Current management strategies for the pain of elderly patients with burning mouth syndrome: a critical review

Reappraising the psychosomatic approach in the study of "chronic orofacial pain": looking for the essential nature of these intractable conditions

As burning mouth syndrome (BMS) and atypical odontalgia (AO) continue to remain complex in terms of pathophysiology and lack explicit treatment protocol, clinicians are left searching for appropriate solutions. Oversimplification solves nothing about what bothers us in clinical situations with BMS or AO. It is important to treat a complicated phenomenon as complex. We should keep careful observations and fact-finding based on a pragmatic approach toward drug selection and prescription with regular follow-up. We also need to assess the long-term prognosis of treatment with a meticulous selection of sample size and characteristics. Further investigation of BMS and AO from a psychosomatic perspective has the potential to provide new insight into the interface between brain function and "chronic orofacial pain."

QTc Shortening on Electrocardiogram With Amitriptyline May Indicate No Effect on Pain Relief in Burning Mouth Syndrome

OBJECTIVE

Burning mouth syndrome (BMS) is an intractable chronic pain disorder characterized by a burning sensation without organic abnormalities in the oral mucosa. Amitriptyline may be effective for BMS or, conversely, may exacerbate pain. QTc is necessary for monitoring psychotropic adverse effects, but it is not known if it is a predictor of efficacy for BMS. We investigated the efficacy of amitriptyline in BMS and its effect on QTc.

METHODS

Visual analog scale and electrocardiogram were examined before and 1 month after treatment in 51 consecutive patients diagnosed with BMS according to the International Classification of Headache Disorders, Third Edition (ICHD-3), criteria and treated with amitriptyline.

RESULTS

There were 26 amitriptyline responders and 25 nonresponders, with no differences in age, sex, and amitriptyline dosage. Amitriptyline responders showed little change in QTc, whereas nonresponders showed a trend toward significantly shorter QTc. Changes in visual analog scale correlated statistically significantly with changes in QTc (Spearman rank correlation coefficient: 0384; P = 0.0054). The degree of pain tended to worsen with QTc shortening.

CONCLUSION

Amitriptyline provides analgesia in about half of BMS patients, but some BMS patients have worse pain with amitriptyline. Not only do changes in the QTc detect amitriptyline adverse effects with prolongation, but also, conversely, its shortening predicts amitriptyline ineffectiveness.

Gender differences in pain perception among burning mouth syndrome patients: a cross-sectional study of 242 men and 242 women

Several orofacial painful conditions are influenced by gender-related factors, but no studies are available with regard to Burning Mouth Syndrome (BMS). The present study aimed at investigating gender differences among BMS patients and their influence on pain perception. 242 BMS males (BMSm) and 242 BMS females (BMSf) matched for age were consecutively enrolled. Sociodemographic and clinical characteristics were recorded and the numeric rating scale (NRS), the Total Pain Rating Index (T-PRI), the Hamilton rating scale for anxiety and depression (HAM-A, HAM-D), the Pittsburgh sleep quality index (PSQI) and the Epworth sleepiness scale (ESS) were administered. The BMSm presented statistically significant higher levels of education and rate of employment compared to the BMSf (p-values: 0.001**). Moreover, the BMSm were greater consumers of alcohol and had a higher BMI than the BMSf (p-values: < 0.001**, 0.034*). With respect to systemic comorbidities, cardiovascular diseases were statistically more prevalent among the BMSm, while hypothyroidism was more frequent in the BMSf (p-vales: < 0.001**). No differences were noted between the two groups in terms of oral symptoms and in the median scores of NRS, T-PRI, HAM-A, HAM-D, PSQI and ESS. Interestingly, the multivariate regression analysis revealed that, while anxiety, high BMI, poor sleep and high level of T-PRI were correlated to the intensity of pain (NRS) in both groups, low education was additional predictor of pain in BMSf. Further, depression, alcohol and intensity of pain were factors positively associated to the quality of pain (T-PRI) in the BMSm, whereas low education, non-married status and NRS were correlated to the T-PRI, in the BMSf. Surprisingly, smoking was inversely correlated to the intensity of pain and quality of pain respectively in BMSf and BMSm. Sociodemographic and risk factors were found to differently influence pain perception in BMSm and BMSf. Therefore, clinicians should take into account gender differences in the assessment of BMS patients to better tailor the overall pain management.

Goal Attainment Scaling in Patients With Burning Mouth Syndrome: A Real-World Clinical Study Protocol

Introduction Burning mouth syndrome (BMS) is characterized by persistent chronic burning pain. Because BMS shows various symptoms, levels of severity, and treatment outcomes, measuring recovery is difficult in this patient population. Goal attainment scaling (GAS), a flexible and responsive technique for assessing outcomes in complex interventions, assimilates the achievement of individual goals into a single standardized "goal attainment scale." To our knowledge, this is the first clinical study protocol to investigate the effectiveness of adopting GAS in patients with BMS. Methods This study will involve two phases. In phase 1, the suitability of GAS for BMS will be examined in 30 patients. All practitioners will be trained to support patients in setting their clinical goals. In phase 2, all 155 patients with BMS will set two clinical goals emphasizing specific, measurable, achievable, realistic, and timed (SMART) goals at the initiation of psychopharmacotherapy for BMS. During the follow-up at weeks four, 8, 12, and 24, the GAS T-scores for each patient will be derived from the result of the individual goal attainment scores multiplied by goal weighting. Other clinical rating scales, including the visual analog scale (VAS), oral dysesthesia rating scale, pain catastrophizing scale, patient's global impression of change, and clinical global improvement will be assessed simultaneously with the assessment of goal attainment. The interactions between GAS T-scores and other clinical scales or clinical characteristics, including baseline age and sex, will be analyzed, followed by a discussion on the effectiveness of adopting the GAS for BMS. Results The information gleaned from phase 1 will help train practitioners and develop the use of GAS for BMS. In phase 2, analyzing the GAS T-score, a quantitative assessment, will accurately reveal patient outcomes and satisfaction. The effectiveness of using the GAS and some factors contributing to patient satisfaction will be revealed by analyzing the interaction between the T-score and other clinical scales. Conclusions In addition to revealing the usefulness of GAS for BMS, we believe this study will prompt further investigations to clarify the factors contributing to patient satisfaction and shed light on a new treatment strategy that reinforces the previous treatments for BMS.

Management of Burning Mouth Syndrome

This article provides an update for the practicing dentist and/or oral and maxillofacial surgeon on the recognition, identification, and treatment of burning mouth syndrome (BMS). We discuss the most common clinical findings and most common causes of BMS. This article provides a classification flowchart that assists the practitioner in diagnosing and classifying BMS. The article then discusses the pathophysiology and treatment of BMS updated in the literature from the latest studies and reviews. Treatment can vary from topical or systemic medication to behavioral therapy.

Clinical Features and Variations of Pain Expressions in 834 Burning Mouth Syndrome Patients With or Without Psychiatric Comorbidities

Introduction Burning mouth syndrome (BMS) is characterized as chronic burning pain or unpleasant discomfort in the oral region without any corresponding clinical abnormalities. The aim of this study is to investigate the difference in clinical features and the variations of pain expressions between BMS patients with and without psychiatric comorbidities. Methodology The patients with BMS who first visited between April 2016 and March 2020 were involved and the clinical data including the presence of psychiatric comorbidities and scores of self-rating depression scale (SDS), pain catastrophizing scale (PCS), and pain quality from short-form McGill pain questionnaire (SF-MPQ) were collected retrospectively. Results In 834 patients with BMS (700 females, 63.9 ± 13.1 years old), 371 patients (44.5%) had psychiatric comorbidities. There was no significant between-group difference in demographic data. However, significantly higher scores were observed in SDS (p < 0.001) and PCS (p < 0.001) in the patients with psychiatric comorbidities. Moreover, the patients with psychiatric comorbidities showed significantly stronger pain intensity (p < 0.001) besides higher scores of each descriptor in SF-MPQ. In addition, they had chosen more descriptors in SF-MPQ (p < 0.001); furthermore, the number of selected pain descriptors showed a stronger correlation with PCS than with SDS regardless of the presence of psychiatric comorbidities. Conclusion BMS patients may complain of various pain expressions regardless of the psychiatric comorbidities; however, more severe complaints relating to high pain catastrophizing are more likely in patients with psychiatric comorbidities. These results suggested that underlying anxiety exacerbated the variety of pain expressions in BMS patients with psychiatric comorbidities.

An Unusual Case of Burning Mouth Syndrome in an Adult Male: A Case Report

Burning mouth syndrome (BMS) is a rare disorder primarily affecting the oral mucosa and characterized by a chronic burning sensation without specific oral mucosal lesions. This paper presents a case of a 54-year-old adult male patient who complained of chronic burning mouth pain. The clinical diagnosis was made after excluding various differentials, including oral candidiasis, hairy oral leukoplakia, gastroesophageal reflux disease, oral lichen planus, local infective processes, and nutritional deficiencies. Physical examination did not reveal specific signs or lesions related to BMS; however, considering the patient's signs, symptoms, and the exclusion of other possibilities, a possible diagnosis of BMS was considered. The patient was evaluated in an outpatient setting, and management was conducted in this setting to reduce patient costs. This presentation is considered rare, as the disorder predominantly affects postmenopausal females, and most proposed theories behind its pathophysiology revolve around estrogen-mediated modulation of pain receptors. Currently, diagnostic and management criteria for BMS may vary and continue to evolve. The management of this patient focuses on patient education and routine follow-up. This case report presents the management of this particular case, along with a review of other proposed management options.

Salivary Complaints in Burning Mouth Syndrome: A Cross Sectional Study on 500 Patients

BACKGROUND

Xerostomia and sialorrhea often accompany Burning Mouth Syndrome (BMS) despite no change in saliva quantity. This study analyzed BMS patients with different symptom combinations: burning only (B), burning and xerostomia (BX), burning and sialorrhea (BS), and burning with xerostomia and sialorrhea (BXS), using a large sample of 500 patients from the University of Naples Federico II.

METHODS

After a medical evaluation, patients were divided into four groups based on their reported symptoms: B (140), BX (253), BS (49), and BXS (58). Patient data on education, BMI, smoking/alcohol habits, comorbidities, medication use, pain intensity, quality, and psychological profile were collected.

RESULTS

The BX group showed a higher prevalence of patients taking blood thinners. Additional symptoms varied among groups, with the BX group experiencing more dysgeusia and globus, and the BS group reporting more tingling. Multivariate analysis identified BMI, dysgeusia, globus, and blood thinner use as significant factors in the B and BX groups, while male gender, tingling, alcohol use, and pain quality were significant in the BS and BXS groups.

CONCLUSIONS

Overall, BMS patients display a complex range of symptoms, with xerostomia being the most frequent additional symptom. Sociodemographic, psychological, and medical factors cannot fully explain the variations in symptomatology among different patient subgroups. Further research is needed to understand the underlying causes and develop tailored treatment approaches.

Oral Implications of Polypharmacy in Older Adults

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Síndrome de boca ardiente, abordaje otorrinolaringológico. Revisión bibliográfica sistemática

Introducción y objetivo: El síndrome de boca ardiente (SBA) es una afección crónica, que cursa con quemazón o dolor de la mucosa bucal, afectando predominantemente a mujeres de edad media. Puede aparecer como cuadro primario o bien de forma secundaria. La fisiopatología de esta entidad es bastante desconocida. Existe un amplio abanico terapéutico, pero por lo general precisa de un abordaje multidisciplinar. Nuestra intención es realizar una puesta al día de la enfermedad para poder hacerla frente en la consulta de otorrinolaringología. Método: Revisión bibliográfica de la literatura. Fecha de publicación limitada de 2012 a 2022. Resultados: El SBA presenta una etiopatogenia de carácter multifactorial. Para su diagnóstico es necesario realizar una exhaustiva anamnesis y exploración. Se diferencian 3 tipos distintos de SBA, siendo el tipo II el más frecuente y el más refractario a la terapia. El adecuado tratamiento se fundamenta en un correcto diagnóstico y debe ser multidisciplinar. Discusión: Es importante resaltar que es una entidad benigna. Los tratamientos son variados y no hay ninguno que destaque sobre el resto, lo que dificulta el manejo de estos pacientes. Aunque la bibliografía sobre este síndrome es abundante, no se han producido en los últimos años, importantes innovaciones en cuanto a la etiología y tratamiento. Conclusiones: La anamnesis y los estudios de laboratorio son fundamentales para descartar casusas secundarias de la enfermedad. La terapia es diversa y debe incluir derivación a salud mental como parte del manejo multidisciplinar.  

The influence of intolerance of uncertainty on the correlation between the severity of symptoms and satisfaction with oral state in patients with burning mouth syndrome

OBJECTIVE

Intolerance of uncertainty (IU) is thought to be involved with the psychological factors that influence the symptoms in patients with burning mouth syndrome (BMS) and affect their limited satisfaction with the treatments provided. However, the influence of IU on satisfaction has not been explored in detail. Therefore, the purpose of this study was to investigate whether IU can affect the satisfaction of patients with BMS.

METHODS

A total of 34 patients with BMS and 100 patients without the disease who visited the general dental clinic were included in the study. They were required to complete a questionnaire measuring the subjective severity of their symptoms and satisfaction with their oral state, and a short IU scale. The BMS patients were separated from the control patients based on the IU score. The coefficients between the severity of symptoms and satisfaction were calculated to examine the influence of IU on the relationship between the two variables.

RESULTS

The relationship between satisfaction and severity of symptoms was significant in BMS patients with high IU, but not in control patients with low IU.

CONCLUSION

This study demonstrated that IU in BMS patients influences the relationship between the severity of symptoms and the satisfaction, thus indicating that the dissatisfaction in BMS patients with high IU might be prevented by decreasing the IU.

CLINICAL RELEVANCE

Limited satisfaction experienced by BMS patients can influence the patient-doctor relationship. This study provides suggestions for building a good patient-doctor relationship.

Phantosmia and psychogenic non-epileptic seizures in a patient with burning mouth syndrome suffering from severe depression

Burning mouth syndrome (BMS) is a rare but serious medical condition with important psychiatric comorbidity and specific psychological correlates. Psychopathology related with BMS represents a real challenge for clinical decision-making. In this case, depression is the leading psychiatric diagnosis associated with patient's BMS somatic pain and is driven by anxiety and a dissociative functioning. Facing a complex psychosomatic symptomatology, we offer new clinical perspectives for the screening of psychological traits of BMS. Moreover, we highlight the need to foster interdisciplinarity to improve differential diagnosis and defining an optimal care path. This case report stimulates a reflection on management challenges for the consultation-liaison psychiatry and shows the importance of a person-centred approach when communicating the diagnosis.

The use of self-report questionnaires in an analysis of the multidimensional aspects of pain and a correlation with the psychological profile and quality of life in patients with Burning Mouth Syndrome: a case control study

Background

The symptomatology in Burning Mouth Syndrome (BMS) is complex and it should be considered in accordance with a biopsychosocial model.

Objectives

To evaluate the multidimensional aspects of pain with a complete battery of tests and to analyse its relationship with potential predictors such as mood disorders, sleep and quality of life.

Methods

Forty patients with BMS versus an equal number of age and sex‐matched healthy controls were enrolled. The VAS, SF‐MPQ, BPI, PD‐Q, BDI‐II, STAI, PSQI, ESS, SF‐36 and OHIP‐14 were administered.

Results

The scores of the VAS, SF‐MPQ, BPI, PD‐Q, BDI‐II, STAI, PSQI, SF‐36 and OHIP‐14 were statistically significantly higher in the BMS patients than the controls (p < .001**). A strongly linear correlation between pain (VAS, SF‐MPQ, BPI and PD‐Q) and disease onset (STAI, BDI‐II, PSQI and sub‐items of SF‐36 and OHIP‐14) was found. In the multiple regression analysis, the contributions of the BDI‐II and OHIP‐14 were found to be statistically significant with the SF‐MPQ, PD‐Q and BPI in terms of severity and interference, while the contributions of the STAI and sleep were found to be statistically significant with the SF‐MPQ and BPI in terms of severity and interference, respectively.

Conclusions

Pain tests are differently correlated with mood and quality of life. Therefore, a complete analysis of the patient requires several tools to better understand the multidimensional aspects of pain in BMS.

Evaluating the role of perceived injustice in mental health outcomes in cervical cancer care

Purpose

Perceived injustice is a novel psychosocial construct which reflects negative cognitive appraisals of blame, unfairness, and the severity and irreparability of one’s loss. Experiences of injustice are increasingly recognised as a key determinant of recovery outcomes in healthcare. The aim of this study was to explore the impact of perceived injustice on psychological outcomes amongst a group of cancer patients and survivors who received false-negative smear results under a National Cervical Cancer Screening Programme (CervicalCheck).

Methods

Women who received false-negative smear results who were involved in the CervicalCheck controversy in Ireland completed online measures of perceived injustice (IEQ), psychological distress (depression and anxiety as measured by the HADS), and satisfaction with care (PSCC) (n = 144).

Results

Rates of psychological distress in this sample were high, with 76% scoring in the clinical range for anxiety, 51% in the clinical range for depression, and 88% in the clinical range for perceived injustice. Hierarchical regression analyses revealed that perceived injustice contributed unique variance to the prediction of depression and anxiety. Satisfaction with care significantly moderated the association between perceived injustice and depression.

Conclusions

Cancer patients who report high levels of perceived injustice are at greater risk for experiencing psychological distress. The relationship between perceived injustice and depression may vary as a function of satisfaction with care. Addressing issues of perceived injustice in the psychosocial and rehabilitative care of cancer patients may support the early identification of those at risk of significant psychological distress and enhance intervention success. Implications for policy and practice in healthcare are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07060-z.

The Effectiveness and Adverse Events of Amitriptyline and Aripiprazole in Very Elderly Patients With BMS

Burning mouth syndrome (BMS) is defined by chronic oral burning sensations without any corresponding abnormalities. Besides amitriptyline, aripiprazole has been reported as a possible medication to manage BMS. However, especially for elderly patients, the adverse events of these medications would be a problem. The aim of the present study was to investigate the differences in the effectiveness and adverse events of amitriptyline and aripiprazole in very elderly patients with BMS. This is a retrospective comparative study of 80 years old and older patients with BMS who were initially treated with amitriptyline or aripiprazole and who were new outpatients of our department from April 2017 to March 2020. All clinical data, including sex, age, comorbid physical diseases, comorbid psychiatric disorders, the prescribed doses (initial, maximum, and effective dose), prognosis, and adverse events, were collected from their medical charts. Each medication was selected considering their medical history. Amitriptyline was prescribed in 13 patients (11 women, 82.3 ± 2.1 years old) and aripiprazole was prescribed in 27 patients (26 women, 84.2 ± 3.8 years old). There were no significant between-group differences in sex, age, duration of illness, pain intensity, salivation, and psychiatric comorbidity at the first examination. Amitriptyline clinically improved more patients (7 patients, 53.8%) with the effective dose of 10 (7.5, 15.0) mg than aripiprazole (11 patients, 40.7%) of which the effective dose was 1.0 (0.5, 1.5) mg, although there were no significant between-group differences. The adverse events of amitriptyline were found in 9 patients (69.2%) and most patients had constipation (46.2%). For aripiprazole, 7 patients (25.9%) showed adverse events, most of them reported sleep disorder (11.1%). Amitriptyline had significantly longer duration taking medication (p = 0.021) and lower discontinuation (p = 0.043) despite of higher occurrence rate of adverse events (p = 0.015) compared to aripiprazole. These results suggest that both psychopharmacotherapies with a low dose of amitriptyline and aripiprazole are effective for the very elderly patients with BMS. Furthermore, aripiprazole may have some advantages in the adverse events compared to amitriptyline; however, the low dose amitriptyline monotherapy may have more benefit in the effectiveness and tolerability over prudent collaboration with primary physicians.

Oral Implications of Polypharmacy in Older Adults

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Oral cenesthopathy superimposed on burning mouth syndrome treated with aripiprazole: A case report with a phenomenological overview

BACKGROUND

Burning mouth syndrome (BMS) is an idiopathic condition that presents with chronic pain and/or burning sensations in the oral structures. The syndrome mostly affects elderly women with hormonal changes and/or with a diagnosis of comorbid psychiatric disorder. In some rare conditions, the clinical appearance of BMS may also overlap with oral cenestopathy (OC), which is defined in the literature as a special form of delusional disorder of somatic type. Patients with OC may complain about abnormal experiences such as melting, feeling of stickiness, as well as extremely strange feelings of wires, metal coils, etc being present in their mouths.

CASE PRESENTATION

We present an elderly woman whose ongoing symptoms of BMS (burning in the mouth and tongue, taste alterations etc) were, over time, superimposed by cenesthopatic delusions that her gums had melted, and her palate had totally dissolved. We believe that the case is clinically striking and demonstrative for the understanding of complex nosology of BMS and OC, given that (a) the patient exhibited a relatively rare example of overlapping BMS and OS symptoms, which both are not sufficiently recognised by clinicians, (b) OC symptoms have disappeared with low-dose aripiprazole and psychoeducation-based cognitive therapy, which resulted in significant improvement in the patient's quality of life.

CONCLUSION

Clinicians are required to be aware of BMS and OC, two syndromes with multifactorial aetiology and highly heterogeneous presentation, in order to determine the most appropriate treatment options from a multidisciplinary perspective, as well as to avoid unnecessary medical interventions.

Evaluating the Suitability and Potential Efficiency of Cannabis sativa Oil for Patients with Primary Burning Mouth Syndrome: A Prospective, Open-Label, Single-Arm Pilot Study

OBJECTIVE

To evaluate the use of a Cannabis sativa oil in the management of patients diagnosed with primary burning mouth syndrome (BMS).

DESIGN

Prospective, open-label, single-arm pilot study.

SETTING

University hospital.

SUBJECTS

Seventeen patients with diagnosed BMS were included.

METHODS

Subjects were treated for 4 weeks with a full cannabis plant extract, which was prepared from standardized plant material (cannabis flos) in specialized pharmacies by means of Romano-Hazekamp extraction and was diluted in oil (1 g of cannabis in 10 g of olive oil). The primary outcome was the change in pain intensity (assessed by the visual analog scale, Present Pain Intensity scale, McGill Pain Questionnaire, and Oral Health Impact Profiles) at the end of the protocol and during the succeeding 24 weeks; the neuropathic pain was also investigated with a specific interview questionnaire (DN4-interview [Douleur Neuropathique en 4 Questions]). Levels of anxiety and depression were considered as secondary outcomes, together with reported adverse events due to the specified treatment.

RESULTS

Subjects showed a statistically significant improvement over time in terms of a clinical remission of the oral symptoms. Levels of anxiety and depression also changed statistically, displaying a favorable improvement. No serious reactions were detailed. None of the patients had to stop the treatment due to adverse events.

CONCLUSIONS

In this pilot evaluation, the C. sativa oil provided was effective and well tolerated in patients with primary BMS. Further bigger and properly defined randomized controlled trials, with different therapeutic approaches or placebo control, are needed, however.

Personality Traits in Burning Mouth Syndrome Patients With and Without a History of Depression

Objectives: So far, the strong link between neuroticism, chronic pain, and depression has been well-documented in literatures. Some suggested that they might share etiological factors, thus resulting in overlapping constructs. However, such effect has never been tested in burning mouth syndrome (BMS) patients, a complex phenomenon influenced by both neuropathic and psychopathological factors. We aim to clarify how personality affects individual's pain and pain-related experiences. Methods: Two hundred forty-eight patients with BMS provided demographic information and psychiatric history; completed Ten-Item Personality Inventory, a Visual Analog Scale of pain, and McGill Pain Questionnaire; and provided adequate parameters of depressive state, catastrophizing thinking, and central sensitization. Results: BMS patients with depression history suffered more severe clinical symptoms and scored higher in neuroticism and less in openness and extraversion than did those without psychiatric diagnoses. After age, sex, and duration of pain were controlled, neuroticism in BMS patients with depression correlates with affective dimension of pain. Instead, if psychiatric history is absent, neuroticism correlates with sensory dimension and pain intensity. In both groups, higher neuroticism, unlike other personality facets, contributed to a more severe clinical condition. Conclusion: Of the five traits, neuroticism appears to be the most crucial dimension associated with the pain symptoms and patient's conditions. This study implies that management of pain must extend beyond solely providing pain-relieving medication and must require a holistic and multidisciplinary approach.

Case Report: Hidden Oral Squamous Cell Carcinoma in Oral Somatic Symptom Disorder

Background: Burning mouth syndrome (BMS) is a common condition of predominant oral pain without evident cause, that maxillofacial surgeons and otolaryngologists often refer to psychiatrists as somatic symptom disorder. In very rare cases, its typical burning symptom mimics those of other diseases in which serious fatal comorbidities may be missed. We encountered three rare cases of oral squamous cell carcinoma (OSCC) with the first symptom of burning tongue. Case Presentation: Case 1: A 68-year-old woman had burning pain on the left lingual margin for 8 years. Antidepressant treatment was not efficacious. Cytology and biopsy revealed OSCC. Case 2: A 70-year-old man had burning sensation and paralysis of the tongue for 6 months. Magnetic resonance imaging (MRI) revealed a 37 × 23-mm mass under the floor of the mouth and enlargement of lymph nodes on both sides. Case 3: A 90-year-old man had burning sensation of the tongue for 1 year. MRI revealed a 12 × 12-mm mass on the mandible with bone absorption. Conclusion: This case series suggests that psychiatrists must always be careful in regarding BMS as somatic symptom disorder and be cautious of the possibility of OSCC, especially in elderly patients.

Health-related quality of life in burning mouth syndrome - a case-control study

Objectives The cardinal symptom of burning mouth syndrome (BMS) is long-lasting pain and comprehensive health-related quality of life (HRQL) assessments may estimate how well patients with BMS live in relation to their health issues. The aims of the study were to explore general and BMS-specific HRQL based on an HRQL model and to compare HRQL in patients with BMS and age-matched controls. Methods For this case-control study 56 female patients with BMS and 56 female controls completed the following: A general questionnaire with Global items for life satisfaction, general health and oral health; General Population-Clinical Outcomes in Routine Evaluation (GP-CORE); Hospital Anxiety and Depression Scale (HADS); and Oral Health Impact Profile-14 (OHIP-14). Patients with BMS completed additional questionnaires which included BMS-problem severity, a global item for ratings of overall severity perceptions measured by visual analog scale (VAS); and BMS-modified Multidimensional Pain Inventory-Swedish version (MPI-S). BMS-modified MPI-S includes the three subscales Pain severity, Interference and Social support. Results Patients with BMS scored worse on all global items, GP-CORE, HADS and OHIP-14 compared to controls and the differences were large. Patients with severe BMS problems, as defined by a median split on BMS-problem severity, scored worse on the BMS-modified MPI-S subscale Pain severity and the difference was large. Conclusions We found clearly impaired general HRQL in patients with BMS compared to controls. For specific HRQL, the severity of pain was worse among patients with higher overall BMS-problem severity. The HRQL model with global ratings together with physical, psychological and social concepts has capacity to increase comparability and validity of studies, however further evaluations of the measures are needed. The HRQL model may be used over time to increase the understanding of different HRQL aspects and their internal relationships. In clinical settings, with an increased knowledge of one´s own distinctive quality of life abilities and restrictions, the patients with BMS can be guided and supported to manage their long-lasting pain. The HRQL model may be an aid toward bridging distinctions between general and oral health to further encourage collaboration between medicine and odontology.

Vortioxetine versus other antidepressants in the treatment of burning mouth syndrome: An open-label randomized trial

OBJECTIVES

This randomized open-label trial compared the efficacy and tolerability of vortioxetine (15 mg/daily) with different antidepressants in the treatment of patients with burning mouth syndrome (BMS).

METHODS

One and hundred fifty BMS patients were randomized into five groups and treated with either vortioxetine, paroxetine (20 mg/daily), sertraline (50 mg/daily), escitalopram (10 mg/daily) or duloxetine (60 mg/daily). The Visual Analogue Scale (VAS), Total Pain Rating Index (T-PRI), Hamilton Rating Scales for Depression (HAM-D) and Anxiety (HAM-A), and Clinical Global Impression Improvement (CGI-I) and Efficacy scales (CGI-E) were performed at baseline and after 2, 4, 6, and 12 months of treatment. Any adverse events (AEs) were tabulated for each group. Descriptive statistics, including the Kruskal-Wallis non-parametric test and the Friedman non-parametric test for median comparisons between different times, were used.

RESULTS

All the antidepressants (AD) were associated with a significant decrease in the VAS, T-PRI, HAM-A, HAM-D, CGI-I, and CGI-E scores in the long-term (p < .001). However, the response rate of the vortioxetine group showed a significant reduction after six months. The medians, after 6 months, were as follows: VAS 0.0; T-PRI 2.0; HAM-A 7.0; HAM-D 7.0; CGI-I 1.0; and CGI-E 1.0 with a lower incidence of AEs (p < .019).

CONCLUSION

Vortioxetine was efficacious with a shorter latency of action and fewer AEs compared with other ADs.

Photobiomodulation Therapy in the Management of Burning Mouth Syndrome: Morphological Variations in the Capillary Bed

Burning mouth syndrome (BMS) is an idiopathic condition that manifests itself primarily with the onset of a burning sensation. The aim of this research was to perform photobiomodulation therapy (PBM) using a diode laser on the oral mucosa of BMS patients, followed by an objective evaluation of the morphological changes in the vascular bed underlying the mucosa using polarized light videocapillaroscopy. A group of 40 patients were included in the study. The patients were randomly divided into two groups (using simple randomization) as follows: 20 patients were assigned to the laser group and 20 patients were assigned to the placebo group. Each patient of the laser group received eight irradiations (with 4 Watt of power, wavelength 800 nm, energy 1200 Joules, irradiation time of 300 s, energy density 50 J/cm², 60 mW continuous wave laser, and irradiance 180 mW/cm²), twice a week, blinded to the type of irradiation administered, for four consecutive weeks. The patients in the placebo group underwent the same sessions as the other patients, the only difference was the non-emission of the laser. An initial check of the vascular bed was performed with a polarized light videocapillaroscope. This was followed by treatment with a therapeutic diode laser and a subsequent check with a videocapillaroscope. We observed that in the group of patients who underwent laser therapy, there was a lasting improvement in symptoms. The capillary oral bed of patients in the placebo group did not show any statistically significant difference (p > 0.05). In the laser group we observed the following: in the buccal mucosa the diameter of the capillary had a reduction of 3 μm; in the upper lip mucosa, there was a reduction of 3 μm; in the lower lip mucosa, there was a reduction of 3 μm; and in the dorsal lingual surface, there was a reduction of 2 μm. An increase in capillary length was also obtained in all irradiated regions in the laser group patients (p < 0.05). PBM induces microcirculatory changes that are still present over a long period of time, such as an improvement in the clinical picture. The improvement in the symptoms has been correlated to the reduction of the capillary diameter. The placebo effect only led to a temporary improvement in symptoms that were unrelated to changes in the microcirculatory pattern.

The Geriatric Syndrome and Oral Health: Navigating Oral Disease Treatment Strategies in the Elderly

Poor oral health in the geriatric population is being framed as a potentially new geriatric syndrome; an oral and maxillofacial geriatric syndrome. As such, the treatment of oral diseases will require a comprehensive approach that considers the multimorbidity of disease, and polypharmacy that is precipitated/exacerbated by oral and maxillofacial dysfunction. This is challenging because oral diseases are not 1 discrete systemic illness but a combination of many with common causes. This article presents a roadmap approach to evaluate symptoms and apply therapeutic strategies for 5 common oral and maxillofacial dysfunctions seen in the elderly.

Therapeutic Dose of Amitriptyline for Older Patients with Burning Mouth Syndrome

OBJECTIVE

To assess the therapeutic dose and safety of amitriptyline and the outcome following treatment with amitriptyline among older patients with burning mouth syndrome (BMS).

METHODS

187 consecutive patients were prescribed amitriptyline as a first-line medication from April 2016 to September 2018 and followed-up for >1 month. Patients were divided into 3 groups: group 1, 113 patients aged <65 years; group 2, 52 patients aged between 65 and 74 years; and group 3, 22 patients aged 75 years or older. The visual analog scale (VAS), Pain Catastrophizing Scale (PCS), Somatic Symptom Scale-8 (SSS-8), Patient Global Impression of Change (PGIC), and Short-form McGill Pain Questionnaire (SF-MPQ) were used for analysis.

RESULTS

Thirty-two patients (17 in group 1, 10 in group 2, and 5 in group 3) stopped taking amitriptyline due to side effects. There were no differences among the groups with respect to sex; scores of VAS, PCS, and SSS-8; and drop-out ratio. There were no significant differences in the VAS, PCS, and PGIC scores among the groups after 1 month. The mean daily dose after 1 month was 20.4 ± 8.6 mg in group 1, 17.3 ± 8.7 mg in group 2, and 13.2 ± 5.8 mg in group 3; this difference was significant (p value = 0.003). About 76% of patients showed improvements in their symptoms (PGIC ≥ 3). About 90% of patients reported side effects. No serious side effects occurred.

CONCLUSION

The therapeutic dose of amitriptyline may be lower for older BMS patients than for younger patients.