glossitis
Description
An acute or chronic inflammation of the tongue
Glossitis may be a result of a primary disease or treatment of a disease, or the symptom of a systemic disease
May be caused by lifestyle irritants, such as tobacco, alcohol, hot foods, or chemical irritants such as mouthwash or toothpaste
May also be the result of a local trauma, such as badly fitting dentures
Treatment measures include avoidance of aggravating irritants, specific therapy for oral infections, scrupulous oral hygiene, and, in some cases, a dental evaluation should be requested
Cardinal features
An acute or chronic inflammation of the tongue
May be a localized form secondary to trauma etc, or generalized secondary to a systemic etiology
May be secondary to local trauma such as badly fitting dentures or irritants such as tobacco, alcohol, toothpaste, mouthwash, malnutrition, anemia, skin disease, herpes simplex virus, or HIV infection
Depending on the etiology, there may be ulcers, white patches, denuded smooth areas, nonpainful solitary ulcerations, or a combination of ulcers, nodules, or linear fissures

Causes
Common causes
The most common cause is oral candidiasis caused by Candida albicans
Reflux and peptic ulcer disease
Malnutrition with hypovitaminosis
Pernicious anemia or iron-deficiency anemia
Local infections such as viral infections, tuberculosis, or streptococcal infections
Local trauma such as badly fitting dentures, or burns
Alcohol, smoking, hot and/or spicy foods, excessive peppermint, citrus fruits, excessive exposure to chemical irritants such as mouthwash and toothpaste, or certain drugs

Rare causes
Inflammatory infections such as lichen planus, pemphigus vulgaris, and erythema multiforme
Cancers and malignancy
HIV infections/AIDS
Syphilis

Serious causes
HIV infection: predisposes an individual to candidiasis and herpes simplex virus infection, which may result in loss of papillae.
Contributory or predisposing factors
Antibiotic usage
Inhaled steroids for the treatment of COPD/asthma may cause glossitis - rinsing the mouth out after inhalation significantly reduces the risk
Low socioeconomic class: associated with poorer nutrition, and higher levels of smoking and alcohol consumption
Poor nutrition: vitamin B deficiency predisposes to glossitis
Dentures: if poorly fitting, can create local trauma leading to glossitis
Smoking: lifestyle irritant, which can cause or exacerbate glossitis
Advancing age: elderly individuals more likely to be denture-wearers and have poor nutritional status
Immunocompromised status: HIV-infected individuals more prone to infections such as tuberculosis, Candida albicans, which are causes of glossitis

Epidemiology
Demographics
Age
Can occur at all ages, although old age is a risk factor.
Gender
More common in males.
Socioeconomic status
Mostly seen in persons of lower socioeconomic status or malnourished patients.

Clinical presentation
Symptoms
Painful tongue
Burning tongue
Swollen tongue
Signs Tongue may be reddened at the tip and edges
Tenderness of the tongue
Tongue may be red, swollen, and ulcerated with pellagra, or smooth and pale with anemias
Depending on the etiology, there may be ulcers, white patches, denuded smooth areas, nonpainful solitary ulcerations, or a combination of ulcers, modules, and linear fissures
Associated disorders
Associated systemic infections
HIV infection
Diabetes mellitus

Differential diagnosis
Iron-deficiency anemia
Common, and the cause of iron-deficiency anemia must be investigated.
Features
Weakness, fatigue, lightheadedness, palpitations
Pica, dysphagia due to webs in postcricoid area (Plummer-Vinson syndrome), anorexia, nausea, constipation
Angular stomatitis
Atrophic glossitis
Common causes include menorrhagia and gastrointestinal bleeding from a peptic ulcer, gastric or colonic carcinoma, hiatus hernia or diverticulosis
Investigations include fecal occult blood, sigmoidoscopy, and barium enema
Treatment is of the underlying cause and iron replacement

Pernicious anemia
Autoimmune disease caused by antibodies to intrinsic factor and gastric parietal cells. The main features of pernicious anemia are as follows.
Features
Symptoms include generalized weakness, delirium, glossitis, peripheral sensory neuropathy, loss of joint position sense, pyramidal or long track
signs
There may be splenomegaly and mild hepatomegaly
Treatment strategies include parenteral vitamin B12 replacement therapy

Candidiasis
Candidiasis is an inflammatory process involving the mouth, vulva, and/or vagina.
Features
Caused by infection with Candida species; Candida albicans is the causative agent in 85-95% of cases
Treatment of oral candidiasis includes nystatin, fluconazole, ketoconazole, or itraconazole

Squamous cell carcinoma of the tongue
Squamous cell carcinoma is an epithelial malignancy.
Features
Associated with poor oral hygiene, smoking, and alcohol use
Treatment strategies include surgical excision with radio- and/or chemotherapy, and cessation of smoking

Pemphigus vulgaris
Pemphigus vulgaris is a bullous skin disease associated with HLA-DRW4 or HLA-A10 in 91% of patients.
Features
Separation of the epidermal cells from above the basal layer leads to blister formation
Skin forms baggy blisters since the overlying epidermis is thin
Treatment involves steroids, cyclophosphamide, azathioprine, nicotinamide, and tetracycline
Antibody titers should be monitored

Syphilis
Syphilis is a sexually transmitted disease caused by infection with Treponema pallidum.
Features
Characterized by primary skin lesions and secondary eruptions involving the skin and mucous membranes
Characteristic lesion of primary syphilis is the presence of a painless chancre in the mouth, genitalia, or anus
Secondary syphilis occurs after 4-8 weeks and patients have maculopapular lesions on their palms and soles, fever, chancre, malaise, and lymphadenopathy
Tertiary syphilis follows 2-20 years latency and patients have gummas (granulomas of the skin, mucosa, bone, joints, and viscera)
Quaternary syphilis includes cardiovascular and neurologic features
Treatment is with systemic penicillin

Erythema multiforme
Erythema multiforme is an inflammatory disease which may be secondary to immune complex formation and deposition in the skin and mucous membranes.
Features
Skin lesions are symmetrical with a classic target appearance
Lesions most common on the backs of hands and feet rather than in the mouth
The majority of cases of erythema multiforme occur after outbreaks of herpes simplex

Behcet's syndrome
Behcet's syndrome occurs as an immune complex small vessel vasculitis.
Features
Characterized by deep, painful oral ulcerations, which may be aphthous or herpetiform
Signs and symptoms are recurrent
Oral ulcers may respond to tetracycline oral rinses

Lichen planus
Lichen planus is an irritative skin disorder of unknown cause.
Features
Occurs at any age
Usually presents on the buccal mucosa
Pruritic rash, often accompanied by purple papules with white lacy markings on the surface (Wickham striae)
The flexor aspects of the wrists, forearms, ankles, and legs are commonly affected
Lesions often arise at sites of trauma
Reported association with hepatitis C virus infection
Treatment of oral lichen planus includes a cyclosporin rinse and moderate to potent topical steroids
Lesions persist between 6 and 18 months

Workup
Diagnostic decision
Reduced hemoglobin and hematocrit, and alterations in mean corpuscular volume are indicative of anemias
Reduced vitamin B12 levels are indicative of vitamin B12 deficiency
Positive potassium hydroxide scrapings confirm the presence of Candida albicans infection
Biopsy: rules out possibility of malignancy
Don't miss!
Nonhealing ulcerations/lesions may be an indication of malignancy and the patient should be referred immediately. These lesions may or may not be painful
The median rhomboid glossitis may be accompanied by a contact lesion on the palate suggesting immunosuppression. The condition is referred to as CIT-NIP syndrome or Candida infection of the tongue and nonspecific inflammation of the palate; this is the thumbprint of AIDS in advanced stages of HIV infection

Questions to ask
Presenting condition
Do you smoke? Tobacco is an irritant, which can result in glossitis and is associated with malignancy
How much alcohol would you drink on average in a week? Alcohol is an irritant, which can result in glossitis
How often do you visit your dentist? Poorly fitting dentures may result in local trauma and cause glossitis
Do you eat a well-balanced diet? A diet deficient in iron or vitamins of the B group may result in iron-deficiency anemia or vitamin B12 deficiency, which predisposes an individual to glossitis
Have you been using any medicines bought from the chemist/pharmacist? Broad-spectrum antibiotics and steroids can predispose the patient to oral candidiasis
Contributory or predisposing factors
Do you have reflux or peptic ulcer disease? Reflux or peptic ulcer disease is a common cause of glossitis
Do you have COPD or asthma? Inhaled steroids for the treatment of COPD/asthma may cause glossitis. Rinsing the mouth out after inhalation significantly reduces the risk
What work do you do/where do you live? Lower socioeconomic classes are associated with poorer nutrition and higher levels of smoking and alcohol consumption, all of which are risk factors for glossitis
What are your dietary habits? A deficiency in iron or vitamin B predisposes to glossitis
What is your tobacco and alcohol consumption? Excessive consumption of tobacco or alcohol is a risk factor for glossitis
Are you suffering from an immunosuppressive condition? Immunocompromised individuals are more prone to infections that can result in glossitis

Examination
Is the tongue swollen/tender/painful? All are symptoms of glossitis
Are there any ulcers? There may be pellagra, aphthous ulcers, neoplasms
Is the tongue smooth and pale? Glossitis may be the result of anemia
Are there any white patches on the tongue? Glossitis may be the result of Candida albicans infection
Is there a concomitant contact lesion on the palate? Refer immediately as this is the thumbprint for AIDS in advanced HIV infection

Summary of tests Complete blood count: hemoglobin and hematocrit levels indicate whether patient is anemic; mean corpuscular volume is indicative of iron-deficiency or vitamin B12 deficiency depending on whether levels are reduced or increased
Vitamin B12 levels: test for deficiency
Serum folate and ferritin: will both be reduced in deficiency states
Smear and culture lesions: to exclude infections
VDRL test and fluorescent treponemal antibody-absorption test (FTA-ABS): to exclude diagnosis of syphilis
10% potassium hydroxide scrapings: histologic confirmation of suspected candidiasis
Biopsy: any lesions that do not respond to treatment after one month should be biopsied
Tests
Complete blood count
Further Reading
Description
Whole blood.
Normal
Hemoglobin: 13.6-17.7g/dL (male) or 12-15g/dL (female)
Hematocrit: 39-49% (male) or 33-43% (female)
Mean corpuscular volume: 76-100mcm3
Abnormal
Hemoglobin levels and hematocrit are reduced
Mean corpuscular volume may be increased or decreased
Cause of abnormal result
Reduced hemoglobin and hematocrit indicative of anemia
Increased mean corpuscular volume may indicate vitamin B12 deficiency
Decreased mean corpuscular volume may indicate iron-deficiency anemia
Medications, disorders and other factors that may alter results
Administration of the antiretroviral drug, zidovudine, may lead to increased mean corpuscular volume
Other hematologic diseases including sickle cell disease, thalassemia, and myeloplasia lead to altered CBC parameters

Vitamin B12 radioimmunoassay
Description
Blood serum sample.
Advantages/disadvantages
Advantage: useful for detecting vitamin B12 deficiency
Disadvantage: does not detect cause of the low vitamin B12
Normal
190-900ng/mL.
Abnormal
Levels of vitamin B12 are dramatically reduced.
Cause of abnormal result
Reduced vitamin B12 levels may be indicative of pernicious anemia.
Medications, disorders and other factors that may alter results
False low levels occur in patients with severe folate deficiency or in patients taking high doses of ascorbic acid
False high levels or normal levels may occur in vitamin B12-deficient patients with severe liver disease or chronic granulocytic leukemia
Serum folate
Description
Venous blood sample.
Advantages/disadvantages
Advantage: simple test
Disadvantage: involves needlestick to obtain blood
Normal
2.2-18mcg/L.
Abnormal
Results outside normal reference range.
Cause of abnormal result
Folate deficiency, which may be secondary to poor nutrition.
Serum ferritin
Further Reading
Description
Venous blood sample
Initial investigation of choice if iron deficiency is suspected
Advantages/disadvantages
Advantage: simple test
Disadvantage: involves needlestick
Normal
10-350ng/mL.
Abnormal
Results outside normal reference range.
Cause of abnormal result
Iron deficiency.
Medications, disorders and other factors that may alter results
Treatment with multivitamins containing iron
Acts as an acute phase reactant with inflammatory condition and may be misleading
Smear and culture of lesions
Further Reading
Description
Swab of lesions for microscopic examination and culture.
Advantages/disadvantages
Advantage:
Simple test
Disadvantages:
Culture result may take a few days
If tuberculosis infection is suspected, special culture medium is required and result will take longer
Normal
No evidence of infection on microscopy or culture.
Abnormal
Infecting organisms are identified.
Cause of abnormal result
Infective lesions on the tongue.
VDRL test
Further Reading
Description
Whole blood sample
Serologic testing for syphilis infection
Advantages/disadvantages
Advantages:
Diagnostic for syphilis
Quick and relatively noninvasive
Inexpensive
Sensitivity high
Disadvantage:
Low specificity and false-positives occur
Normal
Negative.
Abnormal
Presence of Treponema pallidum or other treponemal diseases including yaws, pinta, and bejel.
Cause of abnormal result
Syphilis.
Medications, disorders and other factors that may alter results
The following diseases can have a false-positive test:
Systemic lupus erythematous and other autoimmune diseases
Infectious mononucleosis and atypical pneumonia
HIV
Malaria and leprosy
Relapsing fever and typhus fever
Infectious mononucleosis
FTA-ABS test
Further Reading
Description
Specific antibodies to T. pallidumin in the patient's serum are detected by fixation to fluorescein-labeled gamma globulin under microscopy.
Advantages/disadvantages
Advantage: very specific to the diagnosis of syphilis
Disadvantage: not a screening test; screen first with VDRL then confirm with FTA-ABS
Normal
Negative - no fixation of antibodies.
Abnormal
Fixation of fluorescein-labeled antibodies on fluorescence microscopy.
Cause of abnormal result
Exposure to T. pallidum and production of antibodies.
Medications, disorders and other factors that may alter results
Rare false-positive results have been reported in patients with active systemic lupus erythematosus and active yaws or pinta infections.
Potassium hydroxide scrapings
Further Reading
Description
Useful to diagnose fungal infection through scrapings of the tongue
Specimen obtained from scraping the white skin patches found on the tongue
Scrapings are mixed with potassium hydroxide
Abnormal
Pseudohyphae on 10% potassium hydroxide examination of skin scrapings.
Cause of abnormal result
Presence of Candida albicans, rarely Candidatropicalis or Candidaglabrata.
Lesion biopsy
Further Reading
Description
Solitary lesions found on the tongue can be biopsied.
Advantages/disadvantages
Advantage:
Useful to investigate cause of lesion
Disadvantages:
Can be a painful procedure
Risk of infection at biopsy site
Risk of profuse and heavy bleeding
Consent from the patient must be obtained prior to procedure
Normal
Normal histologic appearance.
Abnormal
Occult tumor cells are likely to be visible.
Cause of abnormal result
Squamous cell carcinoma of the tongue.
Clinical pearls
Distinguish between glossitis and stomatitis, as these are different disease processes
Glossitis is most commonly secondary due to a Candida infection and must be treated
Reflux disease may be a contributing factor and needs to be treated
Inhaled steroids for the treatment of COPD/asthma may cause glossitis - rinsing the mouth out after inhalation significantly reduces the risk
Heavy mouth-washing and certain toothpaste may cause glossitis - discontinuing toothpaste containing tartar control and peroxide ingredients is recommended
For any white patch on the tongue, syphilis needs to be ruled out. A VDRL test must be carried out
Consider consult
Refer to a dentist/dental hygienist for dental evaluation

Goals
To determine etiology
To reduce pain, swelling, and inflammation
To treat any infections that may be present
To prevent recurrences
To educate the patient to avoid any irritants or sensitizing agents
Immediate action
If primary cause is not identified or cannot be corrected, enteric nutritional replacement therapy should be considered in malnourished patients.
Therapeutic options
Summary of therapies
Initial measures include the avoidance of irritants/agents, scrupulous oral hygiene, switching to plain toothpaste without additives, discontinuing mouthwashes, and a dental evaluation for correction of ill-fitting dentures or dental braces
Lifestyle changes should be implemented, such as avoidance of alcohol and cessation of smoking
Local treatment including lidocaine mouthwashes anesthetize the tongue. Sodium bicarbonate mouthwashes are useful for irritation and aphthous ulcers, and triamcinolone in dental paste may be useful for alleviation of aphthous ulcers
Malnutrition should be treated with multivitamins, such as vitamin B complex or vitamin E
Iron-deficiency anemia should be treated with iron supplementation (ferrous gluconate, ferrous fumarate, ferrous ascorbate, ferrous sulfate, or carbonyl iron)
Candidiasis may be treated with nystatin, fluconazole, clotrimazole, or ketoconazole
Underlying peptic ulcer and reflux disease should be treated with dietary measures, antacids, H2 receptor antagonists, proton pump inhibitors
Efficacy of therapies
Candida should resolve within 10-14 days.
Medications and other therapies
Lifestyle
Risks/benefits
Risk: smoking, alcohol, and poor diet are all risk factors for glossitis
Benefit: cessation of smoking, a reduction in alcohol consumption, and a balanced diet with essential vitamins (vitamin B12) and minerals (iron) alleviate the symptoms of glossitis and prevent recurrence
Patient and caregiver information
Cessation of smoking, and limiting alcohol intake and exposure to irritants (hot, spicy foods) are beneficial in reducing the occurrence of this disorder.
Lidocaine
Further Reading
Dose
2% viscous mouth rinse, one to two tablespoons every 4h as needed.
Efficacy
Good.
Risks/benefits
Risks:
Use extreme caution if there is sepsis or severely traumatized mucosa in the area of application
Patients should not eat for one hour after application to the mouth as topical anesthesia may impair swallowing and subsequently increase the risk of aspiration (this is very important in children)
Side-effects and adverse effects
Gastrointestinal: impairment of swallowing, numbness of the tongue or buccal mucosa.
Contraindications
Hypersensitivity to lidocaine.
Acceptability to patient
High.
Follow-up plan
Follow up after one month.
Sodium bicarbonate
Further Reading
Antacid.
Dose
Half a teaspoon of sodium bicarbonate in 240mL warm water, four times daily used as a mouthwash.
Risks/benefits
Risks: none listed.
Side-effects and adverse effects
None listed.
Interactions
None listed.
Contraindications
None listed.
Acceptability to patient
High.
Triamcinolone
Further Reading
Corticosteroid.
Dose
0.1% triamcinolone in dental paste applied to lesions (aphthous ulcers) as needed.
Risks/benefits
Risks: none listed.
Side-effects and adverse effects
None listed.
Interactions
None listed.
Contraindications
None listed.
Acceptability to patient
High.
Vitamin B complex
Further Reading
Dose
Vitamin B1 (thiamin): 1.5-10mg/day
Vitamin B2 (riboflavin): 1.7-30mg/day
Vitamin B6: 2-20mg/day
Vitamin B12: 3-30mcg/day
Niacin: 20-100mg/day
Efficacy
Effective in treating malnutrition.
Risks/benefits
Risk: high doses can cause peripheral neuropathy.
Side-effects and adverse effects
Central nervous system: parasthesia, sensory neuropathic syndromes
Gastrointestinal: nausea, altered liver function tests
Interactions
Alcohol
Amiodarone
Carbamazepine
Cycloserine
Ethionamide
Fosphenytoin
Hydralazine
Isoniazid
Levodopa
Oral contraceptives
Penicillamine
Phenelzine
Phenobarbital
Phenytoin
Theophylline
Valproic acid
Contraindications
Hypersensitivity to any vitamin B.
Vitamin E
Further Reading
Dose
Adult over 19 years of age: 1000mg/day
Adolescents: 800mg/day
Risks/benefits
Risk: use caution in lactation.
Side-effects and adverse effects
Central nervous system: headache, tiredness
Eyes, ears, nose, and throat: visual disturbances
Gastrointestinal: nausea, diarrhea, vomiting, abdominal pain
Metabolic: thyroid, pituitary and adrenal hormone imbalances
Interactions
Anticoagulants
Iron
Iron supplements
Further Reading
Include ferrous gluconate, ferrous fumarate, ferrous ascorbate, and ferrous sulphate
Iron supplementation; available OTC
Dose
Adult: 2-3mg/kg/day in three divided doses.
Risks/benefits
Risk:
Use caution in patients with elevated serum ferritin levels
Benefits:
Preparation is well tolerated
Subjective improvement is seen quickly
Side-effects and adverse effects
Gastrointestinal: nausea, vomiting, bloating, black stools, constipation.
Interactions
Alkalinizers
Antacids
Calcium carbonate
Chloramphenicol
Cimetidine
Doxycycline
Famotidine
Levodopa
Methyldopa
Nizatidine
Pancreatic enzymes
Penicillamine
Quinolones
Ranitidine
Tetracycline
Vitamin E
Contraindications
Hypersensitivity to any iron-containing supplement
Hemochromatosis
Hemosiderosis
Pregnant women and nursing mothers should not use more than RDA amounts (30 and 15mg/day, respectively)
Acceptability to patient
High.
Nystatin
Further Reading
Dose
400,000-600,000 units five times daily for 10 days as an oral rinse, then swallow
100,000 units pastilles dissolved slowly in the mouth four to five times daily for 10-14 days
Efficacy
Effective against Candida infection.
Risks/benefits
Risks:
Use caution with pregnancy and lactation
Use caution in diabetes mellitus
Side-effects and adverse effects
Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain, gastrointestinal distress
Metabolic: hyperglycemia
Skin: rashes, urticaria, stinging and burning, Stevens-Johnson syndrome
Interactions
None recorded.
Contraindications
Known hypersensitivity
Pregnancy
Acceptability to patient
High.
Follow-up plan
Follow up at 2-3 weeks to check clearance of Candida infection.
Fluconazole
Further Reading
Antifungal.
Dose
200mg on the first day followed by 100-200mg/day for 5-10 days.
Efficacy
Good.
Risks/benefits
Risks:
Use caution in hepatic and renal disease
Has been associated with rare cases of serious hepatic toxicity, including fatalities primarily in patients with serious underlying medical condition
Risk of anaphylaxis (rare)
Side-effects and adverse effects
Central nervous system: seizures, dizziness, headache
Gastrointestinal: abdominal pain, diarrhea, hepatitis, altered liver function, vomiting, nausea
Hypersensitivity: anaphylaxis
Skin: exfoliation, Stevens-Johnson syndrome
Interactions
Antihistamines
Antilipemic statins
Benzodiazepines
Buspirone
Caffeine, theophylline
Celecoxib
Cisapride
Cyclosporine, tacrolimus
Felodipine
Losartan
Methadone
Oral anticoagulants
Phenytoin
Pimozide
Quinidine
Rifampin
Ritonavir
Sulfonylureas
Zidovudine
Contraindications
Pregnancy and breast-feeding
Nursing mothers
Clotrimazole
Further Reading
Antifungal.
Dose
10mg lozenges, orally, five times daily for 10 days.
Efficacy
Good.
Risks/benefits
Benefit: effective in eradicating Candida species.
Side-effects and adverse effects
Gastrointestinal: nausea, abdominal pain (oral administration)
Genitourinary: dyspareunia, urinary frequency
Skin: burning, rash, urticaria, stinging
Interactions
Cyclosporine
Tacrolimus
Contraindications
Known hypersensitivity
Pregnancy and breast-feeding
Acceptability to patient
High.
Ketoconazole
Further Reading
Antifungal.
Dose
200mg orally, once daily
The duration of therapy is usually 14 days
Efficacy
Good.
Risks/benefits
Risks:
Use caution in renal and hepatic disease
Use caution in children under 2 years old
Use caution in sulfite sensitivity
Side-effects and adverse effects
Central nervous system: headache, dizziness
Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain
Hematologic: blood cell disorders
Skin: rashes, urticaria, irritation, stinging
Interactions
Alfentanil
Antacids
Antiulcer agents (cimetidine, famotidine, omeprazole, nizatidine)
Antivirals (amprenavir, didanosine, indinavir, ritonavir, nelfinavir, saquinavir)
Antimuscarinics
Anxiolytics (buspirone, chlordiazepoxide)
Astemizole
Benzodiazepines
Calcium channel blockers (dihydropyridines)
Cyclosporine
Corticosteroids
Cisapride
Ethanol
Isoniazid
Methadone
Oral anticoagulants
Estrogens
Phenytoin
Quinidine
Rifampin
Statins
Sucralfate
Sildenafil
Tacrolimus
Terfenadine
Tolteridine
Warfarin
Contraindications
Hypersensitivity to ketoconazole
Pregnancy and breast-feeding
Fungal meningitis
Ketoconazole tablets have not been systematically studied in children of any age, and essentially no information is available on children under 2 years. Ketoconazole tablets should not be used in pediatric patients unless the potential benefit outweighs the risks
Acceptability to patient
High.
Management in special circumstances
Coexisting disease
Reflux and peptic ulcer disease. Treatment with H2 blockers or proton pump inhibitors is necessary to prevent persistent acid irritation of the tongue
HIV infection: immunosuppression from HIV is a risk factor for oral candidiasis and other infections that may result in glossitis. Control of HIV may make these infections less likely to occur
Coexisting medication
Zidovudine: this antiretroviral treatment for HIV infection may induce vitamin B12 deficiency
Inhaled corticosteroids: asthma treatment can lead to oral candidiasis and glossitis
Patient and caregiver issues
Questions patients ask
Is glossitis contagious? No, unless secondary to herpes simplex infection
How likely am I to have an oral cancer? Oral cancer can occur in patients with risk factors such as tobacco use, betel nut use, alcohol use, or repetitive trauma such as ill-fitting dentures
Health-seeking behavior
What steps have you taken (if any) towards reducing smoking and alcohol intake? The presence of oral cavity lesions in someone who is smoking and using alcohol, and who is not reducing intake, requires close follow-up
What are you thoughts on good oral hygiene? Dental referral should be made for inadequate responses
What does your typical diet and fluid intake consist of? The dietary responses may lead the physician to think of nutritional causes for glossitis
Follow-up
Plan for review
Monitor patients periodically until healing occurs
If lesions do not respond within one month, a biopsy may be indicated
Information for patient or caregiver
Advise patient that certain lifestyle changes such as the avoidance of tobacco, alcohol, hot/spicy foods, and chemical irritants may have a beneficial effect in glossitis
Patient education leaflet available
Ask for advice
Question 1
What is the cause of geographic tongue?
Answer 1
Once the more serious causes listed in differential diagnosis have been ruled out, the etiology is most likely viral.
Question 2
What is the treatment for burning tongue?
Answer 2
This common and frustrating disorder is not well understood. The most likely infectious etiologies are C. albicans and viral. After treatment with an antifungal, a trial of a steroid mouthwash is warranted but infrequently successful. Most of the cases are self-limited, so supportive care is generally all that is required. Always encourage meticulous oral hygiene.
Question 3
When should a patient with an oral ulceration be referred to a specialist?
Answer 3
Any nonhealing ulcer of the oral cavity that persists longer than 3 weeks or is resistant to first-line therapies should be immediately referred to an ENT or oral surgeon.
Question 4
What is the cause and treatment of a black hairy growth on the tongue?
Answer 4
The 'hairs' are actually elongated filiform papillae (taste buds) that for some reason have not desquamated, or have formed keratin much too rapidly. The condition is benign and usually self-limited. Treatment consists of having the patient use a tongue scraper to remove the accumulated keratin, along with a commercially available mouthwash.
Question 5
What is the treatment for aphthous ulcers (canker sores)?
Answer 5
Isolated lesions respond well to application of a topical steroid such as triamcinolone acetonide in a protective dental base. Multiple or diffuse lesions may require a steroid mouth rinse, such as betamethasone syrup. Severe involvement may require systemic steroid therapy for the first 3 days in addition to topical therapy. Again, meticulous oral hygiene is helpful in limiting the course of the disease, which may respond to topical tetracycline rinse.
Consider consult
Refer to an otolaryngologist or head/neck surgeon for any nonhealing ulcer/lesion or persistent pain, for a biopsy to be performed to rule out malignancy.


Prognosis
Further Reading
Prompt improvement when the cause of glossitis is identified and properly treated
Aphthous ulcers and erythema multiforme may recur

Prevention
Smoking: tobacco is an irritant which is a risk factor for glossitis
Excess alcohol consumption: another irritant
Diet: hot and/or spicy foods may cause irritation of the mouth and tongue. Deficiencies in certain vitamins or minerals may result in anemia, which predisposes an individual to glossitis
Dentures: badly fitting dentures or dental braces may cause local trauma resulting in glossitis
Mouthwashes and/or other chemical irritants: certain mouthwashes, excess peppermint (in toothpaste), or other chemicals such as some orally administered drugs may result in irritation
Primary prevention
Further Reading
Modifiable risk factors
If a denture-wearer, regular dental check-ups are advised to ensure that dentures are properly fitting
Rinse mouth after inhaled steroid usage
Discontinue mouthwashes or salt rinses and switch to plain toothpaste without additives
Tobacco
Minimize smoking or cease smoking altogether since this is an irritant.
Alcohol and drugs
Minimize or abstain from alcohol consumption.
Diet
Avoid hot and/or spicy foods that may cause direct irritation or secondarily cause reflux disease
Ensure diet is well balanced and contains all essential vitamins and minerals to eliminate vitamin B12 or iron deficiency
Secondary prevention
Minimize risk factors (smoking, alcohol consumption, poor diet)
Undertake full dental evaluation to ensure dentures or dental braces are fitting properly
Ensure scrupulous oral hygiene
Identify causative agents if infection suspected and treat immediately