Journal reading
報告者： PGY2 曾智皇 報告日期 : 103.07.08 指導老師 : 林立民 醫師 陳玉昆 醫師
Introduction
• Burning mouth syndrome (BMS) is typically described by the patients as a burning
sensation of the oral mucosa
absence of clinically apparent mucosal alterations
• Overall prevalence ranging from 0.7% to 7%
• Prevalence up to 12% to 18% for post- menopausal women with BMS
• BMS often affects the tongue (particularly the tip and lateral borders), lips, and hard and soft palate
• Unremitting oral mucosal pain, dysgeusia, and xerostomia
Diagnostic criteria
• Oral burning or pain
Unremitting for at least 4–6 months
Continuous throughout almost all the day
Seldom interferes with sleep and never worsens
May be relieved, by eating and drinking
• Other oral symptoms:
Dysgeusia
Xerostomia
Presence of sensory/chemo-sensory anomalies
Mood changes
Disruptions in patient personality traits
• Can not have any signs of oral mucosal pathology !!
• Detailed review of patient’s medical and dental histories
• Careful analysis of data obtained from physical and laboratory examinations
Classification and subtypes
Lopez-Jorne et al Type 1 BMS:
• Pain-free waking gradually increasing reaching its peak intensity by evening
• 35%
• Linked to systemic disorders such as
nutritional deficiency, diabetes mellitus
Type 2 BMS:
• Continuous symptoms throughout the day
• 55%
• Usually associated with psychological disorders
Type 3 BMS:
• Intermittent symptoms
• 10%
• Show allergic reactions
• Scala et al. classified BMS into 2 clinical forms
1. Primary BMS:
a. Essential or idiopathic
b. Peripheral and central neuropathological pathways are involved
2. Secondary BMS:
c. Caused by local, systemic or psychological factors
Primary BMS
• 1st subgroup:
Peripheral small-diameter fiber neuropathy of intraoral mucosa (50–65%)
• 2nd subgroup:
Subclinical lingual, mandibular, or trigeminal system pathology (20–25%)
• 3rd subgroup:
Hypofunction of dopaminergic neurons in the basal ganglia (20–40%)
• Lauria et al Significantly lower density of epithelial nerve fibers in patients with BMS than in control subjects
• Just et al Patients with BMS exhibit a decreased somatosensory and gustatory perception
• Albuquerque et al Patients with BMS had less volumetric activation throughout the
entire brain
Secondary BMS
• Local factors: poorly fitting prostheses,
parafunctional habits, dental anomalies, allergic reactions, infection, chemical factors, galvanism, taste alterations, and xerostomia
• Systemic factors: endocrine alterations
(hypothyroidism, diabetes, and menopause), vitamin B complex, iron and zinc deficiencies, anemia,
gastrointestinal anomalies, medication, Sjogren’s syndrome, and esophageal reflux
• Psychological factors: anxiety, depression, compulsive disorders, psychosocial stress, and cancerphobia
• Netto et al
Significant association of the presence of gastrointestinal diseases and urogenital diseases with BMS
Significant correlation between the intake of H-2 receptor antagonist or proton-pump
inhibitor and BMS
• Gao et al
87(BMS) and 82
No statistical difference in blood analyses
(including white blood cell count, red blood cell count, hemoglobin (Hb), and
platelet count ) between the BMS and control groups
Significantly higher serum follicle-stimulating hormone level and a significantly lower serum estradiol level in the menopausal or post-
menopausal women with BMS
Anxiety and depression scores in patients with BMS are higher
Habit of tongue thrusting, lip sucking,
periodontitis, smoking, outcome of recent medication, and depression are the principal risk factors for the BMS
• Lin et al
Patients with BMS had a significantly higher frequency of Hb, iron, or vitamin B12
deficiency
Abnormally elevated blood homocysteine level
Serum GPCA (gastric parietal cell antibody) positivity
• Boras et al
Significantly lower serum neurokinin A is found in patients with BMS
Indicating an inefficient dopaminergic system in patients with BMS
• Pekiner et al
Significantly lower serum IL-2 and TNF-a levels in patients with BMS
Significantly lower mean salivary Mg level in patients with BMS
• Maragou and Ivanyi, Cho et al
Significantly lower mean serum zinc level in patients with BMS
• Pokupec-Gruden et al
Anxiety and depression are most common in patients with BMS
General consideration for treatment of BMS
• Detailed review of patient’s medical and dental histories and a careful analysis of patient’s data
setting up a therapeutic regimen
• Treatment or elimination of these factors
(local, systemic, psychological) usually results in a significant clinical improvement
• If patients still have the symptoms drug therapy should be instituted
• The custom-made or combination therapy for each patient with BMS
the greatest benefit to the patient and lessen the treatment duration
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
Vitamin supplement treatment
• Sun et al
• Vitamin BC capsules plus relatively high doses of corresponding deficient hematinics
a. reduce the abnormally higher mean serum homocysteine levels
b. raise the corresponding lower mean deficient hematinic and Hb levels
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
Zinc replacement treatment
• Cho et al
• Evaluated the serum zinc level in 276 patients with BMS
• Zinc replacement therapy in BMS patients with zinc deficiency is effective
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
Hormone replacement treatment
• Wardrop et al
prevalence of oral discomfort is significantly higher in perimenopausal and post-
menopausal women 43% <-> 6%
• Forabosco et al
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
Topical drug treatment
• Epstein and Marcoe
• Gremeau-Richard et al
• Peripheral nervous system dysfunctions in patients with BMS
• Sardella et al
• Lopez-Jornet et al
• Topical Aloe vera has been shown to promote the healing process in the treatment of burns, psoriasis, and oral lichen planus
1. Vitamin supplement treatment 2. Zinc replacement treatment
3. Hormone replacement treatment 4. Topical drug treatment
5. Systemic drug treatment
Systemic drug treatment
• Petruzzi et al
• Its use is not recommended for extended treatment
• Grushka et al
• Heckmann et al
• Ko et al
• Investigated outcome predictors of clonazepam therapy
• Amos et al
• Combined topical and systemic clonazepam
administration is an effective regimen for treatment of BMS
• Femiano et al
• Antioxidant mitochondrial coenzyme
neuroprotective effect
• Marino et al
• prolonged therapy in chronically affected patients with BMS is needed for maintaining a more
permanent effect
• Maina et al
• No serious adverse effects are referred in any of the three groups
• Rodriguez-Cerdeira and Sanchez-Blanco
• Amisulpride seems to be effective and well tolerated
• Yamazaki et al
• A tricyclic antidepressant
• The side effects are minor and transient and no serious safety issues are observed
• Bergdahl et al
Summary
• BMS is probably of multifactorial origin and may be idiopathic
• Clinicians should first try to identify the precise causative factors for the BMS
• If patients still have the symptoms after the removal of potential causes, drug therapy should be instituted
• Previous clinical trials have found that drug therapy with capsaicin, alpha-lipoic acid, clonazepam, and antidepressants
relief of oral burning or pain symptom
• Psychotherapy and behavioral feedback may also help eliminate the BMS symptoms
