What is the treatment for glossitis?

Treatment of Glossitis

The treatment of glossitis depends critically on identifying and correcting the underlying cause, with nutritional deficiencies requiring hematinic supplementation and infectious causes requiring antimicrobial therapy.

Diagnostic Evaluation Before Treatment

Before initiating treatment, obtain the following laboratory tests to guide therapy 1:

• Complete blood count to identify anemia
• Serum iron, vitamin B12, and folic acid levels
• Serum homocysteine level
• Autoantibodies: gastric parietal cell antibody (GPCA), thyroglobulin antibody (TGA), and thyroid microsomal antibody (TMA) 1

This workup is essential because 19% of glossitis patients have anemia, 16.9% have iron deficiency, 5.3% have vitamin B12 deficiency, and 2.3% have folic acid deficiency 1.

Treatment Based on Etiology

For Nutritional Deficiency-Related Glossitis

Vitamin B12 deficiency (Hunter's glossitis):

• Administer vitamin B12 supplementation, which leads to improvement in tongue appearance, subjective symptoms, and taste function 2
• For patients with hematinic deficiencies, provide vitamin B complex capsules plus corresponding deficient hematinics 1
• This approach achieves complete remission of oral symptoms and glossitis in many patients 1

Important consideration: GPCA-positive patients have higher frequencies of hemoglobin, iron, and vitamin B12 deficiencies and require more aggressive hematinic replacement 1

For Infectious Glossitis (Candidiasis)

First-line topical therapy:

• Nystatin oral suspension (100,000 units/mL, 4-6 mL four times daily for 7-14 days) 3
• Clotrimazole troches (10 mg five times daily for 7-14 days) 3
• Miconazole oral gel (applied four times daily for 7-14 days) 4

Systemic therapy for resistant cases:

• Oral fluconazole (100 mg/day for 7-14 days) is superior to topical therapy and more effective than ketoconazole 3
• Itraconazole solution (200 mg/day for 7-14 days) is comparable in efficacy to fluconazole 3

For refractory candidal glossitis:

• Itraconazole at doses >200 mg/day (preferably as solution) is effective in approximately two-thirds of fluconazole-refractory cases 3
• Amphotericin B oral suspension (1 mL four times daily of 100 mg/mL suspension) for cases not responding to itraconazole 3
• Intravenous amphotericin B (0.3 mg/kg/day) as last resort for refractory disease 3

For Inflammatory/Atopic Glossitis

• Apply topical corticosteroids four times daily to reduce inflammation 4
• For severe cases, consider systemic corticosteroids under medical supervision 5

Supportive Care Measures (All Types)

Symptomatic relief:

• Apply white soft paraffin ointment to the tongue every 2-4 hours for protection and moisturization 6, 5, 4
• Use benzydamine hydrochloride rinse or spray every 2-4 hours, particularly before eating, for pain relief 5, 4
• Maintain oral hygiene with warm saline mouthwashes daily 6, 5, 4

Avoid:

• Alcohol-containing mouthwashes, which cause additional pain and irritation 5, 4
• Petroleum-based products for chronic use, as they promote mucosal dehydration and increase infection risk 6

Special Populations

Immunocompromised patients:

• Require more aggressive and prolonged antimicrobial therapy 3, 5, 4
• Consider suppressive antifungal therapy only if recurrences are frequent or disabling to reduce development of antifungal resistance 3

Treatment Monitoring

Reassess within 2 weeks 6, 5:

• If no improvement, reevaluate the diagnosis
• Assess patient compliance with therapy
• Consider alternative or additional underlying causes

Common Pitfalls to Avoid

• Do not treat glossitis empirically without laboratory evaluation, as nutritional deficiencies are present in a substantial proportion of patients and require specific replacement therapy 1
• Do not use suppressive antifungal therapy routinely, as this promotes antifungal resistance; reserve for frequent or disabling recurrences 3
• Do not overlook systemic conditions such as diabetes mellitus, Helicobacter pylori colonization, or xerostomia as contributing factors 1
• Do not assume all glossitis is infectious; protein-calorie malnutrition and multiple vitamin deficiencies (riboflavin, niacin, pyridoxine, zinc, vitamin E) can cause atrophic glossitis 1