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 burn ing 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 sympa thetic output related to stress or from alter ations 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
*Laboratory results abnormal management & correction do not lessen BMS
*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 precipitat ing 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
*Patients with unilateral symptoms thorough evaluation of trigeminal & other cranial nerves eliminate neurologic source of pain
*Clinical characteristics sudden or intermittent onset of pain, bilateral presentation, progressive increase during the day & remission with eating
*Burning persists after management of sys temic 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 (benzodia-zepine derivative) GABA (gamma-aminobutyric 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 use-dependent 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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