What is the likely diagnosis and recommended evaluation and management for a 64‑year‑old woman with a chronic burning sensation localized to the tip of the tongue?

Chronic Burning Tongue Sensation in a 64-Year-Old Woman

Likely Diagnosis

This is almost certainly primary burning mouth syndrome (BMS), a chronic neuropathic pain condition that predominantly affects postmenopausal women and characteristically involves the tongue tip with normal-appearing oral mucosa. 1

The clinical presentation—chronic burning sensation localized to the tongue tip in a 64-year-old woman—fits the classic demographic and anatomic pattern of primary BMS, which most commonly affects the anterior two-thirds of the tongue in peri- and postmenopausal women. 1

Diagnostic Evaluation

Initial Clinical Assessment

Begin with a thorough oral examination specifically looking for:

• Visible mucosal lesions, ulcerations, or non-healing areas that would suggest malignancy or other pathology 1
• Sharp edges of residual tooth roots or crowns, ill-fitting dentures, or signs of thermal/chemical injury 1
• Evidence of candidiasis (white plaques or erythema) 1
• Normal-appearing mucosa, which is characteristic of primary BMS 1

Document the specific pain characteristics:

• Onset, duration (symptoms lasting over a year in this case), and character of the burning 1
• Bilateral versus unilateral involvement (unilateral pain raises concern for malignancy or post-traumatic neuropathy) 1
• Associated symptoms such as dry mouth, taste alterations, or dysgeusia 1

Obtain a focused history:

• Recent dental procedures, facial trauma, or injections within the past 3-6 months (post-traumatic trigeminal neuropathic pain can develop 3-6 months after such events) 1
• History of herpes zoster infection (post-herpetic neuralgia can cause persistent burning) 1
• Complete medication review to identify drugs that may cause oral burning as a side effect 1

Essential Laboratory Testing

Order the following blood tests to exclude secondary causes: 1

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

These tests identify nutritional deficiencies, diabetes, and thyroid dysfunction—all treatable secondary causes of burning mouth symptoms. 1

Additional Diagnostic Considerations

Tongue biopsy or specialist referral is indicated only if: 1

• Suspicious lesions are present on examination
• Unilateral symptoms raise concern for malignancy
• Ulceration or non-healing lesions are observed

A common pitfall: Most cases will be primary BMS after excluding secondary causes, so avoid over-testing or unnecessary biopsies in patients with normal-appearing mucosa and bilateral symptoms. 1

Management Approach

If Secondary Causes Are Identified

Address the underlying etiology: 1

• Correct nutritional deficiencies (vitamin B12, iron, vitamin D)
• Optimize diabetes control
• Treat thyroid dysfunction
• Discontinue offending medications
• Treat candidiasis if present

Treatment of secondary causes usually results in significant symptom improvement. 2

For Primary BMS (After Excluding Secondary Causes)

Provide patient education and reassurance: 1

• Explain that BMS is a neuropathic pain condition involving peripheral nerve fiber dysfunction
• Reassure that symptoms are unlikely to worsen, though spontaneous remission is rare
• Set realistic expectations that treatment is palliative rather than curative

First-line pharmacologic therapy—choose one of the following: 1

• Gabapentin: Start at 300 mg at bedtime, titrate up to 900-3600 mg daily in divided doses (reduces burning sensation in 50% of patients) 3
• Alpha-lipoic acid: Effective for symptom relief in multiple trials 1, 2
• Topical clonazepam: Apply to affected areas; benzodiazepines have been used as first-line medication in clinical practice 1, 4
• Topical diazepam: Alternative topical benzodiazepine option 1

Alternative or adjunctive medications if first-line therapy fails: 3

• Amitriptyline (tricyclic antidepressant)
• Topical lidocaine
• Capsaicin

Non-pharmacologic interventions: 1

• Cognitive behavioral therapy (CBT): Should be initiated early to address psychological components, improve coping strategies, and enhance quality of life
• Complementary and alternative medicine approaches may provide additional benefit 4

Critical Clinical Pearls

• Primary BMS follows a chronic course with low likelihood of complete spontaneous remission—managing patient expectations is essential. 1
• The bilateral nature and normal-appearing mucosa strongly favor primary BMS over focal pathology such as malignancy or infection. 5
• If laboratory testing reveals deficiencies, correct them first before diagnosing primary BMS, as secondary BMS often improves with treatment of the underlying cause. 1
• Avoid the pitfall of misdiagnosing post-traumatic trigeminal neuropathy—always ask about dental procedures or trauma 3-6 months prior to symptom onset. 1