Burning Mouth Syndrome (BMS).

Oral Communication presented at the XI National and IV International Meeting of the Spanish Gerodontology Society: "Burning Mouth Syndrome: Mandibular Compromise". Authors: Larena-Avellaneda J., Acosta Llanos MM., López Marquez A. and Jiménez Brito A.. Sevilla, June 17-18, 2011.

We summarize current general knowledge and underline our contributions by explaining and solving the Burning Mouth Syndrome.

Concept.

Burning Mouth Syndrome, BMS, is a very common clinical condition, characterized by burning pain, stinging, intraoral itching, in tongue, palate, with taste disorders, bitter or metallic and salivation alterations, thick saliva, hyposialia or xerostomia(dry mouth).

Normal appearance of the entire oral mucous.

Kaposi, glossodynia, tongue pain in 1885; Verneuil, buccal burning, and in 1980 is known as BMS.

Synonyms: dry mouth, glossodynia, orodinia, glossopyrosis, stomatodynia, estomatoporosis, buccolingual pain, buccolinguaal paresthesia, oral disestesia, buccofacial discomfort, modern man illness.

It affects to + 50 years, + female in 7:1. Europe: between 20% and 30% of the population. United States: up to 42% of the population experience this problem. 

For us, BMS clinical condition is  an specific and sensitive symptomatology expression of a traumatic functional pathology of the Maxillo-Mandibular Impigement, MMI, as a peculiar variant in some patients, so it may or may not coincide with headaches and/or dizziness.

1.

Pathogenesis

Salivary disorders, medicine, stress, psychic (anxiety, depression), menopause, autoimmune, systematic (diabetes, rheumatism, etc.), specific altered nerve terminations function that are responsible for carrying the sensation of taste , candidiasis, nutritional deficiencies, poorly adjusted dental prosthesis, normal aging process, poor oral hygiene, dental fractures, gastroesophageal reflux, gastritis, smoking, relation between discomfort and certain substances or food  in contact with oral mucosa ( fillings or another types of dental treatment), helicobacter pylori infection.

For us, BMS symptoms are caused by MMI when impacting vertical mandibular ramus inner surface against maxilla, prosthesis, splint, fixed or removable orthopedic and orthodontic aparatology, tooth or tuberosity, and lingual nerve suffering from contusion and/or compression performing protrusive mandible movements, opening and closing or lateral, when talking, chewing, doing physical exercise, etc.

2. Trigeminal branch III, deep layer, missing portion of ascending ramus has been        

removed along with external pterygoid.

Clinical

Painful sensation of burning or itching generally located at the tip and sides of the tongue, lips and palate, without noticeable harm or mucosa alteration at discomfort areas or adjacent parts. Burning feeling also reaches the lower labial mucosa inner side.

Sometimes, discomfort perceived only in one side of the mouth, although it is usual that it will extend to both sides and symmetrical..

Disgusia: metallic taste.

Foreign body sensations inside the mouth: roughness, spikes,grit, skins, threads, foreign and sticky substances accumulation, stickiness, dysphagia. Continuous thirst, dry throat, escalated mouth sensation.

The explanation of symptoms is simple and clear as it affects the lingual nerve at MMI level and then the stimulation of  taste receptors of the VII, general sensitives of V and parasympathetic visceral sublingual and submandibular glands of the VII, are altered and efferent or afferent signal to the cerebral cortex is pathological, so the patient feels burning, disgusia, salivary alterations, etc.

3.  Nerves of the tongue.

Increase of symptoms intensity as day goes by. Disappearance of symptoms during intake-chewing process and upon asleep.

“Since I wake up in the morning until I go to sleep at night, my mouth is a living hell, stings and hurts me a lot, sometimes I feel like if I had dry mouth and others my saliva is thick and sticky.”

Regarding pain pattern, many studies have reported that most people with BMS, have referred burning pain starting at mid-morning or early afetrnoon and reaches maximum intensity at the end of the afternoon and constant pain throughout the day in the others.

Chronology explanation of the symptoms is because it performs MMI  when talking, chewing, etc. and at night if doesn’t sleep by the MMI side symptoms disappear.

Discomfort in 80% of cases started after dental surgery, such as dental fillings, full or partial plaques, teeth extraction and fixed or removable jumpers.

Obsession relating the onset of the disease with some treatment, drink, food eaten, prosthetic treatment or prosthetic elements, not being able to demonstrate a cause-effect relation. Prosthesis intolerance.

It is obvious that the trigger of the symptomatology goes through some dental or prosthetic treatment, having an open mouth for a long time, by changing the side of chewing, a prosthesis that “steals” space  to move the mandible, etc., and  it “ wakes up” the MMI.

4.  Frontal cut through the temporomandibular joint condyle. Posterior half cut in front view. Conjunctive tissue interposed between both pterygoid, has been separated in order to make visible lingual nerves and lower alveolar.

It is related to parafunctional habits, bruxism, compulsive tongue movements, headaches, sleeping disorders, arthralgias, CMD, atypical facial pain, atypical toothache, irritability, dizziness, palpitations, dry eyes, vaginal itching. These symptoms usually go with the MMI.

Summary of BMS symptoms:

-       Stinging or burning in the oral mucosa area, that in frequency order would be  the tip and tongue sides, palate, pharyngeal pillars, lower lip inner side and cheek mucosa.

-       Dry mouth sensation (xerostomia), which does not always correspond to a reduction of the volume of saliva (hyposialia) and its flux.

-       Foreign body sensation inside the mouth (roughness, skins, threads, foreign and sticky substances accumulation).

-       Obsession relating the onset of the disease, with some treatment, drink, food eaten, prosthetic treatment or prosthetic elements, not being able to demonstrate a cause-effect relation.

-       Disappearance of symptoms once asleep.

-       Increase in the intensity of symptoms as the day goes by.

-       Alteration of taste sensation.

Based on pain pattern, Lamey and Lewis have proposed classifying BMS into three categories:

-       Type 1: that in which patient does not suffer any symptoms at awakening, but they emerge and increase in intensity.

-       Type 2: symptoms are present upon awakening, and persist continuosly throughout the day.

-       Type 3: symptoms are intermittent, not daily, having days in which the patient remains free of any symptom.

5. Lower alveolar nerve trajectory, and pterygomandibular space covered from the rear.

Diagnosis.

Performing the same anamnesis, exploration and MMI testing.

Treatment.

MMI: avoid from occurring or eliminating the cause whenever we can. Postural, occlusal, aparatology and surgery.

Discussion.

Why if MMI  is not bilateral burning appears on the tongue bilaterally?

What kind of stimulus are sent by taste buds when they get excited with a flavor that  it changes the signal  when MMI suffers and the brain interprets it as “  burning”?

Is it because are there any chemoreceptors and no mechanoreceptors?

The order of appearance is the tip, sides, one side first and then the other one, depending on which side is more affected from MMI, palate and finally lower lip. It means that the most sensible part is the tip and the least is the lower lip. By eliminating the burning it disappears in the opposite direction starting with the lower lip, palate, etc.

CASES.

Patient:  G.G.A.

Age: 64 years old.. Date: 12/07/10.

Anamnesis:

Ringing in the left ear. Noises when chewing, opening and closing on the right TMJ. Dizziness 6 months ago. It took medication and disappeared. Migraine headaches since he was 20 years old on the left side. It starts in temples, eye and it radiates all over the head. Every 10 days has migraine and increases when eating chocolate, drinking wine, stress..

2 months ago started feeling burning in the upper lips, more on the left side, buccal vestibule and tongue. Feels” bumps, like marbles” in the lips. Feels very uncomfortable.  He notices burning in lips and tongue. Protuberances in lips more in the lower one, he is very uncomfortable..

Comes with “ Burning Mouth” diagnosis.

Orthopantomography checked.

Diagnosis:

BMS  caused by MMI in the left side.

Must sleep on the right side and chew on the left side.

Extraction  tooth #  +8 and left side osteotomy. He feels better.

16/07/10. Extraction tooth # 28 tuberosity osteotomy.

19/07/10. Everything is good, doesn’t feel anything. He is surprised for not having migarines for 4 days but above all he was able to eat chocolate without pain.

23/07/10. Stitches removed.

05/10/10. Perfect, not any symptom.

6. Patient with left MMI by right chewing that triggers BMS.

7. Upper left chordal is the cause.

8. The cause was eliminated: extraction tooth # 28. Osteotomy of the left maxillary tuberosity.

Patient:  B.P.E.

Age: 59 years old. Date: 09/12/10.

Reason for consultation:

Burning sensation in tongue.

In february 2010, I went to the dentist for teeth cleaning and a few days later started feeling a little burning sensation at the tip of the tongue, mucous and palate. I went back to the dentist and told him that it seemed as if I had put on some " Vicks Vapor".

From that moment in which the dentist told me that I did not have anything, my life has been one visit after another one to different doctors.

Later on , burning sensation in the tongue it radiated to the lower inner lip.

The burns were changing. Not alwayas all at once.

It comes and goes, the same in both sides and it disapperas at bed time. After having breakfast started all over again.

Instability, dizziness. It doesn’t have headaches.

Saliva is bit thick. Itchy throat.

I even went to visit doctors in Austria and Germany. All the same. They took off my medication, they told me that I had menopause.

Diagnosis:

BMS due to MMI.

Treatment:

Placed an inverted Equi-Plano and if doesn’t get any better perform an osteotomy and teeth extraction  # 7+7. Measurements and articualtion.

14/12/10. Equi-Plano placed. Photos.

20/12/10. I’m fine. I’m wearing dental device and I have noticed an improvement in palate, lip and tongue. Weird sensation in palate. Burning sensation in lip and tongue has disappeared.

07/01/11. By the phone: from what it was left, no symptoms in palate or itchy throat. Now it says that has dry mouth when she didn’t have before.

26/01/11. There is only pain in the right side of the tongue and tip. It notices that worsens when talking because she had the flu for about a week and didn’t talk, everything has disappeared. She notices dry mouth when sleeping because she sleeps with her mouth open.

01/02/11. It says that spoke a lot on the phone and she removed Equi-Plano. 15 minutes later burning sensation began, starting at the tip of the tongue and from there to the right lateral. Then, she put Equi-Plano back on and burning sensation disappeared in the reverse direction, right lateral first and the tip after. It says that so far in the left lateral of the tongue, palate and lower lip hasn’t repeated burning sensation. It doesn’t feel dry mouth either.

Before going to bed removes Equi-Plano because sleeps without it, brushes her teeth and starts a little itching at the tip, goes to bed and takes about 15-18 minutes for itching to disappear at the tip of the tongue.

Notices more space with the tongue in the MMI area left side than in the right side.

Must eat by the right side, her usual chewing side, to observe changes.

9. Patient with bilateral MMI and BMS, + right side.

10. MMI caused by maxillary tuberosities

11. Treatment: Inverted Equi-Plano enough to increase vertical dimension of the denture and avoiding mandibular protrusion, so it increases the gap between mandibular branches and maxillary tuberosities, so it doesn’t impact and MMI disappears, and therefore BMS.

Patient: R.M.M.

Age: 47 years old.. Date: 09/05/07.

Anamnesis:

Left CAT by chewing on the right side and subluxation when talking.

Treatment:

Extraction tooth + 28. Equi-Plano. It hasn’t had headaches again. Sleeping and eating by the right side to cure left subluxation.

30/12/10. It has a feeling of warmth and bitterness in the mouth 4 weeks ago. It feels “scratchy” in the mucosa around the lower teeth and labial commissure and saliva has a metallic taste, as it sucking metal. Setting lower incisor teeth on edge.

Diagnosis:

BMS caused by left MMI.

Treatment:

Measurements and articulation to change Equi-Plano from normal to inverted. Photos.

Sleeping face-up and chewing on the left side.

04/01/11. by the phone: doesn’t have any symptoms. Continues to sleep facing up and chewing on the left side until monday 10 when will place inverted Equi-Plano.

11/01/11. It hasn’t had BMS again. Inverted Equi-Plano placed.

18/01/11.Will call back to see how it has gone.

12. Patient with bilateral MMI by upper molar included.

13. Observe the print in mucosas caused by bilateral MMI.

14.  

15. Treatment: upper third molar extraction and Equi-Plano to increase the gap and avoid protrusive and MMI, which causes BMS. 

Patient: V.D.M.

Age: 80 years old.. Date: 25/01/11.

Anamnesis:

Dry mouth, tension or stretching at the end of the soft palate, difficulty swallowing, feeling of having air in the eyes and has to close them halfway, sometimes discomfort inside and out lower lip and skin too. When reading out loud gets tired and starts hurting the palate.

No headaches, no dizziness, no paresthesias, normal reflexes, bilateral MMI pain on palpation.

It has been proposed to cut out prosthesis and bilateral osteotomy.

16. Full upper prosthesis, that causes bilateral MMI in closure, lateralities and protrusive

       17. Gap missing between vertical mandibular branches and prosthesis at vestibular posterior level

18. The cause is the size of maxillary tuberosities and which is added prosthetic vestibular portion running out of space to mov emandible at vertical branches level and impacting in closure, lateralities,etc. leading to MMI and BMS.

Patient: D.D.R.

Age: 61 years old.. Date: 17/12/09.

Consultation reason:

Can not stand prosthesis. Tongue and lips are “burning”. It wore prosthesis for 20 years and didn’t have any problems until september 21, after having put on a new prosthesis and carried fine until next day when dry mouth started. He feels acid saliva. Fungus treated. It wants to eliminate the possibility that could be for taking medication, has to consult with the cardiologist and then call back.

It takes Koropez and orphidal.She hasn’t left cardiologist’s medication and remembers that on June started hormone treatment for menopause.

18/01/11. Consultation. To confirm BMS and is positive.

Can not stand upper prosthesis. Feels burning in tongue. Sometimes it takes off prosthesis and symptoms go away. She’s got to have chewing gum in her mouth very often for refreshing.

She feels fine while chewing.

She wakes up fine, discomfort feeling doesn’t wake her up. Less saliva. Taste has diminished. The center of the tongue where it touches prosthesis also “burns”.

She had headaches on the right side for many years and pain disappeared 2 years ago.

Photos. Upper prosthesis cut off., photos, if gets any better, perform bilateral osteotomy.

Bring orthopantomography. Must chew soft food and sleep facing up. It doesn’t chew gum.

21/01/11. The daughter says that she has had changes; notices more saliva, doesn’t have the need of chewing gum, tongue burns a little less. Perform an osteotomy when she decides it.

02/02/11. The daughter came to the office and said that her mother is deciding to make an osteotomy because she has proven that cutting off prosthesis has improved her self  and is more relaxed.

19. Full upper prosthesis causing bilateral MMI in closure, lateralities and protrusive.

20. Large tuberosities and prosthetic distal vestibular portion is added, decreasing space between mandibular vertical branches and maxilla.

21. Marked upper prosthesis with portion ready to cut off in order to decrease MMI at tuberosity level.

22. Cut off prosthesis creating gap between mandibular vertical branches and prosthesis.