Burning Mouth Syndrome (BMS) is a chronic condition that causes oral burning for more than two hours daily over three months without any evident clinical changes or lesions in the oral mucosa (Figure 1). This burning sensation is usually associated with dry mouth and taste disturbances [1]. Nutritional deficiencies, including vitamins B1, B2, B6, and B12, as well as folic acid and zinc, have been linked to BMS. [2]
Figure 1. 52-year-old female patient diagnosed with Burning Mouth Syndrome. No evident clinical signs nor lesions in the oral mucosa attributed to the burning sensation on the tongue.
BMS Classification: There are several classifications of BMS, for instance, according to the location, possible etiology, and symptoms presented during the day.
- Based on location:
Typical BMS: affecting the dorsal tongue
Atypical BMS: affecting another site of the oral cavity than the tongue
- Based on Etiology:
Primary BMS: Idiopathic etiology, no known cause
Secondary BMS: associated with a cause as vitamin deficiency,
- Based on symptoms presentation during the day
Type 1:
Typically, it has no symptoms on waking and progressively worsens throughout the day, with variable nighttime symptoms. It may be related to nutritional deficiency or endocrine conditions such as diabetes mellitus.
Type 2:
It is associated with chronic anxiety and displays symptoms throughout the day.
Type 3:
It displays intermittent daytime symptoms and may have periods without any symptoms. Food allergy is thought to be a potential underlying mechanism. [3]
The main symptoms:
1. Pain in the oral mucosa: burning, scalding, tingling, numb feeling
2. Dysgeusia: Altered taste or taste disturbance
3. Xerostomia [4]: Dry mouth sensation. Subjective feeling report by the patient
Treatment options:
BMS is not a well-understood pain condition that most probably presents elements of neuropathy involving peripheral and central components. Therefore, the management tries to address these two components, which can combined or include the following:
- Cognitive behavioral treatment
- Topical medications (e.g., benzodiazepine, anticonvulsants, anesthetics, among others)
- Systemic medications (e.g., Tricyclic antidepressants, antiepileptics benzodiazepines, among others)
- Over the counter vitamins and supplements
Over-the-counter options to consider for BMS management
- Topical capsaicin rinse
Several studies have reported that topical capsaicin is an analgesic for treating BMS with positive results. BMS appears to be associated with increased levels of nerve growth factor (NGF) in the nerve fibers and increased expression of cation channel vanilloid subfamily member 1 (TRPV1) (also known as the capsaicin receptor) fibers in the tongue papillae. Capsaicin provides analgesic and anti-inflammatory effects on sensory neurons, increases saliva production, and provides anti-inflammatory properties in the salivary glands.
A study conducted by Viktors Jankovskis and Guntars Selga determined whether vitamin B complex and zinc supplements or 0.02% topical capsaicin rinse can help alleviate BMS pain/burning levels. The result showed that vitamin B and zinc supplement therapy and topical capsaicin rinse therapy can be an effective way to decrease pain/burning sensation levels in patients with BMS with few side-effects. [5]
This study has also reported that patients with BMS may have decreased levels of vitamins B1 (thiamine), B2 (riboflavin), B6 (pyridoxine), B12 (cobalamin) which can be considered as a cause of neurological disorders such as neuropathy. [5]
- Vitamin B12
Vitamin B12 plays a crucial role in oral health, and its deficiency can lead to a spectrum of oral manifestations. These include glossitis, glossodynia, recurrent ulcers, cheilitis, dysgeusia, lingual paresthesia, burning sensations, and pruritus.
Pernicious anemia (PA) is a primary cause, accounting for 20 %–50 % of documented cases of vitamin b12 deficiency in adults.
The deficiency of vitamin B12 finally resulted in high blood homocysteine levels in BMS patients. Burning sensation, dry mouth, and tongue numbness were these patients’ three most common symptoms. [6]
Vitamin or mineral deficiencies may have a role in BMS, but data regarding the prevalence and relevance of hematinic deficiencies are conflicting. It is reasonable to screen for fasting blood glucose, vitamin D (D2 and D3), vitamin B6, zinc, vitamin B1, and TSH. Deficiencies of vitamin B12 in patients with BMS and consider supplement therapy. [7]
- Zinc
The essential trace element zinc (Zn) has many physiologic roles, required for the immune system’s growth and functioning. It can be postulated that zinc deficiency and lower serum zinc level are involved in the pathogenesis of oral mucosal diseases. [8]
A recent study by Cho (4) showed that in an animal study reported that zinc deficiency can be a potential causal factor for BMS, however it has not been found to play a definitive role in the etiology of BMS. A study reported that Zinc-replacement therapy was effective in reducing pain at 6 months in patients with BMS and zinc deficiency. Cho reported that zinc replacement therapy had a greater effect than other symptomatic treatments in patients with zinc deficiency. [3, 5]
- Alpha-lipoic acid (ALA)
Early studies suggested that ALA might help with BMS, and one meta-analysis found that ALA had favorable outcomes for treating diabetic neuropathy, which has similar causes to BMS.
In one double-blinded controlled study of ALA therapy for BMS, there was a significant improvement in pain, compared with placebo, with the majority of test subjects showing some improvement after 2 months, and more than 70% of the subjects maintained this improvement at 1 year.
Alpha lipoic acid (ALA) is a potent antioxidant that is produced naturally in the body. It can also be found in some natural foods, such as potatoes, tomatoes and spinach. ALA’s main contribution is to slow down cutaneous aging. [9]
Alpha-lipoic acid (ALA) is a dietary supplement designated as an antioxidant that does not require prescription. ALA contains sulfur and is produced in plants, animals, and humans. It acts as a coenzyme in the Krebs cycle and as a cofactor in energy production in the cell. Glutamate toxicity is a major contributor to pathological death in the nervous system. ALA exerts its effect on the BMS by scavenging free radicals and may play a role in nerve repair. [9]
- Iron Deficiency
Patients with iron defeincy may present with burning mouth syndrome, chronic glossitis, and pale mucosal membranes.
Patients with papillary atrophy more frequently have iron deficiency (26.7%) than vitamin B12 deficiency (7.4%)
Both dysphagia and burning mouth should bring attention to possible iron deficiency and other nutritional deficiencies. Dysphagia and burning mouth resolve after iron supplementation in the majority of patients. [10]
Conclusion:
Burning mouth syndrome is a very challenging condition that brings patients to dental medicine clinics. It represents various symptoms ranging from burning to dry mouth and taste changes. The exact etiology of a burning mouth cannot be frequently identified, but the cause may be determined in many patients. Nutrition deficiencies and anemia represent one of the possible causes or aggravated factors of a burning mouth.
Combined supplements and vitamin treatments can significantly reduce the symptoms of patients with BMS. However, it is highly recommended that patients follow their providers’ indications and do not attempt to use these supplements without supervision about the doses and combination with other additional treatments, including topical and systemic management approaches for this condition.
References:
- Corsalini M, Di Venere D, Pettini F, Lauritano D, Petruzzi M. Temporomandibular disorders in burning mouth syndrome patients: an observational study. Int J Med Sci. 2013 Oct 29;10(12):1784-9. doi: 10.7150/ijms.6327. PMID: 24273452; PMCID: PMC3837237.
- Jankovskis V, Selga G. Vitamin B and Zinc Supplements and Capsaicin Oral Rinse Treatment Options for Burning Mouth Syndrome. Medicina (Kaunas). 2021 Apr 17;57(4):391. doi: 10.3390/medicina57040391. PMID: 33920654; PMCID: PMC8072709.
- Kim MJ, Kho HS. Understanding of Burning Mouth Syndrome Based on Psychological Aspects. Chin J Dent Res. 2018;21(1):9-19. doi: 10.3290/j.cjdr.a39914. PMID: 29507908.
- Coculescu EC, Radu A, Coculescu BI. Burning mouth syndrome: a review on diagnosis and treatment. J Med Life. 2014 Oct-Dec;7(4):512-5. PMID: 25713611; PMCID: PMC4316128.
- Cho GS, Han MW, Lee B, Roh JL, Choi SH, Cho KJ, Nam SY, Kim SY. Zinc deficiency may be a cause of burning mouth syndrome as zinc replacement therapy has therapeutic effects. J Oral Pathol Med. 2010 Oct;39(9):722-7. doi: 10.1111/j.1600-0714.2010.00914.x. Epub 2010 Jul 2. PMID: 20618611.
- Lin HP, Wang YP, Chen HM, Kuo YS, Lang MJ, Sun A. Significant association of hematinic deficiencies and high blood homocysteine levels with burning mouth syndrome. J Formos Med Assoc. 2013 Jun;112(6):319-25. doi: 10.1016/j.jfma.2012.02.022. Epub 2012 Jun 12. PMID: 23787008.
- Morr Verenzuela CS, Davis MDP, Bruce AJ, Torgerson RR. Burning mouth syndrome: results of screening tests for vitamin and mineral deficiencies, thyroid hormone, and glucose levels-experience at Mayo Clinic over a decade. Int J Dermatol. 2017 Sep;56(9):952-956. doi: 10.1111/ijd.13634. Epub 2017 Apr 23. PMID: 28436021.
- Bhoopathi V, Mascarenhas AK. Zinc-replacement therapy may not reduce oral pain in patients with zinc-deficient burning mouth syndrome (BMS). J Evid Based Dent Pract. 2011 Dec;11(4):189-90. doi: 10.1016/j.jebdp.2011.09.016. PMID: 22078830.
- Christy J, Noorani S, Sy F, Al-Eryani K, Enciso R. Efficacy of alpha-lipoic acid in patients with burning mouth syndrome compared to that of placebo or other interventions: a systematic review with meta-analyses. J Dent Anesth Pain Med. 2022 Oct;22(5):323-338. doi: 10.17245/jdapm.2022.22.5.323. Epub 2022 Sep 27. PMID: 36246031; PMCID: PMC9536947.
- Radochová V, Slezák R, Radocha J. Iron Deficiency as Cause of Dysphagia and Burning Mouth (Plummer-Vinson or Kelly-Patterson Syndrome): a Case Report. Acta Medica (Hradec Kralove). 2020;63(3):128-132. doi: 10.14712/18059694.2020.30. PMID: 33002400.
