What could be causing a burning sensation on my tongue and how can I treat it?

Burning Tongue: Diagnosis and Treatment

What's Causing Your Burning Tongue

Your burning tongue is most likely Burning Mouth Syndrome (BMS), a neuropathic pain disorder that predominantly affects peri- and post-menopausal women, but you must first exclude secondary causes like nutritional deficiencies, oral infections, and medication side-effects before confirming this diagnosis. 1

Primary vs Secondary Causes

Primary BMS occurs when no underlying cause can be identified and represents a disorder of peripheral nerve fibers with central brain changes, typically affecting the tongue tip, lateral borders, lips, and palate bilaterally with completely normal-appearing oral mucosa. 2, 1

Secondary causes that must be ruled out include: 2, 1, 3

• Nutritional deficiencies: Vitamin B12, iron, vitamin D, zinc 3, 4
• Oral infections: Candidiasis (even without visible thrush) 3, 4
• Hematological disorders: Anemia 1, 3
• Autoimmune conditions: Sjögren's syndrome 5
• Endocrine disorders: Diabetes, thyroid dysfunction 3, 6
• Medication side-effects: Review all current medications 2, 1
• Dental trauma: Recent procedures, ill-fitting dentures, sharp tooth edges 3
• Post-traumatic trigeminal neuropathy: Develops 3-6 months after dental procedures or facial trauma 2, 3

Required Diagnostic Workup

Before diagnosing primary BMS, obtain these specific tests: 3

• Complete blood count with differential
• Iron studies (ferritin, serum iron, TIBC)
• Vitamin B12 level
• Fasting glucose and HbA1c
• Vitamin D 25(OH) level
• Thyroid function tests (TSH, free T4)
• Oral examination to exclude visible lesions
• Oral swabs if fungal/bacterial infection suspected 1

Treatment Algorithm

Step 1: Weeks 0-2 - Foundation 1

Reassurance is crucial: Tell the patient explicitly that BMS will not worsen—this alone is often therapeutic. 2, 1

Cognitive Behavioral Therapy (CBT) is the primary intervention, addressing psychological components that contribute to symptoms. 1, 3

Manage associated symptoms: 1

• For dry mouth: increase hydration, limit caffeine, use saliva substitutes or moisture-preserving rinses
• For severe dry mouth: consider systemic sialagogues (cevimeline or pilocarpine)
• Avoid crunchy, spicy, acidic, or hot foods
• Use bland oral rinses (salt and sodium bicarbonate solution) for taste disturbances
• Avoid oral care products with alcohol or strong flavoring agents

Step 2: Weeks 2-6 - First-Line Pharmacotherapy 1

If inadequate response to CBT and reassurance:

Gabapentin 300 mg is the first-line medication, demonstrating efficacy in reducing burning sensation in 50% of patients in randomized controlled trials. 1

Step 3: Weeks 6-10 - Combination Therapy 1

If partial response to gabapentin:

Alpha-lipoic acid combined with gabapentin shows superior outcomes compared to monotherapy. 1, 7

Step 4: Alternative Pharmacological Options 1, 7, 4

If gabapentin is ineffective or not tolerated:

• Amitriptyline: Has shown benefit in open-label studies 1
• Topical clonazepam or diazepam: May provide symptomatic relief 1, 7
• Topical capsaicin: Some evidence for effectiveness 1, 7, 4
• Duloxetine or pregabalin: Alternative neuropathic pain medications 7

Note on topical lidocaine: While viscous lidocaine may provide temporary relief, FDA labeling warns against use on mucous membranes and notes that transient burning may occur upon application. 8

Step 5: Refractory Cases 1

After 4-6 weeks of inadequate response:

• Refer to pain specialist or neurologist
• Evaluate for comorbid depression or anxiety and treat appropriately
• Consider combination therapy with multiple agents
• Non-pharmacological options: laser therapy, acupuncture, transcranial magnetic stimulation 7

Critical Clinical Pearls

The prognosis is generally poor—only a small number of patients achieve complete resolution, but symptoms typically do not worsen. 2, 1 Treatment failures are common with high percentages reported. 2

Combination approaches (CBT plus pharmacotherapy) generally outperform monotherapy. 1

Most common presentation: Continuous burning affecting tongue tip bilaterally, with severity ranging from mild to severe, often accompanied by dry mouth, abnormal taste, and depression. 2, 1

Red flags requiring biopsy or specialist referral: Unilateral pain, ulceration, non-healing lesions, or suspicious visible changes suggest possible malignancy rather than BMS. 3

Avoid this pitfall: Failing to provide adequate reassurance that the condition won't worsen is a critical error—this reassurance is often fundamental to therapeutic success. 1