Topical tretinoin treatment for burning mouth syndrome: a pilot study

OBJECTIVES

Burning mouth syndrome is an intraoral chronic pain condition characterized by a moderate to severe sensation of burning from the oral mucosa. No clinical signs are found and there is no efficient treatment.

METHOD AND MATERIALS

This pilot study included 10 women that were resistant to other previous treatments or noncompliant to systemic medications. Patients were asked to apply tretinoin gel 0.05% on their tongues twice daily for 14 days. Treatment effectiveness was assessed by completing a pre-study psychologic questionnaire and recording a daily wellbeing and pain log.

RESULTS

Significant pain-score decrease in 50% of the patients (delta numerical rating score -3.15 ± 3.02, P value = .005) was recorded. This finding was in concordance with the verbal statements including major quality-of-life improvement (P value = .05), without any treatment positive or negative predictive factors.

CONCLUSIONS

Topical tretinoin exhibits potential efficacy in patients with treatment resistant burning mouth syndrome and may also be used as a primary treatment modality.

Salivary concentrations of nickel and chromium in patients with burning mouth syndrome

It has been documented in vitro and in vivo that metal dental appliances release metal ions due to corrosion. Dentists must choose among many dental casting alloys available, often without knowledge of their biological properties and effect on oral mucosa. The aim of this study was to measure metal content of nickel (Ni) and chromium (Cr) in whole saliva of 85 patients with and without metal dental appliances. Unstimulated whole saliva was collected and analyzed by using electrothermal atomic absorption spectrometry. History data, subjective complaints and objective findings on oral mucosa were recorded. The concentration of metal ions was investigated in correlation to burning mouth syndrome, erythema of oral mucosa, pH and smoking habit. Results showed a higher Ni concentration in patients with metal restorations, especially wearers of predominantly base metal appliances. The concentration of Cr showed no difference between patient groups. Although burning mouth syndrome was more frequent in the group with dental casting alloys, there was no correlation between higher Ni and Cr concentrations and burning mouth syndrome. Erythema of oral mucosa was a common finding in study patients, but did not correlate with salivary Ni and Cr ion concentrations. Salivary Ni and Cr concentrations were not related to either pH or smoking habit.

A 10-year retrospective study on palladium sensitivity

BACKGROUND

Palladium has become an important contact allergen because of increased use in industry, jewelry, and dentistry.

OBJECTIVE

To determine the frequency of palladium allergy in a US patch-test population tested to palladium.

METHODS

A 10-year retrospective review (1997-2006) was performed on patients sensitive to palladium at the Department of Dermatology, Mayo Clinic, Rochester, MN.

RESULTS

A total of 910 patients were tested to a series that included palladium chloride 2% in petrolatum. A palladium-positive patch-test result was noted in 110 patients (12.1%). Of the 106 patients sensitized to palladium who had records available for review, 15.1% had a diagnosis of lichen planus-like eruptions; 13.2%, burning mouth; 27.4%, stomatitis; and 29.2%, hand and body dermatitis.

CONCLUSION

Palladium sensitivity is more common in oral diseases than in skin. We describe a previously unknown high degree of co-reactivity of gold with palladium to the same degree as the known co-reactivity with nickel.

Drug-induced burning mouth syndrome: a new etiological diagnosis

Burning mouth syndrome (BMS) is defined as a burning sensation of the oral mucosa, in the absence of specific oral lesions. The underlying etiology remains unclear. Peripheral alterations may be related to the density or reactive capacity of the oral mucosal membrane receptors - these being largely influenced by BMS-related risk factors such as stress, anxiety, the female gender, climacterium and advanced age. The present study compiles the cases of BMS induced by drugs reported in the literature, and attempts to draw a series of conclusions. A search was conducted in the PubMed database using the following key words: burning mouth syndrome, drug-induced, antihypertensive and chemically-induced. The search was carried out in April 2007. The literature yielded clinical cases in which oral burning sensation is described after the administration of drugs belonging to different therapeutic groups: antiretrovirals, antiseizure drugs, hormones and particularly antihypertensive medication. Curiously, among the different types of antihypertensive drugs, BMS was only associated with those compounds that act upon the angiotensin-renin system.

Oral adverse effects due to the use of Nevirapine

AIM

The aim of this article is to present the clinical characteristics and management of an oral adverse effect stemming from the use of the antiretroviral medication Nevirapine (NVP).

BACKGROUND

NVP is a non-nucleoside reverse transcriptase inhibitor used in the treatment of Human Immunodeficiency Virus (HIV) infection.

CASE REPORT

A 29-year-old black man, HIV-infected since 1996, began highly active antiretroviral therapy (HAART) with zidovudine, lamivudine, and indinavir. From 1996 to 2002 several medications were changed due to their adverse effects: indinavir (renal colic and fever), nelfinavir (cutaneous rash), and efavirenz (nausea and temporary memory loss). When the patient presented to our service he was taking NVP, zidovudine, and lamivudine. A whitish plaque in the lips and bilateral buccal mucosa, burning, taste disturbance, and xerostomia were observed. The discontinuation of HAART led to the complete resolution of signs and symptoms. The patient has received follow-up treatment for three years and five months without local or systemic effects observed.

SUMMARY

Unfortunately, the clinical features of the oral adverse effect from NVP are not well known. This paper contributed to the identification of possible reactions in the oral cavity due to antiretroviral medication. Although HAART is very important in the treatment of HIV, its side effects are responsible for patients' non-adherence to medications. While more studies are needed to better understand the mechanism of action after suspending HAART, the complete resolution of the signs and symptoms was observed. Therefore, physicians and dentists alike must understand how to identify and prevent these adverse effects in order to further improve HIV patient treatments.

Expression of contact allergy in undergoing prosthodontic therapy patients with oral diseases

AIM

Contact allergy is a postponed reaction of hypersensitivity where a localised cutaneous or mucosal lesion occurs due to a recurrent contact with an allergen. Placement of a fixed or removable prosthetic replacement into the oral cavity causes corrosive processes on the surface of the restoration and discharge of ions, which as haptens can induce allergic reactions. The purpose of this study was to examine occurrence of allergies to basic and auxiliary restorative dental materials in patients with lichen, stomatitis and stomatopyrosis by means of an epicutaneous allergy test.

METHODS

The study included 32 patients with a fixed and/or removable replacement and 7 patients with one of the mentioned diagnoses, but without any replacement. Testing was conducted using a standard method (patch test), and hypersensitivity to 13 most common allergens in prosthodontics was examined.

RESULTS

The research results revealed higher frequency of positive allergic reactions in persons with the mentioned diseases and with a restoration. Patients with lichen indicated positive patch test in the majority of cases. The allergens of nickel, cobalt and chromium demonstrated the highest score of positive results, and negative score was found for dibutylphthalate and HH mix. Stomatopyrosis was more common in persons with hypersensitivity to chromium. A lower incidence of positive allergic reactions to epoxide resins was found in female than in male subjects.

CONCLUSIONS

The epicutaneous (patch) test performed in the subjects examined in this study, showed that the majority of positive reactions was caused by mixes of nickel, cobalt and chromium; however, unwanted reactions also to other auxiliary materials used in dental practice should also be considered.

A review of drug-induced oral reactions

Every drug can produce untoward consequences, even when used according to standard or recommended methods of administration. Adverse drug reactions can involve every organ and system of the body and are frequently mistaken for signs of underlying disease. Similarly, the mouth and associated structures can be affected by many drugs or chemicals. Good oral health, including salivary function, is very important in maintaining whole body health. Regarding different parts of the oral system, these reactions can be categorized to oral mucosa and tongue, periodontal tissues, dental structures, salivary glands, cleft lip and palate, muscular and neurological disorders, taste disturbances, drug-induced oral infection, and facial edema. In this article, the drugs that may cause adverse effects in the mouth and related structures are reviewed. The knowledge about drug-induced oral adverse effects helps health professionals to better diagnose oral disease, administer drugs, improve patient compliance during drug therapy, and may influence a more rational use of drugs.

Antimicrobial activity of garlic, tea tree oil, and chlorhexidine against oral microorganisms

OBJECTIVE

To compare the antimicrobial activity of tea tree oil, garlic, and chlorhexidine solutions against oral microorganisms.

METHOD

The five-week study consisted of thirty subjects. The first week was considered baseline. All subjects used a control solution (second week), and were randomly divided into the three groups (third week): G1-0.12% chlorhexidine; G2 - 2.5% garlic (Allium sativum, L.); and G3 - 0.2% tea tree oil (Melaleuca alternifolia). Dishes containing blood agar and Mitis Salivarius Bacitracin agar (MSB) were inoculated with the subjects' saliva (collected twice a week). Total microorganisms and mutans streptococci were counted in blood agar and MSB, respectively.

RESULTS

Chlorhexidine and garlic groups showed antimicrobial activity against mutans streptococci, but not against other oral microorganisms. The tea tree oil group showed antimicrobial activity against mutans streptococci and other oral microorganisms. Maintenance of reduced levels of microorganisms was observed only for garlic and tea tree oil during the two consecutive weeks (fourth and fifth). Unpleasant taste (chlorhexidine 40%, tea tree oil 30%, garlic 100%), burning sensation (chlorhexidine 40%, tea tree oil 60%, garlic 100%), bad breath (chlorhexidine 40%, tea tree oil 20%, garlic 90%), and nausea (chlorhexidine 0%, tea tree oil 10%, garlic 30%) were reported.

CONCLUSION

Garlic and tea tree oil might be an alternative to chlorhexidine.

Burning mouth syndrome after taking clonazepam

OBJECTIVE

To report the first published case of clonazepam-induced burning mouth syndrome (BMS).

CASE SUMMARY

A 52-year-old white woman presented to the clinic with burning mouth symptoms. The patient was previously maintained on alprazolam therapy for anxiety, but was switched to clonazepam because of increased anxiety and panic. Clonazepam significantly relieved her symptoms, but after four weeks of therapy, she reported a constant, mild, oral burning sensation. An oral examination was negative for mucosal abnormalities, and laboratory tests were unremarkable. The clonazepam dose was reduced, and the symptoms decreased, but remained intolerable. Clonazepam was discontinued, and the burning mouth symptoms completely resolved. Since no other medications relieved the anxiety and panic symptoms, the patient requested clonazepam to be reinitiated, but she again developed intolerable burning mouth symptoms. As clonazepam was discontinued, the symptoms resolved.

DISCUSSION

The clinical presentation of BMS includes burning and painful sensations of the mouth in the absence of mucosal abnormalities. Candidiasis, anemia, menopause, diabetes mellitus, medications, anxiety, and depression are some causes of this syndrome. Paradoxically, clonazepam has been studied for the treatment of BMS and has demonstrated mild to moderate improvement. In this patient, underlying causes of BMS were eliminated when possible. The association between clonazepam and BMS was highly probable according to the Naranjo probability scale.

CONCLUSIONS

This is the first published report describing BMS with a benzodiazepine. Although uncommon, clinicians should be aware of this potential adverse effect due to the widespread use of benzodiazepines.

Burning mouth syndrome due to cadmium in a denture wearer

We report the case of a female denture wearer who was referred to our service due to burning of the lips and tongue but with no visible oral lesions. Her biochemical data, complete blood cell count, sedimentation rate, thyroid and sex hormones were normal. Tongue culture was negative. Patch tests, performed with a panel of 20 potential denture allergens, gave positive results (+++) only to a 2% petrolatum cadmium sulfate, which was present in the denture. Removal of the denture led to the clearing up of oral symptoms in 3 days. In light of these findings, carrying out patch tests with the allergens related to denture materials should be considered in these cases.

"Scalded mouth syndrome" caused by angiotensin converting enzyme inhibitors: two case reports

Two cases of "scalded mouth syndrome" are presented and discussed. This condition is a rare side effect of angiotensin converting enzyme inhibitors. Angiotensin converting enzyme inhibitors are known to cause several other oral and extra-oral side effects. In scalded mouth syndrome, the patient's complaints concern a burning pain of the oral soft tissues. There are no clinical findings.

Contact sensitivity to menthol and peppermint in patients with intra-oral symptoms

We report 12 cases of contact sensitivity to the flavouring agents menthol and peppermint oil in patients presenting with intra-oral symptoms in association with burning mouth syndrome, recurrent oral ulceration or a lichenoid reaction. The patients were referred from the Glasgow Dental Hospital over a 4-year period for assessment of the possible contribution of contact sensitivity to their complaints. 5 patients with burning mouth syndrome demonstrated contact sensitivity to menthol and/or peppermint, with 1 patient sensitive to both agents, 3 positive to menthol only and 1 to peppermint only. 4 cases with recurrent intra-oral ulceration were sensitive to both menthol and peppermint. 3 patients with an oral lichenoid reaction were positive to menthol on patch testing, with 2 also sensitive to peppermint. 9 of the 12 cases demonstrated additional positive patch test results. After a mean follow-up of 32.7 months (range 9-48 months), of the 9 patients that could be contacted, 6 patients described clearance or improvement of their symptoms as a consequence of avoidance of menthol/peppermint.

An unusual cause of burning mouth sensation

A case of burning mouth and disturbed taste following accidental exposure to pyrethroid in an insecticide is reported. The symptoms were more prolonged than have been previously reported following cutaneous exposure.

Allergy to octyl gallate causing stomatitis

Octyl gallate is an antioxidant (European Community number 311). It is used as a preservation agent in a wide variety of foods and other non-dietary substances. We report a case of a 49-year-old female with a 10-year history of 'burning mouth' and clinical erythema of the tongue, who, after investigation, proved to be allergic to octyl gallate. Management with an exclusion diet proved effective in both controlling the burning sensation and resolving the erythema of the tongue.

Palladium in dental alloys--the dermatologists' responsibility to warn?

Palladium is increasingly used in industry, but also in fine jewelry and in dentistry. Thus, palladium-silver alloys comprise a substantial part of the noble metal ceramic alloy sales in Western countries. The increased use of this metal seems, however, to be paralleled by a rise in the number of reports of palladium allergy. Recently a European study reported a sensitization rate of 2.8%. In Austria, where palladium has started to displace amalgam in dental fillings because of concerns about mercury toxicity, and gold due to price factors, we have found a sensitization rate of 8.3% in unselected eczema patients. Despite the current lack of clear clinical relevance of this finding, these numbers should motivate us to question this substance as "the alloy of the future".

Oral manifestations of poisoning

The purpose of this paper is to describe the variety of chemical agents and medicines which can produce oral manifestations following poisoning. Rapid diagnosis is essential in covert cases to ensure early treatment. Furthermore, oral care is an important part of the general management of many poisoned patients.

Lisinopril-induced "scalded mouth syndrome"

OBJECTIVE

To report a case of "scalded mouth syndrome" (SMS) caused by lisinopril.

PATIENT

A woman being treated with lisinopril for hypertension developed a burning sensation of her lips and buccal mucosa. The condition persisted with continued use of lisinopril and subsided when the medication was discontinued.

CONCLUSIONS

The symptoms described by our patient were similar to those reported in previous cases of SMS associated with the use of enalapril and captopril, two other angiotensin-converting enzyme (ACE) inhibitors. This reaction to ACE inhibitors appears to be dose related, and subsides with a decreased dosage or discontinuation of the medication.

Burning mouth syndrome: a possible etiologic role for local contact hypersensitivity

BACKGROUND

The pathogenesis of the burning mouth syndrome (BMS) is not yet understood. Apart from psychologic factors, several etiologic "somatic" factors have been reported.

OBJECTIVE

In 22 patients (19 women, 3 men, mean age 56 years) classified with BMS, clinical and laboratory investigations were performed, with particular emphasis on the role of contact hypersensitivity. Twenty of the 22 patients wore a complete or partial denture.

METHODS

Besides clinical and laboratory investigations patch testing was performed with a standard routine series and a standardized denture-dental (acrylate and metal) series.

RESULTS

Folate, iron, pyridoxine deficiency, and Candida infections were found, but correction of the deficiency or treatment of the infection was of no benefit. Contact allergy to allergens used in the production of acrylate-based dentures was observed in six (27%) of the cases (all wore a denture); positive reactions were seen to N,N,-dimethyl-4-toluidine (3 cases), to 4-tolyldiethanolamine (2 cases), to benzoylperoxide (2 cases), and to oligotriacrylate (1 case). In six cases (27%) a possible relevant sensitization was seen to dental metals and in particular to gold chloride (four cases).

CONCLUSION

The possible role of local hypersensitivity reactions to denture or dental components as etiologic factors in BMS must be considered.

Contact allergy to denture materials in the burning mouth syndrome

Several factors may be responsible for stomatitis in general and the burning mouth syndrome in particular. The results of patch testing are reported in 4 patients with burning mouth symptoms thought to be due to sensitization to denture material. 2 patients reacted to substances in Luxene dentures, but the allergens were not identified. In a 3rd patient, sensitization was found to monomeric methyl methacrylate. The other patient gave positive patch tests to epoxy resin (and bisphenol A), probably present in glue used for repair of dental plates. To obtain a complete diagnosis in cases of suspected contact stomatitis due to allergens in dentures, a reliable standard test series is required.

The role of cadmium as a skin sensitizing agent in denture and non-denture wearers

Positive patch test reactions to cadmium were observed in 8 out of 21 denture wearing persons with burning mouth sensations during 1979 and 1980, and in 13 of 125 consecutive outpatients being routine tested at the Dermatological Department in late 1980 and early 1981. Retesting 17 of these patients after at least 3 months delay with 2.0% cadmium chloride and 2% cadmium sulphate in water showed only 7 with a definite positive reaction. At serial dilution of cadmium sulphate, only 1 person reacted to a 1% aqueous solution. An exposure to cadmium could in 1 case be traced back to a 2-year period of work in a PVC plant, while in the remaining 6 cases the most probable exposure factor seemed to be chronic heavy cigarette smoking. The observations did not lend support to the pink acrylic denture base material being a relevant cadmium exposure factor.

[Plastic bonding material as the origin of mucosal disorders]

A case reported in which the patient complained of sensations in the musoca over a period of one year. Various other specialists were consulted, but the cause of these sensations could not be established. When the plastic facing on the upper anterior crowns was removed, the sensations disappeared. A metal-ceramic bridge was inserted, and the patient was fitted with a removable dental prosthesis containing teeth made of mineral substance and a base of injection moulding (Copodon). The patient is still free of complaints.