Tongue Discoloration and Other Changes

The papillary surface (dorsum) of the tongue may become discolored by smoking or chewing tobacco, consuming certain foods or vitamins, or by surface growth of pigmented bacteria.

Black discoloration on the dorsum may be due to oral bismuth preparations. Brushing the tongue with a toothbrush or scraping it with a tongue scraper may remove such discoloration.

Blue-black discoloration, focal, small, and unchanging, on the ventral surface, may be an amalgam tattoo.

A pale, smooth tongue can be caused by atrophic glossitis, which can occur with iron deficiency Iron Deficiency Iron (Fe) is a component of hemoglobin, myoglobin, and many enzymes in the body. Heme iron is contained mainly in animal products. It is absorbed much better than nonheme iron (eg, in plants... read more or vitamin B12 deficiency Vitamin B12 Deficiency Dietary vitamin B12 deficiency usually results from inadequate absorption, but deficiency can develop in vegans who do not take vitamin supplements. Deficiency causes megaloblastic anemia, damage... read more .

Magenta tongue suggests vitamin B12 deficiency.

A strawberry-red tongue may be the first sign of scarlet fever or, in a young child, be among the signs of Kawasaki disease Kawasaki Disease Kawasaki disease is a vasculitis, sometimes involving the coronary arteries, that tends to occur in infants and children between the ages of 1 year and 8 years. It is characterized by prolonged... read more or multisystem inflammatory syndrome in children (MIS-C) Risk factors for severe disease COVID-19 is an acute, sometimes severe, respiratory illness caused by the novel coronavirus SARS-CoV-2. Prevention is by vaccination and infection control precautions (eg, face masks, handwashing... read more .

A smooth red tongue and painful mouth may indicate general inflammation of the tongue (glossitis) or be caused by niacin deficiency Niacin Deficiency Dietary niacin deficiency (causing pellagra) is uncommon in countries with low rates of food insecurity. Clinical manifestations include the three Ds: localized pigmented rash (dermatitis);... read more .

The most common tongue surface changes, all 3 benign, are

In geographic tongue, areas of the tongue are red and smooth (due to atrophy of filiform papilla) and are often surrounded by a slightly elevated yellow-white border. Other areas may be white or yellow and rough, representing psoriaform changes or coexisting psoriasis itself. The areas of discoloration can migrate over a period of weeks to years. The condition is usually painless, and no treatment is needed. If people have symptoms, applying low doses of topical corticosteroid sometimes helps.

Fissured tongue is an idiopathic condition usually occurring in about 5% of adults in the US (and in up to 30% of older adults). Deep grooves are located either along the midline or are distributed over the dorsum. Fissured tongue may occur with geographic tongue, Down syndrome Down Syndrome (Trisomy 21) Down syndrome is an anomaly of chromosome 21 that can cause intellectual disability, microcephaly, short stature, and characteristic facies. Diagnosis is suggested by physical anomalies and... read more , or Melkersson-Rosenthal syndrome, a rare syndrome that also features facial palsy and granulomatous cheilitis.

Hairy tongue is due to accumulation of keratin on normal filiform papillae that gives the tongue a hairy appearance. Hairy tongue is caused by lack of mechanical stimulation to the tongue (eg, due to poor oral hygiene) with trapping of residual food debris among the papillae. Hairy tongue may also appear after a fever, antibiotic treatment, or with excessive use of peroxide mouthwash. It is common in heavy smokers. Hairy tongue should not be confused with hairy leukoplakia, which usually is associated with immunodeficiency (especially HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more ) and caused by the Epstein-Barr virus. It appears as white, hairy-appearing patches on the side of the tongue.

Other tongue surface changes include tongue ulcers, whitish patches, and red patches.

Tongue ulcers may be herpetiform aphthous ulcers (ventral tongue surface) or be due to trauma from accidental biting or from rubbing against a fractured tooth or restoration.

Whitish patches on the tongue, similar to those sometimes found inside the cheeks, may be due to

Red patches on the tongue may indicate

Leukoplakia and erythroplakia may be manifestations of oral squamous cell carcinoma Oral Squamous Cell Carcinoma Oral cancer refers to cancer occurring between the vermilion border of the lips and the junction of the hard and soft palates or the posterior one third of the tongue. Over 95% of people with... read more ; biopsy is indicated for both.