A 48-year-old male patient reported to the department of oral medicine for a complaint of bitter taste in his mouth for over two years. He said that his mouth tasted bitter all the time, constantly making him feel nauseated. He was unable to appreciate the difference between sweet, salty or spicy anymore. There were also minor complaints of his gingiva feeling rough and slight burning sensation on the labial mucosa. The patient had seen several doctors with this problem, had all sorts of investigations done but nothing appeared to be wrong. He was currently taking antidepressants. The intraoral examination was unremarkable.
We also had a 54-year-old female come in the same week with a complaint of inability to tolerate chillies in food. She said that even black pepper made her buccal mucosa and tongue hurt. These symptoms were not constant, she would be able to enjoy a good meal occasionally. She also said that eating fruits (like mangoes and watermelon) make her tongue feel like it had spikes. She was diagnosed with erosive lichen planus by a general dentist and given a course of topical corticosteroids but her symptoms had not improved. However, it is important to note that her oral examination was unremarkable as well.
We diagnosed both these cases as Burning Mouth Syndrome.
Patient no. 1 was a little reluctant in accepting our diagnosis. He kept returning for follow ups asking us to give him something that will make his symptoms go away. We gave him 0.25 mg of Clonazepam to take before bedtime on his second visit because there is some evidence in the literature that favors this practice. Upped the dose to 0.5 mg on his third visit, but unfortunately it did not improve his symptoms. The patient was lost to follow up after that.
Patient no. 2 took her diagnosis relatively well. Once she understood what she had, she refused treatment. She said that now that she knows that it is not something significant, it will not affect her as much. We asked her to return in case she wanted us to try Clonazepam for her symptoms, we have not seen her back since.
Dr. K's Notes:
Burning Mouth Syndrome:
Burning mouth syndrome has diverse presentations as evident from our cases above. Patients always present with elaborate symptoms that are significantly affecting their lives, but nothing is ever identified clinically. Since dentists and other physicians are usually not aware of this conditions, these patients can go undiagnosed for several years. This just adds to the patient's frustrations.
In simple words burning mouth syndrome can be explained as nerves relaying the wrong information to your brain. This disturbance can manifest in three ways; pain, altered sensation and modified taste. For example, your nerves are telling your brain that your tongue is sore, the food is bitter and your mouth is feeling rough. At any time, one, two or all three disturbances may be present.
Unfortunately this is not communicated by the name given to condition. The misnomer gives dentists and other physicians a false impression that "burning" of the tongue is a mandatory symptom. As you can see from our examples, it is not always the case.
The problem arises when we are asked to treat this condition. We can't see nerves, there is no technology that enables us to do this yet. So if we can't see where the damage is, we can't fix it. Most of the treatment modalities tried and tested in literature have failed. A double-blind placebo-controlled study showed promising results with Clonazepam, but only in patients that had the pain component. It is did not treat their pain but did put their symptoms in the background. So in patient no. 1 this was not a practical choice, but we tried it anyways. Patient no. 2 might have been a right candidate for this but she was just ecstatic about the fact that she did not have cancer.
