Treatment and Patient Education Protocol

The literature currently available suggests removal of any local contributing factors as the first step in treating patients with BMS. These considerations may be mechanical irritation, galvanic current, infections, oral products, highly flavored dental products or spicy foods that burn. And adding to the mixture of problems, dryness is a commonly observed complaint and can involve current medications the patient is using. All these factors may be contributing to perceived dryness and need to be assessed. Grushka, et al. 2002 state that BMS is often not a sole symptom, but is frequently associated with two other complaints - dry mouth and altered taste.43

Recommending dental products that have low additives and minimal flavoring agents without whitening agents or anti-calculus ingredients is optimal since these patients may be reacting to some of the additives that may make the condition much worse. Flavoring agents such as cinnamic aldehyde have been found to cause reactions for many patients with mucosal diseases.12 Other products may include mints, gum or other breath aids.25 Problems related to bruxing should be managed with acrylic occlusal bite guards, while discomfort associated with a tongue thrust or tongue rubbing habit often benefits from fabrication of soft, clear, 1 or 2mm thick full arch protective appliances that extend into the vestibule, palate and to the floor of the mouth to assist in preventing the patient from rubbing their soft tissues against teeth.25

Many patients with BMS report sleep disturbances because of the pain and burning sensations. Sleep is extremely important in total body health, and when sound sleep is experienced, many patients notice an improvement in their overall well-being, pain or discomfort.

Some medications that are used to treat anxiety such as the tricyclic antidepressants also promote sound sleep. When the patient is rested, the body may respond to symptoms in a much stronger and healthier way. These medications have seen favorable results in patients with BMS but again, many patients do not like the way certain medications make them feel and may fail to use them consistently. The medications help to reduce the activity of nerve fibers that are believed to be involved in the pain of BMS. Clonazepam, in doses of 0.25-1.0mg. once or twice daily acts as a tranquilizer and produces muscular relaxation and slight inhibition of the central nervous system.33 Amitriptyline, a tricyclic antidepressant, may sooth neural inflammation when used at a dosage of 10-40mg daily. The side effect of grogginess with these medications has been a complaint of many patients. Savage suggests using the lowest dose possible for the shortest amount of time.34 Some selective serotonin inhibitors appear to provide good results with some patients. Experts in the treatment of BMS may use various treatment modalities or combinations in order to find one that will assist with the individual patient.

Apha-lipoic acid has been used in trials with good results.30 Fermiano and Scully observed improvement in patients, but other studies have not seen any significance using alpha-lipoic acid.6,13,30 Alpha-lipoic acid may act as a neuro-protective agent and assist with repair of neural damage. A combination of approaches is often the best course of action. Zinc, vitamin therapy and hormonal replacement are sometimes used with success depending upon the needs of the patient.38 Complete blood analyses to determine any vitamin deficiency is necessary, and blood analysis is crucial to rule out diabetes, anemia and other disorders.30

Ironically, most medicaments that are beneficial in managing BMS may cause increased oral dryness which may sometimes interfere with patient acceptance. Whenever oral dryness is a component of the patient’s condition, efforts should be made to increase salivary flow. This can be improved with anti-xerostomic mouthrinses and gels, by chewing sugarless gum or using sugar free lemon flavored mints in small quantity. Two drugs, cevimaline and pilocarpine, can be prescribed in an effort to stimulate the patient's basic salivary gland output. However, due to the medical maladies of many BMS patients the drugs may be contraindicated. Medical consultation may be advised.

See Table 4 for a listing of drugs often used in BMS treatment.

Table 4. Commonly used therapy for primary (established) BMS.47,59
  • Antidepressants
  • Anticonvulsants
  • Antidepressants
  • Analgesics
  • Alphalipoic acid
  • Benzodiazepines
  • Hormone replacement therapy
  • Topical or systemic capsaicin

In 2012 de Moraes et al provided an evidence based review of published randomized clinical trials (RTC) regarding therapy for BMS.47 They found 12 RTC that met the Cochran Reviewers Guidelines criteria for critical analysis. In these studies, BMS patients were treated with systemic alpha-lipoic acid (8 groups), while 1 group was treated with alpha-lipoic acid and gabapentin in combination. Three groups were treated with capsaicin, 1 systemically and 2 topically applied. One group was treated with gabapentin while, as previously described, 1 group received gabapentin combined with alpha-lipoic acid. One group each used topical Benzydamne, Trazadne, systemic Bethanecol, lysozyme-lactoperoxidase oral solution (naturally occurring antibiotics in saliva) and Hipericin (St John’s Wort). Statically significant improvement were reported with topical clonazepam, systemic alpha-lipoic acid and systemic and topical capsaicin. However, all RTCs evaluated were flawed in one way or another. To date, no definitive cure for BMS has been found but some agents may offer improvement in symptoms and quality of life.

Non-pharmacologic approaches such as reducing parafunctional issues may be used with appliances such as mouth guards. Oral care products that minimize flavoring agents, alcohol-free mouth rinses and contact allergy elimination may produce good results. Sugar-free candies or gum, sialagogues, non-caffeinated beverages have been suggested to stimulate the saliva flow and decrease the dryness. When used alone or in combination with systemic medications, other adjunct therapies with favorable results are stress management, yoga, tai chi, psychotherapy, moderate exercise and biofeedback. Cognitive behavioral therapy has been used with good results to decrease pain intensity.

Acupuncture is cited as obtaining good results in a group of patients by altering the microcirculation, resulting in a significant variation of the vascular pattern. Scardina, et al. studied a group of patients and conducted an in vivo study using video capillaroscopy over a six-month period to document the vascular changes in 30 patients. The burning sensation reduction benefits lasted for 18 months. Follow up and further research is needed to evaluate whether there was a psychological component from just administering the acupuncture or whether there is a reduction in pro-inflammatory metabolites.35

Topical approaches such as capsaicin (Capsicum frutescens L) have shown usefulness with some patients; although the capsaicin is very strong and not tolerated by many patients. Using lidocaine initially and then applying the capsaicin to diminish the initial pain of the product have also lessened local pain.30 Capsaicin has also been used systemically, but with long-term use patients reported gastric pain. Clonazepam used topically reduces burning in some patients, lidocaine and benzydamine hydrochlorate 0.15% used as a mouth rinse have produced favorable results.38 Aloe vera has been used in the treatment of BMS in conjunction with the use of a tongue protector with favorable results in reducing pain and burning tongue, but further study is needed.26

Medicaments that are beneficial in managing BMS may cause increased oral dryness which may sometimes interfere with patient acceptance.

Whenever oral dryness is a component of the patient’s condition, efforts should be made to increase salivary flow if possible. This can be improved with anti-xerostomic mouthrinses and gels, by chewing sugarless gum or using sugar free lemon flavored mints in small quantity. Two drugs, cevimeline and pilocarpine, can be prescribed in an effort to stimulate the patient’s salivary gland output.

A few relatively recent studies have indicated that low level laser therapy may sometimes be of benefit for patients afflicted with BMS. However, at present there does not appear to be enough data to validate the usefulness of this therapeutic approach.68-70