Transcript Zinc replacement treatment

Journal reading
報告者：PGY2 曾智皇
報告日期 : 103.07.08
指導老師 : 林立民 醫師
陳玉昆 醫師
Introduction
• Burning mouth syndrome (BMS) is typically
described by the patients as a burning
sensation of the oral mucosa
absence of clinically apparent mucosal
alterations
• Overall prevalence ranging from 0.7% to 7%
• Prevalence up to 12% to 18% for postmenopausal women with BMS
• BMS often affects the tongue (particularly the
tip and lateral borders), lips, and hard and soft
palate
• Unremitting oral mucosal pain, dysgeusia, and
xerostomia
Diagnostic criteria
• Oral burning or pain
Unremitting for at least 4–6 months
Continuous throughout almost all the day
Seldom interferes with sleep and never
worsens
May be relieved, by eating and drinking
• Other oral symptoms:
Dysgeusia
Xerostomia
Presence of sensory/chemo-sensory
anomalies
Mood changes
Disruptions in patient personality traits
• Can not have any signs of oral mucosal
pathology !!
• Detailed review of patient’s medical and
dental histories
• Careful analysis of data obtained from physical
and laboratory examinations
Classification and subtypes
Lopez-Jorne et al 
Type 1 BMS:
• Pain-free waking  gradually increasing 
reaching its peak intensity by evening
• 35%
• Linked to systemic disorders such as
nutritional deficiency, diabetes mellitus
Type 2 BMS:
• Continuous symptoms throughout the day
• 55%
• Usually associated with psychological
disorders
Type 3 BMS:
• Intermittent symptoms
• 10%
• Show allergic reactions
• Scala et al. classified BMS into 2 clinical forms

1. Primary BMS:
a. Essential or idiopathic
b. Peripheral and central neuropathological
pathways are involved
2. Secondary BMS:
a. Caused by local, systemic or psychological
factors
Primary BMS
• 1st subgroup:
Peripheral small-diameter fiber neuropathy of
intraoral mucosa (50–65%)
• 2nd subgroup:
Subclinical lingual, mandibular, or trigeminal
system pathology (20–25%)
• 3rd subgroup:
Hypofunction of dopaminergic neurons in the
basal ganglia (20–40%)
• Lauria et al  Significantly lower density of
epithelial nerve fibers in patients with BMS
than in control subjects
• Just et al  Patients with BMS exhibit a
decreased somatosensory and gustatory
perception
• Albuquerque et al  Patients with BMS had
less volumetric activation throughout the
entire brain
Secondary BMS
• Local factors: poorly fitting prostheses,
parafunctional habits, dental anomalies, allergic
reactions, infection, chemical factors, galvanism,
taste alterations, and xerostomia
• Systemic factors: endocrine alterations
(hypothyroidism, diabetes, and menopause), vitamin
B complex, iron and zinc deficiencies, anemia,
gastrointestinal anomalies, medication, Sjogren’s
syndrome, and esophageal reflux
• Psychological factors: anxiety, depression,
compulsive disorders, psychosocial stress, and
cancerphobia
• Netto et al
Significant association of the presence of
gastrointestinal diseases and urogenital
diseases with BMS
Significant correlation between the intake of
H-2 receptor antagonist or proton-pump
inhibitor and BMS
• Gao et al
87(BMS) and 82
No statistical difference in blood analyses
(including white blood cell count, red blood cell count, hemoglobin (Hb), and
platelet count )
between the BMS and control groups
Significantly higher serum follicle-stimulating
hormone level and a significantly lower serum
estradiol level in the menopausal or postmenopausal women with BMS
Anxiety and depression scores in patients with
BMS are higher
Habit of tongue thrusting, lip sucking,
periodontitis, smoking, outcome of recent
medication, and depression are the principal
risk factors for the BMS
• Lin et al
Patients with BMS had a significantly higher
frequency of Hb, iron, or vitamin B12
deficiency
Abnormally elevated blood homocysteine
level
Serum GPCA (gastric parietal cell antibody) positivity
• Boras et al
Significantly lower serum neurokinin A is
found in patients with BMS
Indicating an inefficient dopaminergic system
in patients with BMS
• Pekiner et al
Significantly lower serum IL-2 and TNF-a levels
in patients with BMS
Significantly lower mean salivary Mg level in
patients with BMS
• Maragou and Ivanyi, Cho et al
Significantly lower mean serum zinc level in
patients with BMS
• Pokupec-Gruden et al
Anxiety and depression are most common in
patients with BMS
General consideration for
treatment of BMS
• Detailed review of patient’s medical and
dental histories and a careful analysis of
patient’s data
setting up a therapeutic regimen
• Treatment or elimination of these factors
(local, systemic, psychological) usually results
in a significant clinical improvement
• If patients still have the symptoms  drug
therapy should be instituted
• The custom-made or combination therapy for
each patient with BMS
 the greatest benefit to the patient and
lessen the treatment duration
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
Vitamin supplement treatment
• Sun et al
• Vitamin BC capsules plus relatively high doses
of corresponding deficient hematinics
 a. reduce the abnormally higher mean serum
homocysteine levels
b. raise the corresponding lower mean deficient
hematinic and Hb levels
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
Zinc replacement treatment
• Cho et al
• Evaluated the serum zinc level in 276 patients
with BMS
• Zinc replacement therapy in BMS patients
with zinc deficiency is effective
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
Hormone replacement treatment
• Wardrop et al
prevalence of oral discomfort is significantly
higher in perimenopausal and postmenopausal women
 43% <-> 6%
• Forabosco et al
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
Topical drug treatment
• Epstein and Marcoe
• Gremeau-Richard et al
• Peripheral nervous system dysfunctions in patients
with BMS
• Sardella et al
• Lopez-Jornet et al
• Topical Aloe vera has been shown to promote
the healing process in the treatment of burns,
psoriasis, and oral lichen planus
1.
2.
3.
4.
5.
Vitamin supplement treatment
Zinc replacement treatment
Hormone replacement treatment
Topical drug treatment
Systemic drug treatment
Systemic drug treatment
• Petruzzi et al
• Its use is not recommended for extended treatment
• Grushka et al
• Heckmann et al
• Ko et al
• Investigated outcome predictors of clonazepam
therapy
• Amos et al
• Combined topical and systemic clonazepam
administration is an effective regimen for treatment
of BMS
• Femiano et al
• Antioxidant mitochondrial coenzyme
neuroprotective effect
• Marino et al
• prolonged therapy in chronically affected patients
with BMS is needed for maintaining a more
permanent effect
• Maina et al
• No serious adverse effects are referred in any of the
three groups
• Rodriguez-Cerdeira and Sanchez-Blanco
• Amisulpride seems to be effective and well tolerated
• Yamazaki et al
• A tricyclic antidepressant
• The side effects are minor and transient and no
serious safety issues are observed
• Bergdahl et al
Summary
• BMS is probably of multifactorial origin and
may be idiopathic
• Clinicians should first try to identify the
precise causative factors for the BMS
• If patients still have the symptoms after the
removal of potential causes, drug therapy
should be instituted
• Previous clinical trials have found that drug
therapy with capsaicin, alpha-lipoic acid,
clonazepam, and antidepressants
 relief of oral burning or pain symptom
• Psychotherapy and behavioral feedback may
also help eliminate the BMS symptoms
Thank you for your
attention