Diagnosis of BMS

BMS is thought to be multifactorial in nature (See Table 2). A careful health assessment with laboratory tests may facilitate the diagnosis but laboratory findings are often non-contributory. The clinician should begin with a careful review of the patient’s complaints and medical/dental history. Mignogna, et al. cited three patients who had been seen by 8, 10 and 12 different healthcare providers for assistance in an initial diagnosis.31,36 The reason for this professional delay and patient delay is that patients may have varying complaints, and the symptoms voiced by one patient may not fit a clear pattern for a diagnosis of BMS. There may be mixed etiologies related to oral pain as well within the same patient.

Table 2. Possible Contributing Factors Associated with Oral Burning.
  • Tongue thrusting.
  • Bruxism and clenching.
  • Endocrine disorders including diabetes and thyroid disease.
  • Allergies-environmental and dental/oral allergies.
  • Ill-fitting dentures and appliances-mechanical irritation.
  • Intolerance or allergy to denture materials or materials used in restorative dentistry causing tissue irritation.
  • Mucosal diseases such as lichen planus, pemphigus vulgaris, benign mucous membrane pemphigoid, etc.
  • Supertasters are often prone to BMS as well as those individuals with taste perception disorders.
  • Xerostomia (may be caused by medications or actual disease states such as Sjogren’s disease).
  • Certain medications, e.g., diuretics, angiotensin converting enzyme inhibitors.
  • Deficiency of vitamins B1, 2, 6 or 12, folic acid or zinc.
  • Iron deficiency anemia.
  • Fungal (Candidiasis), bacterial and viral infections.
  • Migratory glossitis.
  • Systemic diseases: gastroesophageal reflux (GERD), diabetes, hypothyroidism.7
  • Smoking cessation (a rise in the incidence of BMS has been noted upon quitting).
  • Psychological factors: cancer phobia, severe stress, obsessive compulsive disorder (OCD), general anxiety and depression.

A diagnosis is made by excluding all other causes of the burning tissues that have been described by the patient through observation and testing. Mignogna, et al. describe the typical display of products a patient will bring with them because they have been to multiple practitioners over long periods of time searching for answers.31 Items include mouthwashes, antifungal medications, antibiotics, vitamins, topical steroids and a long written medical history of complaints relating to pain. The previous misdiagnosis of patients within the study were, candidiasis, depression, allergic reaction to a prosthesis, hypovitaminosis, hyposalivation/xerostomia, trigeminal neuralgia, viral hepatitis, gastroesophageal reflux disease, bruxism, tracheitis and food intolerances. Recent studies by Farah, et al. found no association with candida load and BMS dysesthesia.66

Notations should be made of clinical dental findings. Careful questioning of the patient is needed since the patient may not be aware of the time elements of occurrences such as pain worsening in mid-day or the absence of pain during eating. Keeping a log of events is helpful in establishing patterns. Muzyka and DeRossi noted food and drink may relieve the symptoms.28 Those in group 3 with possible contact allergies sometimes may experience worsening with food and drink. Salivary flow is best assessed by both stimulated and unstimulated flow. However, as described earlier, in BMS, unstimulated saliva may be found to be diminished while stimulated remains within normal limits.51 Parafunctional habits such as tongue thrust and bruxism are evaluated. Assessing systemic and psychological implications is also performed to rule out systemic factors.

Medications should be identified and reviewed since they may or may not contribute to the burning discomfort.40 After other causes are ruled out, and depending on the findings, some BMS patients should be informed that a solution to their problems may or may not be solved readily.37 Treatment is often prolonged over several weeks to months as the clinician strives to eliminate all reversible etiologic factors and successfully treat irreversible factors. Patients appreciate your honesty, interest and concern with their well-being and usually express an interest in undergoing whatever treatment you may have to offer.

Al Quran reported results from a group of 32 patients with matched controls on several personality factors.1 The researcher suggested the patients with BMS had increased levels of neuroticism, depression, hostility and anxiety. However, disease states that may produce similar characteristics of BMS are iron deficiency, deficiency in the B vitamins, diabetes, thyroid diseases, hormonal disorders, autoimmune diseases, esophageal reflux, taste disturbances such as those of supertasters, and drugs producing dryness of the tissues such as diuretics. Medications may also produce oral conditions such as xerostomia and candidiasis. Zur comments that it is unclear whether “psychological factors are a cause or a consequence, or whether they both play a role and exacerbate each other.”40 After other causes are ruled out, Spanemberg, et al. makes the point “the patient needs to admit to the presence of this disorder and learn to live with it, being aware that a solution may not be found.”37 Ultimately, the problem could be lifelong in nature. Lamey, et al. report that people who experience adverse life events may be vulnerable for BMS later in life.24 Mignogna, et al. conducted a prospective study with a group of patients and concluded that “The great majority of BMS patients presented with several additional unexplained extraoral comorbidities, indicating that various medical disciplines should be involved in the BMS diagnostic process. Furthermore, the results suggest that BMS may be classified as a complex somatoform disorder rather than a neuropathic pain entity.”32 Acharga, et al. reported that study participants with BMS felt “dissatisfied to very dissatisfied” with their life. They also reported more arthritis, fibromyalgia, allergies and back pain.63