What is burning tongue syndrome

Burning tongue or burning mouth syndrome is the medical term for ongoing (chronic) or recurrent burning sensation in the mouth without an obvious cause ¹. This discomfort may affect the tongue, gums, lips, inside of your cheeks, roof of your mouth or widespread areas of your whole mouth. The burning sensation can be severe, as if you scalded your mouth.

Burning mouth syndrome can appear suddenly or develop gradually over time. Unfortunately, the cause often can’t be determined and there has also been no clear consensus on the pathogenesis or treatment of burning mouth syndrome ². Although that makes treatment more challenging, you can often get burning mouth syndrome under better control by working closely with your health care team.

Burning tongue or burning mouth syndrome is believed to be neurogenic, affecting nerves of pain and taste. Causes of secondary burning tongue or burning mouth syndrome include

• Nutritional deficiency (vitamin B12, iron)
• Diabetes mellitus
• Candida infection (candidiasis)
• Allergy (foods, dental products)
• Xerostomia (or significant dry mouth)
• ACE inhibitors

Burning tongue or burning mouth syndrome may cause burning, tingling, or numbness of the tongue or other areas of the mouth, including the lips. Dry mouth or altered taste may occur. The pain may be constant or increase throughout the day and may be relieved by eating or drinking. Duration of symptoms of BMS is variable and may recur if the cause is not addressed.

Based on the makeup of most studies published to date, burning tongue or burning mouth syndrome appears to be most prevalent in postmenopausal women ³. It has been reported in 10 to 40 percent of women presenting for treatment of menopausal symptoms ⁴. These percentages are in contrast to the much lower prevalence rates for oral burning in epidemiologic studies (0.7 to 2.6 percent) ⁵. The reason for the gender difference between study populations (approximately 85 percent of study subjects have been women) and epidemiologic studies (which demonstrate a more equal distribution of oral burning in men and women) may be related to the definition used in each study design.

Symptoms of burning tongue

In more than one half of patients with burning tongue or burning mouth syndrome, the onset of pain is spontaneous, with no identifiable precipitating factor ⁶. Approximately one third of patients relate time of onset to a dental procedure, recent illness or medication course (including antibiotic therapy). Regardless of the nature of pain onset, once the oral burning starts, it often persists for many years ⁷.

The burning sensation often occurs in more than one oral site, with the anterior two thirds of the tongue, the anterior hard palate and the mucosa of the lower lip most frequently involved ³. Facial skin is not usually affected. No correlation has been noted between the oral sites that are affected and the course of the disorder or the response to treatment.

In many patients with the syndrome, pain is absent during the night but occurs at a mild to moderate level by middle to late morning. The burning may progressively increase throughout the day, reaching its greatest intensity by late afternoon and into early evening ⁷. Patients often report that the pain interferes with their ability to fall asleep. Perhaps because of sleep disturbances, constant pain, or both, patients with oral burning pain often have mood changes, including irritability, anxiety and depression ⁸. Earlier studies frequently minimized the pain of burning mouth syndrome, but more recent studies have reported that the pain ranges from moderate to severe and is similar in intensity to toothache pain ⁹.

Little information is available on the natural course of burning mouth syndrome. Spontaneous partial recovery within six to seven years after onset has been reported in up to two thirds of patients, with recovery often preceded by a change from constant to episodic burning ³. No clinical factors predicting recovery have been noted.

Most studies have found that oral burning is frequently accompanied by other symptoms, including dry mouth and altered taste ³. Alterations in taste occur in as many as two thirds of patients and often include complaints of persistent tastes (bitter, metallic, or both) or changes in the intensity of taste perception. Dysgeusic tastes accompanying oral burning are often reduced by stimulation with food ⁷. In contrast, application of a topical anesthetic may increase oral burning while decreasing dysgeusic tastes.

Symptoms of burning mouth syndrome may include:

• A burning or scalded sensation that most commonly affects your tongue, but may also affect your lips, gums, palate, throat or whole mouth
• A sensation of dry mouth with increased thirst
• Taste changes, such as a bitter or metallic taste
• Loss of taste

The discomfort from burning tongue or mouth syndrome typically has several different patterns. It may:

• Occur every day, with little discomfort when you wake, but become worse as the day progresses
• Start as soon as you wake up and last all day
• Come and go

Whatever pattern of mouth discomfort you have, burning mouth syndrome may last for months to years. In rare cases, symptoms may suddenly go away on their own or become less frequent. Some sensations may be temporarily relieved during eating or drinking.

Burning mouth syndrome usually doesn’t cause any noticeable physical changes to your tongue or mouth.

When to see a doctor

If you have discomfort, burning or soreness of your tongue, lips, gums or other areas of your mouth, see your doctor or dentist. They may need to work together to help pinpoint a cause and develop an effective treatment plan.

Causes burning tongue / mouth syndrome

The cause of burning mouth syndrome can be classified as either primary or secondary.

Primary burning mouth syndrome

When no clinical or lab abnormalities can be identified, the condition is called primary or idiopathic burning mouth syndrome. Some research suggests that primary burning mouth syndrome is related to problems with taste and sensory nerves of the peripheral or central nervous system.

Secondary burning mouth syndrome

Sometimes burning mouth syndrome is caused by an underlying medical condition. In these cases, it’s called secondary burning mouth syndrome.

Underlying problems that may be linked to secondary burning mouth syndrome include:

• Dry mouth (xerostomia), which can be caused by various medications, health problems, problems with salivary gland function or the side effects of cancer treatment
• Other oral conditions, such as a fungal infection of the mouth (oral thrush), an inflammatory condition called oral lichen planus or a condition called geographic tongue that gives the tongue a map-like appearance
• Nutritional deficiencies, such as a lack of iron, zinc, folate (vitamin B-9), thiamin (vitamin B-1), riboflavin (vitamin B-2), pyridoxine (vitamin B-6) and cobalamin (vitamin B-12)
• Dentures, especially if they don’t fit well, which can place stress on some muscles and tissues of your mouth, or if they contain materials that irritate mouth tissues
• Allergies or reactions to foods, food flavorings, other food additives, fragrances, dyes or dental-work substances
• Reflux of stomach acid (gastroesophageal reflux disease or GERD) that enters your mouth from your stomach
• Certain medications, particularly high blood pressure medications
• Oral habits, such as tongue thrusting, biting the tip of the tongue and teeth grinding (bruxism)
• Endocrine disorders, such as diabetes or underactive thyroid (hypothyroidism)
• Excessive mouth irritation, which may result from overbrushing your tongue, using abrasive toothpastes, overusing mouthwashes or having too many acidic drinks
• Psychological factors, such as anxiety, depression or stress.

Table 1. Possible Causes and Management of Burning Tongue or Mouth Symptoms

Condition	Characteristic pattern	Management
Mucosal disease (e.g., lichen planus, candidiasis)	Variable pattern Sensitivity with eating	Establish diagnosis and treat mucosal condition.
Menopause	Onset associated with climacteric symptoms	Hormone replacement therapy (if otherwise indicated)
Nutritional deficiency (e.g., vitamins B1, B2 or B6, zinc, others)	More than one oral site usually affected Possibly, mucosal changes	Oral supplementation
Dry mouth (e.g., in Sjögren’s syndrome or subsequent to chemotherapy or radiation therapy); altered salivary content	Alteration of taste Sensitivity with eating	High fluid intake Sialagogue
Cranial nerve injury	Variable pattern Usually bilateral Decreased discomfort with eating	Central pain control: benzodiazepine, tricyclic antidepressant, gabapentin (Neurontin) Local desensitization: topical capsaicin
Medication effect	Onset related to time of prescription	If possible, change medication.

[Source ⁶]

Risk factors for burning tongue or mouth syndrome

Burning mouth syndrome is uncommon. However, your risk may be greater if:

• You’re a woman
• You’re postmenopausal
• You’re over the age of 50

Burning mouth syndrome usually begins spontaneously, with no known triggering factor. However, certain factors may increase your risk of developing burning mouth syndrome, including:

• Recent illness
• Previous dental procedures
• Wearing dentures
• Allergic reactions to food
• Medications
• Traumatic life events
• Stress
• Anxiety
• Depression

Complications of burning tongue or mouth syndrome

Complications that burning mouth syndrome may cause or be associated with are mainly related to discomfort. They include, for example:

• Difficulty falling asleep
• Difficulty eating
• Depression
• Anxiety

Prevention of burning tongue or mouth syndrome

There’s no known way to prevent burning mouth syndrome. But by avoiding tobacco, acidic foods, spicy foods and carbonated beverages, and excessive stress, you may be able to reduce the discomfort from burning mouth syndrome or prevent your discomfort from getting worse.

Diagnosis of burning tongue or mouth syndrome

There’s no one test that can determine if you have burning mouth syndrome. Instead, your doctor or dentist will try to rule out other problems before diagnosing burning mouth syndrome.

Your doctor or dentist will review your medical history and medications, examine your mouth, and ask you to describe your symptoms, oral habits and oral care routine. In addition, your doctor will likely perform a general medical exam, looking for signs of other conditions.

You may have some of the following tests:

• Blood tests. Blood tests can check your complete blood count, glucose level, thyroid function, nutritional factors and immune functioning, all of which may provide clues about the source of your mouth discomfort.
• Oral cultures or biopsies. Taking and analyzing samples from your mouth can determine whether you have a fungal, bacterial or viral infection.
  Allergy tests. Your doctor may suggest allergy testing to see if you may be allergic to certain foods, additives or even substances in dentures.
• Salivary measurements. With burning mouth syndrome, you may feel that you have a dry mouth. Salivary tests can confirm whether you have a reduced salivary flow.
• Gastric reflux tests. These tests can determine if you have GERD.
• Imaging. Your doctor may recommend an MRI, CT scan or other imaging tests to check for other health problems.
• Temporarily stopping medication. If you take medications that may contribute to mouth discomfort, your doctor may suggest temporarily stopping them, if possible, to see if your discomfort goes away. Don’t try this on your own, because it can be dangerous to stop some medications.
• Psychological questionnaires. You may be asked to fill out questionnaires that can help determine if you have symptoms of depression, anxiety or other mental health conditions.

Treatment of burning tongue or mouth syndrome

For secondary burning mouth syndrome, treatment depends on any underlying conditions that may be causing your mouth discomfort.

For example, replacing poorly fitting dentures or taking supplements for a vitamin deficiency may relieve your discomfort. That’s why it’s important to try to pinpoint the cause. Once any underlying causes are treated, your burning mouth syndrome symptoms should get better.

There’s no known cure for primary burning mouth syndrome and no one sure way to treat it. Solid research on the most effective methods is lacking. Treatment depends on your particular symptoms and is aimed at controlling them. You may need to try several treatment methods before finding one or a combination that helps reduce your mouth discomfort.

Treatment options may include:

• Saliva replacement products
• Specific oral rinses or lidocaine
• Capsaicin, a pain reliever that comes from chili peppers
• An anticonvulsant medication called clonazepam (Klonopin)
• Certain antidepressants
• Medications that block nerve pain
• Cognitive behavioral therapy

The treatment of burning mouth syndrome is usually directed at its symptoms and is the same as the medical management of other neuropathic pain conditions (Table 2). Studies generally support the use of low dosages of clonazepam (Klonopin) ¹⁰, chlordiazepoxide (Librium) ¹¹ and tricyclic antidepressants (e.g., amitriptyline [Elavil]) ¹². Evidence also supports the utility of a low dosage of gabapentin (Neurontin) ¹³. Studies have not shown any benefit from treatment with selective serotonin reuptake inhibitors or other serotoninergic antidepressants (e.g. trazodone [Desyrel] ¹⁴.

Although benzodiazepines might exert their effect on oral burning by acting as a sedative-hypnotic, this possibility appears to be unlikely because the maximal effect of clonazepam is usually observed at lower dosages ¹⁵. The beneficial effects of tricyclic antidepressants in decreasing chronic pain indicate that, in low dosages, these agents may act as analgesics ¹⁶.

Topical capsaicin has been used as a desensitizing agent in patients with burning mouth syndrome ¹⁷. However, capsaicin may not be palatable or useful in many patients.

Table 2. Medical Management of Burning Mouth Syndrome

Medications	Examples of specific agents	Common dosage range*	Prescription
Tricyclic antidepressants	Amitriptyline (Elavil)	10 to 150 mg per day	10 mg at bedtime; increase dosage by 10 mg every 4 to 7 days until oral burning is relieved or side effects occur
	Nortriptyline (Pamelor)
Benzodiazepins	Clonazepam (Klonopin)	0.25 to 2 mg per day	0.25 mg at bedtime; increase dosage by 0.25 mg every 4 to 7 days until oral burning is relieved or side effects occur; as dosage increases, medication is taken as full dose or in three divided doses
	Chlordiazepoxide (Librium)	10 to 30 mg per day	5 mg at bedtime; increase dosage by 5 mg every 4 to 7 days until oral burning is relieved or side effects occur; as dosage increases, medication is taken in three divided doses
Anticonvulsants	Gabapentin (Neurontin)	300 to 1,600 mg per day	100 mg at bedtime; increase dosage by 100 mg every 4 to 7 days until oral burning is relieved or side effects occur; as dosage increases, medication is taken in three divided doses
Capsaicin	Hot pepper and water	Variable (see next column)	Rinse mouth with 1 teaspoon of a 1:2 dilution (or higher) of hot pepper and water; increase strength of capsaicin as tolerated to a maximum of 1:1 dilution.

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[Source ⁶]

Home remedies for burning tongue or mouth syndrome

In addition to medical treatment and prescription medications, these self-help measures may reduce your symptoms and your mouth discomfort:

• Drink plenty of fluids to help ease the feeling of dry mouth, or suck on ice chips
• Avoid acidic foods and liquids, such as tomatoes, orange juice, carbonated beverages and coffee
• Avoid alcohol and products with alcohol, as they may irritate the lining of your mouth
• Don’t use tobacco products
• Avoid spicy-hot foods
• Avoid products with cinnamon or mint
• Try different mild or flavor-free brands of toothpaste, such as one for sensitive teeth or one without mint or cinnamon
• Take steps to reduce stress

Coping and support for burning tongue or mouth syndrome

Burning mouth syndrome can be uncomfortable and frustrating. It can reduce your quality of life if you don’t take steps to stay positive and hopeful.

Consider some of these techniques to help cope with the chronic discomfort of burning mouth syndrome:

• Practice relaxation exercises, such as yoga
• Engage in pleasurable activities, such as physical activities or hobbies, especially when you feel anxious
• Try to stay socially active by connecting with understanding family and friends
• Join a chronic pain support group

What is Leukoplakia

Leukoplakia are thickened white patches on your tongue, in the mouth, on your gums or on the inside of your cheeks ¹⁸.

Doctors don’t know what causes leukoplakia but consider chronic irritation from tobacco — whether smoked, dipped or chewed — to be the main culprit in its development.

Most leukoplakia patches are noncancerous (benign), though some show early signs of cancer. Cancers on the bottom of the mouth can occur next to areas of leukoplakia. And white areas mixed in with red areas (speckled leukoplakia) may indicate the potential for cancer. So it’s best to see your dentist or primary care professional if you have unusual, persistent changes in your mouth.

A type of leukoplakia called hairy leukoplakia, sometimes called oral hairy leukoplakia, primarily affects people whose immune systems have been weakened by disease, especially HIV/AIDS.

Figure 1. Leukoplakia on tongue

Figure 2. Leukoplakia on the gum

Symptoms of Leukoplakia

Leukoplakia usually occurs on your gums, the insides of your cheeks, the bottom of your mouth — beneath the tongue — and, sometimes, your tongue. It isn’t usually painful and may go unnoticed for a while.

Leukoplakia may appear:

• White or grayish in patches that can’t be wiped away
• Irregular or flat-textured
• Thickened or hardened in areas
• Along with raised, red lesions (speckled leukoplakia or erythroplakia), which are more likely to show precancerous changes
• Painful when the mouth patches come into contact with acidic or spicy food
• Unable to be scraped off

Hairy leukoplakia

Hairy leukoplakia causes fuzzy, white patches that resemble folds or ridges, usually on the sides of your tongue. It’s often mistaken for oral thrush, an infection marked by creamy white patches that can be wiped away, which is also common in people with a weakened immune system.

When to see a doctor

Even though leukoplakia doesn’t usually cause discomfort, sometimes it can indicate a more serious condition.

See your dentist or primary care professional if you have any of the following:

• White plaques or sores in your mouth that don’t heal on their own within two weeks
• Lumps or white, red or dark patches in your mouth
• Persistent changes in the tissues of your mouth
• Ear pain when swallowing
• Progressive reduction in the ability to open your jaw

Causes of leukoplakia

Although the cause of leukoplakia is unknown, chronic irritation, such as from tobacco use, including smoking and chewing, appears to be responsible for most cases. Often, regular users of smokeless tobacco products eventually develop leukoplakia where they hold the tobacco against their cheeks.

Other causes may include chronic irritation from:

• Jagged, broken or sharp teeth rubbing on tongue surfaces
• Broken or ill-fitting dentures
• Long-term alcohol use

Your dentist can talk with you about what may be causing leukoplakia in your case.

Hairy leukoplakia

Hairy leukoplakia results from infection with the Epstein-Barr virus (EBV). Once you’ve been infected with EBV, the virus remains in your body for life. Normally, the virus is dormant, but if your immune system is weakened, especially from HIV/AIDS, the virus can become reactivated, leading to conditions such as hairy leukoplakia.

Risk factors for leukoplakia

Tobacco use, particularly smokeless tobacco, puts you at high risk of leukoplakia and oral cancer. Long-term alcohol use increases your risk, and drinking alcohol combined with smoking increases your risk even more.

Hairy leukoplakia

People with HIV/AIDS are especially likely to develop hairy leukoplakia. Although the use of antiretroviral drugs has reduced the number of cases, hairy leukoplakia still affects a number of HIV-positive people, and it may be one of the first signs of HIV infection.

Complications of leukoplakia

Leukoplakia usually doesn’t cause permanent damage to tissues in your mouth. However, leukoplakia increases your risk of oral cancer. Oral cancers often form near leukoplakia patches, and the patches themselves may show cancerous changes. Even after leukoplakia patches are removed, the risk of oral cancer remains.

Hairy leukoplakia

Hairy leukoplakia isn’t likely to lead to cancer. But it may indicate HIV/AIDS.

Prevention of leukoplakia

You may be able to prevent leukoplakia if you avoid all tobacco products or alcohol use. Talk to your doctor about methods to help you quit. If you continue to smoke or chew tobacco or drink alcohol, have frequent dental checkups. Oral cancers are usually painless until fairly advanced, so quitting tobacco and alcohol is a better prevention strategy.

Hairy leukoplakia

If you have a weakened immune system, you may not be able to prevent hairy leukoplakia, but identifying it early can help you receive appropriate treatment.

Diagnosis of leukoplakia

Most often, your doctor diagnoses leukoplakia by:

• Examining the patches in your mouth
• Attempting to wipe off the white patches
• Discussing your medical history and risk factors
• Ruling out other possible causes

Testing for cancer

If you have leukoplakia, your doctor will likely test for early signs of cancer by:

Oral brush biopsy. This involves removing cells from the surface of the lesion with a small, spinning brush. This is a non-invasive procedure, but does not always result in a definitive diagnosis.

Excisional biopsy. This involves surgically removing tissue from the leukoplakia patch or removing the entire patch if it’s small. An excision biopsy is more comprehensive and usually results in a definitive diagnosis.

If the biopsy is positive for cancer and your doctor performed an excisional biopsy that removed the entire leukoplakia patch, you may not need further treatment. If the patch is large, you may be referred to an oral surgeon or ear, nose and throat (ENT) specialist for treatment.

Hairy leukoplakia

If you have hairy leukoplakia, you’ll likely be evaluated for conditions that may contribute to a weakened immune system.

Treatment of leukoplakia

Leukoplakia treatment is most successful when a lesion is found and treated early, when it’s small. Regular checkups are important, as is routinely inspecting your mouth for areas that don’t look normal.

For most people, removing the source of irritation ― such as stopping tobacco or alcohol ― clears the condition.

When this isn’t effective or if the lesions show early signs of cancer, the treatment plan may involve:

• Removal of leukoplakia patches. Patches may be removed using a scalpel, a laser or an extremely cold probe that freezes and destroys cancer cells (cryoprobe).
• Follow-up visits to check the area. Once you’ve had leukoplakia, recurrences are common.

Treating hairy leukoplakia

Usually, you don’t need treatment for hairy leukoplakia. The condition often causes no symptoms and isn’t likely to lead to mouth cancer.

If your doctor recommends treatment, it may include:

• Medication. You may take a pill that affects your whole system (systemic medication), such as antiviral medications. These medications can suppress the Epstein-Barr virus, the cause of hairy leukoplakia. Topical treatment may also be used.

• Follow-up visits. Once you stop treatment, the white patches of hairy leukoplakia may return. Your doctor may recommend regular follow-up visits to monitor changes to your mouth or ongoing therapy to prevent leukoplakia patches from returning.

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