Burning Mouth Syndrome

Pain disorders seen in the oral and facial region occupy an important place among headache disorders and can seriously reduce patients’ quality of life. Among these conditions, Burning Mouth Syndrome (BMS) is a complex neurological pain condition that requires special expertise in both diagnosis and treatment.

In Burning Mouth Syndrome, despite the absence of any wounds, infection, or visible pathology in the mouth, patients experience sensations of burning, stinging, tingling, and pain on the tongue, palate, lips, or oral mucosa. Patients often describe this sensation as “It’s like my tongue is burning as if I ate pepper” or “There’s a pain like being scalded with boiling water.”

This syndrome is particularly more common in women during menopause. Hormonal changes, stress, anxiety, dry mouth, and neuropathic mechanisms play important roles in the emergence of the disease.

Burning Mouth Syndrome, which requires multidisciplinary evaluation, can lead not only to physical pain but also to sleep disorders, eating difficulties, depression, and a significant decrease in quality of life. Therefore, accurate and early diagnosis, appropriate treatment planning, and regular follow-up are extremely important.

What is Burning Mouth Syndrome?

Burning Mouth Syndrome (BMS) is a neuropathic pain disease characterized by burning, stinging, tingling, and painful sensations that occur despite the absence of any visible wound, infection, or structural problem in the mouth. It primarily affects the tongue, inner surface of lips, palate, and gums. Complaints may gradually increase during the day and can seriously reduce quality of life.

The most important feature of this syndrome is that the inside of the mouth appears completely normal upon clinical examination. In other words, despite the intense pain felt, there is no lesion in the patient’s mouth that the doctor can see.

Burning Mouth Syndrome is divided into two main groups:

Primary (Idiopathic) Burning Mouth Syndrome

Despite all detailed examinations, no underlying cause can be found. The real problem is a functional disorder developing in the nerve pathways carrying sensations from the tongue and mouth. Therefore, it is considered a neuropathic pain condition. Treatment is mainly directed at controlling the patient’s complaints and regulating nerve function.

Secondary (Due to Secondary Causes) Burning Mouth Syndrome

In this case, there is an identifiable underlying cause and treatment is shaped according to this cause. The most common causes are:

Vitamin-mineral deficiencies (B12, folate, iron, etc.)
Dry mouth (Sjögren’s, medication side effects)
Diabetes and blood sugar irregularities
Hormonal changes (especially menopause)
Allergic contact reactions (dental fillings, oral care products)
Inappropriate dentures
Reflux and irritant substances

In secondary cases, complete recovery with cause-directed treatment is possible. Burning Mouth Syndrome does not always mean there is a problem inside the mouth; it is especially related to nerve-sensory disorders and systemic diseases. Therefore, multidisciplinary evaluation is of great importance.

What Causes Burning Mouth Syndrome?

Burning Mouth Syndrome is often a complex condition in which multiple factors play a role together. Therefore, patients need to be evaluated in detail and treatment needs to be personalized. The main mechanisms involved in the emergence of Burning Mouth Syndrome are examined in four main groups:

1. Neurological Factors (The Most Fundamental Mechanism)

Scientific studies show that Burning Mouth Syndrome is largely a neuropathic pain syndrome.
Functional disorders in the trigeminal nerve responsible for oral sensations can lead to the following results:

Normal stimuli are perceived as pain (allodynia)
Hypersensitivity develops at nerve endings
The balance of neurotransmitters such as serotonin, dopamine, and GABA is disrupted

This situation causes the pain to be severe, persistent, and treatment-resistant.

2. Hormonal and Metabolic Causes

Burning Mouth Syndrome is particularly common in women during menopause. Most commonly:

Decrease in estrogen levels
Thinning and development of dryness in oral tissues

form the basis of this condition.

Additionally, the following metabolic diseases and deficiencies also increase risk:

Diabetes
Thyroid disorders
B12 vitamin, folate, and iron deficiency
Conditions leading to decreased saliva secretion

Therefore, blood tests are quite valuable in the diagnostic process.

3. Psychological and Psychosomatic Factors

Psychological factors have a strong role in the onset and continuation of Burning Mouth Syndrome:

Anxiety, depression, chronic stress
Excessive focus on the oral region
Bruxism (teeth grinding) and similar oral habits

These conditions cause increased pain perception and chronicity of the disease.

4. Systemic Diseases and Medication Use

Some systemic diseases and medications can also lead to or worsen existing Burning Mouth Syndrome:

Sjögren’s syndrome, lupus, oral lichen planus → Dry mouth and irritation
Antidepressants, diuretics, antihistamines, ACE inhibitors → Decreased saliva
Allergic reactions to oral care products and dental materials

When the underlying cause is treated in these cases, significant improvement in pain can be achieved. Burning Mouth Syndrome is not due to a single cause. Nervous system disorders + hormonal and metabolic changes + psychological factors are effective together. Therefore, treatment may require neurological, systemic, and psychological approaches.

What Are the Symptoms of Burning Mouth Syndrome?

Although the symptoms of Burning Mouth Syndrome vary from person to person, they create a clinical picture that is chronic, persistent, and significantly reduces quality of life. A good understanding of the symptoms is of great importance for accurate diagnosis and treatment.

Burning and Pain in the Mouth

The main complaint seen in almost all patients is a burning sensation. This sensation:

Is felt most intensely on the tip and edges of the tongue
Can spread to the lips, palate, and gums
Increases in the later hours of the day
Generally lessens or disappears at night during sleep

The pain character has neuropathic features; patients generally use the following expressions:

“Like being scalded with boiling water”
“As if there’s pepper in my mouth”
“Like electricity is hitting my tongue”
“My mouth constantly hurts and burns”

This sensation can last for weeks, months, or even years.

Taste and Dry Mouth Changes

Many patients with Burning Mouth Syndrome experience:

Dry mouth (xerostomia)
Metallic or bitter taste
Reduced ability to taste food (hypogeusia)
Complete change in taste (dysgeusia)

complaints. Decreased saliva production both increases pain and can lead to oral wounds.

Sensory Sensitivity

In some patients:

Excessive sensitivity to hot-cold foods
Increased pain related to foods
Pain even with light contact to oral tissues (allodynia)

is observed. For this reason, patients may frequently start avoiding eating.

Psychological and Social Effects

When Burning Mouth Syndrome persists for a long time, it creates a psychosomatic burden:

Development of anxiety and depression
Social avoidance, discomfort while speaking
Loss of appetite and weight loss
Sleep disorders due to continuous pain
Difficulty concentrating and fatigue

These effects can further increase the severity of the disease, creating a vicious cycle. Burning Mouth Syndrome is not just a burning sensation in the mouth; it is a complex pain syndrome characterized by taste changes, psychological stress, and serious deterioration in quality of life. This vicious cycle can be broken with early diagnosis and multidisciplinary treatment.

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria – 13.11 Burning mouth syndrome (BMS)

According to ICHD-3, Burning Mouth Syndrome (BMS) is a primary (idiopathic) pain disorder characterized by burning-type pain occurring without a visible cause in the mouth.

The following criteria are required for diagnosis:

Burning/stinging type pain in the mouth
– At least 2 hours/day
– Must have been continuing for 3 months or longer
There must be no clinically explanatory mucosal lesion or local pathology along with mouth pain
(Trauma, infection, aphthae, candidiasis, denture irritation, etc. must be excluded)
Pain may be accompanied by sensory changes:

Taste changes (dysgeusia, metallic taste)
Dry mouth sensation
Increased pain with light touch (allodynia)

These findings are present or absent → but there should be no explanatory disease.

Pain is neuropathic in character:

Tends to increase during the day
Lessens or disappears at night during sleep

The following must be excluded:

Local dental/mucosal diseases
Vitamin-mineral deficiencies (B12, iron, folate, etc.)
Systemic diseases such as Sjögren’s syndrome, diabetes
Medication side effects
Gastroesophageal reflux, fungal infections

How Is Burning Mouth Syndrome Diagnosed?

The diagnosis of burning mouth syndrome is a diagnosis of exclusion; that is, it is made after all possible factors that could cause the burning sensation in the mouth are ruled out through detailed evaluation. This process includes clinical history, oral examination, laboratory tests, and imaging methods if necessary.

Clinical Evaluation

The first and most important step of diagnosis is detailed history. The physician queries the following characteristics:

The onset, duration, and daily variation pattern of pain
Which areas in the mouth the burning sensation occurs
Triggers such as stress, menopause, sleep disorders
Previously undergone dental treatments, oral traumas
Medications used, denture fit, smoking habits
Accompanying symptoms such as dry mouth, taste changes, metallic taste

In physical examination, oral tissues are evaluated holistically:
Local pathologies such as mucosal color, cracks, candidiasis, lichen planus, aphthae are excluded.
Saliva flow and quality are examined.

Laboratory Tests

The following tests are requested to reveal secondary causes:

B12, folic acid, iron, zinc levels
Thyroid function tests (TSH, T3-T4)
Diabetes screening (Fasting glucose, HbA1c)
Complete blood count, kidney-liver functions
Autoimmune panel (if Sjögren’s or similar diseases are suspected)

When necessary:

Fungal culture from inside the mouth (to exclude candidiasis)
Allergy tests (dental materials, foods, etc.)

Imaging and Neurological Examination

Although imaging is usually not required in burning mouth syndrome:

Cranial MRI if trigeminal nerve pathology is suspected
Salivary gland function tests if Sjögren’s syndrome is suspected
Zinc and taste tests can be used if taste disorder is prominent.

Differential Diagnosis

Diseases that should be excluded in diagnosis:

Oral candidiasis
Aphthous stomatitis
Geographic tongue (glossitis)
Sjögren’s syndrome
Dental/denture incompatibility, trauma
Trigeminal neuralgia
Reflux, food allergies
Suspicion of malignancy

If one of the above causes is detected, the diagnosis is evaluated as secondary Burning Mouth Syndrome.

What Happens at the End of the Diagnostic Process?

If no organic cause is found despite all examinations, the patient is diagnosed with Primary (idiopathic) Burning Mouth Syndrome.

Early diagnosis is very valuable in preventing unnecessary tooth extractions, wrong medication use, and long-term psychosocial effects.

Burning Mouth Syndrome Treatment

Since burning mouth syndrome can occur through different mechanisms, there is no single form of treatment. The best results are obtained with a personalized and multifaceted treatment approach. The goal is both to eliminate underlying causes and to control pain and burning sensations.

Etiological Treatment (Directed at the Underlying Cause)

Especially in secondary Burning Mouth Syndrome cases, the first thing to do is to correct the factors causing the problem:

Treatment of vitamin-mineral deficiencies (B12, iron, folate, zinc replacement)

Bringing diabetes and thyroid diseases under control (Regulating blood sugar can significantly reduce pain)

Review of medications causing dry mouth (antihistamines, diuretics, antidepressants, etc. If used, discontinuation of these medications)

Dental or denture-related problems → Dentist evaluation

With these interventions, many patients’ complaints can significantly lighten.

Pharmacological Treatment Options

Since pain in burning mouth syndrome is usually neuropathic in character, medications targeting this mechanism are preferred in treatment. In the first step, gabapentinoid group medications (gabapentin, pregabalin) are mostly used, and these medications help reduce pain symptoms by decreasing hypersensitivity at nerve endings. Especially in the presence of sleep disorder or anxiety accompanying pain, gabapentin may be preferred.

Tricyclic antidepressants (amitriptyline, nortriptyline) can be quite effective due to both their pain perception-reducing effects and their properties that improve depressive mood and anxiety that can be frequently seen in burning mouth syndrome patients. More well-tolerated SNRI group antidepressants (duloxetine, venlafaxine) provide success especially in patients where stress and anxiety are predominant. The effects of these medications generally become evident within a few weeks, and doses are gradually increased according to the patient’s tolerance.

Additionally, alpha-lipoic acid, which has strong antioxidant properties, has been found beneficial in reducing neuropathic pain in some studies and can be added as supportive therapy. Systemic medication selection must be made taking into account the patient’s general health condition, accompanying diseases, and other medications used. Therefore, it is important that treatment is planned and regularly monitored by an experienced physician.

Topical Treatments

Clonazepam buccal application
Capsaicin (0.025-0.075% spray/gel)
Topical preparations containing Lidocaine

Provides local relief but it is important that they be used under doctor’s supervision.

Complementary and Supportive Treatments

Since the stress mechanism plays an important place, psychosocial support is a key part of treatment.

Potentially beneficial methods:

Cognitive Behavioral Therapy (CBT)
Mindfulness, relaxation techniques
Acupuncture and hypnosis
Splint therapy for teeth grinding/bruxism

Additionally:

Alcohol-free mouthwash
Soft toothbrush
Mouth moisturizers and saliva stimulants can alleviate the patient’s complaints.

Nutrition and Lifestyle Modifications

Triggering foods are important in most patients.

Things to avoid:

Spicy, acidic, very hot foods
Alcohol, vinegar, citrus
Excessive caffeine

Recommended:

Warm, soft foods
Plenty of water
Sugar-free gum → increases saliva flow
Regular sleep and physical activity

Smoking must be quit.

Long-term Follow-up and Prognosis

The course of the disease varies from person to person:

Significant improvement in 30-50% of patients
Partial improvement in 20-30% of patients
Persistent chronic pain in a small group

The most important factors increasing treatment success:

Regular follow-up
Continuation of psychosocial support
Patient compliance with treatment

Multidisciplinary approach (Neurology + Dentistry + Psychological support) provides the best results.

Frequently Asked Questions About Burning Mouth Syndrome

1. What causes burning mouth syndrome?

Burning mouth syndrome is a complex condition that can occur with the effect of many factors. The most common causes include neuropathic mechanisms, hormonal changes related to menopause, vitamin-mineral deficiencies, dry mouth, stress, and side effects of some medications. Sometimes no obvious cause can be found and in this case it is evaluated as primary (idiopathic).

2. Does burning mouth syndrome go away? Can I recover completely?

Significant improvement can be achieved in most patients with appropriate treatment. If there is an underlying cause, directing treatment towards it increases the recovery rate. However, in cases where the neuropathic pain mechanism is dominant, treatment may take time and symptoms may have a chronic course in some patients. Regular follow-up and personalized treatment are the most important success factors.

3. Is burning mouth syndrome a symptom of cancer?

No. Burning mouth syndrome is not a condition associated with cancer and does not carry a risk of turning into cancer. However, it is important to have a dental and neurology examination to rule out other organic diseases that may cause oral pain. However, some indirect relationships may be involved:

1. Hormonal Changes

Burning mouth syndrome is most commonly seen during menopause and postmenopause.
Hormonal treatments (e.g., tamoxifen) used in breast cancer treatments suppress estrogen receptors.
This situation can trigger or worsen the syndrome by increasing dry mouth, mucosal sensitivity, and burning sensation.

2. Cancer Treatment Side Effects

Chemotherapy and radiotherapy can cause damage to oral mucosa and functional loss in salivary glands.
These changes sometimes lead to complaints similar to burning mouth syndrome.

3. Psychological Burden

Increased anxiety, depression, and stress after cancer diagnosis can negatively affect the course of burning mouth syndrome.

4. Which specialist should I see for burning mouth syndrome?

In diagnosis and treatment, neurology, oral and maxillofacial surgery, otolaryngology, and dentistry departments usually work together. The first application should usually be made to a neurology specialist experienced in neuropathic pain.

5. I also have pain-free times, can it still be burning mouth syndrome?

Yes. In burning mouth syndrome, pain is not always at a constant intensity. It usually shows a course that is mild in the mornings, increases during the day, and intensifies in the evening hours. It can significantly decrease with rest or during sleep. This is one of the typical features of the disease.

6. When Should I Worry About Burning Mouth Syndrome?

In case of unilateral pain with continuously increasing severity,
Oral non-healing wounds,
Difficulty swallowing, voice changes,
If there are additional symptoms such as unexplained weight loss, detailed evaluation must be done in the early period.

The possibility of malignancy should be meticulously ruled out through dental and neurology examination along with ENT specialist and imaging methods if necessary.