The tongue: geographic tongue, glossitis and what to worry about
- Oral pathology
Many tongue changes are harmless variants. A smooth red tongue suggests a deficiency; a lump or ulcer on the side needs a biopsy.
See it in 3D: Tongue
What it is
The tongue's surface is covered by papillae; changes in them alter its colour and texture. Geographic tongue (benign migratory glossitis) shows smooth red patches with white borders that move over days, is harmless and sometimes sore with spicy food. A fissured tongue is a normal variant, often with geographic tongue. Black hairy tongue is overgrowth of filiform papillae with pigment, linked to smoking, antibiotics and poor hygiene. Atrophic glossitis (a smooth, red, sore tongue) reflects deficiency of iron, vitamin B12, folate or riboflavin, or coeliac disease. A «strawberry tongue» is seen in scarlet fever and Kawasaki disease. Macroglossia suggests hypothyroidism, amyloidosis or acromegaly.
How to recognise it
- Geographic tongue: migrating map-like red patches; benign.
- Smooth red tongue: check iron, B12 and folate; consider coeliac disease.
- Strawberry tongue in a febrile child: scarlet fever or Kawasaki disease.
- Macroglossia: hypothyroidism, amyloidosis, acromegaly, Down syndrome.
- A persistent ulcer or lump on the lateral border is suspicious for cancer.
Differential and risks
- Kawasaki disease in a child with five days of fever, red lips and strawberry tongue needs urgent assessment because of coronary risk.
- Atrophic glossitis with neuropathy suggests B12 deficiency; treat before folate alone.
- Unilateral tongue weakness and deviation point to the hypoglossal nerve (XII).
Next step / Initial management
- Geographic or fissured tongue: reassure; avoid irritant foods during flares.
- Smooth sore tongue: full blood count, ferritin, B12 and folate; coeliac serology if indicated; treat the deficiency.
- Strawberry tongue with prolonged fever: assess for Kawasaki disease and refer urgently.
- Persistent ulcer, lump or induration on the tongue: refer for biopsy.
Test yourself
Think of the answer, then tap the question to see it.
What is geographic tongue?
A benign condition with migrating smooth red patches bordered by white lines on the tongue.
Which deficiencies cause atrophic glossitis?
Iron, vitamin B12, folate and riboflavin, among others; coeliac disease can be the cause.
Which two febrile illnesses of children cause a strawberry tongue?
Scarlet fever and Kawasaki disease.
Elsewhere in DurgiPedia
Connections
See it in 3D1
The structures of Durgical's 3D anatomy where it is found.
Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.
Sources: Geographic Tongue (StatPearls Publishing (NCBI Bookshelf), 2023); Glossitis (StatPearls Publishing (NCBI Bookshelf), 2023); Tongue Cancer (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.