Burning Mouth Syndrome; any pearls?

[Ligament]

---

Members do not see this ad.

Hi All,

I have a burning mouth syndrome coming into the office tomorrow...first one I've seen. Any pearls other than membrane stabilizers? Waldman describes a very dangerous sounding injection which I cannot recall the details of...

 

[NOSfan]

Hi All,

I have a burning mouth syndrome coming into the office tomorrow...first one I've seen. Any pearls other than membrane stabilizers? Waldman describes a very dangerous sounding injection which I cannot recall the details of...

On thorough oral physical exam don’t forget to check underneath the tongue.

Ensure no psychological factors (quite common), check B12, TSH, T3 levels, and HgA1c. Rule out any potential medications as an etiology.

Try treating with topical Diphenhydramine or Clonazepam by swish and spit. If these fail, then Lamotrigine (start with 25 mg and increase by 25 mg per week (if not on Valproic Acid) to a maximum of 100 mg BID while watching for rash/SJS) or Topiramate to a maximum of 200 BID.

 

[Ligament]

On thorough oral physical exam don’t forget to check underneath the tongue.

Ensure no psychological factors (quite common), check B12, TSH, T3 levels, and HgA1c. Rule out any potential medications as an etiology.

Try treating with topical Diphenhydramine or Clonazepam by swish and spit. If these fail, then Lamotrigine (start with 25 mg and increase by 25 mg per week (if not on Valproic Acid) to a maximum of 100 mg BID while watching for rash/SJS) or Topiramate to a maximum of 200 BID.

THANKS!

I'm not familiar with the diphenhydramine or clonazepam swish and spits; are these compounded or ready made?

I would not have reached for Lamotrigine or Topamax off the bat but I'm certainly open to them; do these tend to work better than Lyrica/cymbalta/TCAs in burning mouth?

 

[Tenesma]

most common cause of burning mouth (when med side-effects are ruled out) is candidiasis.... so it doesn't hurt to try an anti-fungal lozenge... nothing to lose

 

[lobelsteve]

Anything interventional?

SPG/Gasserian?

Topical lidocaine- but this is probably as bad as the burning.


Underlying physiology?

 

[drusso]

Anything interventional?

SPG/Gasserian?

Topical lidocaine- but this is probably as bad as the burning.


Underlying physiology?

You can ask a dentist to do a diagnostic lingual nerve block.

 

[lobelsteve]

I can do superior and inferior alveolar blocks, but they are more useful for making people go home from the ER with dental pain.

Narc seekers in ER with dental abscess: Toradol 60mg IM, Augmentin Rx, S/I Alveolars. Cut em loose.

 

[Ligament]

Anything interventional?

SPG/Gasserian?

Topical lidocaine- but this is probably as bad as the burning.


Underlying physiology?

There is some recent literature showing small fiber peripheral neuropathy on tongue biopsies in these patients, as well as some disfunctions in blink reflex, as well as trigeminal fiber neuropathy, so the thought crossed my mind of trying a gasserian block or pulsed RF as a end line procedure if nothing else worked. I don't think there is any literature on this.

I don't like doing gasserian blocks, as cool as they are.

 

[Tenesma]

why would you do a tongue biopsy when a small skin biopsy will show the same thing? sounds kinda mean to me...

if you really want to be nifty i would recommend peripheral implant... imagine an IPG under each clavicle.

 

[NOSfan]

I believe that the Sodium Channel blockade MOA of LTG and TPX do well with BMS.

Anyhow, clonazepam can be compounded by your friendly compounding pharmacist. Usual dose is 1 mg swish for 3 minutes then spit TID.
For Diphenhydramine I just use the OTC Benadryl preparation.

WOW acronym city!

 

[Ligament]

I believe that the Sodium Channel blockade MOA of LTG and TPX do well with BMS.

Anyhow, clonazepam can be compounded by your friendly compounding pharmacist. Usual dose is 1 mg swish for 3 minutes then spit TID.
For Diphenhydramine I just use the OTC Benadryl preparation.

WOW acronym city!

Awesome NOSfan, thanks for the help.

Everybody else too!

 

[Mister Mxyzptlk]

I would give some Traumeel. http://azpaincenters.com/

 

[Tenesma]

this is funny - i had a lady last week who swears by it - it cured her cervical radiculopathy and she uses a Traumeel salve...

either that - or she is an undercover Traumeel drug rep... in which case, when did they replace the hot drug reps with elderly 87 year old women with heavy portguese accents???

 

[olafa]

.

 

[ParaVert]

I had some pretty good success with TCA swish/spit QID. The tricyclics have well-documented topical local anesthetic properties. Doxepin swish/spit has been described in Anes/Analg for mucositis - did that at MD Anderson with better results (personal N of 3) than viscous lido.


http://www.anesthesia-analgesia.org/cgi/content/abstract/103/2/465

 

[Ligament]

Update:

Have seen the patient twice in followup now and she is >50% after starting Alpha lipoic acid!

 

[Doctodd]

how did the alpha LA come about?

 

[Ligament]

how did the alpha LA come about?

There are about 6 papers out of Italy documenting its use for this issue, why or how they choose this I do not know but surprisingly, the evidence for ALA for this pain condition is just as well supported if not more so than anything else out there..!!!

She got it at a natural health food store per my rec...

 

[lobelsteve]

So funny- had a patient come in for follow-up yesterday- I have him on hydrocodone for FBSS, but he is seeing a Neurologist for a slew of conditions. I asked why he was taking Neurontin and he said it was for Burning Mouth Syndrome. I gave him an Rx for a compounded swish and spit of Benadryl, Klonopin, Elavil. Let you know in a month of it works.

 

[pokenburn]

Do you recall the dose of the compounded benadryl, klonopin and elavil? Did it work for you patient? Thank you

 

[lobelsteve]

Klonopin 6mg
Elavil 120mg
Benadryl as 12.5mg per 5ml

180ml total

5-15ml tid prn swish and spit

 

[drusso]

Klonopin 6mg
Elavil 120mg
Benadryl as 12.5mg per 5ml

180ml total

5-15ml tid prn swish and spit

Steve,

FYI: I tried this on one of my cancer pain patients with bad, bad ulcerative stomatitis and it worked like a charm! 👍

 

[brori]

just got a referral from ENT. Working diagnosis is neuroma at tonsillectomy site. Thought about gargle and spit with some of the above, but concerned about accidental swallowing of the klonopin/elavil/benadryl brew. What do you all think? Start with the doxepin solution gargle and spit?

 

[Ligament]

just got a referral from ENT. Working diagnosis is neuroma at tonsillectomy site. Thought about gargle and spit with some of the above, but concerned about accidental swallowing of the klonopin/elavil/benadryl brew. What do you all think? Start with the doxepin solution gargle and spit?

Has anybody injected the neuroma yet? Could try that; its done all the time in the tonsil region...

 

[brori]

Yep, ENT has done that twice, second time with kenalog.