Role of Medications in Burning Mouth Syndrome: A Review

 

Dr. Ritika Gupta¹, Dr. Esha Verma², Dr. Rashmi Saikhedkar³, Dr. Arunendra Singh Chauhan⁴

¹Senior Lecturer, Dept of Oral and Maxillofacial Surgery, College of Dental Sciences and Hospital,

F-12 Jhoomer Ghat, Rau, Indore (M.P) - 453331

²Reader, Dept of Periodontics and Implantology, College of Dental Sciences and Hospital,

F-12 Jhoomer Ghat, Rau, Indore (M.P) - 453331

³Professor, Dept of Oral and Maxillofacial Surgery, College of Dental Sciences and Hospital,

F-12 Jhoomer Ghat, Rau, Indore (M.P) - 453331

⁴Senior Lecturer, Dept of Public Health Dentistry, College of Dental Sciences and Hospital,

F-12 Jhoomer Ghat, Rau, Indore (M.P) – 453331

 

ABSTRACT:

Burning mouth syndrome refers to the burning painful condition of the oral cavity in the absence of any other pathologic entity. It is a chronic condition of at least 4-6 months duration and is mainly confined to tongue, lower lip and buccal mucosa. Few local factors, as irritation due to ill fitting prosthesis, candidal infections and xerostomia and few systemic factors as diabetes mellitus, nutritional deficiencies are found associated with burning mouth syndrome. Management of burning mouth syndrome includes medications, psychiatric counselling and correction of any underlying disease. This review presents role of medications and their efficacy in the management of burning mouth syndrome.

 

 

 

INTRODUCTION:

Burning mouth syndrome (BMS) is a chronic burning stinging painful disorder of the oral cavity without the presence of any other organic disease. Burning Mouth Syndrome is characterized by complain of intensely burning mouth with a completely normal appearing oral mucosa.

 

Burning Mouth Syndrome is also known by other terms as glossodynia, stomatodynia, Glossopyrosis, stomatopyrosis and oral dysesthesia. Burning Mouth Syndrome was initially described in early 20th century by Butin and Oppenham as glyssodynia mainly because tongue was the main headquarter of location of pain in majority of the patients¹.

 

International association for study of pain ASP has identified Burning Mouth Syndrome as a distinct nosological entity characterised by burning oral sensation or pain, unremitting while in absence of objective clinical changes in oral mucosa lasting for at least 4-6 months²_.

 

Scala et al identifies Burning Mouth Syndrome as pain located bilaterally lasting for atleast 4-6 months duration in the oral mucosa which otherwise appears to be clinically healthy³.

 

EPIDEMIOLOGY

Prevalence of Burning Mouth Syndrome as reported by international studies ranges between 0.7 to 4.6%⁴. Burning Mouth Syndrome rarely effects people with age group of less than 30years old, and mainly effects people between 38-78 years age group. Male to female ratio of 3.1 to 16.1 have been reported, with female preponderance especially in peri and post menopausal women of age 50-60 years. Prevalence of Burning Mouth Syndrome in peri and post menopausal women increases by 12-18 %³.

 

CLASSIFICATION:

Various classifications have been proposed for Burning Mouth Syndrome. One classification based on daily fluctuations of symptoms was proposed by Danhair Millew⁶.

 

TYPE 1: Characterized by progressive pain which starts in the morning and increases as the day passes by. This type is associated with some systemic diseases as diabetes mellitus, nutritional deficiences and others. This type effects 35% of people.

 

TYPE 2 : This variant effects 55% of the patients. In this type, symptoms remain throughout the day and are associated with difficulty in sleep and other psychiatric problems.

 

TYPE 3 : Characterised by intermittent pain that lasts for only few times in a day Effects 10% of the people. Contact allergy by local allergies is found as an associated factors.

 

Scala et al classified Burning Mouth Snydrome as per two clinical variants :

1) PRIMARY/ESSENTIAL:

Exact cause is unknown

Peripheral and central neurogenic pathways may be found associated

 

2) SECONDARY:

Basically caused due to presence of some local or systemic conditions as contact allergy due to ill fitting prosthesis, candidal infections or diabetes mellitus, anxiety etc.

 

ETIOPATHOGENESIS:

Exact cause of Burning Mouth Syndrome is not known and is said to be multifactorial. Etiology is said to involve psychological behavioural and neurophysiological mechanisms^7.

 

A) SYSTEMIC FACTORS:

Various systemic factors are said to cause and be involved in Burning Mouth Syndrome.

 

1) Nutritional deficiencies:

Deficiencies of  vitamins B6, B12, Zinc , folic acid makes person susceptible to BMS.

 

2) Systemic diseases:

Presence of certain diseases as diabetes mellitus certain autoimmune diseases, make present susceptible to BMS.

 

 

3) Regular use of certain medications:

Regular use of certain medications predisposes person to Burning Mouth Syndrome. These include antihypertensives, antihistamines, neuroleptics, benzodiazepine. Among these antihypertensives are well known to cause burning mouth syndrome.

 

B) LOCAL FACTORS:

1) Direct irritation and allergy

Chronic irritation as due to a poorly or ill fitting denture is known to cause Burning Mouth Syndrome.

 

2) Oral infections:

Infections as candidiasis and other fungal infections of oral cavity predisposes to Burning Mouth Syndrome.

 

3) Xerostomia:

Dry mouth decreases immunity of oral cavity and can lead to Burning Mouth Syndrome.

 

4) Supertasters:

Some women have high density of fungiform papillae on anterior 2/3 of tongue and can percieve a bitter taste in a better way, they have prone to develop Burning Mouth Syndrome.

 

CLINICAL FEATURES:

Onset of symptoms of Burning Mouth Syndrome is said to be spontaneous without any recognizable triggering factors in approx 50% of the patients⁸. Few other 17-33% of the patients attribute the onset of symptoms to upper respiratory infections or some other medications.

 

Clinical features of Burning Mouth Syndrome show varied symptoms. Chief complain of patient with BMS is pain which is of tingling, stinging and annoying type mainly confined to anterior 2/3 of tongue, anterior part of hard palate and lower labial mucosa.

 

The oral burning pain usually increases progressively during the day and gets maximum by evening and dissppears at night. Xerostomia, an ill fitting denture, or an candidal infection might be associated. Otherwise the oral cavity is normal. Systemic diseases as diabeties mellitus and nutritional defciences, any psychiatric ailments might be an associated feature.

 

70% of individuals also complain of altered disturbed taste sensation mostly bitter, metallic or both⁹.

 

DIAGNOSIS:

Absence of any oral mucosal pathology is mandatory for diagnosing Burning Mouth Syndrome. Comprehensive, thorough history is the key to diagnosing burning mouth syndrome. History of type of pain, its duration, intensity, severity, are important in history.

Associated systemic diseases, if any should be check up and corrected. Use of any regular medications if being taken is vital in diagnosing burning mouth syndrome

 

Certain lab tests as CBC, sugar tests, nutritional levels, oral cultures might be of help.

 

TREATMENT:

Treatment of Burning Mouth Syndrome is multidisciplinary. Firstly the type of Burning Mouth Syndrome should be ruled out if its primary or secondary.

 

3 strategies have been established for treating Burning Mouth Syndrome. These are helpful when used alone or in combination as per requirement¹⁰.

 

A) SYSTEMIC APPROACHES:

Involves diagnosing and managing any underlying systemic illness. Regular use of medications if any should be evaluated, altered and adjusted accordingly if they are found to be involved with Burning Mouth Syndrome.

 

Few systemic oral medications are helpful in treating Burning Mouth Syndrome.

1)  Tricyclic antidepressants

Amitriptyline 5-10mg/day to 50 mg

Desipramine 5-10 mg/dayto 50 mg

Imipramine 5-10 mg/day to 50mg

These can cause xerostomia and so need to be monitored well as therapy.

2) Selective antidepressants which are seratonin reuptake inhibitors which include :

Seritraline 30-60 mg / day.

Dulextine 30-60 mg / day.

3) Others as benzodiazepines, anticonvulsants and analgesics have been also helpful.

4) Alpha lipoic acid (ALA) 600mg/day for 2months. Its a good antioxidant and powerful neuroprotective agent.

Alpha lipoic acid acts by helps increase intracellular glutamine and decrease symptoms in patients with idiopathic dyesthesia¹¹.Alpha lipoic acid also generates other antioxidants as vitamin C and E.Alpha lipoic acid treatment with psycotherapy has been found to be beneficial as combination therapy to treat Burning Mouth Syndrome.

5) Systemic Capsaicin has also proved to be effective in reducing pain intensity 0.25% capsules 3 times for 1 month.

6) Correction therapy with medications. These include :

Supplementation with vitamin B12, vit B6, zinc, folic acid, helps to increase and maintain nutrient level and need improve overall general well being, of individual and help lessen symptoms of Burning Mouth Syndrome.

Harmonal replacement therapy (H.R.T) in peri and post menopausal women also is said to be beneficial in treating Burning Mouth Syndrome.

 

Local /topical approach and medicatons:

1) CAPSAICIN 0.25% cream has been found to be helpful as desensetizing  agents and acts by as inhibiting substances which induces pain. Bad taste and toxicity limits use of capsaicin¹².

2)  Rinsing with 0.15% Benzydamine HCL thrice a day benefits by having analgesic, antiinflammatory and anaesthetic agents. Duration of action is very limited and so not very useful.

3) Swish and spit technique. Using anxiolytics as clonezepam 1 mg tablet by crushing in oral cavity and using it topically at the local area, followed by spitting it out helps relieve symptoms¹⁴.

4)   Lignocaine hydrochloride been tried but without any success due to its short duration.

5)   Topical steroid and other antiinflammatory medications have been also tried but with limited results.

 

COGNITIVE THERAPY:

These include cognitive behavioural approaches group psychotherapy or both. Counselling session for patients with Burning Mouth Syndrome in detail is found to be helpful to decrease local symptoms, help improve well being of the patient. Patient is adviced not to take too much of stress and let it go¹⁵.Certain medications as placebos along with combination of psychotherapy and psychopharmacotherapy have yielded good results in the management of Burning Mouth Syndrome. Combination of local, systemic and psychotherapy treatment all together or alone have generally helped to manage Burning Mouth Syndrome satisfactorily.

 

Results of treating Burning Mouth Syndrome have given varied results. Sardella et al 2006 in a study showed result of psychopharmacotherapy have yielded good results in managing burning mouth syndrome.

 

Combination of local, systemic, psychotherapy all together or alone have generally helped to manage Burning Mouth Syndrome satisfactorily.

 

Results of treating Burning Mouth Syndrome have given varied results. Sardella et al 2006 in a study showed results of numbers of cases being treated by various modalities. 28.3 % showed moderate improvement, 49% showed no change while¹⁷, 18.9 % had worsening of the symptoms

 

Inspite of so many treatment modalities, complete spontaneous remission of Burning Mouth Syndrome is said to be rare.

CONCLUSION:

Burning Mouth Syndrome is a complex disorder and yet to be completely understood. Its multifactorial features require in depth understanding and management. Correctly diagnosing Burning Mouth Syndrome and covering all aspects of treatment modalities will help achieve satisfactory results in its management.

 

CONFLICT OF INTEREST:

None.

 

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Accepted on 18.12.2018           © RJPT All right reserved

Research J. Pharm. and Tech 2019; 12(2):881-884.