Glossitis

What is Glossitis?

If you’ve noticed changes in your tongue such as pain, different texture, or color, you may have a condition called glossitis, which means inflammation of the tongue. The observation of the tongue is a critical part of a normal health check-up and sometimes, dentists may refer you to a doctor for these concerns. Interestingly, the tongue can show signs of other systemic health conditions.

The tongue is a muscular organ inside the mouth that is necessary for swallowing and speaking. When you are an embryo, a bump known as the median lingual swelling forms your tongue. The tongue is innervated, or supplied with nerves, by the hypoglossal nerve, except for one muscle that is supplied by the vagus nerve. Two distinct nerves carry sensations from the front two-thirds of your tongue: the lingual nerve is responsible for general sensations, and the chorda tympani takes care of taste. The back one-third of your tongue gets its nerve supply from the accessory nerve.

There is a central groove dividing the tongue, called the median sulcus. This groove begins at the tip of the tongue and extends to a small hole known as the foramen cecum, forming a V-shaped groove or the sulcus terminalis. The top surface of your tongue has tiny bumps, especially on the front two-thirds, which are classified into three types. The most common type, called the filiform papillae, are distributed all across the top surface and do not have taste buds. The pointed filiform papillae give the tongue a rough texture and enable functions like licking and chewing.

A third type, the fungiform papillae, mostly appear on the front part of the tongue and are identified visually by their dome shape and red color. The back part of the tongue contains lymphoid tissue known as lingual tonsils. The bottom part of the tongue contains the lingual veins and lingual frenulum, which connects the tongue to the floor of your mouth. The ducts from your submandibular glands, also known as Wharton’s ducts, run parallel to the lingual frenulum.

What Causes Glossitis?

Glossitis, or inflammation of the tongue, can have several causes including:

1-Blood problems:

* Low iron levels

* Pernicious anemia, a kind of anemia caused by a lack of vitamin B12

2-Lack of certain vitamins:

* Vitamin B1

* Vitamin B2

* Vitamin B3

* Vitamin B6

* Vitamin B9

* Vitamin B12

3-Infections:

* Viruses: herpes viruses, and the inflammation of the tongue after herpes

* Bacteria: these are rarities in people with a healthy immune system

* Fungi: mostly Candida species, which is a type of yeast

* Parasites: such as malaria or spirochetes, a type of bacterium

4-Certain medications:

* ACE inhibitors, which are used to treat high blood pressure

* Albuterol, used to treat breathing difficulties

* Antimicrobial drugs containing organosulfur compounds (like sulphanilamide, sulphathiazole)

* Birth control pills

* Lithium carbonate, a medication used in the management of bipolar disorder

5-Other reasons:

* Emotional or mental health issues (like conversion disorders, anxiety)

* Contact with things that irritate the tongue, like alcohol, spicy food, and tobacco

* Familial characteristics (like a fissured or geographic tongue)

* Physical damage (like burns, regular dental trauma)

* Not hydrating well enough or drinking insufficient water

* Down syndrome, a genetic disorder

* Autoimmune conditions like psoriasis

* Burning mouth syndrome, a condition where a burning sensation is felt in the mouth without any obvious reason

Risk Factors and Frequency for Glossitis

Glossitis, an inflammation of the tongue, can be caused by various factors and its exact statistics are hard to pin down due to the multiple potential causes. It can be caused by a lack of certain vitamins, which is common in some parts of the world and can change depending on the population’s overall nutrition. Glossitis can also result from an infection or adverse reaction to medication. The good news is, glossitis typically clears up once the root cause is addressed, whether that’s treating a vitamin deficiency, eradicating an infection, or stopping a medication.

According to the Third National Health and Nutrition Examination Survey III, oral exams were conducted on over 17,000 adults. Out of this group, 27.9% had a total of 6,003 observed oral lesions. About 14.2% of these lesions were found on the top surface of the tongue, while only 1.3% were on the side of the tongue. As for specific forms of glossitis, the prevalence of geographic tongue (a harmless, map-like pattern on the tongue) ranged from 1.41 to 2.29%, and 0.46 to 0.30% for median rhomboid glossitis (a diamond-shaped inflammation on the middle of the tongue).

Signs and Symptoms of Glossitis

When assessing a patient with glossitis (an inflammation of the tongue), a detailed medical history is crucial. Doctors should find out about the patient’s overall nutritional status, diet restrictions, alcohol and tobacco use, and if their glossitis symptoms change with food or exposure to different environments. Information about any ongoing diseases that may weaken the immune system, any history of cancer, and any autoimmune or endocrine disorders are also important. Any changes to the patient’s medications, which may affect their glossitis symptoms, should be reviewed.

The common symptoms of glossitis include tongue pain, redness, swelling, loss of tongue papillae (small bumps that contain taste buds), and the development of new visible tongue lesions. The doctor should also ask about any family history of “geographic tongue” (a tongue condition that causes a map-like pattern to appear on the tongue).

An examination of the tongue is a crucial part of the physical check-up and forms part of the overall examination of the mouth. The doctor should take note of the top and bottom surface of the tongue, the nature of the mucosa (whether it’s wet, dry, reddened, has white patches, etc.), any visible tongue lesions, and the overall oral health. The doctor should be able to tell the difference between changes to the mucosa due to constant rubbing against rough teeth and changes because of direct problems with the tongue. The tongue and floor of the mouth should be physically examined for any tenderness or unusual feel.

A thorough check of the head and neck should also be conducted to note any swollen lymph nodes. Specific conditions and their symptoms include:

• Atrophic glossitis: This is characterized by a red tongue, a lack of lingual papillae, giving the tongue a smooth, shiny, dry appearance.
• Median rhomboid glossitis: This presents as central rhombic-shaped areas of thickened skin. These typically appear as red, elevated, plaque-like lesions that might be tender to touch. Usually, they appear in the central part of the movable part of the tongue.
• Benign migratory glossitis: Symptoms include areas of smooth tongue with loss of papillae. These areas may have a white border that may change position (migrate) over time and might be sensitive to touch or specific foods. It’s important to differentiate these from persistently white or red and white lesions which could be a sign of cancer.
• Geometric glossitis: Characterized by painful, linear cracks throughout the movable parts of the tongue.
• Strawberry tongue: This condition gives the tongue a red, peeled appearance on the top surface and is accompanied by persistently enlarged taste buds.

Testing for Glossitis

If you’re dealing with glossitis, which is an inflammation or infection of the tongue, your doctor will usually start by taking your medical history and conducting a physical examination. Glossitis may have a variety of causes, so your doctor might need to do additional tests based on their early diagnosis.

For instance, if they think a blistering disease like pemphigus vulgaris or bullous pemphigoid could be the cause, you might need to get a biopsy. A biopsy is when a small sample of tissue is collected to be examined under a microscope. A biopsy might also be done if there’s a particular spot on your tongue that isn’t healing or that your doctor is worried about; this helps rule out the possibility of cancer.

Lab tests can also be useful in diagnosing glossitis. If your doctor thinks you might have a vitamin deficiency, they could check your vitamin levels. Or if they believe your glossitis could be because of a condition where the body attacks itself (an autoimmune condition) like scleroderma, they may run a group of tests called rheumatologic studies. These tests could include checking levels of substances in the blood like rheumatoid factor, anti-ro, anti-la, other proteins, and the measures of overall body inflammation, like erythrocyte sedimentation rate and C-reactive protein.

If the glossitis might have been caused by a weakened immune system or an infection that takes advantage of a weakened immune system (opportunistic infection), tests like complete blood count or HIV testing might be necessary. Similarly, if conditions such as diabetes or a thyroid disorder are suspected, your doctor might order endocrine studies, which can include tests such as hemoglobin A1c or thyroid function tests.

Finally, while imaging (getting a deeper look at what’s going on inside your body using technology like X-rays or ultrasound) isn’t normally needed for glossitis, if there’s a possibility the inflammation might be due to cancer, your doctor might order a computed tomography (CT) scan of your neck with IV contrast. This test involves using a special X-ray machine to take multiple pictures of your neck from different angles, which are then combined by a computer to produce detailed images.

Treatment Options for Glossitis

Glossitis, a condition where your tongue becomes swollen and changes color, can typically resolve itself and often doesn’t need any medical treatment. However, if the condition is painful or causing discomfort, good oral hygiene and mouth rinses can help. Some people find “magic mouthwash” helpful, which is a special mix that often contains corticosteroids (to reduce inflammation) and lidocaine (to numb the area and relieve pain).

Sometimes, specific treatments may be required:

If you have atrophic glossitis (when your tongue is smooth and glossy), your doctor might recommend injections of vitamin B12.

For median rhomboid glossitis (a smooth, red patch on your tongue), you might need antifungal treatments if you have symptoms. An example of this is a nystatin swish-and-swallow solution.

Benign migratory glossitis, also known as geographic tongue, is a harmless condition that affects the surface of your tongue. If you’re experiencing an acute episode (one that comes on very quickly), mouth rinses can help with the discomfort.

In the case of geometric glossitis (a pattern on the tongue), antiviral treatments might be used, but this has had limited success. Again, simply reassuring the patient can be the best approach, as the condition is usually harmless.

Strawberry tongue, which makes your tongue look berry-like (red and blotchy), can be treated with vitamin B12 supplementation.

Medication-induced glossitis can occur as a side effect of certain medications. If this happens, the offending medication needs to be stopped.

If your glossitis is caused by an infection, it will need to be treated. If opportunistic infections are suspected (these are infections that take advantage of a weakened immune system), an immunology workup may be required, along with controlling diabetes if that’s a factor.

What else can Glossitis be?

When a doctor is trying to diagnose glossitis, which means an inflammation of the tongue, they look at the appearance of the tongue, which can help narrow down the possible causes. These can include:

Normal-looking tongue might be caused by:

• Burning mouth syndrome
• Diabetic neuropathy
• Post-herpetic glossitis (after a herpes outbreak)
• Acid reflux

Atrophic glossitis, when the tongue looks smaller or smoother than usual, could be due to:

• Protein-calorie malnutrition
• Vitamin B12 deficiency
• Blistering diseases
• Yeast infection (candidiasis)
• Dry mouth (xerostomia)

Median rhomboid glossitis, characterized by a diamond or rhombus-shaped patch on the tongue, might be associated with:

• Blood vessel tumor (hemangioma)
• Geographic tongue (a map-like appearance)
• Deposits of abnormal protein in tissues (amyloidosis)
• Yeast infection (candidiasis)
• Skin cancer of the tongue (squamous cell carcinoma)

A strawberry red tongue could be a symptom of:

• Yellow fever
• Kawasaki disease
• Toxic shock syndrome

Geographic tongue may occur due to:

• Oral lichen planus (a condition that can cause swelling and irritation in the mouth)
• Chemical or inhalational irritant, like smoking
• Dehydration
• Yeast infection (candidiasis)
• Connective tissue disease
• Blistering diseases
• White patches in the mouth (leukoplakia)

What to expect with Glossitis

The outcome of glossitis, a condition where the tongue becomes inflamed, largely depends on its cause. Even though it is generally harmless, it can last for a long time, or even be lifelong, with occasional bouts of symptoms, like geographical tongue (patterns on the tongue that shift around). Some patients are highly sensitive to, and distressed by, the look of their tongue and/or the physical discomfort.

Medications to reduce anxiety can be used if necessary. Many glossitis causes are treatable, and the condition can get better once the root cause is taken care of. If there’s any suspicion of cancer, a biopsy (removal of a small piece for examination) of the area should be carried out immediately, so that prompt treatment can be started if needed.

Possible Complications When Diagnosed with Glossitis

The main complication that people often experience is anxiety about how their tongue looks, and it can be quite tough to reassure them. To give both the patient and the provider peace of mind that there is no serious illness like cancer causing the changes on the tongue, it may be wise to perform a biopsy.

Complications & Solutions:

• Common complication: Anxiety due to tongue appearance
• Difficulty: Reassuring the patient
• Potential solution: Biopsy to confirm the absence of serious conditions like cancer

Preventing Glossitis

Glossitis is usually a harmless condition that affects the top surface of the tongue, and often doesn’t require any specific treatment other than providing the patient with the necessary information about their condition. If symptoms persist such as inflammation or pain, mouth rinses that reduce inflammation and relieve pain can be used. If there’s a persistent or unchanging sore in the mouth or on the tongue, a biopsy should be performed to ensure it’s not cancerous. Maintaining good oral hygiene can help lessen the symptoms of glossitis.