Key distinguishing features of the most common diagnoses
Possible:Vitamin B12, folate and ferritin assays, swab.
- FBC initially to screen for anaemia.
- Vitamin B12, folate and ferritin assays: If indicated by FBC.
- Swab of tongue may be helpful if appearance not obviously candidal.
- Biopsy of suspicious lesion to determine diagnosis (especially if possible carcinoma or pemphigus).
- Take note of self-medication. Aspirin sucked for toothache can cause a mucosal burn.
- A long history of soreness with spicy or bitter foods suggests geographic tongue or median rhomboid glossitis.
- A miserable, mildly febrile child with a painful tongue caused by numerous ulcers is likely to have a viral infection such as herpes simplex or hand, foot and mouth disease.
- Check the skin for other lesions in obscure cases – this may reveal the diagnosis (e.g. pemphigus, lichen planus).
- Patients with recurrent aphthous ulcers often erroneously believe they are deficient in vitamins – broach this concern with them.
- If an ulcer in an adult fails to heal within a few weeks of presentation, refer urgently (though most oral neoplastic lesions are initially painless).
- The border of geographic tongue changes shape within weeks. This is not the case with more serious pathology.
- In candidal infections without an obvious cause, consider underlying diabetes or immunosuppression.
- Glossodynia characteristically produces burning pain on the tip of the tongue – a ‘burner’ is a dentist’s heartsink and the symptom may signify underlying depression.