Diabetic neuropathy masquerading as glossodynia

Oral burning: local and systemic connection for a patient-centric approach

Burning symptoms in the oral cavity are caused by a range of systemic and local factors, in addition to the neuropathic pain disorder burning mouth syndrome (BMS). Patients may state oral burning as a standalone symptom or may report as a secondary symptom in association with other factors, most commonly with oral dryness, oral mucosal lesions, or certain systemic conditions. There is a level of uncertainty in the presentation of this condition which creates a diagnostic challenge from both the patient's perspective and the practitioner evaluating these individuals. The diagnoses are complicated due to the lack of a clear definition of BMS and clinical guidelines to distinguish BMS from other conditions that are responsible for oral burning symptoms. A clinician should be able to differentiate oral burning from burning mouth syndrome. This integrative review discusses on local and systemic etiologies of oral burning based on current evidence that needs to be excluded for a diagnosis of BMS. It also provides an algorithm for diagnostic workup and therapeutic management to medical providers for patients experiencing oral burning symptoms. This comprehensive system provides a systematic stepwise workup in diagnosing and managing patients presenting with a complaint of oral burning that optimally meets a predictive, preventive, and personalized medicine (PPPM) approach.

Serious Abuse Potential

This review examines literature on the efficacy and abuse potential of carisoprodol, makes recommendations for use of this agent in the hospital setting, and outlines applicable federal and state regulations. A Medline search using key words and MeSH terms was conducted. In addition, International Pharmaceutical Abstracts (1970–2002), Current Contents (1996–2002), Cochrane Database of Systematic Reviews (1999–2002), and Psych Info (1872–2002) were searched for relevant literature. Articles cited in the bibliographies produced by these searches were included in the review. A Web of Science search was conducted for all citations found in all the searches. Pain is a common physical symptom in patients with musculoskeletal problems, and pharmacologic therapy is often combined with nonpharmacologic measures to treat the pain etiology and symptomatology. Skeletal muscle relaxants (SMRs) and nonsteroidal anti-inflammatory drugs (NSAIDs) represent the most common drug therapy choices in patients with mild-to-moderate somatic pain. Carisoprodol (Soma) is an SMR that has a poorly defined mechanism of action and a high potential for abuse. This literature review produced little evidence to support the use of carisoprodol in pain control. The research also showed that patients with a history of previous substance abuse are more likely to abuse this drug; thus carisoprodol does not meet safety and efficacy standards and should be removed from the market. At the very least, states should reschedule carisoprodol as a schedule IV controlled substance to minimize chronic misuse and abuse. If carisprodol is listed in hospital formularies, it should be handled as a controlled substance regardless of its federal status. Alternative sedatives (eg, phenobarbital) should be used to manage patients experiencing carisoprodol withdrawal symptoms.

Geriatric oral and maxillofacial dysfunctions in the context of geriatric syndrome

OBJECTIVES

To propose the application of the concept of geriatric syndrome for common geriatric oral and maxillofacial dysfunctions and to suggest the necessity of developing effective evaluation methods for oral and maxillofacial frailty.

DESIGN

The concepts of frailty and geriatric syndrome based on multi-morbidity and polypharmacy were applied to five common geriatric oral medicinal dysfunctional problems: salivary gland hypofunction (dry mouth), chronic oral mucosal pain disorders (burning mouth symptoms), taste disorders (taste disturbances), swallowing disorders (dysphagia), and oral and maxillofacial movement disorders (oromandibular dyskinesia and dystonia).

RESULTS

Each of the dysfunctions is caused by various kinds of diseases and/or conditions and medications, thus the concept of geriatric syndrome could be applied. These dysfunctions, suggested as components of oral and maxillofacial geriatric syndrome, are associated and interacted with each other in a complexity of vicious cycle. The resulting functional impairments caused by this syndrome can cause oral and maxillofacial frailty.

CONCLUSIONS

Geriatric oral and maxillofacial dysfunctions could be better appreciated in the context of geriatric syndrome. The development of effective methods for evaluating the severity of these dysfunctions and the resulting frailty is essential.

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

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

Evaluation of select neurophysiological, clinical and psychological tests for burning mouth syndrome

OBJECTIVE

The objective of this study was to identify, among an array of potential risk factors for burning mouth syndrome (BMS), those that are potentially the most significant in the development of the disease.

STUDY DESIGN

Sixty-three participants, divided into group I (with BMS: 33 patients ages 41 to 82 years [mean age: 61.5 ± 9.4]) and group II (without BMS: 30 healthy volunteers ages 42-83 years [mean age: 60.5 ± 10.5]) were studied. All underwent a dental examination and psychological tests. Neurological tests (neurophysiological test, electroneurography, and tests of the autonomic nervous system) were performed. Mean parameters were analyzed by Student t test, Kruskal-Wallis test, and χ(2) test, and multifactor analysis was performed with logistic regression and by calculating the odds ratio.

RESULTS

In the logistic regression test, 3 factors were significant in the etiopathogenesis of BMS: a value more than 39 μV for the amplitude of the positive peak of the potential induced by stimulating the trigeminal nerve on the left side (P2-L); a value above 5.96 ms for the latency of wave V of the brainstem auditory evoked potentials on the right side (V-R); and a value over 2.35 ms for the latency of the sensory ulnar nerve response.

CONCLUSIONS

The BMS sufferer was characterized as having mild sensory and autonomic small fiber neuropathy with concomitant central disorders.

Candida-associated denture stomatitis in type 2 diabetes mellitus

OBJECTIVE

To describe the clinical appearance of Candida-associated denture stomatitis (DS) in subjects with type 2 diabetes (T2DM). The relationships between the types of DS, oral complaints and associated conditions were assessed in terms of glycemic control as determined by glycated hemoglobin (HbA1c) measurements.

MATERIALS AND METHODS

Demographic and clinical data were obtained from questionnaires and oral examinations of 110 edentulous patients with T2DM and 50 control subjects.

RESULTS

Type II DS commonly occurred in diabetics (57.3% vs 30%; p=0.002) together with DS related oral complaints (60.9% vs 24%; p<0.001) compared with controls. Burning sensation of the mouth (BS) was the most common complaint. Dryness of the oral mucosa (DOM) (50.9% vs 6%; p<0.001), angular cheilitis (26.4% vs 8%; p=0.01) and glossitis (27.3% vs 6%; p=0.003) occurred more frequently in diabetics. Oral complaints and associated conditions of DS coincided with elevated HbA1c levels (p<0.001). Diabetics with extensive type of inflammation had higher HbA1c levels than type I/III DS subjects (p<0.001).

CONCLUSIONS

Diffuse type of inflammation was associated with T2DM. BS and DOM were the most common oral complaints. Inadequately controlled diabetes with Candida-associated DS was linked to a high incidence of an extensive type of inflammation, oral complaints and associated conditions.

Effect of an aldose reductase inhibitor on alveolar bone loss associated with periodontitis in diabetic rats

Periodontitis is a lesser known but frequent complication of diabetes mellitus and is the major cause of tooth loss in patients with diabetes. Dental therapy for this complication is primarily focused on the control of oral infections. No current therapy directly addresses the potential effects of diabetes itself on this complication. In studies conducted in young normal control and streptozotocin diabetic rats (100 g) treated with and without the aldose reductase inhibitor (ARI) imirestat, experimental periodontitis was induced in one side of the mouth by 3 injections of lipopolysaccharide (LPS) from Escherichia coli 055:B5 9 into the palatal gingiva between the first and second maxillary molars at 48-hour intervals. The other control side was injected with phosphate buffered saline (PBS). Fourteen days after the final injection, all rats were euthanized and the heads were defleshed. The maxillary area was separated from the remaining skull. The cleaned maxillary alveoli were stained in 5% aqueous toluidine blue to identify the cemento-enamel junction (CEJ) on the molars. Alveolar bone loss was measured according to standard methods by determining both the distance between the CEJ and the alveolar bone on the 2 molars between which the injections were made, and by measuring the ratio of root area/enamel area in the same region. These measurements showed that LPS injections resulted in significant bone loss compared with PBS injections in both control and diabetic rats, and that this bone loss was not present in the ARI-treated diabetic rats (P < 0.05). These results suggest that the sorbitol pathway plays a critical role in the pathophysiological mechanism(s) of diabetic periodontitis and that AR may be a direct pharmacological target for the treatment for this disease.

Burning mouth syndrome and peripheral neuropathy in patients with type 1 diabetes mellitus

OBJECTIVE

Burning mouth syndrome (BMS) has been attributed secondarily to diabetes, poor glycemic control, and diabetic neuropathy. The prevalence and predictor factors of BMS were compared in type 1 diabetes mellitus (T1DM) and nondiabetic subjects.

STUDY DESIGN

An assessment of 371 adult T1DM subjects and 261 control subjects participating in a cross-sectional epidemiological study of oral health complications of diabetes was performed. Subjects were participants of the Pittsburgh Epidemiology of Diabetes Complications study. Prevalence of BMS was determined by response to the following questions: "Do you now or in the last month had any persistent uncomfortable sensations in your mouth or tongue? If yes, would you describe the feeling as tingling, burning, sore, numb, or other?"

RESULTS

Burning mouth syndrome symptoms were reported by 28 T1DM and control subjects (4.6%). Eleven had oral pathologies that might explain the BMS, including atrophy of the tongue papillae, fissured tongue, denture stomatitis, and candidiasis. The prevalence of BMS within the two groups with no pathologies was similar; 12/371 (3.2%) vs. 5/233 (2.1%). Multivariate analyses of the 12 T1DM subjects with BMS found significant associations for female gender (P=.042) and a diagnosis of diabetic peripheral neuropathy (P=.024).

CONCLUSIONS

In this T1DM population, BMS or related discomforts occurred slightly more frequently than in the control group. Symptomatic T1DM subjects were more likely to be female who had also developed peripheral neuropathy. These findings and other similarities between BMS and diabetic peripheral neuropathy suggest that a neuropathic process may be an underlying source of BMS in some patients who have no apparent oral abnormality.

Burning mouth complaints: clinical characteristics of a Brazilian sample

OBJECTIVE

Evaluation of the clinical characteristics of burning mouth complaints (BMC) in a series of Brazilian patients referred to a large teaching hospital.

MATERIALS AND METHODS

66 patients with burning mouth complaints were evaluated through a standardized protocol.

RESULTS

56 women and 10 men were examined, ranging in age from 35-83 years. The primary location of the complaints was reported to be the tongue. Thirty-six patients reported a precipitating event. The mean VAS pain levels were 7.5 in women and 6.11 in men. The average estradiol levels in women were low (<13 pg/ml); 80% of all patients reported a concomitant chronic disease, 55% of all patients wore total dentures, 54% of all patients reported subjective xerostomia, 48% of all patients reported sleep disturbances and 66% reported phantom taste. No statistical differences were found between groups with or without a precipitating event in VAS: (p=0.139), in the Number of Words Chosen (NWC) (p=0.259) and Pain Rating Index (PRI) (p=0.276) sections of the McGill Pain Questionnaire (MPQ).

CONCLUSION

The existence of systemic comorbidities, self-reported sleep disturbances and taste alterations indicates possible correlations and the need for a careful systemic evaluation of each patient; there were no differences between patients with and without precipitating events.

Orofacial Pain--Part II: Assessment and management of vascular, neurovascular, idiopathic, secondary, and psychogenic causes

Chronic orofacial pain is a common health complaint faced by health practitioners today and constitutes a challenging diagnostic problem that often requires a multidisciplinary approach to diagnosis and treatment. The previous article by the same authors in this issue discussed the major clinical characteristics and the treatment of various musculoskeletal and neuropathic orofacial pain conditions. This second article presents aspects of vascular, neurovascular, and idiopathic orofacial pain, as well as orofacial pain due to various local, distant, or systemic diseases and psychogenic orofacial pain. The emphasis in this article is on the general differential diagnosis and various therapeutic regimens of each of these conditions. An accurate diagnosis is the key to successful treatment of chronic orofacial pain. Given that for many of the entities discussed in this article no curative treatment is available, current standards of management are emphasized. A comprehensive reference section has been included for those who wish to gain further information on a particular entity.

[Mouth dryness and burning sensation of the oral mucosa: causes and possibilities for treatment]

Both sets of complaints, mouth dryness and a burning sensation of the oral mucosa, can have a variety of causes. Local and regional as well as systemic causes can be responsible for burning mouth syndrome. Diseases of the oral mucosa can have genetic, inflammatory, or neoplastic origins. Autoimmune diseases and allergies as well as different afflictions relating to internal medicine can be accompanied by a burning sensation in the oral mucosa. Neurological and psychiatric illnesses must be clarified during interdisciplinary diagnostics in order to identify idiopathic forms. The causes of mouth dryness are similarly complex. In addition to inadequate fluid intake, particularly in elderly patients, drug side effects or systemic diseases are frequently also responsible. Treatment is directed at the underlying disease; in ambiguous cases, symptomatic therapy can provide relief for medical complaints.

Update on burning mouth syndrome: overview and patient management

Burning Mouth Syndrome (BMS) is a chronic pain syndrome that mainly affects middle-aged/old women with hormonal changes or psychological disorders. This condition is probably of multifactorial origin, often idiopathic, and its etiopathogenesis remains largely enigmatic. The present paper discusses several aspects of BMS, updates current knowledge, and provides guidelines for patient management. There is no consensus on the diagnosis and classification of BMS. The etiopathogenesis seems to be complex and in a large number of patients probably involves interactions among local, systemic, and/or psychogenic factors. In the remaining cases, new interesting associations have recently emerged between BMS and either peripheral nerve damage or dopaminergic system disorders, emphasizing the neuropathic background in BMS. Based on these recent data, we have introduced the concepts of "primary" (idiopathic) and "secondary" (resulting from identified precipitating factors) BMS, since this allows for a more systematic approach to patient management. The latter starts with a differential diagnosis based on the exclusion of both other orofacial chronic pain conditions and painful oral diseases exhibiting muco-sal lesions. However, the occurrence of overlapping/overwhelming oral mucosal pathologies, such as infections, may cause difficulties in the diagnosis ("complicated BMS"). BMS treatment is still unsatisfactory, and there is no definitive cure. As a result, a multidisciplinary approach is required to bring the condition under better control. Importantly, BMS patients should be offered regular follow-up during the symptomatic periods and psychological support for alleviating the psychogenic component of the pain. More research is necessary to confirm the association between BMS and systemic disorders, as well as to investigate possible pathogenic mechanisms involving potential nerve damage. If this goal is to be achieved, a uniform definition of BMS and strict criteria for its classification are mandatory.