Tongue conditions

Last updated: February 12, 2025

Summary

The tongue's appearance holds a wealth of information about a patient's general health status, and specific changes (e.g., strawberry tongue) can provide valuable clues in the diagnosis of diseases such as scarlet fever, candidiasis, Kawasaki syndrome, nutritional deficiencies, and certain cancers. Accordingly, the ability to identify tongue findings may become crucial in making the right diagnosis and initiating the proper treatment early in the course of a disease.

Overview

Tongue conditions

Common tongue conditions
	Features	Etiology	Treatment
Leukoplakia	Persistent white plaques that cannot be scraped off	Not fully understood Associated with alcohol and tobacco use	Cryotherapy Laser ablation Surgical removal
Oral cavity cancer and tongue carcinoma	Tongue and mouth pain Infiltrative or exophytic lesions: nonhealing, white or red ulcers on tongue and in oral cavity Accompanied by bleeding in the mouth, halitosis, pain, and lymphadenopathy Advanced stages Dysarthria, dysphagia, odynophagia Nerve involvement: ipsilateral tongue deviation (hypoglossal nerve), numbness in the chin, lower lip, and/or mandibular teeth (inferior alveolar nerve), altered tongue sensation (lingual nerve)	Exposure to carcinogens (e.g., alcohol, tobacco, HPV)	Surgical excision Radiation therapy
Oral lichen planus	Thin, gray-white lines that form a reticular pattern (Wickham striae) Painful, atrophic, and erosive lesions may be present.	Not fully understood Associated with dental materials, drugs (e.g., NSAIDs, ACE inhibitors), infection, autoimmunity (e.g., PBC), and IBD ^[1]	High potency topical corticosteroids PLUS antifungal therapy
Oral candidiasis/oral thrush	White lesions that can be scraped off, resulting in red, inflamed, or bleeding areas	Candida species	Topical antifungal agent (e.g., clotrimazole, nystatin)
Atrophic glossitis	Painful, erythematous, edematous tongue with a smooth appearance	Nutritional deficiencies (e.g., iron deficiency, vitamin B₁₂ deficiency, folate deficiency, riboflavin deficiency, niacin deficiency) Infection (e.g., syphilis, candida) Amyloidosis Celiac disease Protein-calorie malnutrition Sjogren syndrome	Treatment of the underlying condition
Erythroplakia ^[2]	A red patch on the tongue	Not fully understood Associated with tobacco and alcohol use	Tobacco and alcohol use cessation Carbon dioxide laser excision
Oral hairy leukoplakia	Benign, painless, irregularly shaped white plaques with feathery or hairy appearance Most commonly located on the lateral tongue, but can also occur on the floor of the mouth, palate, or buccal mucosa Patches cannot be scraped off (in contrast to oral thrush)	EBV Immunosuppression (e.g., patients with a history of organ transplantation) Immunocompromise (e.g., HIV-positive individuals)	Treatment of the underlying condition
Herpetic gingivostomatitis	Erythema, painful erosions, and intact vesicles on perioral skin and oral mucosa, especially inner cheek, soft palate, and tongue Accompanied by pharyngitis and cervical lymphadenopathy	HSV-1 Predominantly affects children	Treatment of HSV-1 infection (oral acyclovir) ^[3]
Lingual thyroid ^[4]	An abnormal mass of ectopic, thyroid tissue at the base of the tongue Dysphagia for solids, dysphonia, hypothyroidism (in individuals with hypoactive thyroid tissue) Occasional bleeding, upper airway obstruction	Failure in descent of the thyroid gland to its normal position during embryogenesis	Supplemental thyroxine: for symptomatic, hypothyroid patients Surgical excision of the mass Ablative radioiodine therapy

Oral leukoplakia Oral cancer Oral lichen planus Oral candidiasis HIV patient with oral hairy leukoplakia Herpetic gingivostomatitis

Tongue findings

Common tongue findings
Finding	Features	Associated conditions and factors	Treatment
Geographic tongue (benign migratory glossitis)	Solitary, irregular patches of red and white tongue discoloration that resemble a geographic map Lesions migrate and patients experience exacerbations and remissions over time Caused by loss of filiform lingual papillae	Atopy Psoriasis Reactive arthritis	Topical steroid gels, topical anesthetic agents, or antihistamine mouth rinses may reduce pain or discomfort in patients with increased sensitivity to hot or spicy food.
Median rhomboid glossitis ^[5]^[6]	Painless area of reddish discoloration located in the middle third of the tongue, ventral to the foramen cecum	Smoking Use of corticosteroid inhalers HIV infection Candida infection	Topical antifungals (e.g., nystatin, fluconazole, clotrimazole) in severe cases
Fissured tongue ^[2]	One or more deep grooves located on the dorsum of the tongue Possibly halitosis and discoloration if food gets trapped in the fissures and causes inflammation	Associated with Melkersson-Rosenthal syndrome Psoriasis Acromegaly Down syndrome	In case debris causes inflammation, it may be necessary to rinse or brush the affected area.
Black hairy tongue ^[2]^[7]	Brown, black, or yellowish discoloration of the tongue with fuzzy appearance	Smoking Coffee/tea consumption Poor oral hygiene Penicillin and tetracycline use Seen in patients on a gastrostomy tube	Brushing affected area with toothbrush Practicing good oral hygiene Avoiding alcohol and tobacco
White tongue	Temporary white or gray accumulation of debris on the dorsum of the tongue	Accumulation of dead cells, food residue, and bacteria, promoted by: Poor oral hygiene Dehydration Mouth breathing Smoking, alcohol consumption	Practicing good oral hygiene Avoiding alcohol and tobacco
Strawberry tongue	Painful, bright red swollen tongue with papillary hyperplasia resembling a strawberry/raspberry	Scarlet fever	Treatment of scarlet fever Oral penicillin V or amoxicillin In the case of penicillin allergy, cephalosporins, macrolides, or clindamycin can be used.
Strawberry tongue		Kawasaki syndrome	Treatment of Kawasaki syndrome IVIG, high-dose Oral aspirin IV glucocorticoids
Tongue fasciculations	Involuntary twitching of the tongue	Lower motor neuron lesion (e.g., amyotrophic lateral sclerosis)	Treatment of the underlying condition
Telangiectasias	Dilated small superficial blood vessels on the tongue	Osler-Weber-Rendu syndrome	No specific treatment for the tongue abnormality
Bluish-black patches	Bluish-black discoloration of the tongue and mucous membranes	Adrenal insufficiency	Treatment of the underlying condition
Macroglossia	Enlarged tongue with scalloped lateral margins May result in cosmetic and/or functional impairment Dyspnea and obstructive sleep apnea Dysphagia Dysphonia Sialorrhea	Congenital disorders Trisomy 21 Muscular hypertrophy (e.g., Beckwith-Wiedemann syndrome, hemihyperplasia) Vascular malformations (e.g., lymphangioma or hemangioma) Multiple endocrine neoplasia type 2B Glycogen storage disease type 2 Neurofibromatosis Acquired conditions Myxedema and hypothyroid disorders Amyloidosis Acromegaly Angioedema (e.g., due to ACE inhibitors) Tumors (e.g., squamous cell carcinoma of the tongue)	Mild cases: speech therapy Severe cases: surgery (reduction glossectomy) Treatment of the underlying acquired cause (e.g., radiotherapy for tumors)
Squamous cell papilloma	Solitary exophytic lesions with a verrucous surface	Human papillomavirus (mostly HPV-6 and HPV-11)	Surgical excision Laser ablation

Geographic tongue (benign migratory glossitis) Median rhomboid glossitis Fissured tongue and cheilitis granulomatosis (Melkersson-Rosenthal-Syndrome) Black hairy tongue Strawberry tongue Typical findings in Kawasaki disease Osler-Weber-Rendu disease Macroglossia in light-chain amyloidosis Facial features of Down syndrome

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