DISORDERS AFFECTING THE ORAL CAVITY
20
BURNING MOUTH SYNDROME
When researching orofacial diseases in a
scientific manner, it is fundamentally im-
portant that there is agreement on what con-
stitutes the condition and what features are
necessary for diagnosis. In the case of the
condition that we shall call burning mouth
syndrome (BMS), the oral mucosa appears
clinically normal. Patients, however, say that
the areas affected feel burning or hot or occa-
sionally scalded.
Historically this condition was described as
glossodynia,1-7, 21, 31. 55. 83. 110. 117, 174 glossa-
pyrosis,2O, 34, 91 stomatodynia,122 stomato-
~ ~ tongue,52*58, 131 burning
p y r o s i ~ , ~sore
38, 47, I3O, 174 oral dysesthesia,66,140
burning mouth condition,” and burning
mouth syndrome.60, 95, 136 It is not always clear
from these descriptions, however, if the oral
mucosa appeared normal in all cases, and
therefore articles reporting burning mouth
are not referring necessarily to burning
mouth syndrome (BMS). When terms other
than BMS are used they often include patients
who have an obvious clinical abnormality
such as geographic erosive lichen
p l a n ~ sor
, ~oral
~ c a n d i d o s i ~In . ~the
~ latter con-
ditions, patients also may complain of a burn-
ing sensation but clearly do not have BMS.
The history of burning reported by patients
with these conditions is different and usually
only occurs on eating hot or spicy foods.66
Furthermore, the histopathologic features of
these conditions are characteristic, whereas in
BMS there are no specific histologic fea-
From the Department of Oral Medicine, School of Clinical Dentistry, The Queen’s University of Belfast, Belfast,
Northern Ireland
DERMATOLOGIC CLINICS
VOLUME 14 * NUMBER 2 * APRIL 1996
0733-8635/96 $0.00 + .
Philip-John Lamey, BSc, BDS, MBChB
t u r e ~ . ’Occasionally
~~ such conditions are
present coincidentally in patients with BMS,
but the diagnosis of BMS should be confined
to patients with an apparently normal oral
mucosa.
Some discussion has taken place about the
nomenclature of BMS and in particular the
inclusion of the word syndrome.” By defini-
tion, a syndrome is a collection of signs and
symptoms, which in BMS is a normal-looking
mucosa and a burning sensation. We increas-
ingly recognize that BMS also can be associ-
ated with burning at other bodily sites and
therefore may be as much a systemic condi-
tion as a localized oral disorder. Personally, I
favor the retention of syndrome.
SITES AFFECTED
The tongue is the most common site to be
reported by patients with BMS followed by
the upper alveolar region, palate, lips, and
lower alveolar region.89The burning is almost
always bilateral and symmetrical. Rarely,
other sites such as the buccal mucosa, floor
of the mouth, and throat may be affected.
The precise site of burning is important and
may help identify precipitating factors. For
example, burning at the tip of the tongue
in a dentate subject may suggest a tongue
thrusting habit. The same complaint in a com-
plete denture wearer may suggest faulty den-
ture design, leading to tongue restriction.
339
340 LAMEY
Burning on the dorsum of the tongue in a
denture wearer may suggest a tongue postur-
ing habit possibly to help stabilize a nonreten-
tive denture. Even if sites such as the lips
alone are involved in BMS, the same precipi-
tating factors pertain when more typical in-
traoral sites are affected.88
If patients are asked about burning at other
body sites they frequently also report burning
in the anogenital region.50Male clinicians are
less likely to elucidate this information than
their female counterparts. The significance of
burning at these other sites is presently un-
clear, but BMS may be a systemic syndrome.
EPIDEMIOLOGY
There are no global figures available for the
prevalence of BMS. In selected populations in
the United States attempts recently have been
made to estimate the prevalence and distribu-
tion of a variety of orofacial pain disorders
including BMS.'O'
In Finland, one study of 431 predominantly
female subjects reported that 15% had experi-
enced a prolonged oral burning sensation.60
These patients also underwent a thorough
clinical examination and about half of the
15% who complained of burning had some
demonstrable mucosal abnormality such as
geographic tongue, lichen planus, or oral can-
didosis. It would appear therefore that in a
Finnish adult population the prevalence of
BMS is around 7%. Women were more fre-
quently affected by BMS than men.
Another study investigated 145 oophorec-
tomized women by means of a postal ques-
t i ~ n n a i r eNo
. ~ ~individual was examined clin-
ically but approximately 18% reported a
burning sensation affecting the tongue or lips.
It was not possible to determine the true
prevalence of BMS, but the survey did show
no temporal reduction in the frequency of
oral symptoms after oophorectomy. The in-
troduction of estrogen therapy did not im-
prove the patients' oral symptoms, including
burning, leading the authors to conclude that
estrogen deficiency following the climacteric
produced vasomotor changes that may lead
to neurosis.
GENDER EFFECTS
All published studies of patients with BMS
agree that the condition is more common in
women than men. The female to male ratio is
about 7:1, but this varies with site.89Burning
of the lips alone is even more common in
women, with a female to male ratio of 12:1.88
The reason for this sex prediliction has not
been explained fully, but several other orofa-
cia1 pain syndromes such as atypical facial
pain and temporomandibular disorders are
also more common in women. The exception
to this is periodic migrainous neuralgia,
which is more common in men.87
There is broad agreement in the literature
that BMS is a condition particularly affecting
the middle-aged and elderly p ~ p u l a t i o n . ~ ~
The youngest patient in one study was 28
years old. The condition has never been re-
ported in children, which is odd because sev-
eral of the recognized precipitating factors in
BMS also can affect children.6
The mean age of BMS patients is approxi-
mately 62 years, and several studies have re-
ported roughly the same figure. Because
women of this age would be postmenopausal,
early reports highlighted the significance of
the climacteric in the etiology of BMS.'jOAs is
discussed further, however, such hormonal
changes are probably of no significance.
SUBTYPES
Several years ago, my colleagues and I pro-
posed a classification of BMS into three sub-
t y p e (Table
~ ~ ~ 1).
~ Originally we observed that
some patients had burning only occasionally,
Table 1. SUBTYPES OF BURNING MOUTH
SYNDROME
Relative
Frequency
Type ("/) Symptoms
1 35 Burning present every day, not
present on waking but
developing as the day goes
on, being maximal in the
evening
2 55 Burning present all day, every
day
3 10 Burning only on some days
and tending to affect
unusual sites such as
buccal mucosa, floor of
mouth, and throat

others had it every day, but only as the day
went on, and still others had burning all day,
every day. We presumed, incorrectly as it
transpired, that their different history repre-
sented an evolving process, but we subse-
quently realized this is not the case.89
Type 1 Burning Mouth Syndrome
In this subtype patients have burning every
day. The burning, however, is not present on
waking, but comes on as the day goes on,
being maximal in the evening. Around 35%
of BMS patients give this history.
Type 2 Burning Mouth Syndrome
In this subtype patients have burning every
day, which is present all day from waking.
Approximately 55% of BMS patients give
this history.
Type 3 Burning Mouth Syndrome
In this subtype burning is only present on
some days, and on others patients are asymp-
tomatic. In contrast to type 1 and type 2 pa-
tients, the burning tends to affect unusual
sites such as floor of mouth, buccal mucosa,
and throat. Around 10% of BMS patients give
this history, which previously was reported
as atypical burning mouth
Recent demographic data comparing UK
and US BMS populations have given almost
identical prevalence rates for the subtypes in
these two populations.81
The subtypes have merit because they are
of prognostic significance and also indicate
the necessity for specialist investigations such
as patch testing to identify allergic compo-
nents to the burning. A recent study of type
3 BMS patients showed that their main pre-
cipitating factors were emotional instability
and allergic factors.97It is, however, inappro-
priate to patch test all BMS patients. Simi-
larly, in evaluation of treatment outcomes,
type 2 patients are the most difficult to treat
successfully because a high proportion have
chronic anxiety, which is the most recalcitrant
obstacle to cure.86
It has taken many years to establish BMS as
a distinct clinical entity and having done so we
are now recognizing that it is not a homoge-
BURNING MOUTH SYNDROME 341
neous condition. If subtyping helps us manage
our patients better, then it is useful.
PATIENT EVALUATION
For many BMS patients an oral medicine
specialist is not their first port of call. Many
have been to their doctor, dentist, general
physician, general surgeon, and specialists
such as otorhinolaryngologists, to no avail.
Of the 700 or so BMS patients who have
consulted me, not one has ever heard of any
other person with the same complaint. This
circuit of referral and feeling that they are the
only person in the world with the complaint
leads to increasing isolation and in some
cases feelings of hopelessness. The complaint
itself, that is, ”my tongue is burning or feels
on fire,” also sounds (even to the patient)
odd, and they don’t want to be labeled as
having a psychiatric problem. When numer-
ous generalists and specialists have pro-
nounced that their tongue looks normal, this
adds to the feeling that they must be imagin-
ing it, which of course they are not. In addi-
tion, fear that the burning will develop into
cancer heightens their concern to seek treat-
ment.
It is clear that BMS patients must be treated
in a sympathetic manner. An unhurried clini-
cal environment is helpful, and privacy is
essential. All our BMS clinics are run jointly
by an oral medicine specialist, a prosthodon-
tic specialist, and a clinical psychologist. One
of the clinicians is a woman. Having more
than one specialist is helpful because, as with
all pain clinics, some patients do not take to
one clinician, and trust is never established.
By having three specialists, including one of
their own sex, the patient is likely to trust
one of us and feel at ease to discuss causes of
stress, tension, or marital disharmony.
Having reassured the patient that he or she
is one of many sufferers, it is important to go
into the history in detail and subtype the
BMS. All patients are asked to quantify the
burning using a 0 to 10 visual analog scale in
which 0 is no burning and 10 is the worst
burning imaginable. Typical pretreatment
values are shown in Figure 1. This quantifi-
cation also allows the response to treatment
to be measured prospectively. Because social
circumstances also can influence pain percep-
tion, all patients are asked to quantify what
we call their home circumstances, that is, how
they get along with their family and friends
342 LAMEY

50 1
40 -

&
30 -
n
5
= 20-

10 -
0-
Score Known

Figure 1. Reported severity of BMS patients pretreatment.

and their job and financial considerations. A
linear analog scale also is used, but in this
scale, 10 means everything is perfect and 0
means that things could not be worse. When
the patient chooses a score of 6, for instance,
he or she is then asked what would have to
happen to take their 6 score to 10. I have
never had a patient refuse to do this and the
results are illuminating, for it identifies exact
problems. A typical social circumstances pro-
file is shown in Figure 2. The clinician has
not been seen to pry or ask lengthy irrelevant
questions about possible stress, but the pa-
tient has chosen the score, and the patient
has been asked to justify the score including
identification of social problems if any.
The general medical and dental history also
is assessed, and at the end of the first inter-
view the clinician has a good grasp of the
problem, its duration, its subtype, and its se-
verity, and a knowledge of the social circum-
stances.
Subsequently, many investigations are un-
dertaken, all based on our knowledge of pre-
cipitating factors in BMS from the literature.
The plethora of recent reviews on BMS in
several languages has not added anything to
our knowledge.* It is the relative importance
of each individual precipitating factor that is
*References 1, 7, 15, 25, 48, 49, 61, 100, 108, 116, 132,
139, 148.

0 1 2 3 4 5 6 7 8 9 10
Visual Analog Score

Figure 2. Reported home and social circumstances scores by BMS patients at

initial presentation.
 BURNING MOUTH SYNDROME 343

important. To date, this has been the case in 6). In half of these patients, the deficiency
only one prospective state was deemed as the sole cause of BMS
because the condition resolved following ap-
propriate replacement therapy. In a subse-
PRECIPITATING FACTORS quent report by the same 40% of 37
patients again were identified as being vita-
The following factors listed are thought to min B12, folic acid, and iron deficient. Again,
be important in precipitating BMS. They are hematinic deficiency was thought to be pri-
not presented in any particular order. marily responsible for the BMS as judged by
response to treatment.
Hematinic deficiency states
In an American study, only 1 patient of 57
Undiagnosed maturity onset diabetes mel-
was found to be hematinically defi~ient.~ That
litus study was not of BMS patients alone, how-
Oral candidal infection
ever, but included patients with mucosal dis-
A degree of xerostomia ease such as lichen planus.
Denture design faults
The rationale for investigating vitamin B12,
Parafunctional habits
folic acid, or iron deficiency in BMS patients
Fear of cancer in some ways reflects what investigations are
Allergy to a variety of substances and ma-
routinely available. Such data do not exclude,
terials of course, other deficiency states, although
Psychological states, particularly chronic assay of those may not be routinely available.
anxiety
One group of vitamins of importance are
Drug-induced disease
those of the B complex group. Biskindl6
thought that there was an intimate relation-
ship between vitamin B complex status and
Hematinic Deficiency States levels of estrogen but lacked quantitative
data. Nevertheless, one study of 86 post-
It has been known for many years that menopausal patients who presented with oral
deficiency states such as sideropenia, iron de- symptoms including BMS reported one third
ficiency anemia, pernicious anemia, and folic to respond promptly to vitamin B complex
acid deficiency could result in oral mucosal
discomfort described as a burning sensa-
tion.12,22, 42, 65, 73, lo5, 172 Occasionally, the defi-
ciency states reported were accompanied by Table 2. THE RELATIVE IMPORTANCE OF
visible changes in the affected oral tissues, PRECIPITATING FACTORS IN BURNING MOUTH
SYNDROME
but the complaint of a burning sensation
could be present when no obvious mucosal Factor Percentage of Patients
changes were evident. Hematinic deficiency states
The exact mechanism by which a variety of Anemia (1
deficiency states can lead to a burning sensa- Ferritin 6
tion is uncertain. In the case of sideropenia Folic acid Nil in our clinic
Vitamin B,, 8
and iron-deficiency anemia, depletion of iron- Vitamin B,,BPI and B6 37
related compounds such as cytochrome oxi- Undiagnosed maturity onset 3-5
dase leads to functional epithelial changes. diabetes
In vitamin B,, and folic acid deficiency oral Oral candidal infection 32% isolation but only 5%
mucosal morphologic changes similar to respond to antifungal
therapy
those described in bone marrow and red cell A degree of xerostomia Stimulated parotid flow rate
precursors have been r e p 0 ~ t e d . I ~ ~ reduced in 12%
The incidence of deficiency states reported Denture design faults Variable but only 25% are
in BMS varies (Table 2). Personally, I believe improved by new
dentures of good design
the incidence data are less important than the Parafunctional habits 20-61
fact that deficiency states can precipitate BMS Fear of cancer 20
and therefore need to be sought in all cases. Allergy 5
In one study of 55 BMS patients,lo553% were Psychological state Variable and complex but
sideropenic and 4% were low in folic acid. In approximately 36% have
marked chronic anxiety
another study,12 7 of 21 BMS patients were Drug induced Rare
low in vitamin B,, (n = 1) or folic acid (n =
344 LAMEY
replacement therapy."O Others also suggested
a link between glossodynia and vitamin B
complex defi~iency.~,
A fairly recent study quantified vitamin B1,
B2, and B, levels in BMS patients and age-
and sex-matched control subject^.^, Of 70 pa-
tients, 28 were deficient in one or more vita-
mins. Replacement therapy with vitamin Bl
(300 mg daily), vitamin B, (20 mg daily), or
vitamin B, (150 mg daily) was given to 28
deficient patients and 27 patients with BMS
who had normal levels of vitamins B1, B2,
and B,. Eighty percent of BMS patients with
proven vitamin deficiency were asymptom-
atic at 3 months compared with none of the
nondeficient group, although 7% of the latter
group reported improvement. Others recently
have repeated similar studies with disap-
pointing results, but the doses of vitamins
prescribed were not e q ~ i v a l e n t . ~ ~
Finally, other deficiency states have been
investigated in BMS patients. Zinc levels are
equivalent in BMS patients compared with
age- and sex-matched control subjects.'06
Undiagnosed Maturity Onset
Diabetes Mellitus
One of the first to relate oral symptoms and
diabetes mellitus was Sheppard, who re-
viewed the literature prior to 1942.'33He con-
sidered the link largely a reflection of the
preinsulin era and with treatment the oral
cavity of diabetics should differ little from
nondiabetic subjects.
Other researchers studied the link and sug-
gested the oral cavity to be a sensitive indica-
tor of abnormal glucose tolerance.134, 13s Of 26
patients with abnormal glucose tolerance test
results, 9 reported occasional oral burning. In
another report, 12 of 45 patients with a vari-
ety of oral complaints including burning had
abnormal glucose tolerance test results con-
sistent with laboratory criteria at that time for
diabetes mellitus.2yThe technical quality of
the latter report was reviewed and urinalysis
questioned as a sensitive means of detecting
diabetes mellitus or prediabetes.Il7 There are
anecdotal reports of "sore tongue" in patients
with diabetes mellitus resolving following the
institution of glycemic
Unselected patients with various oral com-
plaints have been subjected to glucose toler-
ance tests.I9 In one study, 30% had abnormal
results, but it was thought that early small
blood vessel disease precluded resolution of
oral sympt0ms.5~Other studies have reported
more encouraging results.53Of 43 previously
undiagnosed noninsulin-dependent diabetics
(NIDD) 16 had BMS, and all resolved follow-
ing glycemic therapy. A similar result was
found in a study in which 4 of 150 BMS
patients were found by glucose tolerance test
(75 g load) to be NIDD. In that study BMS
resolved entirely on instituting glycemic con-
Another study found 1 NIDD patient
t1-01.~~
in 20 BMS patients, so an overall figure of
about 5% of BMS patients being NIDD seems
reasonable.'osIt should be appreciated that in
a UK population 5% is a high figure consider-
ing that 1%of the population are known dia-
betic and 1%undiagnosed. Indeed, a patient
is twice as likely to be NIDD when presenting
with a variety of oral complaints. In practice,
all patients with BMS need diabetes mellitus
excluded, preferably by fasting blood sugar
estimation.
The relationship between BMS and diabetes
mellitus also has been investigated by study-
ing diabetic patients for symptoms of BMS.
BMS was found in 10% of patients in one
study (n = 110) and was the second most
common oral complaint after xerostomia in
another.12 Various reasons have been pro-
posed to explain the relationship between
BMS and diabetes mellitus, including meta-
bolic alterations in the oral mucosa, accompa-
nying xerostomia, and oral candidosis.
Denture Aspects
Denture design faults that increase the level
of functional stress or restrict normal function
of the lingual musculature can lead to BMS.12
Denture-bearing areas of the oral mucosa are
subjected to stress for which they were not
designed and assume the role of the peri-
odontal membrane on transferring functional
forces to the underlying bone.138, 147 His-
tologically, such loads produce variable
changes in the oral mucosa as little as 1 year
after denture insertion.*
In a study of 33 patients with BMS, 50%
had an error in denture design that was
thought to be related causally to their BMS.*05
In a much larger study of 150 patients of
whom 120 were edentulous, 60% had denture
design faults, but replacing dentures alone
only helped 25% of BMS patientse9 Thus,
"References 3, 26, 68, 76, 79, 109, 111, 114, 118, 156,
157, 161, 162.

even if the patient's BMS is coincidental with
complete denture provision, the dentures
alone account for BMS only in a quarter of
patients. This of course reflects the multifacto-
rial nature of BMS. Good dentures on a com-
promised mucosa can produce BMS, good
dentures on a healthy mucosa can produce
BMS secondary to parafunction, and so on.
As well as being of good fit, occlusal errors
also can produce a burning sensation,"j5and
the dentures themselves have to be made cor-
rectly to maintain the health of the underly-
ing mucous membrane.166
Excess loading on dentures was reported
by Thomson145to produce a burning sensa-
tion principally in the palate, but also on the
tongue and lips. Symptoms of burning could
appear within minutes of denture insertion
and be relieved by removing the dentures.
Systemic factors such as deficiency states also
may have been relevant to his observations,
and treatment should aim to deal with exces-
sive load, such as by correcting the vertical
dimensions2,lUa or improving the supporting
tissues. Parafunctional activity also leads to
excessive occlusal loading99and is probably
more common than was realized previously
in dentate and edentulous individual^.^'^, 120
Patients who clench or grind their teeth also
often thrust their tongue against their teeth,
and this can give rise to BMS. Such activity
in BMS patients appears to be related to anxi-
ety as detected by the Hospital Anxiety and
Depression Scale.9oOthers also have linked
stress to increased muscle activity and
clenching.167, Parafunction may be uncon-
scious,17 and if the patients wear dentures
with acrylic teeth, wear facets indicate this
habit.lU
If BMS patients wear dentures, they may
be contributing to their complaint. Careful
assessment of the vertical dimension should
ensure an adequate freeway space.", 98,
Io4, lUa Similarly, tongue movements should
not be restricted. The denture bases them-
selves should ensure maximal load distribu-
tion.14 Underextended denture bases are the
most common design and the area
available for support can be increased by up
to 50% with fully extended bases.145
Salivary Aspects
It is debatable whether salivary gland func-
tion reduces with age.13,30, 41, 69, Few studies
have been undertaken in a logical manner
BURNING MOUTH SYNDROME 345
using identical sampling techniques. Salivary
gland output does appear related to gland
size, and this varies between i n d i v i d ~ a l s . ~ ~
Because BMS occurs predominantly in
postmenopausal women, a reduction in sali-
vary flow in this group has been suggested
as a possible cause of the burning, but good
data are lacking.38In one study, parotid sali-
vary flow rate (resting and stimulated) was
reduced in postmenopausal women, thus
lending support to a link with BMS.71Another
study, however, showed no differences in
resting mixed saliva between postmeno-
pausal women who had burning tongues and
those who did and others have shown
similar results.8oXerostomia itself is multifac-
torial, and factors contributing to xerostomia
also may influence BMS.30In one study, 40%
of BMS patients complained of a degree of
xerostomia, but only 12% had reduced stimu-
lated parotid gland Of clinical interest
is that the 12% of patients in whom reduced
salivary function could be shown said that
the burning and dryness were "the same
thing." If this is the case, then saliva substi-
tutes may have a role to play in the manage-
ment of some patients with BMS. Other
changes in saliva rather than just the volume
of saliva could be important, namely compo-
sitional changes. Some authors have claimed
elevated protein, potassium, and phosphate
levels in women with BMS and a relationship
to hormonal status.14Recent studies have sug-
gested no change in protein profiles between
BMS patients and control Our own
studies have, however, identified a novel pro-
tein in the parotid saliva of BMS patients.126
There is no evidence that BMS is associated
with histopathologic changes at least in minor
salivary glands.l15 In a study of minor pala-
tine glands in patients with or without the
complaint of burning, no histologic changes
were found. It was, however, unclear from
that study if patients did indeed have BMS.
Microbiologic Aspects
There are few good studies on the oral
microflora of BMS patients. What is funda-
mentally important is that patients can harbor
pathogenic numbers of candidal species in-
traorally, yet have no clinical mucosal
changes.57
In health, about 40% of patients harbor
candidal species intraorally as assessed by
culture of mixed saliva.loThe techniques for
candidal isolation are important. Various
346 LAMEY
techniques are in use including 153
imprint cultures: epithelial smears, impres-
sion cultures? and the oral rinse technique.125
The oral rinse technique is simpler to perform
and is quantifiable, as well as allowing detec-
tion of Staphylococcus aureus and coliforms.
Application of the oral rinse technique to
BMS patients showed a higher prevalence of
Candida species and coliforms in BMS patients
than control The Candida species
most frequently isolated was Candida albicans,
and Enterobacter and Klebsiella were the most
prevalent coliforms. It is likely that the coli-
forms were transferred to the mouth via the
patients’ fingers, perhaps when investigating
the mouth for disease.
Treating BMS patients in which candidal
species were isolated (37% of 150 patients)
improved symptoms in only 6%.89 Other
studies using various isolation techniques
claim figures of 10% candidal isolation in
glossodynia patients? 13% in burning mouth
patients, and 3.5% in a heterogenous group.’”
Overall, it would appear that candidal spe-
cies play a minor role in BMS. Nevertheless,
in one study 5% of patients had sustained
improvement following antifungal therapy
and confirmed elimination of candid^.^' Can-
didal species still should be sought in BMS
patients, preferably by using the oral rinse
technique.
Allergic Aspects
It previously has been emphasized that
even if a patient’s symptoms of BMS began
when new dentures were provided, it is not
likely that the dentures alone were responsi-
ble. Nevertheless, this apparent association
led to several publications linking BMS to
allergy to polymethyl methacrylate on the as-
sumption that allergy to the acrylic resin or
metal component of the denture base was
present.
It is generally accepted that true allergy to
polymethyl methacrylate in acrylic is rare.33
Many reported claims for allergy were dubi-
ous both in the clinical complaint and the
way in which allergy testing was undertaken.
Indeed, contact allergic reactions in the
mouth themselves are rare.7oThis rarity has
been attributed to rapid absorption and dis-
persal of potential allergens through the mu-
cosa and to dilution and removal of potential
allergens by saliva.45
Some reports of allergy to denture materi-
als have been in patients who complain of a
burning mouth, but do not have BMS because
they had clinically obvious oral change^.^ At-
tempts to reduce residual monomer levels by
various means, such as boiling, are largely
unsuccessful.9 There are, however, rare cases
of true allergy to polymethyl methacrylate
in BMS patients who have responded to the
provision of alternative denture base materi-
als such as nylon.35It would appear that such
patients give a type 3 BMS history, and that
other allergens, such as the constituents of
foodstuffs, are more important.97A recent de-
tailed study of type 3 BMS patients suggested
that about 50% have allergy as a major pre-
cipitating factor, and the other 50% have emo-
tional instability as a major factor. Appro-
priate patch testing by a dermatologist
experienced in the technique and professional
advice on dietary evidence largely resolved
their condition. Numerous other substances
have been reported as having an association
with BMS by being allergenic in susceptible
individuals. These substances have included
sorbic nicotinic acid epoxy
resin (and bisphenol A),155 pyrethroid
(an in~ecticide):~palladium? octyl gallate (an
anti~xidant),”~ benzoylperoxide, 4-tolyl dietha-
nolamine, N,N-dimethyl-4-t0luidine?~ peanut
extract,163 cinnamon adel~de,2~ and nickel
159
Cancerphobia
About 20% of patients with BMS have a
strong fear of cancer.89This fear almost is
never volunteered by the patient but should
be asked about by the clinician.38Reassurance
that BMS is in no way related to oral cancer
can do much to put a patient’s mind at ease.
Indeed, the outcome of treatment of BMS pa-
tients who are slightly anxious is even better
than patients who are not anxious, and this
is almost certainly because cancerphobia is
producing additional anxiety.86In type 1 and
2 BMS patients, the presence of symptoms on
a daily basis and the possible lack of success
in the early consultation period also contrib-
ute to the feeling that BMS represents a seri-
ous disorder about which the clinician is not
telling the patient. Patients who say that they
think that part of their mouth looks abnormal
have almost certainly been examining it in
the mirror and think they notice pathology.
Repeated self-examination is almost pathog-
nomonic of cancerphobia.

The Climacteric
In 1946, Ziskin and M o ~ l t o n ’described
~~
the typical BMS patient as a postmenopausal
woman unduly emotionally disturbed by her
oral condition and complaining of ner-
vousness, depression, hopelessness, and in-
somnia, or alluding to significant cancerpho-
bia. They also stated that younger female
patients rendered sterile by oophorectomy
also could be affected. It was claimed that
lack of female sex hormones produced histo-
logic changes (progressive atrophy) in the
oral and vaginal epithelium.lZ2Primate stud-
ies reported reversal of histologic changes in
the oral mucosa of oophorectomized mon-
k e y ~ ; and
~ ~ Ziskin’” repeated these studies
in women. The same group and others
showed that although estrogen administra-
tion produced histologic changes in the oral
mucosa, it did not relieve symptoms of BMS.
Other studies claimed benefit from hor-
mone replacement therapy alone or in combi-
nation with vitamin B complex therapy.”O
Some authors considered that, although the
oral symptoms may be related to the climac-
teric, they were psychological in origin.71
Menopause clinics have been used to inves-
tigate oral symptoms that such patients may
have. In one study, 20% of patients had some
oral symptoms, but not all had BMS.12 The
prevalence of oral symptoms at the climac-
teric, including a burning sensation, is
high.150,170 Hormone replacement therapy was
of doubtful benefit, suggesting that estrogen
deficiency is an uncommon cause of BMS.&
Some authors have attempted to identify oral
nuclear estrogen receptors immunohisto-
chemically in an attempt to identify patients
likely to benefit from hormone replacement
The present situation is that there
is no proven benefit of hormone replacement
therapy in BMS.
Psychological Factors
Psychological factors of importance in BMS
include simple fear of personality
disorders,s6 uncommon depre~sion,’~~ and
most significantly chronic anxietyg0or emo-
tional in~tability.~~ Emotional instability is
present in approximately 50% of type 3 BMS
patients.97Such patients can respond quickly
to a stressful situation by developing symp-
toms of BMS, which then resolve when the
situation reverts to normal. It is important
BURNING MOUTH SYNDROME 347
when assessing patients’ psychological status
to be objective, and many psychological pro-
formas are available to allow the clinician or
psychologist to do this. Some proformas, such
as the Hospital Anxiety and Depression scale,
are quick and simple to complete and have
been validated and applied to BMS patients2O
One such study emphasized that anxiety was
much more common than depression. Others
also have noted hypochondriacal tendencies
(i.e., anxiety) in their 179 The
sources of anxiety are many and various, but
include ”dissatisfaction with life.” It is for
this reason that, when evaluating patients
with BMS, a home circumstances score is
used because it is a nonconfrontational means
of allowing patients to verbalize their con-
cerns and qualify them.
Personality traits in BMS patients have
been assessed using Cattell’s 16PF Question-
naire.86 This questionnaire is fairly lengthy
and requires specialist interpretation. It can,
however, highlight personality traits in BMS
as shown in Figures 3 and 4. Such individuals
tend to be anxious, somewhat introverted and
self-reliant, but with low self-esteem. Others
have claimed that although BMS patients ap-
pear superficially kind and sensitive, they ac-
tually show suppressed hostility.18
Schoenberg128considered depression to be
a feature of BMS, but patients in that study
were excluded if any organic factor was
found. A degree of dependency and ”symp-
tom formation” can develop in BMS pa-
tient~:~and in managing them, such patients
should receive attentive listening. Verbal ex-
pression was encouraged, as well as offering
appropriate explanations to social difficul-
ties.31,83 Additional studies, this time using a
psychological proforma, highlighted a preoc-
cupation with ~ o s s . ~ ~ ~
This range of psychological problems that
some BMS patients have emphasizes the need
for the clinician to adopt a sympathetic ap-
proach with reassurance and avoidance of
excessive treatment.12,56, 78, lo2,lo3 It is still not
clear if psychological aspects of BMS are
cause or effect, and indeed, some patients
may have a chronic pain personality.6oState
and trait anxiety are elevated in BMS pa-
t i e n t ~ with
, ~ ~ figures
~ varying between 44YOZ4
and 62%.86 In the latter study, type 2 BMS
patients were more severely psychologically
disabled than type 1 BMS patients, and anxi-
ety seemed the most recalcitrant obstacle to
cure. Overall, in management there is a re-
quirement for an objective assessment of psy-
348 LAMEY

A
-
X

-
5.1
B 4.9
C 3.9* Unstable

E 4.3

F 4.3' > Serious

G 6.6* * Precise
H 5.2

6 1
c 4.7
L!L 4.3' 4 Trusting

M 4.7
N 6.y * Shrewd
0 6.3
Q1 4.3* * Conservative
Q2 7.3 * Independent
Q3 5.2
6 .*5* * Tense
Q4
-
3 4 5 6 7 8
Stens

Figure 3. Mean profile recorded by Cattell's 16PF Questionnaire

Form C for BMS patients (n = 47) compared with age general
population. = P <0.001, ** = P <0.01

dormal Abnorma
4.9 5.2

5.3 4.5
5.2 3.1 Unstable

5.3 5.0
4.7 4.0

6.3 6.7
5.4 5.1
4.5 4.8
4.3 4.2

4.5 4.8
6.1 6.8
5.2 7.0 -Apprehensive
4.1 4.4
7.1 7.8
6.2 4.5 ICasual

4.6 7.7 - Tense

Stens

Figure 4. Mean profile recorded by Cattell's 16PF Questionnaire Form

C for BMS patients with (0-c [n = 281) and without (0-0 [n = 191)
an abnormal psychological profile.

chological status as well as a regimen to cater
to psychological as well as medical and den-
tal needs. Clearly life events are important in
BMS 86, 149 but it has been claimed
recently that BMS symptoms do not necessar-
ily correlate with stressful life events.86
Drug-related Burning Mouth
Syndrome
The only drugs of significance in appar-
ently precipitating BMS are angiotensin-con-
verting enzyme (ACE) inhibitor^.'^^ Reported
cases refer to scalded mouth . syndrome
(SMS), but they almost certainly mean BMS.
The three drugs involved are all ACE inhibi-
tors and are lisinopril, captopril, and enala-
pril. Although the mechanism of BMS induc-
tion by ACE inhibitors is not known, it does
appear dose related and subsides on reduc-
tion or discontinuation of therapy.
Relationship to Systemic Disease
BMS may involve the complaint of burning
at other body sites and as such may be a
systemic disorder.50It has also, however, to be
borne in mind that accompanying psychiatric
problems can produce somatization and re-
sult in multiple perceived somatic problems.
Only rarely is BMS a manifestation of un-
derlying organic disease. Two recent reports,
however, have associated the complaint of
BMS with acoustic n e ~ r o m aand ~ ~ temporal
arteritis51 (also known as giant cell arteritis).
In the case of temporal arteritis, which affects
the same age group as BMSY4 recognition of
the underlying disease is important because
permanent blindness is a serious complica-
t i ~ n A. ~useful
~ clinical clue to the potential
for a patient having giant cell arteritis is that
they usually feel systemically unwell at tlie
time of presentation.
Associated Sensory Changes
Several groups of investigators have stud-
ied sensory changes including taste in BMS
patients. In one study, sensory and pain
thresholds to brief argon laser stimulation
showed abnormal prepain perception and
disturbances in the perception of nonnocicep-
tive and nociceptive thermal stimuli in pain-
affected and normal regions.*41This suggests
BURNING MOUTH SYNDROME 349
a perceptual deficit unrelated to pathophysio-
logic mechanisms in BMS. The authors con-
cluded that this alteration in sensory function
may be more plausible than a psychological
explanation of BMS.
When taste accompany BMS,6I
it has been stated that treatment is unsatisfac-
tory, but that depression frequently accompa-
nies chemosensory distortion.l12It is not clear
from these studies if candidal carriage had
been sought or treated. It is common for taste
abnormalities to be due to candidal species,
even in the absence of clinical changes.
Sensory changes of BMS have themselves
formed the basis of attempts to objectively
diagnose the condition.27Thermoesthesiome-
try, which, it is claimed, accurately detects
surface temperature, showed that in BMS the
surface mucosal temperature was lower than
in control subjects, and this was attributed to
reduced blood circulation in the area. The
diagnostic benefit of this test is still to be
subject to independent study.
NOVEL TREATMENT OPTIONS IN
BURNING MOUTH SYNDROME
Two recent publications have suggested
novel ways of treating BMS. These reports are
clearly only initial observations but warrant
inclusion in any free-thinking academic com-
munity.
One study evaluated the use of soft laser
therapy in patients with BMS.27 Forty
”stomatopyrosis” and ”stomatodiniae” pa-
tients underwent 5 days of therapy for 3 min-
utes daily on 1 cm2 of oral tissue. The re-
ported response, was complete healing by
which one assumes the patients were asymp-
tomatic. No follow-up data were presented.
The second novel treatment involves the
use of c a ~ s a i c i n Capsaicin
.~~ is a neurotoxin
that destroys a major class of nociceptors,
primarily C polymodal and some A delta noc-
iceptors. Although a mixed group of ”oral
neuropathic pain” patients were described,
some would appear to have BMS. Further
data on this treatment are required as is de-
tailed information concerning patient investi-
gation.
MANAGEMENT PROTOCOL
This protocol is based on scientific evalua-
tion of the known precipitating factors in
BMS and is what I follow routinely.
350 LAMEY
1. Hematinic assay of hemoglobin, ferri-
tin, vitamin BIZ, and corrected whole
blood folate. Deficiencies detected need
investigation for cause prior to supple-
mentation.
2. Assay of vitamin B, and vitamin B,. If
these are not available, then empirical
treatment with vitamin B, (300 mg
daily) and vitamin B6 (50 mg every 8
hours). Both are prescribed for 4 weeks
or rarely for 8 weeks. Patients should
discontinue all self-medication with vi-
tamins.
3. Assay of blood glucose on a morning
fasted sample. If results are equivocal,
a glucose tolerance test (75 g load) is
performed with referral to a physician
with an interest in diabetes.
4. Measurement of stimulated parotid
flow rate using a Carlsson-Crittenden
cup and stimulated with 1 mL of 10%
citric acid. Flow of less than 0.7 mL/
min is low, and the patient may benefit
from saliva substitutes.
5. An oral rinse for Candida species. The
distinction between carriage and infec-
tion (without clinical signs) is vague,
but in practice all BMS patients in
whom Candida is isolated should re-
ceive 4 weeks of topical antifungal ther-
apy. Advice on a low carbohydrate diet
and denture hygiene also should be
given, if appropriate.
6. Reassure about cancerphobia. This may
need to be repeated at subsequent vis-
its.
7. Objective psychological assessment.
For screening purposes the Hospital
Anxiety and Depression scale is useful
and can be supplemented with others
if required. Involvement of a clinical
psychologist also can be helpful. If
there is a clear psychological problem,
then appropriate therapy is needed.
Prothiaden (dothiepin), 75 mg nocte, is
our drug of choice because it combines
anxiolytic and antidepressant proper-
ties and is not addictive. The drug
should be avoided in patients with car-
diac arrhythmias.
8. Assessment of denture status if rele-
vant. The main features of note are re-
stricted tongue space, lack of freeway
space, and underextended denture
bases. Obvious design features need to
be corrected.
9. Inquire about parafunctional habits
such as tongue thrusting or tooth
clenching. It can be difficult for patients
to refrain from such habits. Sometimes
sugar-free chewing gum allows pa-
tients to break their habit.
10. In type 3 patients who are psychologi-
cally normal, patch testing is appro-
priate. Once identified, avoidance of
the relevant allergen(s) usually resolves
the complaint, but the patient should
realize that this may take several
months.
In our hands this management protocol
renders approximately 7@/0 of patients
asymptomatic or greatly reduces their burn-
ing score. This protocol fails 28% of patients,
however, and indeed made 2% of patients
worse. The reason for this may lie in the
patients' home circumstances and chronic
anxiety. We also should bear in mind that
other factors,, possibly organic, which we do
not yet know about, also may be important.
PROGNOSIS
It has been stated that there is not a predict-
able endpoint in the outcome of treating BMS
patients.57This is certainly the case if not all
relevant investigations are undertaken. There
can be few conditions more multifactorial
than BMS, and we all owe it to our patients
to manage them to the best of our ability
and take cognizance of our current scientific
knowledge. If all investigations are under-
taken, it would seem that approximately 70%
of BMS patients can be rendered asymptom-
atic or nearly so by treatment.89Initially, the
follow-up period in that study was 18
months, and longer follow-up data are
awaited. In a mixed group of patients re-
viewed 8 to 10 years after treatment, over
50% of patients still thought they needed
treatment and continued to be high consum-
ers of healthcare resource^.'^^
In our present state of knowledge, we do
not know the long-term prognosis for BMS
patients. Spontaneous remission has been
claimed>12but this is not my experience. The
application of statistic methods to predict out-
come has not proved usefu1.'07,lZ1
CONCLUSION
Our knowledge of BMS has advanced enor-
mously in the last 10 years. These advances

have arisen from carefully controlled pro-
spective studies aimed at addressing outcome
of treatment. Hypotheses on the role of addi-
tional organic causes of BMS should be pur-
sued. It is also important for our patients to
have a logical scientific approach to care and
make sure they benefit from the knowledge
we have already. Science cannot replace a
caring and supportive clinical approach, but
it can help us confirm what we do know and
help us understand what we do not.
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Royal Victoria Hospital
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Northern Ireland