- Citado por SciELO
versão impressa ISSN 1698-4447
Med. oral patol. oral cir. bucal (Ed.impr.) vol.10 no.4 Ago./Out. 2005
Association of burning mouth syndrome with xerostomia and medicines
Asociación de síndrome de boca ardiente con xerostomía y medicamentos
Maria Sueli Marques Soares (1), Eduardo Chimenos Küstner (2), Carles Subirá Pifarrè (3),
Mª Eugenia Rodríguez De Rivera Campillo (4), José López López (2)
(1) Profesora Titular de Estomatología, Universidad Federal de Paraíba (Brasil)
(2) Profesor Titular de Medicina Bucal
(3) Profesor Titular de Gerodontología
(4) Profesora Asociada de Medicina Bucal.
Centro: Facultad De Odontología, Universidad De Barcelona (España)
Dr. Eduardo Chimenos Küstner
Vía Augusta 124, 1º 3ª
08006 Barcelona (España)
Received: 28-05-2004 Accepted: 10-10-2004
Marques-Soares MS, Chimenos-Küstner E, Subirá-Pifarrè C, Rodríguez De Rivera-Campillo ME, López- López J. Association of burning mouth syndrome with xerostomia and medicines. Med Oral Patol Oral Cir Bucal 2005;10:301-8.
Objective: A case control study to identify risk factors for burning mouth syndrome (BMS).
Key words: Burning mouth syndrome, salivary flow, xerostomia, hyposalivation, medications.
Objetivo: Identificar factores de riesgo para el síndrome de boca ardiente (SBA) a través de estudio de casos y controles.
Palabras clave: Síndrome de boca ardiente, flujo salival, xerostomía, hiposalivación, medicamentos.
Burning mouth syndrome is a complex pathology which is characterised by its symptoms of burning, stinging, heat, itching or pain in the oral cavity and lips, the mucosa being clinically normal (1). Its aetiology is unknown. However, multiple aetiological factors of local, systemic and psychological origin have been suggested (2-8). It is a relatively common illness, difficult to manage due to lack of therapeutic efficacy (9). No cause-effect relationship between the possible aetiological factors and the aetiology of the syndrome has been established; therefore, it continues to be a field open to new investigations. In the present study, the possible association of the salivary flow, subjective xerostomia, consumption of medicines and psychological factors with BMS are investigated, with the objective of identifying risk factors for the above mentioned syndrome.
MATERIAL AND METHODS
The study sample consisted of 80 adult patients selected in the Odontology Clinic, Faculty of Odontology, University of Barcelona. A group of 40 cases of BMS and a control group of 40 patients not suffering from BMS were formed, paired by age and sex. A clinical examination of the oral cavity was carried out on all patients. The diagnosis of BMS was established when the patient showed symptoms of oral burning sensation and presented with clinically normal mucosa. The intensity of the symptoms was estimated using a visual analogue scale. Patients who replied positively to the question: "are you normally aware of your dry mouth?", were considered to have subjective xerostomia (10-12). The total salivary flow rates, at rest and stimulated were determined according to Laudenbach and Huynh (13). The resting salivary flow (RSF) was considered normal for values ≥0.3ml/min; reduced for values >0.1 ml/min and <0.3 ml/min and hyposalivation for values≤0.1ml/min. The stimulated salivary flow (SSF) was considered normal for values ≥0.5 ml / minute and hyposalivation for values less than 0.5 ml/min (14). The salivary pH was determined by placing a strip of litmus paper, universal indicator pH 1-10 (Merck KgaA - Germany), on the dorsum of the tongue. For the evaluation of psychological disturbances self-applicative questionnaires on Beck depression (The Beck Depression Inventory - BDI) and on Beck anxiety (The Beck Anxiety Inventory BAI), using the Castilian version adapted by Vázquez and Sanz, according to Comech, Díaz and Vallejo (15). The medication taken by each patient and the systemic illnesses which they suffered were recorded. The data was subjected to descriptive and comparative analysis. ANOVA were used to compare the means and the Odds Ratio (OR) index to evaluate the association between the variables studied. Values of p≥0.05 were considered significant.
Thirty-seven patients with BMS (92.5%) were women and three (7.5%) males, with a mean age of 63±11.8 years. The evolution time of the symptoms of BMS varied between 4 months and 8 years, with a mean of 2.3±1.9 years. The sensations produced by BMS were described as: burning sensation (62.5%), heat (57.5%), stinging (27.5%), itching (25%), pain (17.5%), swelling (17.5%) and sensation of scalded mouth (15%). The frequency of the symptoms were said to be continuous in 62.5% of the cases and intermittent in 37.5%. The intensity of the symptoms varied from 2 to 10, with an average of 7.4±2.1, being able to qualify it as a high intensity symptom. The presence of subjective xerostomia was experienced by 75% of patients with BMS, and by 45% of the control group. As regards the RSF in patients with BMS, the mean was 0.13±0.09 ml / minute. Only 12.5% presented with a normal flow rate, 40% reduced flow and 47.5% presented with hyposalivation. In the control group the mean RSF was 0.16±0.13 ml/min, in which 29% of patients presented with a normal RSF rate, 30% with a reduced flow and 50% presented with hyposalivation (Figure 1). The stimulated salivary flow amongst the patients with BMS gave a mean of 1.25±0.67 ml/min. 90% of the patients presented with a normal flow and 10% with hyposalivation. In the control group 87.5% were seen to have a normal SSF and 12.5% with hyposalivation, with a mean of 1.27±0.73 ml/min. The mean salivary pH of the tongue in the patients with BMS was 6.7±0.61 and in the controls, 6.6±0.71.
The 40 patients with BMS took 1 or more drugs, with a mean of 3.9±2.0 medicines/day. Ninety-five% of the drugs taken were xerostomising agents and the mean of these was 2.6±1.7 xerostomising medicines/day. In the control patients, 75% took one or more drugs, 67.5% being xerostomising medicines. The mean number of drugs in these patients was 2.5±2.6 drugs/day and 1.3±1.6 xerostomising drugs/day. The categories of the drugs most consumed by the BMS group were: psychotropic, analgesic/anti-inflammatory, drugs for the cardiac system, drugs for the digestive system and hypotensives/diuretics. In the control group of patients a higher consumption of analgesics/anti-inflammatory, hypotensives/diuretics, drugs for the cardiac system and psychotropics was seen.
It was seen that 65% of patients with BMS presented with anxiety, against 42.5% in the control group. Depression affected 65% of the patients with BMS and 37.5% of the control group of patients. The differences were statistically significant for the presence of symptoms of anxiety and depression, with p=0.001 and p=0.036 respectively. 100% of the BMS patients suffered from one or more illnesses, with a mean of 4±2.2 illnesses/patient. In the control group, 82.5% of the patients had one or more systemic illnesses with a mean of 2.7±2.1 illnesses/patient. There were significant differences, with p=0.006. The most prevalent illnesses were present in the two groups, but in very different proportions (Table 1). Amongst all the variables studied, there was only an association of BMS with subjective xerostomia and with hypotensives/diuretics (Table 2).
The maintenance of equilibrium in the functioning of the mouth depends on the feeling of wellbeing experienced in the oral cavity. Burning mouth syndrome is characterised by oral discomfort, giving rise to oral dysfunction with a complex association with psychological disturbances. Xerostomia and hyposalivation also cause discomfort in the oral cavity. They can aggravate the prognosis and determine the treatment of BMS. Burning mouth syndrome has a prevalence of 4 to 5% in the general poulation /1). The majority affected are women, with a mean age of 62 years and a ratio of 7:1 compared to men (16). In the current study, a mean age of 63 years was seen, but one of the patients was only 34 years of age. The presence of BMS in earlier years has also been mentioned in other studies (1,2,16). Xerostomia has been identified in 75% of the cases of patients with BMS. A much higher percentage than that found in the studies carried out by Gorsky, Silverman and Chinn (17), Lamey and Lamb (18) in whose studies they found 39% and 34% of xerostomia, respectively. However, it is similar to the 66% of cases of xerostomia found by Bergdahl and Bergdahl (1). Eguía del Valle et al (2), Somacarrera et al(19) and Grushka (20) also reported a prevalence of xerostomia equal to or greater than 60% of patients with BMS. In the present study, it has been shown that patients with BMS were significantly more prone to suffering from xerostomia than patients without the syndrome. These data agree with the findings in the study by Bergdahl (12), who determined an Odds ratio of 5.3 in considering the relationship between oral heat and the presence of xerostomia. The sensation of dry mouth is a common symptom which is present in adults of any age and on which it appears to be dependent. It is estimated that this symptom is more prevalent in older women. However, there is no evidence that the symptom is a result of the ageing process. It is believed that more than the ageing process per se,other factors such as the consumption of medications, the presence of chronic systemic illnesses, the functional capacity of the patient and psychological states, are implicated in the aetiology of xerostomia. The strong association of xerostomia with BMS, in this study, can be explained, if it is considered that among the patients studied, the variables, consumption of medications, number of systemic illnesses and the presence of anxiety and depression presented with very high means with statistically significant differences when compared to the control group. Studies which include the analysis of salivary gland function in the pathogenesis of BMS show divergent findings, therefore it is still not definite that hyposalivation is a characteristic sign of the syndrome. In the current study it was seen that the mean of the total resting salivary flow among patients with BMS was lower than in the control group, but statistically significant differences were not seen. On the other hand, the mean rate of the stimulated salivary flow in these patients was normal. That is to say, the functional capacity of the salivary glands was preserved. Bergdahl (12 also found that the stimulated salivary flow rate was normal in patients with BMS. The mean was 2.38±1.36 ml/min in men, and 1.58±0.84 among women. These values are similar to those seen in the present study. Tammiala-Salonen and Söderling (21) found an increased stimulated salivary flow in women. These results show that, in the majority of patients with BMS, the salivary glands continue to respond adequately to stimulation, despite the large number of factors that could affect their function. Nevertheless, there are contradictory findings such as those published by Hammarén and Hugoson (22), who found a reduction in the SSF with a mean of 0.9 ml/min and 44% with hyposalivation. In the present study a high proportion of patients were identified as having hyposalivation as regards the resting saliva flow (RSF ≤0,1 ml/min), whilst the stimulated saliva flow was normal in the great majority of patients in both groups. In addition, the percentages of xerostomia were very high in both groups. This finding makes it possible to infer that the sensation of dry mouth is related more with the RSF rate and consequently, with the secretion of the minor salivary glands, as suggested by Sreebny and Valdini (10). It is important to mention that, in this study, the presence of xerostomia did not coincide with hyposalivation in 36.7% of patients with BMS, while in the control group the two entities did not coincide in only 10% of cases. Bergdahl and Bergdahl (11) demonstrated that psychological factors play an important role in the presence of xerostomia without hyposalivation and this fact is significantly associated with depression, anxiety and the consumption of antidepressants. Therefore, it appears that patients with BMS present with a psychological profile different from the rest of the general population. In the present study, a high prevalence of alterations in the psychological state of patients with BMS was seen, with statistically significant differences between the means of anxiety and depression in the two groups of patients studied. On the other hand, a within group analysis did not show a predominance of anxiety or depression symptoms among patients with BMS. This differs from the findings of Bergdahl, Anneroth and Perris (23), Hugoson and Thorstensson (24), who noted there was a predominance of anxiety and depression symptoms among patients with BMS. Furthermore, they differ from those of Eguía del Valle et al (2), Rojo et al (5), and Zilli et al (6), who found a greater prevalence of depression related to BMS. Although it has been observed that anxiety states and depression were significantly more predominant among patients with BMS, no association was seen with BMS.
The co-morbidity of different chronic systemic illnesses could be a characteristic finding in patients with BMS (2,6), as well as the daily ingestion of multiple medications. In our study, the co-morbidity and the consumption of multiple drugs among patients with BMS were significantly higher than in the control group. These findings can be explained by the high mean age and the psychological condition of the patients in the study with BMS. It is known that one of the main factors which can influence the secretion of the salivary glands is the ingestion of medications (25); some of the most important are the psychotropics, antihypertensives and diuretics. In the present study, more than 67.5% of the patients who consumed psychotropic medications were identified. This figure agrees with that of Somacarrera et al (19), who found 68,3% of BMS patients taking psychotropics, and with the findings of Lamey et al (26), who showed that 73% of patients with BMS consumed this category of medications. Lower percentages were reported by Grushka (20), Hammarén and Hugoson (22) and Hugoson and Thorstensson (24). In the present study, it was observed that, among the different drug categories that were taken by patients with BMS, only the hypotensives and diuretics presented as a risk factor for burning mouth syndrome. These data agree with results found by Hakeberg et al (27), who also identified hypotensives and diuretics as the medications with a higher risk of symptoms of BMS. The results also corroborated with those of Tarkkila et al (28), who showed that the consumption of anti-hypertensives significantly increased the risk of suffering from hot mouth. These findings are particularly interesting, given that, in the literature some clinical cases have been published in which BMS has developed from medications pertaining to this category, specifically the angiotensin converting enzyme (ACE) inhibitor anti-hypertensives (29). Analgesics, psychotropics, medications for the digestive system and medications for the cardiac system, have been identified as protective factors from BMS in the present study. Pajukoski et al (30)found similar results for analgesics, but on the other hand showed psychotropics and anticoagulants as risk factors for BMS.
The analysis of the data in the study has allowed us to conclude that: 1) There is an association between burning mouth syndrome and subjective xerostomia, as well as between BMS and the ingestion of anti-hypertensives and diuretics. 2) There was no association with BMS and the presence of anxiety, depression, use of psychotropics, analgesics, drugs for the cardiovascular system, drugs for the digestive system, resting salivary flow and stimulated salivary flow. 3) The RSF rate of patients with BMS was reduced, but without significant differences when compared to the control group. 4) The differences were statistically significant as regards the symptoms of anxiety, depression, drugs/day, xerostomising drugs/day, systemic illnesses and subjective xerostomia, when compared to the control group.
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