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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 65-71

Burning mouth syndrome in Southwestern Saudi Arabian population – Part I: Prevalence


1 Department of Diagnostic Sciences and Oral Biology, College of Dentistry, King Khalid University, Abha, Saudi Arabia
2 Department of Diagnostic Sciences, Alfarabi Dental College, Jeddah, Saudi Arabia

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Ali Azhar Dawasaz
Post Box: 3263, College of Dentistry, King Khalid University, Abha 61471
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjos.SJOralSci_64_18

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  Abstract 


Introduction: Burning mouth syndrome (BMS) is a chronic, spontaneous, nonremitting, painful burning sensation in the oral mucosa with no identifiable local lesion. The aim of this study was to determine the prevalence of BMS in Abha, Saudi Arabia.
Materials and Methods: Patients attending for dental care completed a questionnaire before examination. A general health screen was then performed during which information about various conditions and medications was collected. Reports of burning/pain sensation were recorded using visual analog pain scale. Details of the dental examination, panoramic radiographs, and a structured interview concerning orofacial pain and discomfort were recorded.
Results: Of 2264 patients screened, 159 were identified as having a potential diagnosis of BMS. The prevalence of BMS was 7.03% (primary in 2.87% and secondary in 4.15%). The highest prevalence was in patients aged >65 years. Forty-two percent of the 159 cases had primary BMS. There were more cases of type 1 diabetes in the group with secondary BMS. The tongue was the most common site of BMS (in 81.9%). The mean visual analog pain scale score was 4.3. Altered taste sensation was reported by 15.9% of patients and xerostomia by 47.6%. Patients taking antihypertensive medication were more prone to secondary BMS. The tongue, soft palate, and lower gums were significantly more likely to be affected (P ≤ 0.05).
Conclusion: This is the first reported population-based prevalence data for BMS in the Saudi Arabian population and contributes to the nascent literature on the epidemiology of BMS.

Keywords: Burning mouth syndrome, prevalence, Saudi Arabia


How to cite this article:
Assiri K, Dawasaz AA, Alshehri A, Mohammad F, Alyami Y. Burning mouth syndrome in Southwestern Saudi Arabian population – Part I: Prevalence. Saudi J Oral Sci 2019;6:65-71

How to cite this URL:
Assiri K, Dawasaz AA, Alshehri A, Mohammad F, Alyami Y. Burning mouth syndrome in Southwestern Saudi Arabian population – Part I: Prevalence. Saudi J Oral Sci [serial online] 2019 [cited 2019 Nov 19];6:65-71. Available from: http://www.saudijos.org/text.asp?2019/6/2/65/264768




  Introduction Top


The International Headache Society [1] defines burning mouth syndrome (BMS) as “an intraoral burning or dysesthetic sensation that occurs for >2 h per day over >3 months, without clinically evident causative lesions.” There is no clear understanding of neurophysiologic mechanisms underlying the symptoms, so BMS lacks a confirmatory diagnostic test.[2] Depending on the etiology, BMS can be classified as primary (essential and idiopathic) or secondary. Despite typical symptoms of neuropathic pain, primary BMS lacks clear clinical signs of nerve involvement. Unlike primary BMS, the secondary form is determined by local systemic or psychologic factors.[3]

BMS has been reported to have a prevalence of 1% in general population and mainly affects postmenopausal women aged 60–69 years.[4] The prevalence of BMS has also been reported to increase with advancing age. The prevalence data available are sparse and highly variable, ranging from 1% to 40%. The tongue, lips, and palate are the sites most commonly affected in BMS. The burning sensation is frequently accompanied by oral dysesthesia, dysgeusia, and xerostomia.[5] The aim of this study was to determine the population-based prevalence of BMS in Abha region of Saudi Arabia.


  Materials and Methods Top


A consecutive random sample of Saudi women who attended the dental clinics at our institution in Saudi Arabia between September 2016 and December 2017 was screened for enrollment in this observational cross-sectional study. The study was approved by our institutional ethical review committee (approval number: SRC/ETH/2015-16/017). All participants provided written informed consent. The study is reported in accordance with the STROBE guidelines.

Enrollment of participants

A 13-item questionnaire was filled in Arabic with assistance by female dental students trained in data collection to all women attending the dental clinics to check for the presence or absence of symptoms of BMS. Any local (including candidiasis) or systemic factors, if present, the patient was placed in the category of secondary BMS. Similarly, the absence of any local or systemic factor with the presence of burning sensation was categorized as primary. The questionnaire was based on previous literature on BMS with minor modifications.[6] After completion of the questionnaire, participants identified to have BMS were asked to participate in the study and underwent thorough general health screening and orodental examinations. Primary and secondary BMS were then distinguished based on the intraoral findings and systemic factors if present. The patients' medical records were retrieved, and their complete demographic data and subjective/objective assessment notes were retrospectively analyzed. Patients with dry mouth and/or changes in taste sensation as a chief complaint but not associated with burning sensation were excluded from the study. Patients who had burning sensation on the face but not in the mouth were also excluded.

General health screening

Patients subsequently underwent general health screening beginning with history-taking and questionnaires to obtain each patient's medical history and medications, including but not limited to antidiabetic and antihypertensive agents, thyroxine, bronchodilators, iron supplements, and diuretics. Control of diabetes was assessed from the previous fasting blood sugar values that were either documented in the patient files or gleaned from the responses to the questionnaire. Reports of altered taste sensation were also recorded. Any factors that could potentially aggravate or alleviate the pain were also identified.

Orodental examination

The dental examination included an intraoral clinical examination, panoramic radiography, and a 13-item questionnaire [Table 1] concerning pain and discomfort in the oral and facial regions, including location, diurnal variation in pain and its effect on mastication, swallowing, and taste sensation. Burning/pain sensation was scored on a visual analog scale (VAS) ranging from 1 (no pain/complaints) to 10 (extreme pain/discomfort). The participants were then asked to rate the frequency of the pain sensation on a 4-point scale (1 – daily; 2 – once a fortnight; 3 – once in 3 weeks; and 4 – once a month), any variation in severity over a 24-h period, and the time of day when the pain is worst. The questions covered areas that included pain history, other precipitating factors and xerostomia [Table 1]. The patients were also asked to score the duration of their pain as 1 (1 week), 2 (1 week to 2 months), 3 (2–4 months), or 4 (longer than 6 months). Assuming a Poisson error distribution, the level of significance was set at 0.05 with a 95% confidence interval.
Table 1: 13-point questionnaire

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  Results Top


Of 2264 female patients screened, 159 were identified as potentially having a diagnosis of BMS. Twenty-six patients who were unwilling to provide informed consent or did not wish to participate in the study and 10 patients who did not have Saudi resident status were excluded, leaving data on 2218 patients available for inclusion in the analysis.

The prevalence of BMS was 7.02% [primary in 2.87% of cases and secondary in 4.15%; [Table 2]. The mean patient age was 57.31 years (standard deviation: 5.24; range: 44–69 years). The highest prevalence was in women aged 54–58 years. Negative kurtosis indicated a discrete uniform distribution in the sample population. Almost 72% of patients reported the duration of BMS to have been more than a year. Sixty-five (43.33%) of the 159 patients with BMS had tongue involvement and 63 (42%) had involvement of the buccal mucosa. The mean pain intensity score on the VAS was 4.44 [standard deviation: 2.18; median: 5; [Table 3]. Symptom intensity was frequently described as mild (the VAS score was 2 in 30.2% of patients). Pain was typically experienced in a continuous pattern (82.7%) throughout the day (59.3%). Altered taste sensation was reported by 12.4% of participants and xerostomia by 58.2%. Analysis of variance revealed significant between-group differences in the numbers of patients complaining of burning sensation on the tongue, soft palate, and lower gums [P = 0.018, P = 0.018, and P = 0.032, respectively; [Table 4]. There was no significant association of age with type of BMS (P = 0.481).
Table 2: Distribution of lesions/conditions

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Table 3: Visual analog scale in sample population

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Table 4: One-way analysis of variance

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Only one patient in the study population (in the secondary BMS group) complained of burning sensation affecting the uvula. Pearson's correlation revealed that patients with BMS secondary to a systemic condition were more likely to develop burning sensation in the buccal mucosa [P = 0.022; [Table 5]. Furthermore, the VAS score for pain intensity was negatively correlated with patient age (Pearson's correlation = −0.01).
Table 5: Pearson's correlation of secondary burning mouth syndrome between different regions of oral cavity

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There was a significant association of age with burning sensation on the lip in patients with primary BMS (P = 0.036) and a weak negative correlation with soft-palate involvement [Pearson's correlation = −0.015; [Table 6]. Patients with secondary BMS complained of burning sensation on the tongue more often than those with primary BMS. Patients taking antihypertensive agents were more prone to developing BMS and those taking antidepressant medication had a higher incidence of burning sensation in the buccal mucosa. Furthermore, patients with orofacial pain and bruxism habit were more prone to developing BMS. Many patients had both xerostomia and burning sensation. There was no statistically significant difference in the dental findings related to number of teeth, fillings, crowns/bridges, or dental visiting habits between the BMS group and non-BMS group.
Table 6: Pearson's correlation of primary burning mouth syndrome between different regions of oral cavity

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  Discussion Top


Some studies have reported the prevalence of BMS in the adult population to be as low as 0.7%,[7] whereas others have reported it to be up to 15%,[8] and reports of its incidence range from 1% to 40%.[9],[10],[11],[12],[13] The markedly higher proportion of patients found to have BMS in our study likely reflects the fact that our center is the only tertiary care institution in Southwestern Saudi Arabia that receives a high number of referrals from different specialties.

BMS can be classified as primary or secondary.[6] Local and systemic organic causes are not involved in primary BMS, but peripheral and central neuropathic pathways have been identified.[3] However, the epidemiologic data in the literature are imprecise because of the lack of a universal definition of BMS.

There is a growing belief that the pain of BMS is caused mainly by hormonal factors.[2],[14] Of note in this regard is that our study population was comprised exclusively of women older than 44 years of age. The theories postulated about the pathogenesis of BMS include increased taste sensation, an increased number of filiform papillae, and the presence of the TAS2R38 gene.[14]

BMS is often associated with taste alterations and dry mouth.[15],[16] We assessed the subjective sensation of oral dryness rather than the salivary flow rate and found our results to be in accordance with those of a previous study.[9] We also observed that altered taste sensation was less commonly reported than dry mouth because of inaccurate reporting. It is noteworthy that the tongue was the most common site of BMS involvement, given that the tongue is also a common site in many other conditions. Therefore, differential diagnosis is essential.

The demographic and subjective data collected in our study are comparable with those in a previous report on the prevalence of BMS.[13] Furthermore, a previous finding that BMS was most common in postmenopausal women is in concordance with our results.[17] Moreover, to the best of our knowledge, there are no studies on the prevalence of BMS in the Abha region of Saudi Arabia.

Many definitions of primary BMS have been used in previous prevalence studies. In our present study, 42% of 159 cases of BMS were primary and 58% were secondary [Figure 1]. These figures are higher than in the previous studies.[9],[13]
Figure 1: Distribution of primary and secondary burning mouth syndrome

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The pain or burning sensation of the mucosa caused by a known disease process is recognized as secondary BMS.[18],[19] In our study, type 1 diabetes was more common in the group with secondary BMS [Table 2]. Therefore, the increased incidence of BMS in postmenopausal women in our study could be related to the chronicity of type 2 diabetes mellitus. There was a statistically significant association between the burning sensation of BMS and certain intraoral sites, particularly the tongue, soft palate, and lower gum [P = 0.05; [Table 3]. Iron, zinc, Vitamin B12, and folic acid deficiency; certain medications; Sjogren's syndrome, diabetes, erosive mucosal lesions, Candida infection, ill-fitting dentures, parafunctional habits such as tongue thrusting, and denture-induced allergy are some of the factors that have been proposed to cause BMS. These have not been confirmed to play a role in the pathophysiology of primary BMS;[20],[21] however, burning mouth symptoms in patients with secondary BMS can often be managed successfully with an etiological treatment,[22],[23] for example, in patients with candidiasis or allergy, which is the participant of the next phase of our research.

This study applied strict criteria for primary BMS, including persistent symptoms of oral pain/discomfort, no clinical/radiographic findings on oral examination, and exclusion of other causes of oral burning. Although secondary BMS was diagnosed if there was a potentially causative systemic or local condition, there was only one case of an intraoral lesion causing burning sensation.

Our study has some limitations. First, patients with various conditions that could contribute to the sensation of oral burning, including poor nutrition, were not included in the study, so the exact mechanism through which local and systemic factors cause BMS were not considered. Second, the VAS pain score is a subjective assessment method. Third, stringent BMS criteria were used, which could be considered both strengths and limitations of this research, in that reporting of prevalence statistics specifically for patients with oral symptoms of BMS is undoubtedly strength, whereas the exclusion of patients who did not meet our diagnostic criteria could be seen as a limitation. Since the study was carried out in totality within female campus, all study participants were females. However, a multicenter study of male and female campuses will be able to overcome this limitation.

To our knowledge, this is the first report of population-based prevalence data for BMS in the Saudi Arabian population and is a preliminary attempt by the authors to improve the limited amount of relevant literature available. An earlier report indicated that BMS most commonly affects women older than 50 years of age, which is in accordance with our study.[20],[21],[24],[25] Further studies are needed to evaluate the impact of medication intake, nutritional status, and the effect of both local and systemic diseases on the prevalence of BMS.


  Conclusions Top


In this epidemiological survey of BMS, most patients were middle-aged or elderly women and approximately 7% reported symptoms of burning mouth. In a majority of cases, symptoms of burning mouth had persisted for >6 months, indicating that BMS may have a chronic course. We also found that primary BMS was more likely to develop in a specific region of the oral cavity. The authors are currently embarking on a further study in which the patients in the present study will be treated according to whether their BMS is primary or secondary.

Further study

The authors are involved in the sequel of this study, whereas in the above, patients will be treated based on their diagnosis of BMS as primary or secondary. A further study on both the sexes in multiple centers will be conducted.

Ethical approval

All study procedures involving human participants were performed in accordance with the ethical standards of the institutional and/or national committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Acknowledgments

We would like to thank all the nursing staff of our college for their hard work at every stage of patient data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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