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What are the causes of a burning tongue?

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BMS PostThis question was submitted by a general dentist: What are the causes of burning tongue?

 

 

Dr. Gary Klasser in collaboration with Dr. Suham Alexander, Oasis Clinical Editor, provided this quick initial response

(Glossodynia, Glossopyrosis, Stomatodynia, Stomatopyrosis, Sore tongue, Oral dysaesthesia)

Burning mouth syndrome (BMS) is an idiopathic condition which predominantly affects peri- or post-menopausal women in a higher frequency than it affects men. The condition has not been reported in children. The burning sensation may occur in several sites of the oral cavity, such as the hard palate, gums and lower lip; however, it most often presents bilaterally on the tip and sides of the tongue. The pain usually increases in the morning, peaks in late afternoon or evening, and does not disrupt sleep. The condition’s symptoms and intermittent or constant pain may last for several months or years. In addition to pain and discomfort, patients may also experience xerostomia, dysaesthesia, and/or dysguesia. BMS is diagnosed after excluding other oral burning sensations which may be caused by local and/or systemic conditions.

To date, no specific etiological factors have been identified for this condition. The syndrome may present in conjunction with other medical and dental conditions, including:

  • Nutritional deficiencies (anemias)
  • Mucosal diseases
  • Fungal infections (Candidiasis)
  • Endocrine imbalances (Diabetes mellitus, hypothyroidism)
  • Autoimmune/connective tissue disorders (Sjogren’s disease etc)
  • Gastroesophageal reflux disease
  • Parafunctional behaviours (tongue thrusts, bruxism)
  • Denture-related factors
  • Allergic contact stomatitis

One method of classifying BMS is based upon the fluctuation of symptoms.

Type 1 (35%)

Daily pain may not present on waking, but worsens during the day and is most severe in the evening (Not normally associated with psychiatric disorders).

Type 2 (55%)

Patient wakes up with daily and constant pain (Usually associated with psychiatric disorders, chronic anxiety).

Type 3 (10%)

Patient experiences bouts of pain. Pain occurs in atypical sites, such as the buccal mucosa, floor of the mouth, and throat (Most often associated with allergies to food additives or colourings). 

Management

  1. Obtain medical and dental history
    • Pain – duration, site, pattern, character
    • Inquire about depression, anxiety, fear of cancer
    • Other factors – mouth rinses, food, cosmetics, smoking?
    • Medications – any that may cause xerostomia?
    • Pain related to previous dental work?
  2. Perform oral examination
    • Oral evaluation: reassure patient and address their concerns about oral cancer.
    • Note presence/absence of lichen planus, erythema, ulcers, glossitis, candidiasis, geographic tongue, dentures, or atrophy.
  3. Perform dental examination
    • Note potential dental problems: broken teeth/fillings, broken dentures, parafunctional habits, and refer to specialists, as required.
  4. If nutritional deficiencies are suspected, have patient consult with physician to obtain appropriate laboratory work. Patient may require iron, B12, folate or zinc replacement.
  5. Assess risk and/or control of diabetes mellitus. Patients with known diabetes may need to alter medication or dosage . Patients with thyroid abnormalities and/or dysfunction may also present with BMS and should be referred to their physician for further testing and diagnosis.
  6. Treat oral candidiasis with oral fluconazole (Diflucan).
    • 100 mg (15 pills)
    • Day 1 – 2 pills
    • Day 2-7 – 1 pill daily
    • Day 8-21 – 1 pill every alternate day
  7. Dry mouth symptoms may be relieved by finding alternative medications (after consulting with the practitioner who prescribed these medications), if the current medications are causing xerostomia. Artificial saliva substitutes may also aid in reducing symptoms (MouthKote, Moi-Stir, Optimoist). Sialogogues such as Pilocarpine (Salagen), Cevimeline (Evoxac), Bethanechol (Urecholine), Anethole Trithione (Sialor) and sugar-free gum and candies may also help.
  8. In idiopathic cases, suggest B-complex vitamins and anti-candidal agents and recommend that patients refrain from alcohol-based mouth rinses, mints, cinnamon and smoking. Patients should be referred to their physician for a comprehensive evaluation.
    • Physicians may prescribe Doxepin (up to 75 mg qd) for anxiety and depression.
    • Symptomatic relief can be found in any combination of Benadryl and Kao-Pectate or viscous Lidocaine (swish and spit q3h).

References

  1. Shivpuri A, Sharma S, Trehan M, Gupta N. Burning mouth syndrome: A comprehensive review of literature. Asian Journal of Oral and Maxillofacial Surgery 23 (2011): 161-166.
  2. Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome. Cochrane Database Syst Rev 2005(1):CD002779.
  3. Patton LL, Siegel MA, Benoliel R, De Laat A. Management of burning mouth syndrome: systematic review and management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103 Suppl:S39 e1-13.
  4. De Moraes M, do Amaral Bezerra BA, da Rocha Neto PC, de Oliveira Soares AC, Pinto LP, de Lisboa Lopes Costa A. Randomized trials for the treatment of burning mouth syndrome: an evidence-based review of the literature. J Oral Pathol Med. 2012 Apr;41(4):281-7.
  5. Mock D. Burning Mouth/Tongue Syndrome AAOMS Symposia (2009)
  6.  Buttaravoli P. Minor Emergencies. Elsevier Inc. (2012): Chapter 44.
  7. Femiano F, Lanza A, Buonaiuto C, Gombo F, Nunziata M, Cuccurullo L, Cirillo N. Burning mouth syndrome and burning mouth in hypothyroidism: proposal for a diagnostic and therapeutic protocol. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology – January 2008 (Vol. 105, Issue 1, Pages e22-e27, DOI: 10.1016/j.tripleo.2007.07.030).

 

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