Dermatol Clin 21 (2003) 135 145

Burning mouth syndrome

Lisa A. Drage, MD*, Roy S. Rogers III, MD
Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

The burning mouth syndrome (BMS) is defined as

a symptom complex of those patients with mouth
pain who have a clinically normal oral mucosal
examination. BMS is a diagnosis of exclusion. Many
oral mucosal diseases present with mouth pain; a few
examples include lichen planus, recurrent herpes
simplex virus infections, and recurrent aphthous
stomatitis. A thorough oral examination must be
completed to exclude these and other oral diseases
before diagnosing BMS. Synonyms for BMS have
included glossodynia, glossopyrosis, glossalgia, stomatodynia, stomatopyrosis, sore tongue and mouth,
burning tongue, oral or lingual paresthesia, and
oral dysesthesia.
Burning mouth syndrome is often stereotyped as a
purely psychosomatic disorder occurring in postmenopausal women, which is resistant to therapy.
Although BMS can be a diagnostic and therapeutic
challenge, multiple studies have linked BMS to real
organic and psychiatric disease and show an improvement in symptoms in about 70% of patients with
directed therapy [1 6]. Faced with a patient who has
BMS, dermatologists and other clinicians need to be
familiar with its associations and management, and
optimistic about potential outcome.
The patient variably describes a burning, tingling,
painful, hot, scalded, or numb sensation in the oral
cavity. The magnitude of BMS pain is quantitatively
similar to a toothache [7]. This sensation occurs most
commonly on the anterior two thirds and tip of the
tongue. Multiple oral sites may be involved. These
may include the upper alveolar region, palate, lips,
and lower alveolar region [1,2,5,6,8]. Less commonly

* Corresponding author.
E-mail address: drage.lisa@mayo.edu (L.A. Drage).

affected are the buccal mucosa, floor of the mouth,

and the throat [4]. With prevalence in the general
population of 3.7% [9], BMS affects women seven
times more frequently than men [5]. It particularly
affects the middle-aged and elderly population (mean
age 60) [2,6,10] and has not been reported in children.
The average duration of BMS is 2 to 3 years [2,11],
with rare patients suffering for decades. Most BMS
patients have consulted multiple dentists, physicians,
and other health care providers for their complaint and
may have tried a host of over-the-counter and prescription medications before their presentation [2,4].
Over half state they received insufficient information
about BMS from their health care provider [12].
Burning mouth syndrome has been divided into
three subtypes based on the daily variation of the
symptoms (Table 1) [13]. Type 1 BMS (35%) is
characterized by daily pain that is not present on
awakening but progresses throughout the day with
the greatest problems occurring in the evening hours.
Type 2 BMS (55%) patients awake with a constant
daily pain, whereas Type 3 BMS (10%) patients have
intermittent pain with symptom-free intervals and the
pain occurs in unusual sites, such as the buccal
mucosa, floor of mouth, and throat. Nonpsychiatric
factors have been linked with Type 1 BMS, chronic
anxiety with Type 2, and food additives or flavoring
allergies with Type 3 BMS. The patients with Type 2
BMS tend to be most resistant to therapy [13,14].

Associated factors
Many conditions have been associated with BMS
(Table 2) [2]. It should not be surprising that oral pain
like any type of pain can have more than one cause.
The four main categories are (1) systemic, (2) local,

0733-8635/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 7 3 3 - 8 6 3 5 ( 0 2 ) 0 0 0 6 3 - 3

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Table 1
Lamey classification of subtypes of BMS [13]

Type 1
Type 2
Type 3

Clinical course

Association

Daily pain, not present on awakening, increases throughout day

Daily pain, constant
Intermittent pain, unusual sites (buccal mucosa, floor of mouth)

Nonpsychiatric
Psychiatric, especially chronic anxiety
Allergic contact stomatitis to flavorings, additives

From Lamey PJ, Lamb AB, Hughes A, et al. Type 3 burning mouth syndrome: psychological and allergic aspects. J Oral Pathol
Med 1994;23:216 9; with permission.

(3) psychiatric or psychologic, and (4) idiopathic

factors. The most common associations include psychiatric or psychologic disorders, xerostomia, nutritional deficiencies, allergic contact stomatitis,
denture-related factors, parafunctional behavior, candidiasis, diabetes mellitus, and menopause or hormonal alterations [2].
Multifactorial
In more than a third of patients, multiple, concurrent causes of BMS may be identified and need to be

addressed simultaneously to achieve the best outcome

possible [1 5,12,15].
Psychiatric or psychologic disorders
Psychiatric disease is a common underlying factor
in patients with BMS. A psychiatric disease association has been reported in many series ranging from
19% to 85% [3 5,9,11,13 25]. At least one third of
patients may have an underlying psychiatric diagnosis, most commonly depression or anxiety disorders [2]. A phobic concern regarding cancer is also

Table 2
Reported etiologic agents of BMS [2]
Systemic

Local

Psychogenic and psychiatric

Deficiencies
Iron
Vitamin B12
Folate
Zinc
B complex vitamins
Endocrine
Diabetes mellitus
Hypothyroidism
Menopause or hormonal

Denture factors
Dental work
Mechanical
Oral habit or parafunctional behavior
Clenching
Bruxism
Tongue thrusting
Myofascial pain
Allergic contact stomatitis
Dental restoration or denture materials
Foods
Preservative, additives, flavorings
Neurologic
Referred from tonsils or teeth
Lingual nerve neuropathy
Glossopharyngeal neuropathy
Acoustic neuroma
Infection
Candidiasis
Antibiotic related
Denture related
Local trauma
Corticosteroid
Diabetes mellitus
Fusospirochetal
Xerostomia
Irradiation
Local disease

Psychiatric
Depression
Anxiety
Obsessive compulsive disorder
Somatoform disorder
Cancerphobia
Psychosocial stressors

Xerostomia
Connective tissue disease
Sjogrens syndrome
Sicca syndrome
Drug-related
Anxiety or stress
Medication
ACE inhibitor
Esophageal reflux
Anemia

Idiopathic

From Drage LA, Rogers RS III. Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth
symptoms. Mayo Clin Proc 1999;74:223 8; with permission.

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

prominent in 20% of patients [5]. The BMS patient

may be concerned that the symptoms are caused by
oral or systemic cancer, although the patient rarely
shares this concern spontaneously with the physician.
Repeated self-examination may be a marker for
cancerphobia [4].
Although BMS may be a somatic symptom of
depression in some cases, the association does not
always equate to a causal relationship. Depression and
psychologic disturbance are common in chronic pain
populations and may be secondary to chronic pain
rather than the cause of BMS. Studies have reported
similarities between the personality characteristics of
chronic oral pain patients and other chronic pain
populations [7]. Similar sleep disturbances have also
been documented in these populations [8]. In addition,
many of the medications used to treat psychiatric
disease can cause xerostomia and exacerbate BMS.
Although psychiatric disorders are clearly significant for some patients with BMS, it is important
not to leap to the conclusion that all BMS is caused
by psychiatric problems. Unfortunately, psychiatric
causes are frequently postulated when no easy
answer is apparent. Each patient with BMS should
receive a careful evaluation for both psychiatric and
organic causes of pain. This thorough examination
may unveil a local or systemic cause for their
symptomatology and is often therapeutic, reassuring
the patient about concerns regarding oral cancer.
During the evaluation, direct questions about depression, anxiety, and fear of cancer and a family history
of psychiatric disorders or oral cancer should be
posed. When warranted, further evaluation and documentation of psychiatric disease by psychiatric consultation should be sought. A team approach is
important; psychiatric staff may not feel as comfortable confirming the diagnosis of BMS because they
are less familiar with oral disease.
Xerostomia
A dry mouth is a frequent complaint among BMS
patients and can be found in up to 25% [2,5,6] of
patients with these complaints. Decreased oral lubrication may result in increased friction and discomfort leading to BMS (Fig. 1). Xerostomia itself can be
multifactorial. Drug-related xerostomia is common
[2,22] and can occur with many medications including tricyclic antidepressants, benzodiazepines, monamine oxidase inhibitors, antihypertensives, and
antihistamines. Connective tissue diseases, such as
Sjogrens syndrome or sicca syndrome, can cause
xerostomia [2,8], as can a history of local irradiation
or diabetes mellitus. Even stress and anxiety can lead

137

Fig. 1. Xerostomia. A dry mouth is a common complaint of

patients with burning mouth syndrome (BMS). Note the dry,
erythematous, fissured tongue plus angular cheilitis.

to a dry mouth. Although hypothesized, age-related

or menopausal xerostomia has not been conclusively
documented [26].
Nutritional deficiencies
Because of rapid cell turnover and trauma, the oral
cavity is especially sensitive to nutritional deficiencies and may be the first indicator of such a problem.
Iron deficiency anemia, pernicious anemia (an autoimmune B12 deficiency), zinc deficiency, and B
complex vitamin deficiency [20] have all been
reported to cause BMS. Nutritional deficiencies have
been claimed to cause BMS in as few as 2% [15] and
as many as 33% [1] of patients. The mucosal alterations associated with these deficiency states, such as
erythema, glossitis, loss of papillae, or atrophy, may
be absent in BMS patients (Fig. 2). Replacement
therapy may be helpful in BMS patients with documented deficiencies [2,5,6,20,27].
Allergic contact stomatitis
The role of allergens in BMS is somewhat controversial. Although some studies claim a high prevalence of allergy to dentures and dental materials,
such as acrylates, nickel, mercury, gold, and cobalt
[28 30], more recent studies [2,31] were unable to
implicate denture or denture materials as a frequent
cause of BMS. Because true allergies to denture
materials are rare, patients should not be considered
allergic to denture or dental material until controlled
patch testing has been correlated with clinical symp-

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design faults, but only half of these patients improved

after denture replacement. The main denture design
faults of concern are (1) restricted tongue space, (2)
lack of freeway space, and (3) underextended denture
bases [4]. These denture design faults can increase the
stress on surrounding tissues or change the normal
function of the tongue. Most BMS patients with
dentures or significant dental work benefit from
referral for a formal dental consultation to assess
dental work, dentures, occlusion, and the need for
modification or replacement. This topic is addressed
by Kupp and Sheridan elsewhere in this issue.
Parafunctional behavior
Burning mouth syndrome associated with parafunctional behavior is probably more common than is
realized and is often under appreciated by physicians.
Lamey and Lamb [5] found parafunctional activity a
concern in 13% of a group of patients with BMS.
Patients who clench or grind their teeth, thrust their
tongue repetitively (Fig. 3), run their tongue against
Fig. 2. Smooth tongue. A smooth tongue is atrophic with
loss of filiform papillae. This permits an increased sensitivity to irritants causing BMS. A smooth tongue may
indicate a systemic condition, such as pernicious anemia,
iron deficiency anemia, or gluten-sensitive enteropathy.

toms. Patients with Type 3 BMS (intermittent pain)

are more likely to have positive patch tests [13].
Flavoring or food additives have been implicated.
This subtype clearly merits patch testing. Lamey et al
[13] noted 65% of Type 3 BMS cohort had positive
patch tests and 80% of this group improved with
avoidance of the implicated allergen. Cinnamon aldehyde (cinnamon), sorbic acid, tartrazine, benzoic
acid, propylene glycol, menthol, and peppermint have
all been identified as potential causes of mouth pain
[2,13,31]. Note the contribution of LeSueur and
Yiannis on contact stomatitis elsewhere in this issue.
Denture-related problems
Pain affecting only denture-bearing tissue, a temporal association with denture use, or improvement
with discontinuation of dentures is a clue to denturerelated BMS. Rather than an allergic response to
denture material, denture-related pain is usually
caused by faulty design, irritation, or parafunctional
behavior. Candidiasis can also contribute to denturerelated pain. Main and Basker [6] attributed BMS to
denture design faults in 50% of patients; with replacement of dentures the patients improved. Lamey and
Lamb [5] noted 60% of BMS patients had denture

Fig. 3. Tongue thrusting. Parafunctional habits, such as

tongue thrusting, may cause, or occur secondary to, the
symptoms of BMS. Note the crenulated or scalloped borders
to the tongue. Similar findings are seen with macroglossia.

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

their teeth, or try to reseat an ill-fitting denture with

their tongue may develop oral pain. These behaviors
may be unconscious or may only occur at times of
stress. Examination of the tooth surface and dentures
can sometime give clues to parafunctional behavior.
Dental consultation may be helpful in identifying and
managing these behaviors.
Candidiasis
Reported as a causative factor in 6% [5] to 30%
[15] of patients with BMS, the mucosal alterations
typically associated with candidiasis may be minimal
or absent in BMS patients. Osaki et al [32] reported
subclinical candidiasis as a cause of BMS in 25% of a
patient cohort. Glossal pain subsided with treatment
with 3% amphotericin mouthwash solution. Oral
candidiasis is an opportunistic infection. A normal
constituent of the mouth in 40% of patients, candidal
overgrowth occurs with xerostomia, corticosteroid
treatment, antibiotic treatment, denture use, and diabetes mellitus. Empiric treatment for oral candidiasis
is often prescribed to patients with BMS.

139

group of women exists and may be tied with menopause, there is currently no proven benefit of hormone replacement therapy in BMS.
Drug-related BMS
The ACE inhibitors enalapril, captopril, and lisinopril can cause scalded mouth or BMS. There is
improvement with reduction or discontinuation of the
medication [36].
Normal mucosal findings
Often regarded as asymptomatic variants of normal, multiple studies have shown geographic (Fig. 4),
fissured (Fig. 5), or scalloped tongues more frequently
in patients with tongue pain [2,15,37,38]. Although
the patient with oral pain and these findings technically does not fit under the rubric of BMS, the
connection between these oral findings and oral pain
has been documented and should be recognized.
These findings can also increase the patients fear of
cancer. The article on glossitis by Byrd et al elsewhere
in this issue addresses this topic in greater detail.

Diabetes mellitus
Metabolic alterations in the oral mucosae, diabetic
neuropathy, and angiopathy are all proposed mechanisms behind BMS in patients with diabetes mellitus.
Xerostomia and oral candidiasis may also contribute
to the problem. About 5% of BMS patients have
diabetes mellitus [4]. BMS is the second most common oral complaint after xerostomia in a study of
diabetic patients [1]. Control of diabetes mellitus may
lead to improvement or cure of BMS.

Evaluation and work-up of the patient with BMS

The many causes and multifactorial nature of
BMS make an organized approach to evaluation
important (Table 3). Diagnosis and treatment may

Menopause or hormonal alterations

Most patients seen by physicians for BMS are
women. All the literature on BMS finds that this
condition is more common in women than men with a
ratio of 7 to 1 [4]. Other oral pain syndromes are also
seen more commonly in women [33]. In light of the
prevalence of BMS in postmenopausal women, a role
for a hormonal impact on BMS has long been
suspected [1,34]. In controlled clinical trials with
systemic or local estrogen treatment, however, neither
was more effective than placebo in the treatment of
BMS [10,35]. No significant differences are found
between women with mouth pain and a control group
in number of years since menopause, use of estrogen
replacement therapy, or number of years of use of
estrogen replacement therapy [8,33]. Although
clearly a significant link between BMS and this age

Fig. 4. Geographic tongue. The geographic tongue is a

combination of an atrophic tongue with a red base caused by
diminished filiform papillae (with resultant hypersensitivity)
and a furred tongue with a white base and hyperplasia of
filiform papillae. The geographic tongue may be symptomatic. (From Drage LA, Rogers RS III. Clinical assessment
and outcome in 70 patients with complaints of burning or
sore mouth symptoms. Mayo Clin Proc 1999;74:223 8;
with permission.)

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Laboratory examination should include the pertinent tests in Table 2. Biopsy specimens are
unlikely to be beneficial if a normal clinical
examination is confirmed. Patch testing is especially important and fruitful in the patient with
Type 3 BMS and should include a standard series,
metal series, and oral flavorings and preservatives
(Box 1). The list of allergens is discussed in the
contribution by LeSueur and Yiannis elsewhere in
this issue.

Management
Fig. 5. Fissured tongue. The fissured tongue is rare in
neonates and more common with age. About one sixth of
older patients have grooves and fissuring of the tongue
dorsum. Impaction of food and keratin debris can predispose
to inflammation and halitosis.

be achieved best by a multidisciplinary approach

involving the dermatologist and the primary care
provider, dentist, psychiatrist, and otorhinolaryngologist. Simply treating the patient in a sympathetic
manner may improve the interaction and perhaps the
outcome [2,3,12].
Directed history concentrating on the medical,
dental, and psychologic or psychiatric history and
review of symptoms should occur. The description
of oral pain should include the following: duration;
character; level (scale of 1 to 10); site of involvement; and subtype or pattern. Frank questions about
depression, anxiety, and fear of cancer should be
posed. Exacerbating factors, such as food and oral
preparations (mouthwash, gum, mints, toothpaste,
lip cosmetics, and smoking), should be elicited.
Relationship of pain to denture use, dental work,
and parafunctional oral behavior (tongue thrusting,
bruxism, or jaw clenching) should be documented.
All medications must be assessed for xerostomic potential.
Physical examination with emphasis on a thorough oral examination must be completed. Besides
identifying other diseases that could cause mouth
pain, this reassures the patient that cancer is not
present. Evaluation should include assessment for
erythema, glossitis, atrophy, candidiasis, geographic
tongue, lichen planus, and xerostomia. Clinicians with
knowledge and experience in the broad range and
presentation of oral disease are best equipped to
certify a truly normal oral mucosal examination.
Examination of dental work, dentures, denture function, and signs of parafunctional behavior may be
assessed best by a dental consultation.

Burning mouth syndrome is a manageable problem with most patients responding to tailored therapy
(Box 2). Management should focus on controlling or
eliminating all potential causes of BMS, keeping in
mind that in many patients more than one factor
plays a role. Because of the number of conditions
causing oral pain, a single treatment protocol is not
appropriate. Treatment is tailored to the proposed

Table 3
Work-up of BMS
Thorough history and review of symptoms
Medications causing xerostomia
Dental or denture work
Oral care, oral products
Oral habits or parafunctional behavior
History of depression, anxiety, cancerphobia
Family history of oral cancer, psychiatric diagnoses, and
connective tissue disease
Oral examination
Erythema, candidiasis, xerostomia or other mucosal
abnormalities
Tongue disorders, such as a geographic, fissured, or
atrophic tongue
Dental work or dentures
Laboratory tests
Complete blood count
Iron, total iron binding capacity, iron saturation, ferritin
Vitamin B12, folate, zinc
Glucose, glycosylated hemoglobin
Culture for Candida
Patch testing
Include standard series, metal series, oral flavors and
preservatives
Further consultation if indicated by history and review
of systems
Psychometric testing and psychiatric consultation
Dentistry
Neurology
Otorhinolaryngology

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

Box 1. Patch testing in BMS

1. Standard series (The Mayo
Clinic series includes 68 different
allergens)
2. Oral flavorings and preservatives
3. Metal series
The allergens tested should include (but
not be limited to) the following:
Methyl methacrylate
Ethyl acrylate
Ethyleneglycol dimethacrylate
Triethyleneglycol dimethacrylate
BIS GMA
Benzoyl peroxide
Propylene glycol
Sorbic acid
Benzoic acid
Tartrazine yellow
Peppermint
Spearmint
Cinnamic aldehyde
Menthol
Fragrance mix
Balsam of Peru
Cobalt chloride
Nickel sulfate
Gold sodium thiosulfate
Amalgam
Mercuric chloride
Cadmium chloride
Potassium dichromate
Formaldehyde
p- Phenylenediamine

causes. Management plans for different scenarios

are reviewed.
Psychiatric disorders
A supportive environment is beneficial for continued treatment of the patient and may aid resolution of the symptoms in concert with other therapies
[2,3]. Psychiatric evaluation, medication, and psychotherapy [39] may play a role in alleviating the
symptoms. Although optimally undertaken with the
guidance of a psychiatrist or psychologist; some
patients are resistant to psychiatric evaluation. Antidepressants and anxiolytics with less anticholinergic
impact (hence less xerostomia) are preferred. Serotonin reuptake inhibitors typically cause less xero-

141

stomia and may be a good choice in this setting.

Reassurance that cancer is not present should be
stated clearly and repeatedly.
Denture or dental-related pain
Evaluation of dental work, dentures, denture
design faults, and parafunctional behavior by a specialist should be sought. Adaptation or replacement
may lead to relief of BMS. Removal of dentures at
night may be helpful. Avoidance of irritants, treatment of dentures with anti-candidal agents, and a
review of dental hygiene should occur.
Deficiency syndromes
Replacement of iron, B12, folate, or zinc should
occur in patients with documented deficiencies. Gradual improvement may follow. Evaluation into the
cause of the document deficiency must occur before
supplementation. Supplementation in absence of
documented deficiency is difficult to justify aside
from B vitamin replacement [20]. Lamey [3] recommends empiric replacement of vitamins B1 (300 mg,
once a day) and vitamin B6 (50 mg, three times a day)
for 4 weeks.
Allergic contact stomatitis
Patch testing to dental and denture components,
metals, additives, preservatives, flavors and a standard series should occur under the supervision of a
dermatologist who is experienced in their proper use
and interpretation. The clinical correlation between
the patch test results and patient exposure history is
the most important component of the testing. Patient
education and training regarding the avoidance of
identified allergens is imperative.
Candidiasis
Because Candida is a normal part of the oropharyngeal flora, a positive culture does not equate
to a pathologic process. Tests that quantitate Candida infection are not available routinely. Typically,
empiric treatment for oral candidiasis is offered to
the patient with BMS and may benefit a subset of
patients. Treatment may include use of nystatin or
clotrimazole, which are available in multiple forms
including creams, rinses, and troche. One example
of an effective treatment regimen includes the use
of oral fluconazole, 100 mg Number 15: Day 1,
two pills; days 2 7, one pill; days 8 21, one pill
every other day. Dentures should also be treated for

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L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

Box 2. Management strategies for BMS

Tenets of treatment:
1. Focus on controlling or eliminating
all potential causes of BMS
2. Tailor treatment for individual patient based on suspected causes
3. Resort to empiric therapy only if
no cause of BMS is found or failure
of treatment

Management plans may include the

following:
Psychiatric and psychologic disorder
Maintain supportive environment
Psychiatric evaluation and
management
Appropriate medication or
psychotherapy
Reassure cancer is not present
Denture or dental work
Evaluation by dentist
Adaptation or replacement as needed
Deficiency syndromes
Document deficiency
Evaluate cause of deficiency
Replacement therapy
Allergic contact stomatitis
Referral to dermatologist with experience in use and interpretation of
patch tests
Patch test to standard, metal, oral
preservatives, flavor series
Clinical correlation
Patient education in avoidance of identified allergen
Candidiasis
Culture
Treatment with anti-candidiasis agents
Diabetes mellitus
Referral for management and education
Parafunctional behavior
Dental evaluation

Behavioral therapy
Sugar-free chewing gum
Xerostomia
Discontinue medications that
cause xerostomia
General measures
Saliva substitute
Sialogogues
Idiopathic (empiric treatment)
Avoid irritants
Trial of treatment with
anti-candidal agent
B-vitamin replacement
Doxepin trial
Low-dose tricyclic antidepressants
Local clonazepam
Consider referral to specialist in
oral medicine

candidiasis and dental hygiene reviewed. Dentures

should always be removed at night. Many patients
sleep with dentures in place all night. This predisposes to parafunctional habits and recurrent candidiasis (denture stomatitis).
Diabetes mellitus
All patients with BMS need to have diabetes
mellitus excluded with fasting blood glucose levels.
Patients with abnormal findings should be referred
for management and education. Control of diabetes
mellitus many lead to decrease in BMS. Change of
the diabetic medications can sometimes be helpful.
Some patients may need oral agents or some may
need insulin therapy.
Parafunctional habits
Once identified, management many include modification of denture design; behavioral therapy consisting of habit monitoring, biofeedback, and relaxation
techniques [12]; and use of sugar-free chewing gum,
mouth guards, and even hypnotherapy.
Xerostomia
A number of general measures may be instituted
to counteract xerostomia (Box 3). The discontinuation or substitution of medications with potential for

L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

Box 3. Xerostomia management

General measures include the following:
Review medications and replace
those with known xerostomic potential. Discontinue unnecessary
medications.
Increase water intake throughout
the day
Use humidifier in bedroom
Avoid alcohol and alcohol-containing
mouthwash
Avoid caffeine
Use sugar-free candy, gum, and
beverages
Use petroleum jelly on lips before bed
and throughout day
Frequent dental examination. Patients
with xerostomia have increased risk
of cavities and gum disease.
Commercial saliva substitutes: use as
often as needed and before bed;
available without a prescription.
Examples include the following:
Mouth Kote (spray)
Moi-stir-spray and swabs
Optimoist (spray)
Sialogogue
Pilocarpine, 5 mg tid
Civemeline, 30 mg tid

causing xerostomia should be sought. Because xerostomia is a very common medication side effect,
sometimes a simple reduction in the number of
drugs used may improve xerostomia. Artificial saliva substitutes may be helpful. Sialogogues, such as
pilocarpine, are sometimes used [32]. Note the
contribution by Parks and Lancaster on oral manifestations of systemic disease elsewhere in this issue
for additional discussion of xerostomia and therapy
of the dry mouth.
Idiopathic
If no underlying cause for BMS is found or
treatment targeted to a proposed etiology is not
beneficial, treatment options may follow a more
empiric approach. This may include discontinuation
of irritating substances (alcohol-based mouthwashes,
cinnamon or mint products, and smoking); a trial

143

treatment with anti-candidal agents; and trial treatment with B complex vitamins [3]. Doxepin, familiar to many dermatologists, is often prescribed in
doses up to 75 mg for its antianxiety and antidepressant affects. At higher doses doxepin has a
greater potential for cardiac arrhythmia, xerostomia,
and full antidepressant effect and needs to be
carefully monitored
If no response is seen, tricyclic antidepressants
may be used in a chronic pain protocol manner
[2,5,26]. Typical doses include amitriptyline, 10 to
75 mg. Low doses of tricyclic antidepressants may
have an analgesic affect that is separate from their
action as antidepressants [33]. Use of benzodiazepines [40,41] including systemic clonazepam [18]
have been reported to be effective in BMS.
Although the mechanism for their action may not
rely solely on their anxiolytic effect, concerns
regarding the chronic nature of BMS and the potential for abuse of this class of medication merits
cautious use. Interestingly, Woda et al [42] reported
benefit in 52% of patients treated with local application of clonazepam (0.5 to 1 mg) two to three times
a day. They theorized that local application of
clonazepam acts locally to disrupt the neuropathologic mechanism that underlies BMS. More unusual
treatments reported have included use of capsaicin
[43] and infrared laser [44].
Burning mouth syndrome is a treatable syndrome.
Treatment is associated with improvement in about
70% of patients [1 6] using a directed approach. If
that fails, an empiric approach is warranted. Spontaneous remissions have also been noted to occur
[45,46].

Summary
Burning mouth syndrome is the occurrence of oral
pain in a patient with a normal oral mucosal examination. It can be caused by both organic and psychologic or psychiatric factors, which can be broken
down into local, systemic, psychologic or psychiatric,
and idiopathic causes. The most frequently associated
conditions are psychiatric (depression, anxiety, or
cancerphobia); xerostomia; nutritional deficiency;
allergic contact dermatitis; candidiasis; denturerelated pain; and parafunctional behavior. Multiple
different factors contributing to the oral pain are
common, and a systematic approach to the evaluation
is important.
Identification of correctable causes of BMS should
be emphasized and psychiatric causes should not be
invoked without thorough evaluation of the patient. A

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L.A. Drage, R.S. Rogers III / Dermatol Clin 21 (2003) 135145

directed history and careful oral examination must be

completed to exclude local diseases and identify clues
to potential causes. Assessment of medications, psychiatric history and background, and selected laboratory and patch tests may help identify the etiologies of
these symptoms.
Treatment should be tailored to each patient and
may best be managed in a multidisciplinary approach
with input from dermatologists, dentists, psychiatrists,
otorhinolaryngologists, and primary care providers. A
thoughtful and structured evaluation of the patient
with BMS has been associated with improvement in
about 70% of patients. The remaining patients may
benefit from empiric therapy with a chronic pain protocol and continued supportive interactions.

[14]

[15]

[16]

[17]
[18]

[19]

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