Reprinted from ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY, St. Louis Vol. 72, No.2, PP. 192-195, Augult, 1991 (Printed in the U.S.A.) (Copyright o 1991 by Moaby-Ycar Book, Inc.)

Clinical characteristics and management outcome in the burning mouth syndrome An open study of 130 patients

Meir Gorsky, DMD,a Sol Silverman Jr., DDS, MA,b and Henry Chinn, DDS, MS.C San Francisco, Calif.

DIVISION OF ORAL MEDICINE, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

Clinical characteristics and treatment responses were studied in 130 patients with burning mouth syndrome (BMS). Most patients were postmenopausal women, and the tongue was the most frequently afflicted site. Although 39% of the patients complained of dry mouth, no causative factors were evident. Therefore BMS is assumed to be a functional disorder. This was at least partially confirmed because the most effective management was in response to mood-altering drugs. From our data BMS appears to be a chronic condition with variations in symptoms among patients and without a predictable endpoint. (ORAL SURG ORAL MED ORAL PATHOL 1991;72:192-5)

Our previous report I on patients with the burning mouth syndrome (BMS) described 98 persons, of whom postmenopausal women comprised more than three fourths of the group. The tongue was involved alone or with other oral sites in 78% of the patients. Besides the occurrence of glossitis migrans in 15%, no other mucosal lesions were evident. Psychogenesis appeared to be the most important etiologic factor. Other contributory factors included xerostomia and oral candidiasis. The roles of dentures, anemia, hypertension, allergies, and hyperglycemia were un­certain.

The purpose of this prospective open study was to further describe clinical characteristics of this com­plex syndrome and to record some treatment re­sponses in a prospective open approach. This would then form the basis for a rigidly designed prospective study to assess therapeutic efficacy.

MATERIAL AND METHODS

One hundred thirty patients who were referred to the Oral Medicine Clinic, University of California, San Francisco, for evaluation and management of BMS comprised the study group. Medical histories, oral examinations, and laboratory tests were obtained or performed. Minimal tests included complete blood

•Visiting Postdoctoral Scholar; Associate Professor, Sackler School of Dental Medicine, Tel Aviv, Israel. bProfessor and Chairman. °Ciinical Professor. 7/13/23282

192

Table I. Demographics of 130 patients with BMS

Gender

F M

n

IOI 29

Age (yr)

Mean I 59 54

Range

25-87 25-79

Smokers(%)

I6 IO

cell counts, fasting blood sugar levels, and fungal (Candida) cultures. Table I describes the predomi­nantly female and elderly composition of the patients together with their smoking habits. All patients were followed prospectively for treatment andfor observa­tion. Medications were prescribed, in an attempt to evaluate oral symptoms, on the basis of findings, pre­vious drug use, and patient input as to alternative treatment approaches.

RESULTS

Although the burning can involve any mucosal site, the tongue was by far the most commonly reported site, either alone or when multiple sites were involved (Table II). Aside from a relatively common complaint of mouth dryness {39%), no other correlative factors were evident {Table III). Although 28% had positive fungal cultures, clinically there was no evidence of candidiasis or other relevant mucosal lesions.

Table IV describes the various treatment ap­proaches used to modify patient complaints. Medica­tions tried before referral were not reinstated, thereby accounting for the variable number of drugs used in

Volume 72 Number 2

Table II. Sites of burning in 130 patients

Tongue Other* or

Burning mouth syndrome 193

Frequency of symptomatic oral site(%)

Gender only multiple sites Tongue I Hard palate I Lips I Othert

F 37 64 M II 18

Total 48 82

•Four women and two men had burning in either hps or hard palate only. tBuccal and )JbiJI mucosa, soft palate, mouth Ooor.

Table Ill. Findings in 130 patients with BMS

72 24 28 37 70 28 10 34 72 25 24 36

Cardiovascular Positive Candida Site Xerostomia (%) medications (%) culture (%) Diabetes (%) Anemia(%)

Tongue only 48 43 33 44 9 4 Multiple or other sites 82 36 24 19 5 0

Total 130 39 28 28 7 2

Table IV. Prescribed medications and outcome

Outcome(%) No. of

Complete remission I I I No change I Drug* patients Marked benefit Slight benefit Worse

Chlordiazepoxide (Librium) 78 14 35 15 36 0 Antifungal agents 37 0 35 3 59 3 Amitriptyline (Elavil) 26 0 II 8 73 8 Prednisone 16 0 13 12 75 0 Pilocarpine II 0 36 0 55 9 Vitamin B complex 8 0 0 0 100 0 Diazepam (Valium) 6 33 33 0 33 0

0 Not given 10 Jny >pccml order when prescribed; not used if administered before study and of no benefit.

patient treatment. Chlordiazepoxide (Librium) in dosages of 5 to 10 mg three times daily was the most frequently prescribed and most effective drug. The order of administration did not appear to influence the response (Table V).

In patients who elected to continue daily chlordiaz­epoxide for longer periods of time, there did not seem to be a relative advantage regarding alterations in symptoms (Table VI). The results with diazepam (Valium) (6 to 15 mgjday in six patients) were sim­ilar to those given chlordiazepoxide. Despite the rel­atively common complaint of dryness, salivary stim­ulation by systemic administration of a pilocarpine hydrochloride solution (5 mg four times daily) was not helpful in most patients with xerostomia.

DISCUSSION

BMS describes a variety of chronic oral symptoms that often increase in intensity at the end of each day and that seldom interfere with sleep. The main man­ifestation is a burning sensation at one or more oral

Table v. Assessment of chlordiazepoxide outcome and order of administration

Chlordiazepoxide administered as

first drug

++ I + 0

Gender n (%) (%) (%)

F 37 14 43 43 M 18 33 45 22

Total 55 20 44 36

All chlordiazepoxide trials irrespective

of order used

++ + n (%) (%)

54 9 50 24 29 54 78 IS 52

0 (%)

41 17 33

++, Complete remi»ion ; +.some benefit; 0, no change.

sites and is usually accompanied by a variety of com­plaints that may include dryness and an altered or disturbing "taste." BMS almost always diminishes the patient's perceived quality of life. The magnitude of disturbance can vary from a slight annoyance to complete functional disruption.

This current study confirms our previous observa-

194 Gorsky, Silverman, and Chinn ORAL SURG ORAL MED ORAL PATHOL August 1991

Table VI. Patient outcome and length of chlordiazepoxide treatment

Up to I mo

Site n + ±

Tongue 22 6 Multiple and other sites 56 5 16

Total 78 6 22

+, Complete remission: ±, some benefit; 0, no change.

tions of the primary occurrence in postmenopausal women, the tongue as the most frequent site, and lack of evident causative systemic explanation: This· find­ing is similar to those of other authors who have studied BMS.2- 16 Interestingly, 39% of our patients complained of xerbstomia. Although about one third benefited from salivary gland stimulation with a sia­logogue, most patients did not benefit. Therefore the cause-effect relationship of xerostomia to BMS re­mains unclear. 17•19 Because causative organic factors have not been consistently identified, it is assumed that BMS, at least in most patients, is a functional disorder entailing psychologic, emotional, and neuro­logic dysfunctions.20-23

Because the most effective management is found in response to mood-altering drugs, a major behavioral component appears to be confirmed. This also has been concluded by other investigators. The primary psychopharmacologic drug used in this group was chlordiazepoxide. Although its mechanism of action is unknown, in low dosages it has been shown to re­lieve anxiety. In higher dosages it also has sedative and weak analgesic effects. In animals its action has been shown to be on the limbic system, which is involved in emotional responses. Specifically, chlor­diazepoxide has been shown to alter behavior in mon­keys and rats.

In some of our patients the benefits of treatment persisted after discontinuation of therapy; in others continuous or intermittent treatment was necessary. In those who did not respond to our conventional pharmacologic approaches, other modalities were not helpful. These have included hypnosis, acupuncture, psychotherapy, biofeedback, and various types of lo­cal injections (i.e., local anesthetics). Our present study does not report long-term outcome; however, the long-term, steady-state chronicity of BMS further supports a functional or behavioral basis. Although a "burnout" phase has been indicated by some inves­tigators, 24 this has not been confirmed by others nor is such an endpoint predictable.

It is evident that a long-term, controlled, prospec-

1-2 mo >2 mo

0 + ± 0 + ± 0

3 I 4 2 2 2 16 2 6 3 I 6 I 19 3 10 5 3 8 2

tive study is required, preferably with a multi-institu­tional base, to clarify this relatively common enigma that frequently alters the quality of life for those af­fected.

REFERENCES I. Gorsky M, Silverman S Jr, Chinn H. Burning mouth syn­

drome: a review of 98 cases. J Oral Med 1987;42:7-9. 2. Basker RM, Sturdee DW, Davenport JC. Patients with burn­

ing mouths: a clinical investigation of causative factors, including the climacteric and diabetes. Br Dent J 1978; 145: 9-16.

3. Lowenthal V, Pisanti S. The syndrome of oral complaints: eti­ology and therapy. ORAL SURG ORAL MED ORAL PATHOL 1978;46:2-6.

4. Main DMG, Basker RM. Patients complaining of a burning mouth: further experience in clinical assessment and manage­ment. Br Dent J 1983; 154:206-11.

5. Zegarelli D. Burning mouth: an analysis of 57 patients. ORAL SURG ORAL MED ORAL PATHOL 1984;58:34-8.

6. Lamey PJ, Hammond A, Allan BF, Mcintosh WB. Vitamin status of patients with burning mouth syndrome and the response to replacement therapy. Br Dent J 1986; 160:81-4.

7. Katz J, Benoliel R, Leviner E. Burning mouth sensation asso­ciated with fusospirochetal infection in edentulous patients. ORAL SURG ORAL MED ORAL PATHOL 1986;62:152-4.

8. Grushka M, Shupak R, Sessle BJ. A rheumatological investi­gation of27 patients with burning mouth syndrome. J Dent Res 1986;26:533.

9. Grushka M. Clinical features of burning mouth syndrome. ORAL SURG ORAL MED ORAL PATHOL 1987;63:30-6.

10. Vander Ploeg, van der Wal N, Eijkman MAJ, van der Waal I. Psychological aspects of patients with burning mouth syndrome. ORAL SURG ORAL MED ORAL PATHOL 1987;63: 664-8.

II . BrowningS, Hislop S, Scully C, Shirlaw P. The association between burning mouth syndrome and psychosocial disorders. ORAL SURG ORAL MED ORAL PATHOL 1987;64:171-4.

12. Zegarelli DJ, Zegarella-Schmidt EC. Oral fungal infection. J Oral Med 1987;42:76-9.

13 . Lamey P J, Lamb AB. Prospective study of aetiological factors in burning mouth syndrome. Br Med J 1988;296: 1243-6.

14. Lamb AB, Lamey PJ, Reeve PE. Burning mouth syndrome: psychological aspects. Br Dent J 1988; 165:256-60.

15. Wardrop RW, Hailes J, Burger H, Reade PC. Oral discomfort at menopause. ORAL SURG ORAL MED ORAL PATHOL 1989; 67:535-40.

16. Truelove E, Epstein J, Schubert M, Grushka M. Burning mouth syndrome. In: Millard HD, Mason DK, eds. Perspec­tives on 1988 World Workshop on Oral Medicine. Chicago: Year Book, \989:262-71.

17. Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry mouth in man. J Dent Res 1987;66:648-53.

Volume 72 Number 2

18. Tylenda CA, Ship JA, Fox PC, Baum BJ . Evaluation of sub­mandibular salivary flow rate in different age groups. J Dent Res 1988;67: 1225-8.

19. Sreebny LM, Valdini A. Xerostomia. Part 1: relationship to other oral symptoms and salivary gland hypofunction. ORAL SURG ORAL MED ORAL PATHOL 1988;66:451-8.

20. Grushka M, Sessle BJ , Howley TP. Psychophysical assessment of tactile, pain and thermal sensory functions in burning mouth syndrome. Pain 1987;28: 169-84.

21. Grushka M, Sessle BJ, Miller R. Pain and personality profiles in burning mouth syndrome. Pain 1987;28: 155-67.

22. Lamey PJ, Lamb AB. The usefulness of the HAD scale in as­sessing anxiety and depression in patients with burning mouth syndrome . ORAL SURG ORAL MED ORAL PATHOL 1989;67: 390-2.

23 . Zilli C, Brooke Rl, Lau CL, Merskey H. Screening for

Burning mouth syndrome 195

psychiatric illness in patients with oral dysesthesia by means of the General Health Questionnaire- twenty-eight item ver­sion (GHQ-28) and the Irritability, Depression and Anxiety Scale (IDA). ORAL SURG ORAL MED ORAL PATHOL 1989;67: 384-9.

24. Grushka M, Katz RL, Sessle BJ. Spontaneous remission in burning mouth syndrome (BMS) [Abstract 1341]. J Dent Res 1987;66(special issue):274.

Reprint requests: Sol Silverman Jr., DDS, MA School of Dentistry, Box 0432 University of California, San Francisco San Francisco, CA 94143