What are the common causes of a stinging or burning sensation on the tongue?

What Causes a Stinging Tongue Sensation

The most common cause of a stinging or burning tongue is Burning Mouth Syndrome (BMS), a chronic neuropathic pain condition that predominantly affects peri- and post-menopausal women and presents with continuous burning, stinging, or itchy sensations—most commonly on the tongue tip and anterior two-thirds—with completely normal-appearing oral mucosa on examination. 1, 2, 3

Primary vs. Secondary Causes

Primary Burning Mouth Syndrome

• Primary BMS is a neuropathic disorder involving peripheral nerve fiber dysfunction with central nervous system changes, not an inflammatory or infectious process 1, 3
• The condition typically affects the tongue tip bilaterally, lips, palate, and buccal mucosa with continuous symptoms ranging from mild to severe 1, 3
• Patients often report associated dry mouth, abnormal or metallic taste, and symptoms that may worsen with acidic foods like tomatoes or orange juice 4, 5
• The diagnosis is made by exclusion after ruling out all secondary causes 1, 2, 3

Secondary Causes Requiring Investigation

Nutritional and metabolic deficiencies:

• Vitamin B12 deficiency and iron deficiency anemia are well-established causes that frequently present with burning tongue and lips 2, 3
• Zinc deficiency can also contribute to oral burning symptoms 5

Endocrine disorders:

• Diabetes mellitus can cause neuropathic tongue symptoms 3, 4
• Thyroid dysfunction (both hypo- and hyperthyroidism) may manifest with oral burning 2, 3

Infectious causes:

• Oral candidiasis can cause burning sensations even without visible thrush; diagnosis requires scraping with KOH preparation or culture 2, 3

Medication side effects:

• Various medications can cause oral burning as an adverse effect; a thorough medication review is essential 1, 3

Autoimmune and salivary gland disorders:

• Sjögren's syndrome and sicca syndrome manifest with oral burning due to salivary gland dysfunction 2

Post-traumatic neuropathic pain:

• Develops within 3-6 months following dental procedures, facial trauma, or injections 1, 2, 3
• Presents as continuous burning or tingling in the trigeminal distribution with possible sensory changes 1, 3

Post-herpetic neuralgia:

• Follows herpes zoster infection in the oral cavity 1, 3
• Characterized by continuous burning at the site of previous infection with allodynia and hyperalgesia 1, 6

Diagnostic Workup Algorithm

Initial laboratory testing should include: 2, 3

• Complete blood count with differential
• Vitamin B12 level
• Iron studies (ferritin, serum iron, TIBC)
• Fasting glucose and HbA1c
• Thyroid function tests (TSH, free T4)
• Vitamin D 25(OH) level

Clinical assessment must document: 2, 3

• Thorough oral examination to identify any visible mucosal lesions, sharp tooth edges, ill-fitting dentures, or signs of candidiasis
• Onset, duration, location, and character of the stinging sensation
• Assessment for xerostomia and salivary gland function
• Complete medication review
• History of recent dental procedures or facial trauma

Additional testing when indicated: 2, 3

• Qualitative sensory testing if neuropathic etiology is suspected
• Tongue or lip biopsy only if suspicious lesions develop or diagnosis remains uncertain after initial workup

Critical Clinical Pearls

• The absence of visible lesions strongly favors a neuropathic process over infectious or inflammatory causes 2
• Bilateral and migratory symptoms are characteristic of primary BMS rather than focal pathology 2
• If antihistamines are tried and prove ineffective, this further supports a neuropathic rather than allergic etiology 2
• Most cases will ultimately be diagnosed as primary BMS after excluding secondary causes 2, 3
• The condition shows a chronic course with poor prognosis for complete resolution, though reassurance that symptoms will not worsen is often crucial for patients 1

Management Approach

For secondary BMS: 3, 5

• Address underlying causes: correct nutritional deficiencies, manage diabetes, control thyroid dysfunction, discontinue offending medications, or treat candidiasis
• Treatment or elimination of causative factors usually results in significant clinical improvement

For primary BMS: 1, 3, 5

• Reassurance and education about the neuropathic nature of the condition
• Cognitive behavioral therapy (CBT)
• Pharmacologic options include gabapentin, alpha-lipoic acid, topical clonazepam or diazepam, and antidepressants
• Current treatments are palliative; spontaneous remission is rare 4