A diagnostic and therapeutic approach to primary burning mouth syndrome

Duloxetine improves chronic orofacial pain and comorbid depressive symptoms in association with reduction of serotonin transporter protein through upregulation of ubiquitinated serotonin transporter protein

ABSTRACT

Chronic orofacial pain (COP) is relieved by duloxetine (DLX) and frequently causes depressive symptoms. The aim of this study was to confirm effects of DLX on pain and depressive symptoms, and to associate with their effectiveness in platelet serotonin transporter (SERT) expression, which is a target molecule of DLX and plasma serotonin concentration in COP patients with depressive symptoms. We assessed for the severity of pain and depressive symptoms using the Visual Analog Scale (VAS) and 17-item Hamilton Depression Rating Scale (HDRS), respectively. Chronic orofacial pain patients were classified into 2 groups based on their HDRS before DLX-treatment: COP patients with (COP-D) and without (COP-ND) depressive symptoms. We found that the VAS and HDRS scores of both groups were significantly decreased after DLX treatment compared with those before DLX treatment. Upregulation of total SERT and downregulation of ubiquitinated SERT were observed before DLX treatment in both groups compared with healthy controls. After DLX treatment, there were no differences in total SERT of both groups and in ubiquitinated SERT of COP-D patients compared with healthy controls; whereas, ubiquitinated SERT of COP-ND patients remained downregulated. There were positive correlations between changes of serotonin concentrations and of VAS or HDRS scores in only COP-D patients. Our findings indicate that DLX improves not only pain but also comorbid depressive symptoms of COP-D patients. Duloxetine also reduces platelet SERT through upregulation of ubiquitinated SERT. As the result, decrease of plasma serotonin concentrations may be related to the efficacy of DLX in relieving pain and depression in COP patients.

Non-Communicable Diseases and Associated Risk Factors in Burning Mouth Syndrome Patients

Background and Objectives: Noncommunicable diseases (NCDs) are a group of non-transmissible conditions that tend to be of long duration and are the result of a combination of genetic, physiological, environmental, and behavioral factors. Although an association between oral disorders and NCDs has been suggested, the relationship between Burning Mouth Syndrome (BMS) and NCDs and their associated risk factors has not been deeply investigated. In this study, we aim to identify associations between BMS and NCDs in the Romanian population. Materials and Methods: Ninety-nine BMS patients and 88 age-matched controls (aged 50 and over) were clinically evaluated for the presence of eight noncommunicable diseases (NCDs) and their most common risk factors, including hypertension, dyslipidemia, smoking, and obesity. Results: The results of our study showed that the BMS in the Romanian population seems to be significantly associated with cardiovascular diseases (CVDs) (p < 0.001) and two of their risk factors, hypertension (p < 0.001) and dyslipidemia (p < 0.001). Moreover, evaluating the Framingham Risk Score (FRS) in the individuals not affected by CVDs (73 CTRL and 38 BMS), we found that 13.2% of BMS patients reported a moderate risk of developing CVDs in ten years, compared to the controls, all of whom presented a low risk (p = 0.002). Conclusions: Our findings suggest that a multidisciplinary clinical approach, which also includes a cardiovascular evaluation, is essential for the successful management of BMS. Moreover, these data highlighted the importance of introducing an integrated strategy for the prevention and care of NCDs in BMS patients.

The present and the future of benzydamine: expert opinion paper

Objectives

Benzydamine is a compound indicated in the treatment of symptoms of irritation/inflammation of the oropharyngeal cavity, including those associated with pain. Objectives of this expert opinion narrative review is to summarize current indicated benzydamine applications and elicit further ones to be explored.

Materials and methods

In this expert opinion paper, evidences underlying the mechanism of action and clinical application of benzydamine are reviewed. Insights are also provided on possible new clinical applications of the drug and new formulations.

Results

Current recognized indications of benzydamine include: relief of symptoms associated with inflammatory conditions of the mouth and oropharynx, symptomatic treatment of gingivitis and stomatitis, oral mucositis induced by chemotherapy and/or radiotherapy and post operative sore throat. In addition, among new applications that need to be explored experts embed: oral lichen planus, burning mouth syndrome, post intubation sore throat, antifungal action and new anticancer target agents induced mucositis.

Conclusions

Benzydamine is a very versatile compound able to play an auxiliary and adjuvant role in the prevention and treatment of oral cavity/oropharynx disorders. According to experts' opinion there is the need to design clinical trials to highlight novel possible applications of benzydamine and implemented translational analyses to fine-tune patients' selection and open future research scenarios.

Treatments for Burning Mouth Syndrome: A Network Meta-analysis

The aim of this systematic review and network meta-analysis (NMA) of randomized controlled trials was to evaluate the effectiveness of treatments for pain relief of burning mouth syndrome (BMS). Five databases and gray literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. The primary outcome was pain relief or burning sensation, and the secondary outcomes were side effects, quality of life, salivary flow, and TNF-α and interleukin 6 levels. Four comparable interventions were grouped into different network geometries to ensure the transitivity assumption for pain: photobiomodulation therapy, alpha-lipoic acid, phytotherapics, and anxiolytics/antidepressants. Mean difference (MD) and 95% CI were calculated for continuous outcomes. The minimal important difference to consider a therapy beneficial against placebo was an MD of at least -1 for relief of pain. To interpret the results, the GRADE approach for NMA was used with a minimally contextualized framework and the magnitude of the effect. Forty-four trials were included (24 in the NMA). The anxiolytic (clonazepam) probably reduces the pain of BMS when compared with placebo (MD, -1.88; 95% CI, -2.61 to -1.16; moderate certainty). Photobiomodulation therapy (MD, -1.90; 95% CI, -3.58 to -0.21) and pregabalin (MD, -2.40; 95% CI, -3.49 to -1.32) achieved the minimal important difference of a beneficial effect with low or very low certainty. Among all tested treatments, only clonazepam is likely to reduce the pain of BMS when compared with placebo. The majority of the other treatments had low and very low certainty, mainly due to imprecision, indirectness, and intransitivity. More randomized controlled trials comparing treatments against placebo are encouraged to confirm the evidence and test possible alternative treatments (PROSPERO CRD42021255039).

Salivary characteristics in burning mouth syndrome: a systematic review

INTRODUCTION

Compare through case-control studies, the salivary characteristics of patients with and without BMS.

EVIDENCE ACQUISITION

Searches in Embase, PubMed, Web of Science, Scopus, Cochrane, and BIREME were conducted for the identification of case-controls studies reported.

EVIDENCE SYNTHESIS

Thirty-three studies were included, of which 26 articles evaluated OSB, 17 SRF, and 7 SE. Nineteen organic biomarkers showed higher levels in BMS patients, the two most indicated being α-amylase and cortisol. Ten organic biomarkers, including Tumor Necrosis Factor-alpha (TNF-α) and IL-6, showed lower levels in BMS patients. Regarding salivary flow rate (SFR), five articles indicated that BMS patients have less unstimulated SFR (uSRF)Two articles indicate that stimulated SFR (sSRF) is lower in BMS patients nevertheless, but eight did not show differences. Sialochemical analysis revealed that sodium (Na), chloride (Cl), potassium (K), sodium (Na), and calcium (Ca), showed higher levels in BMS patients according to three studies, but two studies did not establish any differences. Two study established that BMS patients have lower Mg salivary levels.

CONCLUSIONS

Qualitative salivary characteristics suggest that BMS has neuropathic, inflammatory, emotional, immune, and hormonal involvements. BMS can be associated with changes in salivary biomarkers of inflammation and oxidative stress, is related to anxiety and degree of pain.

[Oral hygiene and microcirculation of the mucous membrane of the tongue and gums dynamics in patients with burning mouth syndrome as a result of the use of a toothbrush with a gold-zinc electroplating]

THE AIM OF THE STUDY

Was to assess the level of oral hygiene and microcirculation of the mucous membrane of the tongue and gums in patients with burning mouth syndrome (BMS) as a result of using a toothbrush with a gold-zinc electroplating.

MATERIALS AND METHOS

The study included 50 patients of both sexes aged 45-64 years with the diagnosis of BMS divided into two groups. In the main group, the complex of hygienic measures included the use of a toothbrush with a gold-zinc electroplating and a paste with the fluorine content of 1350 ppm. In the comparison group, a regular manual toothbrush and a paste with a fluoride content of 1350 ppm were used for oral hygiene. A control group consisted of 25 healthy people with the mean age of 44±4.5 years without clinical signs of BMS in the oral cavity and concomitant acute somatic pathologies.

RESULTS

Tongue mucosa microcirculation level in patients using the toothbrush with a gold-zinc electroplating was significantly higher than in the comparison group using conventional manual toothbrush. Oral hygiene level assessment showed statistically significant better brushing efficacy in patients using the toothbrush with a gold-zinc electroplating.

CONCLUSION

The use of a toothbrush with a gold-zinc electroplating contributes to the normalization of microcirculation in the mucous membrane of the tongue and gums and is recommended for inclusion in the complex of therapeutic measures in patients with BMS.

Salivary characteristics may be associated with burning mouth syndrome?

Background

Burning mouth syndrome (BMS) it is characterized by burning and uncomfortable sensations with no clinical alterations or laboratory findings. The evaluation of the salivary characteristics of people with BMS can help the understanding of the pathogenesis of this condition. This case-control study aimed to trace the salivary profile of women with burning mouth syndrome (BMS).

Material and Methods

40 women with BMS and 40 control women were recruited. Unstimulated salivary flow rate (uSFR), pH, salivary cortisol levels, salivary viscosity, and oral health impact profile (OHIP-14 questioner) were determined. P< 0.05 was considered statistically significant.

Results

For uSFR, mean values obtained for BMS and for control group respectively were 0.35 and 0.61 mL/min; for pH, 7.23 and 7.34; for cortisol levels, 0.36 and 0.15 μg/dL; for viscosity values, 31.1 and 45.01 mPas and for OHIP-14 scores, 21.7 and 5.7. To uSFR, cortisol levels, viscosity values and OHIP-14 scores, differences were statistically significant. Salivary cortisol levels and OHIP-14 scores were correlated positively (rho = 0.624; p< 0.05).

Conclusions

BMS women have lower uSFR and salivary viscosity and higher salivary cortisol levels that were associated with worse quality of life, compared with the control group.

Key words:Xerostomia, Burning mouth syndrome, Viscosity.

The Association between Emotional Stress, Sleep Disturbance, Depression, and Burning Mouth Syndrome

INTRODUCTION

Burning mouth syndrome (BMS) is one of the challenging clinical problems not only in its diagnosis and treatment but also its concurring mental impact. This study is aimed at determining the association between psychological factors, including emotional stress, depression, anxiety, and sleep pattern among BMS patients.

METHODS

In this cross-sectional study, 19 patients with idiopathic BMS were enrolled along with a control group equivalent in age and sex, but without BMS. Questionnaires used were the Visual Analog Scale (VAS), the Pittsburgh Sleep Quality Index (PSQI), and the Depression, Anxiety, and Stress Scale (DASS-21). Demographic information was also recorded and analyzed.

RESULTS

There was a significant correlation among the two groups of BMS and non-BMS patients regarding stress, depression, and sleep disorder. The average severity of the burning score was 8.31 among the patients. Furthermore, a significant correlation was observed among mental disorders and educational level and sex, but not with age. There was also no significant correlation among the severity of the burning score with sex, education, and mental disorder.

CONCLUSION

BMS is significantly associated with psychological symptoms. This condition requires proper treatment and support because it can represent psychological or mental issues and/or have a significant effect on daily life.

Effect of a Homemade Salivary Substitute Prepared Using Chamomile (Matricaria chamomilla L.) Flower and Flax (Linum usitatissimum L.) Seed to Relieve Primary Burning Mouth Syndrome: A Preliminary Report

Objectives: To evaluate (1) the effect of a salivary substitute prepared using chamomile (Matricaria chamomilla L.) flower and flax (Linum usitatissimum L.) seed to relieve Primary burning mouth syndrome (BMS) symptoms, (2) their effect on the inhibition of matrix metallopeptidase 2 (MMP2) and MMP9 metalloproteinases, and (3) their potential cellular cytotoxic effect. Subjects: 40 women aging >40 years with diagnosis of primary BMS. Settings/Location: Center of Diagnosis of Diseases of the Mouth, Federal University of Pelotas, Brazil. Design: This was an open clinical trial where primary BMS patients used the homemade salivary. At the first appointment, after 30 and 60 days, the authors evaluated the pattern and intensity of BMS and xerostomia symptoms, and then determined and compared the unstimulated salivary flow rate (SFR), viscosity, and salivary pH. MMP2 and MMP9 activities in saliva and cytotoxicity were assessed using different concentrations of chamomile flower and flax seed separately. Interventions: Subjects used the homemade salivary substitute for 3 months and were instructed to rinse their mouth three to four times daily for 1 min. Outcome measures: A numeric rating scale to evaluate the intensity of burning sensation and xerostomia symptoms, salivary flow rate (SFR) to determine salivary volume, dynamic rheology technique for viscosity and a digital meter for salivary pH. MMP2 and MMP9 activities in saliva and cytotoxicity were assessed by zymography and cell viability assay respectively. Results: After treatment, severity of BMS symptoms decreased, the SFR increased, salivary viscosity decreased, and severity of xerostomia sensation (in patients who reported having this symptom) improved (p < 0.05). Chamomile flower and flax seed had no effect on inhibiting MMP2 and MMP9 activities, and neither showed cellular cytotoxic effects. Conclusion: This homemade salivary substitute is an economical, viable, easily manipulated, noncytotoxic, and a practical alternative to relieve BMS symptoms.

Developing a research diagnostic criteria for burning mouth syndrome: Results from an international Delphi process

OBJECTIVE

To develop a beta version of a preliminary set of empirically derived research diagnostic criteria (RDC) for burning mouth syndrome (BMS) through expert consensus, which can then be taken into a test period before publication of a final RDC/BMS.

DESIGN

A 6 round Delphi process with twelve experts in the field of BMS was used. The first round formed a focus group during which the purpose of the RDC and the definition of BMS was agreed upon, as well as the structure and contents. The remaining rounds were carried out virtually via email to achieve a consensus of the beta version of the RDC/BMS.

RESULTS

The definition of BMS was agreed to be 'an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without evident causative lesions on clinical examination and investigation'. The RDC was based upon the already developed and validated RDC/TMD and formed three main parts: patient self-report; examination; and psychosocial self-report. A fourth additional part was also developed listing aspirational biomarkers which could be used as part of the BMS diagnosis where available, or to inform future research.

CONCLUSION

This Delphi process has created a beta version of an RDC for use with BMS. This will allow future clinical research within BMS to be carried out to a higher standard, ensuring only patients with true BMS are included. Further validation studies will be required alongside refinement of the RDC as trialling progresses.

Clinical presentation of burning mouth syndrome in patients with oral lichenoid disease

BACKGROUND

To analyze the presence of burning mouth syndrome (BMS) in a group of patients diagnosed with oral lichenoid disease (OLD).

MATERIAL AND METHODS

A retrospective study of 217 patients diagnosed with OLD; 158 (72,8%) women and 59 (27,2%) men, with an average age upon diagnosis of 56,4 years (SD 11,88). We carried out a detailed and complete characterization of symptoms, with special emphasis on BMS diagnostic data specified by the International Headache Society.

RESULTS

Four patients (1.8%) presented with long-term clinical symptoms of burning mouth, indicative of BMS and they fulfilled the IHS 2018 criteria, except for criterion D, i.e."Oral mucosa is of normal appearance". The observed lichenoid mucosal lesions were not considered to be able to account for the reported intraoral pain in any of our patients. Thus neither diagnosis was considered to be exclusive.

CONCLUSIONS

Patients diagnosed with OLD, and who simultaneously present clinical characteristics of BMS should be studied in detail, in order to evaluate the possibility of both diagnoses concurring.

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.

Burning Mouth Syndrome

Burning mouth syndrome is a chronic condition characterized by an intraoral burning sensation in the absence of a local or systemic cause.

Effectiveness of photobiomodulation in the treatment of primary burning mouth syndrome-a systematic review and meta-analysis

To evaluate the effectiveness of photobiomodulation (PBM) on primary burning mouth syndrome (pBMS). We searched Chinese and English studies published before February 10, 2020. The databases used include PubMed, EMBASE, the Cochrane Library, Web of Science, Wanfang Database, and China National Knowledge Infrastructure (CNKI). Randomized controlled clinical trials (RCTs) that used the PBM to treat pBMS and reported specific treatment outcomes were considered for inclusion. We eventually included 12 RCTs, and 574 samples were included in these studies. The primary outcomes investigated were pain reduction and life quality improvement. A meta-analysis performed on 9 groups in 5 trials showed that PBM was effective in reducing pain compared with placebo (MD - 1.86, 95% CI - 2.59 to - 1.13, Z = 4.99, P < 0.00001). Meta-analysis was also performed on 7 groups in 4 trials and showed that PBM was effective in improving life quality compared with placebo (MD - 3.43, 95% CI - 5.11 to - 1.75, Z = 4.00, P < 0.0001). Qualitative analysis of the included RCTs found that PBM might also play a role in the decrease of TNF-α and IL-6 in saliva. Three studies that compared PBM with medications were evaluated by descriptive analysis. None of the treatment-related adverse event was reported. Up to date, PBM appears to have an effect on pain reduction and life quality improvement in pBMS patients. However, more evidence is still required to warrant its efficacy and safety in treating pBMS.

Burning Mouth Syndrome and Contact Dermatitis

: Burning mouth syndrome (BMS) is a condition that remains a diagnostic challenge and is frequently difficult to treat. Rather than being a singular entity, more recent research has suggested that the diagnosis of BMS encompasses a family of syndromes. Of this family, type 3 has been identified as being related to contact dermatitis. Although this subtype has been most commonly associated with dental allergens, several food, cosmetic, and pharmaceutical products have also been identified as allergens related to the onset of BMS. Failure to identify these allergens prevents timely diagnosis and initiation of treatment for patients with BMS related to contact dermatitis. This article identifies the allergens most relevant to this type 3 and describes the commercially available allergy panels needed to ensure that all relevant allergens are included during patch testing. This study also describes approaches to diagnosis of BMS and discusses approaches to treatment based on subtypes of the condition.

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

Burning Mouth Syndrome (BMS), a chronic intraoral burning sensation or dysesthesia without clinically evident causes, is one of the most common medically unexplained oral symptoms/syndromes. Even though the clinical features of BMS have been astonishingly common and consistent throughout the world for hundreds of years, BMS remains an enigma and has evolved to more intractable condition. In fact, there is a large and growing number of elderly BMS patients for whom the disease is accompanied by systemic diseases, in addition to aging physical change, which makes the diagnosis and treatment of BMS more difficult. Because the biggest barrier preventing us from finding the core pathophysiology and best therapy for BMS seems to be its heterogeneity, this syndrome remains challenging for clinicians. In this review, we discuss currently hopeful management strategies, including central neuromodulators (Tricyclic Antidepressants - TCAs, Serotonin, and Norepinephrine Reuptake Inhibitors - SNRIs, Selective Serotonin Reuptake Inhibitors - SSRIs, Clonazepam) and solutions for applying non-pharmacology approaches. Moreover, we also emphasize the important role of patient education and anxiety management to improve the patients’ quality of life. A combination of optimized medication with a short-term supportive psychotherapeutic approach might be a useful solution.