ARCMESA Educators glossodynia (BURNING MOUTH SYNDROME) ABOUT THE AUTHOR Dr. Javed A. Qazi is a graduate of Khyber medical College and received a BDS degree from University of Peshawar in 1980. He obtained a Master of Science degree in Oral Medicine and Periodontia in 1991 from Khyber College of Dentistry, Peshawar.
ARCMESA Educators glossodynia (BURNING MOUTH SYNDROME) ABOUT THE AUTHOR Dr. Javed A. Qazi is a graduate of Khyber medical College and received a BDS degree from University of Peshawar in 1980. He obtained a Master of Science degree in Oral Medicine and Periodontia in 1991 from Khyber College of Dentistry, Peshawar.
ARCMESA Educators glossodynia (BURNING MOUTH SYNDROME) ABOUT THE AUTHOR Dr. Javed A. Qazi is a graduate of Khyber medical College and received a BDS degree from University of Peshawar in 1980. He obtained a Master of Science degree in Oral Medicine and Periodontia in 1991 from Khyber College of Dentistry, Peshawar.
AN INDEPENDENT CE STUDY COURSE FOR DENTAL PROFESSIONALS GLOSSODYNIA (BURNING MOUTH SYNDROME) File Name: amelogo and usage.eps As of Date: 04/2004 www.arcmesa.com
GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com ABOUT THE AUTHOR Dr. Qazi a graduate of Khyber Medical College and received a BDS degree from University of Peshawar in 1980. In 1982, he was appointed as Lecturer. He obtained a Master of Science degree in Oral Medicine & Periodontia in 1991 from Khyber College of Dentistry, Peshawar. He worked as a periodontist at Royal Dental Hospital; KSA from 2001-2003. Dr. Qazi is active in several national dental organizations and has written numerous dental journal articles. He maintains a private practice of generalized & specialized dentistry. Presently, he is working as Senior Lecturer at Khyber Medical College and been awarded exemption in Membership in Oral Medicine of Royal College of Surgeons of Edinburgh, UK (Part 1). He is also an Examiner of BSc in dental technology and BDS examinations. Dr. Qazi is member of IADR and is actively involved in research of glossodynia. O i 2006 ArcMesa Educators, LLC/Dr. Javed A. Qazi All rights reserved. This CE/CME course, or any part thereof, may not be duplicated or reproduced without the permission of the authors.
O ii COURSE OBJECTIVES Upon successful completion of this course, the participant will: 1. Comprehend the local, systemic and psychogenic causes of glossodynia 2. Understand the various symptoms of glossodynia 3. Know the significance of the multiple causes in relation to other possible chronic diseases Target Audience This course was developed to provide an overview of glossodynia for dental professionals. Accreditation ArcMesa Educators, LLC is an ADA CERP Recognized Provider for Dental Continuing Education, an Academy of General Dentistry Accepted National Sponsor (#90564) for FAGD/MAGD Credit, a Florida Board of Dentistry Provider (#BP-00246), and a registered provider with the Dental Board of California (RP 4365). Credit Designation By reviewing the course content and completing the post test at the end of this continuing medical education activity, you are entitled to receive one credit hour if you achieve a score of 70% or greater. Estimated time to complete this activity is one hour. Disclosure It is the policy of ArcMesa Educators, LLC to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. All faculty/authors are expected to disclose any relevant financial relationships they may have with commercial interests in relation to this activity. These relationships, along with the educational content of this program, have been reviewed and any potential conflicts of interest have been resolved to the satisfaction of ArcMesa Educators. Dr. Javed Qazi has indicated he has nothing to disclose relative to this activity. ArcMesa Educators, LLC staff has nothing to disclose relative to this activity. Date of original release: June 2006 Date of most recent review/approval: N/A Medium used: Monograph / Internet Expiration Date: June 2009 GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com O iii TABLE OF CONTENTS ABOUT THE AUTHOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i COURSE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii COURSE INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ETIOLOGIC FACTORS OF GLOSSODYNIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 LOCAL FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 SYSTEMIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 PSYCHOGENIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 MULTIPLE ETIOLOGIC FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 COURSE EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
COURSE INSTRUCTIONS FOR INTERNET AND HOME STUDY PARTICIPANTS! Read the course material carefully. Internet participants may study online or print a copy of the course for off-line study. Start when you are fresh and take your time. This course includes an "open book" exam. You may review the text at any time as a learning aid or to check the accuracy of your responses before submitting your completed exam. Be sure to answer each exam question; blanks are counted as incorrect answers. A minimum score of 70% is required for successful completion of this exam. The processing fee for this course entitles only one person to receive a certification of com- pletion. A history of courses taken and certificates earned can be found in your "Member History" section of our online program and/or available traditionally by contacting our cus- tomer services department. After successful completion of the course exam, Internet users are returned to their "Member History" page where you may view and/or print your Certificate of Completion. Please note that each certificate is uniquely identified with an ArcMesa "Certificate ID Number". Numbers may be used for certificate validation by various authorized organiza- tions. Mailed or faxed exams and evaluations are processed within 48 hours of receipt. Certificates are posted for return by 1st Class U.S. Mail the next day. If you fail an on-line exam, you may retest immediately by selecting the "Repurchase Exam" link found directly across from the course title within your "Member History" page. Note: Traditional users will be notified by ArcMesa and may retest upon purchasing a new exam. Please complete the brief course evaluation form at the end of the exam. Your responses and suggestions will allow us to upgrade our procedures and course materials to serve you more effectively in the future. PROBLEMS OR QUESTIONS? If you have any questions about your examination or your Certificate of Completion, please call ArcMesa at 1-800-597-6372 Your Certificate of Completion will reflect the following data: Date of completion, name, profession/occupation, license number (if provided), course title, CE/CME hours awarded, provider name and approval number (if applicable). Internet users receive an online grade report. Home study users may request a grade report. Thank you for choosing ArcMesa Educators! O iv GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 1 INTRODUCTION GLOSSODYNIA, is also known as burning mouth syndrome (BMS), Glossalgia, Glossopyrosis, Stomatodynia or oral dysphasia. It has been recognized worldwide and affects 2.6 percent of the general population and more than 1 million people in the United States. 1 Glossodynia is characterized by intra oral pain disorder with burning or altered sensation in the tongue, gingiva, lips or denture bearing areas. The burning may be unilateral or bilateral and tends to be relieved by eating or drinking. Other symptoms commonly associated with this disorder include dry mouth, headache, sleep disturbances and severe postmenopausal symptoms in women. Traditionally it has been described as a chronic syndrome without specific organic etiology and those diagnosed with BMS are often emotionally disturbed postmenopausal women. Women are particularly affected by the condition; they are diagnosed with symptoms seven times more frequently than males. Schoenberg et al reported that the symptoms occur in men as well as in women and are not necessarily confined to old age. 2 Glossodynia can be divided into two types: 3 1. With observable alterations of the tongue and 2. Without any observable alterations of the tongue The common observable signs of BMS are inflamed fungi form papillae, a localized reddening due to trauma or atrophy of the filiform papillae, localized or generalized lobulations and generalized redness. These symptoms may alter an individuals sense of taste. In the second type of BMS with no observable alterations of the tongue, there is no evidence of tissue abnormalities and both the filiform and fungi form papillae of the tongue are without any atrophic changes. Although the burning sensations are readily recognizable symptoms, the underlying cause is always obscure. The clinician must consider various etiological factors with careful and thorough clinical examination plus laboratory investigations before diagnosing a case of glossodynia. The purpose of this course is to present a systemic approach to the differential diagnosis of glossodynia. Etiologic factors of glossodynia include: local, systemic and psychogenic causes. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 2 ETIOLOGIC FACTORS OF GLOSSODYNIA LOCAL FACTORS Candidiasis Migratory Glossitis Lichen Planus Trauma Oral Cancer Denture faults Impression surface Polished surface Occlusal surface Denture Plaque Residual monomer Sensitivity to dental materials Radiation therapy (xerostomia) Periodontal diseases Electro galvanic discharge CANDIDIASIS One of the most common causes of glossodynia is candidiasis or moniliasis. It is caused by candida albican, a fungal organism that exists in the oral cavity as a part of normal flora. There is a competitive inhibition with other organisms in the oral flora. The host immune defenses maintain the candida population low numbers. When there is a disruption of the ecosystem or the host defense mechanism is lowered, the candida proliferate and as a result candidiasis develops. Candidiasis can also occur from the prolonged use of antibiotics, corticosteroids and cancer chemotherapy. Those with debilitating diseases like diabetes mellitus, often have candidiasis as well. Trauma from ill-fitting dentures along with poor oral hygiene allows candida organisms to penetrate the oral tissues, thus resulting in candidiasis. Oral manifestations of candidiasis range from erythema to creamy whiter colonies that may be associated with angular cheilosis. There is burning sensation of entire oral mucosa rather than only the tongue. The treatment consists of rinsing the mouth with Nystatin oral suspension or clotrimazol troches. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 8 LICHEN PLANUS Lichen Planus is a dermatological disease with oral manifestations. Recent studies indicate that oral lesions are present without skin lesions in 65% of Lichen Planus cases. Lichen Planus represents 9% of all oral white lesions and appear in three forms (as atrophic and bullous subtype): 4 Striated Plaque like & Erosive The exact etiology of Lichen Planus is unknown but it is presumed to be an autoimmune or psychosomatic disease. The predisposing factors for Lichen Planus are emotional stress, trauma, viral or bacterial infection, hypersensitivity, or drug therapy. Oral manifestations of Lichen Planus include: wickhams striae (lacy white configuration), erosions, ulcers or white plaques (which may or may not be present). The buccal mucosa is the most common site but the tongue and gingival area may also be affected. About 50% patients with oral Lichen Planus also have raised purple, itchy papules with white lacy striae on the skin. 5 The symptoms of burning and pain occur most often with erosive Lichen Planus. The diagnosis is made by a histological examination and biopsy. Local or systemic corticosteroid therapy is frequently helpful in the acute phase of erosive Lichen Planus. The incidence of malignant transformation of erosive Lichen Planus varies from 0% to 10%. Therefore, careful monitoring is recommended, as chronic oral ulcerative might represent a cofactor in the development of malignancy in certain people. 5 TRAUMA Low incidence of trauma may be on the list of causes for oral burning. Trauma may be in the form of physical, chemical or thermal injury. Biopsy and surgical repair of tongue can also result in Glossodynia. ORAL CANCER Glossodynia may be caused by oral cancer, which is normally present on the lateral borders of the tongue or the oropharynx. The incidence of oral cancer varies in different parts of the world. In 1980, oral and pharyngeal cancer ranked the sixth most common form of cancer worldwide. In India, for example, 40% of all cancers occur in the mouth while in England there is incidence of 2% oral cancer. Binnie et al reported a rate of 1.9% for oral cancers compared to all cancers in England and GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 9 Wales. Whenever leukoplakia or erythroplakia persist with accompanying burning symptoms, the biopsy is mandatory. 6 The incidence of the oral cavity and oropharynx cancers represent approximately three percent of all malignancies in men and two percent of all malignancies in women in the United States. Over 90 percent of these tumors are squamous cell carcinomas, which arise from the oral mucosal lining. Approximately 2,000 patients a year are diagnosed with oral cancer in New York State alone. Governor George Pataki has taken a leadership role in the United States by mandating and funding training for dentists in the prevention and early detection of oral cancer. Dental surgeons because of its continual association with the oral cavity have the greatest opportunity to detect early oral cancer and can educate prevention among their patients. Patients with persistent leukoplakia and accompanying burning symptoms need to have a biopsy in order to test for oral cancer. MIGRATORY GLOSSITIS Migratory Glossitis (Geographic tongue) is an asymptomatic inflammatory condition that can be painful. A patient with migratory glossitis will often go to the dentist because of the unusual appearance of the tongue, rather than complaints of pain. Migratory Glossitis is a common idiopathic recurring condition, which manifests as an area of depapillation of the filiform papillae of the tongue with white hypertrophic borders. The patient may complain of a burning sensation of the tongue in the depapillated area after eating hot or spicy foods. The treatment is symptomatic and patient is assured of its benign condition. The treatment for Migratory Glossitis is given as a symptomatic treatment, according to each symptom. As there is no helpful therapy, most patients are relieved to know that the disease is not contagious, life-threatening, and not a sign of any serious internal problem. In patients who experience pain, analgesics are prescribed. Patients with a history of anxiety are often prescribed anxiolytic drugs to relieve their anxious symptoms. DENTAL CAUSES A faulty denture design in any three surfaces (Impression, polished or occlusal surface) may promote the burning sensation due to an increased level of functional stress to the circum oral or lingual musculature. The presence of dental plaque can also cause glossodynia. A patient, who has an allergy to the denture base material such as monomeric methyl methacrylate, is a potent tissue irritant that can cause glossodynia. The GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 10 allergy is an infrequent cause of burning mouth syndrome because once the denture design is modified the symptoms are alleviated. Other allergens, which cause burning mouth syndrome, include propylene glycol, sorbic acid, benzoates and cinnamon aldehyde. XEROSTOMIA Xerostomia is a subjective condition in which there is less than the normal amount of saliva present in the mouth. The relation between burning and dry mouth has been recognized since the 1930s and present literature also provides statistical support for this inter relationship. Xerostomia may be reversible or irreversible. The patients with severe xerostomia will often complain of dry, burning mouth, which can be very painful and interfere with functions. Xerostomia is normally caused by a local factor, radiation therapy. Ionizing radiation causes pronounced changes in salivary glands, and the degeneration of acini. Replacement of resultant fibrous or fatty may be necessary depending on the effects from the amount of radiation therapy. Saliva substitute and fluoride gel should be used to reduce the risk caries from radiation therapy. SYSTEMIC FACTORS Climacteric as postmenopausal hypoestrogenism Diabetes Sjogrens syndrome (Xerostomia) Drug reactions (Xerostomia) Deficiency states Anemias (Iron, Vitamin B 12 , Folic Acid deficiencies) Lingual artery atherosclerosis Rheumatoid arthritis Gastric disturbances such as hyperacidity Xerostomia Hypothyroidism DIABETES Diabetes mellitus is the most common of the endocrine disorders. Its prevalence in Britain is over 1% although 50% of those affected remain undiagnosed. The oral manifestations of diabetes comprise of painless swelling of the parotid, increased GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 11 amounts of glucose in serous saliva, increased risk of periodontal disease and caries. Glossodynia may be one of the symptoms of diabetes, which is often associated with xerostomia and candidiasis. There also may be diabetic neuropathies, which manifest in the head and neck region contributing glossodynia. Basker et al reported that diabetes might not be an important etiological factor in glossodynia as the association between diabetes and burning mouth syndrome is small. Recently Zegarelli reported that he did not find any case of hyperglycemia among the 57 patients with burning mouth syndrome. 9 The treatment of diabetic glossodynia is achieved by the correct management of diabetes as directed by the patients physician for such treatment. A saliva substitute and fluoride gel should be used in the cases of xerostomia and the other infections. SJOGRENS SYNDROME Sjogrens Syndrome is a chronic disease in which the bodys white blood cells attack the moisture-producing glands causing various symptoms, one being dry mouth. It is one of the most prevalent autoimmune disorders, striking as many as four million Americans. Glossodynia may appear early in the course of the disease, before other symptoms appear. The oral symptoms of Sjogrens syndrome are due to xerostomia. The diagnosis is made by histological and hematological examinations with serologic findings. Although there is no effective treatment, saliva substitute and fluoride gel should be prescribed for the relief of these oral symptoms. DRUG REACTIONS (XEROSTOMIA) Many drugs used to treat a variety of systemic disorders produce varying degrees of xerostomia, such as pharmacologically induced xerostomia and Iatrogenic xerostomia. Drugs that are frequently used for long periods of time can cause prolonged decrease in salivary flow and eventually xerostomia occurs. Short-term xerostomia itself often does not cause oral discomfort and dental problems rather the prolonged use of certain drugs that lead to xerostomia may produce oral discomfort with an increased incidence of caries. The primary neural control of salivary flow is exerted through the parasympathetic division of the autonomic nervous system. An increase in cholinergic activity will increase the salivary flow where as the decrease in nerve activity results in the decrease of flow. Likewise drugs that alter cholinergic activity either at sites in the central nervous system or in the periphery will alter salivary flow rate. The most striking example of the cholinergic drugs on salvation is the profound decrease in flow seen after administration of cholinergic (muscarinic) blocking drugs such as atropine propantheline and glycopyrrolate. These drugs block the action of GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 12 acetylcholine, a neurotransmitter, at peripheral muscarinic receptors. Other drugs such as antihypertensive agents (CLONIDINE) act on the central nervous system to decrease cholinergic nerve output to peripheral sites such as salivary gland. Xerostomia can also be caused by opium and its derivatives, bronchodilators (ephedrine), central nervous system stimulants, Tricyclic anti-depressant (Imipramine) and diuretics. NUTRITIONAL DEFICIENCIES (ANEMIAS) Glossodynia may be one of the symptoms of deficiency states especially iron, Vitamin B 12 and folic acid reported as early as in 1922 by Beal. 10 Iron deficiency can cause oral discomfort with glossodynia and angular cheilitis. There are atrophic changes in the epithelium of any part of oral mucosa, which may result in non-specific ulceration. These atrophic changes in the oral pharyngeal mucosa may lead to wide spread soreness and dysphasia. The diagnosis can be made by estimation of hemoglobin content, serum iron, ferritin level and iron binding capacity. The treatment is by iron replacement therapy. The recent data indicates that the burning sensation may also result from the deficiency of vitamin B 1 and B 6 also produces greasy dermatitis of the face. In pernicious anemia, there may be generalized atrophy of the oral mucosa with ulceration as in iron deficiency anemia. The soreness of tongue is due to atrophic changes in the lingual papillae termed as Beefy red tongue. The tongue often shows a shiny smooth appearance and may be painful and tender to hot or spicy foods. Glossodynia is a common symptom. The diagnosis can be made by RBC morphology and serum vitamin B 12 parental therapy. Complex vitamins Iron deficiency is not a disease but a sign of disease and associated with glossodynia. The high incidence of iron deficiency anemia in women often occurs in the second half of pregnancy due to the increased demand for iron. In postmenopausal women and adult males, the common cause of iron deficiency is gastrointestinal bleeding by non-steroidal anti-inflammatory drugs and hook worms infection. 11 Patients suffering from iron deficiency states are also particularly susceptible to candida albican infection, a skin infection caused by a yeast-like fungus. With this infection, there is an atrophy of tongue epithelium with resulting disturbance of underlying nerve that causes taste disturbance and pain in the tongue. This change in sensitivity of tongue can be of diagnostic value in determining possible vitamin deficiency states. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 13 Iron deficiency anemia has insidious onset with gradual fatigue, irritability, dizziness, palpitation, breathlessness and headache. These changes in metabolism of oral epithelial cells are due to minor variations in the overall quality of the blood supply. The changes in the blood supply give rise to abnormalities of cell structure and keratosis pattern of the oral epithelium resulting in the atrophy and possible elimination of the filiform papillae of the tongue. The atrophic changes in the tongue may lead to ulceration and soreness, and in many cases affect the whole oral mucosa and lead to ulceration. In a small group of patients, the atrophic changes in the oral and pharyngeal mucosa may lead to wide spread soreness and dysphasia. This is known as Plymmer-Vinson syndrome or achlorhydria. The patient may experience angular cheilitis, thrush and complain of taste disturbance due to atrophy of the tongue epithelium (from the disturbance of underlying nerve endings). Folic acid like vitamin B 12 is involved with RNA and DNA metabolism. A deficiency of folic acid may lead to burning mouth angular cheilitis and glossodynia. The tongue shows varying degrees of papillary atrophy which progresses until the surface of tongue is smooth and shiny. The diagnosis is done by RBC morphology and serum folate level. Likewise, niacin deficiency causes generalized erythema of the oral mucosa along with papillary atrophy. A proper diagnosis can be made by the measurement of niacin level. It is treated with niacin and vitamin B-complex vitamins. 12 PSYCHOGENIC FACTORS Anxiety Depression A cancer phobia Psychogenic factors are often implicated as being etiologic in burning mouth syndrome and are the most frequent factor in many patients. Engman first recognized the psychogenesis of burning mouth in 1920 that studied eleven patients suffering from burning mouth syndrome who were mostly women having the fear of cancer. 13 It is reported that Glossodynia is one of classic symptoms of anxiety and depression precipitated by psychological stress. The specific psychological stress is a real or threatened loss of love, person, valuable object or bodily function. Chronic illness of psychosomatic origin can be traced to dental operation, proper fitting dentures and the failure of the patients to adjust to these procedures. Losing a tooth GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 14 according to an old adage means, losing a friend but it also means in the unconscious loss of strength and virility. Thus the patients suffering from burning mouth syndrome often associate the onset of symptoms as correlating with a time several weeks after exodontias, periodontal surgery or extensive restorative dental treatment. Ewalt noted that a common complaint in depression is a peculiar taste, stinging or burning sensation around teeth, gingival or tongue. 14 The diagnosis of psychologically induced glossodynia is established after all local and systemic factors are excluded by a negative clinical picture, negative laboratory findings and positive historical data regarding emotional factors. The burning sensation is confined to tongue but the palate and lips are frequently involved. Pain could be aggravated by hot and/or spicy foods and relieved by local anesthetics. Main and Basker claim that 20% patients complaining of burning mouth syndrome have or do not have anxiety towards a cancer-phobia. 15 Browning et al concluded that 44% of burning mouth patients had an associated psychiatric disorder. 16 Recently, Lamb et al indicated that 60% of burning mouth patients has had psychological factors and anxiety was most difficult to cure. 17 Glossodynia may be symptom of cancer-phobia. Reassuring the patients after a complete diagnosis is often helpful in relieving the symptoms. The treatment of psychogenic Glossodynia is anxiolytic/antidepressant drugs or by referring the patients for psychiatric consultation. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 15 MULTIPLE ETIOLOGIC FACTORS Occasionally, some patients are diagnosed with glossodynia from the presence of multiple etiologic factors. The exact amount of burning sensation from each cause is unknown but it is evident that more than one can exist in such patients. Zegarelli reported that multiple etiologic factors for glossodynia exist in 12.3% of the cases in 57 patients he studied with burning mouth syndrome. 9 In 1984, a study conducted at the Division of Stomotology at Columbia Presbyterian Medical Center concluded that out of 57 patients, 7 patients with BMS had multiple co existent causes (12.5%). Psychogenesis moniliasis was found in 4 of patients, 2 male and 2 female. All four had history of a psychiatric disorder (depression) and were taking anti depressive therapy with demonstrable xerostomia and candidiasis. Treatment for these patients included anti fungal and anti depressant drugs. In the same study two female patients had psychogenesis and geographic tongue while one was having geographic tongue and moniliasis. In this case, anti fungal therapy was given and within 9 days there was 75% improvement. When multiple causes of glossodynia exist, treatment is provided for each cause. 9 GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 16 CONCLUSION A systematic approach to the diagnosis of burning mouth syndrome is suggested for the successful management of this condition. The following diagnostic protocol is recommended. HISTORY A detailed history for each patient must be taken with reference to his complaint. The emphasis should be placed on the following points; exact site of burning sensation, duration, and severity and in case of edentulous patients, any association with denture must be assessed. The relationship of symptoms with chemotherapy or dental procedure should be noted. For the denture wearer, specific questioning about the age of present denture, length of denture wearing experience, association of symptoms with previous denture, whether denture worn at night, any repair and relining done. The patients prescription or non-prescription drug history should be taken in order to determine potential systemic factors that can cause xerostomia or hypersensitivity reactions. CLINICAL EXAMINATION Routine extra and intra oral examination should also be performed. Any abnormality in color texture of oral mucosa particularly at the site of burning must be noted. When erythema presents its precise relationship to adjacent natural teeth or dentures, this must be noted. All dentures should be examined with regard to material, plaque formation and design of impression occlusal or polished surfaces. SPECIAL LABORATORY INVESTIGATIONS Every patient should be advised for a complete blood, urine and stool examination. Patients having xerostomia must have their blood glucose level checked in order to prevent xerostomia from becoming worse. A smear should be taken for cytological examination from dorsal surface of tongue for the presence of candida infection. Whenever necessary, panoramic x-rays and biopsy should be performed. If inconclusive results are obtained after all efforts mentioned above, then a psychiatric consultation should be considered. Whenever diagnosis is confirmed then appropriate treatment should be given with necessary periodic follow up. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 17 REFERENCES 1. Grushka M, Sessle BJ. Burning mouth syndrome, a historical review. Clinical Journal of Pain 1987; 2:245-252. 2. Schoenberg B, Carr AC, Kutscher AH., Zegarelli EN. Chronic idiopathic orolingual pain: psychogenesis of burning mouth NY state J Med 1971; 71: 1932-7. 3. Glass BJ, Kuhel RF, Langlais RP. Treatment of common orofacial condition. Dent clinic of N. America 1986; 30: 3, 443-445. 4. Shklar G, Mccarthy PL. The oral manifestations of systemic diseases. Ist Ed PP 74-75 Boston and London, Butterworths, 1976. 5. Kaplan B and Barnes. Oral Lichen Planus and squamous cell carcinoma: case report and update of the literature. Arch Otolaryngol. III (8): 543-547, 1985. 6. Fowler CB, Rees TD, Smith BR, Squamous cell carcinoma on the dorsum of the tongue arinsin in a long standing lesion of erosive Lichen Planus. JADA 1987; 115: 707-709. 7. Binnie WJ, Cawson RA, Hill GB, Soaper AE. Oral Cancer in England and Wales. A national study of morbidity, mortality, Curability and related factors. Office of population censuses and surveys studies on medical and population subjects. No. 23 London, HMSO, 1972. 8. Basker RM, Sturdee DW, Davenport JC. Patients with burning mouth. A clinical investigation of causative factors including the climacteric and diabetes. Br Dent J 1978; 145: 9-16. 9. Zegarelli DJ. Burning mouth. An analysis of 57 patients oral surg 1984; 58: 34-38. 10. Beal H. Glossopyrosis. Dent Cosmos 1922: 64: 474. 11. Qazi JA. Glossodynia associated with iron deficiency anemia; case report. Pak Oral and Dental J 1989; 9: 2; 56-59. 12. Gallagher FJ, Baxter DL, Denobile J, Taybos GM. Glossodynia, iron deficiency anemia and gastrointestinal malignancy report of a case. Oral surg oral Med oral Path 1988; 65: 1, 130-133. 13. Engman MF. Buring tongue. Arch dermatol syphilol 1920; 6: 137-8. 14. Ewalt J. Somatic manifestations of depression. Hosp. Med 1966; 2:6. 15. Main DMG, Basker Rm. Patients complaining of burning mouth Br Dent J 1983; 154: 206-211. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 18 16. Browning S, Hislop S, Scully S, Shirlan P. The associated between burning mouth syndrome and psychological disorders. Oral surg oral Med oral Path 1978; 64, 171-74. 17. Lamb AB, Lamey PJ, Reeve PE. Burning mouth syndrome psychological disorders. Br Dent J 1988; 165: 256-260. 18. Zegarelli DJ, Schmidt ECZ. Oral fungal infection. Journal of Oral Med 1987; 42: 2, 76-79. 19. Harris M. Psychosomatic disorders of mouth and face. Practioner 1975:214:372-379. 20. Grushka M, Epstein JB, Gorsky M.Burning mouth syndrome. Am Fam Physician. 2002 Feb 15; 65(4): 615-20. Review. 21. Muzyka BC, De Rossi SS. A review of burning mouth syndrome. Cutis. 1999 Jul; 64(1): 29-35. Review. 22. Savage NW, Boras VV, Barker K.Burning mouth syndrome: clinical presentation, diagnosis and treatment. Australas J Dermatol. 2006 May; 47(2): 77-81 23. Kugu N, Akyuz G, Dogan O.Burning mouth syndrome and depression: a case report] Turk Psikiyatri Derg. 2002 Autumn; 13(3): 232-7 24. Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin. 2002 Jul-Aug; 52(4): 195-215 25. WHO. World health statistics Annual Geneva. WHO 1967. 26. Tyldesley Wr. Oral Medicine for Dental Practitioner. Brit Dent J 1974, 136: 111. 27. Lamey PJ AB. Prospective study of aetiological factors in burning mouth syndrome. Brit Dent J 1988; 296: 1243-46 28. Chimenos-Kustner E, Marques-Soares MS.Burning mouth and saliva. Med Oral. 2002 Jul-Oct; 7(4): 244-53. Review. English, Spanish. 29. Lamey PJ, Lewis MAO. Oral Medicine in practice: Orofacial allergic reactions. Br Dent J 1990; 168: 59-63 30. Gruskha M., Clinical features of burning mouth syndrome. Oral Surg Oral Med Oral Path 1987; 62: 30-6 31. Macleod J, Edwards C, Bouchier I. Davidsons Principles and practice of Medicine. 15th Ed PP 461-62 ELBS, 1987. 32. Taybos Gm and Terezhalmy GT. Glossodynia: Diagnosis and Treatment. US Navy MED Sept-Oct 1983; 74: 18-19. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 19 33. Gilman AG, Goodman LS, Rall TW, Murad F. Goodman and Gilmans The Pharmacological Basis of Therapeutics, 7th Ed, PP 135, New York; Macmillan Publishing Company, 1985. 34. Tyldesley Wr. Oral Medicine, the oral mucosa in generalized disease (2) 1st ed. PP 133-34 Oxford E I B S, Oxford University Press, 1985. 35. Lamey PJ, Allam BF. Vitamin status of patients with burning mouth syndrome and the response to replacement therapy. Br Dent J 1986; 160; 81. 36. Vander Pleog HM, vander waal N, Eijkman MAJ, vander waal I. Psychological aspects of the patients with burning mouth syndrome. Oral surg 1987; 63: 664-668. 37. Dworkin SF, Burgess JA. Orofacial pain of psychologenic origin. Current concepts and classification. JADA 1987; 115: 565-571. 38. Kutscher AH, Schoenberg B, Carr AC. Death, grief and dental thanatology as related to dentistry. JADA 1970; 81: 1373-7. 39. Forabosco A, Negro C. Burning mouth syndrome. Minerva Stomatol. 2003 Dec; 52(11-12): 507-21. Review. 40. Domb GH and Chole RA. The burning mouth and tongue. Ear nose throat J 1981; 60: 310-314 41. Kaaber S, Crames M, Jespen Fl. The role of cadmium as a skin sensitizing agent n denture and non-denture wearers. Contact Dermatitis 1982, 8: 308- 313 42. Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syndrome. Cochrane Database Syst Rev. 2005 Jan 25;(1): CD002779. Review. 43. Hammaren M, Hugoson A. Clinical psychiatric assessment of patients with burning mouth syndrome resisting oral treatment. Swed Dent J. 1989; 13(3): 77-88. 44. Grushka M. Clinical features of burning mouth syndrome. Oral surg Oral Med Oral Path 1987; 63: 30-36. 45. Pinto A, Stoopler ET, DeRossi SS, Sollecito TP, Popovic R.Burning mouth syndrome: a guide for the general practitioner. Gen Dent. 2003 Sep-Oct; 51(5): 458-61 46. Kerr AR Cruz GD Oral cancer. Practical prevention and early detection for the dental team. : N Y State Dent J. 2002 Aug-Sep; 68(7): 44-54. GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 20 COURSE EXAMINATION Traditional Completion: To complete the examination, please circle the appropriate answer for each question on the Examination Answer Sheet provided and return to ArcMesa customer service. Online Completion: We suggest using this page to prepare for the online examination. If you have purchased the program, and are ready to complete the online examination, select the Take Exam link located directly across from the program title within your online ArcMesa Member History section. 1. Glossodynia has been reported worldwide and affects what percentage of the general population? a. 2.6% b. 5% c. 10% d. 25% 2. One of the local causes of glossodynia is: a. Diabetes b. Drug reactions c. Oral Cancer d. Deficiency states 3. Glossodynia is classified into: a. Two types b. Four types c. Five types d. Six types 4. The glossodynia and oral symptoms of Sjogrens syndrome are due to: a. Bacterial Infection b. Xerostomia c. Thermal Injury d. Salivary Gland enlargement 5. The treatment of diabetic Glossodynia is: a. Steroid therapy b. Analgesic drugs c. Topical application of Betnovet Cream d. Referral to physician for diabetic management GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 21 6. The administration of cholinergic drugs such as atropine, propatheline and glycopyrrolate effect on salivation is: a. Increase in salivation b. Profound decrease in viscosity/flow c. Stops the salivation d. Has no effect 7. Beefy Red tongue is a symptom of: a. Iron deficiency anemia b. Blood loss anemia c. Pernicious anemia d. Hereditary Spherocytosis 8. Migratory Glossitis is a benign condition: True False 9. Oral Lichen Planus is present without lesions in: a. 25% of cases b. 65% of cases c. 75% of cases d. 100% of cases 10. The psychogenesis of the mouth was first recognized in: a. 1920 b. 1930 c. 1950 d. 1975 11. Glossodynia may occur in an individual who has a fear of developing cancer: True False 12. Losing a tooth according to old age means Losing an enemy. True False 13. Erosive Lichen Planus has symptoms of burning and pain. True False 14. Candida albican does not exist in the oral cavity as a part of normal flora. True False GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
O 22 15. The relationship between burning and dry mouth has been recognized since: a. 1930s b. 1980s c. 1990s d. 2005 16. Common complaint in depression is: a. Peculiar taste, stinging or burning sensation b. Xerostomia, candidiasis and altered taste c. Glossodynia, Xerostomia and excessive salivation d. Halitosis, burning of mouth & caries 17. Anxiety is not an etiological factor of glossodynia. True False 18. Glossodynia may be present in postmenopausal women as one of the systemic causes. True False 19. A deficiency of folic acid in a glossodynia patients diet causes greasy dermatitis of the face. True False 20. The primary cause of glossodynia in recent studies is denture defects. True False GLOSSODYNIA (BURNING MOUTH SYNDROME) ARCMESA EDUCATORS www.arcmesa.com
1. (A) (B) (C) (D) 2. (A) (B) (C) (D) 3. (A) (B) (C) (D) 4. (A) (B) (C) (D) 5. (A) (B) (C) (D) 6. (A) (B) (C) (D) 7. (A) (B) (C) (D) 8. True False 9. (A) (B) (C) (D) 10. (A) (B) (C) (D) 11. True False 12. True False 13. True False 14. True False 15. (A) (B) (C) (D) 16. (A) (B) (C) (D) 17. True False 18. True False 19. True False 20. True False Examination Answer Sheet If completing the exam traditionally, please remove the Examination Answer Sheet and Evaluation page and return to ArcMesa when completed. Important Note: Please retain a copy or be sure to mark your answers on the examination page(s) for your own records. GLOSSODYNIA (BURNING MOUTH SYNDROME) Use a dark pen or pencil to circle the appropriate answer for each of the questions from the examination. If you wish to FAX your answer sheet back to ArcMesa, it is best to use a dark pen. ARCMESA EDUCATORS www.arcmesa.com Credit Card Information (For online users completing traditionally): If you have not yet purchased this course, and would like to complete the course traditionally, Mail or Fax both the Answer Sheet and Evaluation form with your credit card information to: ArcMesa Educators, 615 Hope Road, Bldg 1, Eatontown, NJ 07724 or Fax to: 732-380-1104. ONLINE USERS PLEASE NOTE: Your account will be charged an additional $5.00 processing and grading fee for traditional completion, and a certificate of completion will be mailed upon receipt of a passing grade. ArcMesa Educators 615 Hope Road, Building One, Eatontown, NJ 07724 Voice: 732-380-1101 Fax: 732-380-1104 Method of Payment: K VISA K Mastercard K American Express K Discover Total Payment: $ _______.____ Card Number: Expiration Date: Signature: Date: Please add any other comments about this course or your suggestions for future courses: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Course Evaluation COURSE TITLE: GLOSSODYNIA (BURNING MOUTH SYNDROME) 1. After participating in this course do you feel that A. the learning objectives were met? K Yes K No ____________________________ B. your knowledge has been enhanced? K Yes K No ____________________________ C. your skills have been improved? K Yes K No ____________________________ D. the course was effective in meeting identified needs? K Yes K No ____________________________ E. you are satisfied with the course content? K Yes K No ____________________________ F. the information gained applies to your profession? K Yes K No ____________________________ G. the information gained will assist in improving your professional performance? K Yes K No ____________________________ 2. Your overall rating of this course ("A" being the best): A B C D 3. Please estimate the number of hours spent to complete the course and examination. No. of hrs? ________ Please provide us with your candid evaluation so that we can continue to improve these continuing education materials. We thank you for your comments and appreciate your suggestions for future courses. Comments ARCMESA EDUCATORS www.arcmesa.com Personal Data ( PL EASE PRI NT CL EARLY) Required information for proper certification and individual record retention. First Name Last Name Address City State Zip Telephone Fax Profession Email State of Licensure License # Validation: I certify that I have studied the course materials and have personally completed the course examination. Please sign for proper CE/CME certification: ____________________________________________ THIS SPACE FOR OFFICE USE ONLY Examination Personal Information and Evaluation Form Mail or fax back to: ArcMesa Educators 615 Hope Road, Building One, Eatontown, NJ 07724 Fax: 732-380-1104