This course was published in the May 2022 issue and expires May 2025. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Explain postural orthostatic tachycardia syndrome (POTS) and its etiologies, symptoms and sequela.
- Describe care strategies for this patient cohort, the oral implications of POTS, and the dental team’s role in treatment.
- Discuss specific considerations for anesthesia in this population and patient movement/transfer to and from the dental chair.
Postural orthostatic tachycardia syndrome (POTS) causes lightheadedness, fainting, and a rapid increase in heartbeat. These symptoms arise when standing up from a reclining position and are relieved by sitting or lying back down. It is an autonomic instability occurring during postural changes and has been reported to affect 1% of all teens, and possibly as many as 3 million Americans.1–3 This hemodynamic dysregulation results in insufficient cerebral perfusion, leaving affected individuals with migraine headaches, palpations, fatigue, memory issues, nausea, dizziness, and pallor due to vascular vasoconstriction and blood pooling in the lower extremities.2,4
This syndrome has come to the attention of the medical community due to recent reporting as a potential autoimmune disease,1 but its presentation is quite limited in the dental literature. Even less clearly understood and underrepresented are POTS’ oral implications of xerostomia, refractory periodontitis, dysgeusia, and burning mouth symptoms.3 Effective management thus requires a multidisciplinary approach. In addition to managing oral symptoms, the dentist can spearhead medical, pharmacologic and dietary consultations for these patients, and provide palliative care. This paper will report on a patient with a history of POTS and oral burning sensations, with limited resolution of oral symptoms — possibly due to a high salt diet prescribed as part of POTS management.
A 34-year-old female presented to the clinic at Midwestern University College of Dental Medicine, Arizona, in spring 2021 with a chief complaint of a lingering, painful burning sensation — primarily after eating — on the tongue, and, occasionally, anterior palate. These symptoms had been present sporadically for approximately 10 years, and although she had consulted with several physicians and dentists, there had been no definitive diagnosis.
Nystatin had been prescribed in the past by the patient’s physician to rule out candidiasis. She continued to complain of the same burning sensations after eating, with no resolution. Clinical examination revealed fissuring on the lingual dorsum, with multiple erythemic atrophic patches on the anterior and lateral borders of the tongue (Figure 1). In addition, there was inflammation and a history of burning symptoms of the palatal rugae and incisive papilla (Figure 2). The patient indicated she had many “difficult to diagnose” medical symptoms in early childhood.
Her medical history was significant, including a functional heart murmur and fibromyalgia diagnosed at age 14. In addition, after many years of fainting and migraine headaches, she was diagnosed with POTS at age 23. The patient reported an unknown etiology for POTS, while exhibiting lowered blood pressure and higher heart rate upon standing. In the literature, POTS has been associated with post-viral infections, but the patient denied a history of Epstein-Barr or mononucleosis infection.1 At age 27, she began treatment for gastroesophageal reflux disease, which has been related in the literature to burning mouth syndrome (BMS) and osteoarthritis. Her current medications included fludrocortisone 0.1mg tablet, midodrine HCL 5 mg tablet, metoprolol succinate ER 25 mg tablet, and omeprazole 20 mg. Though several of the medications are known to cause xerostomia, the patient reported only mild or early symptoms.
Anaphylactic allergies were present to penicillin and sulfonamide antibiotics, sumatriptan and codeine. It has been noted that over 15% of those with POTS have multiple allergies to medications.3 The patient had routine childhood vaccinations, but denied having received the human papillomavirus vaccine as an adolescent or adult, though some research has pointed to a correlation of cases of POTS arising after such immunizations.5 Diet, food allergies, dental products, and stress levels were discussed with the patient. The only known food allergy was red onions. The patient was instructed to keep a food diary for a month to see if there were certain foods known to irritate geographic tongue and contribute to burning mouth symptoms, such as strawberries, citrus or cinnamon.
Additionally, gluten was removed from the diet for two weeks to determine a possible underlying gluten intolerance. After two weeks, the patient stated that the burning sensations were about the same; however, symptoms notably increased when table salt was increased in the diet. Conversely, there was a significant decrease in the burning sensations with less salty foods. Individuals diagnosed with POTS, including this patient, are oftentimes managed with a high sodium diet meant to increase blood plasma volume.6 Unfortunately, as was the case with this patient, these individuals may be advised to continue a high salt diet and may therefore exhibit pronounced and persistent oral complications.
The clinical diagnosis was symptomatic benign migratory glossitis (geographic tongue), with burning mouth symptoms contributory from the patient’s history of POTS. The patient preferred a conservative approach that would not treat with oral steroids or other medications at this time. Even though the burning sensations were not notably decreased, the patient was pleased to finally receive a diagnosis and understand the contributory factors.
Considered a debilitating disease, POTS is often associated with myriad symptoms, sequela and comorbidities, such as Raynaud’s syndrome,4 mitral valve prolapse, Ehlers-Danlos syndrome,3 fibromyalgia, B12 deficiencies and Sjogren’s syndrome, with contradictory treatments and uncertain prognosis. It has been reported to be triggered by post-viral infections, such as COVID-191 or Epstein-Barr, with resultant mononucleosis and chronic fatigue syndrome.1,3 Trauma or surgery, as well as hormonal changes in adolescence and pregnancy, have also been implicated.2
Reports place onset at a mean age of 29 years and the condition primarily affects females by a 6:1 ratio.3 While POTS is considered a common syndrome in both children and adults, according to the nonprofit Stand Up to POTS (standinguptopots.org), 80% of patients have been misdiagnosed. The Dysautonomia International Organization (dysautonomiainternational.org) reports that it can take an average of nearly six years to be correctly diagnosed.
The patient in this case report also communicated the frustration of being told for many years that symptoms were “all in your head.” In fact, POTS has often been assigned to psychiatric conditions rather than dysautonomic, with many patients treated for depression and anxiety.2,3 According to Stand Up To POTS, less than 20% of adolescents outgrow POTS symptoms in 10 years, 50% recover completely after five years if the disease is brought on by viral infection, while those with a familial form of primary hyperadrenergic POTS may face lifelong challenges, with no resolution.
The condition has been considered a dysautonomic orthostatic intolerance. It is diagnosed by qualitative responses of tachycardia, with a positive tilt table test4 or a standing test with an increased heart rate of > 30 bpm within 10 minutes of standing,2,7 or an increase in serum norepinephrine levels > 600 pg/ml when standing upright.4 Recent research by Gunning et al1 has associated POTS with elevated cytokines and chemokines often characteristic of autoimmune diseases, thereby linking these results to a potential biomarker for the diagnosis of this syndrome with a blood test in the future.
ISSUES AFFECTING DENTAL TREATMENT
There are myriad systemic issues encountered with POTS that may affect dental treatment. Oral health professionals should be aware of inherent capillary fragility resulting in the risk of bleeding and poor wound healing,7 as well as heart murmurs and possible mitral valve regurgitation (with the need for antibiotic premedication if advised by the patient’s cardiologist). Affected patients may also experience tachycardia with epinephrine, shorter anesthetic duration, prolonged hypotension during sedation,2,7 severe dental anxieties, sleep disturbances, and syncope with even mild positional changes in the dental chair.3
A multidisciplinary approach for medical consultations with cardiologists and physicians is recommended for dental teams treating patients either diagnosed with POTS or exhibiting POTS-associated symptoms. Prior to prescribing medications, dentists are advised to perform a medication review with the pharmacist, as drug allergies are present in an unusually high percentage of these individuals.3 Managing dental anxiety and panic disorders may best be handled in consultation with the psychiatrist or physician, and dental providers should seek approval for use of nitrous oxide and/or oral anxiolytic medications prior to treatment.2,7 Limiting or avoiding local anesthetics with epinephrine, and constant intraoperative monitoring of blood pressure and heart rate are advised. When treating these patients, Momota et al2 recommend the addition of a heart rate variability monitor to analyze variations in the intervals between consecutive heartbeats during dental care to better maintain healthy homeostasis.
Orthostatic symptoms are exacerbated with dehydration, so increased fluid intake is advised prior to dental treatment. Since many of these patients exhibit “brain fog” or difficulty concentrating, providing written directions and postoperative instructions may be helpful.3 Most importantly, avoid rapid changes in the patient’s posture during treatment in the dental operatory. Following care, a slow, careful movement of the patient from a supine position in the dental chair may prevent syncope and medical emergencies.2,3
BURNING MOUTH and INDIVIDUALIZED CARE
Because oral symptoms vary in this group, the management for individuals with BMS or burning sensations should be customized for each patient. Described as a chronic orofacial pain disorder,8 BMS has no specific diagnostic tests and is characterized by a persistent burning sensation of the oral cavity in the absence of oral lesions, erosions, erythema or mucosal atrophy. As with the patient in this case report, benign migratory glossitis is often associated with BMS. The burning sensation is described as spontaneous and symmetrical, with fluctuations in severity. The symptoms are typically less severe in the morning and worsen as the day progresses, with maximum intensity in the afternoon/early evening. That noted, it is not normally reported to occur at night.8
The most common location of BMS is the anterior two-thirds and lateral border of the tongue, thus, terminologies such as glossodynia (“painful tongue”) or glossopyrosis (“burning tongue”) have been used. Other oral sites may also be affected, such as the hard palate, gingiva, lower lips and pharynx. Burning sensations may have accompanying symptoms, including xerostomia, taste alteration, sleep problems, and psychological disorders.9
In the general population, BMS is most prevalent among middle-aged and older individuals, with marked predilection for women (by a 3:1 margin). It rarely occurs in individuals younger than 30, and cases in children or adolescents have not been reported.8 Patients with POTS and BMS may be the exceptions to these findings. A thorough oral examination is essential, and parameters of the burning sensation should be carefully documented. Clinicians should note onset, severity, location, duration, and exacerbating/relieving factors, as well as other accompanying oral habits, such as tongue thrust or bruxism, and symptoms such as xerostomia, paresthesia and taste alteration. A complete medical, dental and psychological history is recommended to determine underlying systemic diseases with symptoms similar to BMS, such as candidiasis, herpes simplex 1, diabetes, hypothyroidism, Sjogren’s syndrome, and B-vitamin deficiencies.8
Though no definitive cause has been found, neurological research has shown that patients with BMS often present with mild dysautonomia, which include conditions such as POTS and Parkinson’s disorder.10 Several studies have suggested that since fungiform papillae on the tongue are responsible for taste, a higher density of these taste buds is present in many patients exhibiting BMS. This patient population, known as “supertasters,” has an increased number of fungiform papillae and the ability to recognize the bitter taste of a substance called 6-n-propylthiouracil (or PROP).
The fact that many individuals with BMS are supertasters, together with the presence of taste alteration, suggest a possible connection between the sense of taste and oral discomfort.8 It has also been hypothesized that hypofunction of the chorda tympani nerve is responsible for the taste alteration and affects the central inhibition mechanism. This leads to hyperactivity of the trigeminal nociceptive pathway, eventually resulting in a more intense sensory response.9 Other research postulates that salivary composition is altered in individuals with BMS, as these patients show a significant increase in sodium, with low molecular proteins and immunoglobulins. These alterations in taste perception are thought to be another possible cause for the burning sensations noted primarily on the tongue.8
In dietetic counseling for those with POTS, patients may be advised to increase salt intake (recommended at 10 to 20 grams per day)3,6 to improve venous return.6 The recommendation of additional salt in the diet comes with the understanding the fungiform papillae involved in taste may be altered and susceptible to burning mouth pain, as noted in the literature and also seen in this case report.8 Affected patients should be advised to avoid food that contain nitrates, such as ham or bacon, and over-the-counter herbs and supplements, such as garlic or ginseng, which may affect blood pressure. As part of efforts to relieve BMS symptoms, patients should limit tobacco, cinnamon, acidic foods, coffee, tea and alcohol.3
Palliative treatment for patients experiencing POTS and/or BMS may include proper hydration. For example, patients with POTS should drink a minimum of 1 liter of water per day to maintain homeostasis.6 Dehydration is detrimental to orthostatic stability7 and encourages xerostomia, which has been reported as a concomitant symptom in 30% to 60% of patients with BMS.8 Such burning sensations are often treated with antidepressants, antipsychotics, antiepileptics, analgesics, and prescription or over-the-counter oral mucosa protectors. Low-dose tricyclic antidepressants, such as amitriptyline and nortriptyline, are found to be effective in reducing oral pain, but should be avoided in patients with xerostomia, as their side effects can cause symptoms to worsen.9
Likewise, patients diagnosed with POTS are regularly prescribed antidepressant and antihypertensive medications, which also have a direct medication-induced relationship to xerostomia.3 Oral health professionals should consider recommending topical fluorides due to elevated caries risk with xerostomia, and to advise patients to avoid dental products containing alcohol or sodium lauryl sulfate (a surfactant added to toothpaste), since it is a known epithelial irritant.9
Another conservative palliative treatment for burning mouth symptoms is topical capsaicin therapy, but many patients find the taste intolerable. If the burning sensation is affecting daily quality of life, or if the patient is unable to eat, topical anesthetics or topical corticosteroids, appropriate mouthrinses, or antihistamines may also be prescribed.8
While POTS is a known entity in the medical community, oral health professionals should also be familiar with the signs and symptoms of this complicated syndrome. Dental treatment adaptations are advised for this patient population, such as limited use of epinephrine, consulting with physicians and pharmacists, and being aware of the possibility of syncope and dental anxiety. In addition, it is incumbent upon providers to be current with their understanding of related oral conditions — including xerostomia, symptomatic migratory glossitis, and burning mouth symptoms — as they may be found in conjunction with POTS among this patient cohort.
ACKNOWLEDGMENT: This report was approved by the Midwestern University Office of Research and Sponsored Programs Institutional Review Board AZCS-169.
- Gunning WT 3rd, Stepkowski SM, Kramer PM, Karabin BL, Grubb BP. Inflammatory biomarkers in postural orthostatic tachycardia syndrome with elevated G-protein-coupled receptor autoantibodies. J Clin Med. 2021;10:623.
- Momota Y, Tomioka S, Otsuka R, Shioguri D, Takano H, Azuma M. Well-managed postural orthostatic tachycardia syndrome during dental therapy and analysis of heart rate variability: A case report. IOSR-JDMS. 2015;14:23–26.
- Brooks JK, Francis LA. Postural orthostatic tachycardia syndrome: Dental treatment considerations. J Am Dent Assoc. 2006;137:488–493.
- Landero J. Postural orthostatic tachycardia syndrome: a dermatologic perspective and successful treatment with losartan. J Clin Aesthet Dermatol. 2014;7:41–47.
- Jorgensen L, Gotzsche PC, Jefferson T. Benefits and harms of the human papillomavirus (HPV) vaccines: systematic review with meta-analyses of trial data from clinical study reports. Syst Rev. 2020;9:43.
- Garland EM, Gamboa A, Nwazue VC, et al. Effect of high dietary sodium intake in patients with postural tachycardia syndrome. J Am Coll Cardiol. 2021;77:2174–2184.
- Ruzieh M, Dziuba M, Hofmann JP, Grubb BP. Surgical and dental considerations in patients with postural tachycardia syndrome. Auton Neurosci. 2018;215:119–120.
- Lopez-Jornet P, Camacho-Alonso F, Andujar-Mateos P, Sanchez-Siles M, Gomez-Garcia F. Burning mouth syndrome: An update. Med Oral Patol Oral Cir Bucal. 2010;15:e562–e568.
- Tan HL, Renton, T. Burning mouth syndrome: An update. Cephalalgia. 2020;3:1–18.
- Koszewicz M, Mendak M, Konopka T, Koziorowska-Gawron E, Budrewicz S. The characteristics of autonomic nervous system disorders in burning mouth syndrome and Parkinson disease. J Orofac Pain. 2012;26:315–320.
From Decisions in Dentistry. May 2022;8(5)30-33.