Edmond Truelove
This chapter addresses the diagnosis and management of oral mucosal pain. Box 23-1 identifies the conditions commonly associated with mucosal pain. The most common mechanisms involve an initiating event (eg, infection, injury, drug toxicity, autoimmune disease) that triggers the peripheral release of mediators that cause inflammation.1 These activate and sensitize primary afferent nociceptors, resulting in hyperalgesia and pain2 (see also chapters 4 and 6). Conversely, some mucosal pain conditions such as burning mouth syndrome (BMS) may be associated with changes in trigeminal small-fiber afferents or changes in the central nervous system (CNS).3,4
| Box 23-1 Common painful mucosal conditions | |
| Infections | |
| • Herpetic stomatitis | |
| • Varicella zoster | |
| • Candidiasis | |
| • Acute necrotizing gingivostomatitis | |
| Immune/Autoimmune | |
| • Allergic reactions (dentifrices, mouthwashes, topical medications) | |
| • Erosive lichen planus | |
| • Benign mucous membrane pemphigoid | |
| • Aphthous stomatitis and aphthous lesions | |
| • Erythema multiforme | |
| • Graft versus host disease | |
| Traumatic and iatrogenic injuries | |
| • Factitial, accidental (burns: chemical, solar, thermal) | |
| • Self-destructive (rituals, obsessive behaviors) | |
| • Iatrogenic (chemotherapy, radiation) | |
| Neoplasias | |
| • Squamous cell carcinoma | |
| • Mucoepidermoid carcinoma | |
| • Adenocystic carcinoma | |
| • Brain tumors | |
| Neurologic | |
| • Burning mouth syndrome (stomatodynia) | |
| • Neuralgias | |
| • Postviral neuralgias | |
| • Posttraumatic neuropathies | |
| • Dyskinesias and dystonias | |
| Nutritional and metabolic | |
| • Vitamin deficiencies (B12, folate) | |
| • Mineral deficiencies (iron) | |
| • Diabetic neuropathy | |
| • Malabsorption syndromes | |
| Miscellaneous | |
| •Xerostomia, secondary to intrinsic or extrinsic conditions | |
| • Referred pain from esophageal or oropharyngeal malignancy | |
| • Mucositis secondary to esophageal reflux | |
| • Angioedema | |
Symptom management may require a primary therapy directed toward etiology, a second front targeting pain, and a third front directed at behavioral factors. It is risky to address pain management alone since the underlying condition could be serious systemic pathology.1 Control of symptoms may lull the patient and clinician into a false sense that the condition is benign and self limiting when it is not.
Assessment and Diagnosis
If a patient complains of pain in the oral mucosa, the initial step is to identify any cause that represents a risk to local or general health. This means assessing peripheral, central, and behavioral factors that may play a role in symptom production. It is equally important to assess the impact of the mucosal pain on daily general functioning (eg, sleeping) as well as on oral functioning.5
History
Findings of importance in the medical history include immunosuppressive diseases, hematologic disorders, HIV, diseases of the CNS (eg, tumors, demyelinating disorders, vascular lesions, brain injury), chronic viral infections, medications, and conditions known to cause peripheral neuropathies (eg, diabetes, multiple sclerosis, antineoplastic medications). Burning in the presence of oral lesions should prompt an exploration of the patient’s history of communicable diseases and medications known to cause mucositis or depress immune competence. A prior history of severe stomatitis followed by development of residual pain and burning suggests the presence of a postmucositis/ stomatitis pain disorder.
Clinical findings
Most mucosal pain is associat/>
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