Update on burning mouth syndrome: overview and patient management

Effect of eye movement desensitization and reprocessing therapy in a patient with anxiety and burning mouth syndrome

OBJECTIVE

To propose an alternative treatment for burning mouth syndrome (BMS).

BACKGROUND

BMS is a serious condition that negatively affects the physical and emotional health of the elderly. Pharmacological interventions are not always appropriate in this population and may have significant side effects.

MATERIALS AND METHODS

We present the case of an 86-year-old woman who has been suffering from BMS for 30 years and has been experiencing impaired quality of life, particularly sleep disturbances. Because standard pharmaceutical medications failed to alleviate the patient's pain, we proposed EMDR as an alternative therapeutic approach. Baseline measures included depressive symptoms, anxiety symptoms, daytime and nighttime pain and sleep quality. To anticipate anxious thoughts associated with pain, seven 45-min EMDR sessions were conducted.

RESULTS

Therapy resulted in reduced anxiety symptoms (-30%), improved pain control (-10% daytime, -60% nighttime) and improved sleep quality (+50%). This positive effect lasted for 4 months, and no serious negative effects were observed.

CONCLUSION

EMDR therapy may help older adults with BMS improve their pain and psychological management.

Comprehensive analysis of the oral microbiota and metabolome change in patients of burning mouth syndrome with psychiatric symptoms

Background

Burning mouth syndrome (BMS) is a chronic idiopathic facial pain with intraoral burning or dysesthesia. BMS patients regularly suffer from anxiety/depression, and the association of psychiatric symptoms with BMS has received considerable attention in recent years. The aims of this study were to investigate the potential interplay between psychiatric symptoms and BMS.

Methods

Using 16S rRNA sequencing and liquid chromatography-mass spectrometry (LC/MS) to evaluate the oral microbiota and saliva metabolism of 40 BMS patients [including 29 BMS patients with depression or anxiety symptoms (DBMS)] and 40 age matched healthy control (HC).

Results

The oral microbiota composition in BMS exhibited no significant differences from HC, although DBMS manifested decreased α-diversity relative to HC. Noteworthy was the discernible elevation in the abundance of proinflammatory microorganisms within the oral microbiome of individuals with DBMS. Parallel findings in LC/MS analyses revealed discernible disparities in metabolites between DBMS and HC groups. Principal differential metabolites were notably enriched in amino acid metabolism and lipid metabolism, exhibiting associations with infectious and immunological diseases. Furthermore, the integrated analysis underscores a definitive association between the oral microbiome and metabolism in DBMS.

Conclusions

This study suggests possible future modalities for better understanding the pathogenesis and personalized treatment plans of BMS.

Duloxetine improves chronic orofacial pain and comorbid depressive symptoms in association with reduction of serotonin transporter protein through upregulation of ubiquitinated serotonin transporter protein

ABSTRACT

Chronic orofacial pain (COP) is relieved by duloxetine (DLX) and frequently causes depressive symptoms. The aim of this study was to confirm effects of DLX on pain and depressive symptoms, and to associate with their effectiveness in platelet serotonin transporter (SERT) expression, which is a target molecule of DLX and plasma serotonin concentration in COP patients with depressive symptoms. We assessed for the severity of pain and depressive symptoms using the Visual Analog Scale (VAS) and 17-item Hamilton Depression Rating Scale (HDRS), respectively. Chronic orofacial pain patients were classified into 2 groups based on their HDRS before DLX-treatment: COP patients with (COP-D) and without (COP-ND) depressive symptoms. We found that the VAS and HDRS scores of both groups were significantly decreased after DLX treatment compared with those before DLX treatment. Upregulation of total SERT and downregulation of ubiquitinated SERT were observed before DLX treatment in both groups compared with healthy controls. After DLX treatment, there were no differences in total SERT of both groups and in ubiquitinated SERT of COP-D patients compared with healthy controls; whereas, ubiquitinated SERT of COP-ND patients remained downregulated. There were positive correlations between changes of serotonin concentrations and of VAS or HDRS scores in only COP-D patients. Our findings indicate that DLX improves not only pain but also comorbid depressive symptoms of COP-D patients. Duloxetine also reduces platelet SERT through upregulation of ubiquitinated SERT. As the result, decrease of plasma serotonin concentrations may be related to the efficacy of DLX in relieving pain and depression in COP patients.

Clinical characteristics and salivary biomarkers of burning mouth syndrome

OBJECTIVES

To investigate the clinical characteristics and salivary biomarkers in each type of burning mouth syndrome (BMS) patients.

MATERIALS AND METHODS

Ninety-eight postmenopausal female patients with BMS were included. Fifty and 21 patients were assigned to the primary and secondary groups, respectively. Twenty-seven patients with both primary and secondary characteristics were assigned to the intermediate group. Comprehensive clinical characteristics and salivary biomarkers were analyzed.

RESULTS

Significant differences in age, proportion of hyposalivator patients based on unstimulated whole saliva (UWS), symptom distribution, severties of burning sensation and effect of oral complaints in daily life (Eff-life), and positive symptom distress index (PSDI) were observed among the three groups. The primary group had significant higher UWS flow rate, fewer UWS hyposalivator proportions, and lesser severity of Eff-life than the secondary group. The intermediate group had significantly greater intensities of burning sensation and Eff-life and higher PSDI score than did the primary group. The primary group had significantly higher cortisol and dehydroepiandrosterone (DHEA) levels in stimulated whole saliva than did the secondary group.

CONCLUSIONS

This study's findings show that clinical characteristics differentiate each BMS type. Cortisol and DHEA levels are potential salivary biomarkers for discriminating between the primary and secondary types of BMS.

Amitriptyline effectiveness in burning mouth syndrome: An in-depth case series analysis

OBJECTIVES

To assess the effectiveness of amitriptyline (AMT), and to identify the determinants of the treatment's effectiveness in patients diagnosed with burning mouth syndrome (BMS).

BACKGROUND

Treatment of BMS is challenging and no established treatment protocol is available. AMT may be an important treatment option, cout not all patients benefit from this drug. Studies assessing factors related to treatment response are valuable in improving decision-making.

MATERIALS AND METHODS

This case series study examined the medical records of all patients diagnosed with BMS at an oral medicine unit in a university hospital from 2008 to 2022. The patients were divided into responders to AMT and non-responders to AMT. Data on demographic information, comorbidities, medications, types of symptoms and oral subsites affected were collected. Descriptive and bivariate analyses were conducted to assess the association between the independent variables and the outcome, using the Chi-squared test (P < .05).

RESULTS

Three hundred and fourty-nine patients reported a burning mouth sensation, 50 of them (14.3%) being diagnosed with primary BMS. Of these, 35 were treated with AMT, and 26 (74.2%) responded significantly to AMT. All males responded to AMT, whereas only 67.9% of females responded. The mean dose of AMT among responders was 29.8 ± 12.3 mg, with most patients achieving a response with 25 mg (61.5% of patients), followed by 50 mg (23%). The concomitant use of an anticonvulsant resulted in non-response.

CONCLUSIONS

AMT may be effective in BMS management for most patients.

Salivary and serum biomarkers to evaluate psychological disorders in burning mouth syndrome: A systematic review and meta-analysis

BACKGROUND

Burning mouth syndrome is a chronic pain syndrome mainly characterized by an intensive burning sensation of tongue. Previous studies have suggested that saliva/serum biomarkers in burning mouth syndrome might be associated with psychological disorders. The aim of systematic review was to observe whether the biomarkers in serum/saliva could be an alternative method to evaluate the psychological disorders in patients with burning mouth syndrome.

MATERIALS AND METHODS

The PubMed, Embase, and Cochrane Library databases were searched for papers published up to March 15, 2023. Risk of bias was measured by using the Newcastle-Ottawa Scale. RevMan was used for meta-analysis.

RESULTS

A total of 467 articles were screened, which of 12 studies were included. These studies collected 43 different biomarkers in saliva and 35 in serum. Of these biomarkers, only three (cortisol, α-amylase, and IL-6) were analyzed in two or more studies. Only salivary cortisol levels were significantly higher in the patient group compared to the controls (Mean Difference = 1.39; 95% CI [0.80-1.97]; p < 0.001). Moreover, cortisol might be relevant to psychological scores, especially anxiety.

CONCLUSION

Different papers have investigated salivary and serum biomarkers in burning mouth syndrome patients with controversial results. This meta-analysis showed that cortisol levels in saliva may be a potential biomarker to assess the psychological disorders in burning mouth syndrome patients.

Photobiomodulation alleviates Burning Mouth Syndrome pain: Immediate and weekly outcomes explored

Burning Mouth Syndrome (BMS) is an intraoral chronic burning or dysesthetic sensation, without clinically evident causative lesions on clinical examination and investigation.

AIM

To assess immediate and weekly effects of photobiomodulation (PBM) on BMS patients.

METHODS

Thirty BMS patients were treated intra-orally with photobiomodulation 940(±10) nm (InGaAsP) 3 W, semi-conductor diode, weekly, for up to 10 weeks. Pain intensity, measured using the Visual Analogue Scale (VAS), and characteristics were recorded immidiately after each treatment, along with a weekly average VAS.

RESULTS

Immediate mean VAS score decreased from a starting score of 7.80 ± 1.83 to 2.07 ± 2.55 (p < 0.001). The mean weekly VAS score for the week after the final treatment session was higher (5.73 ± 2.80, p < 0.001) than the immediate response, but still significantly lower than the starting score (p = 0.017). We observed a trend of pain improvement with more treatments, but this was only statistically significant up to the third treatment. Male gender and unilateral pain correlated with better PBM efficacy (p = 0.017, 0.022, respectively).

CONCLUSION

PBM provides significant immediate pain relief for BMS patients after each treatment; however, the efficacy decreases notably over the following week. A trend of increasing pain relief across treatments was observed, statistically significant up to the third treatment.

Clinical and epidemiological profile of burning mouth syndrome patients following the International Headache Society classification: a systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to determine the clinical and epidemiologic profile of patients with burning mouth syndrome (BMS) following the current classification of the International Headache Society (IHS)-the International Classification of Headache Disorders (ICHD-3) and the International Classification of Orofacial Pain (ICOP).

STUDY DESIGN

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and involved a comprehensive search on PubMed, Scopus, EMBASE, Web of Science, LILACS, and the gray literature.

RESULTS

Of the 4,252 studies identified, 41 were included. In general, there were no differences between the clinical and epidemiologic profiles of patients with BMS classified based on ICHD-3 or ICOP. Studies were pooled in meta-analyses and showed a significant prevalence of female patients between the sixth and seventh decade of life. The burning sensation and the tongue were the most prevalent descriptors and affected location. Significant associations were demonstrated between BMS and anxiety (P = .0006), depression (P = .004), and poor oral hygiene (P = .00001).

CONCLUSIONS

Under the existing contemporary classification systems, patients with BMS were found to be mostly females in the sixth and seventh decade of life with a burning sensation on the tongue. Experiencing depression and anxiety was a commonly existing comorbidity.

WWOM VII: Effectiveness of topical interventions in the management of burning mouth syndrome: A systematic review

OBJECTIVES

To assess the effectiveness of topical interventions in the management of burning mouth syndrome (BMS), based on the core outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT).

METHODS

A systematic literature review of RCTs on topical interventions for the management of BMS, published in PubMed, Web of Science, PsycInfo, Cochrane Database/Central, and Google Scholar through May 2021 was performed.

RESULTS

Eight RCTs (n = 358 study participants) were included in this study. Due to underreporting of IMMPACT domains, publication bias, high degree of heterogeneity between studies, meta-analysis was not undertaken. Based on changes in visual analogue pain scores (ΔVAS), the most reported outcome, the effectiveness of the topical interventions was demonstrated; however, it is low level of evidence.

CONCLUSIONS

High levels of variability (interventions, outcomes, outcome measurement tools, and intervention effects evaluated), heterogeneity, publication bias, and underreporting of IMMPACT domains were observed across the RCTs. This systematic review highlights the need for application of standardized outcome measures to future RCTs. At the present time, there is lack of moderate-strong evidence on short- and long-term outcomes to support or refute the use of any particular topical intervention in managing BMS. Future RCTs with standardized outcome measures are needed.

Antidepressant-induced burning mouth syndrome: A case report

Burning mouth syndrome is a chronic condition characterized by oral pain in the absence of intraoral clinical signs. The pathogenesis and etiology of burning mouth syndrome are not fully understood. Both men and women of all ages are at risk of developing this syndrome, but women are at an even higher risk. The management of burning mouth syndrome usually consists of the use of antidepressants. In this case report, we present a case of a 75-year-old lady who presented to the psychiatric clinic for management of her depressive symptoms. She was prescribed escitalopram and her dose was later increased. She then started experiencing a burning sensation in her mouth. She was seen by dental, medical, and psychological specialties regarding her symptoms. After careful historical and clinical evaluation, she was finally diagnosed with antidepressant-induced burning mouth syndrome. Antidepressant-induced burning mouth syndrome is a rare but very important condition to recognize. It has a huge effect on patients' quality of life. The management of patients with antidepressant-induced burning mouth syndrome needs the involvement of a multidisciplinary team. Further high-quality studies are needed to help healthcare professionals better approach such patients.

Hypovitaminosis D, objective oral dryness, and fungal hyphae as three precipitating factors for a subset of secondary burning mouth syndrome

Objective

Elucidating the concurrence and interdependence of three precipitating factors as contributors of a subset of secondary burning mouth syndrome (BMS), which is defined having detectable precipitating factors.

Design

47 secondary BMS and 15 non-BMS cases were sourced from medical records of an Oral Pathology Specialty Clinic in Canada (2017-2021). Each case had Cytology, Hematology, and Sialometry tests to detail the state of three precipitating factors (the presence of fungal hyphae, hypovitaminosis D, and objective oral dryness). Three factors were compared between secondary BMS and non-BMS groups independently, in pairs, and as a triple-factor by Fisher's exact tests, Contingency Coefficients, and Logistic Regressions.

Results

Rates of objective oral dryness (89.36%) and hypovitaminosis D (74.47%) in the secondary BMS group significantly differ from the non-BMS group (p = 0.0013, p = 0.0016). No difference was found in the incidence of fungal hyphae between BMS (91.49%) and non-BMS groups (p = 0.0881). Rates of three precipitating factors in pairs and as a triple-factor within the secondary BMS group significantly differ from the non-BMS group (p-values from 0.0011 to <0.0001). Their significant correlations with secondary BMS are found independently (excluding fungal hyphae), in pairs, and as a triple-factor (C-values from 0.371 to 0.461, p-values from 0.002 to <0.001). The highest C-value belongs to the triple-factor. Objective oral dryness (p = 0.009) and hypovitaminosis D (p = 0.008) are confirmed as significant predictors for secondary BMS.

Conclusions

The presence of fungal hyphae contribute to a subset of secondary BMS only when coinciding with objective oral dryness, hypovitaminosis D, or both. This interdependent relationship leads to a hypothesis that hypovitaminosis D, which is commonly called "a low value of vitamin D", and objective oral dryness make an oral environment conducive to insidious Candida invasion, which is an intermediate status of the host-fungal interaction staying between healthy oral mucosa (non-infection) and oral candidiasis (infection).

Association between Salivary Cortisol and α-Amylase with the Psychological Profile of Patients with Oral Lichen Planus and Burning Mouth Syndrome: A Case-Control Study

The aim of our study was to assess the relationship between the concentration/activity of salivary stress biomarkers (cortisol, α-amylase) and the psychological profile of patients with oral lichen planus (OLP) and primary burning mouth syndrome (BMS). A total of 160 subjects participated in this case-control study: 60 patients with OLP; 60 patients with primary BMS; and 40 control subjects. Unstimulated whole saliva (UWS) was collected between 9 and 10 a.m. Salivary biomarkers were analyzed by enzyme-linked immunosorbent assays (ELISAs). Psychological assessment was evaluated with the Depression, Anxiety, and Stress Scale (DASS-21). The patients with primary BMS had higher salivary cortisol concentrations and α-amylase activity (0.52 vs. 0.44 µg/dL; 160,531 vs. 145,804 U/L; one-way analysis of variance (ANOVA) with post hoc Scheffe test) compared with patients with OLP. The patients with primary BMS had statistically significant higher scores for depression, anxiety, and stress compared with patients with OLP and control subjects (p < 0.001, Kruskal-Wallis test). There was a strong positive correlation between anxiety and depression, stress and depression, and stress and anxiety in patients with OLP and BMS (p < 0.001 and p < 0.001, respectively; Spearman's correlation). There was a good positive correlation between symptom intensity (pain/burning) and psychological profile (depression, anxiety, stress) in patients with primary BMS (r = 0.373, p = 0.003; r = 0.515, p < 0.001; r = 0.365, p = 0.004, respectively; Spearman's correlation). This case-control study is the first to compare the psychoendocrinological profile of patients with two different oral diseases. The patients with BMS showed a higher concentration/activity of salivary stress biomarkers (cortisol, α-amylase) and a stronger association with mental disorders compared with patients with OLP. However, an interdisciplinary psychoneuroimmunological approach is equally important in both patient groups (OLP and BMS), regardless of whether mental disorders are the cause or the consequence.

Effects of self-perceived psychological stress on clinical symptoms, cortisol, and cortisol/ACTH ratio in patients with burning mouth syndrome

BACKGROUND

Psychological stress is a crucial parameter in defining the symptoms of burning mouth syndrome (BMS). We hypothesized that the level of psychological stress in patients with BMS would correlate with severity of clinical symptoms, cortisol levels, and cortisol/ adrenocorticotropic hormone (ACTH) ratio. We aimed to comprehensively investigate the influence of clinical and hematologic parameters on the hypothalamic-pituitary-adrenal axis, particularly concerning the presence or absence of self-perceived psychological stress in patients with BMS. In addition, we aimed to identify parameters predicting psychological stress in these patients.

METHODS

One hundred and forty-one patients with BMS (117 women, 82.98%; 56.21 ± 13.92 years) were divided into psychological stress (n = 68; 55 females, 56.39 ± 12.89 years) and non-psychological stress groups (n = 73; 62 females, 56.03 ± 14.90 years), and inter- and intra-group statistical analyses were conducted. Significant predictors of psychological stress in patients with BMS were investigated through multiple logistic regression analysis.

RESULTS

The prevalence of xerostomia was significantly higher (67.6% vs. 34.2%, p < 0.001), while unstimulated salivary flow rate was lower (0.66 ± 0.59 vs. 0.91 ± 0.53 mL/min, p < 0.01) in the psychological stress group than in the non-psychological stress group. SCL-90R subscale values for somatization, hostility, anxiety, and depression, as well as cortisol and ACTH levels and the cortisol/ACTH ratio, were also higher in the psychological stress group (all p < 0.05). Above-mean values for cortisol (AUC = 0.980, 95%CI: 0.959-1.000) and cortisol/ACTH (AUC = 0.779; 95%CI, 0.701-0.856) were excellent predictors of psychological stress, with cortisol (r = 0.831, p < 0.01) and cortisol/ACTH (r = 0.482, p < 0.01) demonstrating substantial correlations. Above-average values for cortisol (OR = 446.73) and cortisol/ACTH (OR = 6.159) significantly increased incidence of psychological stress in patients with BMS (all p < 0.001).

CONCLUSIONS

Among patients with BMS, xerostomia, decreased salivary flow rate, increased cortisol levels, and cortisol/ACTH ratio were associated with psychological stress, highlighting the psycho-neuro-endocrinological features of this condition. Cortisol and cortisol/ACTH ratio were strong predictors of psychological stress in patients with BMS.

Exploring the Association of Burning Mouth Syndrome with Depressive and Anxiety Disorders in Middle-Aged and Older Adults: A Systematic Review

BACKGROUND

Burning Mouth Syndrome (BMS) is an idiopathic condition mainly affecting middle-aged and older individuals with hormonal disturbances or psychiatric disorders and is characterized by chronic pain. The etiopathogenesis of this multifactorial syndrome is largely unknown. The objective of the present systematic review was therefore to evaluate the relationship of BMS with depressive and anxiety disorders in middle-aged and older individuals.

METHODS

We selected studies evaluating BMS and depressive and anxiety disorders assessed with validated tools, published from their inception up to April 2023, using PubMed, MEDLINE, EMBASE, Scopus, Ovid, and Google Scholar databases and adhering to the PRISMA 2020 guidelines/PRISMA 2020 27-item checklist. This study is registered on PROSPERO (CRD42023409595). The National Institutes of Health Quality Assessment Toolkits for Observational Cohort and Cross-Sectional Studies were used to examine the risk of bias.

RESULTS

Two independent investigators rated 4322 records against the primary endpoint and found 7 records meeting the eligibility requirements. Anxiety disorders were found to be the most common psychiatric disorders related to BMS (63.7%), followed by depressive disorders (36.3%). We found a moderate association of BMS with anxiety disorders, with multiple studies included (n = 7). Moreover, we found a low association of BMS with depressive disorders (included studies, n = 4). The role of pain appeared to be controversial in explaining these associations.

CONCLUSIONS

In middle-aged and older subjects, anxiety and depressive disorders may be potentially related to the development of BMS. Furthermore, also in these age groups, females showed higher risk of developing BMS than males, even when taking into account multimorbidity such as sleep disorders, personality traits, and biopsychosocial changes as suggested by study-specific findings.

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.

Oral Implications of Polypharmacy in Older Adults

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Psychological Functioning of Women Diagnosed with Lichen Planus and Other Diseases of the Oral Cavity-Explorative Study

The role of psychosocial factors in the development of changes in lichen planus and other diseases of the oral cavity has been implicated, but is still understudied. Therefore, the aim of our study was to describe the specific profile of psychological functioning of patients with these diseases, including the role of temperamental traits, action-oriented personality components, and self-esteem. In total, 94 adult women participated in the study: (1) with lichen planus (LP; n = 46; Mage = 54.80, SD = 12.53), (2) with other oral conditions (n = 25; Mage = 34.76, SD = 16.03), (3) without chronic disease (n = 24; Mage = 40.96, SD = 13.33). The following questionnaires were used: ZKA-PQ/SF, Polish Adaptive and Maladaptive Perfectionism Questionnaire, ACS-90, PROCOS, and MSEI. Results indicated no significant differences in temperament dimensions between studied groups. However, women diagnosed with LP presented lower levels of maladaptive perfectionism and social support than healthy women. Furthermore, women with LP also obtained lower scores for social resourcefulness and higher scores for moral self-approval than healthy women. Summarizing, patients with LP often use compensatory mechanisms that negatively affect their social functioning; thus diagnostic/therapeutic programs directed towards those group should be holistic, including psychologists and psychiatrists who support patients' psychological well-being.

Orofacial Pain Management: An Overview of the Potential Benefits of Palmitoylethanolamide and Other Natural Agents

Pain is the most common symptom that dentists are confronted with, whether acute (pulpitis, acute periodontitis, post-surgery, etc.) or chronic diseases, such as periodontitis, muscle pain, temporomandibular joint (TMJ) disorders, burning mouth syndrome (BMS), oral lichen planus (OLP) and others. The success of therapy depends on the reduction in and management of pain through specific drugs, hence the need to analyze new pain medications with specific activity, which are suitable for long-term use, with a low risk of side effects and interactions with other drugs, and capable of leading to a reduction in orofacial pain. Palmitoylethanolamide (PEA) is a bioactive lipid mediator, which is synthesized in all tissues of the body as a protective pro-homeostatic response to tissue damage and has aroused considerable interest in the dental field due to its anti-inflammatory, analgesic, antimicrobial, antipyretic, antiepileptic, immunomodulatory and neuroprotective activities. It has been observed that PEA could play a role in the management of the pain of orofacial origin, including BMS, OLP, periodontal disease, tongue a la carte and temporomandibular disorders (TMDs), as well as in the treatment of postoperative pain. However, actual clinical data on the use of PEA in the clinical management of patients with orofacial pain are still lacking. Therefore, the main objective of the present study is to provide an overview of orofacial pain in its many manifestations and an updated analysis of the molecular pain-relieving and anti-inflammatory properties of PEA to understand its beneficial effects in the management of patients with orofacial pain, both neuropathic and nociceptive in nature. The aim is also to direct research toward the testing and use of other natural agents that have already been shown to have anti-inflammatory, antioxidant and pain-relieving actions and could offer important support in the treatment of orofacial pain.

The efficacy of alpha-lipoic acid in the management of burning mouth syndrome: An updated systematic review of randomized controlled clinical trials

Background and Aims

Burning mouth syndrome (BMS) causes burning or uncomfortable feelings in the oral cavity without any obvious injuries. This condition's etiopathogenesis is still unknown, consequently, BMS management is very challenging. Alpha-lipoic acid (ALA) is a naturally occurring potent bioactive compound that has been found to be useful in the management of BMS in many studies. Therefore, we conducted a comprehensive systematic review to investigate the usefulness of ALA in the management of BMS based on randomized controlled trials (RCTs).

Methods

Different electronic databases, including PubMed, Scopus, Embase, Web of Science, and Google Scholar, were extensively searched to find relevant studies.

Results

This study included nine RCTs that matched the inclusion criteria. In most studies, ALA was given at a dose of 600-800 mg/day, with up to two months of follow-up. The majority of studies (six out of nine studies) indicated that ALA was more effective in BMS patients than in the placebo-controlled group.

Conclusions

This comprehensive systematic review provides evidence of the positive outcomes of the treatment of BMS with ALA. However, more research might be needed before ALA can be considered the first-line therapy for BMS.

Circadian rhythm of PERIOD2::LUCIFERASE expression in the trigeminal ganglion of mice

Introduction

The trigeminal nerve conveys delicate sensations such as warmth, pain, and tactile pressure in the oral and facial regions, and most trigeminal afferent cell bodies are located in the trigeminal ganglion. Our previous study has shown that sensations in trigeminal nerve innervated areas, specifically in the maxillofacial region, exhibit diurnal variation and that sensitivity changes time-dependently. In this study, we aimed to clarify the rhythm of expression of clock gene in the trigeminal ganglion of mice to elucidate the mechanism of circadian regulation in the same area.

Methods

Immunohistochemistry examined the expression of the PER2 protein in the suprachiasmatic nucleus and trigeminal ganglion of wild-type mice. To measure gene expression as bioluminescence, PERIOD2::LUCIFERASE knock-in (PER2::LUC) mice were used. Unilateral trigeminal ganglion and brain sections including the suprachiasmatic nucleus were incubated ex vivo. Bioluminescence levels were then measured using a highly sensitive photodetector. The same experiments were then conducted with Cry1 gene-deficient (Cry1−/−) or Cry2 gene-deficient (Cry2−/−) mice.

Results

In the trigeminal ganglion, immunohistochemistry localized PER2 protein expression within the neuronal cell body. Mouse trigeminal ganglion ex vivo tissues showed distinct circadian oscillations in PER2::LUC levels in all genotypes, wild-type, Cry1−/−, and Cry2−/−. The period was shorter in the trigeminal ganglion than in the suprachiasmatic nucleus; it was shorter in Cry1−/− and longer in Cry2−/− mice than in the wild-type mice.

Conclusion

The expression of Per2 in neurons of the trigeminal ganglion in ex vivo culture and the oscillation in a distinct circadian rhythm suggests that the trigeminal ganglion is responsible for the relay of sensory inputs and temporal gating through autonomous circadian oscillations.

WWOM VII: Effectiveness of systemic pharmacotherapeutic interventions in the management of BMS: A systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of systemic pharmacotherapeutic interventions compared to placebo in burning mouth syndrome (BMS) randomized controlled trials (RCTs) based on the core outcome domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT).

METHODS

A systematic literature review of RCTs, concerning systemic pharmacotherapeutic interventions for BMS, published from January 1994 through October 2019, and meta-analysis was performed.

RESULTS

Fourteen RCTs (n = 734 participants) were included. Of those, nine were eligible for the quantitative assessment due to the availability/homogeneity of data for at least one of the IMMPACT domains. Pain intensity was the only domain reported in all RCTs. Weighted mean changes in pain intensity, based on visual analogue scale (ΔVAS), were reported in three RCTs at 6 ± 2 weeks and only one RCT at 10+ weeks follow-ups. Quantitative assessment, based on ΔVAS, yielded very low evidence for the effectiveness of alpha-lipoic acid and clonazepam, low evidence for effectiveness of trazodone and melatonin, and moderate evidence for herbal compounds.

CONCLUSIONS

Based on the RCTs studied, variable levels of evidence exist that suggest that select pharmacological interventions are associated with improved symptoms. However, the underreporting of IMMPACT domains in BMS RCTs restricts the multidimensional assessment of systemic interventions outcomes. Standardized outcome measures need to be applied to future RCTs to improve understanding of intervention outcomes.

Salivary metabolome indicates a shift in tyrosine metabolism in patients with burning mouth syndrome: a prospective case-control study

ABSTRACT

The pathophysiology of primary burning mouth syndrome (BMS) remains controversial. Targeted analyses or "omics" approach of saliva provide diagnostic or pathophysiological biomarkers. This pilot study's primary objective was to explore the pathophysiology of BMS through a comparative analysis of the salivary metabolome among 26 BMS female cases and 25 age- and sex-matched control subjects. Secondary objectives included comparative analyses of inflammatory cytokines, neuroinflammatory markers, and steroid hormones among cases and control subjects, and among BMS patients according to their clinical characteristics. Salivary metabolome, neuroinflammatory markers, cytokines, and steroids were, respectively, analysed by liquid chromatography coupled with mass spectrometry, ELISA and protease activity assay, and multiparametric Luminex method. Among the 166 detected metabolites, univariate analysis did not find any discriminant metabolite between groups. Supervised multivariate analysis divided patients into 2 groups with an accuracy of 60% but did not allow significant discrimination (permutation test, P = 0.35). Among the metabolites contributing to the model, 3 belonging to the tyrosine pathway ( l -dopa, l -tyrosine, and tyramine) were involved in the discrimination between cases and control subjects, and among BMS patients according to their levels of pain. Among the detectable molecules, levels of cytokines, steroid hormones, and neuroinflammatory markers did not differ between cases and control subjects and were not associated with characteristics of BMS patients. These results do not support the involvement of steroid hormones, inflammatory cytokines, or inflammatory neurogenic mediators in the pathophysiology of pain in BMS, whereas the observed shift in tyrosine metabolism may indicate an adaptative response to chronic pain or an impaired dopaminergic transmission.

Relationship of Depression, Anxiety, and Bipolar Disease with Burning Mouth Syndrome: A Nationwide Cohort Study

Burning mouth syndrome (BMS) is a chronic, painful condition of the oral mucosa. Although the pathogenesis remains unclear, psychological and neuroendocrine factors are considered the major contributors. Few longitudinal studies have investigated the effects of psychological factors on the occurrence of BMS. Therefore, we evaluated the risk of BMS in patients with affective disorders using a nationwide population-based cohort dataset. We identified patients with depression, anxiety, and bipolar disorder and then selected comparison participants using the 1:4 propensity score-matching method. We investigated the incidence of BMS events during the follow-up period using survival analysis, the log-rank test, and Cox proportional hazards regression models. After adjusting for other contributing conditions, the adjusted hazard ratio (HR) for developing BMS was 3.37 (95% confidence interval [CI]: 1.67-6.80) for depression and 5.09 (95% CI: 2.19-11.80) for anxiety; however, bipolar disorder showed no significant risk. Specifically, female patients with depression and anxiety had an increased risk of BMS. Moreover, patients with anxiety showed an increased adjusted HR of BMS events during the first 4 years after diagnosis, whereas patients with depression did not. In conclusion, depression and anxiety disorders are significantly associated with the risk of BMS. Additionally, female patients showed a significantly higher risk of BMS than male patients, and anxiety showed increased BMS events earlier than depression. Therefore, clinicians should consider the risk of BMS when treating patients with depression or anxiety.

Dental sleep-related conditions and the role of oral healthcare providers: A scoping review

Dental sleep medicine as a discipline was first described about a quarter of a century ago. Snoring, obstructive sleep apnea, sleep bruxism, xerostomia, hypersalivation, gastroesophageal reflux disease, and orofacial pain were identified as dental sleep-related conditions. This scoping review aimed to: i) identify previously unidentified dental sleep-related conditions; and ii) identify the role of oral healthcare providers in the prevention, assessment, and management of dental sleep-related conditions in adults. A systematic literature search was conducted in PubMed, Embase.com, Web of Science, and Cochrane. Studies that reported an actual or likely role of oral healthcare providers in the prevention, assessment, and/or management of sleep-related conditions were included. Of the 273 included studies, 260 were on previously listed dental sleep-related conditions; the other 13 were on burning mouth syndrome. Burning mouth syndrome was therefore added to the list of dental sleep-related conditions for the first aim and categorized into sleep-related orofacial pain. For the second aim, the role of oral healthcare providers was found to be significant in the prevention, assessment, and management of obstructive sleep apnea and sleep bruxism; in the assessment and management of snoring, sleep-related orofacial pain, and oral dryness; and in the assessment of sleep-related gastroesophageal reflux condition.

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.

Association of medications with burning mouth syndrome in Taiwanese aged patients

Background/purpose

Burning mouth syndrome (BMS) occurs more frequently in middle-aged or elderly patients, especially the older female patients. It may relate to multiple medications in the older people. This study aimed to evaluate the association of polypharmacy with BMS.

Materials and methods

Eighty BMS patients aged from 45 to 80 years were recruited into this study, and their medical data, especially the medication records, were collected and analyzed to assess the association of polypharmacy with BMS.

Results

Of the 80 BMS patients, 14 did not take any medication, 38 took 1-4 medicines, 17 took 5-8 medicines, and 11 took ≥9 medicines. The mean number of medicines taken by each BMS patient is 4.49. For the 80 BMS patients, the mean number of medicines taken by each BMS patient was significantly higher in the older age group (7.00 ± 7.76; age ≥65 years; n = 31) than in the relatively younger age group (2.90 ± 2.95; age 45-64 years; n = 49) (P = 0.001). The similar result was also observed in the female BMS patients. We also found that psychotropics, gastroprotectors and gastrointestinal tract (GI)-associated drugs, and antihypertensives were the three most commonly used drugs in our 80 BMS patients. Among them, the relatively high frequencies of using anxiolytics and antidepressants in the psychotropics, and beta-blockers in the antihypertensives were observed.

Conclusion

Our findings suggest that multiple medications (polypharmacy) may play an important role in the development of BMS, especially for the older female BMS patients.

Síndrome de boca ardiente, abordaje otorrinolaringológico. Revisión bibliográfica sistemática

Introducción y objetivo: El síndrome de boca ardiente (SBA) es una afección crónica, que cursa con quemazón o dolor de la mucosa bucal, afectando predominantemente a mujeres de edad media. Puede aparecer como cuadro primario o bien de forma secundaria. La fisiopatología de esta entidad es bastante desconocida. Existe un amplio abanico terapéutico, pero por lo general precisa de un abordaje multidisciplinar. Nuestra intención es realizar una puesta al día de la enfermedad para poder hacerla frente en la consulta de otorrinolaringología. Método: Revisión bibliográfica de la literatura. Fecha de publicación limitada de 2012 a 2022. Resultados: El SBA presenta una etiopatogenia de carácter multifactorial. Para su diagnóstico es necesario realizar una exhaustiva anamnesis y exploración. Se diferencian 3 tipos distintos de SBA, siendo el tipo II el más frecuente y el más refractario a la terapia. El adecuado tratamiento se fundamenta en un correcto diagnóstico y debe ser multidisciplinar. Discusión: Es importante resaltar que es una entidad benigna. Los tratamientos son variados y no hay ninguno que destaque sobre el resto, lo que dificulta el manejo de estos pacientes. Aunque la bibliografía sobre este síndrome es abundante, no se han producido en los últimos años, importantes innovaciones en cuanto a la etiología y tratamiento. Conclusiones: La anamnesis y los estudios de laboratorio son fundamentales para descartar casusas secundarias de la enfermedad. La terapia es diversa y debe incluir derivación a salud mental como parte del manejo multidisciplinar.  

Stress as worsening of the signs and symptoms of the geographic tongue during the COVID-19 pandemic: a pilot study

BACKGROUND

Geographic Tongue (GT) is a benign inflammatory disorder of unknown etiology, which is characterized by the loss of epithelium due to the atrophy of filiform papillae. It usually occurs on the dorsum of the tongue and may extend to its lateral edges. It appears as an erythematous area surrounded by whitish and slightly elevated margins. In most cases, the condition is asymptomatic, although some individuals may report symptoms that include a burning sensation of the tongue.

OBJECTIVE

Assess whether there was a change in the clinical aspect of Geographic Tongue (GT) during the COVID-19 pandemic.

METHODS

Thirty-two participants were recruited from Dentistry School Universidade Federal Fluminense. Anamnesis and oral examination were performed to collect medical history. The participants were split into two groups: control group (no GT) n = 20 and test group (with GT) n = 12. In the second step, nine participants from a 12 (75%) of the test group were contacted by phone and answered a questionnaire about changes in the signs and symptoms of GT during the pandemic. The subjects were subdivided into two groups: GT with and without signs and symptoms exacerbation.

RESULTS

In the first phase of the research, no statistical difference between control and test groups was observed regarding clinical criteria such as age (p + 0.72), gender (p = 0.24), and systemic diseases (p = 0.58). In the second phase, there was a statistical difference between GT groups with or without symptom exacerbation in terms of age and stress as a factor of the oral symptoms (p = 0.3 and 0.2), respectively. Younger patients showed a worsening of the oral lesions related to GT (p = 0.3) and reported stress during the pandemic (p = 0.02).

CONCLUSION

Younger patients were more susceptible to stress and presented more exacerbation of the oral lesions related to GT.

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.

Oral and Mucosal Complaints among Institutionalized Care Seniors in Malopolska Voivodeship-The Utility of the Mirror Sliding Test in an Assessment of Dry Mouth

The purpose of this article was to evaluate reported oral and mucosal complaints among seniors residing in institutionalized 24-h care of the Municipal Center for Older and Dependent People (MHCOD) and the 3-month rehabilitation program of the Daily Medical Care House (DMCH). We evaluated the feasibility of using the dental mirror slidding test to assess dry mouth of seniors. Patients underwent a questionnaire, and clinical examination. The Visual Analogue Scale (VAS) was used to assess pain, Fox's questionnaire and Challacombe's scale with Clinical Oral Dryness Score to assess dryness of the mouth, dental mirror slidding test to assess buccal mucosal resistance. Dryness, mucosal burning, impaired taste, food intake are symptoms associated with seniors, and their frequency does not depend on the type of care. The incidence of mucosal burning (Mdn = 4.0, IQR = 4.75, p = 0.032) and difficulty in using dental prosthetics (Mdn = 3.0, IQR = 4.00, p = 0.010) increase with the length of stay at MHCOD. Seniors are at risk of side effects of polypharmacy, which cause dryness (p = 0.036), complaints of lack of saliva (p = 0.009) and taste disorders (p = 0.041. Seniors with higher levels of dry mouth are more likely to exhibit mucosal burning (p = 0.026) and difficulty in taking food (p = 0.037). The implementation of the dental mirror slidding test in the scope of the primary care of geriatric examination should be discussed.

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.

Challenge in the diagnosis, evaluation, and management of burning mouth sensation: A retrospective cohort study

BACKGROUND

Burning mouth sensation is a common symptom with varying etiologies that can affect patient quality of life. The authors aimed to investigate the clinical characteristics, differentiate the underlying causes, and evaluate the impact on quality of life of patients with burning mouth sensation.

CASE DESCRIPTION

A retrospective cohort study of 583 patients with burning mouth sensation symptoms was conducted. Demographic features, clinical characteristics, and associated systemic comorbidities of patients were collected. The 14-item Oral Health Impact Profile Questionnaire score and posttreatment follow-up were evaluated and analyzed among patients. In total, 583 patients with burning mouth sensation symptoms were enrolled; perimenopausal women were most affected; mean (SD) age was 57.04 (12.03) years, and the female to male ratio was 7:1. Patients were stratified into 178 patients (30.53%) with burning mouth syndrome (BMS) and 405 patients (69.47%) without BMS. No significant differences were found for age, sex, clinical characteristics, and 14-item Oral Health Impact Profile Questionnaire scores between BMS and no BMS groups. Notably, 72 of 119 patients without BMS who participated in follow-up had received referrals and treatment for systemic diseases, of which 76.39% achieved complete (45.83%) or partial (30.56%) remission. Among these patients, treatment for gastrointestinal disorders (92.59%), oral candidiasis (78.57%), thyroid diseases (66.67%), and avoidance of local irritants (62.50%) were most effective, and they were perpetuated as the common underlying causes.

PRACTICAL IMPLICATIONS

The study results implied significance of adopting multidisciplinary management of burning mouth sensation. It is imperative for dentists and physicians to strengthen their collaborative relationships and focus on both systemic and oral conditions in these patients.

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.

Candidiasis and Other Bacterial Infections among Patients Diagnosed with Burning Mouth Syndrome

Background and Objectives: Burning mouth syndrome (BMS) is a state in which a patient experiences intraoral burning or a dysesthetic sensation without clinically evident causative lesions in the oropharyngeal area. The disorder is linked to a variety of conditions, including dry mouth, Candida, and bacterial infections. The aim of this study was to determine the incidence of oral Candida and/or bacterial infections among patients with BMS and whether they have an effect on pain/burning and salivary flow levels. Objectives: (1) Gather patient data regarding the presence of oral infections, dry mouth, and pain levels in the morning, afternoon, and evening periods; (2) data analysis and assessment to determine medians, means, frequencies, correlations, and statistically significant differences between patient groups. Materials and Methods: Overall, 173 patients (23 males and 150 females) with BMS and 13 controls (five males and eight females) took part in the study. We measured pain/burning levels, unstimulated and stimulated salivary flow, the percentage of patients infected with Candida species and/or bacterial species, and the said species growth in Petri dishes. Results: Candida albicans was the most commonly found infection among patients with BMS (n = 28, 16.2%). Overall, 21.4% patients with BMS were diagnosed with either C. albicans or another Candida species. Enterobacter had the richest growth among patients with BMS (7.5% out of the infected 10.4% BMS patients). No statistical significance could be noted between the existence of either Candida species or bacterial species infections and changes in pain/burning and salivary flow levels. Negative correlations were noted between age and unstimulated and stimulated salivary flow, and positive correlations were noted between age and Candida andspecific bacteria species’ growth levels. Conclusions: Although patients with present bacterial or Candida infections showed a marginal increase in pain/burning levels, no direct statistically significant associations could be made between the presence of Candida species or other bacteria and the symptoms among patients with BMS.

Salivary characteristics in burning mouth syndrome: a systematic review

INTRODUCTION

Compare through case-control studies, the salivary characteristics of patients with and without BMS.

EVIDENCE ACQUISITION

Searches in Embase, PubMed, Web of Science, Scopus, Cochrane, and BIREME were conducted for the identification of case-controls studies reported.

EVIDENCE SYNTHESIS

Thirty-three studies were included, of which 26 articles evaluated OSB, 17 SRF, and 7 SE. Nineteen organic biomarkers showed higher levels in BMS patients, the two most indicated being α-amylase and cortisol. Ten organic biomarkers, including Tumor Necrosis Factor-alpha (TNF-α) and IL-6, showed lower levels in BMS patients. Regarding salivary flow rate (SFR), five articles indicated that BMS patients have less unstimulated SFR (uSRF)Two articles indicate that stimulated SFR (sSRF) is lower in BMS patients nevertheless, but eight did not show differences. Sialochemical analysis revealed that sodium (Na), chloride (Cl), potassium (K), sodium (Na), and calcium (Ca), showed higher levels in BMS patients according to three studies, but two studies did not establish any differences. Two study established that BMS patients have lower Mg salivary levels.

CONCLUSIONS

Qualitative salivary characteristics suggest that BMS has neuropathic, inflammatory, emotional, immune, and hormonal involvements. BMS can be associated with changes in salivary biomarkers of inflammation and oxidative stress, is related to anxiety and degree of pain.

Efficacy of oral nystatin treatment for patients with oral mucosal dysesthesia but without objective oral mucosal manifestations and necessity of Candida culture test before oral nystatin treatment

Background/purpose

Materials and methods

Results

Conclusion

Thermography as a Non-Ionizing Quantitative Tool for Diagnosing Burning Mouth Syndrome: Case-Control Study

Objectives: Thermography is an imaging technique based on the acquisition and analysis of thermal data. The present study evaluates the use of tongue infrared thermography (IRT) as a tool for the diagnosis of burning mouth syndrome (BMS). Material and methods: An IRT study was carried out in patients diagnosed with BMS according to the criteria of the International Association for the Study of Pain (n = 32) and in healthy controls (n = 35). Burning sensations, dry mouth and taste disturbances were assessed, and three temperature values were recorded for each tongue surface (dorsal, right lateral, left lateral and tip), along with body temperature and environmental temperature. Results: A statistically significant difference was recorded in the temperature of the dorsal surface of the tongue between the BMS group and the controls (p = 0.01). The area under the curve (AUC) was 0.731 (95% CI: 0.402–0.657; p = 0.003). The sensitivity and specificity obtained was 62% and 77%, respectively. Conclusions: Infrared thermography appears to be useful as a complementary tool for the diagnosis of BMS, though further studies are needed in this field.

The influence of intolerance of uncertainty on the correlation between the severity of symptoms and satisfaction with oral state in patients with burning mouth syndrome

OBJECTIVE

Intolerance of uncertainty (IU) is thought to be involved with the psychological factors that influence the symptoms in patients with burning mouth syndrome (BMS) and affect their limited satisfaction with the treatments provided. However, the influence of IU on satisfaction has not been explored in detail. Therefore, the purpose of this study was to investigate whether IU can affect the satisfaction of patients with BMS.

METHODS

A total of 34 patients with BMS and 100 patients without the disease who visited the general dental clinic were included in the study. They were required to complete a questionnaire measuring the subjective severity of their symptoms and satisfaction with their oral state, and a short IU scale. The BMS patients were separated from the control patients based on the IU score. The coefficients between the severity of symptoms and satisfaction were calculated to examine the influence of IU on the relationship between the two variables.

RESULTS

The relationship between satisfaction and severity of symptoms was significant in BMS patients with high IU, but not in control patients with low IU.

CONCLUSION

This study demonstrated that IU in BMS patients influences the relationship between the severity of symptoms and the satisfaction, thus indicating that the dissatisfaction in BMS patients with high IU might be prevented by decreasing the IU.

CLINICAL RELEVANCE

Limited satisfaction experienced by BMS patients can influence the patient-doctor relationship. This study provides suggestions for building a good patient-doctor relationship.

Relationship between subjective taste sensations and taste strip test in patients with taste disorders with and without burning mouth syndrome

Background/purpose

Both subjective and objective evaluations are required to assess taste function. Evaluation of taste function has important clinical significances in patients with burning mouth syndrome (BMS) due to pain-taste interactions. The purpose of this study was to investigate the relationship between subjective and objective taste evaluations in patients with taste disorders based on the presence of BMS.

Materials and methods

Fifty–one patients with taste disturbances were included. The patients completed questionnaires on subjective taste sensations. The taste strip test was performed to examine objective taste function. The patients were divided into two groups: subjects with BMS (n = 24, 3 males and 21 females) and without BMS (n = 27, 8 males and 19 females).

Results

Significant differences were not observed in age, age distribution, and gender distribution between the groups. There were no significant differences in self-reported taste abilities based on the presence of BMS. However, the taste strip test showed higher correct answer rates for bitterness (P = 0.027) in the patients with BMS. In addition, a significant difference (P = 0.034) was observed in the distribution of objective types of taste disorders between the groups. A significant correlation between the subjective and objective evaluation results was observed only in patients with BMS.

Conclusion

In patients with taste disorders, patients with BMS had significant correlations between subjective and objective evaluations and different distributions in the types of taste disorders compared with those without BMS. The presence or absence of BMS should be evaluated in the diagnosis and management of taste disorders.

Response to Treatment with Melatonin and Clonazepam versus Placebo in Patients with Burning Mouth Syndrome

Objective: to evaluate the efficacy of melatonin and clonazepam versus placebo in patients with burning mouth syndrome (BMS). Methods: a prospective double-blind study was carried out in patients with BMS and randomized to three groups: melatonin (1 mg once a day), clonazepam (0.5 mg/twice a day), or a placebo once a day, for 8 weeks. The clinical changes were evaluated, including xerostomia, the Oral Health Impact Profile 14 (OHIP-14) score, Pittsburg Sleep Quality Index, and the Hospital Anxiety and Depression Scale (HADS). Oxygen saturation and heart rate were recorded, with an analysis of salivary biomarkers in the forms of oxytocin, ferritin, adenosine deaminase (ADA), total proteins, and alpha-amylase. Results: a total of 64 patients were analyzed. A significant decrease in burning sensation was recorded with melatonin (7.8 ± 1.54 pre-treatment, 5.78 ± 2.54 post-treatment; p < 0.001) and clonazepam (8.75 ± 1.2 pre-treatment, 5.5 ± 3.6 post-treatment (p < 0.01). With regard to quality of life (OHIP-14), significant improvements were observed before and after the administration of melatonin (p < 0.001) and clonazepam (p = 0.001). On the other hand, with regard to the changes in salivary biomarkers following treatment, negative correlations were found between oxytocin and drainage (r = −0.410; p = 0.009) and between the HADS-D score and ferritin (r = −0.312; p = 0.05). While salivary amylase showed positive correlation with heart rate (r = 0.346; p = 0.029) and oxygen saturation (r = 0.419; p = 0.007). Conclusions: melatonin and clonazepam were shown to be effective at reducing the burning sensation and improving quality of life. Both drugs were found to be safe, with no major adverse effects in patients with BMS. Melatonin may be regarded as an alternative treatment for patients with BMS, though further studies are needed to confirm its effectiveness.

Burning Mouth Syndrome (BMS)—Treatment with Verbal and Written Information, B Vitamins, Probiotics, and Low-Level Laser Therapy: A Randomized Clinical Trial

Background: The objective of this study was to determine the most effective treatment option for burning mouth syndrome. Methods: Informative treatment alone, B vitamin injections, oral cavity probiotics, and low-level laser therapy were evaluated and compared. The study included new patients diagnosed with burning mouth syndrome, who were randomly allocated into one of four treatment groups. The primary outcome was improvement in patient’s quality of life as determined by a self-perceived Oral Health Impact Profile-14 (OHIP-14) quality of life questionnaire before and after therapy. The secondary outcome was determination of mucosal symptom intensity according to visual analog scale (VAS) grading from 0 to 10. Data were submitted to statistical analysis. Results: A total of 62 patients completed the study. Oral cavity probiotics and LLLT scores for OHIP-14 resulted in a statistically significant difference before and after therapy. Standardized effect sizes between OHIP scores before and after treatment were the greatest for patients who had received oral cavity probiotics. Conclusions: Oral cavity probiotics and LLLT were the most effective treatment for improvement in quality of life. Further investigation on a larger group of patients is required.

Efficacy of photobiomodulation in reducing pain and improving the quality of life in patients with idiopathic burning mouth syndrome. A systematic review and meta-analysis

Burning mouth syndrome is a chronic condition, which is characterised by a burning sensation or pain in the mucosa of the oral cavity. Treatment options include antidepressants, antipsychotics, anticonvulsants, analgesics, hormone replacement therapies and more recently photobiomodulation. This study aims to perform a systematic review with meta-analysis in order to determine the effect of photobiomodulation on pain relief and the oral health-related quality of life associated with this condition. A bibliographical search of the Pubmed, Embase, Web of Science and Scopus databases was conducted. Only randomised clinical trials were included. Pain and quality of life were calculated as mean difference and pooled at different treatment points (baseline = T0 and final time point = Tf) and laser modality. From a total of 103 records, 7 articles were retrieved for inclusion. PBM group had a greater decrease in pain than control group at Tf with a mean difference =  − 2.536 (IC 95% − 3.662 to − 1.410; I² = 85.33%, p < 0.001). An improvement in oral health-related quality of life was observed in both groups, although this was more significant in the photobiomodulation group mean difference =  − 5.148 (IC 95% − 8.576 to − 1.719; I² = 84.91%, p = 0.003). For the red laser, a greater improvement than infrared was observed, in pain, mean difference =  − 2.498 (IC 95% − 3.942 to − 1.053; I² = 79.93%, p < 0.001), and in quality of life, mean difference =  − 8.144 (IC 95% − 12.082 to − 4.206; I² = 64.22%, p = 0.027). Photobiomodulation, in particular, red laser protocols, resulted in improvement in pain and in quality of life of burning mouth syndrome patients.

A systematic review of treatment for patients with burning mouth syndrome

BACKGROUND

Burning mouth syndrome is a chronic idiopathic intractable intraoral dysaesthesia that remains a challenge to clinicians due to its poorly understood pathogenesis and inconsistent response to various treatments.

AIM

This review aimed to study the short- (≤3 months) and long-term (>3 months) effectiveness and sustainable benefit of different burning mouth syndrome treatment strategies and the associated side effects.

MATERIALS AND METHODS

Randomised controlled trials of burning mouth syndrome treatment compared with placebo or other interventions with a minimum follow up of 2 months were searched from the PubMed, Embase and Cochrane database (published to July 2020).

RESULTS

Twenty-two studies were selected based on the inclusion and exclusion criteria and analysed. Nine categories of burning mouth syndrome treatment were identified: Anticonvulsant and antidepressant agents, phytomedicine and alpha lipoic acid supplements, low-level laser therapy, saliva substitute, transcranial magnetic stimulation, and cognitive behaviour therapy. Cognitive behaviour therapy, topical capsaicin and clonazepam, and laser therapy demonstrated favourable outcome in both short- and long-term assessment. Phytomedicines reported a short-term benefit in pain score reduction. The pooled effect of alpha lipoic acid (ALA) pain score improvement was low, but its positive effects increased in long term assessment.

CONCLUSION

A more significant volume in terms of sample size, multi-centres, and multi-arm comparison of therapeutic agents with placebo and longitudinal follow-up studies is recommended to establish a standardised burning mouth syndrome treatment protocol. Further studies are required to assess the analgesic benefits of topical clonazepam and capsaicin, alternative medicines with neurodegenerative prevention capability and psychology support in treating burning mouth syndrome and reducing systemic adverse drug reactions.Registration International Prospective Register of Systematic Reviews (PROSPERO):Protocol ID - CRD42020160892.

Low intensity extracorporeal shockwave therapy for chronic pelvic pain syndrome patients with erectile dysfunction

INTRODUCTION

In this study, the efficacy of low intensity shock wave therapy (LSWT) in improving symptoms of chronic pelvic pain syndrome (CPPS) and erectile dysfunction (ED) was investigated.

METHODS

Men diagnosed with CPPS and ED (n = 50) were prescribed with LSWT. The LSWT was administered in 10 sessions over the course of 5 weeks at 3,000 pulses with .25 mJ/mm2 energy flow and 5 Hz frequency. Outcome parameters were measured before and after LSWT.

RESULTS

Clinical symptoms related to CPPS and ED were measured using four validated questionnaires namely National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function (IIEF), the International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). The effect of LSWT on each of the three domains of NIH-CPSI, namely Pain, Symptoms, and Quality of Life (QoL) were also analyzed. Uroflowmetry was measured to assess LSWT effect on urine voiding. The mean baseline CPPS symptoms on NIH-CPSI domains of pain, symptoms and QoL were 9.92 ± 5.72 (mean ± SD), 5.14 ± 14.5, and 8.02 ± 3.17, respectively. LSWT resulted in significant reduction of CPPS symptoms on all NIH-CPSI domains (Pain = .9 ± 1.37; Symptoms = .74 ± 1.03; QoL = 1.16 ± 1.78). The baseline means of CPPS symptoms on IIEF, IPSS, and SHIM were 45.42 ± 16.24, 24.68 ± 9.28, and 14.28 ± 6.02, respectively. LSWT significant improved CPPS symptoms on IIEF (49.48 ± 28.30) and IPSS (9.04 ± 7.01) but not on SHIM (16.02 ± 9.85). No statistically significant differences were observed with all uroflowmetry parameters.

CONCLUSION

The current study demonstrated for the first time the safety and efficacy of LSWT administered in 10 sessions over 5 weeks in improving symptoms of CPPS and ED without causing any significant adverse effect to the patient.

Burning mouth syndrome: a review of therapeutic approach

Burning mouth syndrome (BMS) is described by an intense burning sensation of the tongue or other oral areas without a clear etiopathology. The diagnosis of BMS is challenging due to variations of manifestations. The management of BMS is complicated due to the complex etiology of the disease. Many medications and treatment methods have been recommended for BMS management, but no one confirmed as the standard method. In this study, the therapeutic approaches of BMS were evaluated. The data of the article was obtained from PubMed/MEDLINE, Cochrane Library, and Web of Science. The following terms including "burning mouth syndrome", "therapy", and "treatment" were used for search in the databases. A wide range of articles about the therapeutic approach of BMS was searched and reviewed. Pharmacological and non-pharmacological approaches have been used for BMS management. Pharmacological treatments are including Capsaicin, Clonazepam, Low-dose aripiprazole, Alpha-lipoic acid, Duloxetine, Amitriptyline, Gabapentin, and Pregabalin, and ultra-micronized palmitoylethanolamide. Non-pharmacological therapies for BMS are cognitive therapy, Electroconvulsive therapy, Laser therapy, Acupuncture and auriculotherapy, Transcranial Magnetic Stimulation (rTMS), Salivary Mechanical Stimulation, and Botulinum Toxin. A detailed assessment of the etiology and pathophysiology of BMS, and having information about novel therapeutic interventions are essential for the management of BMS.

Enhanced Ocular Surface and Intraoral Nociception via a Transient Receptor Potential Vanilloid 1 Mechanism in a Rat Model of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), characterized by low arterial oxygen saturation during sleep, is associated with an increased risk of orofacial pain. In this study, we simulated chronic intermittent hypoxia (CIH) during the sleep/rest phase (light phase) to determine the role of transient receptor potential vanilloid 1 (TRPV1) in mediating enhanced orofacial nocifensive behavior and trigeminal spinal subnucleus caudalis (Vc) neuronal responses to capsaicin (a TRPV1 agonist) stimulation in a rat model of OSA. Rats were subjected to CIH (nadir O₂, 5%) during the light phase for 8 or 16 consecutive days. CIH yielded enhanced behavioral responses to capsaicin after application to the ocular surface and intraoral mucosa, which was reversed under normoxic conditions. The percentage of TRPV1-immunoreactive trigeminal ganglion neurons was greater in CIH rats than in normoxic rats and recovered under normoxic conditions after CIH. The ratio of large-sized TRPV1-immunoreactive trigeminal ganglion neurons increased in CIH rats. The density of TRPV1 positive primary afferent terminals in the superficial laminae of Vc was higher in CIH rats. Phosphorylated extracellular signal-regulated kinase (pERK)-immunoreactive cells intermingled with the central terminal of TRPV1-positive afferents in the Vc. The number of pERK-immunoreactive cells following low-dose capsaicin (0.33 µM) application to the tongue was significantly greater in the middle portion of the Vc of CIH rats than of normoxic rats and recovered under normoxic conditions after CIH. These data suggest that CIH during the sleep (light) phase is sufficient to transiently enhance pain on the ocular surface and intraoral mucosa via TRPV1-dependent mechanisms.

How Well Do Current Laboratory Biomarkers Inform Clinical Decision-Making in Chronic Pain Management?

OBJECTIVE

Decision-making in chronic pain patients involves a combination of subjective and objective criteria, including patient history, physical examination, imaging, and patient response to prior treatments, clinical experience, probabilities, and recognition of patterns. However, there is a distinct lack of objective laboratory biomarkers in use in routine clinical care. The objective was to review the literature to identify and describe specific biomarkers in chronic pain management.

METHODS

This is a narrative review of the literature regarding the use of laboratory biomarkers in chronic pain. A librarian-assisted literature search of the PubMed, Science Direct, and Google Scholar databases was performed and resulted in 304 possible manuscripts. We included manuscripts assessing laboratory collected biomarkers from urine, serum, cerebrospinal fluid, and saliva. After screening and review of the initial literature search results, a total of 75 manuscripts were included in the narrative review.

CONCLUSION

The studies reviewed suggested that specific biomarkers may help identify those patients at risk of disease development and function as a prognostic indicator for disease progression and treatment response. However, additional research is necessary before specific recommendations can be made, and current clinical decision-making is modified.

Can the chokeberry juice be used as additional therapy for burning mouth syndrome in menopausal women?

The researchers' aims were to evaluate the effects of chokeberry juice in the treatment of burning mouth syndrome (BMS) and oral discomfort in menopausal women. The following validated scales and questionnaires were used before and after treatment: questionnaire used for selection of research participants with xerostomia, the xerostomia inventory, Visual Analogue Scale (VAS), localization of pain before and after treatment, short-form McGill pain questionnaire. There was statistically significant decrease in number of research participants who felt pain after therapeutic procedure (p < 0.05). Chokeberry juice, as additional therapy for BMS, reduced intensity of characteristic types of pain sensations and oral dryness feeling.

State of Evidence on Oral Health Problems in Diabetic Patients: A Critical Review of the Literature

Diabetes mellitus (DM) is a global health problem, having recognized that in the next 20 years the number of diabetic patients in the world will increase to 642 million. DM exerts enormous repercussions on general health diabetic (especially derived from vascular, cardiac, renal, ocular, or neurological affectation). It entails in addition a high number of deaths directly related to the disease, as well as a high health care cost, estimated at $673 billion annually. Oral cavity is found among all the organs and systems affected in the course of DM. Important pathologies are developed with higher prevalence, such as periodontitis (PD), alterations in salivary flow, fungal infections, oral cancer, and oral potentially malignant disorders (OPMD). It has been proven that PD hinders the metabolic control of DM and that the presence of PD increases the possibility for developing diabetes. Despite the relevance of these oral pathologies, the knowledge of primary care physicians and diabetes specialists about the importance of oral health in diabetics, as well as the knowledge of dentists about the importance of DM for oral health of patients is scarce or non-existent. It is accepted that the correct management of diabetic patients requires interdisciplinary teams, including dentists. In this critical review, the existing knowledge and evidence-degree on the preventive, clinical, diagnosis, prognosis, and therapeutic aspects of oral diseases that occur with a significant frequency in the diabetic population are developed in extension.