Pharmacists Can Help Identify Best Treatments for Possible Causes of Burning Mouth Syndrome
Burning mouth syndrome is exactly like it sounds—a mouth that feels like it was scalded or burned—yet, in spite of the pain, it appears healthy. The pain persists, so patients keep going back to their doctors and dentists, who struggle to find a cause. For many years, patients were told it was all in their heads.
Even though experts now acknowledge it’s not psychosomatic, little has improved in the way of diagnosis and treatment. However, one thing is certain—pharmacists are an important source of information and guidance for patients with burning mouth syndrome. Whether they need reliable information or take medications that should be monitored, these patients desperately need your support.
Overview of Burning Mouth Syndrome
Burning mouth syndrome (BMS) was originally considered to be a psychogenic illness, but abnormalities in trigeminal nerve responses and histopathologic changes in nociceptive fibers support the current theory that it arises from neuropathic mechanisms. The characteristic pain usually occurs on the anterior two-thirds of the tongue, but the lips, gums, hard palate and mucosa throughout the mouth may also be involved. Symptoms of BMS include:1
- Pain – described as scalding and burning
- Dry mouth – present in up to 64 percent of patients, but dry mouth usually can’t be objectively confirmed by tests of salivary function; composition of saliva in BMS patients may be different than normal
- Changes in taste – 70 percent of patients have a persistent bitter or metallic taste; ability to taste sweet or sour may intensify or decrease in some cases
BMS is tricky to diagnose thanks a differential diagnosis that must consider about 30 health conditions. Diabetes, GERD, candidiasis, hypothyroidism, anemia, scleroderma and bacterial infection are just a few of the conditions to be ruled out. The range of symptoms doesn’t make it any easier. For example, the pain may range from mild to severe, it can be constant or increase as the day goes on, and food and drink may or may not exacerbate the pain.
The International Classification of Headache Disorders developed the following diagnostic criteria:2
- Oral pain must occur daily for more than 2 hours/day and longer than 3 months
- Pain must have a burning quality and be felt superficially in the oral mucosa
- Oral mucosa has normal appearance and clinical examination including sensory testing is normal
- Not better accounted for by another diagnosis
Treatment Options and Prognosis
When you compare BMS to other health problems it doesn’t seem very threatening, but stop for a moment to think about the impact it would have on your life—chronic burning pain in your mouth every single day for years. It’s no surprise then to learn that psychiatric disorders are reported in more than half of all patients. BMS is associated with depression, anxiety, and paranoid- and schizoid-type personality disorders.
To top it all off, no cure exists and BMS is hard to treat. Different medications have only achieved partial success—all of the following have variable evidence to support their use:
- Clonazepam – low-dose dissolvable wafers or mouthwash3
- Alpha-lipoic acid
- Oral lidocaine
- Topical capsaicin and intermittent oral capsaicin
- Tricyclic antidepressants
- Hormone replacement therapy
- Psychotherapy – cognitive-behavioral therapy, relaxation techniques
Since BMS is a chronic condition, most patients will require long-term treatment with medications, some of which have potentially serious adverse effects. Pharmacists are on the frontline for monitoring compliance and medication problems, so be sure to conduct a quick review when patients pick up refills.
Secondary BMS may be caused by a variety of underlying problems, including hormonal changes, allergies to dental products or materials, acid reflux, and deficiencies in iron, zinc or B vitamins. Some cases have been caused by drugs. Pharmacists should review medications to be sure those with BMS aren’t taking any of the following, which may trigger the condition:
- ACE inhibitors
- Angiotensin receptor blockers
- Antiretrovirals – nevirapine and efavirenz
The first two on the list—ACE inhibitors and angiotensin receptor blockers—are the most common pharmaceuticals noted in cases of BMS. The precise mechanism isn’t known, but higher levels of kallikrein in the saliva of BMS patients suggests an inflammatory response induced by increased bradykinin.
Counseling Tips for Pharmacists
When you have the opportunity to counsel patients with BMS, one of the best—and the most difficult—things you can do is guide their expectations. No one wants to hear they may have chronic and intense pain for years to come, but they need to understand the natural path of their condition so that they can get down to the business of learning how to manage the pain. Helping them form realistic expectations means teaching about medications, both their adverse effects and the fact that some trial-and-error may be in the cards, as some medications may barely help while others could offer nearly complete relief.
You can also suggest lifestyle tips that may alleviate symptoms. Sipping a cold beverage or sucking on ice chips may ease the pain and relieve dry mouth. Smoking cigarettes should be strongly discouraged, and you can assist them in finding a tobacco cessation program or product. They should also avoid acidic and spicy foods and beverages such as:
- Carbonated beverages
- Orange juice and other citrus products
- Spicy-hot foods
- Cinnamon and mint
Information From Pharmacists Keeps Patients on Track
Keep this in the back of your mind when you talk with BMS patients: Some of the information they’ll find on the Internet downplays BMS, so they may not have an accurate concept of the disease. While there’s nothing wrong with saying that simple dietary changes offer relief (and to see their doctor if pain persists), they need more. Patients will get better results with early treatment that’s more aggressive. Advice that misses the mark reflects this statement from an article in Oral and Maxillofacial Surgery Clinics of North America in August 2016, “Burning mouth syndrome (BMS) is an enigmatic, misunderstood, and under-recognized painful condition.”4 With so much conflicting and complex information, patients are depending more than ever on advice from their local pharmacists.
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- “Burning Mouth Syndrome,” June 2016, http://emedicine.medscape.com/article/1508869-overview#a1 ↩
- “Alice in Wonderland Syndrome, Burning Mouth Syndrome, Cold Stimulus Headache, and HaNDL: Narrative Review,” October 2015, http://www.medscape.com/viewarticle/853098_4 ↩
- “The Effect of Clonazepam Mouthwash on the Symptomatology of Burning Mouth Syndrome: An Open Pilot Study,” December 2014, http://painmedicine.oxfordjournals.org/content/15/12/2164.long ↩
- “Burning Mouth Syndrome,” August 2016, https://www.ncbi.nlm.nih.gov/pubmed/27475513 ↩