Download a PDF about this oral disease which includes photographsWhat is burning mouth syndrome?
Burning mouth syndrome is a relatively common condition that is characterized by a complaint of an abnormal sensation of the lining of the mouth that most patients describe as feeling like their mouth has been scalded. Usually this sensation develops in the front part of the mouth, typically affecting the inner surfaces of the lips, the roof of the mouth and the sides and tip of the tongue. In some patients, only the tongue will be affected, however, any combination of these sites may be seen. Some patients may have a decreased taste ability or altered taste sensation (bitter or salty). Other patients may feel that their mouths are dry or sticky. In all cases, however, the lining of the mouth clinically appears normal.

Who gets burning mouth?
Most patients who develop burning mouth syndrome are post-menopausal women. We usually see about ten women for every man who has burning mouth syndrome. This is a relatively common problem that is seen all over the world. For example, in Holland, patients with burning mouth syndrome have formed a support group. This seems to be a condition that affects people of all races and all socioeconomic backgrounds.

What causes burning mouth?
Nobody knows for sure. There are a few uncommon diseases that should be tested for, such as anemia, diabetes and oral yeast infections. For most patients with burning mouth syndrome, however, those tests turn out to be normal. Some investigators have suggested that burning mouth may be a problem related to the nerves in the mouth. We know that burning mouth is not related to anything serious, such as cancer or AIDS. Furthermore it is not contagious so it can’t be passed from one person to another.

How do doctors diagnose burning mouth syndrome?
Burning mouth syndrome is diagnosed by doing blood tests and cultures to make certain that one of the other problems mentioned previously is not present. If those tests are all negative, and if the lining of the mouth appears normal, then we can make a diagnosis of burning mouth syndrome.

How is burning mouth syndrome treated?
Unfortunately, no one has developed a medically proven treatment for burning mouth syndrome. The main problem is that we don’t know what causes burning mouth syndrome, therefore it is difficult to develop a treatment for the condition. A variety of medications (including anti-depressants, anti-seizure drugs, female hormone replacement therapy and vitamin therapy) have been tried, however, such treatments either have no effect or their effect is no greater than what we would expect to see with placebo (sugar pill) treatment.

How long will the burning sensation last?
Again, we cannot say for sure. We know that for about half of the affected patients, the condition will resolve after a period of time, but no one can predict how long that will be for a particular individual. For the most part, this problem is a nuisance, and it is a frustrating situation for both patients and doctors.

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What is cicatricial pemphigoid (sicuh-tri-shul pem-fuh-goyd)?
Cicatricial pemphigoid is a relatively uncommon blistering disease that mostly affects the mucous membranes, that is, the moist linings of the mouth, the eyes, the nose and throat, and the vagina. Sometimes only one or two of these areas are affected at first, and the condition may spread to other areas, including the skin, if it is not treated.

Who gets cicatricial pemphigoid?
Cicatricial pemphigoid is a condition that primarily affects middle-aged or older adults. Either sex can get the disease, but women are affected slightly more often than men.

Can I spread this disease to my family and friends?
No. Cicatricial pemphigoid is not a disease that can be passed from one person to another like the flu. Probably the best explanation as to what is happening in cicatricial pemphigoid is that it is a type of unusual allergic reaction. In the case of cicatricial pemphigoid, however, instead of being allergic to, say, strawberries or seafood, the body is sort of allergic to itself. In other words, the immune system, which normally protects the body by destroying invading organisms, gets confused and actually starts attacking the lining tissues of the body itself. Thus, cicatricial pemphigoid is in the group of diseases that we call autoimmune (literally “self” immune) diseases.

How do doctors diagnose pemphigoid?
The best way to diagnose pemphigoid is to take a tissue sample (biopsy) from the involved area of the mouth. This is a minor surgical procedure, performed using local anesthesia (numbing) in the office. The tissue is then examined in the laboratory under a microscope and special tests are performed to detect the abnormal immune reaction.

Why is it important to diagnose pemphigoid?
The most serious problem associated with untreated cicatricial pemphigoid is possible blindness if the lining of the eye is involved. The word “cicatricial” means “scarring”, and if the disease affects the eye, the scarring that results often leads to blindness if the condition is not diagnosed early enough and treated properly.

Not everyone who has pemphigoid of the mouth will develop pemphigoid in their eyes, but about one person in four will. This is why we advise our patients to be evaluated by an ophthalmologist (medical doctor specializing in eye disease) who is familiar with the signs of eye involvement with cicatricial pemphigoid.

How is pemphigoid treated?
The type of treatment for cicatricial pemphigoid usually depends on the extent of the disease. There are several ways to treat pemphigoid, including tetracycline with niacinamide, cortisone-type drugs that suppress the immune reaction, or a sulfa-type drug called dapsone. With mild oral involvement, topical (surface) application of a cortisone-type medication a few times each day may be able to control the symptoms. Another alternative is the use of tetracycline and niacinamide, taking one capsule of each, four times daily. On the other hand, if symptoms are more generalized or if the eye is involved, then more serious, cortisone-type drugs that are taken internally may be necessary. If the cortisone-type drugs don’t work well or if their side effects are too severe, then dapsone may be tried. A special blood test has to be done, however, to find out if the patient can take dapsone safely.

Can pemphigoid be cured?
In the sense that strep throat, for example, can be cured by a shot of penicillin, no, pemphigoid cannot be cured. The symptoms, however, can usually be controlled with the right medication or combination of medications. Pemphigoid is a condition that may wax and wane on its own to a certain extent, but it usually doesn’t go away completely. Fortunately, it rarely causes death, but the possibility of blindness is certainly serious, and the sores and blisters can be quite a nuisance. The goal of your treatment, then, is to keep the sores and blisters under control so that you can lead a relatively normal life. But please realize that this is a very difficult and complex disease to manage, and cooperation and communication between the patient and doctor are necessary to achieve the best possible treatment results.

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What is geographic tongue?
Geographic tongue (also known as benign migratory glossitis or erythema migrans) is a harmless condition that affects about 2% of the population. Geographic tongue is typically seen as well-defined, reddened areas on and around the sides of the tongue. These red areas usually have a slightly white or yellow-white, raised line around their edges. The condition usually waxes and wanes in severity, with the red patches appearing in one area during a period of several hours to a few days, persisting for a period of time (days to weeks to months, depending on the individual), and clearing up; however, the process usually repeats itself in a different area or areas after a few more days, weeks or months. When the condition is “active”, the tongue is often sensitive (feels like it has been scalded) to hot, spicy or acidic foods.

What causes geographic tongue?
Noone really knows what causes this condition — all we know is that it is not a serious problem. It is not caused by an infection, and it is not related to any other disease. If a biopsy were to be taken from your tongue, it would look a little like psoriasis of the skin (“psoriasiform mucositis”). Geographic tongue patients usually don’t have psoriasis; however, psoriasis is a common skin condition that also has an unknown cause, and occasionally we see a patient with both problems. This may be nothing more than coincidence in many instances.

Who gets geographic tongue? Can people catch this from me?
Anyone can potentially develop geographic tongue, just like anyone can potentially develop, for example, an allergy to penicillin. Why does one person develop the allergy and the next person doesn’t? No one knows. And we can say the same for geographic tongue. No one knows why some people develop the condition. We know that this is not any sort of infection, however, so you don’t have to be worried about passing this on to anyone else.

Is there any cure for geographic tongue?
No, there is no “cure” for geographic tongue, just as there is no cure for arthritis, psoriasis or allergies. Most patients will experience this condition as a mild nuisance or irritation. Infrequently, powerful topical anti-inflammatory drugs (cortisone-like drugs) may have to be prescribed to help control the discomfort for those few patients who are very bothered by the problem.

Will it turn into cancer?
No. Geographic tongue has never been demonstrated to undergo transformation to cancer. Of course, if any oral sore develops which doesn’t behave like typical geographic tongue, the prudent thing to do would be to have it evaluated by the oral pathologist or other health care practitioner with experience in diagnosing oral disease.

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What Is hairy/coated tongue?
“Hairy” or “coated” tongue is a harmless, but sometimes annoying problem that is seen rather frequently. People who complain of this condition are almost always adults, and it can affect men or women.

What causes coated tongue?
Basically, the top surface of the tongue is an area that is typically subjected to a lot or irritation on a daily basis. This irritation is often due to hot drinks or rough foods (tortilla chips, etc.) For this reason, humans have been designed to have the tops of their tongues produce a layer of protective dead cells called “keratin”. This is the same material that forms our hair and fingernails. It is also the same material that forms when we, for example, use a rake in the yard, and calluses develop on the palms of our hands. The calluses are made up of keratin.

The keratin formed on the top of our tongues is knocked off and swallowed when we eat our meals. Normally, the amount of keratin produced is equal to the amount knocked off, and our tongues appear normal. Sometimes, this balance is upset, however, and the condition called “coated tongue” results. This may be due to the keratin not being knocked off as quickly, as seen with people who are eating a softer, less abrasive diet (denture wearers especially). On the other hand, some people will develop this problem when the keratin is produced more quickly than it can be knocked off and swallowed. This increased production of keratin is usually due to irritation of the of the tongue due to drinking hot beverages or smoking tobacco. The accumulation of keratin on the filiform papillae (“taste buds”) of the tongue gives the tongue a kind of “hairy” appearance.

What is the difference between coated and hairy tongue?
The difference between these two terms is basically that of the degree of keratin accumulation. With coated tongue, the accumulation is not severe. With hairy tongue, the amount of keratin is such that hair-like projections of the keratin material form on the top of the tongue.

What about the color of my tongue?
Sometimes it seems black or brown. Because the keratin is composed of dead cells, this material can act as a place for the normal bacteria found in the mouth to accumulate and grow. Some of these bacteria can produce pigments while they grow, resulting in a brown or black color to the of the tongue.The bacteria are harmless and cannot be eliminated from the mouth (regardless of what the mouthwash advertisements suggest!).

Can people catch this from me?
No, absolutely not. While several medical textbooks suggest that this is due to some sort of infection, very little evidence supports that theory. In fact, we have seen numerous cases of coated or hairy tongue that have been treated with a variety of antibiotics that had no effect whatsoever.

Is there any cure for coated tongue?
Generally the most effective treatment for this condition is the daily use of a tongue scraper, which removes the dead keratinized cells from the of the tongue. Stopping or reducing any habits that might cause irritation to the top of the tongue also usually helps reduce the problem. Of course it is important to realize that this is a harmless condition, and if it doesn’t cause too many symptoms, it really doesn’t require treatment.

Download a PDF about this oral disease which includes photographsWhat is leukoplakia and why is it important?
Leukoplakia (luke-o-plake-ee-ah) is a clinical term that is used to describe certain white patches in the mouth. Not all white patches are called leukoplakia – just the ones that cannot be rubbed off and cannot be diagnosed as any other condition or disease. Leukoplakia is important because, over time (typically months to years), a percentage of these white patches will transform to oral cancer.

Who gets leukoplakia?
Most cases of leukoplakia are found in older men, but women can develop this problem as well. The condition is very uncommon in people under 40 years of age, however it has been seen in these individuals as well.

What causes leukoplakia?
Many times a direct cause cannot be identified, but a large percentage of patients with leukoplakia use (or have used) tobacco, typically in the form of cigarettes. We now know that some leukoplakias can be caused by the current or past use of sanguinaria (bloodroot)-containing products (Viadent; The Natural Dentist).

How do doctors diagnose leukoplakia?
The clinical diagnosis of leukoplakia is made by listening to the patient’s medical and social history, looking carefully at the lining of the mouth, and by excluding other possible causes of white patches in the mouth. Often a biopsy is needed.

How is leukoplakia treated?
In most cases, a biopsy will determine how advanced the leukoplakia is in terms of its precancerous potential. Sometimes the changes in the lining of the mouth seen under the microscope are very subtle, and this is sometimes called “epithelial atypia”. The significance of this is unknown. While it is unlikely that “epithelial atypia” will soon become cancerous, we cannot rule out the possibility of this happening sometime in the future. If the changes seen are more suggestive that the lining of the mouth will probably become cancer, this is called “epithelial dysplasia”, and it is usually graded as mild, moderate or severe, depending on what the tissue looks like under the microscope. In a small percentage of cases, the very beginning stages of oral cancer may be seen.

The type of treatment that is recommended will depend on several things, including the location in the mouth of the leukoplakia, how large the leukoplakia is, how “bad” the dysplasia appears under the microscope, and the patient’s age, habits, and other medical problems. For leukoplakias diagnosed as “atypia” or “mild dysplasia” in an older adult who smokes, we usually recommend that the patient stop smoking, and the lining of the mouth should be re-evaluated periodically. For those leukoplakias diagnosed as “moderate” or “severe”, we usually recommend complete removal of the white patch in order to prevent the development of oral cancer. Removal can be done by traditional scalpel excision, electrocautery, liquid nitrogen application or laser surgery. Each treatment has its advantages and disadvantages, and deciding which one should be used depends on each patient’s situation.

What happens after my leukoplakia is treated?
While most cases of leukoplakia are cured once they are removed, it has been well documented that about one in three lesions will grow back. The chance of the leukoplakia returning is increased for those patients who continue smoking. For this reason, we always recommend periodic re-evaluation of the oral mucosa by someone who is familiar with the lining of the mouth. If the leukoplakia should recur, repeat biopsy is generally advisable.

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What is lichen planus (lye-kenplan-us)?
Lichen planus is a benign (not cancer) condition that affects either the skin or the lining of the mouth. Occasionally both areas will be affected. We don’t know what causes lichen planus, but we do know that lichen planus is not caused by an infection (bacteria, virus or fungus) or any identifiable habit (smoking, foods, etc.). What we believe is happening in lichen planus is that the immune cells, which normally protect us by destroying bacteria or viruses, get confused and start attacking the skin or the lining of the mouth.

What does lichen planus look like?
On the skin, lichen planus appears as small, itchy, red-purple, flat-topped bumps that occur in clusters on the forearms and thighs primarily. In the mouth, lichen planus may take on two basic forms:

(1) Reticular lichen planus gets its name from the lace-like pattern of fine white lines that appear most commonly on the inside of the cheeks. It may also be seen on the gums and on the top of the tongue. Usually reticular lichen planus is asymptomatic (doesn’t hurt), so it requires no treatment.

(2) Erosive lichen planus gets its name from the erosions (areas where the lining of the mouth have been destroyed) that develop in this form of the condition. These erosions, or sores, are usually rather tender or painful, particularly when acidic (orange juice, tomatoes), salty, or alcoholic foods or beverages come into contact with the sores. This form of lichen planus is less common than the reticular form. The areas of the mouth that are affected are the same, however (cheeks, tongue and gums). Sometimes a biopsy is necessary to help diagnose lichen planus.

Who gets lichen planus?
Lichen planus is almost always a problem that affects adults, with most patients being between 30 and 60 years of age. Women are affected slightly more often than men.

Can lichen planus be cured?
Because lichen planus isn’t an infection like a strep throat, we can’t prescribe an antibiotic and cause it to go away. In most cases, however, we can control the symptoms so the condition isn’t uncomfortable. With the reticular form of lichen planus, no treatment is needed. Treatment of the more severe, erosive lichen planus requires the use of powerful topical (surface) anti-inflammatory drugs called corticosteroids (cortisone-type drugs). These drugs, when given in large doses over many days, may have many undesirable side effects, producing weight gain, diabetes, osteoporosis, high blood pressure, ulcers and mood changes, to name a few. In the doses required to control lichen planus, however, these side effects rarely develop. One of the goals of treatment, of course, is to minimize the amount of drug needed to control the lichen planus. For this reason, we usually recommend starting treatment by applying a small amount of the corticosteroid medication only to the areas that are uncomfortable, and doing this at least four times each day, particularly after meals and at bedtime. Once the sores have started to heal (usually 3 – 6 days), you should reduce the number of daily applications gradually over a period of 2 -3 weeks. If you can stop using the medication completely and still feel comfortable, that’s fine, but don’t be surprised if the condition flares up again. Just return to applying the corticosteroid four times daily.

What happens with lichen planus in the long-term?
According to one study, patients with oral lichen planus had the condition for an average of ten years, so it probably isn’t going to disappear overnight. Basically, it’s going to be a nuisance, but hopefully a controllable nuisance. There have been occasional reports of cancer developing in erosive lichen planus, but most of these reports are questionable. If you notice a change in the usual appearance of your lichen planus or if you find that the medication isn’t helping, make sure to come back and see us so we can re-evaluate the situation.

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What is candidiasis?
Candidiasis is an infection of the most superficial part of the lining of the mouth that is caused by the yeast-like fungal organism, Candida albicans. Unlike many other infections, candidiasis does not really invade into the living parts of the body – the yeast primarily uses the dead (“keratinized”) cells that are on the surface of the lining of the mouth for food. This organism also causes vaginal yeast infections in some women. It is important to understand that this is not the same yeast that is used for baking bread or brewing beer.

Who gets oral candidiasis?
Just about anyone can get candidiasis, but it seems to occur more often in the very young and in older age groups. Interestingly, this yeast-like fungus is often found in the mouths of otherwise healthy people, although in those situations, there doesn’t seem to be any sign of actual infection – the yeast is said to be in a “carrier” state, and no treatment is necessary.

What causes oral candidiasis?
Can I spread this disease to my family and friends? In many cases, this organism takes advantage of special situations that make it possible to cause infection. For example, if a person takes an antibiotic, this kills off the competing bacteria in the mouth, making it possible for the yeast to take over. In some oral diseases that produce extra keratin, the organism will favor infection of that lining area. Patients who wear dentures, especially a complete upper denture, are more likely to have the yeast in their mouths. Problems with the immune system can also cause a tendency for yeast infection, and this includes patients who are taking cortisone-type drugs. Diabetic patients seem to be more likely to develop oral yeast infections as well. As for spreading to your family or friends, it is likely that they already have the yeast living in their mouths anyhow, and it probably isn’t causing any problems.

How do doctors diagnose oral candidiasis?
This disease may be diagnosed based on the clinical signs and symptoms. A culture (swab) or cytology (scraping) may be necessary to confirm that the yeast is actually present in some situations.

What are the symptoms of oral candidiasis?
Sometimes people can tell that the yeast is present, and in those situations, they may notice a burning or itching sensation. Other times the yeast infection is asymptomatic, and the person is unaware of the infection.

What does oral candidiasis look like?
Generally this condition causes either a red or white (sometimes both) appearance to the lining of the mouth. Redness and cracking of the corners of the mouth is often seen. Some patients will have a red, smooth area that develops in the middle part of the of the tongue, toward the back, or on the roof of the mouth. The term “thrush” has been used to describe the type of candidiasis that appears as white flecks that look a little like cottage cheese.

How is oral candidiasis treated?
Several good antifungal drugs are available for treating this infection. Some can be taken as a daily pill that is swallowed, while others are used as a mouth rinse or lozenge that is dissolved in the mouth four or five times daily. For people who wear complete dentures (“full upper and lower plates”), the dentures must be disinfected by soaking them overnight, each night, for one week using a mild bleach solution (approximately one tablespoon of bleach in a glass of water). Make sure that you rinse the dentures well before putting them back in your mouth. Do not put partial dentures (those that have metal) in a bleach solution because this will ruin them!! There is a special disinfecting solution available for partial dentures, but this usually has to be ordered from a dental supply store.

Can oral candidiasis be cured?
This infection typically is quickly cured by any of the antifungal drugs that are commonly used. There is no evidence that “home remedies”, such as eating yogurt, will treat oral candidiasis. Similarly, there is no reason to avoid foods that use baker’s or brewer’s yeast, as a different type of yeast is used in those situations. However, because the yeast Candida albicans is a common organism, and because some patients are prone to develop this infection, it is not unusual for the problem to return at some time. Should that happen, the signs and symptoms of the yeast infection can be recognized, and the infection can be treated again with appropriate antifungal drugs.

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What are recurrent aphthous ulcerations?
Recurrent aphthous ulcerations (“canker sores”) are a relatively common condition that affects the lining tissues of the mouth. In the typical form of aphthous ulcerations, patients develop from one to five very painful sores that usually last ten to fourteen days. These sores can occur anywhere in the mouth except on the front part of the roof of the mouth (hard palate) or on the gum tissue that is right next to the teeth. Some patients indicate that they can feel a tingling sensation in an area where one of the sores will develop. The frequency of attacks can be quite variable, ranging from as often as once per month up to as rare as once every few years.

Who gets recurrent aphthous ulcerations?
Anyone can develop these lesions. They can develop at any age and in either sex. They seem to affect young adults a bit more commonly than most other groups, and women seem to be affected slightly more often than men.

What causes recurrent aphthous ulcerations? Can I spread this disease to my family and friends?
Recurrent aphthous ulcerations is not a contagious disease, in other words, it cannot be passed from one person to another. It is frequently confused with herpes. However all of the research done so far has indicated that this is not related to any viral, bacterial or fungal infection. Probably the best explanation as to what is happening in recurrent aphthous ulcerations is that they are a type of unusual allergic reaction. In the case of recurrent aphthous ulcerations, however, instead of being allergic to, say, strawberries or seafood, the body is sort of allergic to itself. In other words, the immune system, which normally protects the body by destroying invading organisms, gets confused and actually starts attacking the lining tissues of the body itself. We don’t know what triggers this unusual reaction, although some patients can relate the onset of the lesions to such things as stress, minor injury to the lining of the mouth, or the menstrual cycle.

How do doctors diagnose recurrent aphthous ulcerations?
Recurrent aphthous ulcerations can typically be diagnosed on the basis of the appearance of the sores, the location of the sores, and the fact that there are multiple episodes. In most cases, biopsies, blood tests and cultures for microorganisms are not helpful. There are a few variations of aphthous ulcers that are worth mentioning, although these are relatively uncommon or even rare.

Major aphthous ulcerations: Patients with this condition have much larger sores than usual, and these are almost always present in the mouth.

Herpetiform ulcerations: These patients develop dozens, or even hundreds, of very small aphthous ulcerations that clinically resemble a herpes infection. Because of the location of the lesions and their recurrent pattern, we can easily rule out a diagnosis of herpes however.

Behcet’s syndrome: In this rare condition, patients not only develop mouth sores that are identical to recurrent aphthous ulcerations, but they also suffer from eye problems and similar sores in the genital area.

How are recurrent aphthous ulcerations treated?
Because this is a problem associated with an overactive immune system, we use medications that tend to suppress the immune reaction. These medications are similar to cortisone, only they are much more powerful. In order to avoid the side effects of cortisone, the medications are applied only to areas where the recurrent aphthous ulcerations are developing. The medication should be applied as a thin film at least four or five times per day at the earliest sign of the lesion development.

If this is done, the lesions can usually either be prevented completely or their healing time can be reduced significantly. Some patients may want to alternate the use of the cortisone medication with a protective medication such as Zilactin.

Can aphthous ulcerations be cured?
No (at least not in the sense that a strep throat, for example, can be “cured” by a shot of penicillin). Usually the lesions can be controlled, however, by using appropriate medication. Often the frequency of attacks can be reduced once the cycle of the ulcerations has been interrupted by the treatment. In addition, some patients seem to have fewer problems with recurrences as they grow older. In most cases, this problem is a nuisance that can be controlled so that it doesn’t interfere with everyday life.