Common Issues and Signs to See a Specialist
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Don’t take your tongue for granted. The muscular organ that sits in your mouth and throat does a lot more than help you taste, speak, and swallow. It’s also both a protector and harbinger of health.
“It’s a very, very important organ,” says Alexander Kerr, DDS, MSD, director of oral medicine at the New York University College of Dentistry. “You can certainly tell a lot about a patient from their tongue.”
The tongue can be broken down into two parts. The tongue you see in your mouth, called the oral tongue, only makes up around one-third of the organ, Dr. Kerr explains. The bulk of the tongue, the body or anterior tongue, extends from the back of the mouth and down the throat. There is also a tonsil, called the lingual tonsil, that sits on the body of the tongue.
That anterior part of the tongue is actually part of the immune system.
“If you were to breathe in a virus like COVID, it interacts with those tonsils, and that’s how the body sets up the immune response,” Kerr says.
The color and texture of your tongue can indicate infections, vitamin deficiencies, and disease. Here are some common issues related to tongue health, as well as signs you may need to see an oral health specialist.
Black Tongue
There could be several reasons why your tongue is dark or even black. Often when this happens, your tongue will also appear to be hairy.
While it may sound pretty gross, a condition called black hairy tongue is actually harmless. Tiny hairlike structures on the tongue, called filiform papillae, hold onto the chemicals that tastebuds interpret as salty, sweet, sour, bitter, or umami, which can be described as savory. According to Kerr, a normal diet that includes coarse or crunchy foods naturally whittles down the filiform papillae, so most people don’t even notice them.
If they get too long, filiform papillae can collect bacteria, some of them pigmented. Drinking coffee or colorful fruit juice can also turn the bacteria tangled in the filiform papillae dark, Kerr says. Taking antibiotics can help abnormal bacteria flourish on the tongue, putting a person at higher risk of developing black hairy tongue, he adds.
If someone is a smoker, tar and tobacco can also stain filiform papillae, turning it dark or sometimes yellow. According to the Mayo Clinic, over-the-counter medicines that contain bismuth, such as Pepto-Bismol, may also cause discoloring similar to black hairy tongue. A black tongue could indicate a fungal or viral infection, which should be diagnosed by an oral health specialist, dentist, or healthcare provider.
In rarer cases, a tongue that appears to be black and hairy can be a symptom of hairy leukoplakia, a condition associated with the Epstein-Barr virus, also known as human herpesvirus 4, which usually occurs in people who have human immunodeficiency virus (HIV), according to the National Library of Medicine.
“People can brush or scrape the top of their tongue if the hairs are long and they feel they need to, but a healthy coarse diet and not smoking should keep things stabilized,” Kerr says.
Smooth Tongue
According to Kerr, the tongue can reveal nutritional deficiencies, the most common being iron. If a person does not have enough iron, red blood cells can’t deliver blood to tissues around the body.
The tissue in the mouth in particular is always renewing itself, Kerr notes, but if a person is deficient in iron, some of those tissues don’t get replaced. Filiform papillae get whittled down in their normal way, but new cells don’t replace them.
“Sometimes the tongue can look bald, which may be indicative of some sort of anemia or iron deficiency,” Kerr says, adding that chronic dry mouth can also cause a bald-appearing tongue.
According to a review published in the Journal of the Formosan Medical Association, around 20 percent of people with reported atrophic glossitis, or a bald-like tongue, have anemia. More than 5 percent have a vitamin B12 deficiency.
A clinician can test for vitamin deficiencies, which can usually be corrected with supplements or diet changes.
White Patches
White patches on the tongue may indicate several conditions.
The most likely is a benign condition called geographic tongue, or migratory glossitis. It’s also sometimes called erythema migrans or annulus migrans. According to the Mayo Clinic, geographic tongue is a harmless inflammatory condition that causes patches of filiform papillae to disappear from the tongue, leaving a patchwork effect of white and red on the tongue.
“It’s this strange condition with lesions or spots that migrate around the tongue. Sometimes they disappear and come back, and sometimes they can cause a little soreness, but most times they don’t cause any discomfort,” explains Kerr, adding that the condition is fairly common.
An inflammatory condition called oral lichen planus, which affects the mouth’s mucous membranes can also cause lacy white patches, sores, or a swollen red tongue, according to the Mayo Clinic.
A thick white coating on the tongue and throat can indicate an oral candida, or yeast infection, also called oral thrush, according to the National Library of Medicine. It’s one of the most common side effects of cancer treatments. Wearing dentures, living with diabetes, and taking certain medications (such as antibiotics or steroids) can also increase a person’s risk. Living with HIV puts a person at higher risk of developing oral thrush as well. While improving oral health can improve many conditions that impact the tongue, oral thrush is treated with oral or topical antifungals, usually for one to two weeks.
White or Red Spots or Lesions
Noncancerous issues are much more common than cancers, Kerr says, but tongue cancer can happen, and deadly cases are rising.
According to the American Cancer Society, the death rate for mouth and throat cancers increased by nearly 0.5 percent every year from 2009 through 2020, after decades of decline. This was mostly driven by an increase in deaths from oropharyngeal cancer, a type of head and neck cancer that develops in the oropharynx, which can impact the back part of the tongue.
According to Kerr, tongue cancers are more likely to occur on the side or underside of the oral tongue, whereas the part of the tongue that sits where the throat meets the mouth is at higher risk of oropharyngeal cancer. The types of cancer that impact the back of the tongue are usually caused by the human papillomavirus.
Tongue cancer usually appears as a white patch, red patch, or red and white patch, or as a sore or growth, he notes. The important difference between cancer and a lesion caused by a sharp tooth or food is that a cancer spot typically gets bigger over the course of months or even years, Kerr says. It’s also usually a solitary spot.
“Most things you see on your tongue are benign. The tongue gets rubbed on a sharp tooth or bitten or burned, and that will usually heal over time,” Kerr explains, noting that if a sore on the tongue hasn’t healed in two weeks, you should go see your healthcare provider to make sure it’s nothing to worry about — plenty of tumors are benign, but catching any cancer early is paramount to good outcomes.
“Tongue cancer is pretty serious. As tongue cancers progress, they can spread into the lymph nodes in the neck,” he adds.
Oral herpes can also cause sores or lesions on the tongue. According to a paper published in Malaysian Family Physician, sores on the tongue caused by the herpes simplex virus are ulcers that have a white or mixed white and red appearance. The ulcers can be painful, and they occur often; outbreaks can be managed with oral medications such as acyclovir, valacyclovir, and famciclovir.
Yellow Tongue
A yellow tongue can be caused by smoking or by something a person ate, but it can also indicate an underlying health issue.
According to the Cleveland Clinic, a yellow tongue could also be a symptom of gastritis, a condition that causes inflammation in the stomach lining and side effects such as acid reflux. Like black hairy tongue, a yellow tongue can also be caused by the buildup of filiform papillae, bacteria, and skin cells on the tongue that give it a hairy appearance and trap things like tobacco smoke and pigmented foods and beverages.
If an underlying issue isn’t at the root of any tongue problems you have, practicing good oral hygiene — brushing your teeth, flossing, scraping your tongue if you feel you need to — should keep your mouth, and tongue, healthy, Kerr says.
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