Painful Tongue
Differential Diagnosis
Common Diagnoses
- Geographic Tongue (benign Migratory Glossitis): Painful in some Cases
- Candidal Infection (e.g. Post-Antibiotic, Steroids and Uncontrolled Diabetes)
- Trauma (Bitten, Burnt from Hot Food or Drink)
- Anaemia: Iron, Vitamins B6 and B12, and Folate Deficiency
- Aphthous Ulceration
Occasional Diagnoses
- Viral Infection (e.g. Herpes Simplex, Hand, Foot and Mouth)
- Median Rhomboid Glossitis (Superficial Midline Glossitis)
- Burning Mouth Syndrome (Also Known as Glossodynia)
- Fissured Tongue (Doesn’t Commonly Cause Pain)
- Glossopharyngeal Neuralgia
- Lichen Planus
Rare Diagnoses
- Carcinoma of the Tongue
- Behçet’s Disease
- Pemphigus Vulgaris
- Drugs (e.g. Mouthwashes, Aspirin Burns)
- Moeller’s Glossitis
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Geographic | Candida | Trauma | Anaemia | Aphthous Ulcer | |
|---|---|---|---|---|---|
| Depapillation | Yes | Possible | No | Possible | No |
| White Plaque | No | Possible | No | No | No |
| Localised Pain | No | No | Yes | No | Yes |
| Pale Mucosae | No | No | No | Yes | No |
| Recurrent | Yes | Possible | No | Possible | Yes |
Possible Investigations
Likely:FBC.
Possible:Vitamin B12, folate and ferritin assays, swab.
Small Print:Biopsy.
- 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).
Top Tips
- 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.
Red Flags
- 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.