The problem with BMS is that there are no clinical and laboratory findings that are associated with it. However, certain conditions are usually present with BMS, and these include:

• Dry mouth
• Taste alternations, including a metallic taste in the mouth
• Difficulty in swallowing, other throat problems
• Chronic anxiety or depression
• Various nutritional deficiencies
• Type 2 diabetes
• Changes in salivary function

There doesn’t seem to be any particular factors that precipitate the symptoms. Approximately one third of patients relate the time of onset to a dental procedure, recent illness or medication condition. Once the symptoms of BMS begin, it often continues for several years, many times running its course at about 6-7 years and then either disappearing or diminishing in symptoms (2) (3).

The causes could be simply a reaction to a product or multiple factors. The following are some of the possible causes for BMS:

• Ill-fitting dentures
• Allergies to filling materials such as composite or mercury, or oral galvanism (reaction to dissimilar metals placed in the mouth)
• Dry mouth due to Sjogren’s syndrome (condition that causes dryness of the eyes and mouth)
• Nutritional deficiencies such as iron, zinc, folate and vitamins B-1, B-2, B-6, B-9 B-12 and niacin.
• Candidiasis
• Allergies to toothpaste (sodium lauryl sulfate, other chemicals or flavorings)
• Allergies to mouthwash (alcohol, chemicals or flavorings)
• Food allergies
• Conditions such as: gastric reflux, pernicious anemia, diabetes, rheumatoid arthritis, hypothyroidism
• Problem in the nerves that control taste and pain in the tongue
• Reaction to medications
• Psychologic dysfunction – this may not be a cause but a by-product of the pain and other symptoms associated with BMS
• Chronic pain conditions
• Hormonal changes
• Teeth grinding
• Burning mouth could also be caused by damage to the taste areas of the central nervous system. The damage could be due to trauma or viral infections.

To receive the appropriate treatment, it is very important to find out the cause of BMS. Start with the simple causes and make an inventory list. Below is a sample questionnaire to start with for finding the cause:

1. When did you first notice symptoms associated with BMS? Note if the onset of symptoms was associated with any of the items listed below.
2. Do you wear dentures? If yes, get a dental check up to make sure they are not irritating your mouth.
3. Did you notice symptoms after a dental visit when you had some new fillings or crowns placed in your mouth? If yes, ask your dentist if you have dissimilar metals in your mouth, and consider changing them to one type of material.
4. Discontinue any toothpaste that contain sodium lauryl sulfate. This is a very strong industrial cleanser and many people do have allergies to it. On the other hand, if your toothpaste contains sodium laurel sarcocinate, you should be safe. This is a mild cleanser used for contact lens cleansers and baby shampoos and is usually not associated with allergies. Discontinue any mouthwash with alcohol.
5. If you wake up in the morning with soreness in your jaw area, then you may be clenching or grinding your teeth. .
6. The following is a list of medications that may cause dry mouth or burning mouth. If you are taking any of these and you noticed the onset of your symptoms after you began taking them, ask your doctor to consider a substitute medication:
   • Amitriptyline hydrochloride (Elavil, Endep)
   • Doxepin (Adapin, Sinequan)
   • Nortriptyline (Aventyl, Pamelor)
   • Paroxetine (Paxil)
   • Sertraline (Zoloft)
   • Cyclobenzaprine (Cycloflex, Flexeril)
   • Maprotiline (Ludiomil)
   • Trazodone (Desyrel, Trazon, Trialodine)
   • Fluoxetine Hydrochloride (Prozac)
   • Nefazodone (Serzone)
   • Tizanidine(Zanaflex)

   The following prescription drugs have the most xerostomic (dry mouth) side effects:

   • Zantac (ranitidine)
   • Xanax (alprazolam)
   • Seldane (terfenadine)
   • Naprosyn (naproxen)
   • Prozac (fluoxetine)
   • Proventil (albuterol)
   • Tagamet (cimetidine)
   • Dyazide (triameterene)
   • Hydrochlorthiazide

   The following over-the-counter drugs have the most capability to cause dry mouth:

   • Laxatives – Chronulac, Phospho-Soda
   • Antinauseants – Dramamine
   • Cold and Allergy Products
   • Antihistimines
   • Anti-Diarrheals –Loperamide

   Other drugs that may cause dry mouth:

   • Tobacco
   • Marijuana
   • Cocaine
   • Heroin
   • Amphetamine

7. Eliminate the use of alcohol for several weeks to determine if that was related to the cause.
8. Capsaicin – Red chili peppers extract has been shown to be helpful (4). It is applied in topical form on the site of pain 4 x a day. This is repeated for 4 weeks. Another suggested way to use capsaicin is to mix two parts water and one part (teaspoon) of Tobasco sauce and rinse around the mouth for approximately 15 seconds every 2-3 hours for at least several days. It may burn initially, but some have reported relief. (5) (6) Increase the strength of capsaicin to a maximum of 1:1 dilution, as tolerated.
9. Klonopin or Librium could be helpful and may be prescribed to relieve side effects of BMS.
10. One clinical research in Italy (7) tested 60 patients with constant BMS in a double blind, controlled study for two months. They compared alpha-lipoic acid with a placebo form of treatment. They concluded that following the alpha-lipoic acid treatment the symptoms had improved and were maintained during the 1 year follow-up. Alpha-lipoic acid is an antioxidant (8) that is said to target mitochondria of cells to get rid of harmful free radicals.

Bibliography:
1. Svensson P, Kaaber S. General Health factors and denture function in patients with burning mouth syndrome and matched control subjects. J ral Rehabil 1995;22:887-95
2. Grushka M. Clinical features of burning mouth syndrome. Oral Surg Oral Med ral Pathol 1987;63:30-6
3. Ship JA, Grushka M, Lipton JA, Mott AE, Sessle BJ, Dionne RA. Burning mouth syndrome: an update. J Am Dent Assoc 1995;126:842-53
4. Epstein, J and Marco, J.H. Topical application of capsaicin for treatment of noral neuropathic pain and trigeminal neuralgia. Oral Surg Oral Med Oral Pathol 77:135-40, 1994
5.Caterina et al Nature 1997;389:816-824