There are numerous differential diagnoses for intraoral burning. Perhaps the most well familiar is a condition known as ‘burning mouth syndrome’ (BMS), famously afflicting singer Sheila Chandra. It is preferably called oral dyaesthesia due to the fact that patients with BMS may report oral mucosal pain, altered taste sensation, and a dry mouth in addition to, or sometimes instead of, a burning sensation.

While not actually a syndrome, BMS is defined as “a chronic intraoral burning sensation that has no identifiable cause – either local or systemic condition or disease”. It is associated with normal clinical signs and laboratory findings. It is estimated to affect between 0.1% and 3.9% of the general population and is most typically seen in post-menopausal older women.

Dr Amanda Phoon Nguyen, Oral Medicine Specialist

Dr Amanda Phoon Nguyen, Oral Medicine Specialist

Psychological factors such as somatisation, anxiety, depression and personality disorders are identified more frequently in BMS patients. The cause of BMS is poorly understood, but hypotheses include peripheral neuropathy or neuropathic pain, with central sensitisation.

The most frequently affected area in people with BMS is the tongue. Symptoms are typically bilateral and symmetrical, and the pain tends to follow a temporal pattern, most commonly worsening during the day.

Many treatments have been trialled, including topical or systemic clonazepam, gabapentinoids, tricyclic antidepressants, and anti-spasmodics. Other management strategies including the use of Vitamin B12 or zinc supplementation, alpha lipoic acid, palmitoylethanolamide, low-level laser therapy and capsaicin mouthwashes.

Patient education and anxiety management to improve the patients’ quality of life should also be considered. To date, few effective treatments are available and management of BMS can be difficult.

BMS is a diagnosis of exclusion, and therefore other factors that may be associated with oral burning should be excluded before reaching a BMS diagnosis. Consider infective conditions such as oral candidiasis and traumatic cause such as damage to tongue papillae. This may be because of mucosal disease, damage secondary to salivary gland hypofunction (such as radiotherapy, saliva problems, eating disorders, gastro oesophageal reflux and dehydration).

Other differentials include salivary gland disorders or immune-mediated conditions affecting the salivary glands such as Sjogren’s syndrome, oral mucosal diseases such as oral lichen planus, metabolic issues (e.g. diabetes, thyroid disorders), medication-related adverse effect (e.g. ACE inhibitors), allergies including reaction to dental materials or dentures, oral galvanism, deficiency states (e.g. vitamin B, iron or folate deficiency) and central nervous system disorders including multiple sclerosis or Parkinson’s disease.

key messages

  • Burning mouth syndrome (BMS) may present with symptoms aside from oral burning
  • BMS is a diagnosis of exclusion
  • Management may be difficult, and there should be consideration of any perpetuating psychosocial factors
  • Image caption:  Differential Diagnosis for Oral Burning

References available on request.

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Author competing interests: None to disclose.

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