American Academy of Dermatology Forum on Oral …...Burning Mouth Syndrome Learning Objectives The...

American Academy of Dermatology

Forum on Oral Diseases

American Academy of Dermatology

Forum on Oral Diseases

Friday, March 1st, 2019

Ten Tongue Troubles

Ten Tongue TroublesTen Tongue Troubles

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Roy S. Rogers, III, MDProfessor of Dermatology

Mayo ClinicCollege of Medicine



Disclosure StatementDisclosure Statement

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Mayo Clinic College of Medicine


Mayo Clinic College of Medicine

Consultancy NoneResearch grants NoneFinancial interests None

Consultancy NoneResearch grants NoneFinancial interests None

Disclosure StatementDisclosure Statement

CP1164245-2





This presentation involves discussion of off-label use of drugs.

This presentation involves discussion of off-label use of drugs.

"The copyright for this material is held by Mayo Foundation for Medical Education and Research. All requests for reuse of

this material must be requested in writing from the author and Mayo

Foundation for Medical Education and Research."

Oral Dermatology

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Nasal cavity

Maxillary sinus

Masticatory mucosa

Anterior hard palateAttached gingiva

Specializedmucosa

Ventral mucosaof the tongue

Lining mucosa

Buccal mucosaAlveolar mucosa

Floor of mouth

Vestibule

Mucogingivaljunction

Lineaalba


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FunctionSpeech, expression, gustation, mastication & deglutition

AnatomySalivary glands present on most of tongueLingual tonsils on posterior dorsum & lateral tongueTaste buds are fungiform, circumvallate & foliate papillae

FunctionSpeech, expression, gustation, mastication & deglutition

AnatomySalivary glands present on most of tongueLingual tonsils on posterior dorsum & lateral tongueTaste buds are fungiform, circumvallate & foliate papillae


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DevelopmentAnterior 2/3 – from 1st branchial arch-supplied by VII nervePosterior 1/3 – from 2nd and 3rd branchialarches – supplied by IX nerve

AnatomyFiliform papillae over most of dorsumFungiform papillae irregularly scattered over

dorsumCircumvallate papillae near terminal sulcus

DevelopmentAnterior 2/3 – from 1st branchial arch-supplied by VII nervePosterior 1/3 – from 2nd and 3rd branchialarches – supplied by IX nerve

AnatomyFiliform papillae over most of dorsumFungiform papillae irregularly scattered over

dorsumCircumvallate papillae near terminal sulcus

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Dorsum of TongueDorsum of Tongue

RootRoot

Body(corpus)

Body(corpus)

ApexApex

EpiglottisEpiglottisMedian glossoepiglottic foldMedian glossoepiglottic foldLateral glossoepiglottic foldLateral glossoepiglottic foldValleculaValleculaPalatopharyngeal arch and musclePalatopharyngeal arch and musclePalatine tonsilPalatine tonsilLingual tonsil (lingual follicles)Lingual tonsil (lingual follicles)Palatoglossal arch and musclePalatoglossal arch and muscleForamen cecumForamen cecumSulcus terminalisSulcus terminalisCircumvallate papillaeCircumvallate papillae

Foliate papillaeFoliate papillae

Filiform papillaeFiliform papillae

Fungiform papillaFungiform papillaMedian sulcusMedian sulcus

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Stratified squamous epitheliumStratified squamous epithelium

Schematic stereogramSchematic stereogram

Section of taste budSection of taste bud

Sustentacular cellSustentacular cellTaste cellTaste cellPorePoreConnective tissueConnective tissue

Fungiform papillaFungiform papilla

Cornified tip ofpapillaCornified tip ofpapilla

Filiform papillaeFiliform papillae

Intrinsic muscleIntrinsic muscle

Glands of EbnerGlands of EbnerFurrowFurrow

Taste budsTaste budsCircumvallate papillaCircumvallate papilla

Mucous glandsMucous glandsLymph folliclesLymph follicles

Duct of glandDuct of glandCryptCrypt

Lingual tonsilLingual tonsil

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Simplified FeaturesMain Papillae of TongueSimplified Features

Main Papillae of Tongue

Corial papillae

Fungiform papilla

Cornified layer

Filiform papilla

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Ten Tongue TroublesDiseases of the TongueTen Tongue TroublesDiseases of the Tongue

Mangold AR, Torgerson RR, Rogers RS III: Diseases of the Tongue. Clin Dermatol 2016; 34:458-469.



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•Furred tongue

•Black hairy tongue

•Smooth tongue

•Fissured tongue

•Median rhomboidglossitis

•Furred tongue

•Black hairy tongue

•Smooth tongue

•Fissured tongue

•Median rhomboidglossitis

•Geographic tongue

•Sublingual varices

•Oral hairyleukoplakia

•Herpetic geometricglossitis

•Macroglossia

•Geographic tongue

•Sublingual varices

•Oral hairyleukoplakia

•Herpetic geometricglossitis

•Macroglossia

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Ten Tongue TroublesFurred Tongue


•Hyperkeratosis of filiform papillae

•Noted with fever, smoking, mouth breathing

•Lessened by diet high in fiber and roughage

•Treatment by brushing tongue with dentifrice

•Hyperkeratosis of filiform papillae

•Noted with fever, smoking, mouth breathing

•Lessened by diet high in fiber and roughage

•Treatment by brushing tongue with dentifrice

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• Incidence of 0.5-11.3%

•Male predominance

•More common in older persons

•Length of papillae may be 10-20X normal

• Incidence of 0.5-11.3%

•Male predominance

•More common in older persons

•Length of papillae may be 10-20X normal

Furred TongueFurred Tongue

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Fur on the TongueFiliform Papillary Hypertrophy

Fur on the TongueFiliform Papillary Hypertrophy

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Increases• Smokers• Fasting• Poorly fitting or absent dentures• Dentures not used for eating• Soft processed food diets

Decreases• Vegetarians• High-fiber diets• Broad spectrum antibiotics• Habitual toothbrushing of tongue

Increases• Smokers• Fasting• Poorly fitting or absent dentures• Dentures not used for eating• Soft processed food diets

Decreases• Vegetarians• High-fiber diets• Broad spectrum antibiotics• Habitual toothbrushing of tongue

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Brushing Away Bad BreathBrushing Away Bad Breath

Most importantto brushMost importantto brush

Also important,but less soAlso important,but less so

© 2001 Harriet Greenfield© 2001 Harriet Greenfield

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• Brush with simple dentifrice (5-15 strokes)

• Increase roughage in diet

• Correct mouth breathing

• Stop smoking


• Increase roughage in diet

• Correct mouth breathing

• Stop smoking

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Ten Tongue TroublesBlack Hairy Tongue


• Hyperkeratosis of filiform papillae

• Increased pigment due to bacteria

• Related to antibiotic therapy, smoking

• Hyperkeratosis of filiform papillae

• Increased pigment due to bacteria

• Related to antibiotic therapy, smoking

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Black, Pseudohairy, and Fissured Tougue (PeptoBismol®)

Black, Pseudohairy, and Fissured Tougue (PeptoBismol®)

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• Increase roughage in diet• Correct mouth breathing• Stop smoking• Brush with 1-2% H2O2 solution


• Increase roughage in diet• Correct mouth breathing• Stop smoking• Brush with 1-2% H2O2 solution

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Ten Tongue TroublesSmooth Tongue


• Atrophy of filiform papillae

• Related to nutritional deficiencies, malabsorption states, Riley-Day dysautonia syndrome

• Atrophy of filiform papillae

• Related to nutritional deficiencies, malabsorption states, Riley-Day dysautonia syndrome

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• Bland, soft diet

• Establish systemic cause or causes

• Bland, soft diet

• Establish systemic cause or causes

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Ten Tongue TroublesFissured Tongue


• Surface thrown into deep fissures and folds

• Developmental defect

• Related to Down syndrome, Melkersson-Rosenthal syndrome, age

• Surface thrown into deep fissures and folds


• Related to Down syndrome, Melkersson-Rosenthal syndrome, age

Danish community study668 individuals 65-95 y/o

75% had 1 or more lesionsLingual varicosities (28.3%)Denture stomatitis (12.7%)

Candidiasis (11.8%)Fissured tongue (9.1%)

Frictional keratoses (8.4%)

Oral Dis 2015; 21:721-729.

Prevalence of oral lesions in older people

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• More severe form is called “lingua plicata”

• More common with psoriasis & geographic tongue

• Incidence increases in older patients

• More severe form is called “lingua plicata”

• More common with psoriasis & geographic tongue

• Incidence increases in older patients

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Brush with simple dentifrice (5-15 strokes) after each meal and at bedtime

Brush with simple dentifrice (5-15 strokes) after each meal and at bedtime

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Ten Tongue TroublesMedian Rhomboid Glossitis


• Rhomboid plaque in central tongue


• Persistent tuberculum impar

• Chronic hyperplastic candidiasis

• Rhomboid plaque in central tongue


• Persistent tuberculum impar

• Chronic hyperplastic candidiasis

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• Special stains reveal hyphae

• Low grade chronic hyperplasticcandidiasis

• Can treat with topical or oral azoles

• Special stains reveal hyphae

• Low grade chronic hyperplasticcandidiasis

• Can treat with topical or oral azoles

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Ten Tongue TroublesGeographic Tongue


• Glossitis areata migrans

• Transient, annular plaques of the tongue

• Benign migratory glossitis

• Bald vs hyperplastic patches

• Glossitis areata migrans

• Transient, annular plaques of the tongue

• Benign migratory glossitis

• Bald vs hyperplastic patches

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• 1-2% of population

• More in younger patients; less common with age

• Possible association with atopic diathesis, psoriasis

• 1-2% of population

• More in younger patients; less common with age

• Possible association with atopic diathesis, psoriasis

NHANES III DataWHO Oral Diagnosis Classification

10,030 individuals 2-17 y/oMales > females

Lips > tongue > buccal mucosaLip/cheek bite (1.89%)

Aphthosis (1.64%)Recurrent HSV labialis (1.42%)

Geographic tongue (1.05%)

Int J Paediatr Dent 2005; 15: 89-97

Prevalence of oral lesions in children and youths

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Geographic TongueGeographic Tongue

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Geographic StomatitisGeographic Stomatitis

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• Irritation from foods and flavors

• No associated systemic disease

• Association with psoriasis

• Spontaneous remission will occur

• Reassurance is in order

• Irritation from foods and flavors

• No associated systemic disease

• Association with psoriasis

• Spontaneous remission will occur

• Reassurance is in order

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Ten Tongue TroublesSublingual Varices


•Benign vascular dilatations

•10% population age 40

•No clinical significance


•10% population age 40


Danish community study668 individuals 65-95 y/o

75% had 1 or more lesionsLingual varicosities (28.3%)Denture stomatitis (12.7%)

Candidiasis (11.8%)Fissured tongue (9.1%)

Frictional keratoses (8.4%)

Oral Dis 2015; 21:721-729.

Prevalence of oral lesions in older people

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•Reassurance



•Reassurance


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Ten Tongue TroublesOral Hairy LeukoplakiaTen Tongue TroublesOral Hairy Leukoplakia

• Characteristic white linear “hairy” plaques

• Lateral tongue borders and buccal mucosa

• Association with EBV infection

• Association with immunodeficiency

• Characteristic white linear “hairy” plaques

• Lateral tongue borders and buccal mucosa

• Association with EBV infection

• Association with immunodeficiency

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Courtesy: John Greenspan, DDSCourtesy: John Greenspan, DDS

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Courtesy: John Greenspan, DDSCourtesy: John Greenspan, DDS

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Dermatologica 177:126-128 (1988)

Oral Hairy Leukoplakia in a HIV-Negative Renal Transplant Patient: A Marker for immunosuppression?

Peter Itina, Theo Ruflia, René Rüdlingerb, Gieri Cathomasc, Beat Huserd, Michael Podvinece, Fred Gudatf

Departments of aDermatology, cMicrobiology, dNephrology, and fPathology, University of Basel; bDepartment of Dermatology, University of Zürich, and eDepartment of Otorhinolaryngology, Kantonsspital Aarau, Switzerland

Dermatologica 177:126-128 (1988)

Oral Hairy Leukoplakia in a HIV-Negative Renal Transplant Patient: A Marker for immunosuppression?

Peter Itina, Theo Ruflia, René Rüdlingerb, Gieri Cathomasc, Beat Huserd, Michael Podvinece, Fred Gudatf

Departments of aDermatology, cMicrobiology, dNephrology, and fPathology, University of Basel; bDepartment of Dermatology, University of Zürich, and eDepartment of Otorhinolaryngology, Kantonsspital Aarau, Switzerland

©1988 S. Karger AG, Basel0011-9075/88/1772-0126 $2.75/0

©1988 S. Karger AG, Basel0011-9075/88/1772-0126 $2.75/0

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Ten Tongue TroublesOral Hairy LeukoplakiaTen Tongue TroublesOral Hairy Leukoplakia

• Often asymptomatic

• No malignant potential

• Treatment not required

• Underlying cause of immunosuppression should be addressed

• Often asymptomatic

• No malignant potential

• Treatment not required

• Underlying cause of immunosuppression should be addressed

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Ten Tongue TroublesHerpetic Geometric Glossitis


• Tender/painful linear fissures on dorsal tongue

• Striking geometric pattern• Immunocompromised host defense• Chronic HSV infection• Responsive to acyclovir therapy

• Tender/painful linear fissures on dorsal tongue

• Striking geometric pattern• Immunocompromised host defense• Chronic HSV infection• Responsive to acyclovir therapy

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NEJM 329:1859, 1993NEJM 329:1859, 1993

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Extremely painful longitudinal fissure with branched pattern on dorsum of tongue

Extremely painful longitudinal fissure with branched pattern on dorsum of tongue

NEJM 329:1859, 1993NEJM 329:1859, 1993

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Acute Herpetic GingivostomatitisAcute Herpetic Gingivostomatitis

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Herpetic Geometric GlossitisHerpetic Geometric Glossitis

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• Bland, soft diet• Acyclovir 200 mg every 4-6 hr

or• Valacyclovir 500 mg every 12 hr

or• Famiciclovir 250 mg every 8 hr

• Bland, soft diet• Acyclovir 200 mg every 4-6 hr

or• Valacyclovir 500 mg every 12 hr

or• Famiciclovir 250 mg every 8 hr

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Ten Tongue TroublesMacroglossia


•Tongue enlarged out of pro-portion to jaws

•Many associations

•May require Bx for diagnosis

•Tongue enlarged out of pro-portion to jaws

•Many associations

•May require Bx for diagnosis

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AcromegalyAcromegaly

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Primary: Down Syndrome, developmental

Tumors: Hemangioma, lymphangioma, neurofibroma, neurilemmoma, thyroglossal duct cyst

Infections: Actinomycosis, tuberculosis, histoplasmosis, syphilis

Metabolic: Hypothyroidism, acromegaly, multiple myeloma, amyloidosis

Other: Angioedema, sarcoidosis, superior vena cava syndrome

Primary: Down Syndrome, developmental

Tumors: Hemangioma, lymphangioma, neurofibroma, neurilemmoma, thyroglossal duct cyst

Infections: Actinomycosis, tuberculosis, histoplasmosis, syphilis

Metabolic: Hypothyroidism, acromegaly, multiple myeloma, amyloidosis

Other: Angioedema, sarcoidosis, superior vena cava syndrome


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• Localized granuloma which ulcerates

• Painless leukoplakic patch which ulcerates

• Persists for months• Not infectious

• Localized granuloma which ulcerates

• Painless leukoplakic patch which ulcerates

• Persists for months• Not infectious

Tertiary SyphilisTertiary Syphilis

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AmyloidosisAmyloidosis

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AmyloidosisAmyloidosis

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Amyloidosis

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Ten Tongue TroublesDiseases of the TongueTen Tongue TroublesDiseases of the Tongue



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Clinics in DermatologyVolume 34, Number 4,

July/August, 2016

Oral Dermatology, Part I

Guest Editors: Roy S. Rogers, III, MD and Nasim Fazel, MD, DDS

Oral Dermatology

Clinics in DermatologyVolume 35

September/ October, 2017

Oral Dermatology, Part II

Guest Editors: Roy S. Rogers, III, MD and Nasim Fazel, MD, DDS

Oral Dermatology


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BonusWhat to do with a patient who has

symptoms of a sore, burning mouth?



Burning Mouth SyndromePractice Gaps

Burning Mouth SyndromePractice Gaps

The symptoms of the sore, burning mouth are the result of one or several conditions.

Success in the management of BMS is dependent on identifying ALL factors causing the symptoms and managing these simultaneously.

The prognosis for patients with symptoms of the sore, burning mouth is optimistic for a good outcome.

Burning Mouth SyndromeLearning Objectives

Burning Mouth SyndromeLearning Objectives

The learner will be able to assess the patient suffering from a sore, burning mouth for the many potential causes.

The learner will be able to develop and carry out a plan of management for each factor simultaneously.

The learner will be able to reassure the patient that optimism regarding the prognosis is a realistic goal.

Burning Mouth SyndromeReferences, I

Burning Mouth SyndromeReferences, I

1. Byrd JA, Bruce AJ, Rogers RS III: Glossitis and other tongue disorders. Dermatol Clin 21: 123-134, 2003.

2. Drage LA, Rogers RS III: Clinical assessment and outcome in 70 patients with complaints of burning or sore mouth. Mayo Clin Proc 74: 223-228, 1999.

3. Drage LA, Bruce AJ, Rogers RS III: Burning mouth syndrome. In: Lebwohl MG, et al, editors. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 3rd edition. Saunders/Elsevier; 2010, p. 111-113. (Book chapter)

Burning Mouth SyndromeReferences, II

Burning Mouth SyndromeReferences, II

4. Lehman JS, Bruce AJ, Rogers RS III: Atrophic glossitis from Vitamin B12 deficiency: a case misdiagnosed as burning mouth disorder. J Periodontol 77: 290-292, 2006.

5. Steele JC, Bruce AJ, Davis MD, Torgerson RR, Rogers RS III: Clinically relevant patch test results in patients with burning mouth syndrome. Dermatitis 23: 61-70, 2012.

6. Steele JC: The practical evaluation and management of patients with symptoms of a sore burning mouth. Clin Dermatol 2016; 34: 449-457.

Burning Mouth SyndromeReferences, III

Burning Mouth SyndromeReferences, III

7. Moghadam-Sia S, Fazel N: A diagnostic and therapeutic approach to primary burning mouth syndrome. Clin Dermatol 2017; 35:453-460.

8. Verenzuela CSM, Davis MPD, Bruce AJ, Torgerson RR: Burning mouth syndrome: results of screening tests for vitamin and mineral deficiencies, thyroid hormone, and glucose levels-- experience at Mayo Clinic over a decade. Int J Dermatol 2017; 56:952-956.

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Burning Mouth SyndromeBurning Mouth Syndrome

Symptoms of a sore, burning mouth are common

and distressingThe BMS is a complex, multifactorial condition



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Symptoms of the Burning Mouth SyndromePrevalence

Symptoms of the Burning Mouth SyndromePrevalence

Populations Ageat risk No. % % F range

General dental 392 5 85 40-50practice

Menopause clinic 114 26 100 40-60

Diabetes clinic 110 10 – 50-80

Populations Ageat risk No. % % F range

General dental 392 5 85 40-50practice

Menopause clinic 114 26 100 40-60

Diabetes clinic 110 10 – 50-80

Basker et al: Brit Dent J 145:9, 1978Basker et al: Brit Dent J 145:9, 1978

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Burning Mouth Syndrome Glossodynia

Burning Mouth Syndrome Glossodynia

•Syndrome of burning, stinging, tingling, scalded sensations of mouth, especially the tongue

•Diagnosis of exclusion

•Requires a thorough evaluation

•Incidence of 11.4 per 100,000 person years

•Women 18.8 to men 3.7

Int J Dermatol 2017; 56:952-956.

•Syndrome of burning, stinging, tingling, scalded sensations of mouth, especially the tongue

•Diagnosis of exclusion

•Requires a thorough evaluation

•Incidence of 11.4 per 100,000 person years

•Women 18.8 to men 3.7

Int J Dermatol 2017; 56:952-956.

CP1140017-64


Syndrome of burning, stinging, scalded sensations of mouth, especially the tongue

There are primary and secondary forms of the syndrome of the sore, burning mouth

Syndrome of burning, stinging, scalded sensations of mouth, especially the tongue

There are primary and secondary forms of the syndrome of the sore, burning mouth

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Primary BMS is idiopathic

Secondary BMS may have one or more causes

The key to management of these patients is to seek any and all causes of the distressing symptoms


Secondary BMS may have one or more causes


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Burning Mouth SyndromeBurning Mouth SyndromePrimary BMS is idiopathic


Moghadam-Sia S, Fazel N: A diagnostic and therapeutic approach to primary burning mouth syndrome. Clin Dermatol2017; 35:453-460.



Moghadam-Sia S, Fazel N: A diagnostic and therapeutic approach to primary burning mouth syndrome. Clin Dermatol2017; 35:453-460.

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Secondary Burning Mouth Syndrome


Identify and address each element to insure best

outcomeThe outlook for patients

suffering from symptoms of the BMS is optimistic




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Recommended Work-Up of Burningor Sore Mouth

Recommended Work-Up of Burningor Sore Mouth

• Thorough history• Oral exam• Lab tests

Complete blood cell countIron, total iron-binding capacity, iron saturation, ferritinVitamin B1, B2, B6, B12, D3 and folateZincThyroid function tests (TSH)Glucose and HbAlc

• Thorough history• Oral exam• Lab tests

Complete blood cell countIron, total iron-binding capacity, iron saturation, ferritinVitamin B1, B2, B6, B12, D3 and folateZincThyroid function tests (TSH)Glucose and HbAlc

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Secondary Burning Mouth Syndrome Mayo Series

Secondary Burning Mouth Syndrome Mayo Series

Physical findings No. %Xerostomia 20/70 28.6Dentures 17/70 24.3Geographic tongue 13/70 18.6Furred tongue 9/70 12.9Atrophic tongue 6/70 8.6Fissured tongue 5/70 7.1Papillitis 5/70 7.1

Physical findings No. %Xerostomia 20/70 28.6Dentures 17/70 24.3Geographic tongue 13/70 18.6Furred tongue 9/70 12.9Atrophic tongue 6/70 8.6Fissured tongue 5/70 7.1Papillitis 5/70 7.1

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Secondary Burning Mouth SyndromeMayo Series


Global assessment of 70 patients• Women – 80%• Abnormal tongue exam – 50%• Xerostomia – 30%• Denture wearers – 25%• Follow-up

Improved – 70%Dramatically improved – 35%

Global assessment of 70 patients• Women – 80%• Abnormal tongue exam – 50%• Xerostomia – 30%• Denture wearers – 25%• Follow-up

Improved – 70%Dramatically improved – 35%

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•Careful history and physical exam

•Lab testing for “correctable causes”

•Seek >1 cause

•Treat all potential causes simultaneously

•Careful history and physical exam

•Lab testing for “correctable causes”

•Seek >1 cause

•Treat all potential causes simultaneously

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Secondary Burning Mouth SyndromeCauses

Secondary Burning Mouth SyndromeCauses

Trauma (denture sore mouth)CandidiasisDiabetesNutritional deficienciesXerostomiaDrugsContactantsDepressionCancerophobiaGERD

Trauma (denture sore mouth)CandidiasisDiabetesNutritional deficienciesXerostomiaDrugsContactantsDepressionCancerophobiaGERD

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Management Strategies for theBurning or Sore Mouth*


• Treat dry mouth

• Denture adaptation

• Control of oral habits

• Vitamin and mineral replacement

• Avoidance of allergens

• Avoidance of irritants

• Antifungal agents

• Treat dry mouth

• Denture adaptation

• Control of oral habits

• Vitamin and mineral replacement

• Avoidance of allergens

• Avoidance of irritants

• Antifungal agents*Tailor treatment to suspected causal factor or factors*Tailor treatment to suspected causal factor or factors

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SUMMARYSUMMARY

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Burning Mouth SyndromeBurning Mouth SyndromeIdentify and address each

element to insure best outcome

The outlook for patients suffering from symptoms of

the BMS is optimistic




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Management Strategies for theBurning or Sore Mouth


Correct active causesLow dose tricyclic antidepressant at

dedtime, amitryptyline…10 mg for 4 weeks, 20 mg for 4 weeks, 30 mg for 4 weeks, reassess

Treat depressionReassurance that cancer is not present

Correct active causesLow dose tricyclic antidepressant at

dedtime, amitryptyline…10 mg for 4 weeks, 20 mg for 4 weeks, 30 mg for 4 weeks, reassess

Treat depressionReassurance that cancer is not present

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Prognosis

• Improved substantially – 35%

• Improved moderately – 35%

• Improved minimally – 30%

Prognosis

• Improved substantially – 35%

• Improved moderately – 35%

• Improved minimally – 30%


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What to do when all else fails?Treatment options for chronic sore, burning mouth symptoms

What to do when all else fails?Treatment options for chronic sore, burning mouth symptoms

Moghadam-Sia S, Fazel N: A diagnostic and therapeutic approach to primary burning mouth syndrome. Clin Dermatol 2017; 35:453-460.

CP1140017-85



Topical capsaicinAlpha lipoic acidClonazepam 0.25mg bedtime,

increasing by 0.25 mg each week to 2.0 mg

Gabapentin

Topical capsaicinAlpha lipoic acidClonazepam 0.25mg bedtime,

increasing by 0.25 mg each week to 2.0 mg

Gabapentin

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• Topical capsaicin (Tobasco sauce) (J Otolaryngol 2004; 130:786-788.)

• Alpha lipoic acid 200 mg TID X 12 weeks (J Oral Pathol Med 2002; 31:267-269; Oral Dis; 2008;14:529-532.)

• Topical capsaicin (Tobasco sauce) (J Otolaryngol 2004; 130:786-788.)

• Alpha lipoic acid 200 mg TID X 12 weeks (J Oral Pathol Med 2002; 31:267-269; Oral Dis; 2008;14:529-532.)

*Tailor treatment to suspected causal factor or factors*Tailor treatment to suspected causal factor or factors

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Alpha lipoic acid 200 mg TID X 12 weeks (Oral Dis;2008;14:529-532.)31 of 35 patients took Rx as directed11 of 35 (35%) reported benefit14 of 35 (45%) reported no benefit

Alpha lipoic acid 200 mg TID X 12 weeks (Oral Dis;2008;14:529-532.)31 of 35 patients took Rx as directed11 of 35 (35%) reported benefit14 of 35 (45%) reported no benefit

*Tailor treatment to suspected causal factor or factors*Tailor treatment to suspected causal factor or factors

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