Burning Mouth Syndrome (BMS)

BMS is a chronic orofacial pain disorder that is best defined as an unremitting burning pain in the tongue or other mucous membranes in the absence of any detectable oral mucosa changes or laboratory findings. Clinical Characteristics: Regardless of whether BMS is primary or secondary, the most common chief complaint in almost all patients is a constant burning pain in the tip and anterior two-thirds of the tongue. Other common sites include the hard palate, inner mucosa of the lips and gingival tissues. Symptoms are usually bilateral, but can be unilateral as well. Many patients report a subjective sense of dry mouth (xerostomia) even though the production of saliva is adequate. Another common complaint is a persistent altered taste perception (dysgeusia) which may occur in as many as two-thirds of patients. The dysgeusia is usually described as a bitter and/or metallic taste disturbance which is often reduced by stimulation with food. The combination of burning oral pain, xerostomia and dysgeusia has been referred to as the “symptomatic triad.” Interestingly, pain is usually absent during the night and is at its lowest intensity in the morning upon awakening. It gradually increases during the day, however, peaking by late afternoon or early evening. Many BMS patients report that pain is reduced when eating, sipping cold water, or chewing gum. Spontaneous remission has been reported to occur in approximately 50% of the cases 6 to 7 years after onset. There is no consensus on the cause or pathogenesis of BMS and none have been able to account for the constellation of symptoms seen in BMS. Since BMS usually occurs in the 5th to 7th decade, it seems more than likely there is a hormonal relationship but the role of hormonal changes at menopause is controversial, as is the role of estrogen replacement therapy (ERT) in the management of BMS. Although 20% of BMS patients report a complaint of xerostomia, no consistent connection has been found between BMS and salivary gland dysfunction. Nevertheless, while studies have not demonstrated any decrease in salivary gland function in post-menopausal females, an indirect relationship may exist due to the presence of any concurrent oral and systemic problems. A growing body of scientific evidence seems to indicate BMS is related to neural injury (deafferentation). One proposed model by Bartoshuk and Grushka suggests that taste normally inhibits oral pain through interactions between taste centers in the brain and the trigeminal spinal tract nucleus in the brain stem. The chorda tympani nerve, a branch of the facial nerve, supplies taste sensation to the anterior two-thirds of the tongue while general sensation from this area is mediated by the lingual nerve, a branch of mandibular division of the trigeminal nerve. A reciprocal inhibitory balance between these two systems is thought to exist. But when damage to the chorda tympani taste fibers occurs, this inhibition on the lingual nerve may be released leading to intensified responses to oral stimulation by trigeminal afferents. In susceptible individuals, this may result in burning mouth pain. In summary, BMS has recently been classified as a neuropathic pain disorder with most cases thought to be a deafferentation pain problem related to the loss of inhibition of trigeminal afferents caused by damage to chorda tympani or glossopharyngeal taste fibers. Recent interest has focused on the use of clonazepam, a benzodiazepine, in the treatment of BMS. As a class, the benzodiazepines are GABA receptor agonists that bind to both peripheral and central receptor sites. Clonazepam can either be used systemically or topically. For the management of BMS, low doses of oral clonazepam (0.50 to 1.50 mg daily) have been recommended. A daily dose of 600 mg of alpha-lipoic acid, a potent antioxidant, was also found to improve symptoms of BMS. So, the best way to start with the patient is to have them take 0.50 mg of clonazepam daily for 3-4 days then increase the dose by 0.5mg every 3-4 days until you reach a maximum of 2.0 mg of clonazepam daily or symptoms resolve. If the patient wishes to reduce or eliminate the medication, it is important to wean the patient off of the medication over a couple of weeks rather than stopping the medication all at once If you would like anymore information or have any questions you should call your Golden, CO Dentist.  We can’t wait to help!