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Probability diagnosis

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Geographic tongue (migratory glossitis)

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Atrophic glossitis

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Trauma (bites, teeth, hot food/drink)

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Aphthous ulceration

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Herpes simplex virus (children)

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Fissured tongue

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Disorders not to be missed

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Cancer

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HIV

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Pitfalls (often missed)

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Anaemia: iron, vitamins B6 and B12, folate deficiency

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Glossopharyngeal neuralgia

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Lichen planus

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Fissured tongue (rarely causes soreness)

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Median rhomboid glossitis

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Hand, foot, mouth infection

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Beh├žet syndrome

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Crohn disease

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Coeliac disease

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Masquerades checklist

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Depression

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Diabetes (Candida)

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Drugs (mouthwashes, aspirin)

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Anaemia (various)

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Is the patient trying to tell me something?

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Possible with glossodynia.

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Key clinical features

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Enquire about trauma, dental problems, nutrition, drugs and associated general symptoms. The cause is usually obvious upon examination but there are some obscure cancers. The causes are similar to that of a sore throat or mouth. Investigation may include:

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  • FBE

  • serum vitamin B12, folate and ferritin levels

  • swab and biopsy of a suspicious lesion.

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Diagnostic tips

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  • Look for evidence of trauma, especially from a sharp tooth or dentures.

  • When taking a history, take note of self-medications, especially sucking aspirin, a history of skin lesions (e.g. lichen planus) and consider underlying diabetes or other immunosuppression.

  • Any non-healing or chronic ulcer requires urgent referral.

  • Glossodynia (painful tongue) characteristically presents with a burning pain on the tip of the tongue, without physical signs.

  • Consider depressive illness as an underlying cause.

  • Shared care with a dental or oral medical specialist is important.

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