Nutrient Deficiencies Causing Glossitis
The primary nutrient deficiencies that cause glossitis are riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6), vitamin B12, folic acid, and iron, with riboflavin and vitamin B12 being the most clinically significant. 1
Primary Deficiencies Associated with Glossitis
B-Vitamin Deficiencies
- Riboflavin (Vitamin B2) deficiency manifests with oral-buccal lesions including glossitis, angular stomatitis, and cheilosis 1
- Pyridoxine (Vitamin B6) deficiency presents with glossitis, cheilosis, dermatitis, and peripheral neuritis 1
- Niacin (Vitamin B3) deficiency results in pellagra characterized by cutaneous, gastrointestinal and neurologic symptoms including glossitis 1
- Vitamin B12 deficiency causes atrophic glossitis with a characteristic "beefy, red, smooth tongue" appearance 2, 3
- Folic acid deficiency can produce glossitis, though less commonly than B12 deficiency 2, 4
Other Nutrient Deficiencies
- Biotin deficiency leads to glossitis along with seborrheic dermatitis, anorexia, nausea, pallor, and alopecia 1
- Iron deficiency is associated with atrophic glossitis in 16.9% of affected patients 2, 4
- Zinc deficiency may contribute to glossitis, particularly in malabsorption conditions 2
Clinical Context and Diagnostic Approach
Key Clinical Pattern Recognition
Riboflavin deficiency frequently occurs alongside pyridoxine, folate, and niacin deficiencies, making isolated deficiency uncommon 1. This means patients often present with multiple nutritional deficiencies simultaneously 5.
High-Risk Populations
- Patients with malabsorption syndromes (short bowel syndrome, celiac disease, inflammatory bowel disease) 1, 6
- Patients on hemodialysis or peritoneal dialysis 1
- Alcoholism 1
- Patients on psychotropic drugs, tricyclic antidepressants, or barbiturates 1
- Strict vegetarians (for B12 deficiency) 7
- Elderly patients with decreased dairy intake 1
Essential Laboratory Evaluation
Before diagnosing primary burning mouth disorder, always screen for nutritional deficiencies in patients with glossodynia 3. The workup should include:
- Complete blood count to assess for anemia and macrocytosis 2, 5, 4
- Serum iron, vitamin B12, and folic acid levels 2, 5
- Serum homocysteine level (elevated in 11.9% of atrophic glossitis patients) 2, 4
- Consider serum gastric parietal cell antibody (positive in 26.7% of atrophic glossitis patients) 2, 4
- For riboflavin assessment, use erythrocyte glutathione reductase activity test rather than plasma levels, as it better reflects tissue saturation 1, 6
Critical Clinical Pitfall
Never treat folate deficiency without first checking B12 status, as folate supplementation can improve hematologic parameters while worsening neurological manifestations of B12 deficiency 6, 8. This is particularly important because vitamin B12 deficiency can cause subacute combined degeneration of the spinal cord, and prompt parenteral administration prevents progression of neurologic damage 7.
Treatment Approach
Riboflavin Deficiency
- Acute deficiency: 5-10 mg/day orally until recovery 1
- Severe cases may require IV administration of 160 mg for 4 days 1
Vitamin B12 Deficiency
- Parenteral administration is preferred in malabsorption conditions 7
- Oral absorption is unreliable in pernicious anemia or malabsorption 7
- Treatment typically requires 3-12 months to achieve complete remission 9
General Principles
- Supplementation with vitamin BC capsules (containing multiple B vitamins) plus corresponding deficient hematinics can achieve complete remission of oral symptoms and atrophic glossitis 2, 9
- Treatment duration typically ranges 8.3-11.6 months for symptom resolution 9
- Multiple deficiencies are common, so replacement therapy should address all identified deficiencies simultaneously 5