Is it Sjögren's syndrome or burning mouth syndrome? Distinct pathoses with similar oral symptoms

An Unusual Case of Burning Mouth Syndrome in an Adult Male: A Case Report

Burning mouth syndrome (BMS) is a rare disorder primarily affecting the oral mucosa and characterized by a chronic burning sensation without specific oral mucosal lesions. This paper presents a case of a 54-year-old adult male patient who complained of chronic burning mouth pain. The clinical diagnosis was made after excluding various differentials, including oral candidiasis, hairy oral leukoplakia, gastroesophageal reflux disease, oral lichen planus, local infective processes, and nutritional deficiencies. Physical examination did not reveal specific signs or lesions related to BMS; however, considering the patient's signs, symptoms, and the exclusion of other possibilities, a possible diagnosis of BMS was considered. The patient was evaluated in an outpatient setting, and management was conducted in this setting to reduce patient costs. This presentation is considered rare, as the disorder predominantly affects postmenopausal females, and most proposed theories behind its pathophysiology revolve around estrogen-mediated modulation of pain receptors. Currently, diagnostic and management criteria for BMS may vary and continue to evolve. The management of this patient focuses on patient education and routine follow-up. This case report presents the management of this particular case, along with a review of other proposed management options.

Added value of lymphocyte subpopulations in the classification of Sjögren's syndrome

Sjögren's Syndrome (SjS) is a chronic systemic immune-mediated inflammatory disease characterized by lymphocytic infiltration and consequent lesion of exocrine glands. SjS diagnosis and classification remains a challenge, especially at SjS onset, when patients may have milder phenotypes of the disease or uncommon presentations. New biomarkers are needed for the classification of SjS, thus, we aimed to evaluate the added-value of lymphocyte subpopulations in discriminating SjS and non-Sjögren Sicca patients. Lymphocyte subsets from 62 SjS and 63 Sicca patients were characterized by flow cytometry. The 2002 AECG and the 2016 ACR/EULAR SjS classification criteria were compared with clinical diagnosis. The added discriminative ability of joining lymphocytic populations to classification criteria was assessed by the area under the Receiver-Operating-Characteristic Curve (AUC). Considering clinical diagnosis as the gold-standard, we obtained an AUC = 0.952 (95% CI: 0.916-0.989) for AECG and an AUC = 0.921 (95% CI: 0.875-0.966) for ACR/EULAR criteria. Adding Tfh and Bm1 subsets to AECG criteria, performance increased, attaining an AUC = 0.985 (95% CI: 0.968-1.000) (p = 0.021). Th1/Breg-like CD24^hiCD27⁺ and switched-memory B-cells maximized the AUC of ACR/EULAR criteria to 0.953 (95% CI: 0.916-0.990) (p = 0.043). Our exploratory study supports the potential use of lymphocyte subpopulations, such as unswitched memory B cells, to improve the performance of classification criteria, since their discriminative ability increases when specific subsets are added to the criteria.

Burning Mouth Syndrome: An Overview and Future Perspectives

Burning Mouth Syndrome (BMS) is a complex chronic neuropathic orofacial pain disorder characterized by a generalized or localized intraoral burning, dysesthetic sensation or pain of the oral mucosa, recurring daily for more than 2 h per day for more than 3 months, without any evidence of specific mucosal lesions and/or laboratory findings [...].

Smell and Taste Function and Their Disturbances in Sjögren's Syndrome

Chemosensory disorders are a possible disturbance in Sjögren's syndrome (SS). The aim of the study is to comprehensively present chemosensory disorders in SS and to indicate their possible causes. The possible causes of taste and smell disorders in SS are changes in the structure of exocrine glands and their dysfunction, damage to receptors and weakening of their ability to regenerate, and neurological changes in the form of peripheral neuropathy and impaired cognitive function. Other postulated causes of chemosensory disorders are autoimmune mechanisms, adverse effects of drugs used in SS, and primary potentially SS-triggering viral infections. They are multifactorial and may occur independently of each other. The time of their onset and correlation with other disease symptoms may facilitate the determination of their primary cause in each patient. Awareness of chemosensory disorders in SS may help to ease their progress and eliminate other factors responsible for their more severe manifestation. In the prevention and treatment of chemosensory disorders in SS, the most important thing is to alleviate xerostomia and dryness in the nasal cavity and their effects in the form of chronic local inflammations, counteract receptor atrophy, and an implementation of appropriate neurological diagnosis and treatment.

Clinical Utility of Quantitative Parameters of Salivary Gland Scintigraphy for Diagnosing Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a chronic disorder characterized by a burning sensation in the oral cavity, often accompanied by xerostomia, with no relevant clinical or laboratory findings. This study aimed to investigate diagnostic values of quantitative parameters of salivary gland scintigraphy for BMS in patients with xerostomia. A total of 164 patients who underwent salivary gland scintigraphy for the workup of xerostomia were retrospectively reviewed. All patients were classified into patient groups with primary BMS, secondary BMS, and non-specific xerostomia. From salivary gland scintigraphy, 22 quantitative parameters were calculated and their diagnostic values were assessed based on the area under the receiver operating characteristic curve (AUC) values. Among salivary gland scintigraphy parameters, uptake speed in the left submandibular gland showed the highest AUC value (0.647) for detecting BMS and pre-stimulatory oral activity showed the highest AUC value (0.710) for detecting primary BMS. A salivary gland scintigraphy scoring system based on these two parameters further enhanced the diagnostic ability, demonstrating AUC values of 0.731 for BMS and 0.782 for primary BMS. These results suggest a potential diagnostic value of the quantitative parameters of salivary gland scintigraphy for detecting BMS in patients with xerostomia.

Evaluation of serum neuron specific enolase levels among patients with primary and secondary burning mouth syndrome

INTRODUCTION

Burning mouth syndrome is a painful condition of the oral cavity with ambiguous pathogenesis and diagnosis. Neuron-specific enolase is increased in several conditions including peripheral neuropathy of diabetes, ophthalmopathies, spinal cord injuries and tumors. Evidence on association of burning mouth syndrome and neuron-specific enolase is limited.

AIM

This study aims to evaluate neuron-specific enolase levels in primary and secondary burning mouth syndrome patients and compare the levels of neuron-specific enolase with associated conditions in secondary burning mouth syndrome.

METHODS

One hundred and twenty-eight patients of more than 18 years of age with no gender predilection and having clinical symptoms of burning mouth syndrome and 135 healthy subjects were included. All the patients fulfilled Scala's criteria for the diagnosis of burning mouth syndrome, including "primary" (idiopathic) and "secondary" (resulting from identified precipitating factors) burning mouth syndrome patients. Blood samples were obtained from burning mouth syndrome patients. Serum neuron-specific enolase was evaluated using enzyme-linked immunosorbent assay. To compare means and standard deviations, among primary and secondary burning mouth syndrome, data was analysed with analysis of variance and multiple comparisons test.

RESULTS

The mean age of the study participants for burning mouth syndrome and healthy subjects was 53.30 and 51.6 years, respectively. Amongst the secondary burning mouth syndrome group, 32 (25%) of the patients had menopause, 15 (11.7%) had diabetes, eight (6.2%) of the patients had nutritional deficiency, seven (5.4%) had combined diabetes, menopause, and depression, six (4.6%) had combined diabetes and depression, four (3.1%) were diagnosed with Sjögren's syndrome. A minor percentage of 2.3% (three) had gastroesophageal reflux disease, while the remaining three (2.3%) patients in the secondary burning mouth syndrome group were on anti-depressants. There was a statistically significant increase in the levels of neuron-specific enolase in primary burning mouth syndrome as compared to the secondary burning mouth syndrome and healthy groups. Among the subgroups of secondary burning mouth syndrome, diabetic individuals showed a significant increase in neuron-specific enolase level when compared with other conditions in the secondary burning mouth syndrome patients.Discussion and conclusion: The raised serum neuron-specific enolase levels in patients suffering from primary burning mouth syndrome highlight a possible neuropathic mechanism. It was also increased in the sub-group of secondary burning mouth syndrome patients having diabetes. Although it cannot be ascertained whether the deranged values in the diabetic group were due to burning mouth syndrome or due to diabetes, the raised quantity of neuron-specific enolase in the primary burning mouth syndrome group is a reliable diagnostic indicator. Future studies on the assessment of neuron-specific enolase levels as a diagnostic tool for onset and management of primary and secondary burning mouth syndrome are recommended.

Diagnostic performance of serology against histologic assessment to diagnose Sjogren's syndrome: a systematic review

The objective of this review was to assess and evaluate whether the published diagnostic accuracy studies provide evidence to sustain the current diagnostic guidelines put forth by ACR/EULAR used for patients with suspected Sjögren's syndrome (SS). Literature databases, including Medline, Embase, and EBM Reviews, were searched for relevant studies on the correlation between ACR/EULAR criteria, particularly those with a direct comparison between their accuracy in diagnosing Sjögren's syndrome. We followed Cochrane, QUADAS-2, and STARD guidelines and the four-phase flow diagram by the PRISMA Statement. Reports in several languages, but only human studies were considered. Three studies assessed the accuracy of the current diagnostic tests, and these did not present adequate designs that would allow a well-supported conclusion with a high level of certainty. Due to significant clinical and methodological heterogeneity, a meta-analysis was not performed. A qualitative review of the papers was undertaken. Neither the comparative nor the non-comparative study designs permit conclusive recommendations regarding an alternative diagnostic pathway for SS. Well-designed studies of the diagnostic accuracy of SS tests are needed to validate current guidelines or to suggest changes to the current guidelines.

Sjogren's Syndrome and Pulmonary Disease

Sjogren's syndrome is an autoimmune connective tissue disease targeting the exocrine glands and frequently affecting the respiratory system. The pulmonary disease is the most important extra-glandular manifestation as it carries most of the morbidity and mortality. Typically, it affects the small airways ranging from mild to severe respiratory symptoms. The upper airways are also commonly involved, predisposing sinusitis to occur more frequently than in the normal population. Lymphocytic interstitial pneumonia was initially thought to be the prevailing parenchymal disease; however, multiple cohorts report non-interstitial pneumonia to be the most frequent subtype of interstitial lung disease. In the review of high-resolution computed tomography scans, cystic lesions are commonly found and associate with both the small airways and parenchymal disease. Under their presence, amyloidosis or lymphomas should be considered in the differential. Overall, Sjogren's syndrome has a higher risk for lymphoma, and in lungs this condition should be thought of, especially when the images reveal pulmonary nodularity, lymphocytic interstitial pneumonia and lymphadenopathy. Although, pulmonary artery hypertension was traditionally and exceptionally linked with Sjogren's syndrome, together with systemic lupus erythematosus, they are now acknowledged to be the most common pulmonary vascular disease in east Asian populations, even over patients with systemic sclerosis. Although there are no controlled prospective trials to treat pulmonary disease in Sjogren's syndrome, the mainstay treatment modality still falls on glucocorticoid therapy (systemic and inhaled), combined with immune modulators or alone. Most of the evidence sustains successful outcomes based on reported cases or case series.

Clinical presentation of burning mouth syndrome in patients with oral lichenoid disease

BACKGROUND

To analyze the presence of burning mouth syndrome (BMS) in a group of patients diagnosed with oral lichenoid disease (OLD).

MATERIAL AND METHODS

A retrospective study of 217 patients diagnosed with OLD; 158 (72,8%) women and 59 (27,2%) men, with an average age upon diagnosis of 56,4 years (SD 11,88). We carried out a detailed and complete characterization of symptoms, with special emphasis on BMS diagnostic data specified by the International Headache Society.

RESULTS

Four patients (1.8%) presented with long-term clinical symptoms of burning mouth, indicative of BMS and they fulfilled the IHS 2018 criteria, except for criterion D, i.e."Oral mucosa is of normal appearance". The observed lichenoid mucosal lesions were not considered to be able to account for the reported intraoral pain in any of our patients. Thus neither diagnosis was considered to be exclusive.

CONCLUSIONS

Patients diagnosed with OLD, and who simultaneously present clinical characteristics of BMS should be studied in detail, in order to evaluate the possibility of both diagnoses concurring.

Chemosensory dysfunction, Oral disorders and Oral health-related quality of life in patients with primary Sjögren's syndrome: comparative cross-sectional study

Background

The aim of this study was to evaluate chemosensory function and oral disorders in patients with primary Sjögren’s syndrome (pSS) and to compare these findings with those of age- and gender-matched healthy controls.

Methods

This comparative cross-sectional study included 58 patients with primary Sjögren’s syndrome (pSS) and 55 age- and gender-matched healthy controls. Olfactory and gustatory function, burning sensations in the tongue (BST) and halitosis were assessed. Oral health-related quality of life (OHRQoL) was evaluated using the short-form Oral Health Impact Profile (OHIP-14).

Results

Patients with pSS had significantly lower self-reported visual analogue scale (VAS) smell score (8.6 ± 2.2 vs. 9.6 ± 0.7, p = 0.016) and VAS taste score (8.5 ± 2.1 vs. 9.5 ± 0.7, p = 0.014) than healthy controls. A greater proportion of patients with pSS had anosmia (3.8% vs. 0.0%) or hyposmia (36.5% vs. 13.2%) and ageusia for basic tastes: sweetness (34.0% vs. 7.5%), sourness (10.6% vs. 0.0), saltiness (10.0% vs. 5.7%) or bitterness (19.1% vs. 1.9%) as evaluated using Sniffin Sticks test and taste stripts, respectively. A higher proportion of pSS patients complained of dysgeusia (52.6% vs. 9.4%, p < 0.0001) and BST (45.6% vs. 0.0%, p < 0.0001), while similar number of patients with pSS and controls reported halitosis (31.6% vs. 28.3%, p = 0.434). The mean OHIP-14 score was significantly higher in patients with pSS (6.8 ± 7.0 vs. 2.3 ± 8.5, p < 0.001) indicating patients’ poorer OHRQoL compared with controls.

Conclusions

The majority of patients with pSS had impaired chemosensory function and indicators of oral health in comparison with the age- and gender-matched healthy controls. Further studies of oral hygiene habits and dietary intake of these patients are needed to ensure better management of oral health problems in patients with pSS.

Current and Emerging Evidence for Toll-Like Receptor Activation in Sjögren's Syndrome

While the importance of Toll-like receptor (TLR) signaling is well established in many autoimmune diseases, the role of TLR activation in Sjögren's syndrome (SS) is poorly understood. Studies in mice and humans reveal that TLRs are potent mediators of inflammation in SS. TLRs are expressed and functional in salivary tissue, and TLRs in peripheral blood cells of SS patients are also upregulated and hyperresponsive to ligation. In this review, we will detail observations in mouse models regarding the importance of TLR activation in both local and systemic disease. We will then discuss studies in SS patients that provide evidence of the importance of TLR-mediated signaling in disease. While the ligands that activate TLRs in the context of SS are unknown, emerging data suggest that damage-associated molecular patterns (DAMPs) may be significant drivers of the chronic and unremitting inflammation that is characteristic of SS. We will discuss putative DAMPs that may be of clinical significance in disease. Therapies that target TLR signaling cascades will likely reduce both exocrine-specific and systemic manifestations of SS.

Oral Disorders in Sjögren’s Syndrome

Sjogren’s syndrome (SS) is a complex, chronic, systemic, autoimmune disease that mainly affects the exocrine glands, especially the salivary and lacrimal glands, leading to the dryness of the mouth and eyes, along with fatigue, joint and muscle pain. The prevalence of SS is estimated to be between 0.05% and 1% in European population. Diagnosis of SS is based on the revised criteria of the American-European consensus group (AECG). Sjogren’s syndrome can be subclassified into primary disease (primary Sjogren syndrome, pSS) and a secondary disease (secondary Sjogren syndrome, sSS) when present with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and systemic sclerosis. The decrease in salivary flow and qualitative alterations in saliva could explain many of the oral manifestations frequently present in patients with SS. Low salivary flow may affect chewing, swallowing, speech and sleeping in pSS patients. Oral manifestations include dental erosion, dental caries, mucosal infection, ulcers and oral candidiasis. Recent studies reveal that pSS patients experience impaired olfactory and gustatory functions and have higher occurrence of oral complications such as dysgeusia, burning sensation in the tongue (BST) and halitosis. The exocrine manifestations and systemic involvement in SS significantly impact the patient’s perception of oral healthrelated quality of life (OHRQoL).

Recent Advances in the Etiology and Treatment of Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a debilitating condition that has a striking female predilection. Although the oral mucosa is normal in appearance, patients with BMS experience oral burning that most commonly localizes to the lips and tongue. BMS is a diagnosis of exclusion, and all underlying pathoses associated with allodynia must be ruled out prior to rendering the diagnosis. The etiopathogenesis of BMS remains poorly understood, and thus patient management is challenging. Data indicate that oral and systemic factors both contribute to the development and persistence of the condition. Of particular interest, emerging work identifies structural and functional deficits within the nervous system that may lead to a more mechanistic understanding of BMS pathology. In addition, several novel findings suggest that circadian rhythm dysfunction may be a previously unappreciated yet clinically significant driver of disease. Circadian rhythm controls pain perception, mood, and sleep and plays a key role in the regulation of the hypothalamic-pituitary-adrenal axis. Since these are altered in patients with BMS, this may be reflective of underlying circadian dysfunction. While evidence-based treatment strategies for BMS are lacking, current treatment approaches consist of local and systemic medications, such as clonazepam, alpha lipoic acid, capsaicin, low-level laser therapy, gabapentin, and amitriptylin. In addition, the use of cognitive behavioral therapy is reported. This review provides an overview of the recent literature related to the etiology and treatment of BMS and identifies current challenges facing researchers and clinicians alike.