Painful Tongue

Pain in the tongue is usually caused by something immediately apparent on examination, but there are a few less obvious causes. This is something much more likely to be seen by a dentist, but is not strictly dental and therefore a working knowledge of the symptom is firmly within the GP remit.

Published: 2nd August 2022 | Updated: 18th August 2022

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

GeographicCandidaTraumaAnaemiaAphthous Ulcer
White PlaqueNoPossibleNoNoNo
Localised PainNoNoYesNoYes
Pale MucosaeNoNoNoYesNo

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.