Episode 81 - The Tongue Talks - a podcast by Rio Bravo Family Medicine Residency Program

Episode 81: The Tongue Talks.  

By Idean Pourshams, MD; Golriz Asefi, MD; and Hector Arreaza, MD.   

Drs Asefi, Pourshams, and Arreaza discuss how to discover local or systemic diseases of the tongue. Includes jokes about tongue.

 

In Traditional Chinese Medicine (TCM), regions of the tongue reflect information about specific organ systems, for example the tip of the tongue traditionally depicts ailments of the heart while the anterior-lateral sections of the tongue represent the lungs, and the posterior-lateral regions reflect the health of the liver and gallbladder. But, today we will focus on common tongue lesions.

 

Normal tongue.

The tongue is a muscular organ, highly vascularized and highly innervated. It is normally covered by pink mucosa and has a rough surface caused by the presence of papillae (taste buds). It is vital for chewing and swallowing food and it is essential for speaking. The tongue contains an abundance of blood vessels and is constantly regenerating. The top layer of the tongue is replaced every 2-3 days! A healthy tongue should appear slightly wet, light red or pink with possibly a normal thin white coating. There should not be any fissures, teeth marks or swelling. 

 

On physical exam, ensure that the patient has full range of motion of the tongue. It is very important to look at a patient's tongue during physical examination to note the shape, size, color and texture of the tongue body and coat. Findings can suggest the state of organ functions and progression of any underlying conditions. 

 

Today we will describe certain physical findings on tongue examination and discuss what clues could be drawn when diagnosing or treating our patients.

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

 

Abnormal tongue. 

 

What would be your suspicions if a tongue was described as having patches resembling smooth red islands or patches located on the top or side of the tongue, and the patches may actually change location, size and shape? Any ideas on a diagnosis?

 

This could be a geographic tongue also called benign migratory glossitis which is considered harmless and related to allergic rhinitis and other allergies, but it can also be linked to psoriasis and reactive arthritis. 

 

What about a tongue that is described as dark and furry or hairy, along with a patient complaining of a metallic taste in their mouth? On physical examination you also note halitosis or bad breath. 

 

This could be a diagnosis of black hairy tongue or lingua villosa nigra. Any idea on what may cause black hairy tongue? Possible causes include antibiotic use, tobacco use, mouth breathing, poor oral hygiene, radiation therapy, chronic use of bismuth.

 

Now let’s talk about some vitamin deficiencies that may be represented by changes in the tongue’s appearance. If the patient’s tongue appears purple, and the corners of the mouth display angular stomatitis, it would be wise to suspect a vitamin B2 deficiency. B2: Eyes and mouth. 

 

B2 is also known as riboflavin. Patients can have painful cracks in the corners of the mouth and on the lips known as angular cheilitis, also scaly patches on the head, and a magenta mouth and tongue. It is seen in patients who do not eat enough meats (vegans), but also in chronic disorders such as chronic diarrhea, liver disease, alcohol use disorder, malabsorption, and chronic use of barbiturates. 

 

Giving Vitamin B supplements by mouth may solve the problem. Vitamin B intoxication is virtually impossible, so you can supplement vitamin B along with other vitamins by mouth confidently, especially patients who are on hemodialysis or peritoneal dialysis. Foods rich in riboflavin include grains, mushrooms, and dairy products.

 

Vitamin B2 deficiency is normally not seen just by itself but combined with other vitamin B deficiencies. 

 

Another presentation of a patient’s tongue may be inflammation of the tongue, or glossitis, that is extremely uncomfortable or painful. Any suspicion on what vitamin may be deficient?

 

You might suspect vitamin B3 deficiency, also known as… niacin!

 

While we mentioned angular stomatitis with riboflavin deficiency, that is, cracks on the corners of the mouth; with niacin deficiency, the lips may appear cracked along the surface of the lips themselves. Foods that are rich in niacin include meats and poultry, fish, and nuts.

 

Let’s remember the condition associated with niacin (B3) deficiency: Pellagra. This is an Italian word that translates to “rough skin.” Although nutritional deficiency may be less frequent now than centuries ago, we still may see pellagra in cases of gastrointestinal disease in which absorption of nutrients is diminished, or in patients with malnourishment, possibly from alcoholism.

 

In addition to manifestations of the tongue, pellagra can progress to cause a red rash on the cheeks or around the neck, constipation that then leads to diarrhea, nervousness and depression which lead to dementia, and if left untreated patients will die. 

 

These are the 4 D’s of Pellagra: Dermatitis, Diarrhea, Dementia and Death. 

 

The next description of a tongue is of a patient with a pale, light-colored tongue. What could be a possible diagnosis?

 

This patient may have iron deficiency anemia, and along with the changing color, there may be soreness, atrophy of the taste buds as well as angular stomatitis. These patients may also have fatigue and feeling cold especially in the extremities. While ferrous sulfate can be prescribed for anemia it is important to remember its irritating effect on the stomach mucosa and possible gastrointestinal side effects such as constipation. That’s why supplementation by iron-rich foods is preferred if the anemia is not severe. Food sources with heme iron include red meat, fish and poultry. Non-heme sources of iron include spinach and other dark leafy green vegetables, as well as egg yolks. The food with the highest content of iron is… liver. Remember that iron absorption is improved by vitamin C.

 

Now what if a patient's tongue looks beefy, red, and inflamed with the patient complaining of soreness?

 

This may be vitamin B12 deficiency also known as cobalamin, which is critical for red blood cell maturation. Without cobalamin, patients develop pernicious anemia with symptoms of fatigue, irritability, confusion, depression, numbness and tingling of the extremities and eventually psychosis. 

 

Vitamin B12 is found in many foods such as meat, fish, dairy and eggs, and fermented foods including sauerkraut, yogurt, and kimchi. Do you remember what parietal cells within the gastric mucosa release, which is essential for absorption of vitamin B12 from the digestive tract? If you said intrinsic factor you are correct. 

 

And it is important to remember that the use of antacids can diminish levels of intrinsic factor and contribute to vitamin B12 deficiency, as well as other medications such as PPIs, metformin, colchicine, and aminosalycilic acid (an anti-tuberculosis medication which I’ve never seen prescribed). Interestingly, co-administration of Vitamin B12 with vitamin C may reduce the available amount of Vitamin B12 in your body. So, take vitamin C two or more hours apart from Vitamin B12.

 

Let’s describe another patient, a child with congenital hypothyroidism. What would you expect to see on examination of the mouth or tongue?

 

Such patients may have a thick tongue, that may not even properly fit in the space of the mouth, thus protruding from the mouth. The same is true for adults with enlarged tongues as well as other symptoms of hypothyroidism. The medical term for enlarged tongue is macroglossia. This can also be seen in Down’s syndrome. 

 

Another case can be a patient with thick white patches on the tongue which spread onto the cheeks. These white patches wipe off easily with a gauze.

 

The obvious suspicion would be oral thrush, or to be more specific pseudomembranous oropharyngeal candidiasis, which is a yeast infection seen in both immunocompetent and immunosuppressed children and adults. We cannot talk about the tongue without mentioning oral candidiasis. It is normally associated with infants and children who are bottle-fed or have used antibiotics or corticosteroids to treat asthma or allergic rhinitis, or patients with HIV/AIDS. Also, adults who use dentures are at increased risk of oral thrush.

 

The treatment of oral candidiasis must be individualized, based on the severity of the infection and immune status of the patient, but it is normally treated with topical antifungal in immunocompetent patients with mild disease or systemic therapy in severe cases or immunosuppressed patients. 

 

Also, in cases of white tongue in adults, you should consider leukoplakia also called smoker's keratosis which may or may not be cancerous. Please be vigilant because leukoplakia could be an early sign of cancer.

 

Leukoplakia is a descriptive clinical term used for a white plaque or lesion on the tongue or oral cavity that cannot be wiped off with a gauze. A biopsy for a definite diagnosis may be needed after a 6-week observation to rule out other causes such as mechanical friction. The differential diagnosis of white lesions on the tongue is extensive, and it includes lichen planus, leukoedema, tobacco chewer’s white lesion, chemical burns, HPV, and squamous cell carcinoma.

Another patient presents with small shallow sores on the inside of the mouth, at the base of the gums, and on the sides or surface of the tongue. What do you think the diagnosis might be here?

 

This may be a canker sore or aphthous ulcer. The sores can be painful, making it difficult for the patient to eat and talk. Treatments include oral rinses with benzydamine hydrochloride, and pastes such as benzocaine or steroids like triamcinolone can also be used to reduce inflammation.

 

Finally let's describe a patient who comes in with a trembling tongue. What would be a potential diagnosis in such a patient?

 

It would be important to rule out a stroke, and immediate medical attention is important. Fasciculations of the tongue may indicate a lower motor neuron injury, which can lead to dysarthria or dysphagia, and new onset of fasciculations may be a sign of ALS or amyotrophic lateral sclerosis. Let’s also include the differential of seizure in that case, but the shaking would not only include the tongue, but also the larynx, pharynx, and face in a rare condition called palatal tremor. 

 

We did not cover viral infections, strawberry tongue, lichen planus, Plummer-Vinson Syndrome, ankyloglossia, macroglossia, angioedema, and many more but we’ll leave it for part 2.

 

Conclusion: The tongue talks. The tongue can show signs of disease specific to the tongue but also signs of systemic disease. Let’s remember to check the tongue of our patients. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. When we find tongue abnormalities, let’s keep in mind viral and fungal infections, vitamin deficiencies, immunodeficiencies, premalignant and malignant lesions.

 

Now we conclude our episode number 81 “The Tongue Talks.” Drs Asefi, Pourshams, and Arreaza discussed common findings of the tongue. By examining the tongue you can find clues for significant local or systemic diseases. Keep in mind infections, vitamin deficiencies, benign lesions and even cancer. The tongue is more than an organ for speaking, breathing, swallowing and testing. It is a symbol of the way we talk to others: “A tongue has no bones but it's strong enough to break a heart, so be careful with your words.” Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Idean Pourshams, and Golriz Asefi. Audio edition: Suraj Amrutia. See you next week! 

 

 

 

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References:

Anastasi JK, Chang M, Quinn J, Capili B. Tongue Inspection in TCM: Observations in a Study Sample of Patients Living with HIV. Med Acupunct. 2014 Feb 1;26(1):15-22. doi: 10.1089/acu.2013.1011. PMID: 24761186; PMCID: PMC3929461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929461/

 

Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010 Mar 1;81(5):627-34. PMID: 20187599. https://www.aafp.org/afp/2010/0301/p627.html

 

Geographic tongue - Symptoms and causes - Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/geographic-tongue/symptoms-causes/syc-20354396

 

Wolff, Klaus; Richard Johnson, and Arturo P. Saavedra. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7th edition, McGraw Hill Education, 2013, p. 819.

 

 

 

 

 

 

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