What causes a sore tongue and how is it treated?

Causes and Treatment of Sore Tongue

A sore tongue can result from multiple conditions including burning mouth syndrome, geographic tongue, nutritional deficiencies, infections, or local irritation, with treatment directed at the underlying cause through topical agents, systemic medications, or dietary modifications depending on the specific diagnosis.

Common Causes of Sore Tongue

Burning Mouth Syndrome (BMS)

• Characterized by burning sensation on the tongue, especially the tip, lips, and palate 1
• Most common in peri- and post-menopausal women
• Associated with dry mouth, abnormal taste, and often depression
• Neurophysiological testing suggests it's a disorder of peripheral nerve fibers with central brain changes
• Secondary causes include:
  • Oral candidiasis
  • Mucosal lesions
  • Hematological disorders
  • Autoimmune disorders
  • Pharmacological side-effects

Geographic Tongue

• Chronic condition characterized by red patches with white borders on the dorsal tongue 2
• Prevalence of 1-3% in the population
• Triggered by immune reactions, allergies (particularly to spicy foods like chili), stress, hereditary factors, and nutritional deficiencies
• Can cause significant discomfort and soreness

Nutritional Deficiencies

• Atrophic glossitis (smooth, red tongue) often linked to deficiencies of 3, 4:
  • Iron
  • Folic acid
  • Vitamin B12
  • Riboflavin
  • Niacin
• Multiple nutritional deficiencies can occur simultaneously, complicating diagnosis

Infections

• Candidiasis (fungal infection)
• Viral infections (herpes simplex, varicella-zoster, human papillomavirus)
• Bacterial infections

Other Causes

• Transient lingual papillitis - inflamed fungiform papillae, often at the tip of tongue 5
• Trauma (sharp teeth, dental appliances, burns)
• Medication side effects
• Referred pain from temporomandibular joint (TMJ) syndrome 1

Diagnostic Approach

Clinical Assessment

• Examine the tongue for:
  • Color changes (redness, white patches)
  • Surface changes (smooth areas, fissures, ulcers)
  • Swelling
  • Specific patterns (geographic appearance, fissured appearance)
• Check for dental factors that might cause trauma
• Assess for signs of systemic disease

Laboratory Tests

• Complete blood count, serum iron, B12, and folate levels for suspected nutritional deficiencies 4
• Oral swabs for bacterial, candidal, or viral culture from affected areas 6
• Allergy testing if food allergies are suspected 2

Treatment Approaches

For Burning Mouth Syndrome

• Reassurance that condition will not worsen (crucial for patient comfort) 1
• Cognitive behavioral therapy
• Medications for neuropathic pain:
  • Alpha lipoic acid combined with gabapentin 300mg has shown best outcomes 1
  • Topical clonazepam, diazepam, and capsaicin have shown some effect 1
  • Amitriptyline has shown benefit in open-label studies 1

For Geographic Tongue

• Avoidance of identified triggers (particularly spicy foods if allergic) 2
• Benzydamine hydrochloride mouthwash for symptomatic relief 2
• Topical corticosteroids for inflammation 6

For Nutritional Deficiencies

• Specific replacement therapy based on identified deficiencies 4:
  • Iron supplements for iron deficiency
  • Vitamin B12 injections or supplements
  • Folate supplements
  • B-complex vitamins for other B vitamin deficiencies

For Infectious Causes

• For candidal infections: nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole 6
• For viral infections: appropriate antiviral medications
• For bacterial infections: targeted antibiotics based on culture results

Symptomatic Relief for All Types

• Topical pain management:
  • Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 6
  • Topical anesthetics like viscous lidocaine 2% or 2.5% lidocaine ointment 6
  • Mucoprotectant mouthwash three times daily (e.g., Gelclair) 6
• Antiseptic oral rinses:
  • 1.5% hydrogen peroxide mouthwash twice daily
  • 0.2% chlorhexidine digluconate mouthwash twice daily (may be diluted by 50% to reduce soreness) 6
• Systemic pain relief:
  • Ibuprofen or paracetamol for pain relief 1

Dietary Modifications

• Avoid irritants such as acidic, spicy, hot, raw, or crusty foods 6
• Choose soft, moist, non-irritating foods
• Stay hydrated by drinking ample fluids 6

When to Seek Further Care

• If sore mouth symptoms do not improve within 7 days 7
• If irritation, pain, or redness persists or worsens 7
• If swelling, rash, or fever develops 7
• For persistent cases, consider referral to specialist to rule out more serious conditions like premalignant lesions or squamous cell carcinoma 3

Special Considerations

• Transient lingual papillitis typically regresses spontaneously within a few weeks 5
• Chronic lingual papulosis can persist for years but is rarely painful 5
• For refractory cases of burning mouth syndrome, consider evaluation for underlying systemic conditions 6
• Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon 3