SYNDROME AND
HOMOEOPATHY
Dr. Rajneesh Kumar Sharma MD (Homoeopathy)
Burning mouth syndrome and Homoeopathy
Contents
Definition ....................................................................................................... 2
Etymology ...................................................................................................... 2
Incidence ....................................................................................................... 2
Causes .......................................................................................................... 2
Menopause .................................................................................................. 2
Autoimmunity ............................................................................................... 2
Psychogenic ................................................................................................. 2
Chronic low-grade trauma ................................................................................ 2
Parkinson's disease ......................................................................................... 2
Neurological................................................................................................. 2
Changes in the oral environment ........................................................................ 3
Infections .................................................................................................... 3
Allergic....................................................................................................... 3
Deficiency ................................................................................................... 3
Systemic illness ............................................................................................. 3
Other causes ................................................................................................ 4
Types ............................................................................................................ 4
Primary BMS ................................................................................................. 4
Secondary BMS .............................................................................................. 4
Type 1 ........................................................................................................ 4
Type 2 ........................................................................................................ 4
Type 3 ........................................................................................................ 4
Symptoms ...................................................................................................... 4
Diagnosis........................................................................................................ 5
Common tests............................................................................................... 5
Other tests .................................................................................................. 5
Definition
Burning mouth syndrome is a painful and often frustrating condition, characterized by burning
sensation in the tongue, roof of the mouth, gums, inside of the cheeks and back of the mouth
or throat, often accompanied by dry or sore mouth, tingling or numb sensation throughout the
mouth and tongue and altered taste or smell with no underlying dental or medical cause. (Psora)
Etymology
Synonyms: BMS, burning tongue (or lips) syndrome, scalded mouth syndrome, glossodynia and
stomatodynia
Incidence
Especially common in women during or after menopause.
Causes
The cause of burning mouth syndrome is unknown. Main theories are-
Menopause
As most people with BMS are postmenopausal women, estrogen or progesterone deficit may be
the cause. (Psora)
Autoimmunity
Autoimmunity may be another cause as abnormal antinuclear antibody and rheumatoid factor
can be found in the serum of more than 50% of persons with BMS. (Psora)
Psychogenic
Depression and anxiety are strongly associated with BMS. Cancerphobia, concern about sexually
transmitted infections, or hypochondriasis are often found to generate BMS. (Psora)
Parkinson's disease
BMS is common in persons with Parkinson's disease. (Syphilis)
Neurological
Often people with BMS have unusually raised taste sensitivity, termed hypergeusia (super
tasters). (Psora)
Dysgeusia, usually a bitter or metallic taste, is present in BMS, due to a defect in sensory
peripheral neural mechanisms. (Psora)
Infections
Oral candidiasis (Psora/ Syphilis)
Herpetic infection (Psora)
HIV (Psora/ Sycosis/ Syphilis)
Allergic
Allergic contact stomatitis to oral medications, oral agents and dental materials, foods, metals,
and other substances. (Psora/ Causa occasionalis)
Deficiency
Deficiency of iron, folic acid or various B vitamins or zinc (Psora)
Systemic illness
Hypothyroidism (Psora/ Syphilis)
Type 2 diabetes (Psora/ Syphilis)
Xerostomia, caused by hyposalivation e.g. Sjögren's syndrome (Psora/ Sycosis/ Syphilis)
Multiple myeloma (Psora/ Sycosis/ Syphilis)
Fissured/Glossitic/Mapped/Strawberry Tongues
Other causes
Medications like protease inhibitors and angiotensin-converting-enzyme inhibitors (Causa
occasionalis)
Geographic tongue (Psora)
Fissured tongue (Psora/ Syphilis)
Lichen planus (Psora/ Sycosis/ Syphilis)
Hiatus hernia (Psora/ Syphilis)
Types
Based on causes, BMS can been classified into two types-
Primary BMS
If are no identifiable causes for BMS. This is true BMS.
Secondary BMS
If there is an identifiable cause for a burning sensation. The term BMS is not a proper one to this
condition. (Psora)
Another criterion divides BMS into three categories-
Type 1
No symptoms on waking, but they increase throughout the day (Psora)
Type 2
Symptoms upon waking and run through the day (Psora)
Type 3
Bizarre pattern of symptoms (Psora)
Symptoms
Once burning mouth syndrome begins, it may persist for many years. The burning sensation grows
progressively worse during the day. There may be difficulty falling asleep. (Psora)
The discomfort and restlessness may cause mood changes, irritability, anxiety and depression.
(Psora) The main signs and symptoms are-
Usually bilaterally located on the tongue or less commonly the palate, lips or lower
alveolar mucosa
Pain is chronic, and rarely spontaneously remits
Burning, scalded or tingling. Sometimes the sensation is described as 'discomfort',
'tender', 'raw' and 'annoying' rather than pain or burning.
Subjective xerostomia, dysgeusia, thirst, headaches, chronic back pain, irritable bowel
syndrome, dysmenorrhea, globus pharyngis, anxiety, decreased appetite, depression and
personality disorders
Type 2 is the most common with pain upon waking and throughout day, less commonly
other patterns
Worse by tension, fatigue, speaking, and hot, acidic or spicy foods
Better by sleeping, cold, distraction, and alcohol.
The pain is often relieved by eating and drinking or mental diversion or occupation
Sleep may be unaltered, altered or even insomnia may occur
Diagnosis
A complete case taking with the simple and elimination of various possibilities may diagnose it.
A number of laboratory tests are done to exclude other diseases-
Common tests
Complete blood cell counts (CBC)
Erythrocyte Sedimentation rate (ESR)
Serum iron
Serum ferritin concentration
Iron binding capacity
The concentration of circulating folic acid, vit. B12, zinc, etc.
Blood glucose level
Serum estradiol levels in women
Other tests
Sialometry
Specific investigations of systemic diseases
Allergic epicutaneous tests
Fungal culture for the isolation of Candida species from oral mucosa
Differential diagnosis
Acoustic neuroma
Atypical facial pain
Atypical odontalgia
Denture design or tooth restoration failures
Herpes simplex or herpes zoster
Idiopathic facial arthromyalgia
Neoplastic lesions in the oral cavity
Pemphigoid, pemphigus
Stomatitis
Trauma to lingual or mandibular nerves after dental surgery
Treatment
Multidisciplinary approach including medical and psychosocial therapy may be effective in
symptom relief in patients with BMS. Relapse prevention with a clear understanding of specific
triggers, should be noted. Treatment may include psychotherapies as well as medical therapy.
nat-c. nat-f. Nat-m. Nat-s. Nit-ac. nux-m. nux-v. oena. op. ox-ac. petr. ph-ac. Phos. plat. plb.
Psor. Ran-b. rhus-t. rhus-v. ruta sabad. sal-ac. SANG. sec. seneg. Sep. spig. Spong. squil. staph.
stict. stram. Sul-ac. sul-i. Sulph. symph. tab. tarax. ter. tritic-vg. Verat. vesp. xan. zing.
MOUTH - PAIN - burnt; as if adon. all-c. allox. aloe alum. Am-br. ambr. Apis arg-n. arizon-l. ars.
bad. bamb-a. bar-c. BELL. berb. bov. calad. camph. caust. chin. chinin-ar. Cimx. cina coc-c.
cypra-eg. dios. ferr-m. glon. ham. Hydr. hyos. IRIS jac-c. jatr-c. kali-c. Laur. lyc. Mag-m. mand.
med. Merc-c. merc-i-r. merc. nat-c. op. phasco-ci. plat. psor. Puls. rhus-t. rhus-v. rumx. sabad.
sal-ac. sal-fr. sang. seneg. Sep. sin-n. stict. stram. sulfonam. syph. Tarent. Thuj. Verat-v. wye.
zinc.
MOUTH - PAIN - chewing agg. – burning ph-ac.
MOUTH - PAIN - chill; during – burning ars. cham. lach. mez. Petr. verat.
MOUTH - PAIN - cold - water - agg. – burning Ars. Bufo hir.
MOUTH - PAIN - cold - water - amel. – burning acon-f. berb. cham. dros. dulc. merc-c. ruta
MOUTH - PAIN - cold - water - not amel. – burning merc.
MOUTH - PAIN - dinner; after - burnt; as if alum. ham.
MOUTH - PAIN - eating - after - agg. – burning mez.
MOUTH - PAIN - eating - warm food agg. – burning bros-gau.
MOUTH - PAIN - eating - while - agg. – burning hir.
MOUTH - PAIN - eructations - after – burning kali-c.
MOUTH - PAIN - extending to - Anus – burning Iris
MOUTH - PAIN - extending to - Bronchi – burning ip.
MOUTH - PAIN - extending to - Stomach – burning aesc. am-c. am-caust. brom. chel. gels. gink-
b. iris iris-fl. Merc-c. Mez. nit-ac. sin-n. sul-ac.
MOUTH - PAIN - fever; during – burning ars. mez. Petr.
MOUTH - PAIN - Gums – burning act-sp. Alum. antip. Ars. asar. bell. bufo Caps. castm. Cham.
con. fuch. Graph. lyc. m-arct. mag-c. Merc-c. MERC. mez. mur-ac. Nat-s. nux-v. petr. ph-ac.
phos. Puls. rhus-t. sang. Sep. sil. stront-c. sulph. Ter. ther. THUJ.
MOUTH - PAIN - Gums - burnt; as if ars-met. ars. bell. Cimx. ign. merc. nat-s. nux-v. par. phos.
Sep.
MOUTH - PAIN - Gums - eating - while - agg. – burning mag-c. NAT-M.
MOUTH - PAIN - Gums - Inner – burning puls.
MOUTH - PAIN - Gums - Lower – burning petr.
MOUTH - PAIN - Gums - touch - tongue agg.; when touched by the – burning mag-c.
MOUTH - PAIN - Gums - warm - water - agg. – burning sil.
MOUTH - PAIN - inspiration agg. – burning mez. Phos.
MOUTH - PAIN - Lips - Corners - burnt; as if ant-c. arum-t. graph.
MOUTH - PAIN - Lips - Inner side of – burning calc-s. sacch-a.
MOUTH - PAIN - Lips - Inner side of - Lower – burning anis.
MOUTH - PAIN - Lips - Inner side of - Upper - burnt; as if bar-c.
MOUTH - PAIN - morning – burning am-br. ARUM-T. cupr-s. kali-c. sulph. symph.
MOUTH - PAIN - morning - burnt; as if Am-br. dios. mag-m. mez.
MOUTH - PAIN - morning - menses; during - burnt; as if mag-m.
MOUTH - PAIN - morning - waking; on - burnt; as if bov. nat-c.
MOUTH - PAIN - night – burning kola merc. nit-ac. sulph.
MOUTH - PAIN - Palate – burning Aesc. agro. All-c. ambr. ant-c. arizon-l. arn. Arum-t. arund.
bapt. Bell. benz-ac. Borx. calc. Camph. Canth. carb-v. Caust. Cimx. cina cinnb. coc-c. Cocc.
coloc. crot-t. cypra-eg. dulc. Euph. glon. Grat. gymno. hura-c. hydrog. ign. iris kola lac-h. lach.
laur. Mag-c. manc. merc-c. merc. Mez. mur-ac. naja Nat-s. Nit-ac. nux-m. Nux-v. Par. ph-ac.
Phos. plect. podo. polyg-h. Ran-b. rein. rheum sabad. sacch-a. Sang. sanic. seneg. sep. spig.
Squil. staph. Stram. sul-ac. ther. thuj. tritic-vg. zinc.
MOUTH - PAIN - Palate - burnt; as if arizon-l. arum-t. bar-c. bell. Borx. Calc. caust. cimx. cina
ferr-m. hydrog. iris lac-ac. lach. merc. mez. NIT-AC. nux-v. petr. Phos. phyt. podo. pycnop-sa.
sal-fr. sang. sanic. sep. tarent. verat.
MOUTH - PAIN - Palate - cough agg.; during – burning dig.
MOUTH - PAIN - Palate - evening and night – burning mur-ac.
MOUTH - PAIN - Palate - Hard palate – burning apis Camph. cann-s. canth. Carb-v. caust. cocc.
dulc. euph. ign. laur. mag-c. merc-c. merc. mez. mur-ac. nux-m. par. Ph-ac. phos. rhod. sabad.
Seneg. spig. Squil. staph. thuj.
MOUTH - PAIN - Palate - Hard palate - burnt; as if bar-c. cimic. sep. verat.
MOUTH - PAIN - Palate - menses - during - agg. – burning Nat-s.
MOUTH - PAIN - Palate - morning – burning ARUM-T. coca lyc.
MOUTH - PAIN - Palate - night - burnt; as if Calc.
MOUTH - PAIN - Palate - Soft palate – burning Bell. canth. Cham. nux-m. ran-b.
MOUTH - PAIN - Palate - Spots; in – burning mur-ac.
MOUTH - PAIN - Palate - Velum – burning Ambr. arg-n. Calc. Crot-c. Lach. nux-m. ph-ac. ran-b.
MOUTH - PAIN - Palate - warm drinks agg. – burning sanic.
MOUTH - PAIN - perspiration; during – burning apis ars. Cham. mez. Petr.
MOUTH - PAIN - swallowing; when not – burning ph-ac.
MOUTH - PAIN - Tongue - Across – burning asar. gink-b.
MOUTH - PAIN - Tongue - afternoon – burning mag-m. mag-s.
MOUTH - PAIN - Tongue - Anterior part – burning chir-fl. Coloc. gamb.
MOUTH - PAIN - Tongue - Anterior part - burnt; as if rumx.
MOUTH - PAIN - Tongue – burning acet-ac. achy-a. ACON. adon. aesc. all-c. alum. alumn. am-c.
am-caust. Am-m. ang. Apis arg-met. arg-n. arizon-l. arn. Ars-i. ars-s-f. ARS. Arum-m. ARUM-T.
asar. aur-ar. aur-i. Aur. bad. Bapt. Bar-c. bar-i. bar-s. bell-p. Bell. benz-ac. berb. Bov. bry. calc-
i. calc-p. Calc-s. Calc. Canth. caps. carb-ac. Carb-an. Carb-v. Carbn-s. castm. Caust. cedr.
Cham. chel. chim. CHIN. chinin-ar. chir-fl. chlor. chord-umb. Cimx. coc-c. cocc. coch. coff.
Colch. Coloc. colum-p. con. croc. crot-t. cupr. dios. Dros. dulc. dys. Echi. eos. ferr-ar. ferr-i.
ferr-p. ferr. gamb. gels. glon. graph. ham. hep. Hydr. hyos. ign. indg. iod. Ip. irid-met. IRIS jac-
c. jatr-c. Kali-ar. kali-bi. kali-c. kali-chl. kali-i. kali-m. kali-p. kali-s. kola lac-ac. lac-f. Lach.
lap-la. Laur. led. Lyc. m-ambo. mag-c. Mag-m. manc. mand. Mang. Merc-c. merc-sul. Merc. Merl.
Mez. morg-g. morg-p. mur-ac. naja nat-c. nat-m. nat-s. nat-sil. nit-s-d. ol-an. olnd. op. Ox-ac.
pall. petr. ph-ac. phel. Phos. Phys. Phyt. Plat. plb. Podo. prun. Psor. ptel. puls. Ran-s. raph.
rat. rhod. rhus-t. rhus-v. rumx. ruta Sabad. Sang. sanic. sars. sec. seneg. Sep. sin-n. spig. spong.
stram. Sul-ac. sul-i. Sulph. syph. tarax. Ter. ther. thuj. tritic-vg. VERAT-V. verat. vesp. vip. xan.
zinc-p. zinc.
MOUTH - PAIN - Tongue - burnt; as if adon. aesc. agar. all-c. alum. am-br. am-m. apis Arg-n.
arizon-l. arn. ARS. arum-t. asar. bad. bamb-a. bapt. bar-c. Bell. bit-ar. bov. cact. calc. caps.
carb-v. Caust. chin. chlor. Cimx. colch. Coloc. conv. cund. cupr-s. daph. dios. dys. ferr. glon.
Ham. hep. hydr. hyos. ign. Iris kali-c. kreos. lac-ac. lach. Laur. lavand-a. Lyc. Mag-m. merc-i-r.
Merc. Mez. morg-p. nat-m. Nux-v. ol-an. oncor-t. petr. ph-ac. Phos. phys. Phyt. Plat. plb. podo.
positr. prun. psor. ptel. Puls. ran-s. rhod. rhus-t. Rhus-v. Rumx. sabad. Sang. seneg. sep. sil.
sin-n. sul-ac. symph. term-c. ther. tub. VERAT-V. verat.
MOUTH - PAIN - Tongue - Center – burning arizon-l. bar-c. bry. ferr. ozone Puls. ter.
MOUTH - PAIN - Tongue - Center - burnt; as if arizon-l. chin. hyos. plat. psor. puls. sabad. sep.
ter.
MOUTH - PAIN - Tongue - Center - spot toward tip – burning kali-ar.
MOUTH - PAIN - Tongue - daytime – burning olib-sac.
MOUTH - PAIN - Tongue - eating - after - agg. – burning chir-fl. graph. laur.
MOUTH - PAIN - Tongue - eating - agg. – burning bell-p.
MOUTH - PAIN - Tongue - eating - not eating or drinking agg.; when - burnt; as if ferr.
MOUTH - PAIN - Tongue - eating - while - agg. – burning Ign. Nat-m.
MOUTH - PAIN - Tongue - eating - while - agg. - burnt; as if ign.
MOUTH - PAIN - Tongue - evening – burning alum. cycl. dulc. kali-n.
MOUTH - PAIN - Tongue - extending to - Mouth – burning tub.
MOUTH - PAIN - Tongue - extending to - Palate – burning phos.
MOUTH - PAIN - Tongue - extending to - Stomach – burning apis ars. brom. gels. Mez. puls.
MOUTH - PAIN - Tongue - fissures in – burning mag-m.
MOUTH - PAIN - Tongue - left side – burning chir-fl. iris jac-c. tarax.
MOUTH - PAIN - Tongue - morning – burning am-br. ham. Mag-m. nat-sil. ozone stann. sulph.
tritic-vg.
MOUTH - PAIN - Tongue - morning - burnt; as if bamb-a. mez. nat-c.
MOUTH - PAIN - Tongue - night – burning nat-m. ph-ac. Phos.
MOUTH - PAIN - Tongue - one side – burning Calc.
MOUTH - PAIN - Tongue - Posterior part - burnt; as if phyt.
MOUTH - PAIN - Tongue - protrudes it to cool it – burning irid-met. sanic.
MOUTH - PAIN - Tongue - Root of – burning am-caust. ARUM-T. bapt. benz-ac. Calc-p. Crot-c.
manc. med. tritic-vg.
MOUTH - PAIN - Tongue - Root of - right – burning phos.
MOUTH - PAIN - Tongue - salt agg. – burning Nat-m. petr. spong.
MOUTH - PAIN - Tongue - Sides – burning acon. agar. apis Camph. caust. chir-fl. cycl. ephe-si.
kali-i. mag-c. mur-ac. nat-s. phel. plat. tritic-vg. vip.
MOUTH - PAIN - Tongue - Sides - burnt; as if ant-c. apis canth. caust. dios. puls. spong. sulfonam.
MOUTH - PAIN - Tongue - Sides - left – burning chir-fl. Lach. nat-s. ox-ac.
MOUTH - PAIN - Tongue - Sides - right – burning phos.
MOUTH - PAIN - Tongue - smoking agg. - burnt; as if sep.
MOUTH - PAIN - Tongue - sour food, from – burning petr.
MOUTH - PAIN - Tongue - Spots; in – burning act-sp. Ars. indg. kali-i. ph-ac. ran-s.
MOUTH - PAIN - Tongue - Spots; in - burnt; as if aloe Ars.
MOUTH - PAIN - Tongue - stitching pain – burning androc. Chin.
MOUTH - PAIN - Tongue - Surface of tongue; under – burning aur-m-n. brom. bros-gau.
MOUTH - PAIN - Tongue - talking agg. – burning bell-p.
MOUTH - PAIN - Tongue - Tip – burning Acon. agar. alum. am-c. am-m. arg-met. arg-n. Ars. aur.
bamb-a. bapt. Bar-c. bell. borx. bov. calc-ar. CALC-P. Calc. Camph. caps. carb-ac. Carb-an.
carb-v. carc. castor-eq. caust. chin-b. chir-fl. coff. Coloc. croc. crot-c. cycl. Dros. galla-q-r.
gamb. ger. glon. haliae-lc. hep. hydr-ac. indg. iod. Iris kali-bi. Kali-c. Kali-i. kali-n. kola lact.
lath. laur. led. merc-sul. merc. mez. Nat-c. Nat-m. NAT-S. nat-sil. ox-ac. ozone Phos. Phys.
Phyt. plb. propr. psor. ran-b. rat. rhus-t. ruta Sabad. sacch-a. sang. sel. seneg. sul-ac. sulfonam.
sulph. ter. Thuj. tritic-vg. tub. vip.
MOUTH - PAIN - Tongue - Tip - burnt; as if am-br. am-c. bit-ar. calc-p. calc. caps. carb-v. caust.
chin-b. chin. chir-fl. coloc. ham. hep. ign. kali-c. kola lact. lavand-a. merc-sul. mez. nat-s. Phos.
phys. positr. Psor. sabad. sang. Sep. staph. stront-c. ter. thuj. vip.
MOUTH - PAIN - Tongue - Tip - daytime – burning bamb-a.
MOUTH - PAIN - Tongue - Tip - evening – burning cycl.
MOUTH - PAIN - Tongue - Tip - night – burning hep.
MOUTH - PAIN - Tongue - Tip - touch agg. – burning am-c. bar-c. bell. kola nit-ac.
MOUTH - PAIN - Tongue - Tip - waking; on – burning bros-gau. nat-m.
MOUTH - PAIN - touch agg. – burning nat-c.
MOUTH - PRICKLING - Tongue - scalded; as if chir-fl.
MOUTH - SALIVA – burning manc.
MOUTH - SALIVATION - accompanied by - burning pain nat-f.
MOUTH - TASTE - bitter – burning ambr. berb. op.
MOUTH - TASTE – burning all-c. allox. am-c. crot-t. kali-chl. mez. morg-p. osm. ox-ac. pimp.
sabad.
MOUTH - TASTE – burnt ars. berb. bry. calad. chinin-s. cycl. kali-chl. laur. nat-c. Nux-v. ph-ac.
podo. PULS. ran-b. sabad. sal-ac. sars. squil. Sulph. thuj.
MOUTH - TASTE - milky - burnt, like mez. tab.
MOUTH - TASTE - sweetish - followed by - bitter taste - burning and cadm-s.
Bibliography
Encyclopedia Homoeopathica
Radar 10
Disorders of Smell and Taste > DISORDERS OF TASTE Harrison's Principles of Internal
Medicine, 20e... On rare occasions, migraine (Chap. 422) is associated with a gustatory prodrome
or aura, and in some cases tastants can trigger a migraine attack. Interestingly, dysgeusia occurs
in some cases of burning mouth syndrome (also termed glossodynia or glossalgia...
Oral Manifestations of Disease > NONDENTAL CAUSES OF ORAL PAIN Harrison's Principles
of Internal Medicine, 20e.. thyroiditis.. and transient hyperthyroidism are appreciated. “Burning
mouth syndrome” (glossodynia (e.g., vitamin B 12 deficiency, Fe deficiency, diabetes mellitus...
Chapter 12. Disorders of Smell and Taste > Burning Mouth Syndrome Adams & Victor's
Principles of Neurology, 10e... Another poorly defined disorder is the burning mouth syndrome
, which occurs mainly in postmenopausal women and is characterized by persistent, severe
intraoral pain (particularly of the tongue). We have seen what we believe to be fragmentary
forms of the syndrome in which pain and burning...
Chapter 76. Biology and Pathology of the Oral Cavity > Burning Mouth Syndrome
Fitzpatrick's Dermatology in General Medicine, 8e... Burning symptoms in the mouth
(stomatodynia, stomatopyrosis) may be primary or secondary in nature. Secondary burning
mouth syndrome (BMS) presents as pain, sensitivity, and burning of the oral mucosa secondary
to oral LP, atrophic glossitis from hematinic deficiency, migratory glossitis...
Ear, Nose, & Throat Disorders > GLOSSITIS, GLOSSODYNIA, DYSGEUSIA, & BURNING MOUTH
SYNDROME Current Medical Diagnosis & Treatment 2019The burning mouth syndrome typically
has no identifiable associated risk factors and seems to be most common...
Ear, Nose, & Throat Disorders > GLOSSITIS, GLOSSODYNIA, DYSGEUSIA, & BURNING MOUTH
SYNDROME Current Medical Diagnosis & Treatment 2018... mouth syndrome.” Glossodynia with
glossitis has been associated with diabetes mellitus, drugs (eg, diuretics), tobacco, xerostomia,
and candidiasis as well as the listed causes of glossitis. The burning mouth syndrome typically
has no identifiable associated risk factors and seems to be most common...