Burning Mouth Syndrome (BMS): Open trial of psychotherapy alone, medication with alpha-lipoic acid (thioctic acid), and combination therapy

FEMIANO F, GOMBOS F, SCULLY C. BURNING MOUTH SYNDROME (BMS): OPEN TRIAL PSYCHOTHERAPY ALONE, MEDICATION WITH ALPHA.LIPOIC ACID (THIOCTIC ACID), AND COMBINATION THERAPY. MED ORAL 2004; 9:8-13

SUMMARY

-Objective and study design
This open study of 192 otherwise healthy persons with burning mouth syndrome, examined the efficacy on control of symptoms of psychotherapy alone with two hour sessions weekly for two months; alpha lipoic acid (ALA, tioctic acid; Tiobec) 600 mg/day alone for two months; or combination therapy of psychoanalysis and 600mg/day ALA for two months. Controls received placebo alone.
-Results
Most benefit was obtained with combination therapy. Combination therapy of psychoanalysis and alpha lipoic acid (ALA , tioctic acid; Tiobec. 600mg/day)  for two months gave most benefit and significantly more than psychoanalysis alone  for two 1 hour sessions weekly for two months (p<0.0005), or ALA 600 mg/day alone for two months (p<0.0005) .
-Conclusion
The present results suggest that alpha lipoic acid may complement psychotherapy and can be an acceptable alternative to psychoactive agents, but trials to compare the two approaches are now warranted.

Key words: Burning mouth syndrome, alpha lipoic acid, thioctic acid.

INTRODUCTION

Burning mouth syndrome (BMS) is a common affliction characterised by an intense burning sensation in the mouth, in the absence of a clinically identifiable mucosal lesion (1-3). Females are predominantly affected and it may be possible to recognize a psychological trigger such as stress ( 1-3). Organic disorders such as candidiasis, diabetes or deficiency states can give rise to similar symptomatology, but treatment of these defined causes can produce symptomatic improvement ( 4-6 ).

In idiopathic BMS, recent studies have suggested benefit from alpha lipoic acid (ALA) ( 7), an agent helpful in a number of neuropathies ( 8-11) and it seem possible therefore on the basis of this response and other evidence (12-14) that BMS is a peripheral neuropathy triggered by psychological stressful events whose persistence may explain resistance to pharmacological therapy or recrudescence at the cessation of therapy (1,2,7,15).

The aim of this study on the management of BMS was to examine the effectiveness of psychoanalysis and cognitive psychotherapy alone, as compared with pharmacological therapy (alpha lipoic acid only) alone, and with pharmacological therapy in combination with psychoanalysis and cognitive psychotherapy (alpha lipoic acid plus psychological therapy).

PATIENTS AND METHODS

Local ethical approval was obtained. A total of 326 patients complaining of burning mouth were seen in 1999 and all were screened with a history, examination, and full blood count, serum ferritin, vitamin B12, SGOT, SGPT, ANA, ENA, serum total IgE (PRIST), corrected whole blood folate and blood sugar assays. Patients with a positive medical or drug history, abnormal sialometry, evidence of mucosal disease, or with any biochemical or haematological abnormalities were excluded. A large percentage of female subjects had to be eliminated from the study since they were taking medication and/or had haematological abnormalities.

Thus the original group of 326 patients was reduced to 192 study subjects (104 females and 88 males), aged between 24 to 67 years with a median of 48 years with idiopathic BMS. The duration of the symptoms varied from 2 to 48 months (mean 22 months). The patients were requested to indicate the intensity of their BMS discomfort on a visual analogue type scale (VATS) three times a day for the duration of the investigation (Table 1). All were given a questionnaire designed to elicit psychological problems at the start and completion of the trial. Thus a basis was obtained with respect of the daily development of BMS, against which the psychoanalysis results could be evaluated. The VATS for the preceding week was discussed during two hour psychoanalytical sessions weekly for two months in order to identify the most important patterns in respect of the emotional factors preceding any increase in BMS pain. Following the psychoanalytical sessions, this otherwise healthy cohort of BMS patients were allocated to one of four groups each of 48 subjects matched for sex. Group A were treated with cognitive psychotherapy alone for two 1 hour sessions weekly for two months. Group B were given 600 mg/day alpha lipoic acid (ALA, tioctic acid; Tiobec) alone for two months (7). Group C were given a combination of cognitive psychotherapy and 600mg/day ALA for two months. Group D were control subjects given cellulose starch 100 mg/day for two months. Throughout the trial, negative changes in the VATS score were regarded as the condition "worsening", while positive changes in the VATS scores of 1 grade were classified as "slight improvement", changes of 2 grades as "decided improvement" and changes of 3 grades as "resolution". Results were analysed by Chi squared test for independence.

RESULTS

Events that preceded the onset of BMS, usually associated with a significant loss or change in the life of the patient, were mostly experienced in terms of ambivalent emotions. Most factors manifested as conflict situations and not merely as stressful incidents. Where stressful events did occur, the earlier unresolved conflicts appeared reactivated.

Almost all BMS patients had problematic object relations which appeared to indicate one or more of the following: deprivation, unpredictability, non-involvement and/or authoritarian object(s). Low self-esteem and the absence of a satisfactory and consolidated self was pronounced in all patients with BMS. Some indicated that they were dissatisfied with their life achievements. In all the patients an increase in BMS pain was associated with conflict at the interpersonal level. It was further clear that emotional stress per se did not necessarily result in an increase in BMS pain. Throughout the study, an increase in BMS pain was associated with the frustration of affectional and/or dependency needs that reactivated an earlier unresolved conflict.

The VATS results at 1 and 2 months are presented in Table 2. All subjects and controls were reviewed every 15 days for 2 months. The results obtained after using during two months the various therapeutic regimens are shown in Table 3.

The groups of 48 subjects treated with cognitive psychotherapy alone for two 1 hour sessions weekly for two months (A), or with 600 mg/day alpha lipoic acid (ALA, tioctic acid; Tiobec) alone for two months (B), or with combination therapy of cognitive psychotherapy plus 600mg/day ALA for two months (C) had highly significant improvements in symptomatology compared with those receiving starch placebo (D). Both ALA (group B) and combination therapies (group C) showed significant improvements over cognitive psychotherapy alone (group A). However, most benefit was obtained with cognitive psychotherapy plus 600mg/day ALA for two months.

Subsequently, the patients of groups A, B and C were followed for a further six months showing maintenance of the beneficial effects (Table 4).

DISCUSSION

This study confirmed the efficacy of psychological management (cognitive psychotherapy) alone, alpha lipoic acid (ALA), and a combination of psychotherapy plus lipoic acid to reduce the symptomatology of BMS. Most benefit was obtained from cognitive psychotherapy plus 600mg/day ALA for two months.

Almost all the BMS patients in this study had problematic object relations. Rosenberg et al. (16) pointed out the consequences of this situation: "depriving, rejecting, inconsistent, unpredictable, or overindulgent relationships have led to conflicts around libidinal issues of care, affection, love, and sexuality. These intense and exaggerated concerns about interpersonal relatedness interfere with the development of a sense of self ". Low self-esteem was observed in all patients and some indicated that they were dissatisfied with life achievements (16).

The mouth is a conflict area with respect to the frustration of needs (mainly physiological needs) in the depressed patient, and is also the arena in which reactivated conflict is dramatised and manifested in BMS ( 17 ) which is thus a symbolic expression of the re-activated conflict with the associated ambivalence and guilt and is a dramatisation of an earlier unresolved conflict of the depressive position in the oral phase of development ( 18,19 ). The basic conflict is reactivated prior to the onset of BMS. This loss is of such a nature that it results in intense frustration of the patient's dependency needs and/or needs for affection. Further this frustration can be so intense as to disturb the existing psychological equilibrium to such an extent that the earlier unresolved conflict is reactivated. This conflict is associated with the inability to deal with ambivalent feelings towards a love object and the associated guilt. Because the frustration of needs in depression has the mouth as focus, the mouth is also the arena in which the reactivated conflict is dramatised. Therefore the mouth is understandably a target for blame or guilt ( 20,21) . In all our patients, an increase in BMS pain was associated with conflict at the interpersonal level, though it was further clear that emotional stress per se did not result in an increase in discomfort. Throughout, the increase in BMS pain was associated with the frustration of affection and/or dependency needs that reactivated earlier unresolved conflicts, thus supporting the already considerable evidence that psychological stress can be a factor in BMS and that psychological management such as cognitive psychotherapy and psychoactive agents such as antidepressants or anxiolytics can be of value in some cases ( 1,2,17,21,22 ).

However, the results of the present study also suggest that alpha lipoic acid may complement psychological therapy and could be an acceptable alternative to psychoactive agents, but trials to compare these two approaches are now warranted. ALA may act by being neuroprotective ( 8 ) and assisting recovery of neuronal damage ( 9,11,23 ). Short-term treatment for 3 weeks using 600 mg of ALA per day appears to reduce the chief symptoms of diabetic polyneuropathy, accompanied by an improvement of neuropathic deficits and preliminary data indicate possible long-term improvement in motor and sensory nerve conduction (23).

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