Glossitis · What Is It, Causes, Signs and Symptoms, and More

Glossitis refers to the inflammation of the tongue. The tongue is a predominantly muscular organ situated in the oral cavity, but it also extends into the oropharynx posteriorly. It consists of skeletal muscle fibers essential for chewing, swallowing, and speech, and is covered by a mucosa made of papillae that bears taste buds for tasting. Clinically, glossitis leads to various changes in the texture and color of the tongue and may also be painful, itchy, or burning.  

There are many different types of glossitis, including atrophic glossitis, which presents as a smooth glossy tongue surface caused by loss of papillae; median rhomboid glossitis, where oral candidiasis causes a region without papillae in the central area of the tongue; geographic tongue due to patchy losses of papillae which can appear to move, giving a changing map picture; geometric glossitis, commonly seen in immunocompromised individuals, in which there is a deep fissure with branches in the middle of the tongue; and strawberry tongue, caused by hyperplastic fungiform papillae and commonly associated with infections (e.g., Scarlet fever caused by Streptococcus pyogenes) or inflammation (e.g., Kawasaki disease). 

There are numerous potential etiologies for glossitis, ranging from benign conditions like dehydration or common familial tongue variations (e.g., fissured or geographic tongue) to drug-induced glossitis and more serious underlying conditions, such as vitamin deficiencies, infections, autoimmune disorders, and even certain cancers. 

Nutritional deficiencies, such as iron, folic acid, and several vitamin B deficiencies are common causes of glossitis. Pernicious anemia (i.e., an autoimmune vitamin B12 deficiency) and iron deficiency anemia are generally the most frequent causes. Blood iron levels may be low leading to iron deficiency anemia, due to various reasons like reduced nutritional intake, heavy menses, or occult bleeding from colon cancer. The low levels of myoglobin, a protein necessary for muscle formation, associated with iron deficiency anemia may lead to glossitis and associated changes in tongue appearance. Additionally, prolonged exposure to gluten in celiac disease, an autoimmune disease where gluten triggers an immune response that damages the small intestine lining, may cause glossitis due to malabsorption and nutritional deficiencies.  

Infections caused by bacteria, viruses, yeasts, and fungi can also cause glossitis. Oral herpes and overgrowth of Candida species, especially in immunosuppressed individuals, can affect the tongue’s surface. Accordingly, immunosuppressed individuals with autoimmune conditions may frequently present with oral cavity inflammation. For instance, Sjögren disease is associated with a dry mouth and glossitis, as it reduces the production of bodily fluids, including saliva. Some medications may also alter the texture and color of the tongue. Examples include ACE inhibitors, organosulfur antibiotics (e.g., sulphanilamide), oral contraceptive pills, and albuterol (i.e., a short-acting bronchodilator).  

The most common symptoms of glossitis include changes in tongue color such as redness or a pale appearance; tongue swelling; or changes in texture, such as loss of papillae that creates a smooth surface of the tongue.  

Additionally, individuals can experience tenderness, pain, itching, or burning of the tongue. Consequently, people with glossitis may experience chewing, swallowing, or speaking problems.

Diagnosis of glossitis begins with a history and physical examination. Clinicians may inquire about possible family history of changes in the tongue surface, the individual’s medications, overall nutritional status, dietary restrictions, tobacco and alcohol use, and variation of symptoms with food or environmental exposure. This is typically followed by an examination of the tongue and oral cavity. The mouth may be palpated to assess for tenderness or any palpable lesions, and a thorough head and neck exam may also be necessary to evaluate for any lymphadenopathy.

Additional studies may only be required depending upon the suspected etiology. Blood tests, including iron panel and vitamin levels, can be ordered if nutritional deficiencies are suspected. When autoimmune conditions, such as Sjögren or celiac disease, are suspected, initial serologic studies (e.g., anti-gliadin, anti-tissue transglutaminase antibodies) and rheumatologic studies (e.g., rheumatoid factor, anti-Ro, anti-La antibodies) may be performed. Complete blood count and HIV testing may also be necessary if immunosuppression is suspected or in the setting of infections. Furthermore, any worrisome lesions may warrant further examination to rule out or follow up on malignancies (e.g., contrast-enhanced CT scans, colonoscopy, and biopsy for colon cancer).