What is the workup for a patient presenting with a burning tongue sensation?

Workup for Burning Tongue Sensation

The workup for burning tongue sensation should focus on diagnosing burning mouth syndrome (BMS) through a systematic exclusion of other causes, followed by appropriate management based on symptom severity.

Initial Diagnostic Evaluation

Clinical Assessment

• Assess location and character of pain (typically burning sensation affecting tongue, lips, palate, and buccal mucosa) 1
• Rule out odontogenic or mucosal source of pain 2
• Evaluate for normal-appearing oral mucosa without clinically evident lesions (characteristic of primary BMS) 1
• Document associated symptoms:
  • Dry mouth (xerostomia)
  • Abnormal taste (dysgeusia)
  • Psychological factors (depression, anxiety) 2, 1

Examination

• Thorough oral examination including:
  • Tongue mobility assessment
  • Presence of ulcers or masses
  • Palpation of floor of mouth and tongue
  • Assessment of oropharynx using bright light 1
• Look for sensory changes (allodynia, hyperesthesia) 2

Laboratory Investigations

• Complete blood count
• Fasting blood glucose (to rule out diabetes)
• Vitamin B12, folate, iron, zinc levels
• Thyroid function tests
• Autoimmune markers if Sjögren's syndrome suspected 1

Imaging

• MRI of face and neck for persistent unexplained pain to evaluate cranial nerves, particularly if glossopharyngeal neuralgia is suspected
• CT neck as complementary to MRI to identify deep space neck masses 1

Differential Diagnosis

Primary Conditions to Consider

• Primary BMS (idiopathic) - diagnosis of exclusion
• Secondary BMS (due to identifiable causes):
  • Post-herpetic neuralgia
  • Post-traumatic trigeminal pain
  • Trigeminal neuropathic pain
  • Glossopharyngeal neuralgia
  • Atypical odontalgia 2

Other Considerations

• Medication side effects
• Nutritional deficiencies
• Endocrine disorders (diabetes, hypothyroidism)
• Oral infections (candidiasis)
• Sjögren's syndrome
• Immunotherapy-related oral dysesthesia 2, 1

Management Approach

First-line Treatments

• For mild symptoms:

  • Patient education and reassurance about the chronic nature of BMS 1
  • Dietary modifications (avoid spicy, acidic, hot foods) 2, 1
  • Improve hydration and limit caffeine intake 2, 1

• For moderate to severe symptoms:

  • Gabapentin starting at 300 mg daily with gradual titration is recommended as first-line pharmacological treatment 2, 1
  • Topical treatments:
    • Clonazepam (dissolved in mouth for 3 minutes then spit out) 1
    • High-potency topical steroids (gel or dental paste preferred) 2
    • Viscous lidocaine for temporary relief 2, 1

Second-line Treatments

• Alpha-lipoic acid (may be combined with gabapentin for better outcomes) 2, 3
• Tricyclic antidepressants for patients with comorbid depression 1, 4
• For dry mouth: salivary stimulants (sugarless gum, lozenges) or systemic sialagogues (cevimeline, pilocarpine) 2, 1

Psychological Support

• Cognitive behavioral therapy, particularly effective for patients with psychological factors 1
• Consider referral to mental health professionals for structured psychotherapy if anxiety or depression is significant 2

Special Considerations

• Menopausal women have higher prevalence of BMS and may benefit from hormone replacement therapy if appropriate 1
• Supplement vitamin B complex, zinc, or iron if deficiencies are detected 1, 3
• For immunotherapy-related oral dysesthesia, consider holding immunotherapy if symptoms interfere with oral intake 2

Follow-up

• Regular follow-up to assess treatment response
• Adjust treatment based on symptom severity and impact on quality of life
• Reassure patients that while complete resolution may be limited, symptoms typically won't worsen 1

Remember that BMS is now largely considered neuropathic in origin, and treatment focuses on medications that suppress neurologic transduction and transmission of pain signals 5.