What should be done about the persistent white spot on the tip of my tongue that hasn't improved with nystatin swish and spit?

From the Guidelines

You should see a healthcare provider promptly for evaluation of the persistent white spot on your tongue, as it requires proper diagnosis. While nystatin is effective for oral thrush (fungal infection), your lack of response suggests this may be something different. Possible causes include leukoplakia (a precancerous condition), oral lichen planus, geographic tongue, or potentially oral cancer. Your doctor will likely perform a thorough examination and may recommend a biopsy if the spot appears concerning. In the meantime, maintain good oral hygiene, avoid tobacco and alcohol which can irritate the area, and consider using an alcohol-free mouthwash. Don't try to scrape or treat the spot yourself. The persistence of a white spot despite antifungal treatment is significant because different oral lesions require specific treatments - what works for fungal infections won't work for precancerous lesions or autoimmune conditions. Early diagnosis is particularly important if the spot is painless, has irregular borders, or is accompanied by other symptoms like difficulty swallowing.

Given the information provided, it seems that the patient has already been informed that they can call CHCL dental services to get a dental appointment for evaluation to determine further management strategies of this area on her tongue 1. However, considering the potential seriousness of the condition, it's crucial to prioritize a medical evaluation over a dental one, especially if there's a suspicion of oral cancer or other serious conditions.

Some key points to consider:

• The patient has not responded to nystatin swish and spit, suggesting the white spot may not be a simple fungal infection 1.
• Leukoplakia, a precancerous condition, can present as a white patch or plaque that cannot be wiped away and is not clinically or histologically characterized as any other definable disorder 1.
• Early diagnosis is critical, especially if the spot is painless, has irregular borders, or is accompanied by other symptoms like difficulty swallowing.
• Maintaining good oral hygiene and avoiding irritants like tobacco and alcohol can help prevent further irritation but will not address the underlying cause of the white spot.

It's essential to consult a healthcare provider who can perform a thorough examination and provide a proper diagnosis and treatment plan. Given the potential risks associated with untreated oral lesions, it's better to err on the side of caution and seek medical attention sooner rather than later.

From the FDA Drug Label

INDICATIONS AND USAGE Nystatin Oral Suspension, USP, is indicated for the treatment of candidiasis in the oral cavity. The patient has not shown improvement with nystatin swish and spit, suggesting the white spot on the tip of her tongue may not be due to candidiasis or the treatment was not effective.

• The patient is advised to call CHCL dental services to schedule a dental appointment for further evaluation and management of the white spot on her tongue.
• A dental evaluation is necessary to determine the cause of the persistent white spot and develop an appropriate treatment plan. 2

From the Research

History of Present Illness (HPI)

The patient reports feeling better with the added blood pressure medication and has upcoming appointments with a cardiologist, sleep study, and neurology. However, the patient is concerned about a persistent white spot on the tip of her tongue that has not improved with nystatin swish and spit.

Current Symptoms and Treatment

• The patient has been using nystatin swish and spit, but reports no changes in the white spot on her tongue 3, 4.
• The patient is informed that she can call CHCL dental services to get a dental appointment for evaluation and further management strategies of the area on her tongue.

Diagnostic Considerations

• The history of present illness (HPI) is an essential component of diagnostic evaluation, and digital tools can be used to obtain the HPI from patients before face-to-face evaluation by a clinician 5.
• The HPI can be therapeutic, helping patients make cognitive sense of their illness and serving as a vehicle for sharing the affective burden with the physician 6.
• Organizing the traditional HPI into an "All-Inclusive History of Present Illness" can improve verbal case presenting and clinical diagnostic reasoning skills of medical students 7.

Next Steps

• The patient should follow up with the dental appointment to evaluate the white spot on her tongue and determine further management strategies.
• The patient's upcoming appointments with a cardiologist, sleep study, and neurology should be attended as scheduled to monitor her overall health and address any related concerns.