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.

Temporomandibular Joint Disorders and the Eating Experience

Temporomandibular joint disorder (TMD) is a chronic disorder that significantly affects oral function. It can affect appetite and the mechanical components involved with eating, including mandibular opening, biting, chewing, and even swallowing. Thus, dietary intake and, subsequently, nutrition status are affected. The functional challenges presented by the disorder affect eating-related quality of life and can affect food choices and diet quality and composition. This article addresses disorder-related factors affecting the eating experience of adults with TMDs and approaches to diet management.

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.

Sensory Changes Related to Dental Implant Placement: A Scoping Review

AIMS

To perform a scoping review of the literature to elucidate the occurrence of nerve damage related to dental implant placement and the factors causing the sensory changes.

METHODS

An extensive electronic search was conducted using the Cochrane Library, Medline via Ovid, PubMed, Wiley Online, Science Direct, CINAHL, and the Google Scholar databases from the year 1950 to 2020.

RESULTS

The search resulted in 1,067 articles, out of which 76 were selected for this review. The articles were categorized as literature review articles, retrospective studies, prospective studies, and case series/case reports. Altogether, 2,526 subjects were assessed retrospectively, with 5.27% transient and 1.39% persistent sensory changes, and a cohort of 2,750 subjects were followed prospectively, with 6.22% transient and 1.31% persistent sensory changes. A total of 336 subjects were enrolled in various case reports and case series, with 5.95% transient sensory changes and 84.52% persistent neurosensory changes. The articles included were not of high quality and have variations in their study designs and reporting procedures, with limited sensory change data to include in this study.

CONCLUSION

After surgical placement of dental implants in 5,612 patients, the incidence of transient sensory changes was 5.63%, and the incidence of persistent sensory changes was 6.33%. Factors affecting the incidence were: mandibular location of the implant, with the inferior alveolar nerve as the most commonly affected nerve. The common symptoms reported were paresthesia and dysesthesia. Age and gender were among other factors, for which data were not available in all the articles.

Genetic variation in catechol-O-methyltransferase is associated with individual differences in conditioned pain modulation in healthy subjects

BACKGROUND

Genetic variation in the catechol-O-methyltransferase (COMT) gene is associated with sensitivity to both acute experimental pain and chronic pain conditions. Four single nucleotide polymorphisms (SNPs) have traditionally been used to infer three common haplotypes designated as low, average and high pain sensitivity and are reported to affect both COMT enzymatic activity and pain sensitivity. One mechanism that may partly explain individual differences in sensitivity to pain is conditioned pain modulation (CPM). We hypothesized that variation in CPM may have a genetic basis.

METHODS

We evaluated CPM in 77 healthy pain-free Caucasian subjects by applying repeated mechanical stimuli to the dominant forearm using 26-g von Frey filament as the test stimulus with immersion of the non-dominant hand in hot water as the conditioning stimulus. We assayed COMT SNP genotypes by the TaqMan method using DNA extracted from saliva.

RESULTS

SNP rs4680 (val¹⁵⁸ met) was not associated with individual differences in CPM. However, CPM was associated with COMT low pain sensitivity haplotypes under an additive model (p = 0.004) and the effect was independent of gender.

CONCLUSIONS

We show that, although four SNPs are used to infer COMT haplotypes, the low pain sensitivity haplotype is determined by SNP rs6269 (located in the 5' regulatory region of COMT), suggesting that inherited variation in gene expression may underlie individual differences in pain modulation. Analysis of 13 global populations revealed that the COMT low pain sensitivity haplotype varies in frequency from 13% to 44% and showed that two SNPs are sufficient to distinguish all COMT haplotypes in most populations.

Consensus agreement to rename burning mouth syndrome and improve International Classification of Diseases-11 disease criteria: an international Delphi study

ABSTRACT

The International Classification of Diseases (ICD-11) proposes revisions in the nomenclature, disease definition, and diagnostic criteria for "burning mouth syndrome" (BMS). This process could benefit from additional systematically collected expert input. Thus, the purpose of this study was to use the Delphi method to (1) determine whether revision in nomenclature and alternative names for "BMS" are warranted and (2) identify areas of consensus among experts for changes to the disease description and proposed diagnostic criteria of "BMS," as described in the ICD-11 (World Health Organization). From 31 international invited experts, 23 who expressed interest were sent the survey. The study used 4 iterative surveys, each with a response rate of ≥82%. Consensus was predefined as 70% of participants in agreement. Data were summarized using both descriptive statistics and qualitative thematic analysis. Consensus indicated that BMS should not be classified as a syndrome and recommended instead renaming to "burning mouth disorder." Consensus included deletion of 2 diagnostic criteria: (1) emotional distress or functional disability and (2) the number of hours symptoms occur per day. Additional items that reached consensus clarified the disease definition and proposed more separate diagnostic criteria, including a list of local and systemic factors to evaluate as potential secondary causes of oral burning. Experts in this study recommended and came to consensus on select revisions to the proposed ICD-11 BMS nomenclature, diagnostic criteria, and disease definition. The revisions recommended have the potential to improve clarity, consistency, and accuracy of diagnosis for this disorder.

Developing a research diagnostic criteria for burning mouth syndrome: Results from an international Delphi process

OBJECTIVE

To develop a beta version of a preliminary set of empirically derived research diagnostic criteria (RDC) for burning mouth syndrome (BMS) through expert consensus, which can then be taken into a test period before publication of a final RDC/BMS.

DESIGN

A 6 round Delphi process with twelve experts in the field of BMS was used. The first round formed a focus group during which the purpose of the RDC and the definition of BMS was agreed upon, as well as the structure and contents. The remaining rounds were carried out virtually via email to achieve a consensus of the beta version of the RDC/BMS.

RESULTS

The definition of BMS was agreed to be 'an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without evident causative lesions on clinical examination and investigation'. The RDC was based upon the already developed and validated RDC/TMD and formed three main parts: patient self-report; examination; and psychosocial self-report. A fourth additional part was also developed listing aspirational biomarkers which could be used as part of the BMS diagnosis where available, or to inform future research.

CONCLUSION

This Delphi process has created a beta version of an RDC for use with BMS. This will allow future clinical research within BMS to be carried out to a higher standard, ensuring only patients with true BMS are included. Further validation studies will be required alongside refinement of the RDC as trialling progresses.

IMMPACT-recommended outcome measures and tools of assessment in burning mouth syndrome RCTs: an international Delphi survey protocol

Background

A core outcome set (COS) represents the agreed minimum set of domains and measurement instruments that should be measured and reported in any clinical trial for a given condition. In BMS randomized controlled trials (RCTs), the outcomes identified in the existing literature regarding the efficacy of therapeutic interventions are numerous and diverse. Although the standardized IMMPACT core outcome domains has been developed for measurement of outcomes in chronic pain RCTs, no BMS-specific COS have been adopted and validated. With the evolving landscape of BMS management end points and the development of new therapies, a consensus on a COS for use in future BMS trials is paramount to reduce heterogeneity in outcome reporting. The aim of this study was to reach a consensus for adopting the standardized Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) outcome domains, and their tools of assessment, for burning mouth syndrome (BMS) clinical trials and clinical practice.

Methods

A BMS-specific COS will be developed using the method recommended by the Core Outcome Measures in Effective Trials (COMET) initiative (Registration: http://www.comet-initiative.org/studies/details/1357). Selection of questionnaire outcome measures was informed by the IMMPACT consensus and previous systematic review of RCTs in BMS conducted by the consortium. An international group of clinicians and researchers will be invited to participate in several rounds of a Delphi survey. A consensus meeting will be held with the objective of ratifying the outcomes for inclusion in the COS. A finalized COS explanatory document will be drafted, including all outcomes and measurements as determined by the Delphi rounds and consensus meeting.

Discussion

A COS for the management of BMS will improve the quality of future RCTs, reduce outcome reporting heterogeneity, and facilitate more vigorous data synthesis of management interventions for systematic reviews and meta-analysis. This would ensure enhanced quality evidence for clinical management of the condition.

Orbital pseudotumor presenting as a temporomandibular disorder: A case report and review of literature

BACKGROUND AND OVERVIEW

Orofacial pain has multifactorial causes and is often a diagnostic challenge. Misdiagnosis can result in morbidity or mortality due to misdirected and inappropriate treatment. A delay of necessary treatment, in cases of ominous illnesses, may result in its perpetuation or progression. The authors present a case report that illustrates these possibilities.

CASE DESCRIPTION

This case report describes a 36-year-old woman with the chief symptom of painless, limited mandibular movement. She also reported restricted movement of the left eye. She was previously diagnosed and treated for a traumatic right inferior alveolar nerve neuropathy, migraine, myofascial pain, and bilateral temporomandibular joint disk displacement with minimal benefit. Eventually she sought an orofacial pain evaluation, presuming her problems were related to a temporomandibular disorder. A complete history and comprehensive clinical evaluation including a cranial nerve screening evaluation, intraoral and extraoral examinations, an evaluation of the masticatory system, and dental radiographs were performed. The cranial nerve screening examination found painful, restricted eye movements. Magnetic resonance revealed a large, soft tissue mass in the inferolateral wall of the left orbit with soft tissue components in the infratemporal fossa and pterygoid space, involving the lateral pterygoid muscle and insertion of the temporalis muscle. The patient was referred to appropriate medical specialties and the diagnosis of orbital pseudotumor was confirmed and the patient was treated appropriately.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The case emphasizes the importance of a comprehensive evaluation of a patient with preexisting orofacial pain when new symptoms arise or if there is a change in existing symptoms.

Primary burning mouth syndrome: Literature review and preliminary findings suggesting possible association with pain modulation

Primary burning mouth syndrome (BMS) is a chronic pain of a burning quality affecting the tongue and intraoral mucosa. Currently, there are no definite diagnostic criteria; therefore, the diagnosis is made by exclusion of potential local and systemic causes that could justify the burning sensation. The etiology behind primary BMS remains unclear; however, the most acceptable theories link primary BMS with neuropathic pain. This article provides a review of primary BMS diagnosis, mechanisms, and treatment with focus on the association of BMS with pain modulation. Preliminary data are presented suggesting a link between primary BMS and a faulty inhibitory pain system.

Is there an association between fear avoidance beliefs, and pain and disability in patients with orofacial pain?

Numerous psychosocial factors have been shown to contribute to the development and perpetuation of orofacial pain. One well-recognized model for explaining the link between psychosocial factors and chronic pain is the fear avoidance model. To date, this proposed link has not been studied in subjects with orofacial pain. During the initial evaluation of subjects with orofacial pain, we collected data on fear avoidance beliefs using the Fear Avoidance Beliefs Questionnaire, and disability and pain. At between 6 and 8 weeks follow-up, we re-collected these data, as well as data addressing subjects' perceived change in their condition. Data were analyzed using correlation coefficients and linear regression. Fear avoidance beliefs at intake were inversely correlated with intake disability, There were no significant associations between fear avoidance beliefs at initial evaluation or in changes in fear avoidance beliefs during the 6-8 weeks follow-up period; and changes in disability, pain or perceived change in condition at 6-8 weeks follow-up. Of note, fear avoidance beliefs increased over the follow-up period, despite improvements in all outcome measures. There was insufficient evidence to suggest that high levels of fear avoidance beliefs at initial evaluation are associated with higher levels of disability or pain at intake, or with change in disability, pain or perceived change in condition at 6-8 weeks follow-up. Similarly, there was insufficient evidence to suggest that changes in fear avoidance beliefs during treatment are associated with any of these outcome measures.

Burning mouth syndrome: Current concepts

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

Perspectives on next steps in classification of oro-facial pain - Part 3: biomarkers of chronic oro-facial pain - from research to clinic

The purpose of this study was to review the current status of biomarkers used in oro-facial pain conditions. Specifically, we critically appraise their relative strengths and weaknesses for assessing mechanisms associated with the oro-facial pain conditions and interpret that information in the light of their current value for use in diagnosis. In the third section, we explore biomarkers through the perspective of ontological realism. We discuss ontological problems of biomarkers as currently widely conceptualised and implemented. This leads to recommendations for research practice aimed to a better understanding of the potential contribution that biomarkers might make to oro-facial pain diagnosis and thereby fulfil our goal for an expanded multidimensional framework for oro-facial pain conditions that would include a third axis.

Altered pain modulation in patients with persistent postendodontic pain

Persistent pain may follow nerve injuries associated with invasive therapeutic interventions. About 3% to 7% of the patients remain with chronic pain after endodontic treatment, and these are described as suffering from painful posttraumatic trigeminal neuropathy (PTTN). Unfortunately, we are unable to identify which patients undergoing such procedures are at increased risk of developing PTTN. Recent findings suggest that impaired endogenous analgesia may be associated with the development of postsurgical chronic pain. We hypothesized that patients with PTTN display pronociceptive pain modulation, in line with other chronic pain disorders. Dynamic (conditioned pain modulation, temporal summation) and static (response to mechanical and cold stimulation) psychophysical tests were performed intraorally and in the forearm of 27 patients with PTTN and 27 sex- and age-matched controls. The dynamic sensory testing demonstrated less efficient conditioned pain modulation, suggesting reduced function of the inhibitory endogenous pain-modulatory system, in patients with PTTN, mainly in those suffering from the condition for more than a year. The static sensory testing of patients with PTTN demonstrated forearm hyperalgesia to mechanical stimulation mainly in patients suffering from the condition for less than a year and prolonged painful sensation after intraoral cold stimulus mainly in patients suffering from the condition for more than a year. These findings suggest that PTTN is associated more with the inhibitory rather than the facilitatory arm of pain modulation and that the central nervous system has a role in PTTN pathophysiology, possibly in a time-dependent fashion.

Topical medications as treatment of neuropathic orofacial pain

Understanding mechanisms of neuropathic orofacial pain, targets of treatment, and basic pharmacology and working with informed compounding pharmacists may result in significant benefit for patients. The clinical significance of topical medications is improvement of quality of life for patients by providing a unique medication delivery system for neuropathic orofacial pain and other dental and extraoral conditions. The use of this route of administration has decreased or minimized side effects compared with other methods and is especially useful in medically compromised and elderly patients. These innovations, supported and improved by ongoing research, will augment the armamentarium of the clinician treating orofacial pain disorders.

A longitudinal study of occlusal caries in Newark New Jersey school children: relationship between initial dental finding and the development of new lesions

OBJECTIVE

Dental caries is a significant public health problem especially amongst children from low-income backgrounds. This longitudinal study examined the development of new occlusal caries in 227 Newark, NJ children ages 10-18. The role of previous caries experience and the presence of occlusal white and dark lesions in predicting the development of new lesions were examined.

DESIGN

At each visit, the patient's teeth were given a visual-tactile examination and the subject's decayed, missing and filled (DMFS) score was determined. Next, molars lacking probeable caries or restorations were examined using transillumination for occlusal white and dark spots. This examination was repeated periodically. A Cox proportional hazard was used to analyse data concerning the development of new occusal caries in molars.

RESULTS

The longitudinal data indicates that patients who were caries free at visit-1 developed significantly fewer occlusal caries during the longitudinal study. The hazard ratio for subjects who had first-visit caries was 2.27 compared to caries free subjects. Intact molars with occlusal white or dark lesions had caries hazard ratios of 0.78 and 1.49 respectively, compared to molars lacking initial colour changes.

CONCLUSION

Having a prior caries history places the subject at increased risk of developing future caries. Teeth with dark lesions but not white lesions are at significantly increased risk for developing decay. White lesions may represent remineralizing or slowly progressing lesions. The results of this study can help identify patients and tooth surfaces at risk for future occlusal decay.

Burning mouth syndrome

According to the International Association for the Study of Pain, burning mouth Syndrome (BMS) is defined as a burning pain in the tongue or other oral mucous membrane in the absence of clinical signs or laboratory findings. The etiology is unknown and presents a challenge for both researchers and clinicians. The management of BMS is still not satisfactory. The prognosis is poor and the burning sensation can last for many years causing a dramatic impact on the patient's quality of life. It is important to distinguish between true BMS and symptomatic burning sensation which occurs when the burning sensation is secondary to a local or systemic pathologic condition. Currently, there are no defined diagnostic criteria for BMS. A diagnosis is usually reached by exclusion of other diseases. This may lead to misdiagnoses, presenting an obstacle to successful treatment.

The role of sensory input of the chorda tympani nerve and the number of fungiform papillae in burning mouth syndrome

OBJECTIVE

The aim of this study was to evaluate patients suffering from burning mouth syndrome (BMS) and control subjects by means of sensory testing and fungiform papillae count.

STUDY DESIGN

The left and right anterior two-thirds of the tongue of of 25 BMS subjects and 20 healthy control subjects were evaluated for electric taste and electric detection threshold. The number of fungiform papillae/cm(2) was evaluated by using close-up digital photography.

RESULTS

The electric taste/tingling detection threshold ratio was significantly higher in BMS compared with control subjects (P = .041). No difference was found between the number of fungiform papillae/cm(2) in the BMS compared with the control subjects (P = .277). Patients suffering from BMS for a prolonged period of time presented with a significantly elevated electric taste/tingling detection threshold ratio (P = .031).

CONCLUSIONS

BMS may be a neurodegenerative process with chorda tympani nerve hypofunction potentially playing a role in the pathophysiology of this disorder.

An improved cost-effective, reproducible method for evaluation of bone loss in a rodent model

AIM

This study was designed to investigate the utility of two "new" definitions for assessment of bone loss in a rodent model of periodontitis.

MATERIAL AND METHODS

Eighteen rats were divided into three groups. Group 1 was infected by Aggregatibacter actinomycetemcomitans (Aa), group 2 was infected with an Aa leukotoxin knock-out, and group 3 received no Aa (controls). Microbial sampling and antibody titres were determined. Initially, two examiners measured the distance from the cemento-enamel-junction to alveolar bone crest using the three following methods; (1) total area of bone loss by radiograph, (2) linear bone loss by radiograph, (3) a direct visual measurement (DVM) of horizontal bone loss. Two "new" definitions were adopted; (1) any site in infected animals showing bone loss >2 standard deviations above the mean seen at that site in control animals was recorded as bone loss, (2) any animal with two or more sites in any quadrant affected by bone loss was considered as diseased.

RESULTS

Using the "new" definitions both evaluators independently found that infected animals had significantly more disease than controls (DVM system; p<0.05).

CONCLUSIONS

The DVM method provides a simple, cost effective, and reproducible method for studying periodontal disease in rodents.