This paper describes what is the evidence that BMS is a neuropathic pain disorder, and discusses how having this condition may change the brain of the patient and possibly alter their behavior. To confirm the presence of definitive neuropathic pain, the European Federation of Neurological Sciences suggests that a positive diagnostic test be added to the medical and examination data collected. Unfortunately other than tongue biopsy for small fiber nerve atrophy, no current test is adequate. There have been three studies (from two different laboratories) that suggest that while not all patients with BMS will show small fiber atrophy of the sensory nerve in the fungiform papilla, as many as 75% will be positive on this test. Next, there are multiple animal and some human studies that suggest the brain does indeed go through degenerative and adaptive changes when chronic pain is untreated. Specifically, anxiety increases, sleep disturbance is more prominent and neuronal changes promote hyperalgesia in the periphery. While most of the data on pain induced brain change is drawn from animal studies or human pain problems such as back pain and complex regional pain, there has also been one study on burning mouth patients that provides data consistent with the idea that chronic pains causes brain hypoactivity and reduced brain density.

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Atypical odontalgia (AO), atypical facial pain (AF), glossodynia, and burning mouth syndrome (BMS) are diseases that cannot be explained by physical causes and for which onset is highly related to psychological factors. These conditions are thus referred to as psychological pain, somatoform pain disorders, and functional somatic syndromes. However, recent developments in neuro-imaging suggest the possibility that psychological factors (such as affective/cognitive factors) and or past experiences directly influence brain function, and can modulate pain perception to eventually lead to a situation of chronic pain. These findings are revealing the mechanisms underlying idiopathic pain, and also suggest that centrally acting modalities, such as antidepressants or cognitive behavioral therapy, might be effective to reduce these kinds of central pain.
In this paper, we explain theories of central pain amplification/modulation and elaborate on methods of effective pharmacotherapy that we have applied. The first-choice drug is amitriptyline, a tricyclic antidepressant (TCA), with an average dosage leading to complete pain relief of 80 mg/day. When pain is not relieved using TCAs alone, relief is more likely to be achieved with the addition of anti-psychotics, lithium carbonate or sodium valproate as augmentation therapy. These idiopathic pain disorders tend to recur, so maintenance therapy using a constant dosage of drugs for 6-12 months is critical.
Glossodynia and BMS are generally easier to cure than AO and AF. However, elderly patients with very refractory glossodynia show a greater risk of decreased cognitive ability or intelligence quotient (IQ). Such patients may deteriorate to a state of dementia within years. To clarify the goals of treatment in the first stage, evaluation of cognitive ability and IQ is important

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Purpose: The etiology of burning mouth syndrome (BMS) is not clearly understood and is classified as an idiopathic orofacial pain. The purpose of this article was to let readers to know research trend, currently proposed etiology and treatment recommendation based on available evidences from literature searching.
Study selection: PubMed (Online database, U.S. National Library of Medicine) was used to searching for related publication with burning mouth syndrome. From the extracted list from the searching with the key word “burning mouth syndrome”, reviews in last 5 years and recent published literatures were selected to summalize its epidemiology, etiology, pathophysiology, natural history and long-term prognosis. Also, definition, classification and diagnostic criteria of BMS proposed by international/ related academy were searched for additional review.
Results: 673 articles were extracted from 1967 to 2010 August with the key word of “burning mouth syndrome. Recent expert opinion of research readers in this field summalized that peripheral and central neuropathic mechanisms are involved in pathophysiology underlying BMS. For the management of BMS, 1 cochrane systematic review was extracted by serching, and medical management and cognitive behabioral therapy were recommended.
Conclusions: The growing concern about BMS during last decade was demonsrtated. The epidemiology, pathophysiology, natural history and long-term prognosis were not clearly understood because the etiology is not known and the acculate diagnostic criteria is lacking. Regarding to management of BMS, there is limited information, therefore, non harmful treatment should be selected based on available evidence. Further study is needed to demonstrate its pathophysiology and to provide effective and safe management for BMS patients.

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Patient: A 40-year-old woman visited our clinic with the chief complaint of pain in the left temple, jaw and back of neck and head. The orofacial pain started soon after her right mandibular third molar was extracted in 2002. She first came to our clinic in 2008.
The location and severity of the pain varied each day, and the patient was unable to sleep because of severe pain. Loxoprofen sodium did not alleviate the pain. Intraoral examination revealed generalized gingival inflammation and poor oral hygiene. The diagnosis was chronic periodontitis and atypical facial pain of the left side.
After she received general psychotherapy, the pain during daytime was reduced. The patient reported reduction of pain at night with the intake of rikkosan 2.5 g, and she was able to sleep. We then resumed her dental treatment, which had been stopped because of the orofacial pain. The pain recurred within a few days after dental treatment was started, but it subsided with the intake of rikkosan.
With dental treatment, the patient's intraoral condition recovered functionally and aesthetically within 14 months from the first visit.
Discussion: The etiopathogenesis of atypical facial pain remains unclear. Psychological and neurological factors may be responsible for atypical facial pain. In the present case, rikkosan seems to have acted on the neurological element of the pain. The local anesthetic-like action of rikkosan may have restricted the excitement of intraoral primary neurons, resulting in a reduction of the signals to the central nervous system and consequently alleviating pain.
Conclusion: In cases of atypical facial pain triggered by dental treatment, rikkosan seems to be useful for pain management.

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Patients: A 78-year-old woman complained of pain as paroxysmal electrical sparks on the left cheek. The pain was triggered by eating or speaking. She was given carbamazepine(CBZ) therapy 200 mg per day, which was later discontinued owing to side effects. On her first visit to our clinic, we prescribed zonisamide 100 mg per day; however, her pain was not relieved. Next month, she was hospitalized for stoke. For the next 2 years and 6 months, she had no pain. At her next visit to our clinic, we prescribed CBZ 100 mg per day, after which her pain was relieved significantly. Approximately 2 months later, her pain intensified. We raised the CBZ dose to 200 mg per day; however, the patient developed dizziness. Application of alternating current iontophoresis (AC IOP) relieved her pain. In addition to CBZ, she was also started on Kampo medicine (Rikkousan and Goreisan). Approximately 6 weeks later, her pain intensified again. We increased the CBZ dose to 280 mg per day and applied acupuncture treatment, following which her pain alleviated. Approximately 3 weeks later, her pain developed again. She underwent gamma knife therapy, but her pain was not relieved. Therefore, we continued to administer AC IOP, acupuncture treatment, and medication (CBZ and Kampo medicine), her pain was relieved about 2 months later.
Discussion: We often have difficulty in treating trigeminal neuralgia, when CBZ therapy produces side effects. We report a case of such a resistant patient who was successfully treated by using a combination of CBZ medication and other treatments (AC IOP, acupuncture treatment, and Kampo medicine).
Conclusion: The combination of AC IOP and acupuncture treatment may be a useful for the treatment of resistant trigeminal neuralgia.

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