Although the technology that can identify oral pathology has greatly improved in the past decade, dental professionals should still understand the importance of conducting a visual dental examination and be able to accurately diagnose disease when present. As dental professionals, we are trained to identify routine ailments that involve the teeth and periodontium. Caries, gingivitis or periodontitis, ulcerations, erythroplakias/leukoplakias, etc., are all disease entities that we should be familiar with when performing initial or recare examinations. Unfortunately, one of the most important oral structures that is often overlooked and can be a manifestation of systemic disease is the tongue.
This clinical tip’s intent is to provide the dental health professional with an aid to examining the tongue, recognizing characteristics of a normal disease-free tongue, and identifying the top five pathologies most likely to affect the tongue that could represent larger systemic issues.
Procedure for general dental examination of the tongue:
- Have the patient touch the tip of the tongue to the roof of the mouth and inspect the ventral surface.
- Have the patient protrude the tongue straight out and inspect for deviation, color, texture, and masses.
- Hold the tongue with gauze in one hand while palpating the tongue between the thumb and index finger of the other, noting any masses and areas of tenderness.
When performing a physical examination of the tongue, compare to these three main characteristics of a normal disease-free tongue:
- Color: The tongue should be a pinkish to reddish color on the dorsal and ventral surfaces. The ventral surface may be blueish in nature and have some visible vasculature.
- Texture: The tongue should have a rough dorsal surface due to papillae (taste buds). There should be no hairs, furrows, or ulceration. The ventral side of the tongue should have a smooth surface.
- Size: The tongue should fit comfortably in the mouth with the tip against the lower incisors. The sublingual glands should not be displaced.
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Watch for the top five oral pathologies affecting the tongue that could represent larger systemic issues:
1. Change in surface texture:
a. Atrophic (smooth tongue): The most obvious cause of an atrophic tongue is the use of dentures and the mechanical exfoliation of the dorsal surface. Nutritional deficiencies, especially vitamin B12 deficiency (pernicious anemia), can also be a root cause (figure 1). Other deficiencies that can contribute include vitamin B3, B6, B9, and iron.
Figure 1: Atrophic tongue
2. Changes in color:
a. White: A white tongue may be a sign of oral candidiasis (thrush), which is the result of an infection by Candida albicans (figures 2 and 3). This most typically occurs in patients with some form of immunosuppression (HIV), diabetes, chronic denture use without hygiene, and/or antibiotic use (usually over long-term periods). Painless white plaques on the tongue or oropharynx that can be removed and may result in bleeding are the hallmark of this fungal infection.
Another reason for a white tongue can be due to oral lichen planus (figure 4), a chronic inflammatory condition caused by an autoimmune response. It is characterized by a white lace-like pattern called reticular lichen planus.
Geographic tongue (figure 5) 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. Recent evidence, however, suggests that geographic tongue may be linked with inflammation of the intestine, or what has been dubbed “leaky gut syndrome.”
|Figure 2: Candida albicans||Figure 3: Thrush|
|Figure 4: Oral lichen planus
||Figure 5: Geographic tongue|
b. Red: The most obvious cause of a red tongue is due to color in food or drink or acidic foods that can cause temporary redness and discomfort. However, a 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). A beefy red tongue can also be due to a vitamin B12 deficiency.
c. Black: A black tongue is usually a harmless condition that can be caused by chlorohexidine rinses, medications, smoking, poor oral hygiene, soft diet, or dry mouth (figure 6). Associated with elongated tongue papillae, 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.
Figure 6: Black, hairy tongue
3. Changes in size:
a. Macroglossia: Macroglossia is swelling or enlargement of the tongue and can be caused by routine things such as allergies, medications, and injuries. Allergic reaction to medications, food, or insect bites can cause swelling of the tongue. Tongue swelling can also be a side effect of medication. Some medications that have this side effect are ACE inhibitors, NSAIDs (nonsteroidal anti-inflammatory drugs), and aspirin. An injury from hot food or liquid that burns the tongue or simply biting the tongue can irritate it and cause swelling. A more severe underlying medical condition that has been associated with tongue swelling is amyloidosis, and the distinction must be made. New-onset macroglossia in an adult is pathognomonic for amyloidosis and should be treated as such until proven otherwise.
b. Microglossia: Microglossia may result from damage to the upper motor neurons of the corticobulbar tracts that innervate the tongue. This condition presents with a small, stiff tongue. In newborns there may be an apparent microglossia that results from a congenitally short lingual frenulum (ankyloglossia), commonly called tongue-tie.
4. Changes in taste: Complete loss of taste is called ageusia, partial loss of taste is called hypogeusia, and a distorted sense of taste is called dysgeusia.
a. The most common cause of strange taste is due to medications. The most common change is a metallic taste, and these are associated with some forms of antibiotics; chlorhexidine rinses; antihistamines; antifungals; antipsychotics; blood pressure, diabetes, seizure, and Parkinson’s disease medications; among others.
Other more common things that can change taste are dry mouth, colds or flu, smoking, loss of smell, and nutritional deficiencies (again, B12 and zinc).
5. Ulcerations: When examining ulcers of the tongue, it is important to note their size, number, color, distribution, and whether or not they cause the patient any discomfort. Lesions that do not heal or regress in 10–14 days should be of concern and either biopsied or referred to a specialist.
a. Aphthous ulcers: An aphthous ulcer is a painful form of ulceration frequently encountered. The ulcer appears in one of several patterns: minor, major, or herpetiform. Minor aphthous ulcers (figure 7) are usually 2–8 mm in size and spontaneously heal within 14 days. Major aphthous ulcers are > 1 cm in size and may scar when they heal. Herpetiform ulcers are pinpoint size, often multiple, and may coalesce to form a larger ulcer.
b. Recurrent aphthous ulceration: A recurrent aphthous ulceration occurs in some systemic illnesses, including Crohn’s disease, celiac disease, Behcet’s syndrome, pemphigus, herpes simplex, histoplasmosis, and reactive arthritis (Reiter’s syndrome).
c. Erythroplakia and leukoplakia: Erythroplakia (figure 8) is a red area or lesion on the tongue that cannot be rubbed off. Leukoplakia has the same definition, just white in color. 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 cause for concern if the lesion or sore does not go away or grows larger.
|Figure 7: Aphthous ulcer
||Figure 8: Erythroplakia|
Scott Froum, DDS, a graduate of the State University of New York Stony Brook School of Dental Medicine, is a periodontist in private practice in New York City. He is the editorial director of Perio-Implant Advisory e-newsletter, as well as a contributing author for DentistryIQ and Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a clinical associate professor at both SUNY Stony Brook and the NYU Dental School in the Department of Periodontology and Implantology. He serves on the board of editorial consultants for the Academy of Osseointegration's Academy News. Contact him by e-mail at email@example.com or through his website at drscottfroum.com.