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Nurdiana, drg., Sp.

PM

Burning Mouth Syndrome (BMS)

oral burning in tongue or other oral mucous membranes no detectable cause, do not follow anatomic pathways, no mucosal lesions or known neurologic disorders & no laboratory abnormalities

*BMS

burning lips syndrome scalded mouth syndrome

stomatodynia
glossodynia glossopyrosis

*Prevalence rates in epidemiologic studies


0.7 - 2.6%

*Typically affects middle-aged women *Women 7 times >> men recent


epidemiologic data equal male : female

*Men affected at a later age than women

*Rare in children & teenagers, very


uncommon in young adults

*Most prevalent in postmenopausal women


in mid- to late fifties 10 - 15%

*Most prevalent 3 12 yrs after menopause

Cause unknown

local, systemic & psychological

Lokal
*Pseudomembranous & erythematous
candidiasis BMS

*Gorsky et al patients BMS no clinical


signs of candidiasis 86% improved after using antifungal lozenges & 13% complete elimination of symptoms

*Bacteria (staphylococci, streptococci,


anaerobes)

*Carcinomas of the oral cavity itching or


burning premonitory symptom

*Premalignant entities leukoplakia or


erythroplakia burning or painful sensation

*Faulty denture design promote burning


sensation increased level of functional stress to the circum oral or lingual musculature

*Main & Basker ill-fitting dentures


single greatest contributor

*Majority patients denture abnormalities


adequately corrected BMS persisted

*Chemical irritation & allergic reactions


no evidence result of allergic reactions to food, oral hygiene products, or dental materials (methyl-methacrylate monomer & mecury)

*Contact allergy affect the oral mucosa


burning sensations inflammatory, lichenoid, or ulcerative lesions

*Mechanical irritation/trauma oral habit,


dentures (errors in denture design) & sharp teeth

*Dry mouth higher incidence in BMS


patients no clear association between BMS & decreased salivary flow rate

*Glass xerostomia local contributing


factor, other authors higher or lower prevalence of xerostomia in BMS patients

*No significant decrease in salivary flow


unstimulated or stimulated subjective complaints of mouth dryness & thirst

*Studies significant alterations in salivary


components mucin, IgA, phosphates, pH, buffering capacity, proteins & electrical resistance

*Relationship of changes salivary


composition to BMS unknown altered sympathetic output related to stress or from alterations in interactions between cranial nerves & pain sensation

Systemic
Various systemic factors BMS many of these conditions require further study to verify the correlation

*Increased incidence in menopause women


hormonal changes hypoestrogenemia

*Its mechanism remains unclear not


usually reversible with hormone replacement therapy

*BMS symptoms of deficiency iron,


Vitamin B & folic acid

*Lamey et al

replacement therapy of vitamin B1, B2 & B6 effective in treating BMS in 88% patients management & correction do not lessen BMS

*Laboratory results abnormal

*BMS symptoms of diabetes associated


with xerostomia & candidiasis

*Diabetic neuropathies in the head & neck


region contributing BMS

*Symptoms in diabetic patients did not


decrease after glucose control others found diabetic treatment resolved the oral symptoms

*Burning characteristic of post-traumatic


nerve injuries alterations in perception to touch, temperature, two-point discrimination, & threshold pain BMS infrequent

*Recently secondary to the use of


angiotensinconverting enzyme (ACE) inhibitors (captopril, enalapril, & lisinopril) remitted following discontinuation of the medication

Psychological
*Personality & mood changes psychogenic
problem

*Psychologic dysfunction common in


patients with chronic pain result of the pain rather than its cause

*Lamb et al 60%

BMS patients psychological factors & anxiety was most difficult to control

*BMS symptom of cancer-phobia


reassuring after a proper diagnosis often helpful in relieving symptoms

*Strong psychological component chronic


low-grade trauma parafunctional oral habits rubbing the tongue across the teeth or pressing it on the palate

*In some patients, more than one of these


factors may be contributing to the problem in others, no specific cause can be identified

*> 50% patients BMS onset spontaneous,


no identifiable precipitating factor

* 1/3 patients relate time of onset


dental procedure, recent illness or medication course

*Pain intensity & other symptoms commonly


develop gradually over time

*Persist for many years *Most common sites anterior tongue,


anterior hard palate, & lower lip

*Burning often occurs in more than one oral


site

*Burning intermittent or constant


eating, drinking, or placing candy/chewing gum relieves the symptoms

*Patients with lesions or neuralgias


increased oral burning during eating

*Pain moderate - severe intensity


gradually increases throughout the day max intensity by late evening difficulty falling asleep at night & experiencing interrupted sleep

*Reported mood changes irritability &


decreased desire to socialize related to altered sleep patterns

*Personality characteristics depression &


anxiety may affect the pain or be secondary to the chronic pain

*Frequently accompanied by dry mouth &


thirst despite lack of evidence of decreased salivary flow

*Altered taste (dysgeusia) *Additional pain complaints facial pain &


pain at other sites

*Local anesthetic elixir increases burning


but decreases dysgeusia

*Mechanism by which factors can causes


symptoms completely unknown

*Morphologic alterations in peripheral tissue


injury/disease biochemical & pathophysiologic changes in nociceptive neurons in CNS to previously non-noxious stimuli

*These conditions occur as a result of


common systemic/local disorders nerve damage occurs to either the trigeminal nerve directly or other cranial nerves inhibit oral nociceptive activity

*History taking key to diagnosis *Diagnosis detailed history, clinical


examination, laboratory studies & exclusion of all other possible oral problems

* Even patient reports typical features of BMS


other potential causes should be ruled out

* Patients complaining xerostomia & burning

evaluated for the possibility of a salivary gland disorder mucosa dry & difficulty swallowing dry foods without sipping liquids evaluation of trigeminal & other cranial nerves eliminate neurologic source of pain

* Patients with unilateral symptoms thorough

*Clinical characteristics sudden or


intermittent onset of pain, bilateral presentation, progressive increase during the day & remission with eating

*Burning persists after management of systemic or local oral conditions diagnosis of BMS can be considered

*Making clinical diagnosis not difficult


determining the subtle factor difficult

*C. albicans culture, Sjogren's syndrome


antibodies serum tests, complete blood count, serum iron, total iron-binding capacity, serum B12 & folic acid levels

*Tests individual consideration depend


on clinical history & clinical suspicion

*Biopsy not indicated no typical


clinical lesion is associated

*First exclude other disease *Sources of pain must be dealt with not
too much expectation

*Reassured benign nature of the


symptoms & frightening possibilities such as cancer can be excluded

*If suggests psychogenic factors explain


to the patient that depression & other emotional disturbances can cause physical diseases & emotional disturbances affect almost everyone

*Counseling & reassurance adequate for


mild BMS more severe symptoms drug therapy

*Drug therapies low doses tricyclic


antidepressants (TCA) amitriptyline, desipramine, nortriptyline, imipramine, clomipramine, or doxepin

*Should be stressed drugs not to manage


psychiatric illness analgesic effect

*Clinicians should be familiar potential


serious & annoying side effects

*Benzodiazepines clonazepam (benzodiazepine derivative) GABA (gammaaminobutyric acid) receptor agonist effective for various orofacial pain disorder

*Grushka et al clonazepam effective in


relieving taste dysgeusias & oral dryness along with the oral burning

*Other medications & treatments


neuropathic pain conditions :

* Topical capsaicin the monoamine oxidase


inhibitor tranylcypromine sulphate in combination with diazepam

* Systemic anesthetic mexiletine usedependent sodium channel blocker

*Parafunctional oral habits splint covering


the teeth and/or the palate

*Partial remissions occur in approx 2/3


patients in 6 7 years after onset

*No studies investigated whether earlier


intervention or earlier & better pain control lead to earlier disease remission

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