Med Oral Patol Oral Cir Bucal. 2010 Jul 1;15 (4):e562-8.

Stomatodynia

Journal section: Oral Medicine and Pathology

Publication Types: Review

doi:10.4317/medoral.15.e562

Burning mouth syndrome: Update

Pia Lpez-Jornet, Fabio Camacho-Alonso, Paz Andujar-Mateos, Mariano Snchez-Siles, Francisco GmezGarca

Department of Oral Medicine University of Murcia

Correspondence:
Clnica Odontolgica Universitaria. Medicina Bucal
Hospital Morales Meseguer
Avda. Marques de los Velez s/n
30008 Murcia (Spain)
[email protected]

Lpez-Jornet P, Camacho-Alonso F, Andujar-Mateos P, Snchez-Siles M,

Gmez- Garca F. Burning mouth syndrome: Update. Med Oral Patol Oral
Cir Bucal. 2010 Jul 1;15 (4):e562-8.
http://www.medicinaoral.com/medoralfree01/v15i4/medoralv15i4p562.pdf

Received: 21/08/2009
Accepted: 28/11/2009

Article Number: 3124

http://www.medicinaoral.com/
Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: [email protected]
Indexed in:
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Abstract

Burning mouth syndrome (BMS) refers to chronic orofacial pain, unaccompanied by mucosal lesions or other
evident clinical signs. It is observed principally in middle-aged patients and postmenopausal women. BMS is
characterized by an intense burning or stinging sensation, preferably on the tongue or in other areas of the oral
mucosa. It can be accompanied by other sensory disorders such as dry mouth or taste alterations. Probably of
multifactorial origin, and often idiopathic, with a still unknown etiopathogenesis in which local, systemic and
psychological factors are implicated. Currently there is no consensus on the diagnosis and classification of BMS.
This study reviews the literature on this syndrome, with special reference to the etiological factors that may be
involved and the clinical aspects they present. The diagnostic criteria that should be followed and the therapeutic
management are discussed with reference to the most recent studies.
Key words: Glossodynia, stomatodynia, etiopathogenesis, treatment, review.

Introduction

lateral borders), thus denominated glossodynia (painful tongue) and glossopyrosis (burning tongue) and
glossalgia; other terms used are stomatodynia, stomatopyrosis, oral dysesthesia and burning mouth syndrome.
The frequent association with other symptoms (xerostomia, taste alterations) and the complexity surrounding the condition of the patient means that some authors
prefer to use the expression burning mouth syndrome
(BMS) to refer to this entity. It is characterized by being continuous and spontaneous with an intense burning sensation reported by the patient as if the mouth or
tongue were scalded or burnt (7).
Various groups of investigators have attempted to pro-

Burning Mouth Syndrome (BMS), is condition characterized by a sensation described by the patient as stinging, burning that affects the oral mucosa, in the absence
of clinical or laboratory data to justify these symptoms.
It as a chronic orofacial pain, unaccompanied by mucosal lesions or other evident clinical signs upon examination (1-12). The International Association for the
study of Pain defines it as a pain of at least 4-6 months
duration located on the tongue or other mucosal membranes in the absence of clinical or laboratory findings.
It has been defined principally by the quality or location
of the pain. The most affected area is the tongue (tip and
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mary or essential/idiopathic BMS, in which the causes

cannot be identified, and secondary BMS, resulting
from local factors or systemic conditions. Thus, these
idiopathic and secondary criteria form two different
subgroups of the same pathology.
Danhauer et al. (12) examined 69 patients with BMS
(83% women) with a mean age of 62 years, and a mean
duration of pain of 2.45 years; the mean pain measured
on a visual analogue was 49 mm (on a scale of 0-100
mm). The investigators found no differences between
patients with primary of secondary BMS with respect
to age, duration or intensity of pain and psychological profile. Differences with respect to treatment were
found, secondary BMS improved with treatment, while
no positive results were found in the group with primary BMS.

vide an answer to the questions regarding this topic,

which is the subject of considerable controversy. The
multiplicity of factors related with this nosologic entity,
which in one form or another are involved in the appearance of the symptoms have made it currently one of the
most debated issues (4, 7-17).

Epidemiology

The true prevalence of BMS is difficult to establish due

to the lack of rigorous diagnostic criteria in many of
the published series that do not distinguish between
the symptom of oral burning and the syndrome itself,
including BMS as only a symptom of other diseases.
Thus, figures vary widely, with prevalence varying between 0.7 and 4.5% (6-11).
Bergdahl and Bergdahl (5) carried out a randomized
study in Sweden using a questionnaire on a group of
1427 (669 men and 758 women) aged between 20 and
69 years. All individuals who reported burning mouth
were examined, finding that 53 patients (3.7%) presented BMS, 11 men (1.6%) and 42 women (5.5%). In
the men, BMS was not found in the groups aged 2039 years, while the prevalence in the group aged 4049 years was 0.7%, increasing to 3.6% in the group of
60-69 year-olds. In the women, it did not appear in the
group 20-29 years of age, in the group 30-39 years the
prevalence was 0.6%, increasing to 12.2% in the strata
of 60-69 years. In general, the condition principally affects women, with a relationship of approximately 3:1,
these differences between gender may perhaps be explained by biological, psychological and sociocultural
factors, however such factors have not yet been defined.
This syndrome is rare in patients under 30 years, never
having been described in children or adolescents. No
studies exist in relation to any occupational, educational
or social grouping.

Etiopathogenesis

The various factors related with the etiopathogenesis of

this syndrome have been divided into local, systemic
and psychological. Frequently several factors coincide,
increasing the harmful effect on the mucosa, whether
perceptible or not by the observer (4-17).
Local factors
We should consider those factors which have in common a direct irritant effect on the oral mucosa, these
maybe either physical, chemical or biological (some
bacteria or fungi), and are able to set off the burning
symptoms (7) (Fig. 1).
A mechanical factor to consider is the use of poorlyfitting prostheses that produce microtrauma or local
erythema. These can also restrict the normal action of
the muscles of the tongue. Parafunctional habits such as
tongue thrust or certain tics, continual rubbing over
the teeth or prosthesis; buccal, labial, lingual biting, and
compulsive movements of the tongue etc. should be assessed. Local allergic reactions, due principally to high
levels of residual monomers; other allergens are nylon,
ascorbic acid, nicotinic acid esters, benzoic peroxide,
4-tolyl diethanolamine, N-dimethyl toluidine, nickel
sulfate, etc., not to mention certain additives. In fact,
some authors have reported allergic reactions, with positive epicutaneous tests in patients with BMS without
evident mucosal lesions who have recovered on eliminating contact with the allergen. It may be questionable
if these patients with symptoms of burning mouth and
clinically relevant positive epicutaneous tests should be
classified as BMS or as a subclinical contact dermatitis.
In any case, these findings are useful for the diagnosis
and treatment of the subgroup of patients with intermittent symptoms.
Oral infections produced by diverse microorganisms
have been associated with this syndrome. Infection by
Candida albicans has been considered one of the most
frequent factors in the production of BMS, although

Classification and Subtypes

Different classification types have been proposed based

on the daily fluctuations of the symptoms (7, 12-13).
a) Type 1: characterized by progressive pain, patients
wake up without pain, which then increases throughout
the day, affects approximately 35% of patients. This
type may be associated with systemic diseases, such as
nutritional deficiencies.
b) Type 2: the symptoms are constant throughout the
day and patients find it difficult to get to sleep, represents 55%. These patients usually present associated
psychological disorders.
c) Type 3: symptoms are intermittent, with atypical
location and pain. Constitutes 10% of patients. It seems
that contact with oral allergens could play an important
etiologic role in this group.
A more pragmatic approach is proposed by Scala et al.
(4), who organize BMS into two clinical forms, prie563

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Fig. 1. Most frequent etiopathogenic factors in burning mouth syndrome.

Systemic factors
Systemic factors implicated in BMS; many of these are
deficiencies, such as vitamin deficiencies (in particular
low levels of vitamin B12, and others such as vitamin
B6, folic acid and vitamin C), and anemias. Furthermore, some studies suggest that BMS is associated with
low serum levels of zinc. Hormonal changes (reduced
plasma estrogens), diabetes mellitus, thyroid dysfunction (hypothyroidism) and immunological diseases have
also been described. Many medications are intimately
related with burning mouth; among which are found antihistamines, neuroleptics, some antihypertensives, antiarrhythmics and benzodiazepines. Antihypertensives
are among the most frequently implicated medicines,
principally those that act on the renin-angiotensin system (captopril, enalapril and lisinopril).
Psychological factors
Studies exist that suggest that psychopathologic factors may play an important role in BMS and support the
multifactorial etiology, in which physical changes may
interact with psychological factors (1,7,14).
Many of these patients have symptoms of anxiety, depression and personality disorders, and it has been demonstrated that patients with burning mouth syndrome
have a greater tendency towards somatization and other
psychiatric symptoms.
Cancerphobia can be present in up to 20-30% of these
patients. A lower level of socialization and higher levels
of somatic anxiety have been observed, as well as muscular tension, a higher tendency to worry about health
and greater sadness. BMS is considered a chronic pain
disorder that adversely affects quality of life (8,15).

some authors question its importance. Other oral infections caused by bacteria such as Enterobacter, Klebsiella and S. Aureus have been found with high frequency
in patients with burning mouth. Helicobacter pylori has
also been isolated through oral mucosa biopsies and
molecular biology techniques in 86% of patients with
burning sensation and lingual hyperplasia and halitosis,
while it is detected in only 2.6% of the patients without
oral symptoms.
Xerostomia is a concomitant symptom in patients with
BMS, prevalence varying between 34 and 39% (7,8),
while Grushka et al. (13) find that this is equal to or
greater than 60%. In contrast, some authors consider
that the composition of the saliva could play a major
role in the pathogenesis of BMS, indicating the importance of the identification and characterization of low
molecular weight proteins. A significant increase has
been found in levels of sodium, total protein, lysozyme,
amylase and immunoglobulins in patients with BMS
when compared with a control group; however, other
studies do not support these findings.
In recent years investigations have been carried out into
the alterations in taste perception and tolerance to pain
as a possible cause of the burning sensation. Taste is
located fundamentally on the fungiform papillae, finding in certain patients with burning mouth, above all
women, an elevated number of said papillae, these individuals being denominated supertasters. This theory
proposes that certain people, labeled as supertasters due
to the high density of fungiform papillae present on the
anterior part of the tongue, are more susceptible to developing burning mouth pain. Supertasters are principally women, and are able to perceive the bitter taste of
a substance called PROP (6-n-propiltiouracilo) (4-8).

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Pathogenesis

tions are the oral mucosa, floor of the mouth, soft and
hard palate, and oropharynx. The location of the pain
does not seem to affect the course of the disease or the
response to treatment. In more than half the patients the
symptoms appear spontaneously with no identifiable
trigger factors. Approximately 17% to 33% of patients
attribute the initiation of the symptoms to a previous
condition, such as infection of the upper respiratory airway, dental procedure, or the use of medications. Other
patients relate the appearance of symptoms directly
with stress (7,9).
The oral burning sensation usually increases progressively during the day, reaching a maximum intensity at
the end of the afternoon / early evening, pain being absent during the night in the majority of patients. Patients
do not normally awaken during the night, but do find
it difficult to get to sleep. These patients often present
mood changes, including irritability, anxiety and depression. The majority of studies describe the coexistence of oral burning with other symptoms, such as dry
mouth, dysgeusias, metallic taste, bitter taste or combinations thereof, and/or changes in intensity of taste
perception. In addition, dysphagia and atypical facial
or dental pain may appear. Experience shows that what
the patient defines as oral burning can be identified
by diverse sensations. Although the burning or stinging
sensation can exist alone, other disorders of oral perception may appear, either alternatively or simultaneously, such as pruritus, roughness, sticky sensation,
dysphagia, stinging, burning, irritation of the lingual
papillae, metallic taste and other dysgeusias, sensation
of bad breath, intolerance to prostheses that would include an infinity of subjective perceptions difficult to
describe (Table 1).

An increasing number of investigations are being made

into a possible underlying neurological disorder. Neurophysiological studies suggest that the central and/or
peripheral nervous system are implicated in the pain of
BMS (4,8,9,13).
The presence of taste anomalies, and the fact that many
with BMS are supertasters, suggests an interaction between the taste and nociceptive mechanisms that would
connect the sense of taste and oral pain in the central
nervous system, and indicates that BMS implies pathoogies of the central and peripheral nervous system induced by an alteration in the taste system at the level of
the chorda tympani and/or the glossopharyngeal nerve.
This causes a loss of central inhibition and consequently hyperactivity of the trigeminal nociceptive pathway,
which in turn carries a more intense response to oral
irritants and eventually leads to the appearance of phantom oral pain as a result of this alteration in the taste
system.
Findings in patients with BMS (8):
1. Reduction in thermal sensation and low scores for
tonic painful stimuli in the oral cavity, similar to that
observed in areas with poli or mononeuropathies.
2. Reduction in tolerance to pain caused by heat at the
tip of the tongue in 85% of patients with BMS.
3. Anomalies in the blink reflex in patients with BMS,
possibly indicating a subclinical trigeminal neuropathy.
4. Alterations in saliva composition with respect to a
control group, this directly influences the perception of
flavours.
A lower density of epithelial and subpapillary nerve fibres has been found in biopsies of the tongue in patients
with BMS with respect to controls, reflecting axonal degeneration, BMS being caused by a sensorial neuropathy of the small trigeminal fibres.
Central neuropathic mechanisms have been demonstrated following thermal stimulation of the trigeminal
nerve in patients with BMS. Patients with BMS show
patterns of cerebral activity similar to those that appear
in other neuropathic pain disorders, suggesting that the
cerebral hypoactivity could be an important element in
the pathogenesis of BMS.

Table 1. Clinical factors Burning Mouth Syndrome (7,10).

Pain

Clinical Aspects

The symptoms have been described as continuous

chronic discomfort, with spontaneous acute periods,
with no clearly identifiable precipitating factor, except
stress and other psychological factors. The pain is primarily bilateral and symmetrical on the anterior twothirds of the tongue (71% - 78%), followed by the dorsum and lateral borders of the tongue, the anterior part
of the hard palate, the labial mucosa and gingiva, often
appearing at several locations. Other, less frequent locae565

Description

Burning

Intensity

Variable, with peaks of intensity

Pattern

Continuous, no paroxysm

Location

Independent of nerve pathway. Frequently bilateral and symmetric

Pain during sleep

Infrequent

Other symptoms

Dysgeusia and xerostomia

Signs /symptoms

Absence of evident clinical signs

Sensory / Chemosensory disorders
Psychological profile may be implicated

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Stomatodynia

The profile of a patient with burning mouth syndrome is

that of a woman in late middle age or advancing years,
postmenopausal in the majority of cases, presenting
emotional disorders, or at least having a strong psychological component in their symptoms. Apart from their
oral sensations, patients can present a series of concomitant symptoms such as frequent headaches, weakness,
lower capacity for concentration, insomnia, and almost
always manifest non-specific health problems (7,8).
Over the natural course of burning mouth syndrome,
from among the scant information available, the symptoms occur continuously for months or years with no
periods of suspension or remission, in some studies over
a mean of around two to three years. Some studies have
reported complete or partial remission (with or without intervention) in approximately 50% of patients and
complete spontaneous remission in approximately 20%
of the patients within six to seven years of the start of
the symptoms. The remission of the symptoms, whether
partial or complete, is often characterized by a change
in the pattern of the pain from a constant to sporadic
nature. In contrast, Sardella et al. (17), find complete
spontaneous remission in only 3% of the patients after
five years of follow-up.

sible oral lesions, and is therefore a diagnosis of exclusion of other possible diseases. Other systemic diseases
that can manifest symptoms similar to BMS should be
considered: Sjgrens syndrome, diabetes, candidiasis,
deficiencies of iron, folate, zinc or group B. vitamins. It
is essential to obtain the medical, dental and psychological history of the patients; also to quantify the pain on
a visual analogue scale and to note the symptoms, duration, location and chronology and temporal relationship
(burning/pain), if accompanied by xerostomia and taste
alteration, if alleviated or aggravated by foods, and any
precipitating factors. Special attention should be paid
to the use of medication that can produce xerostomia,
the presence of parafunctional habits, and the clinical
history should provide information on prior or current
psychological and psychosocial stress factors (4,7,16).
An oral and extraoral examination should be made to
discard lesions such as erythema, erosions, depapillated
tongue. The oral cavity should not present any anomalies such as inflammation or atrophy of the mucosa in
order to establish a diagnosis of BMS.
Possible dental problems should be ruled out, reviewing
any prostheses and their occlusion, any probable oral
galvanism and volumetric tests of saliva flow should be
made (Table 2).
Complimentary examinations include analytical studies,
hemogram, glucemia, iron, serumal ferritin, folates, vitamin B12, zinc, serumal antibodies in Sjgrens syndrome and against H. pylori; culture for the detection of
candida, taken from the oral mucosa and palate.

Diagnosis

It is important to emphasize that a diagnosis of BMS

should only be established after all other possible causes have been discarded, there are no specific diagnostic
tests, thus, the diagnosis is made in the absence of vi-

Table 2. Diagnosis and treatment of burning mouth syndrome (4,7,18-20).

Oral
examination

Salivary
Parameters

Hematologic
Parameters

Nutritional
Parameters

Hormonal
Parameters

Medication

ParafuncContact
tional Habits Allergies

Psychological Psychosocial evaluation

Treatment of secondary forms: monitor infection candida albicans, manage medication (antihypertensives renin-angiotensin
system), treat xerostomia, allergies, nutritional deficiencies, endocrine disorders
Topical treatment
Clonazepam
Lidocaine
Capsaicin
Benzydamine hydrochlorate at 0.15%
Systemic treatment:
Nortriptyline
Amitriptyline
Paroxetine
Clonazepam
Gabapentin
Capsaicin
Alfa lipoic acid
Cognitive therapy

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Epicutaneous tests are made on patients presenting intermittent symptoms (metals and other allergens used in
dental prostheses, foods, additives).
The diagnosis is usually late (mean 34 months), often
due to a lack of understanding of the nature of this entity, in addition to the patients taking up many health
resources, since they frequently consult various specialists. It is important to highlight that the diagnosis
of BMS should be established only when all other possible causes have been discounted, being a diagnosis by
elimination.

sing to a maximum of 3 mg/day) has also been evaluated

with variable results, or by topical application (0.5 mg to
1 mg two or three times a day) with better results.
Topical capsaicin has also been applied in BMS, used as a
desensitizing agent in patients with BMS, but it is usually
unaccepted by patients due to its taste. Systemic capsaicin
has been used (0.25%, three times a day, for 30 days) with
a significant reduction in pain intensity compared with
a placebo group. However, its use is not recommended
for extended treatment, since 32% of patients experience
gastric pain after four weeks of treatment.
Trials have also been made on rinsing with benzydamine hydrochloride at 0.15%, having an analgesic and
anti-inflammatory effect, but finding no significant efficacy, as also found with local anesthetic mouthwash
such as lidocaine, which have not been demonstrated as
an effective treatment due to the short duration of the
analgesic effect.
Hormone replacement therapy (HRT) has also been
used, finding that women with symptoms of burning
and estrogen receptors in the oral mucosa respond to
hormone replacement, while this does not occur in
patients without these receptors; however it cannot be
guaranteed that HRT could be an effective treatment for
the oral symptomatology.
Alpha lipoic acid is a powerful neuroprotector that
prevents damage to nerve cells by free radicals, it regenerates other antioxidants such as vitamins C and E,
increasing levels of intracellular glutathione. Thanks
to its antioxidant properties it significantly reduces the
symptoms in the majority of patients with idiopathic
dysgeusia and reduces the symptoms of peripheral neuropathy in diabetics. Several studies suggest that alpha
lipoic acid can improve the symptoms in BMS, showing that at two months, 97% of the patients treated with
alpha lipoic acid (200 mg, three times a day) experienced an improvement in the symptoms. This improvement is maintained during the first year in 70% of the
patients. In other studies, the combination of psychotherapy (2 one-hour sessions weekly for two months)
and alpha lipoic acid (600 mg/day for two months), was
significantly more beneficial than psychoanalysis alone
or alpha lipoic acid alone. The results suggest that alpha lipoic acid could complement psychotherapy and be
an acceptable alternative to psychoactive medication.
However, in studies that compare with a placebo the efficacy is limited (20).
The complex and multifactorial etiology of BMS necessitates collaboration between different specialists
for the management of these patients. In addition, it is
necessary to carry out trials with a strict agreement
on protocols (inclusion/exclusion of patients should be
based on clear diagnostic criteria, that exclude those
cases with a medical or dental cause, as has been suggested in the literature).

Treatment

Treatment should be adapted to each patient, where a

multidisciplinary approach is recommended. Initially
the clinician should determine whether the symptom
is primary (essential or idiopathic) or secondary BMS,
in which the symptoms are attributable to other causes,
candidiasis, vitamin deficiencies, galvanic allergies;
parafunctional habits should be examined; substitution
therapies should be established (in cases of vitamin and
mineral deficiencies). Many of these patients take medication (principally antihypertensives which act on the
renin-angiotensin system), which should be monitored.
It is essential to study and understand the physiopathologic mechanisms of stomatodynia with the aim of selecting treatment. The wide range of treatments used
reflects the current situation, the majority of treatments
are directed towards suspected causal factors, but these
are often unsupported by controlled studies (7,8,10, 1820).
The most-used medications to treat this syndrome are
antidepressants, antipsychotics, antiepileptics, analgesics and oral mucosa protectors. The tricyclic antidepressants such as amitriptyline and nortriptyline at low
doses are useful in BMS, although some authors contraindicate their use in patients with dry mouth as they
can worsen the condition.
Studies have been made to evaluate the efficacy and tolerance of amisulpiride (50 mg/day) and selective serotonin inhibitors: paroxetine (20 mg/day) and sertraline
(50 mg/day) in the treatment of BMS, over eight weeks,
with a reasonably high efficacy (around 70%). However,
the effect of amisulpiride manifests early, after one week
of treatment. No serious adverse effects are referred in
any of the three groups. Serotonin reuptake inhibitors
are effective, above all with an associated depression,
being better tolerated for the absence of anti-cholinergic
effects, particularly in dry mouth.
According to the results obtained with gabapentin, it
seems to have little or no effect in patients with BMS.
The medication was administered at an initial dose of
300 mg/day, increasing by 300 mg/day every two days
to a maximum of 2,400 mg/day.
The efficacy of oral clonazepam (0.25 mg/day increae567

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Stomatodynia

It is important to inform patients about the nature of

the disease so they can understand their pathology. Currently, besides the information provided by the clinician, who continues to be the principal source on health
matters, Internet has become an important source of information, with accredited webpages containing information directed towards the patient with burning mouth
syndrome.

20. Lpez-Jornet P, Camacho-Alonso F, Leon-Espinosa S. Efficacy

of alpha lipoic acid in burning mouth syndrome: a randomized, placebo-treatment study. J Oral Rehabil. 2009;36:52-7.

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