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Why is this woman's tongue sore and spotted?

This woman’s fear of dentists led her to see her GP, Dr Mike Wyndham, about her sore mouth. He describes how he made the diagnosis

This woman's fear of dentists led her to see her GP, Dr Mike Wyndham, about her sore mouth. He describes how he made the diagnosis

The patient

This 29-year-old woman has an aversion of going to the dentist and came to see me about her tongue.

For the previous couple of weeks it had been sore, particularly after eating. She had noticed some prominent white patches and having searched the internet was wondering whether she might have developed cancer.

This patient is a non-smoker who is not taking any medication. She rarely drinks alcohol and prides herself on being physically fit and eating a balanced diet. There is a strong family history of psoriasis.

First instinct

It was easier to say what it wasn't rather than what it was. Oral cancer was very unlikely in view of her age, good dental hygiene and being a non-smoker.

Differential diagnosis

• Burning mouth syndrome (BMS)

• Geographic tongue

BMS tends to cause pain in more than one area of the mouth – the tongue, lips and oral mucosa perhaps being the most commonly affected. Apart from the burning pain, there may be dysgeusia (alteration in taste), dry mouth and improvement with eating.

There is an extensive list of causes, including diabetes mellitus (caused by a peripheral neuropathy), deficiency in vitamin B and iron, drugs such as ACE inhibitors, hypothyroidism or Sjögren's syndrome.

Geographic tongue – also known as benign migratory glossitis – indicates that although symptoms affecting one area of the tongue may settle, another may become affected. Foods that can cause symptoms such as burning include tomatoes, spicy foods and citrus fruits. In most people, though, it is asymptomatic.

Getting on the right track

The biggest clues were in the history. The patient only had symptoms affecting her tongue. This made the diagnosis of BMS much less likely although symptoms may be experienced in other parts of the mouth in geographic tongue.

She also described how her tongue changed periodically. Areas that had appeared normal had undergone change while the originally affected areas appear to resolve.

The appearance of reddish areas of the tongue bordered by white raised areas is characteristic of geographic tongue. In BMS, the tongue usually looks normal to the naked eye.

This patient's relatively young age was a also consideration. Most people with BMS develop the condition around the menopause.

Geographic tongue was diagnosed and the patient was prescribed betamethasone 500µg soluble tablets dissolved in 20ml water to gargle with (but not swallow) qds. This is an unlicensed use but recommended by oral specialists.

Geographic tongue is thought to be more common in those people suffering from psoriasis.

Dr Mike Wyndham is a GP in Edgware, north London

Why is this woman's tongue sore and spotted? Why is this woman's tongue sore and spotted?

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