Journal reading

1. Journal reading 報告者：PGY2 曾智皇 報告日期 : 103.07.08 指導老師 :林立民 醫師 陳玉昆 醫師

2. Introduction • Burning mouth syndrome (BMS) is typically described by the patients as a burning sensation of the oral mucosa absence of clinically apparent mucosal alterations • Overall prevalence ranging from 0.7% to 7% • Prevalence up to 12% to 18% for post-menopausal women with BMS

3. BMS often affects the tongue (particularly the tip and lateral borders), lips, and hard and soft palate • Unremitting oral mucosal pain, dysgeusia, and xerostomia

4. Diagnostic criteria • Oral burning or pain • Unremitting for at least 4–6 months • Continuous throughout almost all the day • Seldom interferes with sleep and never worsens • May be relieved, by eating and drinking

5. Other oral symptoms: • Dysgeusia • Xerostomia • Presence of sensory/chemo-sensory anomalies • Mood changes • Disruptions in patient personality traits • Can not have any signs of oral mucosal pathology !!

6. Detailed review of patient’s medical and dental histories • Careful analysis of data obtained from physical and laboratory examinations

7. Classification and subtypes Lopez-Jorne et al  Type 1 BMS: • Pain-free waking  gradually increasing  reaching its peak intensity by evening • 35% • Linked to systemic disorders such as nutritional deficiency, diabetes mellitus

8. Type 2 BMS: • Continuous symptoms throughout the day • 55% • Usually associated with psychological disorders Type 3 BMS: • Intermittent symptoms • 10% • Show allergic reactions

9. Scala et al. classified BMS into 2 clinical forms  1. Primary BMS: • Essential or idiopathic • Peripheral and central neuropathological pathways are involved 2. Secondary BMS: • Caused by local, systemic or psychological factors

10. Primary BMS • 1st subgroup: Peripheral small-diameter fiber neuropathy of intraoral mucosa (50–65%) • 2nd subgroup: Subclinical lingual, mandibular, or trigeminal system pathology (20–25%) • 3rd subgroup: Hypofunction of dopaminergic neurons in the basal ganglia (20–40%)

11. Lauria et al  Significantly lower density of epithelial nerve fibers in patients with BMS than in control subjects • Just et al  Patients with BMS exhibit a decreased somatosensory and gustatory perception • Albuquerque et al  Patients with BMS had less volumetric activation throughout the entire brain

12. Secondary BMS • Local factors: poorly fitting prostheses, parafunctional habits, dental anomalies, allergic reactions, infection, chemical factors, galvanism, taste alterations, and xerostomia • Systemic factors: endocrine alterations (hypothyroidism, diabetes, and menopause), vitamin B complex, iron and zinc deficiencies, anemia, gastrointestinal anomalies, medication, Sjogren’s syndrome, and esophageal reflux

13. Psychological factors: anxiety, depression, compulsive disorders, psychosocial stress, and cancerphobia

14. Netto et al • Significant association of the presence of gastrointestinal diseases and urogenital diseases with BMS • Significant correlation between the intake of H-2 receptor antagonist or proton-pump inhibitor and BMS

15. Gao et al • 87(BMS) and 82 • No statistical difference in blood analyses (including white blood cell count, red blood cell count, hemoglobin (Hb), and platelet count ) between the BMS and control groups • Significantly higher serum follicle-stimulating hormone level and a significantly lower serum estradiol level in the menopausal or post-menopausal women with BMS

16. Anxiety and depression scores in patients with BMS are higher • Habit of tongue thrusting, lip sucking, periodontitis, smoking, outcome of recent medication, and depression are the principal risk factors for the BMS

17. Lin et al • Patients with BMS had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency • Abnormally elevated blood homocysteinelevel • Serum GPCA (gastric parietal cell antibody) positivity

18. Boras et al • Significantly lower serum neurokinin A is found in patients with BMS • Indicating an inefficient dopaminergic system in patients with BMS

19. Pekiner et al • Significantly lower serum IL-2 and TNF-a levels in patients with BMS • Significantly lower mean salivary Mg level in patients with BMS

20. Maragou and Ivanyi, Cho et al • Significantly lower mean serum zinc level in patients with BMS • Pokupec-Gruden et al • Anxiety and depression are most common in patients with BMS

21. General consideration for treatment of BMS • Detailed review of patient’s medical and dental histories and a careful analysis of patient’s data • setting up a therapeutic regimen • Treatment or elimination of these factors (local, systemic, psychological) usually results in a significant clinical improvement

22. If patients still have the symptoms  drug therapy should be instituted • The custom-made or combination therapy for each patient with BMS  the greatest benefit to the patient and lessen the treatment duration

23. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

24. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

25. Vitamin supplement treatment • Sun et al • Vitamin BC capsules plus relatively high doses of corresponding deficient hematinics  a. reduce the abnormally higher mean serum homocysteine levels b. raise the corresponding lower mean deficient hematinic and Hb levels

26. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

27. Zinc replacement treatment • Cho et al • Evaluated the serum zinc level in 276 patients with BMS • Zinc replacement therapy in BMS patients with zinc deficiency is effective

28. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

29. Hormone replacement treatment • Wardrop et al prevalence of oral discomfort is significantly higher in perimenopausal and post-menopausal women  43% <-> 6% • Forabosco et al

30. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

31. Topical drug treatment • Epstein and Marcoe • Gremeau-Richard et al • Peripheral nervous system dysfunctions in patients with BMS

32. Sardella et al • Lopez-Jornet et al • Topical Aloe vera has been shown to promote the healing process in the treatment of burns, psoriasis, and oral lichen planus

33. Vitamin supplement treatment • Zinc replacement treatment • Hormone replacement treatment • Topical drug treatment • Systemic drug treatment

34. Systemic drug treatment • Petruzzi et al • Its use is not recommended for extended treatment • Grushka et al • Heckmann et al

35. Ko et al • Investigated outcome predictors of clonazepam therapy • Amos et al • Combined topical and systemic clonazepam administration is an effective regimen for treatment of BMS

36. Femiano et al • Antioxidant mitochondrial coenzyme neuroprotective effect • Marino et al • prolonged therapy in chronically affected patients with BMS is needed for maintaining a more permanent effect

37. Maina et al • No serious adverse effects are referred in any of the three groups • Rodriguez-Cerdeira and Sanchez-Blanco • Amisulpride seems to be effective and well tolerated

38. Yamazaki et al • A tricyclic antidepressant • The side effects are minor and transient and no serious safety issues are observed • Bergdahl et al

39. Summary • BMS is probably of multifactorial origin and may be idiopathic • Clinicians should first try to identify the precise causative factors for the BMS • If patients still have the symptoms after the removal of potential causes, drug therapy should be instituted

40. Previous clinical trials have found that drug therapy with capsaicin, alpha-lipoic acid, clonazepam, and antidepressants  relief of oral burning or pain symptom • Psychotherapy and behavioral feedback may also help eliminate the BMS symptoms

41. Thank you for your attention