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Sunday, August 17, 2025

Tongue (sore or white)


Introduction

The tongue is an essential muscular organ involved in speaking, chewing, tasting, and swallowing. When symptoms such as soreness, pain, or discoloration (commonly appearing white) develop, they often indicate an underlying condition ranging from minor irritation to systemic disease. A sore or white tongue may be acute, resolving within days, or chronic, persisting for weeks. Identifying the exact cause is vital because treatments differ based on the underlying etiology.


Clinical Presentation

Symptoms of a Sore Tongue

  • Burning or stinging sensation

  • Pain localized to certain areas or diffuse across the tongue

  • Sensitivity to hot, acidic, or spicy foods

  • Difficulty chewing or swallowing

Symptoms of a White Tongue

  • White patches or coating (may be removable or persistent)

  • Rough or dry tongue surface

  • Foul taste or halitosis (bad breath)

  • In some cases, asymptomatic

Common Causes

1. Oral Candidiasis (Thrush)

  • Caused by Candida albicans overgrowth.

  • Risk factors: antibiotic use, corticosteroid inhalers, diabetes, immunosuppression.

  • Appears as creamy, white patches on the tongue that can be scraped off, sometimes leaving raw red areas.

  • Often accompanied by burning, soreness, or altered taste.

2. Leukoplakia

  • White patches on the tongue that cannot be scraped away.

  • Often linked to smoking, alcohol use, or chronic irritation.

  • Considered precancerous and requires monitoring.

3. Geographic Tongue (Benign Migratory Glossitis)

  • Irregular, map-like patches of smooth red areas surrounded by white borders.

  • Usually harmless but may cause burning or sensitivity.

4. Lichen Planus

  • Immune-mediated condition.

  • White, lacy patches with possible soreness.

  • Chronic course with periodic flares.

5. Nutritional Deficiencies

  • Vitamin B12, folate, or iron deficiency can cause glossitis (painful, inflamed tongue) and pallor or whitening.

6. Trauma or Irritation

  • Burns from hot foods, sharp teeth, ill-fitting dentures, or orthodontic appliances.

  • Typically results in localized soreness and ulceration.

7. Viral or Bacterial Infections

  • Herpes simplex virus: painful ulcers.

  • Syphilis: mucous patches on the tongue.

  • Streptococcal infection: associated with scarlet fever, leading to “strawberry tongue.”

8. Oral Cancer

  • Persistent sore or white patch unresponsive to treatment should raise suspicion.

  • Especially associated with tobacco and alcohol use.

Diagnostic Considerations

  • History: onset, duration, associated systemic symptoms, dietary history, medication use.

  • Examination: scrape test (if lesion can be removed, likely thrush), presence of ulcers, swelling, or induration.

  • Investigations:

    • Swab for fungal culture (candidiasis)

    • Biopsy (suspicious lesions)

    • Blood tests (B12, folate, iron, fasting glucose, syphilis serology)

Treatment Strategies

General Measures

  • Maintain oral hygiene (gentle brushing, flossing, tongue cleaning).

  • Avoid irritants (smoking, alcohol, spicy/acidic foods).

  • Ensure good hydration.

  • Correct poorly fitting dentures or dental appliances.

Pharmacological Management

1. Oral Candidiasis

First-line treatments:

  • Nystatin oral suspension: 100,000 units/mL, 5 mL swished and swallowed 4 times daily for 7–14 days.

  • Miconazole oral gel: apply 2.5 mL to affected area four times daily after meals.

Alternative systemic therapy (for resistant or severe cases):

  • Fluconazole: 150 mg orally once daily for 7–14 days.

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

2. Leukoplakia

  • Eliminate irritants (stop smoking, reduce alcohol).

  • Regular monitoring and biopsy if lesion persists.

  • No standard pharmacological therapy, but topical retinoids (tretinoin) have been studied.

3. Lichen Planus

  • Topical corticosteroids are mainstay:

    • Clobetasol propionate 0.05% gel: apply to lesions 2–3 times daily.

    • Triamcinolone acetonide dental paste: applied thinly 2–4 times daily.

  • For severe cases:

    • Prednisone: 40–60 mg orally daily, tapering over 2–4 weeks.

    • Azathioprine or cyclosporine may be considered under specialist care.

4. Nutritional Deficiencies

  • Vitamin B12 deficiency:

    • Cyanocobalamin: 1000 mcg intramuscular injection weekly for 4–6 weeks, then monthly.

    • Oral therapy: 1000–2000 mcg/day.

  • Iron deficiency:

    • Ferrous sulfate: 325 mg orally once to three times daily with vitamin C.

  • Folate deficiency:

    • Folic acid: 1 mg orally daily.

5. Traumatic Ulcers

  • Symptomatic relief with topical anesthetics:

    • Lidocaine 2% gel: applied directly to sore area up to 3–4 times daily.

    • Benzocaine lozenges: as needed.

  • Healing usually occurs within 7–10 days after removal of irritant.

6. Viral Infections (Herpes Simplex)

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

  • Valacyclovir: 1 g orally twice daily for 7 days.

For recurrent herpes:

  • Suppressive therapy with acyclovir 400 mg twice daily.

7. Bacterial Infections

  • Penicillin V: 500 mg orally every 6 hours for 10 days (for streptococcal pharyngitis with tongue involvement).

  • Amoxicillin: 500 mg orally every 8 hours for 7–10 days.

8. Oral Cancer

  • Requires referral to oral surgeon or oncologist.

  • Treatment may include surgical excision, radiotherapy, or chemotherapy.

  • No role for self-medication.

Pediatric Considerations

  • Oral thrush common in infants.

  • Nystatin suspension remains first-line: 1 mL four times daily, applied with dropper.

  • For persistent thrush, fluconazole (3–6 mg/kg daily) may be prescribed.

Precautions and Warnings

  • Corticosteroid gels should not be swallowed excessively due to systemic absorption.

  • Antifungals like fluconazole interact with warfarin, phenytoin, and certain statins.

  • Iron supplements may cause constipation and dark stools.

  • Any lesion persisting beyond 2–3 weeks despite treatment requires urgent biopsy.

Prognosis

  • Candidiasis: resolves within 1–2 weeks with appropriate therapy.

  • Nutritional deficiencies: reversible with supplementation.

  • Lichen planus: chronic but controllable with steroids.

  • Leukoplakia: requires long-term monitoring due to malignant potential.

  • Oral cancer: prognosis depends on stage at diagnosis; early detection is critical.

Summary of Treatments with Doses

  • Nystatin oral suspension: 5 mL swish/swallow QID × 7–14 days.

  • Miconazole oral gel: 2.5 mL QID after meals.

  • Fluconazole: 150 mg PO daily × 7–14 days.

  • Clobetasol gel 0.05%: topical 2–3 times daily.

  • Triamcinolone dental paste: 2–4 times daily.

  • Prednisone: 40–60 mg PO daily, taper 2–4 weeks.

  • Cyanocobalamin: 1000 mcg IM weekly × 4–6 weeks, then monthly.

  • Ferrous sulfate: 325 mg PO 1–3× daily.

  • Folic acid: 1 mg PO daily.

  • Lidocaine 2% gel: apply up to 3–4× daily.

  • Acyclovir: 400 mg PO TID × 7–10 days.

  • Valacyclovir: 1 g PO BID × 7 days.

  • Penicillin V: 500 mg PO Q6h × 10 days.

  • Amoxicillin: 500 mg PO Q8h × 7–10 days.



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