Burning Mouth Syndrome
Ross Hauser, MD
If we took the combined emails we received about problems of Burning Mouth Syndrome, a common thread would create a cumulative person’s that would go something like this:
My mouth and tongue feel like they have been burnt, like from a hot spoon or scolding coffee. I went to the dentist to see if this was a problem with my gums or an infection in my teeth. None of the x-rays showed anything. He told me that he thought it was burning mouth syndrome. Nothing could be done for it except anti-depressants. When I went to my doctor, I was referred to a specialist, a Psychiatrist.
I have had years of treatments including botox. It is not just Burning Mouth Syndrome but I also have double vision, neck pain, issues with swallowing and non stop pain. My doctors think I am crazy and will not listen to me.
Numb tongue, burning mouth, and other tongue pain from nerve impairment due to cervical instability
Fortunately, some people diagnosed with Burning Mouth Syndrome do get benefits from anti-depressants. We see some of these patients as they continue to seek other options. We also see the people for whom anti-depressants did not provide relief. They are looking for something that may help them.
In this article, we will explore the possibility that some people with burning mouth syndrome may have its cause in cervical spine instability causing compression on the vagus nerve, the facial nerve, and the glossopharyngeal nerve. This would then create an altered sensation (burning) into the tongue and mouth.
Burning mouth a psychiatric problem?
Why anti-depressants? Anti-depressants can help with nerve pain. They are also seen as a way to “buy time.” People who believe that their problems were related to root canals or extensive dental work are typically given drugs such as Amitripyline or Velanfaxine and given the hope that this will hold them over until the pain goes away by itself. Again, I want to point out that this article will focus on the nerves that run into the cervical spine as a cause of the person’s Burning Mouth Syndrome. Anti-depressants may be offered when someone is diagnosed with idiopathic Burning Mouth Syndrome. Idiopathic meaning no known cause. As we will discuss in this article, one unknown or undiagnosed cause may be with the sensory nerves.
Research published in the Journal of Headache and Pain (1) describes the difficulty doctors face in understanding what Burning Mouth Syndrome is and how to treat it.
Here are some of the bullet points of this study, parenthesis are added for emphasis and understanding.
- Burning Mouth Syndrome is a chronic pain condition characterized by persistent intra-oral burning without related objective findings (no reason) and unknown etiology (We can’t figure out where it comes from) that affects elderly females mostly.
- There is no satisfactory treatment for burning mouth syndrome. (This should be pointed out that this refers to traditional treatments including anti-depressants and pain medications).
- (The researchers) aimed to observe the long-term effectiveness of high velanfaxine doses (Anti-depressant nerve medication that can be prescribed for generalized anxiety disorder, panic disorder, and social anxiety disorder), combined with systemic and topical administered clonazepam (a sedative for seizures, panic disorder, and anxiety. Side-effects include suicidal thoughts and paranoia), in a particular subgroup of burning mouth syndrome patients who do not respond to current clinical management.
- Conclusion: “Refractory burning mouth syndrome deserves bottomless psychiatric evaluation and management when currently available treatments fail. Paraclinical investigation including brain imaging and peripheral facial nerve conduction evaluation may be needed.”
Burning mouth a stress and physical activity problem?
An October 2020 study (2) suggests that stress and physical activity may be factors in Burning Mouth Syndrome. Here is what they wrote:
“Burning mouth syndrome is a long-lasting pain condition which is commonly associated with anxiety symptoms and experience of adverse, stressful life events have been reported by those diagnosed with the syndrome. Stress-related biomarkers (Enzymes, such as alpha-amylase and lysozyme) have been related to personality traits in Burning mouth syndrome and a personality with high stress susceptibility and perceived stress may be of importance.”
To test this idea the researchers investigated if personality, perceived stress and physical activity distinguish women with Burning mouth syndrome from women who did not have burning mouth syndrome.
Of course the women with Burning mouth syndrome are going to have more stress
Before we get to the results of this study, you probably are saying to yourself, “Of course the women with Burning mouth syndrome are going to have more stress, I have Burning mouth syndrome and I have a lot of stress.” What we are looking for in this study is what would help this stress. Here is what the researchers suggested:
“Perceived stress was higher and weekly physical activity was lower in women with Burning mouth syndrome compared to controls. Our findings suggest physical activity should be more comprehensively measured in future Burning mouth syndrome studies and, by extension, physical activity may be a treatment option for women with Burning mouth syndrome. Pain management aiming to restore function and mobility with stress reduction should be considered in clinical decision making for women with Burning mouth syndrome who have a personality with stress susceptibility, especially if reporting high perceived stress and insufficient physical activity.”
How do you get women with Burning Mouth Syndrome more physical activity?
The question is then, how do you get women with Burning mouth syndrome more physical activity? You remove pain with pain management so that these women can move better. In this article we will discuss the cervical neck pain element of Burning mouth syndrome. Restoring correct cervical spine curve and motion are key elements to our treatments.
Does anything help?
Recently, doctors and dentists in the United Kingdom released a detailed examination of the conventional treatments available to patients with burning mouth syndrome. (3)
Here is the summary of their findings:
The treatments examined were:
- antidepressants and antipsychotics,
- dietary supplements,
- electromagnetic radiation,
- physical barriers,
- psychological therapies,
- and topical treatments, including capsaicin oral rinse.
They concluded in this group of treatments “evidence for effectiveness was very low for all interventions and all outcomes.”
Many, like you, have many health problems that may be attributed to Burning Mouth Syndrome
Similar to what we see in patients in our clinic are symptoms and health problems noted by researchers in the medical journal Oral diseases.(4) A research group from the School of Dentistry, Complutense University, Madrid, Spain made these observations:
“The relationship of Burning Mouth Syndrome with possible alterations in patients’ general health has been subject of study and controversy during the last years.”
In this paper, the researchers conducted a case-control study to compare the diseases, medications, blood test alterations, disturbances in general health, oral quality of life, xerostomia (dry mouth), sleep quality and psychological status between a group of 20 patients with burning mouth syndrome and a group of 40 patients who did not suffer from this disease.
- Burning mouth syndrome patients suffered more comorbidities and consumed more medications than controls. More mental, behavioural or neurodevelopmental disorders in burning mouth syndrome patients were found, consuming more drugs for nervous and cardiovascular systems, and alimentary tract and metabolism.
Burning mouth a nerve problem or a dental problem?
In the above study, it is suggested that peripheral facial nerve conduction evaluation may be needed. This may point to our suggestion that in some patients burning mouth syndrome may be caused by nerve dysfunction.
A March 2020 study in the Journal of Oral Science (5) comes from the Nihon University School of Dentistry in Japan. Again this is a school of dentistry research paper looking for an answer to burning mouth syndrome. Let’s listen to what they are saying.
“Burning mouth syndrome is one of the most frequently seen idiopathic pain (again this is a pain that comes on suddenly without any reason), conditions in a dental setting. Peri- and postmenopausal women are most frequently affected, and patients who experience burning mouth syndrome complain of persistent burning pain mainly at the tip and the bilateral border of the tongue.
Recent studies have assessed whether burning mouth syndrome is a neuropathic pain condition. (Note: This was based on varying factors including abnormal pain responses (or exaggerated pain response), where the patient is having more pain than they should. I want to point out that the patients do suffer from more pain than they should and it is not a psychiatric disorder).
“Somatosensory studies have reported some abnormal findings in sensory and pain detection thresholds with inconsistency; however, the most distinct finding was exaggerated responses to painful stimuli. Imaging and electrophysiologic studies have suggested the possibility of dysregulation of the pain-modulating system in the central nervous system, which may explain the enhanced pain responses despite the lack of typical responses toward quantitative sensory tests.”
This also may point to our suggestion that in some patients, burning mouth syndrome may be caused by nerve dysfunction.
A Patient’s Case History – Burning Mouth Syndrome
- The patient is a young mother with horrible symptoms of burning mouth, the top of the roof of her mouth is burning, the tongue is burning, the back of the throat is burning,
- She has had these symptoms for two years.
- The patient has seen many physicians, dentists, ENT specialists, and no one has had any success at relieving the terrible burning sensation.
Dr. Hauser at 1:00 of the video:
Why I believe burning mouth syndrome is from cervical instability, specifically upper cervical instability
- I think after I present this case you will understand why I believe burning mouth syndrome is from cervical instability, specifically upper cervical instability.
- This case is always going to illustrate why most unusual neurological conditions are from cervical instability for instance if a person had brain fog or they had tachycardia of the heart that would come and go they have to some unusual symptom that no one can seem to resolve what I would encourage you to ask yourself is could this be a cervical instability issue.
- In this particular patient when you actually question her further she has all the signs and symptoms of a cervical instability case:
- she has horrible dizziness,
- she has poor balance,
- she has terrible digestive problems where she has constipation and diarrhea,
- she has floaters in her eyes, her vision has some issues,
- she gets a migraine headache when she subjected to a lot of light because her pupils can not constrict,
- she has trouble swallowing, like when she eats dry food it gets stuck in her throat,
- she sounds like somebody who is three pack a day smoker as she is very hoarse.
- she has ear fullness.
The patient was an amazing athlete, she met her husband and fell in love with him in college where they both excelled in sports, now she’s very disabled. Her chiropractor thought that her problem was upper cervical instability so that’s why she came to Caring Medical Florida. But her myriad of symptoms suggest that she has irritation of her vagus nerve because all of these symptoms can be because the vagus nerve is not functioning properly, is not giving the right input to the brain, and some of the impulses through the vagus nerve are not getting through.
Patient’s Digital Motion X-Ray reveal possible symptom causes and a syrinx at C5 is examined
This segment of the video begins at 3:30
I think you’ll find her digital motion x-ray very fascinating but before I even talk about that, what is also unusual about her case is when I was reviewing for medical history, she, had a MRI from a while ago that showed us that she had a syrinx from C5 to the mid thoracic area. So she actually has a fluid filled sac in her spinal cord (the syrinx) and it starts at C5. So it will be interesting in reviewing her digital motion x-ray if she has instability right above where the syrinx.
At 4:09 loss of the cervical curve
With our face down lifestyle, a lot of people are getting cervical ligament laxity and what that causes is a loss of the cervical curve that’s what we see in this particular patient we even see that the ligaments in her neck can’t even keep the vertebrae together even at rest.
At 4:34 of the video, Dr. Hauser discusses the patient’s problem with cervical spine instability.
- The C1 vertebra is a little bit tilted
- At C2/C3 the vertebrae are offset (misaligned) so we know this particular person is gonna have severe instability at C2-C3.
- There is also an offset at C3-C4 and an offset at C4-C5. Even before we ask the patient to do certain movements while under the DMX, we know that this particular person is going to have a significant ligament injury in these areas.
- This person also is very loose-jointed and I believe that anybody who has chronic pain and they have extra flexibility throughout their body that more likely than not the cause of their chronic pain is going to be ligament injury.
Neck movement observed under DMX at 5:30
- At C4/C5 – We can see how much instability there is at C4-C5. As noted this patient has a syrinx at C5. This type of instability in the neck can block cerebral spinal fluid flow. In this patient’s case here cerebral spinal fluid flow is getting blocked in C4-C5 and I believe that’s the cause of her syrinx. The syrinx, the fluid filled sac in the spinal cord is not the cause of her burning mouth.
- At 6:29 of the video, the DMX open mouth views demonstrate a significant instability at C1-C2 from cervical capsular ligament laxity.
- Treatment discussion at 7:05. By her third Prolotherapy treatment session, her burning mouth symptoms started to go down. Some people come in with such severe instability it may take 2 or 3 or 4 visits just to get them from the severe stage of instability to a moderate amount of instability. In this patient the prognosis is excellent to get complete relief not just of her burning mouth symptoms but also all the other vagus nerve symptoms that she has, such as a change in her voice quality, the hoarseness, difficulty swallowing, digestive complaints, eye complaints, the ear fullness that she has. So, she’s excited and we’re excited to treat her.
In this video Ross Hauser, MD discusses the problem of Burning Mouth Syndrome and how disruption of the Cranial Nerves, specifically the Vagus Nerve can cause Burning Mouth Syndrome.
A transcript summary and explanation notes are added below.
I remember the first case of burning mouth syndrome I treated, it was about 25 years ago. This patient thought the problem was their teeth, they had a lot of dental work thinking that would rid them of the burning mouth problem they had.
- Following the dental work’s failed pain alleviation, the patient then sought out alternative holistic medicine providers. Here they were suggested to gluten-free and dairy-free diets along with herbal supplementation. They were told to avoid spicy foods, hot foods and beverages, or other foods that may cause them discomfort.
Chiropractor diagnoses patients with upper cervical instability
- When the alternative holistic medicine failed, they sought out care from a chiropractor. The chiropractor felt that the problem was upper cervical instability. The problem of their burning mouth was coming from the neck. That chiropractor did this patient a big favor. This patient came to me, received Prolotherapy treatments and responded very well. As will be explained below Prolotherapy is a series of simple dextrose injections into the cervical spine. The goal of the treatment is to strengthen the cervical spine ligaments and provide stability and a return to the normal cervical spine curve. This will help relieve the possible pressures the vertebrae are causing on the nerves that lead into the mouth, tongue, and face.
The nerves that lead into the mouth, tongue, and face
A study from New York University School of Medicine/Langone Medical Center (6) describes the interaction of the facial nerve (seventh cranial nerve CN VII), the glossopharyngeal nerve (ninth cranial nerve CN IX), and the vagus nerve (tenth cranial nerve CN X) and symptoms of burning mouth syndrome.
“Alterations in taste and quantity of salivation are commonly reported in burning mouth syndrome. The chorda tympani branch of the facial nerve (CN VII) supplies chemoreceptors for taste in the anterior (front) two-thirds of the tongue. The glossopharyngeal nerve (CN IX) provides taste sensation for the posterior (back) third of the tongue. There are also taste receptors on the soft palate supplied by the greater superficial petrosal nerve branch of the facial nerve and on the larynx from the superior laryngeal nerve of the vagus nerve (CN X).”
- Dr. Hauser in the video: The vagus nerve runs right along the anterior border (the front) of the C1-C2 vertebrae, down into the neck and it makes its way to the digestive tract. The cause of burning mouth syndrome can be attributed in some cases to compression or stretching of the vagus nerve along its winding path from neck to stomach. In our practice, we look for compression or stretching of the vagus nerve being caused by excessive movement and instability of the C1-C2-C3 and other cervical vertebrae.
- The vagus nerve has direct connections with the facial nerve and the glossopharyngeal nerve and these three nerves the facial nerve glossopharyngeal nerve and vagus nerves they basically are the nerve supply as far as sensation goes to the tongue. The movement of the tongue, that’s the hypoglossal nerve working. The hypoglossal nerve also comes through the C1-C2 area and it also has connections with the vagus nerve but specifically, the facial nerve CN VII the glossopharyngeal nerve, cranial CN IX, and the vagus nerve, CN X, are interconnected.
Nerve pain from disc compression
- Upper cervical instability can nudge or push on the vagus nerve, this can lead to the development of vagal neuropathy or vagal neuritis or you can get hypoglossal neuritis or facial neuritis all because of upper cervical instability. This can cause the burning, the irritation, the awfulness of that horrible pain in the tongue on the roof of the mouth and in the back of the throat.
- When the pain is just in the tongue is not anywhere else, often that’s irritation of the facial nerve. When there is burning in the back of the throat as well, or in the palette in the roof of the mouth that is indicative glossopharyngeal vagus nerve irritation. Often, this is from upper cervical instability.
Burning mouth syndrome is usually not an isolated problem. There are other symptoms.
- In every case I’ve ever seen a burning mouth syndrome the people also have other symptoms, it can be dizziness, ringing in the ears, clicking in the neck, migraine headaches, tension headaches, speech problems, swallowing problems, a lot of these symptoms again are problems with the vagus nerve.
In this video, Dr. Hauser explains the tell-tale sign of deviated uvula and its possible clue to Burning Mouth Syndrome
There are various clues that the vagus nerve is involved in burning mouth syndrome. One of them is to actually look at the uvula.
- Go to a mirror, shine a flashlight into your mouth and go “ahhh.” If your uvula deviates to the side, we call that a deviated uvula that is one of the biggest signs that the vagus nerve is not functioning correctly.
One of the ways that we objectively document that a person has vagus nerve problems or disrupted or blocked signals from the vagus nerve is by looking at the uvula at the back of the soft palate. When we ask the patient to say “ahhh,” the uvula (the small finger-like tissue that hangs at the back of the soft palate (often mistaken for the tonsils)) should remain centered in the throat.
See (0:40) of the video: When you say “ahhh,” the uvula should stay in the middle. See (0:48) the uvula deviates to the right. This means that the patient’s levator veli palatini (Levator palati) muscle is not supporting or elevating that side of the uvula. That means that this person likely has vagus nerve degeneration and compromised or blocked nerve impulses from the vagus nerve, more specifically, by the pharyngeal branch of the vagus nerve.
Numb tongue, burning mouth, and other tongue pain from nerve impairment due to cervical instability
Ross Hauser, MD and Brian Hutcheson, DC discuss the nerves in the neck and face that affect tongue feeling and function, and when staying in prolonged positions can impair the nerves. The cervical instability one can experience during various movements and positions can cause painful symptoms like burning mouth or numb tongue, and difficulty speaking or moving the tongue.
In many cases of Burning Mouth Syndrome, we would recommend a tag-team approach of Prolotherapy injections to strengthen the cervical ligaments to help restore cervical spine stability, and cervical curve realignment therapy through the use of specialized chiropractic care.
In almost all the cases of Burning Mouth Syndrome or numb tongue we have seen at Caring Medical, there has been some kind of dental work involved. Whether it’s a wisdom teeth being pulled or a crown or a cavity.
- The upper cervical nerves, the C1, C2, C3 have connections to the hypoglossal nerve, the hypoglossal nerve controls the motion of the tongue.
- The upper cervical nerves, the C1, C2, C3 have connections to the trigeminal nerve which is the nerve that helps controls the muscles of the face and sensation that connects to the upper cervical in the spinal cord right
- The upper cervical nerves, the C1, C2, C3 have connections to the chorda tympani which is a branch of the facial nerve that influences sensation and taste in the tongue
Burning tongue / Numb Tongue Syndrome
Problems with these nerves and cervical spine instability can also cause problems of Numb Tongue Syndrome where half or more than half of the tongue feels numb tongue and often that occurs with motion.
If you have a tongue issue whether it’s numbness whether it’s pain, if you have difficulty moving it, you have already been to a neurologist in you’re not good results what can be an answer?
We can sometimes find that under certain motion of the neck, as pointed out, loss of tongue sensation with movement, we find under examination that motion of the cervical spine is causing nerve irritation that is impacting the tongue function.
We just had a case where we helped resolve a burning tongue issue. We provided on treatment of Prolotherapy (this patient will need more treatments to continue the stabilizing efforts) and we offered cervical spine curve correction. In this case the patient benefited most from supine or laying down curve correction. We helped this patient enough on the first visit that she could go home lay on a Denneroll (a cervical orthotic device), which she utilized for a couple of hours and this helped alleviate the burning pain in her tongue. While this type of quick and immediate results may not be common or seen in all patients, it was good to see it in this patient.
The basic message, if you get rid of the irritation of the C1 or C2 nerve roots by positional changes of the cervical vertebrae, or a diagnostic nerve block, and this alleviates your problems. Then a further exploration of your burning mouth and tongue problems and it cervical spine connection should explored.
Burning Mouth Syndrome a case study not requiring narcotic and anti-depressant medications. Treatment with Prolotherapy
If a person has burning mouth syndrome Prolotherapy treatments may offer relief. In this treatment, simple dextrose is injected into the cervical spine at the ligament attachments to the bone. The goal of the treatments is to tighten chronically stretched out ligaments.
In a case history from Caring Medical, a patient had a dental procedure for gum disease. She then developed a severe burning mouth and underwent “hell” for the next two years. She had various teeth taken out, chelation for heavy metal poisoning, and a host of other treatments without relief of her burning mouth. Consultation after consultation with other providers continued to suggest a dental problem. That is until she had a Prolotherapy consultation where it was discovered that her pain was due to previously undiagnosed neck instability.
In our discussion with the patient, she revealed that she had a history of “tension headaches” and a clicking in her neck, for which she sought out occasional chiropractic manipulation. Her digital motion x-ray showed evidence of cervical instability in multiple areas. I told her in hindsight that it probably wasn’t the procedures themselves that caused this, but the head and neck position during the procedures that caused the condition.
Most healthcare providers are unaware of the stretching of ligaments that occurs when people are held in unusual or uncustomary positions for a long period of time, as in dental and surgical procedures.
I believe that during the gum procedure, her head was extended and her mouth was held open for over an hour which of course stretched her temporomandibular and upper cervical ligaments. This led to stimulation of the trigeminocervical nucleus in the cervical spinal cord, giving a burning mouth sensation. She had a double whammy, stimulus from the cervical and trigeminal nerves. Fortunately, after five Prolotherapy sessions to her jaw and neck, the patient reported the situation was resolving.
If this article has helped you understand the connection between cervical spine instability and burning mouth syndrome, get help and information from our office.
1 Mitsikostas DD, Ljubisavljevic S, Deligianni CI. Refractory burning mouth syndrome: clinical and paraclinical evaluation, comorbidities, treatment and outcome. The Journal of Headache and Pain. 2017 Dec 1;18(1):40. [Google Scholar]
2 Jedel E, Elfström ML, Hägglin C. Differences in personality, perceived stress and physical activity in women with burning mouth syndrome compared to controls. Scandinavian Journal of Pain. 2020 Oct 27;1(ahead-of-print). [Google Scholar]
3 McMillan R, Forssell H, Buchanan JA, Glenny AM, Weldon JC, Zakrzewska JM. Interventions for treating burning mouth syndrome. Cochrane Database Syst Rev. 2016 Nov 18;11:CD002779. [Google Scholar]
4 de Pedro M, López-Pintor RM, Casañas E, Hernández G. General health status of a sample of patients with Burning Mouth Syndrome: a case-control study [published online ahead of print, 2020 Mar 10]. Oral Dis. 2020;10.1111/odi.13327. doi:10.1111/odi.13327 [Google Scholar]
5 Imamura Y, Okada-Ogawa A, Noma N, et al. A perspective from experimental studies of burning mouth syndrome [published online ahead of print, 2020 Mar 11]. J Oral Sci. 2020;10.2334/josnusd.19-0459. doi:10.2334/josnusd.19-0459 [not listed yest – Google Scholar]
6 Gurvits GE, Tan A. Burning mouth syndrome. World journal of gastroenterology: WJG. 2013 Feb 7;19(5):665. [Google Scholar]