Painful Tongue

Differential Diagnosis

Common Diagnoses

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
DepapillationYesPossibleNoPossibleNo
White PlaqueNoPossibleNoNoNo
Localised PainNoNoYesNoYes
Pale MucosaeNoNoNoYesNo
RecurrentYesPossibleNoPossibleYes

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.

Published: 2nd August 2022 Updated: 10th April 2024

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Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.