Smooth Tongue
The most common cause of a smooth tongue is the use of dentures. Nutritional deficiencies include iron, folate and vitamin B12 deficiency. B12 deficiency will also make the tongue sore and beefy-red in color. Glossitis, by causing swelling of the tongue, may also cause the tongue to appear smooth. Among women, low-estrogen states may cause a “menopausal glossitis”.
A classic smooth, beefy red tongue from vitamin B12 deficiency (Credit)
Geographic Tongue
Geographic tongue is a benign condition in which discolored, painless patches of the tongue appear and then reappear from atrophy, often in a different distribution. This is seen in 1-3% of the population.
Geographic Tongue (Credit)
Hairy Tongue
White hairs along the sides of the tongue are the classic appearance of oral hairy leukoplakia, the result of EBV infection in HIV-positive individuals. A black hairy tongue in the setting of chronic administration of penicillins is often fungal overgrowth, particularly ofaspergillus.
Oral Hairy Leukoplakia, in an HIV-positive individual. (Credit)
A black, hairy tongue consistent withaspergillusovergrowth (Credit)
Furrowing
Transverse furrows across the tongue may be from a benign condition called scrotal tongue. Furrows that are longitudinal along the length of the tongue are the result of syphilis.
Ulcers
In inspecting ulcers, it is important to note their size, number, color, distribution, and whether or not they cause the patient any discomfort.
Aphthous ulcers, or aphthous stomatitis, are a painful form of ulcer that is frequently encountered. It appears in one of several patterns: minor, major, or herpetiform. Minor aphthous ulcers are usually 2-8mm in size and spontaneously heal within 14 days. Major aphthous ulcers are >1cm in size and may scar when they heal. Herpetiform ulcers are pin-point size, often multiple, and may coalesce to form a larger ulcer. All may result in odynophagia when they occur toward the posterior surface of the oropharynx.
Recurrent aphthous ulceration or stomatitis (RAU/RAS) occurs in some systemic illnesses. These include Crohn's Disease and Ulcerative Colitis, Behcet's Syndrome, pemphigus, herpes simplex, histoplasmosis, and reactive arthritis (Reiter's Syndrome). Other causes of RAU include drug reactions, Marshall Syndrome, and MAGIC (Mouth and Genital ulcers with Inflamed Cartilage) syndrome. The ulcers themselves may become infected, requiring treatment.
A single non-healing, erythematous, painful ulcer suggests lingual or oral cancer, particularly if the patient uses tobacco and/or alcohol. Patient history and risk factors are important to note.
Micro/Macroglossia
Microglossia may result from pseudobulbar palsy, damage to the upper motor neurons of the corticobulbar tracts that innervate the tongue. This presents with a small, stiff tongue. In newborns there may be an apparent microglossia resulting from a congenitally short lingual frenulum (ankyloglossia) commonly called a “tongue tie”.
Assessment of macroglossia should include palpation of the sublingual glands; these will be displaced in true macroglossia. Macroglossia may be congenitally present in individuals with acromegaly. New-onset macroglossia in an adult is pathognomonic for amyloidosis and should be treated as such until proven otherwise.
Fasciculations
Fasciculations of the tongue are indicative of lower motor neuron injury. These may present with dysarthria or dysphagia. New-onset fasciculations are concerning for amyotrophic lateral sclerosis.
