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INTRODUCTION

The causes of a sore or painful tongue are similar to those of a sore mouth or throat. The cause is usually obvious upon examination but there are some obscure causes. Investigations may include an FBE, serum vitamin B12, folate and ferritin, a swab or a biopsy of a suspicious lesion.

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Table T5 Sore tongue: diagnostic strategy model
  • Probability diagnosis

  • Geographical tongue

  • Candidiasis

  • Trauma (bites, teeth, hot food/drink)

  • Aphthous ulceration

  • Herpes simplex (children)

  • Disorders not to be missed

  • Carcinoma

  • HIV

  • Agranulocytosis

  • Pitfalls (often missed)

  • Anaemia: iron, B6, B12, folate deficiency

  • Glossopharyngeal neuralgia

  • Lichen planus

  • Fissured tongue (rarely causes soreness)

  • Median rhomboid glossitis

  • Crohn and coeliac disease

  • Behçet syndrome

  • Masquerades

  • Depression

  • Diabetes (Candida)

  • Drugs (mouthwashes, aspirin)

  • Anaemia (various)

  • Is the patient trying to tell me something?

  • Possible with glossodynia

Tongue tips

  • Look for evidence of trauma, esp. from a sharp tooth

  • A miserable child with a painful mouth and tongue is likely to have acute primary herpetic gingivostomatitis

  • In your history take note of self-medications, esp. sucking aspirin, a history of skin lesions (e.g. lichen planus) and consider underlying diabetes or immunosuppression

  • A long history of soreness with spicy or other foods indicates benign migratory glossitis (geographical tongue) or median rhomboid glossitis

  • Any non-healing or chronic ulcer requires urgent referral

  • Glossodynia (painful tongue) characteristically presents as burning pain on the tip of the tongue—it can be a real ‘heartsink’ presentation; consider depressive illness as an underlying cause

  • Macroglossia (large tongue): consider acromegaly, myxoedema, amyloidosis, lymphangioma

  • Strawberry tongue: consider scarlet fever, Kawasaki disease

ERYTHEMA MIGRANS

Geographical tongue, image 269

BLACK OR HAIRY TONGUE

This causes bad tastes and a malodorous oral cavity. Basically a harmless condition that can be related to smoking, poor oral hygiene or use of antibiotics.

Treatment

  • Brush with toothbrush using sodium bicarbonate paste or

  • Suck fresh pineapple pieces: cut a thin slice into eight segments—slowly suck a segment on the back of the tongue for 40 secs, then slowly chew it

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