Tongue Problems

  • Medical Author:
    Donna S. Bautista, DDS

    Dr. Donna S. Bautista, DDS, completed her undergraduate studies at the University of California, San Diego with a bachelor of arts in biochemistry and cell biology. During her time at UC San Diego, she was involved in basic research including studying processes related to DNA transcription in the field of molecular biology. Upon graduation, she went on to attend dental school at the University of California, San Francisco. In addition to her formal dental training, she provided dental care for underserved communities in the Bay Area through clinics and health fairs. She also worked toward mentoring high school students interested in the field of dentistry.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

Shocking Diseases of the Mouth

Tongue facts

The tongue is a mobile group of muscles that is attached to the floor of the mouth. The top of the tongue is covered with small bumps called papillae. The majority of our taste buds sit on these papillae.

The tongue is used for tasting, swallowing, and chewing food. The tongue is also used to form words for speaking. Typically, a tongue that is pink and moist with a thin white coating on the surface is considered healthy. There are variations of surface texture that are normal and healthy as well. As many of us have experienced, a tongue injury (such as when we accidentally bite our tongue) can be quite painful since the tongue is such an instrumental part of our daily lives through eating and speaking. Though very few people know it, the tongue is actually a very good measure of the well-being of the body. This is why your doctor may use the tongue depressor to look in your mouth and tongue during an examination.

What are common tongue problems?

Some common problems associated with the tongue include:

  • discoloration,
  • increased size,
  • abnormalities of the surface,
  • growths (bumps), pain,
  • taste concerns, and
  • difficulty with movement.

What causes tongue problems?

There are a variety of causes of tongue problems, ranging from harmless to serious. Individuals can be born with a tongue condition that is harmless. A more serious condition such as tongue cancer can be related to risk factors such as smoking and drinking alcohol. Additionally, a tongue problem may be a result of an underlying medical condition.

Quick GuideTop Problems in Your Mouth

Top Problems in Your Mouth

White Tongue Symptoms and Signs

Whitening of the tongue can occur when there is a buildup or coating of bacteria and debris on the surface of the tongue due to:

  • mild dehydration,
  • illness (when there is less use of the tongue for talking or eating), or
  • dryness of the mouth.

A whitening of the top layer of the tongue or the presence of white spots or patches on the tongue can also be seen with infection, irritation, or chronic inflammation of the surface of the tongue. Certain oral infections, notably Candida yeast infections (known as oral thrush), are characterized by a white tongue.

What are the risk factors for tongue problems?

Depending on the tongue problem, risk factors may include smoking tobacco, drinking alcohol, poor oral hygiene, viral infections, a weak immune system, and even stress.

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 white tongue -- a fungal infection referred to as oral thrush, leukoplakia, oral lichen planus, hairy leukoplakia, and linea alba.

Oral thrush (or candidiasis) is a caused by an overgrowth of yeast 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, size of the lesion, and number of 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 during 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 own tissue). It is characterized by a white lace-like pattern called reticular lichen planus. (There is an erosive form that presents as shallow ulcerations 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 immunocompromising condition. Antiviral medications such as acyclovir (Zovirax) may be used. Recurrence of hairy leukoplakia is common.

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 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 discolored red 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, cause for concern can be 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, 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 use of products that contain bismuth such as Pepto-Bismol. ("Hairy tongue" by itself can also be white or tan.) Treatment may involve improving one's diet, smoking cessation, and improved oral hygiene (including gently brushing 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 reaction 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, 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 new treatment may be a possible option for advanced cancers. Each individual should understand the nature of the cancer and options available for treatment in order 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 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, 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' time, but oral herpes can also be treated with antiviral medications 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, supplement for nutrition deficiencies, or medications to treat anxiety or depression).

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. Pain, taste, touch, perception of temperature and perception of relative position and movement (proprioception) may be involved. The sensation of "pin and needles" similar to being numb during a dental procedure may persist. Usually, treatment involves waiting for the nerve to self-repair itself in 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 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 taste. If dysgeusia is due to a temporary condition, it should resolve once the cause is removed. Damage to taste buds through radiation therapy may require time for healing to occur. 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 is able to 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 is restricting the tongue's movements.

What are tongue problems in infants and children?

The most common tongue problem found amongst infants and young children is oral thrush characterized by white patches on the tongue. It often occurs after a course of antibiotics is taken by the infant or breastfeeding mother. "Good bacteria" is killed off allowing for an overgrowth of yeast. Treatment involves antifungal medications for the infant and, if breastfed, the mother to avoid passing the infection back and forth.

Other common tongue problems found in children are:

  • fissured tongue,
  • geographic tongue,
  • traumatic injury, and
  • aphthous ulcers (canker sores).

Less common tongue problems in children include "strawberry tongue," as seen in Kawasaki's disease.

What are tongue problems in pregnancy?

A small percentage of women experience a sore tongue while pregnant. This may be related to the hormonal changes taking place during pregnancy. The soreness could also be in combination with geographic tongue where bare areas are present and disappear as well as reappear. These conditions usually resolve after the pregnancy ends.

What specialists treat tongue problems?

Depending on the tongue problem, there is a specific doctor for treatment. Initially, evaluation of tongue problems can be assessed by a dentist and if needed, an appropriate specialist can be recommended for further evaluation and subsequent treatment.

For tongue lesions such as changes in color, growths, or texture changes, an oral surgeon or an otolaryngologist (ear, nose and throat specialist, also known as an ENT specialist) can evaluate the area, perform a biopsy, and follow up or refer for appropriate treatment such as surgery or medication. Tongue pain may also be addressed with an oral surgeon or ENT, but a neurology specialist may be appropriate if the pain is related to neuralgia. Tongue movement problems stemming from injury may also be treated by a neurology specialist in conjunction with occupational or physical therapists.

For tongue cancer, a group of specialists could be involved depending on the spread of the disease. A head and neck surgeon, an oncologist, a radiation oncologist, an oral surgeon, and a dentist could comprise the team of doctors that help in treating the oral cancer patient.

How do health-care professionals diagnose tongue problems?

During an examination with a physician or dentist, information based on symptoms and clinical appearance is collected. Based on this information, a diagnosis is made. However, if there isn't a unique sign or symptom to distinguish the tongue problem, a differential diagnosis is reviewed. A differential diagnosis lists all the possible causes of the signs and symptoms. It is a systematic process of weighing the probability of one disease versus that of other diseases that may account for the tongue problem. For example, a white tongue lesion may have the differential diagnosis of lichen planus, leukoplakia, or contact inflammation from dentures. Each of these causes can be carefully considered based on what is observed. Subsequently, a plan of treatment can be made.

For many tongue conditions that might be cancer, a special dye called toluidine blue has been useful to aid in diagnosis. Toluidine blue staining is able to help in early identification of precancerous or cancerous lesions.

A more definite diagnosis requires a biopsy. A biopsy is a procedure whereby a sample of cells or tissue is evaluated under a microscope. Optimal treatment requires a precise diagnosis.

Are there home remedies for tongue problems?

For pain related to the tongue, over-the-counter pain-relief medications such as ibuprofen (Advil) or naproxen (Aleve) may help. "Burning tongue" pain may be alleviated with sucking on ice or bathing the tongue in cold water. Such home remedies, however, may provide only temporary relief.

For the most part, tongue conditions that appear to have no known cause (such as an obvious injury) should be evaluated by a physician or dentist for appropriate diagnosis, monitoring, and possible treatment.

What are the treatments for tongue problems?

The treatment of a tongue problem depends on the underlying cause. For some tongue problems, no treatment is necessary whereas for other conditions, medications, surgery, or radiation may be needed. If the tongue issue is a result of an underlying medical condition, treatment of the underlying problem can be key to solving the problem.

Is it possible to prevent tongue problems?

Some tongue problems are preventable by practicing good oral hygiene and eating a healthy, nutritious diet while some tongue conditions cannot be prevented at all, but symptoms may be managed with treatment. Other tongue problems may be a byproduct of an underlying medical condition that needs to be addressed. For example, signs of an HIV infection (or final stage of HIV infection, AIDS) often appear in the mouth along with other bodily symptoms. HIV testing is important in determining if HIV treatment and care is needed.

Exercising moderation or altogether quitting the habit of smoking and drinking alcohol will decrease the risk of developing oral cancer. A vaccine for HPV is being studied, and it may help in guarding against oral cancers, as well. Oral cancer screenings should always take place during routine dental visits. Screenings can also take place with an ear, nose, and throat (ENT) physician. These oral cancer screenings involve an examination of all the soft tissues in the mouth, including the tongue, floor of the mouth (under the tongue), palate (roof of the mouth), inside of the cheeks, and throat area.

What is the prognosis for tongue problems?

Fortunately, most tongue problems are benign and treatable. Therefore, the prognosis is generally very good.

In regard to growths on the tongue, the main concern is oral cancer. Early detection and treatment usually provides the best chance for recovery and survival. The prognosis for oral cancer is dependent upon the stage of the cancer, the location of the tumor, and whether the cancer has spread to blood vessels. Frequent follow-up and close monitoring are crucial parts of care. Unfortunately, the overall prognosis for oral cancer is generally poor. In the U.S., approximately half of individuals newly diagnosed with oral cancer do not survive after more than five years. Despite advances in treatment with surgery, radiation, and chemotherapy, the poor prognosis is due to the cancer being discovered at a later stage in its development.

When treating tongue cancer with surgery, the patient may experience the complication of numbness of the tongue. The numbness may or may not resolve. Radiation and chemotherapy treatment may also cause decreased saliva flow and changes in taste that may take time to improve or not improve at all.

REFERENCES:

Gao, Jianming, et al. "A case-control study on etiological factors involved in patients with burning mouth syndrome." Journal of Oral Pathology & Medicine 38.1 (2009): 24-28.

Majorana, Alessandra, et al. "Oral mucosal lesions in children from 0 to 12 years old: ten years' experience." Oral Surg Oral Med Oral Pathol Oral Radiol Endod (2010).

Reamy, Brian, et al. "Common Tongue Conditions in Primary Care." American Family Physician (2010): 627-634.

Last Editorial Review: 1/31/2017

Reviewed on 1/31/2017
References
REFERENCES:

Gao, Jianming, et al. "A case-control study on etiological factors involved in patients with burning mouth syndrome." Journal of Oral Pathology & Medicine 38.1 (2009): 24-28.

Majorana, Alessandra, et al. "Oral mucosal lesions in children from 0 to 12 years old: ten years' experience." Oral Surg Oral Med Oral Pathol Oral Radiol Endod (2010).

Reamy, Brian, et al. "Common Tongue Conditions in Primary Care." American Family Physician (2010): 627-634.

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