What causes a white tongue?

Causes of White Tongue

White tongue is most commonly caused by poor oral hygiene, but can also result from candidiasis, hairy tongue, geographic tongue, leukoplakia, or systemic conditions that affect oral health. 1, 2

Common Causes

Poor Oral Hygiene

• Accumulation of debris, bacteria, and dead cells on the tongue surface is the most frequent cause of white tongue 1
• Often associated with inadequate brushing or tongue cleaning 2
• May be accompanied by halitosis (bad breath) 1

Oral Candidiasis (Thrush)

• Fungal infection caused by Candida species, particularly common in infants and immunocompromised individuals 2
• Presents as removable white patches or plaques on the tongue and oral mucosa 2
• Risk factors include:
  • Corticosteroid use (inhaled or systemic) 1
  • Immunocompromised states 2
  • Recent antibiotic therapy 1
  • Denture use, especially ill-fitting dentures 3
  • Diabetes mellitus 3

Hairy Tongue

• Characterized by elongation and hypertrophy of the filiform papillae on the dorsal surface of the tongue 1
• Appears as a white, yellow, or brown coating with a hairy appearance 2
• Associated with:
  • Low fiber diet 1
  • Tobacco and alcohol use 1
  • Poor oral hygiene, particularly in older males 1
  • Generally asymptomatic except for unattractive appearance and possible halitosis 1

Geographic Tongue (Benign Migratory Glossitis)

• Characterized by irregular, map-like patches on the tongue surface 1
• Affects up to 3% of the population 1
• Usually asymptomatic, though some patients experience food sensitivity or burning sensation 1
• Pattern changes over time, with areas of papillary atrophy surrounded by white borders 2

Potentially Serious Causes

Leukoplakia

• Appears as white patches that cannot be scraped off 1
• Associated with tobacco and alcohol use 1
• May represent precancerous changes with increased risk of squamous cell carcinoma 1
• Requires biopsy for definitive diagnosis 4

Oral Hairy Leukoplakia

• White, corrugated ("hairy") patches typically on the lateral borders of the tongue 5
• Strongly associated with Epstein-Barr virus infection 5, 6
• Most commonly seen in HIV-positive individuals and can indicate progression to AIDS in the absence of antiretroviral therapy 6
• Can occasionally occur in other immunosuppressive conditions 6

Lichen Planus

• Chronic inflammatory condition affecting up to 2% of individuals 1
• Can present as white, lacy reticulations or erosions and ulcerations 1
• May be asymptomatic or cause significant discomfort 2

Systemic Conditions Associated with White Tongue

Immunodeficiency

• HIV/AIDS may present with oral manifestations including white tongue 6
• Other immunocompromising conditions can predispose to oral candidiasis and other white lesions 2

Nutritional Deficiencies

• Deficiencies in vitamins (particularly B vitamins) and minerals can manifest as tongue changes 2
• May present with glossitis (inflammation of the tongue) with white patches 2

Kawasaki Disease

• In children, can present with "strawberry tongue" - initially white coating that sloughs off to reveal red, swollen papillae 4
• Accompanied by fever, rash, and other systemic symptoms 4

Angular Cheilitis

• White patches at the corners of the mouth 3
• Often associated with Candida infection 3
• Contributing factors include:
  • Ill-fitting dentures 3
  • Loss of vertical dimension in the mouth 3
  • Nutritional deficiencies 3
  • Diabetes or immunosuppression 3

Diagnostic Considerations

• White lesions that cannot be scraped off, persist for more than two weeks, or are accompanied by pain or other concerning symptoms warrant further evaluation 4
• Biopsy may be necessary to rule out dysplasia or malignancy in persistent white lesions, particularly in patients with risk factors like tobacco or alcohol use 4
• Oral examination should include assessment of the entire oral cavity, not just the tongue 4

Prevention and Management

• Regular oral hygiene practices including tongue cleaning can prevent many cases of white tongue 1
• Treatment should be directed at the underlying cause 2
• Antifungal therapy for candidiasis 3
• Improved oral hygiene for hairy tongue 1
• Monitoring and possible biopsy for leukoplakia 4