Burning Mouth Syndrome and Related Orofacial Pain Christopher Herndon, PharmD Kevin Rowland, PhD McKenzie Ferguson, PharmD Cyril Pandarakalam, DDS Rebecca Luebbert, PhD, RN Kimberly Zoberi, MD Gretchen Salsich, PhD, PT Raymond Tait, PhD Contents Burning Mouth Syndrome and Related Orofacial Pain ................................ 1 Introduction .................................................................................................. 9 Interview Beverly ......................................................................................... 11 Interview Subjects .................................................................................... 11 Chief Complaint .................................................................................... 11 What Makes the Pain Better ................................................................. 11 Description of Pain .............................................................................. 12 What Makes the Pain Worse ................................................................ 12 Location of Pain ................................................................................... 13 Duration of Pain ................................................................................... 13 Beverly’s Review of Systems ........................................................................ 14 General .................................................................................................... 14 CNS/Neuro .............................................................................................. 14 Cardiovascular/Pulmonary ..................................................................... 14 Gastrointestinal/Genitourinary ................................................................15 Musculoskeletal/Extremities ....................................................................15 Beverly’s Labs and Tests ............................................................................. 16 Beverly’s Medications .................................................................................. 18 Beverly’s Physical Exam .............................................................................. 19 Interdisciplinary Pain Center ...................................................................... 20 Pain Assessment ...................................................................................... 20 Pain Assessment Tools ......................................................................... 20 Beverly’s Pain Assessment ................................................................... 21 Psychosocial/Psychological Assessment and Evaluation ........................ 22 Beverly’s Psychosocial Assessment: ..................................................... 22 Beverly’s Psychological Evaluation .......................................................... 24 How Pain Affects Beverly’s Life ........................................................... 24 Worst Pain Rating ................................................................................ 24 Least Pain Rating ................................................................................. 24 Average Pain Rating ............................................................................. 25 Pain and Mood ..................................................................................... 25 Daily Change in Pain ............................................................................ 26 Diagnosis ..................................................................................................... 27 Differential Diagnosis .............................................................................. 27 Primary Burning Mouth Syndrome ..................................................... 27 Secondary Burning Mouth Syndrome ................................................. 27 Glossopharyngeal Neuralgia ................................................................ 28 Trigeminal Neuralgia ........................................................................... 29 Post-Herpetic Neuralgia ...................................................................... 30 Temporomandibular Disorder ............................................................. 30 Diagnosis Review Questions .................................................................... 31 Review the following description of an orofacial pain disorder as described by a woman in her thirties and select the corresponding diagnosis. ............................................................................................. 31 Review the following description of an orofacial pain disorder as described by a man in his mid-forties and select the corresponding diagnosis. ............................................................................................. 31 Review the following description of an orofacial pain disorder as described by a man in his early forties and select the corresponding diagnosis. ............................................................................................. 32 Review the following description of an orofacial pain disorder as described by a woman in her late twenties and select the corresponding diagnosis. ............................................................................................. 32 Beverly’s Diagnosis .................................................................................. 33 How would you diagnose Beverly? ...................................................... 33 Treatment .................................................................................................... 34 Pharmacotherapy .................................................................................... 34 Burning Mouth Syndrome ................................................................... 34 Glossopharyngeal Neuralgia and Trigeminal Neuralgia ...................... 36 Post-Herpetic Neuralgia ...................................................................... 38 Temporomandibular Disorder ............................................................. 39 Pharmacotherapy Review Questions ....................................................... 40 Which pharmacotherapy can be best used to treat Burning Mouth Syndrome? ........................................................................................... 40 Which pharmacotherapy can be best used to treat Trigeminal Neuralgia? ............................................................................................ 40 Which pharmacotherapy can be best used to treat Post-Herpetic Neuralgia? ............................................................................................ 40 Which pharmacotherapy can be best used to treat Temporomandibular Disorder? .............................................................................................. 41 Dental Interventions ................................................................................ 41 Counseling ............................................................................................... 41 Complementary and Alternative Therapy ............................................... 42 Outcomes..................................................................................................... 43 Learning Resources ..................................................................................... 44 Pathogenesis of Orofacial Pain ................................................................ 44 Trigeminal Nerve Overview ................................................................. 44 Ophthalmic Branch (CN-V1) ................................................................ 45 Maxillary Branch (CN-V2) ................................................................... 46 Mandibular Branch (CN-V3) ................................................................ 47 Primary Afferent Nerves ...................................................................... 48 Nociceptive Signal Transduction ......................................................... 50 Pathogenesis Descriptions ....................................................................... 52 Organic Etiologies ................................................................................ 52 Burning Mouth Syndrome ................................................................... 52 Glossopharyngeal Neuralgia ................................................................ 52 Trigeminal Neuralgia ........................................................................... 53 Post-Herpetic Neuralgia ...................................................................... 53 Temporomandibular Neuralgia ........................................................... 53 Pathogenesis Review Questions .............................................................. 54 Which of the following descriptions corresponds to symptoms of Burning Mouth Syndrome? ................................................................. 54 Which of the following descriptions corresponds to symptoms of Glossopharyngeal Neuralgia? .............................................................. 54 Which of the following descriptions corresponds to symptoms of Trigeminal Neuralgia? ......................................................................... 54 Which of the following descriptions corresponds to symptoms of Post- Herpetic Neuralgia? ............................................................................. 55 Which of the following descriptions corresponds to symptoms of Temporomandibular Disorder? ........................................................... 55 Review Articles ........................................................................................ 55 Related Websites ..................................................................................... 56 Answer Key .................................................................................................. 57 Pathogenesis Review Questions .............................................................. 57 Which of the following descriptions corresponds to symptoms of Burning Mouth Syndrome? ................................................................. 57 Which of the following descriptions corresponds to symptoms of Glossopharyngeal Neuralgia? .............................................................. 57 Which of the following descriptions corresponds to symptoms of Trigeminal Neuralgia? ......................................................................... 58 Which of the following descriptions corresponds to symptoms of Post- Herpetic Neuralgia? ............................................................................. 58 Which of the following descriptions corresponds to symptoms of Temporomandibular Disorder? ........................................................... 58 Diagnosis Review Questions .................................................................... 59 Review the following description of an orofacial pain disorder as described by a woman in her thirties and select the corresponding diagnosis. ............................................................................................. 59 Review the following description of an orofacial pain disorder as described by a man in his mid-forties and select the corresponding diagnosis. ............................................................................................. 59 Review the following description of an orofacial pain disorder as described by a man in his early forties and select the corresponding diagnosis. ............................................................................................. 60 Review the following description of an orofacial pain disorder as described by a woman in her late twenties and select the corresponding diagnosis. ............................................................................................. 60 Beverly’s Diagnosis Question .................................................................. 61 How would you diagnose Beverly? ...................................................... 61 Pharmacotherapy Review Questions ....................................................... 61 Which pharmacotherapy can be best used to treat Burning Mouth Syndrome? ........................................................................................... 61 Which pharmacotherapy can be best used to treat Trigeminal Neuralgia? ............................................................................................ 61 Which pharmacotherapy can be best used to treat Post-Herpetic Neuralgia? ............................................................................................ 62 Which pharmacotherapy can be best used to treat Temporomandibular Disorder? .............................................................................................. 62 Introduction This module covers Burning Mouth Syndrome and related orofacial pain. After completing this module, you should be able to: • Describe the epidemiology of Burning Mouth Syndrome (BMS) and co-morbid conditions. • Identify common differential orofacial pain disorders. • Review the basic neuroanatomy of the mouth. • Develop multidisciplinary treatment and monitoring plans for a simulated patient with BMS (Beverly). The module features seven categories: • Interview Beverly • Physical Exam • Systems Review • Labs and Tests • Medications • Pain Center • Additional Learning Resources The following provides a description of the introduction to the patient, Beverly: Beverly’s head and shoulders appear in the shot. She speaks directly to the viewer and describes her pain experience: “It’s definitely, um, the roof of my mouth, the tongue especially, um, occasionally the sides. It’s become this thing that just won’t go away. And after having it for so long, I just keep thinking there has to be something that can be done. Um, you know, one person said maybe it was thrush. Um, I take meds for my fibromyalgia and have dry mouth and so that was, you know, maybe that was what the problem was. My dentist suggested I put glycerin in my, um, water and stuff so that it would lubricate and maybe that would help. When it first started, I had braces and so, um, that’s what I thought it was related to. Because I’d had some minor little problems along the way. Um, and when I went to him, he had no idea. He said, ‘You know, I,’ he knew I had a sinus infection and so he said, ‘I’m sure that’s just what the problem is.’ Um, and so I was really irritated with him, so I went to my dentist, who I’ve gone to for years, and she looked in and she really couldn’t see anything either. Um, and so I was like, ‘Okay.’ Um, and then a couple weeks later, um, I went in and I saw my rheumatologist, um, I have Fibromyalgia, and she looked at my mouth, and she said, you know, she could tell it was red, um, and that it was inflamed. And she was surprised that, um, that neither of the dentists, you know, really did much about it. Um, and so then she’s the one that suggested I look into pain management.”