When I first started dental hygiene school, I learned instrumentation on a typodont. After much practice, I became more confident and knew I would do well as a dental hygienist. Then I encountered a real mouth, and a tongue—a squirmy, large muscle that seemed to inflate and take up all the space in the mouth.
Have you ever wished you could take that tongue out of your patient’s mouth during treatment and have clear access to the teeth and gingiva? While the tongue is often a hygienist’s biggest obstacle to patient care, it is one of the body’s most important muscles.
The tongue provides the ability to swallow, speak, chew, sing, and breathe. We would literally be without voice, proper nutrition, and overall health without it. A healthy tongue is pale pink to light red in color and has papillae, or taste buds, that make the top surface rough. The underside of the tongue has blood vessels, ligaments, and a frenum, and it’s mostly smooth. A normal tongue should be free of hair, ulcerations, large bumps, and deep fissures.
The mind-body-mouth connection is one of my passions. Many systemic conditions manifest in the mouth, so the tongue is a great place to start. As we perform dental procedures, we can observe the condition of the tongue and evaluate it.
We can make a friend out of a foe as we use the tongue to tell us more about our patients’ health. The tongue doesn’t lie, so we just need to figure out what it’s trying to tell us. Here are a few common tongue conditions and possible reasons why they are manifesting in the mouth.
Fissured tongue
A fissured tongue is one of the most common conditions of the tongue.1 The tongue typically has small fissures on the surface; however, these fissures can become deeper than normal due to conditions such as age, xerostomia, malnutrition, and vitamin deficiencies. It is also common in patients with Sjögren’s syndrome, Down syndrome, and psoriasis. The problem arises when these deeper fissures collect food and bacteria, providing a breeding ground for infection while increasing the possibility of tongue discoloration, bad breath, and inflammation.
Educating patients on gentle tongue cleaning and good oral hygiene is important for their oral and overall health. More frequent hygiene appointments can help reduce the impact of inflammation and bacteria in the oral environment. A referral to a primary care physician (PCP) can also be beneficial for patient evaluation.1
Atrophic glossitis (smooth tongue)
Atrophic glossitis appears as a glossy, smooth tongue with a reddish-pink border; in some cases, it can be painful.1 This is most likely an oral manifestation of systemic health issues such as celiac disease, Sjögren’s syndrome, drug or chemical reactions, localized and systemic infections (candidiasis), malnutrition or vitamin deficiencies, and pernicious anemia, to name a few. A referral to a PCP can further help patients address physical health conditions that are manifesting in the mouth.1
Coated tongue
Any coating on the tongue is abnormal. Some conditions may be more serious than others. It is important to identify the variety of tongue coatings as they are signs of possible oral thrush, lichen planus, black hairy tongue, or leukoplakia, which may need to be treated or biopsied right away.
Oral thrush (known as the yeast infection candidiasis) is a white, cottage cheese-like coating on the tongue.2 It can be found in infants, the aging population (especially those who wear dentures), and patients who have been on antibiotics. It is also common in patients who have a compromised immune system, diabetes, or are using inhalers containing steroids. The recommended treatment is an antifungal medication rinse; refer to a PCP if a medical diagnosis is needed. Treating oral appliances, dentures, bottles, pacifiers, and the mouth itself with an antifungal rinse can help stop reinfection.2
Lichen planus appears as a lacelike condition found on the dorsal surface of the tongue and on other oral tissues.1 It can coexist with candida infections and is common in patients who are immunocompromised. Severe ulcerative lichen planus should be treated with topical steroids.1
Hairy tongue is a condition where the tongue papillae grow abnormally long, appearing like hairs, creating an environment for harboring bacteria and debris.1 Depending on the patient’s diet or oral habits, a hairy tongue can appear in a variety of colors. Black hairy tongue is most likely found in smokers and/or those who struggle with poor oral hygiene. This often gives the tongue a dark or black appearance and can cause altered taste and bad breath.1 Hairy tongue can also be found in patients taking antibiotics, those with diabetes, or patients undergoing radiation or chemotherapy.2 Many patients struggling with hairy tongue could benefit from three-month hygiene appointments. These appointments can be helpful not only in controlling bacteria but also in providing additional oral hygiene guidance and tobacco counseling when warranted.
Leukoplakia can appear as white patches on the tongue and inside the mouth.1 It is characterized by excessive cell growth, usually caused by irritants such as tobacco use or frequent tongue-biting.2 Leukoplakia could become cancerous, so close monitoring is critical. A dentist or oral surgeon may perform a biopsy to rule out cancer.
Benign migratory glossitis (geographic tongue)
Some clinicians look at geographic tongue as a harmless, unknown, familial dental condition.1,3 But benign migratory glossitis is an inflammatory condition that affects up to 14% of the US population.1 The tiny papillae of the tongue can atrophy and create a smooth, bald patch or lesion.3 These reddish patches can have raised borders and change shape and location on the tongue. Many say the tongue looks like a map, hence the name “geographic tongue.” Common symptoms are burning sensations, pain or stinging, and increased sensitivity to foods, spices, and temperatures.3 Some patients may have mild to no symptoms.
Geographic tongue can also be a sign of other inflammatory health conditions such as type 1 diabetes, environmental and food allergies, vitamin deficiencies (zinc, iron, folic acid, vitamin B6, vitamin B12), and hormone changes. It is also common in people with psoriasis and may have a genetic link to fissured tongue.3 If underlying systemic conditions are a concern, PCP referral may be recommended for patient evaluation. Treatment is only necessary if a patient’s symptoms are causing a lot of discomfort.
Tongue-tie (ankyloglossia)
Tongue-tie is a congenital condition in which the lingual frenum is shortened, tighter, or thicker. It is more commonly found in males.4 In the past, this was primarily a concern with infants who had trouble breastfeeding or swallowing. In the last few years, more attention has been focused on this condition as it is linked to speech problems in children and adults as well as TMJ dysfunction, poor oral hygiene, mouth breathing, and sleep apnea.4 Learning how to identify patients with tongue-tie and helping them get needed treatment can be life-changing.
Consult a certified orofacial myofunctional therapist (OMT) to learn more about orofacial myofunctional disorders (OMDs) and assessments you can use with your patients. Shirley Gutkowski, RDH, and Timbrey Lind, RDH, wrote an informative article in RDH called, “Evaluation of a tongue-tie: The range of motion of the tongue should be assessed in all patients.”5 This article provides insight into OMDs and helpful screening tools. Treatment for OMDs may include a referral for therapy and exercises with a trained myofunctional therapist. In some cases, a frenectomy is required to release the frenum. Screening for OMD in my clinical patients has become routine and has positively impacted their lives.
Conclusion
The tongue may not be our favorite muscle, especially during dental procedures, but it is crucial to pay attention to the story it can tell us about the patient’s overall health. We can then educate patients on what is normal and what to look for that’s out of the norm as they observe their tongue daily. Any lump, bump, or sore on the tongue that does not heal in two to three weeks should be looked at by a dentist, an oral surgeon, or a PCP.
We must reinforce to patients that referrals to other health-care professionals are critical in many cases for diagnosis, healing, and improved systemic health. Chart notes and intraoral images are important for monitoring oral and systemic conditions. Follow-up appointments with the patient and more frequent hygiene prophylaxis can provide additional support and education. Educational handouts are available and can help save time during appointments.
What is the tongue trying to tell you? It just takes a quick look to find out.
Editor’s note: This article appeared in the November/December 2023 print edition of RDH magazine and was updated as of November 2024. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here. A companion article highlighting treatment options for tongue care, including some naturopathic therapies can be accessed here.
References
- Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627-634.
- Allan D. What your tongue can tell you about your health. Cleveland Clinic. December 17, 2019. Accessed January 12, 2023. https://health.clevelandclinic.org/what-your-tongue-can-tell-you-about-your-health/
- Geographic tongue. Cleveland Clinic. Reviewed February 14, 2023. Accessed January 12, 2023. https://my.clevelandclinic.org/health/diseases/21177-geographic-tongue
- Tongue-tie (ankyloglossia). Mayo Clinic. May 15, 2018. Accessed January 12, 2023. https://www.mayoclinic.org/diseases-conditions/tongue-tie/symptoms-causes/syc-20378452
- Gutkowski S, Lind T. Evaluation of a tongue-tie: the range of motion of the tongue should be assessed in all patients. RDH. October 18, 2016. Accessed January 14, 2023. https://www.rdhmag.com/pathology/oral-pathology/article/16409317/evaluation-of-a-tonguetie-the-range-of-motion-of-the-tongue-should-be-assessed-in-all-patients
