Burning Mouth Syndrome

What burning mouth syndrome feels like

• burning, scalding or tingling, as if the mouth has been burned by a hot drink
• usually affects the tip and sides of the tongue, and often the lips, roof of the mouth or gums
• both sides of the mouth equally
• a dry mouth feeling, even with normal saliva
• altered taste: bitter or metallic, or reduced taste
• often mild on waking, building through the day and peaking in the evening
• usually does not disturb sleep
• may ease temporarily while eating or drinking

Symptoms often begin suddenly and can persist for months to years.

Primary vs secondary burning mouth

Doctors only diagnose primary BMS after ruling out secondary causes.

Causes

Primary BMS

Research suggests damage or dysfunction of the small nerve fibers that carry pain and taste in the mouth, and changes in how the brain processes pain. The drop in estrogen at menopause may play a role, which may explain why postmenopausal women are most affected. Anxiety and depression are common alongside BMS, and may be both a contributing factor and a consequence.

Secondary causes

• Dry mouth from medicines, Sjögren syndrome, diabetes or radiation
• Oral thrush, especially in denture wearers and inhaled-steroid users
• Nutritional deficiencies: iron, vitamin B12, folate, B1, B2, B6 and zinc
• Diabetes and other causes of nerve damage
• Hypothyroidism
• Acid reflux reaching the mouth
• Medicines: especially ACE inhibitor blood pressure tablets, and some antiretrovirals and anticonvulsants
• Allergies or sensitivities to toothpaste ingredients (such as sodium lauryl sulfate or cinnamon flavoring), mouthwash, foods or denture materials
• Mouth conditions: geographic tongue, lichen planus
• Habits: tongue thrusting, teeth clenching, rubbing the tongue against teeth

Diagnosis

There is no single test for BMS. Your dentist, doctor or an oral medicine specialist will:

1. Take a history of symptoms, medicines, health conditions, menopause, mood and sleep.
2. Examine the mouth, tongue, teeth and dentures.
3. Order tests to find secondary causes: - blood count, iron studies, B12, folate, zinc - blood sugar or HbA1c - thyroid function - swab for Candida - saliva flow measurement - autoantibodies for Sjögren syndrome - patch testing for allergies - sometimes a biopsy of any visible lesion

If all are normal, the diagnosis is primary BMS. The ICOP definition requires daily burning for more than 2 hours a day for over 3 months.

Treatment

Treat the cause

Correct deficiencies, treat thrush or dry mouth, manage reflux, control diabetes, change a responsible medicine (with your doctor), and replace irritating toothpaste or ill-fitting dentures.

Treatments for primary BMS

• Clonazepam (topical): dissolving a small tablet in the mouth, holding it near the painful area for a few minutes and then spitting it out, has good evidence and helps many people. It is prescription-only and can cause drowsiness.
• Alpha-lipoic acid: an antioxidant supplement with some supporting evidence.
• Capsaicin oral rinse: diluted chili rinse that desensitizes pain nerves over time.
• Nerve pain medicines: low-dose amitriptyline, nortriptyline, gabapentin or pregabalin.
• Cognitive behavioral therapy (CBT): reduces pain intensity and distress and works well with medicine.
• Low-level laser therapy: some evidence; available in some clinics.

Several treatments may be combined, and finding the right one can take time.

Self-care

• Sip cold water or suck on ice chips.
• Chew sugar-free gum to stimulate saliva.
• Avoid spicy, acidic and very hot foods and drinks, alcohol and tobacco.
• Use a mild toothpaste without SLS, whitening agents, cinnamon or strong mint.
• Avoid alcohol-based mouthwashes.
• Manage stress; treat anxiety and depression if present.

Outlook

BMS is not dangerous and does not lead to cancer. It can last for years, but symptoms often improve with treatment, and about a third of people improve partially or fully over several years even without specific treatment. Ongoing support and realistic goals help.

Frequently asked questions

What causes burning mouth syndrome?

Primary burning mouth syndrome is thought to be caused by damage or dysfunction of the small nerves in the mouth and how the brain processes pain, possibly linked to hormonal changes after menopause. Secondary burning mouth is caused by conditions like dry mouth, thrush, vitamin deficiencies, diabetes, reflux or medicines.

Why does my tongue burn but looks normal?

A burning tongue with a normal appearance is the hallmark of burning mouth syndrome. Common hidden causes include dry mouth, iron or B12 deficiency, diabetes, reflux, sensitivity to toothpaste, and some blood pressure medicines. A dentist or doctor can test for these.

Does burning mouth syndrome go away?

It can. Secondary burning mouth often improves once the cause is treated. Primary burning mouth syndrome is usually long-lasting, but many people improve with treatment, and some recover partially or completely over a few years.

Is burning mouth syndrome linked to menopause?

Yes. Burning mouth syndrome is most common in women after menopause, and the fall in estrogen may affect the nerves of the mouth. Hormone therapy is not a proven treatment for it, however.

What is the best treatment for burning mouth syndrome?

There is no single best treatment. Topical clonazepam, alpha-lipoic acid, nerve pain medicines and cognitive behavioral therapy all have evidence. Treating any underlying cause comes first. Many people need a combination of treatments.