An open-label, dose escalation pilot study of the effect of clonazepam in burning mouth syndrome

Therapeutic effects of clonazepam in patients with burning mouth syndrome and various symptoms or psychological conditions

Burning mouth syndrome (BMS) is frequently accompanied by dysgeusia and xerostomia. Clonazepam has been widely prescribed and is effective, but it is unclear whether clonazepam also affects the symptoms that accompany BMS, or whether such symptoms affect treatment outcomes. Here, we investigated the therapeutic outcomes in BMS patients with various symptoms or comorbidities. We retrospectively reviewed 41 patients diagnosed with BMS between June 2010 and June 2021 at a single institution. Patients were instructed to take clonazepam for 6 weeks. Before the first dose, burning pain intensity was measured using a visual analog scale (VAS); the unstimulated salivary flow rate (USFR), psychologic characteristics, site(s) of pain, and any taste disturbance were evaluated. Burning pain intensity was measured again after 6 weeks. Thirty-one of the 41 patents (75.7%) exhibited a depressed mood, whereas more than 67.8% of the patients exhibited anxiety. Subjective xerostomia was reported by ten patients (24.3%). The mean salivary flow rate was 0.69 mL/min and hyposalivation (an unstimulated salivary flow rate ≤ 0.5 mL/min) was apparent in ten patients (24.3%). Dysgeusia was present in 20 patients (48.7%); a bitter taste (n = 15, 75%) was reported by the largest proportion of patients. Patients who reported a bitter taste responded best in terms of burning pain reduction after 6 weeks (n = 4, 26.6%). Overall, 32 patients (78%) reported decreased oral burning pain after clonazepam (mean VAS score changed from 6.56 to 5.34) use. Patients who reported taste disturbances exhibited a significantly greater decrease in burning pain, compared with other patients (mean VAS score changed from 6.41 to 4.58) (p = 0.02). Clonazepam significantly improved burning pain in BMS patients who had taste disturbances.

Treatments for Burning Mouth Syndrome: A Network Meta-analysis

The aim of this systematic review and network meta-analysis (NMA) of randomized controlled trials was to evaluate the effectiveness of treatments for pain relief of burning mouth syndrome (BMS). Five databases and gray literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. The primary outcome was pain relief or burning sensation, and the secondary outcomes were side effects, quality of life, salivary flow, and TNF-α and interleukin 6 levels. Four comparable interventions were grouped into different network geometries to ensure the transitivity assumption for pain: photobiomodulation therapy, alpha-lipoic acid, phytotherapics, and anxiolytics/antidepressants. Mean difference (MD) and 95% CI were calculated for continuous outcomes. The minimal important difference to consider a therapy beneficial against placebo was an MD of at least -1 for relief of pain. To interpret the results, the GRADE approach for NMA was used with a minimally contextualized framework and the magnitude of the effect. Forty-four trials were included (24 in the NMA). The anxiolytic (clonazepam) probably reduces the pain of BMS when compared with placebo (MD, -1.88; 95% CI, -2.61 to -1.16; moderate certainty). Photobiomodulation therapy (MD, -1.90; 95% CI, -3.58 to -0.21) and pregabalin (MD, -2.40; 95% CI, -3.49 to -1.32) achieved the minimal important difference of a beneficial effect with low or very low certainty. Among all tested treatments, only clonazepam is likely to reduce the pain of BMS when compared with placebo. The majority of the other treatments had low and very low certainty, mainly due to imprecision, indirectness, and intransitivity. More randomized controlled trials comparing treatments against placebo are encouraged to confirm the evidence and test possible alternative treatments (PROSPERO CRD42021255039).

Deprescribing clonazepam in primary care older patients: a feasibility study

Background Inappropriate use of clonazepam by older adults is associated with cognitive impairment, delirium, and falls. Strategies to optimize its use are important to increase patient safety. Objective To evaluate the feasibility of a clonazepam deprescription protocol in the elderly. Methods This is a quasi-experimental study. Elderly people with chronic use of clonazepam and attended in primary care units in two Brazilian municipalities were selected. A deprescription protocol was used, which included five fortnightly meetings between the older adults and the research team, to reduce the dose by 25%. Patients received instructions on sleep hygiene behaviors and the advantages of clonazepam deprescription; family physicians followed a flowchart for gradual dose reduction. In the 1st and 5th meetings, there were medical appointments for anamnesis and discharge. The monitoring of patients and the application of tests were carried out by the research team. Results Of the 35 elderly people included in the study, 27 reached the end; 81.5% achieved deprescription: 22.2% stopped completely and 59.3% decreased the dose. At the last meeting, 20% of elderly patients reported an increase in blood pressure. Conclusion The high rate of deprescription and the little relevance of clonazepam withdrawal reactions, showed that the use of the protocol was effective. However, the increase in blood pressure and the worsening of sleep quality in the last meeting show the need for adjustment in the last stage of the deprescription process.

Topical clonazepam for burning mouth syndrome: Is it efficacious in patients with anxiety or depression?

BACKGROUND

Burning mouth syndrome (BMS) is a chronic disorder characterised by pain in the oral cavity without clinically evident causative lesions. The aetiology of this condition is poorly understood, and treatment can be challenging.

METHOD

A retrospective review of the medical records of 82 patients with BMS was performed. Data on demographics, BMS associated symptoms, symptoms' intensity score (NRS: 0-10) and response to treatment with topical clonazepam were extracted from clinical notes based on a standardised clinical questionnaire. Differences in the symptoms' intensity score between patients with or without concomitant anxiety/depression or systemic psychogenic medication use were analysed using the Wilcoxon signed rank test.

RESULTS

Among the entire cohort, the median symptoms' intensity score at baseline was 4.5 and 3.0 at first follow-up, a statistically significant improvement (p < .001; 95% CI). Among the subjects with anxiety/depression and those who were prescribed systemic psychogenic medications, the median symptoms' intensity score at baseline was 5.0 and 3.0 at first follow-up, a statistically significant improvement (p < .001; 95% CI). Among those without anxiety/depression, the symptoms' intensity score at baseline was 4.0 and 2.0 at first follow-up, a statistically significant improvement (p < .05; 95% CI). The median symptoms' intensity score for those who were not on any psychogenic medications at baseline was 4.0 and 2.0 at first follow-up, a statistically significant improvement (p < .001; 95% CI).

CONCLUSIONS

Clinicians are encouraged to prescribe topical clonazepam for BMS regardless of concomitant use of systemic psychogenic medications or comorbid mood disorders as it is an efficacious management approach in the presence or absence of these potentially complicating factors.

Use of a combination of N-acetylcysteine and clonazepam to treat burning mouth syndrome

OBJECTIVE

This study was intended to evaluate the clinical efficacy of a combination of N-acetylcysteine (NAC) and clonazepam for treatment of burning mouth syndrome (BMS).

STUDY DESIGN

A total of 160 patients with BMS were divided into 3 groups: group 1 received NAC (400 mg/d), group 2 received clonazepam (0.5 mg/d), and group 3 received both NAC and clonazepam. We evaluated symptom relief after 8 weeks of treatment using a visual analog scale (VAS). To assess oral health-related quality of life, we used the validated Korean version of an oral health impact profile (OHIP-14K).

RESULTS

The overall response rates of the 3 groups were 60.3%, 51.3%, and 80.0%, respectively. The mean VAS and OHIP-14K scores significantly decreased in all groups after the 8-week treatments. The VAS score changes were -12.2 ± 19.5, -10.0 ± 14.1, and -21.0 ± 24.6, respectively (P = .001), in the 3 groups and the OHIP-14K changes were -2.3 ± 9.2, -4.4 ± 6.9, and -8.7 ± 10.3, respectively (P = .020). Group 3 showed significantly larger differences in VAS and OHIP-14K scores than group 2, before and after treatment.

CONCLUSIONS

In the treatment of BMS, the NAC/clonazepam combination therapy was more effective than either monotherapy.

Salivary characteristics may be associated with burning mouth syndrome?

Background

Burning mouth syndrome (BMS) it is characterized by burning and uncomfortable sensations with no clinical alterations or laboratory findings. The evaluation of the salivary characteristics of people with BMS can help the understanding of the pathogenesis of this condition. This case-control study aimed to trace the salivary profile of women with burning mouth syndrome (BMS).

Material and Methods

40 women with BMS and 40 control women were recruited. Unstimulated salivary flow rate (uSFR), pH, salivary cortisol levels, salivary viscosity, and oral health impact profile (OHIP-14 questioner) were determined. P< 0.05 was considered statistically significant.

Results

For uSFR, mean values obtained for BMS and for control group respectively were 0.35 and 0.61 mL/min; for pH, 7.23 and 7.34; for cortisol levels, 0.36 and 0.15 μg/dL; for viscosity values, 31.1 and 45.01 mPas and for OHIP-14 scores, 21.7 and 5.7. To uSFR, cortisol levels, viscosity values and OHIP-14 scores, differences were statistically significant. Salivary cortisol levels and OHIP-14 scores were correlated positively (rho = 0.624; p< 0.05).

Conclusions

BMS women have lower uSFR and salivary viscosity and higher salivary cortisol levels that were associated with worse quality of life, compared with the control group.

Key words:Xerostomia, Burning mouth syndrome, Viscosity.

Burning mouth syndrome: An update

Background:

Burning mouth syndrome (BMS) is a chronic and debilitating oral pain of the normal oral mucosa. It mainly affects women in their fifth to seventh decade. Its aetiopathogenesis remains unclear and is probably of multifactorial origin, with increasing evidence that BMS may be a neuropathic disorder. BMS is classified as an idiopathic (nociplastic) orofacial pain with or without somatosensory changes by International Classification of Orofacial Pain (ICOP 2020). The diagnosis of BMS, having excluded ‘oral burning mouth symptoms’, has evolved from basic intraoral exclusion screening to extensive clinical and laboratory investigations, which include the screening of comorbidities and other chronic pains and somatosensory testing. There is no standardised treatment in managing BMS, but a proposed combination of supportive and pharmacological treatment has been recommended.

Aim:

To review the current concepts of BMS definitions, classifications, aetiopathogenesis, diagnosis techniques, and evidence-based treatments in managing BMS patients.

Conclusion:

As BMS is a diagnosis by exclusion, thus a stratified approach is required for assessment of patients presenting BMS. A BMS diagnosis protocol is desired using a standardised screening to distinguish BMS from patient’s presenting with ‘oral burning symptoms’, and evaluation of comorbid chronic pain disorders or other medical comorbidities, which will include haematological, fungal, salivary flow, and qualitative sensory testing. Axis II and other additional quantitative sensory testing may further elucidate the causes of this condition. For future BMS prediction and prevention, will be based upon research on the relationship between other chronic pain disorders and familial history, environmental and genetic information.

Treatment outcomes and related clinical characteristics in patients with burning mouth syndrome

OBJECTIVES

To evaluate the treatment outcomes of medication therapies in patients with burning mouth syndrome (BMS) and to identify the clinical characteristics that may affect the efficacy of prescribed medications.

METHODS

This is a retrospective study of 769 patients with oral burning sensations. Of these patients, 420 patients diagnosed as the primary BMS received an "Initial Approach" that involved a detailed explanation about its etiopathophysiology, self-care instruction, and use of an oral lubricant. Neuropathic medications were prescribed for 277 patients who did not respond to the initial approach. Clinical characteristics, prescribed medications, and changes in intensity of oral symptoms were reviewed.

RESULTS

Clonazepam was administered as the first-line medication. Alpha-lipoic acid (ALA), gabapentin, and nortriptyline were commonly administered in combination with clonazepam. More than two-thirds of the patients reported a marked improvement in oral symptoms after treatments with combination of neuropathic medications and ALA. The efficacies of the initial approach and clonazepam had significant positive associations with the initial intensity of oral symptoms and significant negative associations with depression.

CONCLUSIONS

Clonazepam therapy in combination with appropriate medications was effective for managing patients with BMS. The initial intensity of oral symptoms and psychological status were significantly associated with treatment outcomes.

Global research trends in complex oral sensitivity disorder: A systematic bibliometric analysis of the framework

OBJECTIVES

A systematic bibliometric analysis was performed to investigate trends in complex oral sensitivity disorder (COSD) research worldwide and compare the contributions of different countries/institutions, scientific journals, authors, keywords, and citations.

METHODS

Web of Science database from 1985 to 2018 was systematically searched to identify all relevant articles using the MeSH terms "complex oral sensitivity disorder" and all synonyms used in the literature. We included original articles, review articles, letters to the editor, and book chapters in the English language and in 27 different ISI categories of medical sciences. Several bibliometric indicators were used.

RESULTS

We identified 10 633 articles, of which only 3349 were eligible with only 443 being included for quantitative analyses. The annual percentage growth rate for article publication was 9.16 fractionalized articles with the most productive countries (reported only in 428 out of 443 articles) being Italy (n = 66, 15.42%) followed by USA (n = 61, 14.25%) and with Italy achieving the greatest number of citations (n = 1415). Similarly, the most productive institution for article publication was the University of Turku, Finland, with 39 (8.8%) published articles. Among the top 20 departments, 15 were affiliated with dental institutions. The most productive source was "Journal of Oral Pathology and Medicine" with 38 (8.58%) articles, whereas the most productive author was "Lopez-Jornet P" with 19 articles (6.52 fractionalized articles).

CONCLUSIONS

There is an increasing trend for publications on COSD. Collaboration among different countries must improve in order to implement research on this disorder, which seems to be mainly a condition for the dental discipline.

A perspective from experimental studies of burning mouth syndrome

Burning mouth syndrome (BMS) is one of the most frequently seen idiopathic pain conditions in a dental setting. Peri- and postmenopausal women are most frequently affected, and patients who experience BMS complain of persistent burning pain mainly at the tip and the bilateral border of the tongue. Recent studies have assessed whether BMS is a neuropathic pain condition, based on morphologic changes in biopsied tongue specimens, and whether there are abnormal pain responses in patients with this disease. Somatosensory studies have reported some abnormal findings in sensory and pain detection thresholds with inconsistency; however, the most distinct finding was exaggerated responses to painful stimuli. Imaging and electrophysiologic studies have suggested the possibility of dysregulation of the pain-modulating system in the central nervous system, which may explain the enhanced pain responses despite the lack of typical responses toward quantitative sensory tests. Basic studies have suggested the possible involvement of neuroprotective steroids, although the underlying mechanisms of this condition have not been elucidated. Experimental studies are looking for preferable supportive therapies for BMS patients despite the obscure pathogenesis.

Pain reduction in burning mouth syndrome (BMS) may be associated with selective improvement of taste: a retrospective study

OBJECTIVE

The aim of this study was to examine taste function in patients who reported improvement in their pain level after treatment to determine if pain reduction is associated with change in taste function in patients with burning mouth syndrome (BMS).

STUDY DESIGN

This retrospective study of patients with BMS was conducted at a private oral medicine clinic.

RESULTS

Thirty-nine patients with BMS (31 females and 8 males; mean age 56.1 ± 9.4 years) reported improvement in their pain in 1 to 22 months after the initial visit (mean 5.13 ± 4.18). The most commonly used medication was clonazepam 0.25 to 0.5 mg/day. Twenty-eight patients were treated with a combination of medications. "Salt" and "bitter" responses at the fungiform papillae were increased after treatment (P = .026 and P = .044, respectively). "Salt" responses at the circumvallate papillae also increased (P < .001). Pain reduction was significant after treatment in the morning (P = .002) and in the evening (P < .001).

CONCLUSIONS

Treatment of BMS can significantly decrease pain symptoms, resulting in improvement in taste function. Pain reduction often requires a combination of medications.

An updated review on pathophysiology and management of burning mouth syndrome with endocrinological, psychological and neuropathic perspectives

Burning mouth syndrome (BMS) is a chronic oro-facial pain disorder of unknown cause. It is more common in peri- and post-menopausal women, and sex hormone dysregulation is believed to be an important causative factor. Psychosocial events often trigger or exacerbate symptoms, and persons with BMS appear to be predisposed towards anxiety and depression. Atrophy of small nerve fibres in the tongue epithelium has been reported, and potential neuropathic mechanisms for BMS are now widely investigated. Historically, BMS was thought to comprise endocrinological, psychosocial and neuropathic components. Neuroprotective steroids and glial cell line-derived neurotrophic factor family ligands may have pivotal roles in the peripheral mechanisms associated with atrophy of small nerve fibres. Denervation of chorda tympani nerve fibres that innervate fungiform buds leads to alternative trigeminal innervation, which results in dysgeusia and burning pain when eating hot foods. With regard to the central mechanism of BMS, depletion of neuroprotective steroids alters the brain network-related mood and pain modulation. Peripheral mechanistic studies support the use of topical clonazepam and capsaicin for the management of BMS, and some evidence supports the use of cognitive behavioural therapy. Hormone replacement therapy may address the causes of BMS, although adverse effects prevent its use as a first-line treatment. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) may have important benefits, and well-designed controlled studies are expected. Other treatment options to be investigated include brain stimulation and TSPO (translocator protein 18 kDa) ligands.

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 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.

Burning mouth syndrome

Objective

To review the clinical entity of primary burning mouth syndrome (BMS), its pathophysiological mechanisms, accurate new diagnostic methods and evidence-based treatment options, and to describe novel lines for future research regarding aetiology, pathophysiology, and new therapeutic strategies.

Description

Primary BMS is a chronic neuropathic intraoral pain condition that despite typical symptoms lacks clear clinical signs of neuropathic involvement. With advanced diagnostic methods, such as quantitative sensory testing of small somatosensory and taste afferents, neurophysiological recordings of the trigeminal system, and peripheral nerve blocks, most BMS patients can be classified into the peripheral or central type of neuropathic pain. These two types differ regarding pathophysiological mechanisms, efficacy of available treatments, and psychiatric comorbidity. The two types may overlap in individual patients. BMS is most frequent in postmenopausal women, with general population prevalence of around 1%. Treatment of BMS is difficult; best evidence exists for efficacy of topical and systemic clonazepam. Hormonal substitution, dopaminergic medications, and therapeutic non-invasive neuromodulation may provide efficient mechanism-based treatments for BMS in the future.

Conclusion

We present a novel comprehensive hypothesis of primary BMS, gathering the hormonal, neuropathic, and genetic factors presumably required in the genesis of the condition. This will aid in future research on pathophysiology and risk factors of BMS, and boost treatment trials taking into account individual mechanism profiles and subgroup-clusters.

Analgesic effect of topical oral capsaicin gel in burning mouth syndrome

OBJECTIVE

To investigate the effectiveness of repeated topical application of oral capsaicin gel in two different concentrations for relief of burning/stinging sensations in patients with burning mouth syndrome (BMS).

MATERIAL AND METHODS

This randomized double-blind cross-over study included 22 female patients with BMS. The patients were randomized for topical application of either 0.01% or 0.025% oral capsaicin gel on the dorsal part of tongue three times daily for 14 days, followed by 14 days wash-out period, and finally treatment with the other concentration of oral gel three times daily for 14 days. A visual analogue scale (VAS) was used to assess the severity of pain five times during the intervention period.

RESULTS

18 patients completed the intervention. Their VAS score at baseline was 5.5 ± 0.6 cm (mean ± SD). Treatment with the two concentrations of capsaicin gels significantly improved the burning/stinging symptoms assessed on VAS compared with baseline (p = 0.002). There was no statistically significant difference between the two concentrations of the gels on relieving symptoms. Four patients dropped out during the intervention period due to gastrointestinal side-effects.

CONCLUSIONS

Topical capsaicin might be an alternative for the short-term treatment of BMS. However, further studies are needed to investigate especially the gastro-intestinal side-effects which may limit its long-term use.

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.

Oral sensory nerve damage: Causes and consequences

Oral sensations (i.e., taste, oral somatosensation, retronasal olfaction) are integrated into a composite sense of flavor, which guides dietary choices with long-term health impact. The nerves carrying this input are vulnerable to peripheral damage from multiple sources (e.g., otitis media, tonsillectomy, head injury), and this regional damage can boost sensations elsewhere in the mouth because of central interactions among nerve targets. Mutual inhibition governs this compensatory process, but individual differences lead to variation in whole-mouth outcomes: some individuals are unaffected, others experience severe loss, and some encounter sensory increases that may (if experienced early in life) elevate sweet-fat palatability and body mass. Phantom taste, touch, or pain sensations (e.g., burning mouth syndrome) may also occur, particularly in those expressing the most taste buds. To identify and treat these conditions effectively, emerging clinical tests measure regional vs. whole-mouth sensation, stimulated vs. phantom cues, and oral anatomy. Scaling methods allowing valid group comparisons have strongly aided these efforts. Overall, advances in measuring oral sensory function in health and disease show promise for understanding the varied clinical consequences of nerve damage.

Initial development of patient-reported instrument assessing harm, efficacy, and misuse of long-term opioid therapy

Guidelines on long-term opioid therapy recommend frequent reassessment of harm, efficacy, and misuse of these potentially harmful and sometimes ineffective medications. In primary care, there is a need for a brief, patient-reported instrument. This report details the initial steps in the development of such an instrument. An interdisciplinary team of clinician-scientists performed four discrete steps in this study: (1) conceptualization of the purpose and function of the instrument, (2) assembly of an item pool, (3) expert rating on which items were most important to include in the instrument, and (4) modification of expert-selected items based on a reading level check and cognitive interviews with patients. A diverse panel of 47 subject matter experts was presented with 69 items to rate on a 1-9 scale in terms of importance for inclusion in the instrument. The panel highly rated 37 items: 8 related to harm, 4 related to efficacy, and 25 related to misuse. These 37 items were then tested for patient comprehension and modified as needed. Next steps in development will include further item reduction, testing against a gold standard, and assessment of the instrument's effect on clinical outcomes.

Burning mouth syndrome: Current concepts

Burning mouth syndrome (BMS) is a chronic pain condition. It has been described by the International Headache Society as "an intra-oral burning or dysesthetic sensation, recurring daily for more than 2 h/day for more than 3 months, without clinically evident causative lesions." BMS is frequently seen in women in the peri-menopausal and menopausal age group in an average female/male ratio of 7:1. The site most commonly affected is the anterior two-thirds of the tongue. The patient may also report taste alterations and oral dryness along with the burning. The etiopathogenesis is complex and is not well-comprehended. The more accepted theories point toward a neuropathic etiology, but the gustatory system has also been implicated in this condition. BMS is frequently mismanaged, partly because it is not well-known among healthcare providers. Diagnosis of BMS is made after other local and systemic causes of burning have been ruled out as then; the oral burning is the disease itself. The management of BMS still remains a challenge. Benzodiazepines have been used in clinical practice as the first-line medication in the pharmacological management of BMS. Nonpharmacological management includes cognitive behavioral therapy and complementary and alternative medicine (CAM). The aim of this review is to familiarize healthcare providers with the diagnosis, pathogenesis, and general characteristics of primary BMS while updating them with the current treatment options to better manage this group of patients.

Group cognitive-behavioral intervention for patients with burning mouth syndrome

This study was conducted to assess the psychological characteristics of, and determine the effectiveness of group cognitive-behavioral (CB) treatment for, patients with burning mouth syndrome (BMS). The baseline characteristics of 24 female patients (age 69.7 ± 5.9 years) and an identical number of healthy female control subjects (age 69.2 ± 5.5 years) were compared. The patient group had significantly higher anxiety scores (P < 0.05) at baseline. A brief group CB intervention was delivered in a small-group format. Two sessions were planned 6 months apart. A numeric rating scale (NRS) was used to assess pain intensity. Anxiety was evaluated using a state and trait anxiety inventories. Present pain intensity decreased after both the first and second sessions. The session effect was significant (P = 0.02), but no repeat effect was found (P = 0.19). The state anxiety inventory score also decreased after the second session. The session effect was significant (P < 0.01), as was the repeat effect (P < 0.01). The trait anxiety inventory score decreased after the second session, and the session effect was significant (P = 0.013), but the repeat effect was not (P = 0.93). The results suggest that a brief group CB intervention reduces pain intensity and anxiety in patients with BMS.

A valid approach in refractory glossodynia: a single-institution 5-year experience treating with Japanese traditional herbal (kampo) medicine

Glossodynia is often refractory to conventional medicine, and there is only limited evidence to guide clinicians in its management. Patients with refractory glossodynia are often introduced to Japanese traditional herbal (Kampo) medicine experts under such circumstances because Kampo medicine has become known in Japan to be effective in treating a wide variety of symptoms refractory to conventional medicine. Herein, we report our single-institution 5-year experience treating patients with Kampo medicine for primary glossodynia that was refractory to conventional medicine. We found that 69.2% of patients reported a beneficial effect of Kampo medicine on glossodynia, and the average onset of improvement was 8.0 ± 7.7 weeks after starting Kampo treatment. The top two frequently used Kampo medicines for glossodynia were seinetsuhokito and mibakuekkito among high responders who showed a decrease of severity by 50% or more. The top four most overlapped herbs among effective Kampo medicines for glossodynia were Glycyrrhiza Root, Ginseng Root, Hoelen, and Atractylodes (lancea) Rhizome, which compose an essential Kampo prescription called shikunshito. Although more research is required to further clarify the effectiveness of Kampo medicine, it has valid efficacy even in cases of glossodynia that remain incurable by conventional treatments.

Burning mouth syndrome: a review and update

Burning mouth syndrome (BMS) is characterized by the presence of burning sensation of the oral mucosa in the absence of clinically apparent mucosal alterations. It occurs more commonly in middle-aged and elderly women and often affects the tongue tip and lateral borders, lips, and hard and soft palate. In addition to a burning sensation, the patients with BMS may also complain unremitting oral mucosal pain, dysgeusia, and xerostomia. BMS can be classified into two clinical forms: primary and secondary BMS. The primary BMS is essential or idiopathic, in which the organic local/systemic causes cannot be identified and a neuropathological cause is likely. The diagnosis of primary BMS depends mainly on exclusion of etiological factors. The secondary BMS is caused by local, systemic, and/or psychological factors; thus, its diagnosis depends on identification of the exact causative factor. When local, systemic or psychological factors are present, treatment or elimination of these factors usually results in a significant clinical improvement of BMS symptoms. Vitamin, zinc, or hormone replacement therapy has been found to be effective for reducing the oral burning or pain symptom in some BMS patients with deficiency of the corresponding factor. If patients still have the symptoms after the removal of potential causes, drug therapy should be instituted. Previous randomized controlled clinical trials found that drug therapy with capsaicin, alpha-lipoic acid, clonazepam, and antidepressants may provide relief of oral burning or pain symptom. In addition, psychotherapy and behavioral feedback may also help eliminate the BMS symptoms.

Multi-dimensionality of chronic pain of the oral cavity and face

Orofacial pain in its broadest definition can affect up to 7% of the population. Its diagnosis and initial management falls between dentists and doctors and in the secondary care sector among pain physicians, headache neurologists and oral physicians. Chronic facial pain is a long term condition and like all other chronic pain is associated with numerous co-morbidities and treatment outcomes are often related to the presenting co-morbidities such as depression, anxiety, catastrophising and presence of other chronic pain which must be addressed as part of management . The majority of orofacial pain is continuous so a history of episodic pain narrows down the differentials. There are specific oral conditions that rarely present extra orally such as atypical odontalgia and burning mouth syndrome whereas others will present in both areas. Musculoskeletal pain related to the muscles of mastication is very common and may also be associated with disc problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are specific diagnosis with defined care pathways. Other trigeminal neuropathic pain which can be associated with neuropathy is caused most frequently by trauma but secondary causes such as malignancy, infection and auto-immune causes need to be considered. Management is along the lines of other neuropathic pain using accepted pharmacotherapy with psychological support. If no other diagnostic criteria are fulfilled than a diagnosis of chronic or persistent idiopathic facial pain is made and often a combination of antidepressants and cognitive behaviour therapy is effective. Facial pain patients should be managed by a multidisciplinary team.

Temporomandibular disorders in burning mouth syndrome patients: an observational study

BACKGROUND

Burning Mouth Syndrome (BMS) is a chronic disease characterized by absence of any lesions and burning of the oral mucosa associated to a sensation of dry mouth and/or taste alterations. The purpose of our study is to estimate signs and symptoms of Temporomandibular Disorders (TMD) in patients with BMS and to investigate for the existence of an association between BMS and TMD.

MATERIALS AND METHODS

Forty-four BMS patients were enrolled; BMS subtype was established according to the classification of Lamey. After a gnathological evaluation, according to the protocol of the European Academy of Craniomandibular Disorders, patients were classified by RDC/TMD criteria. The data were compared and analyzed using a chi-square test to describe the existence of an association between BMS and TMD.

RESULTS

65.9% the BMS patients showed disorders classified as primary signs and symptoms of TMD according to RDC / TMD criteria, and 72.7% showed parafunctional habits. The chi-square test revealed a statistically significant association (p = 0.035) between BMS and TMD.

CONCLUSION

The data suggest that there is a possible relationship not yet well understood between BMS and TMD, may be for neurophatic alterations assumed for BMS that could be also engaged in TMD pathogenesis.

Burning mouth syndrome

Pain in the tongue or oral tissues described as "burning" has been referred to by many terms including burning mouth syndrome. When a burning sensation in the mouth is caused by local or systemic factors, it is called secondary burning mouth syndrome and when these factors are treated the pain will resolve. When burning mouth syndrome occurs in the absence of identified risk indicators, the term primary burning mouth syndrome is utilized. This article focuses on descriptions, etiologic theories, and management of primary burning mouth syndrome, a condition for which underlying causative agents have been ruled out.

Assessment of anxiety and depression in patients with burning mouth syndrome: A clinical trial

Introduction:

Burning mouth syndrome is a chronic pain syndrome primarily affecting elderly women with hormonal changes or psychological disorders. It is multifactorial in origin, often idiopathic and its etiopathogenesis, majorly being neuropathic, largely remains enigmatic.

Aim:

To determine the prevalence of burning mouth symptom, in elderly women and evaluate local and systemic causes responsible for burning sensation.

Materials and Methods:

100 elderly postmenopausal women were included in the study out of which 56 had a chief complaint of burning sensation. These patients were evaluated for the levels of anxiety and depression by means of questionnaire. The severity of burning and the response to the treatment was assessed with a five point Visual Analog Scale. The results were analyzed using “Chi-square test”.

Results:

There was statistically significant increase in the levels of anxiety and depression in the study group.

Conclusion:

The present study clearly indicates that most of the patients had moderate to severe levels of depression, which suggests that anxiety and depression are constant features in postmenopausal female patients.

Increased prevalence of geographic tongue in burning mouth complaints: a retrospective study

OBJECTIVES

The objective of this study was to assess the frequency of geographic tongue and fissured tongue (GFT) in patients with burning mouth syndrome (BMS). Our hypothesis was that benign soft tissue changes to the tongue, such as GFT, are associated with BMS.

STUDY DESIGN

Retrospective review of 161 patients with BMS and 87 TMJ dysfunction cases as control. Frequency of GFT and demographics for both groups was assessed.

RESULTS

In the BMS group, 26.7% of the subjects were diagnosed with GFT, whereas in the control group, 11.5% had GFT (P < .05). In the subgroup of BMS with GFT, the male-to-female ratio was approximately 1:2, whereas the male-to-female ratio of those with BMS and no GFT was approximately 1:5 (P < .05).

CONCLUSIONS

Our results demonstrate a higher than expected prevalence of GFT among patients with BMS compared with a control group of patients with TMJ. In males, GFT may be a significant predictor for BMS.

Salivary cortisol, 17β-estradiol, progesterone, dehydroepiandrosterone, and α-amylase in patients with burning mouth syndrome

OBJECTIVE

The aim of this study was to investigate salivary markers related with burning mouth syndrome (BMS).

MATERIALS AND METHODS

Thirty female patients with BMS and twenty female control subjects were included. Unstimulated (UWS) and stimulated whole saliva samples (SWS) were collected, and their flow rates were determined. Salivary levels of cortisol, 17β-estradiol, progesterone, dehydroepiandrosterone (DHEA), and enzymatic activity of α-amylase were determined. Salivary transferrin level was measured to determine the level of blood contamination in saliva samples.

RESULTS

  The levels of all analytes in UWS were significantly correlated with those of SWS. The levels of 17β-estradiol, progesterone, and DHEA in UWS were significantly correlated with age. Age-matched comparisons revealed that the patient group had significantly higher levels of cortisol in UWS and of 17β-estradiol in SWS. When the patients were divided into older (≥60years) and younger (<60years) groups, the older group showed a significantly lower level of progesterone in UWS. There were no significant relationships between treatment efficacy and levels of salivary analytes.

CONCLUSIONS

In conclusion, patients with BMS showed significantly higher levels of cortisol in UWS and of 17β-estradiol in SWS compared with controls.

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.

Burning mouth syndrome and secondary oral burning

Burning mouth syndrome is a complex disorder of unclear etiology that is most prevalent in perimenopausal women. It is often accompanied by dysguesia and subjective xerostomia. Recent evidence implicates both central and peripheral neuropathies, possibly representing a phantom pain syndrome in some patients. Ensuring that the patient's oral burning is not secondary to some other local or systemic factor is central to appropriate management. Current standard therapies include clonazepam, paroxetine, and cognitive behavioral therapy, and several promising new alternatives are described.