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Burning Mouth Syndrome
Systemic Factors Causing Reversible Intraoral Burning Sensations

Course Author(s): Nancy W. Burkhart, BSDH, MEd, EdD, AFAAOM; Terry Rees, DDS, MSD

Systemic Factors Causing Reversible Intraoral Burning Sensations

Several systemic disorders have been associated with causing secondary oral burning. These may include neuropathy of undiagnosed, poorly controlled or even well-controlled diabetic patients. Burning discomfort caused by peripheral neuropathy (nerve damage) can affect any peripheral nerve including those that innervate the tongue. Neuropathy can also be initiated by chronic liver or kidney diseases, by HIV infection, by oral candidiasis, by vitamin B deficiency and some other systemic diseases. To date, however, only diabetic neuropathy has been reported as a possibly controllable cause of tongue burning sensations.7

Hypothyroidism has also been associated with burning in the oral cavity, especially the tongue. Although the cause of this association is unclear, the diagnosis and treatment of this endocrine disorder may reverse the burning discomfort. One oral side effect of hypothyroidism is tongue enlargement, and it is theoretically possible the enlargement increases tongue irritation from excessive contact with the teeth and possible tongue thrusting or bruxing.58 Gastroesophageal reflux disease (GERD) is sometimes associated with oral burning probably due to regurgitation of stomach acids into the oral cavity. This too is reversible with successful treatment.38,62

Burning mouth is more common in peri-menopausal or post-menopausal women suggesting a hormonal deficiency as an etiologic factor. However, ironically although hormonal supplementation may markedly relieve menopausal symptoms, it does not always alleviate all burning discomfort.53

Other associated systemic conditions may include, autoimmune connective tissue diseases, trigeminal neuralgia, multiple sclerosis and Parkinson’s disease.62,65 Several case reports have described oral burning sensations in drugs falling into the categories of antiretrovirals, antiseizure agents, antidepressants and several antihypertensives. The antiseizure drug clonazepam and the antidepressant drugs fluoxetine, sertraline and venlafaxine are of special interest since these two drug groups have paradoxically been used in treatment of BMS. Clonazepam is reported to be one of the most effective agents in controlling BMS. Among the antihypertensive drugs, angiotensin converting enzyme inhibitors appear most likely to induce burning mouth.54 Other reversible systemic conditions possibly associated with oral burning include nutritional deficiency (vitamin B12, folic acid, zinc) and iron deficiency anemia.60,62

Table 1. Primary and Secondary BMS.56
Primary:
  • Considered a diagnosis of exclusion of other entities.
  • Characterized by burning sensations of the oral and perioral tissues.
  • Absence of relevant clinical or psychological abnormalities.
  • A neuropathological cause is likely.

Secondary:
  • Characterized by clinical abnormalities such as mechanical and chemical irritants.
  • Allergic contact-environmental, foods and oral products.
  • Possible parafunctional habits such as bruxism, clenching and tongue placement causing a frictional reaction.
  • Fungal, bacterial or viral infections such as Candida and Helicobacter pylori infection on the tongue surface.
  • Systemic problems such as mucosal disease states, e.g., lichen planus and stomatitis.
  • Candida infection.
  • Psychological conditions.
  • Hormonal imbalance.
  • Vitamin B deficiency, folate, iron or zinc deficiency.
Table 2. Possible Contributing Factors Associated with Oral Burning.
  • Tongue thrusting.
  • Bruxism and clenching.
  • Endocrine disorders including diabetes and thyroid disease.
  • Allergies-environmental and dental/oral allergies.
  • Ill-fitting dentures and appliances-mechanical irritation.
  • Intolerance or allergy to denture materials or materials used in restorative dentistry causing tissue irritation.
  • Mucosal diseases such as lichen planus, pemphigus vulgaris, benign mucous membrane pemphigoid, etc.
  • Supertasters are often prone to BMS as well as those individuals with taste perception disorders.
  • Xerostomia (may be caused by medications or actual disease states such as Sjogren’s disease).
  • Certain medications, e.g., diuretics, angiotensin converting enzyme inhibitors.
  • Deficiency of vitamins B1, 2, 6 or 12, folic acid or zinc.
  • Iron deficiency anemia.
  • Fungal (Candidiasis), bacterial and viral infections.
  • Migratory glossitis.
  • Systemic diseases: gastroesophageal reflux (GERD), diabetes, hypothyroidism.7
  • Smoking cessation (a rise in the incidence of BMS has been noted upon quitting).
  • Psychological factors: cancer phobia, severe stress, obsessive compulsive disorder (OCD), general anxiety and depression.
Table 3. Therapy.5,9
Non-pharmacologic:
  • Reduction of parafunctional issues.
  • Use of appliances-mouth guards.
  • Minimize flavoring agents.
  • Stress management, yoga, tai chi, psychotherapy, exercise, acupuncture and biofeedback.

Topical approaches:
  • Capsaicin (Capsium frutescens L).
  • Clonazepam.
  • Lidocaine.
  • Benzydamine hydrochlorate 0.15% (used as a mouthrinse).
  • Aloe vera used in conjunction with a tongue protector.
  • Increase saliva flow, e.g., sugarless gum, sugarless lemon drops.
    • Anti-xerostomic mouthrinses.
  • Prescriptions such as cevimaline or pilocarpine.
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