Burning Mouth JC

8/10/2019 Burning Mouth JC

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JADA 2013;144(10):1135-1142

Defining and diagnosing burning mouth

syndrome: Perceptions of directors of NorthAmerican postgraduate oral medicine andorofacial pain programs


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What is BMS??

- burning pain in the tongue or other oral

mucous membrane persisting for at least fourmonths and associated with normal oralmucosa and normal laboratory findings.

- IASP definition


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Diagnostic criteria??

Burning sensation in tongue or other parts ofthe oral mucosa,

usually bilateral associated with

dysgeusia,

dry mouth

denture intolerance.

IASP diagnostic criteria


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Definition by IHS

An intraoral burning sensation for which nomedical or dental cause can be found.

IHS further noted that pain may be confinedto the tongue with associated xerostomia,paresthesia and altered taste.


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IHS diagnostic criteria

Pain in themouth

Oral mucosa ofnormal appearance

Exclusion of localand systemic

diseases.

Persisting formost of the day


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These somewhat imprecisedefinitions and descriptions

lead to challenges for the health carepractitioners when evaluating patientswith BMS

and the barriers to achieving an accurateand reliable diagnosis.


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BMS prevalence ?

0.7-5.0 % (of general population)

Prevalent in women in the 5thto 7th

decade

Depends upon the methodology (clinicalassessment) and geographical setting ofthe study


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Usually manifests in a period between 3 yrsbefore and 12 yrs after the onset ofmenopause.

Rarely manifests before the age of 30 yrs.

Female:male = 3:1 - 16:1


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Commonly occurs bilaterally,

May occur simultaneously at multiple sites.

Anteriortwo-

thirds ofthe

tongue,

Dorsumand

lateralborders

oftongue

Anterioraspect ofthe hard

palate

Labialmucosaof the

lips.


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Other symptoms!

Taste alterations

Described as a constant foul, bitter

or metallic taste sensation

which may be equally as disturbingas or more disturbing than burningpain itself.


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Other symptoms!

Conflicting data regarding xerostomia inBMS.

Nevertheless, qualitative changes in salivarycomposition seen.


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classification schemes

Classification by Lamey and Lewis (1996)

contains three subtypes according tovariations in pain intensity over 24 hours.

-Br Dent J 1989;167(11):384-389.


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- Pain 2010;149(1): 27-32.

Gremeau-Richard reported two distinct

group based on the location ofneuropathic changes

Mediated by

peripheral or

central nervous system


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Clin Neurophysiol 2012;123(1):71-77

Jaaskelainen proposed three distinct

subclasses based on neuro-physiological,

psychophysical and

functional imaging studies.


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A more pragmatic clinical approach is toseparate BMS into 2 distinct categories:

Primary BMS- lack of evidence of any otherdisease

Secondary BMS- secondary to systemicconditions such as anemia, diabetes, thyroiddisease or gastroesophageal reflux disorder.


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Question??

What is clinicians understanding

of the diagnosis of BMS.


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answer!

Opinions (via a confidence ratingscale [CRS]) from experienced health

care practitioners who treat BMS.


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Answers rated with (CRS?)

CRS is numeric rating scale with anchors of 1 ( I am very uncertain) and

7 (I am very certain),

high confidence rating 6.0.

[enhance the certainty of responses and reduceimprecision in the judged probabilities]

All responses measured according to a CRSexcept those related to the participants clinicalexperience.


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respondentsrated their

confidence inselection of

answer

answered

thequestions

answersaveraged to-

mean scorewith CR and

SD


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Same process used with an array of

oral health issues, and has led toimproved outcomes for those

conditions

such as outcomes assessment for

periodontal therapy,

referral criteria in pediatric dentistry

indications for use of radiography


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AIM Gather data

-about perceptions of a group of oral medicineand orofacial pain training program directors(United States and Canada)

-In terms of

definition of BMS

and the various factors and variables used in, and

assisting with, the determination of its definitive

diagnosis.


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Methods

A structured questionnairewas designed with input from four experienced clinicians in OM

and OFP (2 from each)

did not participate directly.

Most questions wereopen-ended to facilitate

variability of responses. Broad approach captured the most information

without limiting answers

or leading him or her.


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1 question- not open ended

The only question with

designated responsecategories

involved- specific diagnostic testing for

conditions that excluded BMS.


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Items addressed :

Respondents clinical experience asit pertained to BMS

The most common characteristicsto be used in a definition of BMS


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Items addressed :

Criteria necessary to make definitive

diagnosis while addressing local, systemic and psychological

factors to be ruled out

Diagnostic tests used to support diagnosis

Perception regarding etiopathogenesis.


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n = 20; OM = 10; OFP = 10.

Q ti


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Questionnare1. Please list the mean number of patients with burning mouth

syndrom (BMS) seen every three months.

2. Please list the most common characteristic(s)to be used in adefinition of BMS.

3. Please list the criteria(including signs and symptoms)necessary for a definitive diagnosis of BMS.

4. Please list the local factors needing to be ruled out before adefinitive diagnosis of BMS can be made.

5. Please list the systemic factors needing to be ruled out before

a definitive diagnosis of BMS can be made.


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6. Please list the psychological factors needing to be ruled outbefore a definitive diagnosis of BMS can be made.

7. What diagnostic tests are used to rule out local factors,systemic factors or both to support a definitive diagnosis ofBMS? Please circle appropriate letter(s).

a. salivary flow rates b. taste testing

c. serologic studies

d. soft-tissue biopsy

e. microbiological cultures f. medication substitution

8. Please describe the etiopathogenesisof BMS


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Open ended questions

Multiple responses from

each participant

Responses grouped into

broader categories

Discussion


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Answer to question 1

A mean of 7.3 cases diagnosed in

each postgraduate program in

any given three-month period

And approx. 89% of those had beenmanaged.

A t ti 2


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Answer to questions 4,5,6


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The majority of respondents indicatedmeasurement of salivary flow rates (n = 11)

as a diagnostic test to rule out a diagnosis ofBMS

mean [SD] CRS score, 6.2 [0.60],

95 percent confidence interval [CI], 5.82-6.54



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n = 8; mean[SD] CRSscore, 6.1[0.64]; 95percent CI,5.69-6.57

Serologicstudies

n = 7; mean [SD]CRS score, 6.1[0.69]; 95 percentCI, 5.63-6.65

Medication

substitution

n = 5; mean[SD] CRS

score, 6.6[0.55]; 95percent CI,6.12-7.08

Microbiologi-cal cultures

n = 3; mean[SD] CRSscore, 6.3[0.58];

95 percentCI, 5.68-6.98

Soft-tissuebiopsy

n =2;

mean[SD] CRSscore,6.0 [0.0]

tastetesting


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Participants displayed uncertainty in their responses whendefining the etiopathogenesis for BMS as idiopathic or unknown

or psychological or psychosocial


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DISCUSSION


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Notably, only 4 of the 13 programdirectors

reported burning sensation in the tongue and

chronic pain

as characteristics that should be usedin a definition of BMS.


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Majority of respondents did not support the

inclusion of chronic pain (n = 4) in the definitionof BMS

because they considered that an acute onset of anoral burning sensation would be an acceptable

criterion to be included in a definition of BMS.

Alternatively, the concept of chronic pain (pain

lasting longer than three months), was notconsistent with their perception of chronic pain,which possibly involved a longer period (ex: 6

months).


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It is of paramount importance for the healthcare practitioner to understand that

BMS is a diagnosis supported by the nature ofthe symptomatic complaint and

the exclusion of various local and systemicfactors.


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Factors that need to be ruled out in the

diagnosis of BMS.

were reported with a moderate to high levelof confidence (range of mean CRS scores, 5.9-

6.8; 95 percent CI, 5.20-7.24).

The emphasis on the need to rule out fungal

infection may be due to the often associatedelevated prevalence of Candida speciesreported in people with BMS


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Fungal infection often associated with abitter or metallic taste (a symptom alsocommonly reported by patients with BMS)

and clinical findings of erythema orpseudomembranes often represents thetrue source of burning pain.

Patients with these symptoms may reportincreased pain on eating, likely because ofirritation of the mucosa.


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The importance of ruling out the presence ofa fungal infection cannot be understated

and if such an infection is identified, adiagnosis of secondary BMS would beappropriate.


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Before diagnosing BMS, thorough history andexamination is required involving the use ofadjunctive tests, imaging or both when

deemed necessary.

Certain diagnostic tests assist in ruling out

factors that may be responsible for burningsymptoms.


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Eleven respondents endorsed the measurement ofsalivary flow rates as an important diagnostic test todetermine salivary gland hypofunction ordysfunction.

Although there is controversy among cliniciansregarding the role of salivary flow in BMS, this studysuggests that health care practitioners shouldincorporate into their diagnostic armamentariumand decision making processes a means ofobjectively measuring salivary flow rates andmethods of ruling out salivary conditions before theyprovide a definitive diagnosis of BMS.


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Participants did not indicate the need for useof imaging (dental or medical) in the diagnosisof BMS.

This was most likely because participants were not

provided with the option of endorsing thisdiagnostic test, having deliberately excluded it

from the designated response categories.

Three participants endorsed the use of soft tissue


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Three participants endorsed the use of soft-tissue

biopsy as an important diagnostic test to rule out adiagnosis of BMS.

Although there is no established consensusregarding the sampling of soft tissue (for example,

to rule out mucosal disease or to observe small fiberaxonal degeneration in the tongue) for a definitive

diagnosis of BMS,

It is possible these participants responded in this

manner because they suspected other soft-tissue

diseases causing burning sensation that could be

misconstrued as BMS.


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Although the precise etio-pathology of BMSstill is elusive, the results are representative ofthe current published literature regarding

BMS involving both central and peripheralneuropathic mechanisms.

More than one-half of the total number (n =33) of responses (54.5 %) supported theconcept of BMS having a neuropathic

etiopathogenesis.


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Additionally, theories involving psychologicaland psychosocial issues, and hormonal

factors reported in the literature also werereported by the respondents.

Participants displayed a lower level ofconfidence in their responses in this category.

This may be explained by the lack of strong

scientific evidence supporting any oneparticular theory for the etiopathogenesis ofBMS (with the exception of the neuropathiccomponent).

i i i


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Limitations

This study was limited by being based on self-reportsgathered via a mainly open-ended survey.

Open-ended format required categorization ofresponses, which may have introduced

misclassification bias.

Number of people surveyed was limited


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A formal assessment of each participantsknowledge regarding BMS was notconducted and variability in participantseducation was not controlled, However these individuals had considerable clinical

education and experience in the diagnosis and

management of BMS and were active in caring forpatients with these symptoms.

Limitations


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There may have been additional diagnostictesting alternatives that were overlookedand not included in the questionnaire.

Respondents were forced to choose aresponse from a prescribed menu, other

possibilities were not elicited (no spaceprovided to record diagnostic tests notpresent in the menu).

Limitations


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Limitations

Temporal component regarding chronic painnot investigated.

Formal sample-size calculation was not

performed. Furthermore, the reliability of the CRS

technique, owing to its cross-sectional

nature, could not be demonstrated in thisstudy.


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Conclusions

The findings in this study present an initialexploration of the perceptions of programdirectors of OM and OFP postgraduate

programs in North America regardingdiagnostic paradigms, clinical presentationsand etiologic and pathophysiological theories

regarding BMS.


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Similarities were observed amongrespondents who had a high degree ofconfidence regarding variables associatedwith the diagnosis of BMS, such asneuropathic etiopathogenesis andobjective assessment of salivary flow.

Conclusions


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This exercise will lead to development of a

comprehensive consensus statement that

expands the current definitions of BMSdescribed earlier

Conclusions

J C t M d S M J 8( )
http://www.ncbi.nlm.nih.gov/pubmed/24800705http://www.ncbi.nlm.nih.gov/pubmed/24800705http://www.ncbi.nlm.nih.gov/pubmed/24800705http://www.ncbi.nlm.nih.gov/pubmed/24800705http://www.ncbi.nlm.nih.gov/pubmed/24800705


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J Cutan Med Surg.2014 May-Jun;18(3):174-9.

OBJECTIVE: To determine the clinical utility of patch testing inpatients with BMS.

METHODS: Retrospectively reviewed the charts of patientsdiagnosed with BMS who had patch testing performed betweenJanuary 1, 2008, and July 31, 2012.

RESULTS: 132 consented to patch testing; 89 (67%) had allergicpatch test reactions. Of the patients with positive results, 66 (74%)had results that were deemed to have possible relevance. The mostcommon allergens detected were nickel sulfate 2.5%, dodecyl gallate0.3%, octyl gallate 0.3%, fragrance mix 8%, benzoyl peroxide 1%, andcinnamic alcohol 1%.

CONCLUSIONS: Contact allergy may be an etiologic factor in somepatients with BMS. Patch testing is a useful investigation for BMSpatients.


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Arq Neuropsiquiatr.2014 Feb;72(2):91-8. doi: 10.1590/0004-282X20130218.

OBJECTIVE:To assess the efficacy of anti-xerostomic topical medication

(urea 10%) in patients with burning mouth syndrome (BMS).

METHOD:T 38 subjects diagnosed with BMS according to the IASP guidelineswere randomized to either placebo (5% sodium carboxymethylcellulose,0.15% methyl paraben, and 10% glycerol in distilled water ) or treatment(urea 10%) to be applied to the oral cavity 3-4 times per day for 3 months. The

patients were evaluated before and after treatment with the followinginstruments: the EDOF-HC protocol (Orofacial Pain Clinic - Hospital dasClnicas), a xerostomia questionnaire, and quantitative sensory testing.

RESULTS: There were no differences in salivary flow or gustative, olfactory,or sensory thresholds (P>0.05). Fifteen (60%) patients reported improvementwith the treatments (P=0.336).

CONCLUSION: there were no differences between groups, and bothexhibited an association between reported improvement and salivation.


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J Orofac Pain.2013 Fall;27(4):304-13. doi: 10.11607/jop.1109.

AIM: To examine sleep complaints in patients with burning mouthsyndrome (BMS) and the relationships between these disturbances, negativemood, and pain.

METHODS: Fifty BMS patients were compared with an equal number of healthycontrols matched for age, sex, and educational level. The Pittsburgh SleepQuality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Hamilton RatingScales for Depression (HAM-D) and Anxiety (HAM-A) were administered.Descriptive statistics, including the Mann-Whitney U test and hierarchical

multiple linear regression analyses were used.

RESULTS: BMS patients had higher scores in all items of the PSQI and ESS thanthe healthy controls (P < .001). In the BMS patients, a depressed mood andanxiety correlated positively with sleep disturbances. The Pearson correlationswere 0.68 for PSQI vs HAM-D (P < .001) and 0.63 for PSQI vs HAM-A (P < .001).

CONCLUSION: BMS patients reported a greater degree of sleep disorders,anxiety, and depression as compared with controls. Sleep disorders couldinfluence quality of life of BMS patients and could be a possible treatmenttarget.

d d ll
http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24171180http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452


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Int J Med Sci. 2013 Oct 29;10(12):1784-9. doi: 10.7150/ijms.6327. eCollection2013.

OBJECTIVE: To estimate signs and symptoms of Temporomandibular

Disorders (TMD) in patients with BMS and to investigate for the existence ofan association between BMS and TMD.

MATERIALS AND METHODS: Forty-four BMS patients were enrolled; BMSsubtype was established according to the classification of Lamey. After agnathological evaluation, according to the protocol of the European Academy

of Craniomandibular Disorders, patients were classified by TMD criteria. Thedata were compared and analyzed using a chi-square test to describe theexistence of an association between BMS and TMD.

RESULTS: 65.9% BMS patients showed disorders classified as primary signsand symptoms of TMD according to TMD criteria, and 72.7% showed

parafunctional habits. The chi-square test revealed a statistically significantassociation (p = 0.035) between BMS and TMD.

CONCLUSION: The data suggest that there is a possible relationship not yetwell understood between BMS and TMD, may be for neurophatic alterationsassumed for BMS that could be also engaged in TMD pathogenesis.

Mayo Clin Proc 2014 Aug 28 pii S0025
http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/24273452http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397


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Mayo Clin Proc. 2014 Aug 28. pii: S0025-6196(14)00540-0

OBJECTIVE: To calculate the incidence of BMS inOlmsted County, Minnesota, from 2000through 2010.

PATIENTS AND METHODS: By using the medicalrecord linkage system of the RochesterEpidemiology Project, newly diagnosed cases of

BMS from January 1, 2000, through December 31,2010 were identified. Diagnoses were confirmedthrough the presence of burning pain symptomswithout associated clinical signs.
http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397http://www.ncbi.nlm.nih.gov/pubmed/25176397


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J Formos Med Assoc.2013 Jun;112(6):319-25. doi: 10.1016/j.jfma.2012.02.022. Epub 2012 Jun 12.
http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008http://www.ncbi.nlm.nih.gov/pubmed/23787008


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OBJECTIVE: whether there is an intimate association of the deficiency of hemoglobin(Hb), iron, vitamin B12, or folic acid; high blood homocysteine level; and serum gastricparietal cell antibody (GPCA) positivity with BMS.

METHODS: Blood Hb, iron, vitamin B12, folic acid, and homocysteine concentrationsand the serum GPCA level were measured in 399 BMS patients and compared with thecorresponding levels in 399 age- and sex-matched healthy control individuals.

RESULTS: 89 (22.3%), 81 (20.3%), 10 (2.5%), and six (1.5%) BMS patients haddeficiencies of Hb (men:


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