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Table of Contents
Year : 2004  |  Volume : 6  |  Issue : 2  |  Page : 61-70

Oral dryness and burning mouth syndrome - Causes and treatment options

1 Department of Otolaryngology /Head and Neck Surgery Bundeswehr Station Hospital, Ulm, Germany
2 ENT Unit King Fahad Military Medical Complex, Dhahran, Saudi Arabia

Date of Web Publication12-Jul-2020

Correspondence Address:
MD, Col H Maier
Department of Otolaryngology /Head and Neck Surgery Bundeswehr Station Hospital
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-8491.289585

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Both oral dryness and a disorder known as burning mouth syndrome are fairly common oral conditions, It has been estimated that in the United States more than 40 million people suffer from oral dryness and as many as 2.5 million people are afflicted with burning mouth syndrome.
Both conditions are not diseases perse, but a group of complaints and symptoms which are caused by a w ide variety of different factors.
An overview of the causes and treatment options is given. Special attention is paid to those clinical pictures which are of particular relevance to the field of otolaryngology.

Keywords: Oral dryness, burning mouth syndrome, aetiology, diagnosis, treatment

How to cite this article:
Maier H, Al Saif S, Tisch M. Oral dryness and burning mouth syndrome - Causes and treatment options. Saudi J Otorhinolaryngol Head Neck Surg 2004;6:61-70

How to cite this URL:
Maier H, Al Saif S, Tisch M. Oral dryness and burning mouth syndrome - Causes and treatment options. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2004 [cited 2022 Nov 30];6:61-70. Available from: https://www.sjohns.org/text.asp?2004/6/2/61/289585

  Burning Mouth Syndrome Top

A variety of medical terms have in the past been used for describing painful sensations in the mouth or the tongue. Among them are stomatodynia, stomatopyrosis, glossopyrosis. glossodynia or oral dysesthesia. For practical reasons, the generic term “burning mouth syndrome” or BMS has lately been coined to cover these medical names.

Burning mouth syndrome describes a multifactorial condition which may be caused by many local and regional contributory factors or by a variety of systemic diseases. The task of diagnosing and treating this condition is usually very complex and may require an interdisciplinary approach. In many cases it may be necessary to consult an internist, a dentist, a neurologist/psychiatrist, an orthopedist and a dermatologist in the search for the cause of the complaints. In the following, the most important causes of BMS are described with a major focus on local and regional contributory factors.

  Diseases of the Oral Mucosa Top

Lingua plicata (fissured tongue) describes a sometimes familial condition which is inherited as an autosomal dominant disorder and is characterized by the presence of numerous furrows varying in depth and size and noted on the anterior part of the tongue.

Severe forms are found in about 1 percent of the general population. Approximately 20 percent of these patients are also affected by exfoliatio areata linguae, which is often the reason why they seek medical help. As a result of the minimally keratinized and thinned epithelium in the furrows, the mouth becomes more susceptible to bacterial and fungal infections which cause burning pain on the tongue mucosa. Once the diagnosis is confirmed on the basis of smears, patients are administered antimicrobial therapy and, if necessary, receive further treatment that provides symptomatic relief. In rare cases, especially in association with exfoliation, a furrowed tongue can be associated with a burning sensation of the oral mucosa, which is most commonly caused by psychogenic problems. Relief may often be obtained by simply reassuring the patient that no evidence of a significant disease exists.

Lingua geographica (geographic tongue) is characterized by the presence of irregular, red patches with gray-white, slightly raised borders which are caused by desquamated filiform papillae. The etiology of this non-serious condition, which gives the mucous membrane of the tongue a map-like appearance, is unknown. It occurs in approximately 5 percent of the general population and can also affect other sites of the oral mucosa (stomatitis geographica). Psychological stress, allergies, infections and a genetic predisposition have been implicated in the cause of geographic tongue. The lesion is usually asymptomatic. Some patients may present with a complaint of burning sensations of the oral mucosa noted with acidic foods. Similar to lingua plicata, the diagnosis is made from clinical features and reassurance of the patient is extremely important for the success of the treatment. Patients may be advised to avoid acidic foods. An efficient causal therapy is unknown. A topical salicyclic solution 7% in alcohol 70% or tretinoin 0.1% has been used with some success [1],[2].

Lingua villosa (hairy tongue) is a hyperplasia of the filiform papillae affecting the dorsum of the tongue. The elongated papillae are 1 to 2 cm in length and, because of the massive colonization with chromogenic bacteria, assume various colors ranging from gray and yellow to brown or black. This harmless condition affects approximately 1 percent of the adult population. Medications (e.g. antibiotics, corticoids, methyldopa and mouth rinses), heavy smoking and poor oral hygiene are believed to be potential causes of hairy tongue. There are often no symptoms. In more severe cases, especially in association with candidal infection, patients may complain of a foreign body sensation, itching or burning on the tongue or palate. Diagnosis is made from the history and clinical features. In addition, a candidal infection should be ruled out on the basis of smears. Treatment of hairy tongue mainly consists of treating the underlying cause. Patients with candidal infection receive topical antifungal agent treatment (e.g. oral amphotericin B, nystatin or pimaricin rinses). The affected area of the tongue may be treated with a 40% urea solution bid and brushed with a soft toothbrush for 1 to 2 minutes, starting at the affected site and working towards the tip of the tongue. Usually hairy tongue and its symptoms completely subside in 8 to 14 days [3],[4].

Median rhomboid glossitis (MRG) is a benign lesion of the mucosa of unknown etiology which appears as a slightly raised, rarely polypoid-shaped erythematous area involving the area anterior to the foramen caecum. It is seen in approximately 1 percent of the general population and especially in middle-aged men. MRG is thought to result from a dysembryogenetic anomaly or a chronic candidal infection since a colonization of the lesion with Candida is found in most cases [5]. It should be noted that MRG-like lesions are common in HIV- infected patients. Diagnoses are made from clinical features and smears which reveal candidal organisms. Infrequently, especially if the clinical features are insufficient to establish the diagnosis and if the presence of a tumor is suspected, an exci- sional biopsy may be indicated. Although there are usually no symptoms, some patients may complain of itching or burning sensations. The management of MRG mainly consists of treating the patient with antifungal agents. Excision is the treatment of choice only if it offers relief to patients with prominent manifestations or if a precancerous lesion or a tumor is suspected [4].

Hypertrophy of the foliate papillae (on the posterolateral margins of the tongue) may lead to secondary trauma caused, for example, by sharp tooth margins. As a result, papillitis associated with unilateral or bilateral local pain, a burning sensation or increased sensitivity may occur. Once a tumor (squamous cell carcinoma) has been ruled out, treatment consists of eliminating the sources of mechanical irritation and of providing symptomatic relief.

Burning mouth syndrome may also be caused by lichenoid and pemphigoid diseases of the oral mucosa.

Lichen planus affects 0.2 to 0.4% of the general population. Patients affected by this lesion are typically middle-aged adults. The mucosa is involved in more than 50 percent of patients with this inflammatory dermatologic condition. The underlying causes remain unclear. Lichen planus is thought to be an autoimmune disease. Etiological and predisposing factors may include infections, medications (e.g. antimalarials, antihypertensives or antibiotics), metabolic disorders (e.g. diabetes mellitus, hepatopathy), chemical or physical noxae, psychosomatic factors and genetic factors. Clinically, the mucosal lesions appear as gray- white, usually confluent patches. Erosive forms and ulcerations may occur. Whereas some patients have no subjective symptoms, other patients complain of heat sensations, disorders of taste (metallic taste) or burning mucous membranes and severe pain, especially in association with the erosive and ulcerous forms. A malignant degeneration should be considered in the differential diagnosis [6]. Treatment should be provided in close cooperation with a dermatologist and mainly consists of eliminating potential causal factors and providing symptomatic relief. Patients should practice good oral hygiene, use antiseptic mouth rinses and may treat affected areas with topical applications of Dynexan A, which contains Iidocaine. Good results have been reported with daily mouth rinses with 5 ml (500 mg) of Cyclosporin A solution over a period of four weeks [7]. Severe cases require a systemic therapy with corticoids and aromatic retinoids (25 to 50 mg of Acitretin per day) [8],[9]. Since a superinfection with Candida species is common, an antifungal therapy may be instituted as well.

Pemphigoid diseases are autoimmune diseases which can affect the mucosa of the upper aerodi- gestive tract. Clinically, they are characterized by the development of bullae, erosions of the mucosa and pain that may vary in intensity. The treatment of bullous autoimmune disease generally consists of a systemic immunosuppressive therapy (corticosteroids, azathioprine, Cyclosporin A) and is usually provided by a dermatologist.

Pain and a burning sensation of the oral mucosa are characteristic of stomatitis or gingivostomatitis. The severity of the symptoms depends on the underlying cause and varies widely. For example, aphthous or ulcerous lesions like those seen in stomatitis herpetica may occur. Candidastomatitis is associated with more itching and mild burning and is characterized by an erythematous mucosa and whitish patches that can be wiped of.

In addition, the presence of systemic infectious diseases (e.g. infections with HIV, coxsackieviruses, echoviruses as well as gonorrhea, scarlet fever or lues) must be ruled out. Noninfectious aphthous diseases of the oral mucosa such as recurrent benign aphthos ulcers or Behijet’s syndrome must also be considered in differential diagnoses.

Systemic bacterial infections are treated with antiseptic mouth rinses and systemic antibiotics depending on what the smears disclose. Mouth rinses with tetracycline solution (250 mg of tetracycline, 5 ml of H202, qid for one week) are usually sufficient to manage local bacterial infections (e.g. with fusiform bacteria and/or spirochetes) are frequently seen in immunocompromised patients [10]. Candidal infections of the oral mucosa should be treated with topical antifungals such as nystatin tablets (Moronal® tablets) or amphotericin B tablets or suspension (Ampho-MoronaLE tablets or Ampho-Moronal/E suspension). It should be borne in mind that solutions or suspensions usually do not remain long enough in the mouth to be sufficiently effective. Many tablets, on the other hand, contain flavoring agents or sugar for improving the taste of the medicine and, as a result, increase the risk of caries significantly. Particularly good results have been reported with nystatin vaginal tablets (two or three of these sugar-free tablets are taken orally each day and are left on the tongue for 20 to 30 minutes). Dentures should be removed prior to treatment in order to ensure that all parts of the mucosa are treated efficiently. Once removed, dentures should first be thoroughly cleansed and then disinfected with benzalkonium chloride solution during the night. Before they are worn again, dentures should be treated with nystatin powder to prevent reinfection (denture stomatitis). Treatment failures or chronic mucocutaneous candidiasis may require systemic treatment, such as with ketocona- zole or fluconazole, for up to two weeks.

Patients with mild forms of viral stomatitis usually receive symptomatic treatment with analgesics, antiseptic mouth rinses, antipyretics and local applications of antiviral agents such as acyclovir (Zovirax®), idoxuridine (Zostrum®) or vidarabine (Vidarabin 3% Thilo®). The use of topical antiviral agents, however, is effective only in the early stages of the disease. Patients with severe forms may need systemic treatment with antiviral agents (Zovirax Foscavir® given by IV infusion).

Noninfectious aphthoid mucosal lesions are managed by local, systemic or combined therapy depending on the underlying disease. Topical astringents, topical cortisone (e.g. Volon A® ointment, Dynexan H®) and tetracycline mouth rinses (1% solution, 5 ml, several times/day) are effective for symptomatic cases. Mouth rinses with Hank’s solution (sodium chloride 8.4g, potassium chloride 0.4g, calcium dihydrate O.I4g, magnesium sulfate heptahydrate 0.2g, potassium dihydrogenphos- phate 0.06g, dinatirum hydrogen phophate dihydrate 0.06g, glucose monohydrate O.lg, sodium bicarbonate 0.35g, distilled water 1000 ml) are effective in relieving pain[4].

Leukoplakia, erythroplakia and early carcinoma may be associated with burning or itching sensations of the oral mucosa. After proper diagnosis, these changes, which appear as whitish or red patches or raised lesions or as ulcerative or verrucous lesions, require surgical treatment, if possible laser surgery.

Allergies, hypersensitivity reactions, toxic mucositis

In rare cases, allergic reactions, hypersensitivity reactions and toxic reactions can lead to mild to severe burning sensations of the oral mucosa. Clinically, these reactions generally appear as redness of the mucosa. In rare cases, erosions or ulcerations are noticed.

Stomatitis medicamentosa or contact stomatitis may result from the systemic or local application of some medications and oral hygiene products (Table I) [11].

In rare cases, some dental substances can cause contact stomatitis [12], These substances primarily include metals and acrylates and are listed in Table II (according to their clinical relevance).

Food allergy or food intolerance, too, may be associated with burning sensations. Oral allergic reactions to specific foods most commonly occur in patients who are allergic to pollens [13].

Treatment primarily consists of eliminating and avoiding the underlying cause. Patients with severe responses from the mucosa may receive antiallergic and symptomatic analgesic and anti-inflammatory treatment.

Different metals that have been used to restore or replace missing teeth may produce the flow of an electric current in the mouth. These electrochemical reactions are known as dental galvanism and may lead to taste disturbances (metallic taste). In rare cases, patients have been reported to experience sharp or burning pain of the oral mucosa [14].

There is, however, no reliable scientific evidence to support this belief. Electric currents should be measured in patients with severe pain. Measurement results exceeding sixty nano-joules are a reasonably valid indication that electric currents are causing the pain. In such cases, suitable dental treatment should be considered.

Denture stomatitis can be caused by poorly fitting, poorly occluding or unstable dentures, allergic reactions to denture base materials (methyl methacrylates, hydroquinone, dimethyl-p-tolui- dine, benzoyl peroxide, dibuthylphtalat, p- phenylendiamine, formaldehyde and a number of metal compounds), candidal infections in immunocompromised patients or poor oral hygiene[15],[16]. Treatment consists of relieving symptoms (see above) and eliminating the underlying causes. Internal diseases.

Vitamin deficiencies (Bl, B2, B5, B6, B12, folic acid) can cause burning mouth syndrome [17],[18],[19]. This in particular applies to a vitamin B12 deficiency, which leads to megaloblastic anemia (pernicious anemia) and glossitis (Moeller’s or Hunter’s glossitis). This condition is characterized by red patches and localized edematous grayish areas. Whereas the fungiform papillae of the tongue are swollen and appear as vesiculobullous lesions, the filiform papillae of the tongue are flattened. Patients complain of itching and burning sensations of the mucosa of the tongue, taste disturbances and oral dryness. Oral or intravenous administration of vitamin B12 is the treatment of choice and relieves oral symptoms in most cases.

Iron deficiency, too, not only causes hypochromic anemia but also atrophic changes in the mucosa of the mouth, pharynx and esophagus (Plummer- Vinson syndrome). The main clinical features include an atrophic, smooth and reddened surface of the tongue, a pale mucosa of the phaiynx and angular cheilitis. Most patients are females. Apart from general symptoms such as fatigue, irritability, palpitations, dizziness, shortness of breath and headache, some patients complain of dysphagia and burning sensations of the tongue [20],[21]. Once the underlying cause has been determined (a malignant tumor of the gastrointestinal tract must be ruled out), treatment consists of providing iron.

Many patients with diabetes mellitus complain of burning sensations of the oral mucosa and especially the tongue mucosa. However, their mucosa is clinically unremarkable. Gibson et al., 1990 [22] found that 16 of 43 patients who presented with burning sensations of the oral mucosa suffered from diabetes mellitus which had previously gone undiagnosed. Similar cases have been reported by other authors [23], Control of the diabetes is the treatment of choice and relieves the oral symptoms in most cases [22],[24].

Since many patients who are afflicted with burning tongue are postmenopausal women [23], estrogen deprivation has been suspected of causing this condition. However, estrogen replacement has not been successful in the treatment of burning tongue [25].

Last but not least, burning sensations of the orai mucosa have been reported by patients with gout, hypochlorhydria, achlorhydria, hyptothyreosis, arteriosclerosis, cardiovascular diseases, gastrointestinal tumors and HIV infections.

Craniomandibular and craniocervical dysfunction Craniomandibular dysfunction (CMD) is accompanied by a wide variety of symptoms. However, patients may show no cardinal symptoms such as pain, functional impairment, abnormal sensations and the perceptions of sound. Patients who are also afflicted with craniocervical dysfunction (CCD) frequently complain of boring pain in the jaw, burning mouth syndrome, numbness of the tongue, globus sensation and tightness on breathing [26].

An interdisciplinary approach to patients suspected of having craniocervical dysfunction is strongly recommended (dentist, orthopedist). The diagnostic evaluation should include thorough history- taking, measurements of jaw movement parameters, palpation of the supporting muscles of mastication and of the neck and throat muscles, resistance tests, passive movement tests, pain provocation, and x-ray and MRI examinations of the maxillary joints.

Both diagnosis and treatment require close cooperation between dentist or orthodontist and manual therapist. Treatment may consist of drug therapy (analgesics, infiltration of local anesthetics, muscle relaxants), manual and osteopathic techniques (mobilization, thrust techniques, impulse techniques), muscular/fascial techniques, Jones and trigger point techniques and special physiotherapeutic measures and exercises [27].

Neurologic and psychiatric diseases, tongue thrust and bruxism

Attacks of unilateral, excruciating, boring pain of the oral mucosa, occurring especially in association with the intake of food and lasting seconds to a few minutes, suggest the presence of neuralgia and in particular glossopharyngeal neuralgia. In such instances, a 10% cocaine solution should be applied to the ipsilateral tonsillar or pharyngeal area. Significant relief from the symptoms supports the presumptive diagnosis and requires further examinations. Especially neoplastic, vascular or inflammatory causes should be considered in the differential diagnosis and ruled out. Treatment usually consists of drug therapy (e.g. carba- mazepine, baclofen or gabapentin) and should be provided by a neurologist. Recent studies suggest abnormalities of the blink reflex in patients with burning mouth syndrome. Evidence of decreased inhibition in the striatal dopaminergic system has been found in these cases [28],[29], An earlier study suggests that patients with Parkinson’s disease are afflicted with burning mouth syndrome (five times) more often than the general population [30]. Similar findings have been described for patients with atypical facial pain. Lingual nerve damage resulting from surgical treatment of the tongue and/or the floor of the mouth may also cause burning or itching sensations and pain of the tongue.

Psychogenic disorders, too, play an important role in the etiology of burning mouth syndrome. Some studies have shown that more than 50 percent of the patients have been diagnosed as having chronic anxiety or depression [23],[31]. It should be noted that in some of these BMS patients no psychiatric disease had been identified prior to the study. If other possible underlying diseases have been ruled out, the presence of psychogenic problems should therefore always be considered in the diagnosis. It is difficult to assess to what extent burning mouth syndrome in this group of patients is attributable to the treatment with psychoactive substances which often induce xerostomia.

Oral habits such as tongue thrust or bruxism can produce a mechanical irritation of the mucosa and thus cause chronic sensitivity and pain [31]. Patients should be given a splint to be worn over the teeth and in particular undergo relaxation therapy or psychotherapy.

Idiopathic burning mouth syndrome.

When it is impossible to clarify the cause of burning mouth syndrome despite a thorough diagnostic evaluation and an interdisciplinary approach, the patient is diagnosed as having idiopathic burning mouth syndrome. In these cases it is extremely important to talk with the patients about their problem and reassure them that there is no serious underlying disease. In addition, they should be informed that the symptoms may disappear spontaneously. Patient education is often all that is needed to allay any concerns that the patients may have about their disease and to convince them that they require no treatment. By contrast, other patients insist on receiving treatment. Invasive diagnostic and therapeutic measures (excisional biopsy, dental treatment etc.) should be avoided especially because they may cause more severe symptoms in many cases. Symptoms may be relieved at least temporarily by applying salicylic acid 7% and alcohol 70% with a cotton applicator to the burning part of the mucosa several times a day for approximately ten seconds. The mouth should then be rinsed with water. Good results have also been reported with an undiluted salicylic acid solution (i tsp) to rinse with (and spit out) twice a day after meals (see Table III) [3].

In recent years, a number of experimental therapies have been described, some of which appear to be beneficial. Topical application of clonazepam (0.5 or 1 mg, two or three times per day) provided significant pain relief within four weeks [32], A long-term study has shown that this treatment resulted in complete resolution in 10 of 25 patients with idiopathic BMS. Marked improvement occurred in 9 patients, while this treatment was of no benefit in 6 patients. A further study was conducted to assess whether the topical application of capsaicin to the oral mucosa can relieve oral pain. More than 60 percent of the patients reported partial to complete pain relief as a result of this treatment [33]. Good results in the treatment of idiopathic BMS have also been reported with a number of antidepressants such as amilsulpride, clomipramine and mianserin as well as with paroxetine and sertraline, which are selective serotonin reuptake inhibitors [34],[35]. A neurologist should be consulted when a patient with BMS receives psychoactive substances.

Reports indicate that systemic alpha-lipoic acid (thioctic acid, Tiobec®) can significantly relieve BMS symptoms [36]. Marked improvement occurred in more than 60 percent of the patients who were treated with this antioxidant for 30 days (600 mg for 20 days and 200 mg for a further 10 days), which clinical studies had found to be neuroprotective. By contrast, only 15 percent of the patients in the placebo group experienced significant relief. These results in particular suggest that a neurologic disorder should not be ruled out as the cause of idiopathic BMS.

  Oral Dryness Top

The causes of oral dryness are as varied as those of burning mouth syndrome and are described below. Inadequate fluid intake, xerogenic medications, ageing, obstructed nasal breathing Clinically relevant oral dryness may have a wide variety of causes. In many cases, oral dryness is the result of inadequate fluid intake [37]. These patients should simply increase their intake of fluids (2.5 to 3 liters per day) in order to obtain complete symptomatic relief.

The most common cause of temporary oral dryness, however, is the intake of xerogenic medications. For this reason, the physician in charge must be aware of the desiccatory potential of such a drug before he can eliminate the cause of oral dryness and advise the patient to stop taking the drug or to substitute it with another one.[38],[39] Table I lists the most important groups of xerogenic medications.

Xerostomia is most commonly associated with ageing. On the one hand, this is due to the fact that the elderly have a reduced thirst drive and decrease their fluid intake accordingly. On the other hand, elderly people often take drugs which induce oral dryness. In addition, ageing has the effect of impairing the functioning of the minor and major salivary glands [40],[41]. This condition requires monitoring of the fluid balance and, if necessary, may be treated with pilocarpine (Salagen®) given 5 mg tid.

Occasionally, obstructed nasal breathing, which, for example, may result from a deviation of the nasal septum and can lead to increased oral breathing, may cause dryness of the oral mucosa. Management of these patients should focus on normalizing nasal breathing, for example by septoplasty.

  Systemic Diseases Top

Oral dryness may accompany a number of systemic diseases. HIV infections and hepatitis C virus infections are in many cases associated with clinically relevant oral dryness which is often caused by autoimmune sialadenitis [42],[43], Likewise, Sjogren’s syndrome (SS) is a disorder which is associated with extreme dryness of the mouth caused by autoimmune sialadenitis. There is no curative treatment of autoimmune sialadenitis like myoepithelial sialadenitis in SS. Cortisone, cytostatics or antirheumatics have proved to be ineffective. Patients with oral dryness should be advised to drink frequently (8 to 10 glasses of water per day) and to stimulate salivary secretion, for example by chewing (sugarless) gum and sucking on (sugarless) candies. The intake of alcohol and caffeine-containing drinks as well as smoking should be avoided. If possible, drugs that decrease salivary secretion should be substituted by other less drying medications.

The flow of saliva can also be stimulated by a number of sialagogues such as bromhexine, bethanechol chloride, anethole trithione and pilocarpine. In SS patients, the best results have been reported with pilocarpine, which stimulates the muscarinic M3 receptors in the salivary glands and thus increases the flow of saliva. This treatment, however, is effective only if the destruction of the secretory glandular tissue is not too far advanced [44],[45], A single dose of 5 mg is recommended and a total dose of 20 to 30 mg of pilocarpine should not be exceeded.

This dosage increases salivary secretion to two or three times the previous level. Pilocarpine can be taken as a 1% solution (10 drops in a glass of water three to five times a day) or as tablets (Salagen®, MG1 Pharmaceuticals). This dosage of pilocarpine is usually well tolerated. The most common side effect is increased sweating. Gastrointestinal symptoms, urinary frequency, dizziness or palpitations occur in rare cases. This treatment is contraindicated in patients with asthma, narrow-angle glaucoma or acute iritis.

Izumi et al., 1998 [46] report that the irrigation of the parotid duct with a prednisolone solution (2 mg/ml in normal saline solution) has been successful in increasing salivary secretion. Once a week, a catheter was used to instill 1 ml of the solution into the duct system where the solution remained for two minutes. This treatment was repeated three times. After an average of 3.7 weeks, salivary secretion was more than 40 percent above the previous level. This treatment proved to be effective for a period of more than eight months. Since the best results have been obtained in the early stages of the disease, the authors recommend that the irrigation of the duct should begin early after the onset of symptoms.

In an open study, Shiozawa et al.,1993 [47], who assumed that Sjogren’s syndrome was associated with interferon deficiency, treated SS patients with alpha interferon and observed a marked improvement in their patients’ condition. Ferracioili et al.,1996 [48] gave their patients recombinant interferon alpha 2 every 15 days over a period of 11 months and were able to increase lacrimation and salivation by more than 60 percent compared with the previous level. The side effects of this treatment were acceptable.

Acupuncture treatment has been successful in increasing salivary secretion in patients with primary Sjogren’s syndrome after gustatory stimulation. However, acupuncture had no measurable effect on basic secretion [49].

In addition, artificial saliva can help relieve the symptoms of oral dryness. A number of medications based on carboxylmethylcellulose, hydrox- ymethylcellulose or mucin are available such as Optimoist* (Colgate-Hoyt), Glandosane* (Fresenius), MouthKote* (Parnell Pharmaceuticals), Salivart’ (Gebauer), Luborant* (Antigen) or Saliva Orthana1 (Nycomed). These drugs, however, provide only temporary relief [50],[51],[52], The best results have thus far been reported with Optimoist/E, which is a saliva substitute containing hydroxymethylcellulose and calcium phosphate and can be used as a spray [52]. 58 percent of xerostomia patients who took part in an open study experienced significant relief from their symptoms of oral dryness. The treatment aided eating in 75 percent of the patients. In addition, the medication reduced the colonization of the oral mucosa with Candida in as many as 43 percent of the patients. Fluoride compounds and fluoride gel (e.g. Gel-Kam®, Duraphat®; Colgate-Palmolive) should be applied to provide additional protection to the natural teeth of patients with xerostomia.

In advanced cases, oral dryness leads to candidal infections of the mucosa of the mouth, tongue and pharynx. Treatment consists of topical antifungal agent therapy (e.g. Moronal® tablets, Ampho- Moronal® tablets or Ampho-Moronal® suspension). It should be borne in mind that solutions or suspensions usually do not remain long enough in the mouth to be sufficiently effective. Many tablets, on the other hand, contain flavoring agents or sugar for improving the taste of the medicine and, as a result, increase the risk of caries significantly. Particularly good results have been reported with nystatin vaginal tablets (two or three of these sugar-free tablets are taken orally each day and are left on the tongue for 20 to 30 minutes). Dentures should be removed prior to treatment in order to ensure that all parts of the mucosa are treated efficiently. Once removed, dentures should first be thoroughly cleansed and then disinfected with benzalkonium chloride solution during the night. Before they are worn again, dentures should be treated with nystatin powder to prevent reinfection. Treatment failures or chronic mucocutaneous candidiasis may require systemic treatment, such as with ketoconazole or fluconazole, for up to two weeks.

Among the other diseases which can be associated with oral dryness are diabetes mellitus, sarcoidosis and amyloidosis. Treatment mainly consists of treating the underlying disease. If this therapy cannot significantly stimulate the flow of secretions from the salivary glands, only symptomatic treatment, which is the same as that for autoimmune sialadenitis, is possible.

Radiation-induced sialadenitis, chronic sialadenitis, sialadenitis

Radiation therapy of squamous cell carcinoma of the upper aerodigestive tract or radioiodine therapy of thyroid carcinoma can cause damage to the salivary glands of the head, in particular the parotid glands, which varies in severity depending on the radiation dose.

The treatment of radiation-induced sialadenitis consists of gustatory stimulation of the flow of saliva. In addition, antiphlogistics which have an analgesic effect (e.g. diclofenac or ibuprofen) may be given. A bacterial superinfection should be treated with systemic antibiotics as soon as the diagnosis is confirmed on the basis of smears.

In recent years, studies have suggested that it may be possible to use prophylactic drugs to prevent radiation-induced sialadenitis. A prospective randomized study has shown that coumarin 30 mg tid and troxerutin 180 mg tid one week before, during and four weeks after radiation therapy at least appear to protect the salivary glands. [53] By reducing leukocyte adhesion and thrombocyte aggregation, coumarin and troxerutin (Venalot®) protect the endothelium. In addition, these agents promote the flow of saliva.

Even more promising results have been achieved with amifostine (Ethyol®), which is a cytoprotec- tive substance that is accumulated in the salivary glands and has been found to have a significant radioprotective effect in preclinical studies [54],[55]. In the past this finding has been confirmed in first clinical studies of patients who received external radiation therapy for squamous cell carcinoma of the upper aerodigestive tract (500 mg of amifostine weekly) or radioiodine therapy for thyroid carcinoma (amifostine 500 mg/m2 body surface). Apart from the use of prophylactic drugs to prevent xerostomia following radiation therapy, a surgical approach has been introduced recently. When patients with squamous cell carcinoma of the upper aerodigestive tract underwent surgery, their submandibular salivary glands were transferred to the submental region below the anterior belly of the digastric muscle in an attempt to remove them from the radiation field. No patient who received this treatment developed radiation-induced xerostomia. This technique makes the surgical procedure last, on average, 45 minutes longer and causes no additional complications [56].

Acupuncture treatment in association with the use of drugs that stimulate salivary secretion may be useful in patients with radiation-induced xerostomia whose salivary glands have not been completely destroyed. In a study, this treatment has been successful in increasing salivary secretion permanently in 38 patients [57], In addition, patients may benefit from treatment with a number of siala- gogues or artificial saliva, which is the same as that for oral dryness associated with autoimmune sialadenitis.

In patients with chronic sialadenitis or sialadenosis, treatment of the underlying disease (if possible) should be accompanied by gustatory stimulation of salivary secretion (see the overview in Maier, 2001). If the secretory glandular tissue has been significantly and irreversibly damaged in the course of the disease, only symptomatic treatment of xerostomia is possible.

  Conclusion Top

Both burning mouth syndrome and oral dryness may be caused directly or indirectly by a wide variety of diseases which are associated with different medical disciplines. The etiology is uncertain in the majority of cases. Often, the diagnostic evaluation requires an interdisciplinary approach in which not only an otolaryngologist but also a dentist, internist and neurologist should be consulted if necessary as well as perhaps a psychiatrist, dermatologist and orthopedist. Invasive diagnosis, e.g. an excisional biopsy of the oral mucosa, is indicated only in rare cases because invasive procedures may cause even more severe symptoms especially in patients with idiopathic BMS.

If the specific cause of the complaints can be determined, it is possible in many cases to provide successful causal treatment. When the etiology is uncertain, symptomatic treatment should be instituted only after a thorough interdisciplinary evaluation of the patient.

  References Top

Helfman R.J. The treatment of geographic tongue with topical retin-A-solution. Cutis 1979;24:179-180.  Back to cited text no. 1
Henricsson V., Axell T. Palliative treatment of geographic tongue. Swedish Dent J 1980;4:129-134.  Back to cited text no. 2
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