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ArjaKullaa

Burning Mouth and Glossalgia

Essentials

  • Local aetiology is determined by careful inspection of the oral mucosa, tongue and teeth.
  • Underlying systemic diseases are diagnosed (vitamin B12 deficiency, diabetes, Sjögren's syndrome).
  • Dryness of the mouth is identified (causes include pharmaceuticals, such as anticholinergics and tricyclic antidepressants, and Sjögren's syndrome).
  • Burning mouth often has a psychiatric cause that should be treated.

Epidemiology

  • Burning mouth usually originates from areas where the mucosa is mobile, such as the buccal mucosa and tongue. In addition, there may be taste disturbances.
  • Mouth symptoms are more common among middle-aged women than among other people.
  • Burning mouth mostly occurs in association with clinically evident lesions. Stomatitis caused by dentures is the most common lesion of the oral mucosa. Up to every second person with dentures may have oral inflammation.

Aetiology

  • A specific cause of burning mouth is not always found, and the problem can be very complex. Both local and systemic factors may be involved.

Local causes

  • Ulcers (e.g. aphthous stomatitis)
  • Dental calculus, carious teeth
  • Inflammation caused by dentures or other factors (e.g. yeasts)
  • Smoking, use of alcohol
  • Dietary habits: very hot, strongly spiced foods
  • Continual use of mouth rinses
  • Dry mouth (mouth breathing, hyposalivation-inducing drugs, sometimes pregnancy, menopause)
  • Malocclusion
  • Mouth tumours
  • Sometimes even lichenoid oral lesions, leukoplakia, erythroplakia and specific glossal lesions such as fissured tongue, geographic tongue and atrophy of filiform papillae Benign Lesions of the Tongue Glossitis
  • Allergy to dental materials
  • Certain jaw disorders

Systemic causes

Psychiatric causes

  • Burning mouth or facial pain can be a psychiatric symptom related to a number of mental disturbances, such as depression, anxiety and even incipient psychosis.
  • Examination of patients suffering from persistent atypical facial pain will often reveal an underlying psychiatric disturbance.
  • Psychiatric consultation is advisable when dealing with persistent intractable oral or facial pain.

Investigations

History and clinical examination

  • The patient history is essential.
  • Smoking. Clinical examination reveals small reddish dots on the palate, i.e. inflammation of minor salivary glands. Sometimes there may be a reddened area with loss of filiform papillae along the midline of the tongue (central papillary atrophy = CPA).
  • Dietary habits. Very hot, strongly spiced food can cause a burning sensation in the tongue. On the other hand, strong taste stimuli sometimes give rise to a burning sensation on the mucosa. No clinical lesions are encountered.
  • Continual use of mouth rinses irritates the oral mucosa. In some cases, the oral mucosa exhibits small reddish areas that change their location daily. Continual taste stimulation can cause taste disturbances.
    • It is advisable to recommend sodium lauryl sulfate -free toothpastes for the patient.
  • A dry mouth Dryness of the Mouth is susceptible to various forms of irritation and inflammation. Dryness of the oral mucosa can be due to mouth breathing, salivary gland disorders or pharmaceuticals that reduce the secretion of saliva. Menopausal symptoms may be aggravated by changes in the secretion and composition of saliva. Reduced saliva secretion is usually accompanied by taste disturbances.
  • Carious teeth or fillings, heavy dental calculus and large diastemata can cause glossalgia, which is often localized to the tip of the tongue.
  • Pain associated with malocclusion is localized in the tongue and the sites of insertion of masticatory muscles. The patient also has headache. Probable causes of malocclusion problems include a low denture, incomplete dentition and extensively filled teeth.
  • Angular cheilitis and associated denture stomatitis suggest a fungal infection of the mouth Cheilitis. Clinical symptoms include redness and pain of the mucosa underneath the denture. The most severe cases also present with atrophy of filiform papillae on the surface of the tongue. Reduced secretion of saliva makes the mouth susceptible to fungal infections, which should be taken into account in planning therapy. In addition to pharmacological therapy, appropriate treatment of oral fungal infections includes examination and eventual replacement of old dentures (dentist's assessment).
  • Alveolar ridge pain in persons with dentures is generally due to resorption of the bony crest, which renders the alveolar bone sharp as a knife. In such cases, it is advisable to assess potential bone lesions by means of orthopantomography. Treatment consists of ridge remodelling by an oral surgeon.
  • Denture-related pain is very rarely allergic in origin, whereas allergy to filling materials is more common. Clinically, contact allergy is characterized by lichenoid lesions on the oral mucosa, with the lesions being in contact with the filling material. A biopsy should be taken of the lichenoid lesions. Based on the clinical finding and the histopathological diagnosis, the patient may be referred for allergy testing, as required.
  • The most significant drug-induced adverse effect is the reduction of saliva secretion, which brings all sorts of discomfort, including mouth irritation and increased incidence of inflammations and dental diseases. Many different types of pharmaceuticals have been reported to cause oral mucosal symptoms resembling oral lichen. Since burning sensations in the mouth as well as disturbances of the senses of taste and touch may also be drug-related, it is important to enquire about the patient's use of medicines as part of the assessment of oral symptoms.
  • A burning sensation on the oral mucosa may be accompanied by reddish, erosive patches. This is an absolute indication for determining blood count to assess the presence of anaemias.
  • Pain limited to a specific site must always be taken seriously. Especially pain in the lateral side of the tongue can be a sign of a malignant tumour.
  • Neurological disorders (multiple sclerosis, bulbar palsy, ALS, diabetic neuropathy). Other neurological findings may provide clues.

Laboratory tests

  • Blood count (+ differential cell count by cell analyser), blood glucose and HbA1C are the first tests.
  • Any ulcers, leucoplakia or tumour-like changes on the oral mucosa should always be biopsied.
    • If the change is below 2 cm, an excisional biopsy is used. If the change is large, an incisional biopsy is used and taken from several places, as necessary.
    • In the area of moving mucosa, a biopsy is taken with a knife using fusiform (elliptical) excision. In the area of attached mucosa, a biopsy is taken with a punch.
    • For an examination of the mouth and for performing the biopsy, the patient should be referred to a dentist or a specialist in oral surgery.

Follow-up

  • Clinical lesions on the oral mucosa must be monitored initially at three- to six-month intervals if an immediate biopsy is not required.

References

  • Wu S, Zhang W, Yan J, et al. Worldwide prevalence estimates of burning mouth syndrome: A systematic review and meta-analysis. Oral Dis 2022;28(6):1431-1440. [PubMed]
  • Chen GY, Tang ZQ, Bao ZX. Vitamin B12 deficiency may play an etiological role in atrophic glossitis and its grading: A clinical case-control study. BMC Oral Health 2022;22(1):456. [PubMed]
  • Serrano J, Lopez-Pintor RM, Gonzalez-Serrano J, et al. Oral lesions in Sjogren's syndrome: A systematic review. Med Oral Patol Oral Cir Bucal 2018;23(4):e391-e400. [PubMed]