oral rinse (topical treatment) (one RCT, 18 participants), and topical benzodiazepines (one RCT, 66 participants). We found no evidence of a difference for dietary supplements or lactoperoxidase oral rinse. No studies assessing antidepressants, anticonvulsants, cholinergics, electromagnetic radiation or physical barriers evaluated long-term symptom relief.Short-term change in QoL was assessed by seven studies (none long-term).The quality of evidence was very low. A benefit was found for electromagnetic radiation (one RCT, 58 participants), however findings were inconclusive for antidepressants, benzodiazepines, dietary supplements and physical barriers.Secondary outcomes (change in taste and feeling of dryness) were only assessed short-term, and the findings for both were also inconclusive.With regard to adverse effects, there is very low-quality evidence that antidepressants increase dizziness and drowsiness (one RCT, 37 participants), and that alpha lipoic acid increased headache (two RCTs, 118 participants) and gastrointestinal complaints (3 RCTs, 138 participants). We found insufficient/contradictory evidence regarding adverse events for anticonvulsants or benzodiazepines. Adverse events were poorly reported or unreported for cholinergics, electromagnetic radiation, and psychological therapies. No adverse events occurred from physical barriers or topical therapy use.

AUTHORS' CONCLUSIONS

Given BMS' potentially disabling nature, the need to identify effective modes of treatment for sufferers is vital. Due to the limited number of clinical trials at low risk of bias, there is insufficient evidence to support or refute the use of any interventions in managing BMS. Further clinical trials, with improved methodology and standardised outcome sets are required in order to establish which treatments are effective. Future studies are encouraged to assess the role of treatments used in other neuropathic pain conditions and psychological therapies in the treatment of BMS.

[BURNING MOUTH SYNDROME - A FLAME HARD TO EXTINGUISH]

Burning mouth syndrome (BMS) is a common condition that mostly affects elderly women. This symptom presents as a severe chronic burning sensation affecting the oral cavity and especially the dorsum of the tongue and its lateral aspects. Mouth burning sensation can result from an idiopathic primary condition or evolve from a secondary problem. The difficulty in reaching a correct diagnosis and especially to determining an appropriate treatment leads to considerable dissatisfaction among patients. In this paper we review the causes and the characteristics of the primary and secondary forms of the syndrome, the means of diagnosis and known treatment options.

The practical evaluation and management of patients with symptoms of a sore burning mouth

There are many etiologic factors to consider in a patient who presents with symptoms or sensations of a sore burning mouth. These range from local causes within the oral cavity to underlying systemic disease, including psychologic factors. This paper aims to describe the different clinical presentations and to outline a systematic approach to the evaluation and management of such patients. The clinician will be directed to the relevant diagnosis by following the traditional medical model of taking a focused history, performing a thorough clinical examination, considering the potential differential diagnoses, and requesting pertinent and appropriate investigations. The various differential diagnoses and broad treatment options will also be discussed and outlined. This paper will not, however, discuss burning mouth syndrome (oral dysesthesia), which is a diagnosis of exclusion, whereby the oral mucosa is clinically normal and there are no identifiable medical or dental causes to account for the patient's symptoms.

Burning Mouth Syndrome and "Burning Mouth Syndrome"

Burning mouth syndrome is distressing to both the patient and practitioner unable to determine the cause of the patient's symptoms. Burning mouth syndrome is a diagnosis of exclusion, which is used only after nutritional deficiencies, mucosal disease, fungal infections, hormonal disturbances and contact stomatitis have been ruled out. This article will explore the many causes and treatment of patients who present with a chief complaint of "my mouth burns," including symptomatic treatment for those with burning mouth syndrome.

[Burning mouth syndrome - a joint biopsychosocial approach]

Burning mouth syndrome (BMS) is a medical condition that is often refractory to conventional diagnostic and therapeutic methods. Patients suffering from BMS can benefit from a biopsychosocial approach in a joint, medical-psychological consultation model. Such a consultation exists at Geneva University Hospitals, involving the collaboration of the maxillo-facial and oral surgery division and the division of liaison psychiatry and crisis intervention, in order to take into account the multiple factors involved in BMS onset and persistence. This article will describe BMS clinical presentation, and present an integrate approach to treat these patients.

Burning Mouth Syndrome: A Review of the Etiopathologic Factors and Management

Burning mouth syndrome (BMS) is characterized by pain in the mouth with or with no inflammatory signs and no specific lesions. Synonyms found in literature include glossodynia, oral dysesthesia, glossopyrosis, glossalgia, stomatopyrosis, and stomatodynia. Burning mouth syndrome generally presents as a triad: Mouth pain, alteration in taste, and altered salivation, in the absence of visible mucosal lesions in the mouth. The syndrome generally manifests spontaneously, and the discomfort is typically of a continuous nature but increases in intensity during evening and at night. The etiopathogenesis seems to be complex and in a large number of patients probably involves interactions among local, systemic, and/or psychogenic factors. The differential diagnosis requires the exclusion of oral mucosal lesions or blood test alterations that can produce burning mouth sensation. Management is always based on the etiological agents involved. If burning persists after local or systemic conditions are treated, then treatment is aimed at controlling neuropathic symptoms. Treatment of BMS is still unsatisfactory, and there is no definitive cure. As a result, a multidisciplinary approach is required to bring the condition under better control. The aim of this review was to discuss several aspects of BMS, update current knowledge, and provide guidelines for patient management.

Burning mouth syndrome

INTRODUCTION

Burning mouth syndrome mainly affects women, particularly after the menopause, when its prevalence may be 18% to 33%.

METHODS AND OUTCOMES

We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of selected treatments for burning mouth syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2015 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview).

RESULTS

At this update, searching of electronic databases retrieved 70 studies. After deduplication and removal of conference abstracts, 45 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 25 studies and the further review of 20 full publications. Of the 20 full articles evaluated, one systematic review and nine RCTs were added at this update. We performed a GRADE evaluation for five PICO combinations.

CONCLUSIONS

In this systematic overview, we categorised the efficacy for six interventions based on information about the effectiveness and safety of alphalipoic acid, benzodiazepines, benzydamine hydrochloride, cognitive behavioural therapy (CBT), selective serotonin re-uptake inhibitors (SSRIs), and tricyclic antidepressants.

An overview of burning mouth syndrome

Burning mouth syndrome (BMS) is characterised by the presence of a burning sensation in the oral mucosa in the absence of any clinically apparent mucosal sign. It occurs more commonly in older women and often affects the tongue tip and lateral borders, lips, and hard and soft palates. Besides the burning sensation, patients with BMS may complain of unremitting oral mucosal pain, dysgeusia, and xerostomia. The exact pathophysiology of primary BMS remains unknown. A major challenge for the clinician is the treatment of BMS: identifying possible causative factors is the first step, but BMS is often idiopathic. Drug therapy, in addition to behavioural therapy and psychotherapy, may help to eliminate the symptoms. Considering the growing incidence of BMS in older people, further research is required to determine the true efficacy of current management strategies for patients with this disorder.

Efficacy of low-level laser therapy for the treatment of burning mouth syndrome: a randomized, controlled trial

The aim of the present study was to assess the effect of low-level laser therapy (LLLT) in the treatment of burning mouth syndrome (BMS). A diode laser was used in 78 BMS patients who were randomly assigned into four groups: IR1W, n = 20 (830 nm, 100 mW, 5 J, 176 J/cm2, 50 s, LLLT weekly sessions, 10 sessions); IR3W, n = 20 (830 nm, 100 mW, 5 J, 176 J/cm2, 50 s, three LLLT weekly sessions, 9 sessions); red laser, n = 19 (685 nm, 35 mW, 2 J, 72 J/cm2, 58 s, three LLLT weekly sessions, 9 sessions); and control-group (CG), n = 19. Symptoms were assessed at the end of the treatment and eight weeks later; quality of life related to oral health was assessed using the Oral Health Impact Profile (OHIP-14). Statistical analysis was carried out using repeated measures analysis of variance followed by the posthoc Tukey test. There was significant reduction of the symptoms in all groups at the end of the treatment, which was maintained in the follow-up. The scores of the IR1W and IR3W laser groups differed significantly from those of the CG. There was also a decrease in the OHIP-14 scores in the four groups. The IR3W laser group scores differed significantly from those of the CG. LLLT reduces the symptoms of BMS and may be an alternative therapeutic strategy for the relief of symptoms in patients with BMS.

Burning mouth syndrome: a review and update

Burning mouth syndrome (BMS) is mainly found in middle aged or elderly women and is characterized by intense burning or itching sensation of the tongue or other regions of the oral mucosa. It can be accompanied by xerostomia and dysgeusia. The syndrome generally manifests spontaneously, and the discomfort is typically of a continuous nature but increases in intensity during the evening and at night. Although BMS classically has been attributed to a range of factors, in recent years evidence has been obtained relating it peripheral (sensory C and/or trigeminal nerve fibers) or central neuropathic disturbances (involving the nigrostriatal dopaminergic system). The differential diagnosis requires the exclusion of oral mucosal lesions or blood test alterations that can produce burning mouth sensation. Patient management is based on the avoidance of causes of oral irritation and the provision of psychological support. Drug treatment for burning sensation in primary BMS of peripheral origin can consist of topical clonazepam, while central type BMS appears to improve with the use of antidepressants such as duloxetine, antiseizure drugs such as gabapentin, or amisulpride.