Tongue Lesions

💡Traumatic atrophic glossitis

Definition: Inflammation with atrophy of the tongue papillae caused by mechanical trauma or systemic factors.

Causes

• Mechanical irritation.
• Iron deficiency.
• Vitamin B12 deficiency.
• Folate deficiency.
• Other nutritional deficiencies.

Clinical features

• Smooth, red, shiny areas of the tongue.
• Loss of filiform papillae.
• Burning or soreness may occur.
• Distribution may be localized or generalized, depending on the cause.

Diagnosis and management

• Identify and remove local irritants.
• Investigate nutritional deficiencies when indicated.
• Treat the underlying cause.
• Biopsy persistent or suspicious lesions, particularly if erythroplakia or malignancy is a concern.

FCPS tip: A smooth, red, depapillated tongue suggests atrophic glossitis. Consider iron, vitamin B12 and folate deficiencies.

💡Benign migratory glossitis (geographic tongue)

Definition: A benign inflammatory condition characterized by migrating erythematous areas of depapillation surrounded by pale or white serpiginous borders.

Clinical features

• Irregular red patches with white or yellow-white borders.
• Lesions change location and shape over time.
• Commonly affects the dorsal and lateral tongue.
• Often asymptomatic but may cause sensitivity to spicy or acidic foods.
• May be associated with fissured tongue and psoriasis.

FCPS tip: Migrating erythematous patches with serpiginous white borders = geographic tongue.

💡Hairy tongue

Definition: Elongation and accumulation of keratin on the filiform papillae, producing a hair-like appearance.

Predisposing factors

• Poor oral hygiene.
• Smoking.
• Excessive tea or coffee consumption.
• Xerostomia.
• Antibiotic use.
• Reduced mechanical debridement of the tongue.

Clinical features

• Elongated filiform papillae on the dorsal tongue.
• White, yellow, brown or black discoloration.
• Halitosis or altered taste may occur.
• The posterior dorsal tongue is commonly affected.

Management

• Gentle tongue brushing or scraping.
• Improve oral hygiene.
• Stop smoking.
• Correct contributing xerostomia and medication-related factors where possible.

FCPS tip: Hairy tongue results from elongated filiform papillae, not fungal invasion of the papillae themselves.

💡Fissured tongue (scrotal or plicated tongue)

Definition: A benign developmental variation characterized by grooves or fissures on the dorsal tongue.

Clinical features

• Multiple grooves of varying depth.
• Often asymptomatic.
• Food debris may collect within deeper fissures.
• Can coexist with geographic tongue.

Associations

Management

• Usually no treatment is needed.
• Encourage gentle tongue cleaning to prevent food debris accumulation.

FCPS tip: Fissured tongue is benign. Fissured tongue + orofacial swelling + facial palsy suggests Melkersson–Rosenthal syndrome.

💡Chronic ulcers of the tongue

Persistent tongue ulcers require careful assessment because traumatic ulcers can resemble malignant lesions.

Causes

• Mechanical trauma from sharp teeth or restorations.
• Repeated biting.
• Infectious causes.
• Systemic disease.
• Oral squamous cell carcinoma.

Important clinical rule

Any unexplained oral ulcer persisting for more than 2–3 weeks requires assessment and usually biopsy or urgent specialist referral.

Clinical differentiation

FCPS tip: A persistent ulcer on the lateral or ventral tongue with induration must raise suspicion for squamous cell carcinoma.

💡Anemia-induced tongue changes

Nutritional and hematological disorders can cause atrophy of the tongue papillae and mucosal soreness.

Hunter's glossitis

• Associated with vitamin B12 deficiency.
• Produces a smooth, red, shiny or beefy-red tongue.
• May be accompanied by burning and soreness.
• Neurological manifestations support B12 deficiency rather than isolated folate deficiency.

Plummer–Vinson syndrome

The classic triad is:

1. Iron-deficiency anemia.
2. Dysphagia.
3. Esophageal webs.

It is associated with an increased risk of upper aerodigestive tract squamous cell carcinoma.

FCPS tip: Iron-deficiency anemia + dysphagia + esophageal webs = Plummer–Vinson syndrome.

💡Median rhomboid glossitis

Definition: A well-demarcated, erythematous, rhomboid-shaped area of depapillation in the midline of the posterior dorsal tongue, anterior to the circumvallate papillae.

Clinical features

• Smooth, red, oval or rhomboid patch.
• Located in the posterior midline of the tongue.
• Often asymptomatic.
• May be associated with Candida infection.

Management

• Usually requires no treatment if asymptomatic and clinically typical.
• Consider antifungal therapy if candidiasis is suspected and symptoms or examination findings support it.
• Biopsy if the lesion is atypical, indurated or persistent with diagnostic uncertainty.

FCPS tip: Fixed, midline posterior dorsal tongue depapillation = median rhomboid glossitis.

💡Macroglossia

Definition: Abnormal enlargement of the tongue, either true enlargement of the tissue or relative enlargement within the oral cavity.

Causes

Clinical features

• Enlarged tongue.
• Indentations along lateral borders from contact with teeth.
• Speech and swallowing difficulties.
• Tooth displacement or malocclusion in some cases.

Management

• Investigate the underlying cause.
• Correct systemic disease where possible.
• Surgical reduction may be considered in selected severe cases.

FCPS tip: Macroglossia + coarse facial features and systemic signs of amyloidosis should prompt consideration of systemic amyloid disease.

💡Ankyloglossia (tongue-tie)

Definition: Congenital restriction of tongue movement due to a short, thick or abnormally positioned lingual frenulum.

Clinical features

• Restricted tongue protrusion or elevation.
• Difficulty elevating the tongue toward the palate.
• Speech difficulties in selected patients.
• Feeding difficulties may occur in infants.
• The tongue tip may appear notched or heart-shaped on protrusion.

Assessment and management

• Evaluate functional limitation rather than frenulum appearance alone.
• Frenotomy or frenuloplasty may be considered when restriction causes clinically significant problems.
• Speech or feeding assessment may be useful when indicated.

FCPS tip: A heart-shaped tongue tip on protrusion is a classic clue for ankyloglossia.

💡TONGUE LESION DIFFERENTIAL DIAGNOSIS

How to differentiate common tongue lesions

💡Common tongue lesions

💡Oral injuries and radiation complications