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Monday, August 18, 2025

Sore or white tongue


Introduction

The tongue is a highly vascular and muscular organ that plays a central role in speech, mastication, taste, and swallowing. A sore or white tongue is a common clinical presentation encountered in general practice, dentistry, and specialty care, ranging from benign and transient causes to more serious systemic or infectious diseases. The presentation may involve localized pain, diffuse discomfort, burning sensations, or visible changes such as white coatings, plaques, or ulcers

A sore or white tongue is not a disease entity but a clinical manifestation of underlying local or systemic pathology. The condition can arise from infections (fungal, bacterial, viral), trauma, inflammatory conditions, systemic diseases, nutritional deficiencies, autoimmune disorders, and malignancies. Early recognition and accurate diagnosis are crucial for effective treatment.

Anatomy and Physiology of the Tongue

The tongue is divided into anterior two-thirds (oral tongue) and posterior one-third (pharyngeal tongue). It is covered with specialized mucosa containing papillae, taste buds, and keratinized or non-keratinized epithelium. Vascularization is provided by the lingual artery, while innervation involves the hypoglossal nerve (motor), trigeminal nerve (general sensation anterior tongue), chorda tympani branch of facial nerve (taste anterior tongue), and glossopharyngeal nerve (taste and sensation posterior tongue).

Understanding this anatomy is essential, as lesions or soreness may localize to specific neural or mucosal distributions, guiding diagnostic reasoning.

Etiology of Sore or White Tongue

1. Infectious Causes

  • Oral Candidiasis (Thrush):
    Caused by Candida albicans, leading to white, creamy plaques that can be scraped off. Predisposed by immunosuppression, prolonged antibiotics, diabetes, or inhaled corticosteroids.

  • Viral Infections:
    Herpes simplex virus (HSV) may produce painful vesicles and ulcers on the tongue. HIV can predispose to hairy leukoplakia (white corrugated plaques on lateral tongue due to Epstein-Barr virus).

  • Bacterial Infections:
    Secondary bacterial infections from trauma, poor oral hygiene, or periodontal disease.

2. Traumatic and Mechanical Causes

  • Ill-fitting dentures, braces, or accidental biting of the tongue.

  • Thermal burns from hot food or drinks.

  • Frictional keratosis causing white patches.

3. Nutritional Deficiencies

  • Vitamin B12 deficiency – produces glossitis (beefy red tongue with soreness).

  • Iron deficiency – associated with atrophic glossitis and burning sensation.

  • Folate deficiency – similar presentation with ulceration.

4. Inflammatory and Autoimmune Disorders

  • Lichen Planus – white lacy streaks (Wickham striae) with soreness.

  • Geographic Tongue (Benign Migratory Glossitis): red depapillated patches surrounded by white borders.

  • Aphthous Ulcers: recurrent painful ulcers with whitish centers and erythematous halos.

  • Sjögren’s Syndrome: dryness and soreness.

5. Neoplastic and Premalignant Conditions

  • Leukoplakia: white patches that cannot be scraped off, often premalignant.

  • Squamous Cell Carcinoma: persistent sore or white lesion with induration, especially in smokers or alcohol users.

6. Systemic Diseases

  • Diabetes mellitus (predisposes to candidiasis).

  • Anemia.

  • Immunodeficiency (HIV/AIDS).

  • Gastroesophageal reflux disease (GERD).

7. Medication-Induced Causes

  • Antibiotics (alter flora, cause candidiasis).

  • Corticosteroids (inhaled or systemic).

  • Chemotherapy (mucositis and ulcers).

Clinical Presentation

  • Pain: Ranges from mild burning to severe pain interfering with eating.

  • White appearance: Diffuse coating, plaques, or localized patches.

  • Associated symptoms: Halitosis, dysphagia, altered taste (dysgeusia), xerostomia (dry mouth).

  • Systemic features: Fatigue, weight loss, lymphadenopathy (suggesting malignancy or systemic disease).

Diagnostic Evaluation

1. History Taking

  • Onset, duration, progression.

  • Associated systemic symptoms.

  • Risk factors: smoking, alcohol, denture use, medications, systemic disease.

2. Clinical Examination

  • Inspection for location, texture, scrape-ability of white coating.

  • Palpation for induration or tenderness.

  • Oral hygiene assessment.

3. Investigations

  • Swab for fungal/bacterial culture.

  • Blood tests: CBC, iron studies, vitamin B12, folate.

  • HIV testing if risk factors present.

  • Biopsy: essential for persistent white lesions to rule out malignancy.

Treatment of Sore or White Tongue

1. General Measures

  • Maintain oral hygiene (brushing tongue, chlorhexidine mouthwash).

  • Avoid irritants (tobacco, alcohol, spicy food).

  • Hydration and saliva substitutes in xerostomia.

  • Correct nutritional deficiencies with supplements.

2. Pharmacological Treatment

A. Oral Candidiasis

  • Topical antifungals:

    • Nystatin oral suspension 100,000 units/mL, rinse 4–6 mL, swish and swallow four times daily for 7–14 days.

    • Clotrimazole troches 10 mg dissolved slowly in the mouth, five times daily for 7–14 days.

  • Systemic antifungals (for refractory cases):

    • Fluconazole 100–200 mg orally once daily for 7–14 days.

    • Itraconazole 200 mg once daily for 7–14 days.

B. Aphthous Ulcers

  • Topical corticosteroids:

    • Triamcinolone acetonide dental paste 0.1% applied 2–4 times daily.

  • Systemic therapy (severe cases):

    • Prednisone 30–60 mg orally once daily, tapered over 7–10 days.

C. Lichen Planus

  • Topical corticosteroids:

    • Clobetasol propionate gel 0.05% applied thinly 2–3 times daily.

  • Systemic agents (refractory cases):

    • Prednisone 30–40 mg daily short course.

    • Immunomodulators such as azathioprine 1–2 mg/kg/day in severe cases.

D. Burning Tongue due to Nutritional Deficiencies

  • Vitamin B12 replacement:

    • Cyanocobalamin 1000 mcg intramuscularly once weekly for 6–8 weeks, then monthly.

  • Iron deficiency:

    • Ferrous sulfate 325 mg orally three times daily.

  • Folic acid deficiency:

    • Folic acid 1 mg orally once daily.

E. Pain Relief

  • Topical anesthetics:

    • Lidocaine viscous 2% solution – rinse with 5–10 mL every 3 hours as needed.

  • Systemic analgesics:

    • Paracetamol (acetaminophen) 500–1000 mg every 6–8 hours.

    • Ibuprofen 400 mg every 8 hours if no contraindications.

F. Antiviral Therapy (for HSV infections)

  • Acyclovir 400 mg orally three times daily for 7–10 days.

  • Valacyclovir 1 g orally twice daily for 7 days.

G. Malignancy-Associated Lesions

  • Requires referral to oral surgeon or oncologist.

  • Treatment options: surgical excision, radiotherapy, chemotherapy.

Prognosis

  • Benign causes (candidiasis, aphthous ulcers, geographic tongue) usually resolve with treatment and supportive care.

  • Chronic conditions (lichen planus, leukoplakia) may persist and require long-term monitoring.

  • Premalignant or malignant conditions carry significant morbidity and mortality if not diagnosed early.

Precautions and Patient Counseling

  • Stress the importance of oral hygiene and regular dental/medical checkups.

  • Counsel patients on avoiding irritants like tobacco, alcohol, and spicy food.

  • Highlight the need for nutritional balance, including adequate iron, folate, and vitamin B12 intake.

  • Immunocompromised patients must seek prompt treatment at the earliest signs of oral infection.

  • Advise patients on correct use of medications:

    • Nystatin should be swished thoroughly before swallowing.

    • Clotrimazole troches must be allowed to dissolve slowly.

    • Topical corticosteroid gels should be applied after meals and oral rinsing.

Drug Interactions

  • Fluconazole interacts with warfarin (increased bleeding risk), statins (risk of myopathy), and phenytoin.

  • Itraconazole interacts with benzodiazepines, certain antiarrhythmics (QT prolongation).

  • Corticosteroids may increase blood sugar and risk of secondary infections.

  • NSAIDs (Ibuprofen) should be avoided in peptic ulcer disease, renal impairment, or with anticoagulants.

  • Acyclovir requires dose adjustment in renal impairment.

  • Iron supplements interact with tetracyclines, quinolones, and should be taken away from dairy/calcium




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