Burning mouth syndrome

Innovative histological and histochemical characterization of tongue biopsies from patients with burning mouth syndrome

OBJECTIVES

The present pilot study aims to perform an innovative histological and histochemical characterization of samples from patients with burning mouth syndrome (BMS) to correlate these findings with the clinical scenario.

METHODS

To carry out this objective, the study samples were stained with the hematoxylin-eosin stain and later, an histochemical study was carried out to determine the composition of the extracellular matrix (ECM) using the stains of Alcian Blue, Picrosirius, Reticulin from Gomori and Verhoeff.

RESULTS

The results of this study revealed histological patterns compatible with cellular hypertrophy in different layers of the epithelium as well as a greater keratinization in BMS cases. On the other hand, a lower amount of proteoglycans and a greater amount of collagen fibers were observed compared to the control. In addition, older patients had fewer reticular fibers and younger patients had fewer elastic fibers compared to the control.

CONCLUSIONS

In conclusion, the present study shows the existence of a correlation between the histological patterns, age and symptoms of patients with BMS. Therefore, it is necessary to develop synergistic studies in order to assess and implement new classification systems that could improve the therapeutic approach of patients with BMS.

Burning Mouth Syndrome: Aetiopathogenesis and Principles of Management

Burning mouth syndrome (BMS) is a chronic debilitating oral condition characterised by a burning sensation of the oral mucosa in an otherwise apparently normal person. Its aetiology and pathogenesis are obscure, but both psychogenic factors and peripheral and central neuropathies appear to be implicated. There is no cure for BMS, and treatment with either local or systemic medications focuses on the relief of symptoms and on improving quality of life. In recalcitrant cases, psychological/psychiatric intervention may be helpful. In order to improve treatment outcomes, a better understanding of the pathogenesis of this syndrome might provide a basis for the development of more effective management strategies. In this short review, we discuss current knowledge of the diagnosis, aetiopathogenesis, and management of BMS.

A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.

Five Patients With Burning Mouth Syndrome in Whom an Antidepressant (Serotonin-Noradrenaline Reuptake Inhibitor) Was Not Effective, but Pregabalin Markedly Relieved Pain

Burning mouth syndrome (BMS) causes idiopathic pain or a burning sensation in clinically normal oral mucosa. Burning mouth syndrome is a chronic disease with an unknown etiology. Burning mouth syndrome is also idiopathic, and a consensus regarding diagnosis/treatment has not been reached yet. Recent studies have supported the suggestion that BMS is a neuropathic pain disorder in which both the peripheral and central nervous systems are involved. Tricyclic antidepressants (nortriptyline and amitriptyline), serotonin-noradrenaline reuptake inhibitors (SNRIs) (duloxetine and milnacipran), and antiepileptic drugs, potential-dependent calcium channel α2δ subunit ligands (gabapentine and pregabalin), are currently recommended as the first-choice drugs for neuropathic pain. In this study, we report 5 patients with BMS in whom there was no response to SNRI (milnacipran or duloxetine), or administration was discontinued because of adverse reactions, but in whom pregabalin therapy markedly reduced or led to the disappearance of pain in a short period. Pregabalin, whose mechanism of action differs from that of SNRIs, may become a treatment option for BMS patients who are not responsive to or are resistant to SNRIs.

Burning mouth syndrome: Clinical description, pathophysiological approach, and a new therapeutic option

INTRODUCTION

Burning mouth syndrome is defined as scorching sensation in the mouth in the absence of any local lesions or systemic disease that would explain that complaint. The condition responds poorly to commonly used treatments and it may become very disabling.

METHODS

We prospectively analysed the clinical and demographic characteristics and response to treatment in 6 cases of burning mouth syndrome, diagnosed at 2 tertiary hospital headache units.

RESULTS

Six female patients between the ages of 34 and 82 years reported symptoms compatible with burning mouth syndrome. In 5 of them, burning worsened at the end of the day; 4 reported symptom relief with tongue movements. Neurological examinations and laboratory findings were normal in all patients and their dental examinations revealed no buccal lesions. Each patient had previously received conventional treatments without amelioration. Pramipexol was initiated in doses between 0.36mg and 1.05mg per day, resulting in clear improvement of symptoms in all cases, a situation which continues after a 4-year follow up period.

CONCLUSIONS

Burning mouth syndrome is a condition of unknown aetiology that shares certain clinical patterns and treatment responses with restless leg syndrome. Dopamine agonists should be regarded as first line treatment for this entity.

Burning Mouth Syndrome

Burning mouth syndrome (BMS) is multifactorial in origin which is typically characterized by burning and painful sensation in an oral cavity demonstrating clinically normal mucosa. Although the cause of BMS is not known, a complex association of biological and psychological factors has been identified, suggesting the existence of a multifactorial etiology. As the symptom of oral burning is seen in various pathological conditions, it is essential for a clinician to be aware of how to differentiate between symptom of oral burning and BMS. An interdisciplinary and systematic approach is required for better patient management. The purpose of this study was to provide the practitioner with an understanding of the local, systemic, and psychosocial factors which may be responsible for oral burning associated with BMS, and review of treatment modalities, therefore providing a foundation for diagnosis and treatment of BMS.

Temperament and character profiles of patients with burning mouth syndrome

OBJECTIVE

Burning mouth syndrome (BMS) is a chronic disease in which patients feel a burning sensation and pain in the oral cavity. Although personality traits have been suggested to influence the development and course of BMS, they have not yet been examined in detail. We therefore investigated the personality traits of BMS patients.

METHODS

Sample consisted of 65 BMS patients presenting to the Aichi-Gakuin Dental School Hospital between May 2005 and April 2009. They were also diagnosed as having pain disorder by a psychiatrist. The control group consisted of 116 healthy subjects. The Temperament and Character Inventory (TCI) was used to evaluate personality traits, while the Beck Depression Inventory (BDI) was used to evaluate the depression rate in both groups.

RESULTS

In TCI, we found that, in comparison to the control group, the novelty seeking score was significantly lower (p = 0.009), the harm avoidance score was significantly higher (p < 0.001), and the self-directedness score was significantly lower (p = 0.039) in the BMS group. To remove the influence of depression, we performed an analysis of covariance of each TCI item using the BDI score as a covariate. No significant differences were observed in harm avoidance or self-directedness, whereas the differences noted in novelty seeking were significant (p = 0.008).

CONCLUSION

The novelty seeking score was low in BMS patients in comparison to the control group. They also had high harm avoidance and low self-directedness tendencies, but these were attributed to the influence of depression.

The association of openness personality trait with stress-related salivary biomarkers in burning mouth syndrome

BACKGROUND

Burning mouth syndrome (BMS) is a chronic disorder defined as a burning sensation in the oral mucosa without evidence of pathological findings. Its pathophysiology is largely unknown, but psychiatric disorders and personality traits have been implicated.

OBJECTIVE

This study investigated whether there is any association between salivary biomarkers and personality traits in BMS patients.

METHODS

It was a cross-sectional, controlled study that evaluated 30 individuals with BMS and 32 controls. All subjects were assessed with a structured psychiatric interview (Mini International Neuropsychiatric Interview) and the Big Five inventory. Salivary levels of brain-derived neurotrophic factor (BDNF), neural growth factor, tumor necrosis factor-α, interleukin (IL)-6, IL-10 and cortisol were determined.

RESULTS

We found that BMS patients exhibited more traits of neuroticism and lower openness than controls. Openness showed a moderate and negative correlation with cortisol, BDNF and IL-6.

CONCLUSION

Personality traits are associated with salivary biomarkers in BMS.

Psychiatric disorders in burning mouth syndrome

BACKGROUND

Prevalence of psychiatric disorders in burning mouth syndrome (BMS) is high, but their role in the pathogenesis of BMS remains unclear.

OBJECTIVE

The authors aimed to assess the frequency of psychiatric disorders and the severity of psychopathology in BMS.

METHODS

Thirty BMS patients and thirty-one controls underwent a psychiatric evaluation which included a structured interview (MINI-Plus) and five psychometric scales. A Visual Analogue Scale (VAS) was used to measure the intensity of burning sensation.

RESULTS

Patients with BMS showed a higher frequency of current major depressive disorder, past major depressive disorder, generalized anxiety disorder, hypochondria and cancerophobia (p<0.05). In BMS patients, generalized anxiety disorder was significantly associated with current major depression and social phobia (p<0.05). As expected, cancerophobia was significantly associated with hypochondria (p<0.05). Patients with BMS had higher scores in Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI) and Dutch Fatigue Scale (DUFS) (p<0.05).

CONCLUSION

BMS patients may have a particular psychological and/or psychiatric profile. Psychometric scales might be useful in screening psychiatric disorders, as well as for assessment of treatment outcomes. In the presence of clinical relevant psychiatric symptoms, patients must be treated appropriately.

The impact of burning mouth syndrome on health-related quality of life

BACKGROUND

Burning mouth syndrome is a chronic disorder that is characterized by a burning sensation and a normal clinical appearance of the oral mucosa. This condition often affects the health-related quality of life in patients. As such, the aim of this study was to compare the health-related quality of life of patients with BMS and healthy controls, using the validated Portuguese versions of the SF-36 and OHIP-49 questionnaires.

METHODS

A calculated sample of Brazilian patients with BMS (n = 26) was compared with a control group (n = 27), paired for gender and age. Sociodemographic information and clinical characteristics were obtained, and interviews were conducted using the SF-36 and OHIP-49. To evaluate the normality of the variables, we used the Kolmogorov-Smirnov test. The chi-square test, Fisher exact test and Mann-Whitney U-Test were used to compare sociodemographic and clinical characteristics of individuals with BMS and controls Mann-Whitney U-test were carried out to compare SF-36 and OHIP-49 between BMS patients and controls. The significance level was set at 0.05. To compare the dimensions of the SF-36 and OHIP-49 between BMS patients and controls, we considered Bonferroni correction. So for comparison of the dimensions, the significance level was set at 0.00625 for SF-36 and at 0.00714 for OHIP-49.

RESULTS

The clinical and demographic data were similar in both groups (P > 0.05). SF-36 scores were significantly lower in all domains for patients with BMS (P < 0.00625). OHIP-49 scores were higher for individuals with BMS (P < 0.00714).

CONCLUSIONS

BMS has a negative impact on the health-related quality of life of individuals, as can be shown by instruments such as the SF-36 and OHIP-49. So, the evaluation of quality of life might be useful for more information about the nature and severity of BMS, to evaluate the effects of treatment protocols, in order to improve their outcomes by means a humanized clinical practice.

Psychiatric diagnoses in patients with burning mouth syndrome and atypical odontalgia referred from psychiatric to dental facilities

BACKGROUND

Burning mouth syndrome (BMS) and atypical odontalgia (AO) are two conditions involving chronic oral pain in the absence of any organic cause. Psychiatrically they can both be considered as "somatoform disorder". From the dental point of view, however, the two disorders are quite distinct. BMS is a burning or stinging sensation in the mouth in association with a normal mucosa whereas AO is most frequently associated with a continuous pain in the teeth or in a tooth socket after extraction in the absence of any identifiable cause. Because of the absence of organic causes, BMS and AO are often regarded as psychogenic conditions, although the relationship between oral pain and psychologic factors is still unclear. Some studies have analyzed the psychiatric diagnoses of patients with chronic oral pain who have been referred from dental facilities to psychiatric facilities. No study to date has investigated patients referred from psychiatric facilities to dental facilities.

OBJECTIVE

To analyze the psychiatric diagnoses of chronic oral pain patients, diagnosed with BMS and AO, and referred from psychiatric facilities to dental facilities.

STUDY DESIGN

Psychiatric diagnoses and disease conditions of BMS or AO were investigated in 162 patients by reviewing patients' medical records and referral forms. Psychiatric diagnoses were categorized according to the International Statistical Classification of Disease and Related Health Problems, Tenth Revision.

RESULTS

The proportion of F4 classification (neurotic, stress-related, and somatoform disorders) in AO patients was significantly higher than in BMS patients. BMS patients were more frequently given a F3 classification (mood/affective disorders). However, 50.8% of BMS patients and 33.3% of AO patients had no specific psychiatric diagnoses.

CONCLUSION

Although BMS and AO are both chronic pain disorders occurring in the absence of any organic cause, the psychiatric diagnoses of patients with BMS and AO differ substantially.

"Burning tongue" and "burning tip": the diagnostic challenge of the burning mouth syndrome

OBJECTIVE

To investigate the clinical features of burning mouth syndrome (BMS) in a large cohort of patients and to correlate them with the results of tongue biopsy.

METHODS

We screened 98 patients complaining of oral burning pain for at least 6 months. Forty-two patients were excluded after screening for contact sensitivity to dental materials, food allergies, tongue injuries, malignancies, connective tissue and metabolic disorders, oral infectious diseases, vitamin deficiencies, and other systemic diseases known to cause neuropathy. Fifty-six patients underwent neurologic examination and assessment of pain intensity, depression, anxiety, quality of sleep, and quality of life. Tongue biopsy with the quantification of epithelial nerve fibers (ENF) was performed in 51 patients.

RESULTS

Compared with 9 healthy participants (4.13+/-1.85 SD), epithelial innervation density was significantly reduced in 38 patients (1.35+/-1.46 SD; P<0.0001) and normal in 13 patients (6.1+/-2.19 SD). The clinical features differed in the two groups: patients with reduced ENF density complained of pain in the whole tongue, lips, hard palate, and alveolar ridges, reported dysgeusia and xerostomia in 29% of cases (P<0.001), and 24% of them were depressed. Patients with normal innervation complained of pain on the tip of the tongue, reported dysgeusia and xerostomia in 7.7% of cases, and 54% of them were depressed (P<0.017).

DISCUSSION

The diagnostic criteria for BMS are not defined yet and the relationship with depression and anxiety is debated. We proposed a biopsy-supported approach for the diagnosis. Our study shows that BMS can present with two distinct clinical pictures and that tongue biopsy can contribute to the assessment of the diagnosis. Mood disorders occur frequently and should be considered when approaching patients and treatment options. These observations could help physicians in identifying patients with BMS and addressing them with the appropriate diagnostic work-up and treatment.

Effectiveness of milnacipran for the treatment of chronic pain in the orofacial region

OBJECTIVES

The effect of milnacipran for the treatment of chronic pain in the orofacial region, including burning mouth syndrome (BMS) and atypical odontalgia (AO), was assessed while accounting for the influence of concurrent depressive symptoms on the pain-relieving effect.

METHODS

Milnacipran was administered for 12 weeks to 36 patients with chronic pain in the orofacial region (3 men and 29 women, aged between 22 and 76 years with a mean age of 59 years). Of those patients, 22 and 10 patients had BMS and AO, respectively. The initial dose of milnacipran was 15 mg a day, and the dose was raised up to 100 mg a day. Pain was assessed using the visual analog scale, and symptoms of depression were evaluated using the Hamilton Depression Rating Scale at baseline and at weeks 1, 2, 4, 6, 8, 10, and 12 of the study treatment.

RESULTS

Data from 32 patients who completed the study were included in the analysis. The visual analog scale score significantly decreased after the 12-week treatment, and it showed a similar time course of decline irrespective of concurrent depressive symptoms during the 12 weeks.

CONCLUSIONS

Treatment with milnacipran resulted in a significant improvement of chronic pain in the orofacial region irrespective of concurrent symptoms of depression. The present results suggested that milnacipran may be an effective agent for treatment of such disorders.

The menopause and oral health

OBJECTIVES

To review the literature about oral symptoms and signs at the menopause with an emphasis on hormone replacement therapy (HRT). To give practical guidelines for women and their physicians in menopause-related oral health problems.

METHODS

The PubMed and Cochrane databases was searched until mid January 2009 with key words such as "menopause", "menopausal complaints", "postmenopausal complaints" and "oral diseases", "oral discomfort", "dental health", "dental diseases", "saliva", "burning mouth syndrome", "dry mouth", "xerostomia". Because of a scarcity of controlled studies no systematic review could be conducted.

RESULTS

Oral discomfort is found in many menopausal women in addition to more general climacteric complaints. The principal peri- and postmenopausal symptoms are dry mouth and burning mouth (glossodynia) which, in turn, may increase the occurrence of oral mucosal and dental diseases, such as candidiasis. The mechanisms of hormone-related oral symptoms and signs are not known although oestrogen receptors, for example, have been detected in the oral mucosa and salivary glands. In principle, the histology of oral and vaginal mucosa is very similar and thus their symptoms might share a common cause. Yet, hormone replacement therapy use does not necessarily prevent or help women with oral symptoms.

CONCLUSION

Properly controlled long-term randomized studies are needed to assess the effect of HRT on oral discomfort. Future gene profiling could identify women who may or may not benefit from HRT with regard to oral symptoms.