Types of tongue problems
White tongue
Color changes related to the tongue can range from a benign concern to one that requires medical attention. Often, a white tongue could be caused by a removable coating of food debris or bacterial plaque. Otherwise, the following are some common causes of the white tongue: oral thrush, leukoplakia, oral lichen planus, hairy leukoplakia, and linea alba.
Oral thrush (or candidiasis) is caused by an overgrowth of yeast fungus in the mouth. The white patches can be scraped off to expose a red surface on the tongue. Illnesses, medications, stress, and antibiotic treatment can cause oral thrush by throwing off the balance of natural bacteria in the mouth. Those with diabetes are more prone to fungal infections, such as oral thrush. Lozenges, tablets, or liquid antifungals are used for treatment.
Leukoplakia is characterized by white patches that cannot be scraped off and may be related to chronic irritation in the mouth, although the cause is not always known. Tobacco use is the most common factor that contributes to leukoplakia. The condition may resolve after smoking cessation. Sometimes the patches are on the sides of the tongue and could be related to constant rubbing next to the lower teeth. Although leukoplakia is usually benign, it can also be the precursor to oral cancer. The risk of cancer increases with the age of the individual, the size of the lesion, and several lesions present. A biopsy may be recommended after clinical evaluation by the doctor. Sometimes, the area can be monitored for changes by the doctor. Monitoring is usually performed during routine dental visits or visits with an ear, nose, and throat (ENT) specialist.
Oral lichen planus on the tongue is a chronic inflammatory condition caused by an autoimmune response (the body's immune system attacking its tissue). It is characterized by a white lace-like pattern called reticular lichen planus. (There is an erosive form that presents as shallow mouth ulcers and can be treated with topical steroids.) Regular monitoring of this condition is recommended for any changes that (although rare) could lead to oral cancer. A biopsy may be recommended.
Hairy leukoplakia is a white patch on the side of the tongue that appears hairy or rough. This condition is caused by the Epstein-Barr virus and is usually related to immunocompromised individuals. HIV testing should be considered if hairy leukoplakia appears without a known immune-compromising condition. Antiviral medications such as acyclovir (Zovirax) may be used. Recurrence of hairy leukoplakia is common.
The linea alba is a benign condition that is characterized by a thin white line at the lateral (side) borders of the tongue. It is caused by the thickening of the epithelium due to trauma or irritation from chewing. No treatment is necessary for linea alba.
Red tongue
There are obvious causes of the red color change of the tongue, such as something you ate (strawberries or red-colored foods). Some acidic foods can cause temporary redness and discomfort. However, a raspberry-colored tongue can be a sign of an underlying medical condition. Some red color changes on the tongue ("strawberry tongue") could be related to a vitamin deficiency, Kawasaki disease, or a strep infection (scarlet fever).
Erythroplakia is a red area or lesion that cannot be rubbed off on the tongue (except for the color, it is similar to leukoplakia). A lesion with a combined white and red appearance is called erythroleukoplakia. These lesions are all considered to have premalignant potential. Erythroplakia and erythroleukoplakia have an increased risk of premalignancy compared to leukoplakia. In addition to appearance, there is a concern if the lesion or sore does not go away or grows in size. A biopsy is recommended by an oral surgeon or an ENT specialist to rule out oral cancer.
Black tongue
A black tongue is usually a harmless condition that can be caused by medications, smoking, poor oral hygiene, a soft diet, or dry mouth. A black tongue is usually associated with elongated tongue papillae and thus, it is called "black hairy tongue" (lingua villosa nigra). The cause is thought to be a change in the normal bacteria in the mouth after antibiotic treatment or the use of products that contain bismuth such as Pepto-Bismol. ("Hairy tongue" by itself can also be white or tan.) Treatment of black hairy tongues may involve improving one's diet, smoking cessation, and improved oral hygiene (including gently brushing with a soft-bristled toothbrush or scraping the tongue).
Increased size or tongue swelling
Swelling or enlargement of the tongue referred to as macroglossia can be caused by allergies, medications, injuries, or an underlying medical condition such as amyloidosis. Addressing the underlying condition is the usual treatment for macroglossia.
Allergic reactions to medications, food, or even a bee sting can cause swelling of the tongue. In the case of sudden and rapid onset of swelling of the tongue, one should seek emergency care as breathing can become compromised.
Tongue swelling can also be a side effect of medication. Some medications that have this side effect are ACE inhibitors (to treat high blood pressure) and NSAIDs (nonsteroidal anti-inflammatory drugs) such as Aleve, Advil, and aspirin.
An injury from hot food or liquid that burns the tongue or simply biting the tongue can irritate the tongue to cause swelling.
Conditions such as oral thrush or oral herpes viruses can cause the tongue to swell due to inflammation. Other medical conditions include tumorous cancer, acromegaly (giantism), amyloidosis, sarcoidosis, hypothyroidism, and Kawasaki disease. Tongue swelling can also be found in individuals with Down syndrome.
Growths on the tongue
Traumatic fibroma is commonly found on the tongue and appears as a raised, thickened nodule that is dome-shaped, pink, and smooth. It is the result of chronic irritation of one area of the tongue, particularly along the bite line of the tongue. It is considered benign. An excisional biopsy is usually performed to definitively diagnose the lesion and completely excise it from the tongue.
Previously mentioned colored lesions, leukoplakia (white), erythroplakia (red), and erythroleukoplakia (red-white), are also classified as growths of the tongue. In most instances, a biopsy is recommended for these lesions to rule out premalignancy.
Squamous cell carcinoma (SCC) is the most common cancer related to the oral cavity, making up 90% of all oral cancers. Oral cancer makes up approximately 2% of all cancers in the U.S. It commonly involves the lateral surface of the tongue. Risk factors for SCC are older age (age 40 and up), tobacco use, and alcohol use. In younger individuals, cases of SCC often are associated with human papillomavirus (HPV). In recent years, HPV has been found to contribute more to the incidence rate of oral cancers. SCC clinically presents as a thickened rough surface over a red or white base. Nodules and ulcerations may follow as the growth progresses. In some cases, the tumor will be present at the base of the tongue and will be difficult to detect until it reaches its late stage of development. Treatment for SCC involves a mix of surgical removal, chemotherapy, and/or radiation therapy. Immunotherapy and gene therapy are examples of newer treatments being investigated. Clinical trials of a new treatment may be a possible option for advanced cancers. Each individual should understand the nature of cancer and the options available for treatment to make the best decisions.
Abnormalities of the tongue surface
Smooth areas of the tongue may be related to injury (food burn) or a nutritional deficiency of iron, folate, or vitamin B12. A smooth tongue can also result from the use of dentures.
"Geographic tongue" (or benign migratory glossitis) is the most common tongue condition. It is found in up to 14% of the U.S. population. It is a benign condition that appears as bare or smooth areas on the dorsum of the tongue. It may be one area or several areas and may even vary from time to time. It is usually painless; however, the smooth areas may have sensitivity to spicy or acidic foods for some individuals. No treatment is recommended.
Fissured tongue is the second most common tongue condition and is characterized by a deepening of normal tongue fissures and is usually associated with aging. Some medical conditions are linked to the fissured tongue and include Sjögren's syndrome, psoriasis, Down syndrome, and acromegaly. No treatment is required unless food debris and bacteria get trapped and cause inflammation of the tongue's papillae. Gentle brushing should alleviate the problem.
As previously mentioned, the hairy tongue is the hypergrowth of the tongue's papillae and is usually associated with white, tan, or black discoloration. Hairy tongue is the third most common tongue condition and is considered harmless. Gentle brushing or scraping of the tongue may be helpful. No other treatment is necessary.
Median rhomboid glossitis is a lesion at the midline of the dorsum of the tongue. It usually looks like a smooth, red, shiny, and sharply defined area. The underlying cause is usually a fungal infection. Treatment options include topical oral antifungal agents such as nystatin (Mycostatin) or fluconazole (Diflucan).
Tongue pain
Pain with the tongue can be associated with anemia, canker sores (aphthous ulcers), oral herpes, neuralgia, cancer, poorly fitting dentures, or irritation from dental work.
Canker sores are commonly found on the tongue and can be very painful. They appear as a yellow-white center with a red halo. These ulcerations are thought to be caused by local injury, stress, or genetic predisposition; however, no definitive cause has been found. No treatment is usually necessary as these ulcerations generally resolve in less than two weeks.
Oral herpes is caused by the herpes virus and appears as fluid-filled lesions. These lesions usually resolve in two weeks, but oral herpes can also be treated with antiviral medications such as acyclovir (Zovirax) to shorten the duration of symptoms.
"Burning mouth syndrome" is a phenomenon that often includes the tongue (often called "burning tongue"). Other symptoms include increased thirst with the feeling of a dry mouth, as well as an altered or metallic taste. It has been associated with other conditions that include menopause, anxiety, depression, acid reflux, nutritional deficiencies, and mouth conditions such as dry mouth or oral thrush. Treatment is usually for the underlying condition (for example antifungals for oral thrush, supplements for nutrition deficiencies, or medications to treat anxiety or depression).
The altered sensation of the tongue
Paresthesia is an abnormal or altered sensation. Paresthesia of the tongue can occur with damage to the lingual nerve, the nerve of sensation for the tongue. The most common cause of lingual nerve damage occurs during wisdom teeth extractions where the nerve is very close to the tooth being extracted. The nerve damage is usually noticed well after the procedure and symptoms include altered, decreased, or complete loss of sensation. Senses of pain, taste, touch, perception of temperature, and perception of relative position and movement (proprioception) may be affected. The sensation of "pins and needles" similar to being numb during a dental procedure may persist. Usually, treatment involves waiting for the nerve to self-repair itself for a period of six months to a year. If there is no improvement, surgery may be an option to repair the injured nerve.
Taste problems
Dysgeusia is the term used to describe the distortion of the sense of taste. Common causes of dysgeusia include medications, cancer therapy, dry mouth, gum disease, and the common cold or flu. Cancer therapy that involves chemotherapy and radiation to the head and neck area can greatly affect the taste. Radiation therapy can damage taste buds and salivary glands. Decreased flow of saliva causes a dry mouth and further compounds the problem. Cigarette smoking also can affect the taste. Dysgeusia can be a temporary condition and should be resolved once the cause is eliminated. Damage to taste buds through radiation therapy may require time for healing to occur. The taste may slowly return and greatly depends on the amount of damage from radiation therapy. Artificial saliva and zinc supplementation may help in restoring taste for some individuals. A lack of taste sensation (ageusia) is rare.
Problems with tongue movement
Tongue movement problems are often caused by nerve damage (for example, post-stroke or post-surgery nerve damage). Limited tongue mobility can greatly affect our eating, swallowing, and speech. Depending on the extent of nerve damage, sometimes physical therapy may help in regaining control of the tongue.
Ankyloglossia, also known as "tongue-tie," is a less common condition where a band of tissue that connects the tongue to the floor of the mouth is too short or tight and impedes tongue movement. Because the tongue is vital for sucking, infants with ankyloglossia may be unable to breastfeed properly. For toddlers and older children, sometimes the tongue can compensate for most oral functions, but speech may be affected. The treatment for ankyloglossia is a surgical procedure (frenulectomy) that relaxes the tight band of tissue that restricts the tongue's movements.
