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Probability diagnosis

Geographic tongue (migratory glossitis)

Atrophic glossitis

Trauma (bites, teeth, hot food/drink)

Aphthous ulceration

Herpes simplex virus (children)

Fissured tongue

Disorders not to be missed

Cancer

HIV

Pitfalls (often missed)

Anaemia: iron, vitamins B6 and B12, folate deficiency

Glossopharyngeal neuralgia

Lichen planus

Fissured tongue (rarely causes soreness)

Median rhomboid glossitis

Hand, foot, mouth infection

Beh├žet syndrome

Crohn disease

Coeliac disease

Masquerades checklist

Depression

Diabetes (Candida)

Drugs (mouthwashes, aspirin)

Anaemia (various)

Is the patient trying to tell me something?

Possible with glossodynia.

Key clinical features

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:

  • FBE

  • serum vitamin B12, folate and ferritin levels

  • swab and biopsy of a suspicious lesion.

Diagnostic tips

  • 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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