Tongue Lesions

Lesions of the tongue have a broad differential diagnosis ranging from benign idiopathic processes to infections, cancers, and infiltrative disorders.  

The most important thing to remember is that most tongue lesions will resolve spontaneously or with simple therapy within a week…if not, they should be biopsied or evaluated further for a definitive diagnosis of a potentially serious disorder. Some tongue lesions may be clues to other underlying illnesses which require further evaluation.

Common causes of tongue lesions are:

• Malnutrition/Vitamin Deficiencies (especially B vitamins)

• Anemia

• Iron deficiency

• Pernicious Anemia (B12 not absorbed)

• HIV Infection

• Oral Candidiasis, HSV

• Primary Skin Diseases

• Apthous Ulcers, syphilis, lichen planus, erythema multiforme, Behcet’s syndrome (with assoc. vaginal ulcers), etc.

• Certain Prescription Medications (lansoprazole plus an antibiotic for treatment of PUD), other drugs

• Trauma (burns, seizures/tongue biting, ill-fitting mouth gear (dentures, braces, mouth guards, etc)

• Local infection (viral, candidal, streptococcal, TB)

• Irritants (hot foods, spices, chewing or smoking tobacco, alcohol, excessive citrus fruits or peppermint, mouth wash, toothpaste, dyes)

• Malignancy

• Benign/idiopathic

Treatment (In General)

• Treat the underlying disorder if known—see Oral Candidiasis belowb

• Pain Medication as needed

• Avoid all possible irritants (tobacco or hard, hot, acidic, sharp, or irritating foods)

• Good dental hygiene/dental consult if needed

• Topical rinses/treatments—give one of these a try:

  • Topical viscous 2% lidocaine—rinse with ½ tsp. in 2 tsp. water for 2-3 minutes or up to 1 Tbsp. full strength QAC and Q3H prn

  • Coat mouth with milk of magnesia or a Mg containing antacid such as Maalox

  • Mouth rinse with ½ tsp. Sodium bicarbonate in 8 oz warm H2O QID

  • Mouth rinse with carbamide peroxide (Gly-Oxide) 10% ½ mL or 10 drops QID for irritation or apthous ulcers

  • Kenalog in Orabase (triamcinolone 0.1% in dental paste) to specific lesions, esp. apthous ulcers

White Lesions (3 categories)

Oral Candidiasis (Thrush

These white plaques may involve all intraoral surfaces.  The plaques are easily scraped off revealing a red base.  Diagnosis may be confirmed with a scraping and 10% KOH microscopic exam to verify pseudohyphae.  Oral candidiasis in NOT normal in healthy young adults unless they are currently receiving antibiotics, steroids, or other immunosuppressive therapy.  In an otherwise healthy person, HIV infection with immunosuppression must be considered.  All such patients should be evaluated and tested for HIV as soon as possible (3-5 days at most).  If HIV infection is present, early evaluation and treatment by an Infectious Disease specialist is mandatory. 

Undiagnosed diabetes may cause oral candidiasis. Serum or urine glucose should be checked to rule out hyperglycemia.  In the meantime, treatment options for thrush include dilute hydrogen peroxide rinses for pain, as well as antifungals—try clotrimazole lozenges (Mycelex troches) 10mg 5x per day for 2 weeks, Nystatin “swish and swallow” oral solution 1 tsp. QID to be held in mouth 5 minutes before swallowing, or fluconazole (Diflucan) 100mg PO qd for 7 days.

Traumatic plaques 

These are caused by cheek biting, irritants (i.e. tobacco or aspirin), or perhaps sharp margins of carious or maligned teeth—such lesions should improve significantly within a week or so if the underlying problem is corrected.

Hairy Leukoplakia

These are white plaques with a hairy-looking surface found most often on the lateral aspects of the tongue; they are painless; EBV and HPV are often associated.  The pt should be questioned about HIV risk factors and tested for HIV; AIDS develops in many of these patients within a few months of onset of lesions—acyclovir 800mg PO QID may provide temporary regression of lesions.

ALL OTHER WHITE LESIONS should be biopsied

leukoplakia (white patch)

This is often a precancerous lesion with high potential for malignant transformation; 90% of intraoral cancers are squamous cell carcinoma—early detection and prompt excision &/or radiation decrease mortality.  Lichen planus may resemble leukoplakia and must be biopsied.  

Lichenoid reactions 

These may occur secondary to drugs, allergies, or hepatitis—unless lesions quickly resolve after removal of offending agent, the plaques must be biopsied to rule out malignancy. 

Recurrent Apthous Ulcers

These multiple painful shallow ulcers often come and go in crops of 1 to 5 lesions.  Pt’s may also have herpetiform ulcers with 10 to 100 pinpoint lesions.  Such lesions occur throughout the oral cavity, and the cause is not known.  General symptomatic treatment is warranted, and patients should be evaluated for possible vitamin deficiencies (B12, folate, iron) which may be treatable causes.  Irritants and trauma should be avoided.  Topical or oral steroids may be required for persistent lesions. 

Geographic Tongue (Benign Migratory Glossitis)

These are characterized by multiple irregularly shaped pinkish-to-white patches with white borders on the tongue. Single lesions may resolve over a few days and then reappear in different spots—the entire evolution may last weeks to months. These lesions are benign and will eventually resolve.  Treat with reassurance and symptomatically if needed.  Of note, such lesions may be associated with psoriasis or Reiter’s syndrome. 

Scrotal Tongue

This is a congenital abnormality notable for fissuring of the tongue (tongue looks like “scrotal skin”)—the only treatment is good oral hygiene to prevent infection in the deep crevices of the tongue—this will decrease the risk of severe halitosis (bad breath!)

Dry Mouth (Xerostomia)

These patients present with a very dry, sometimes painful tongue.  Temporary (reversible) causes include emotional stress, anticholinergic medications, salivary gland stones, and excessive mouth breathing.  If none of the above is identified or the condition does not improve, and especially if the patient has severely dry eyes (keratoconjunctivitis sicca), the patient should be referred for evaluation of possible scleroderma or other rheumatologic disorders.  Blood glucose should be checked to rule out diabetes.  While awaiting further evaluation, the symptoms may be relieved somewhat with sugar free hard candy or gum and frequent sips of water.  Such patients are at high risk of dental carries and candida—dental consult should be obtained if available. 

Black Hairy Tongue

Brownish or black colored lesions form on the tongue as the tongue papillae elongate (and look slightly hairy)—the color change is due to pigment-producing bacteria.  These lesions are usually secondary to antibiotic therapy, smoking, radiation therapy, or chronic candida infection.  Initial therapy includes brushing the tongue with a soft bristled toothbrush and dilute hydrogen peroxide. 

Smooth Tongue

In this disorder, the anterior 2/3 of the tongue is unusually smooth in appearance secondary to atrophy of the normal papillae.  This is usually caused by an underlying nutritional deficiency which must be identified and treated—i.e. iron deficiency (Plummer-Vinson syndrome), B12 deficiency (pernicious anemia), or niacin deficiency (pellagra). 

Median Rhomboid Glossitis

A well-demarcated, smooth, red, depressed lesion on the surface of the tongue—such lesions may be congenital or may be secondary to candida infection or possibly cancer.  Evaluate and treat for candida.  If not candida, these lesions must be biopsied to rule out carcinoma.

Macroglossia

Enlarged tongue—tumors, infections, infiltrative or metabolic abnormalities must be considered (sarcoidosis, amyloidosis) as well as acute allergic reactions (angioedema) or venous congestion (superior vena cava syndrome)—if unclear, refer for further evaluation—how quickly one is transferred in this case depends on patient stability (airway and vitals—ABC’s!!!)

Other Suspicious Lesions which must be biopsied to rule out cancer

• Chronic ulcers which do not heal within 2-3 weeks

• Nodular or  wart-like lesions

• Pigmented lesions

• Cysts or thickened tissue which cannot be accounted for by trauma or infection

If biopsy is indicated, the patient should be evaluated by an ENT physician, oral surgeon, or general surgeon within 5-7 days.

This section provided by LT April A. Truett, MC, USNR, Naval Medical Center Portsmouth

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