What are the common diseases of the tongue and their treatments?

Common Diseases of the Tongue

Oral Candidiasis (Thrush)

Oral candidiasis is the most common infectious disease of the tongue, presenting as white plaques that can be scraped off to reveal an erythematous base, and should be treated with topical or systemic antifungal therapy depending on severity and patient risk factors. 1

Clinical Presentation

• White plaques on the tongue dorsum, palate, buccal mucosa, and lips that can be mechanically removed 2
• "Strawberry tongue" appearance with erythema and prominent fungiform papillae (though this is more characteristic of Kawasaki disease or scarlet fever) 3
• Erythematous (atrophic) candidiasis presents as red, painful patches without white coating 4
• Angular cheilitis may accompany oral candidiasis, with cracking and fissuring at the mouth corners 4

Risk Factors

• Immunocompromised states (HIV/AIDS, cancer chemotherapy, organ transplantation) 3
• Diabetes mellitus and poor glycemic control 4
• Antibiotic use disrupting normal oral flora 1
• Denture wearing, particularly ill-fitting dentures 3
• Xerostomia (dry mouth) from any cause 1
• Corticosteroid use (inhaled or systemic) 3

Diagnostic Approach

• Clinical diagnosis based on characteristic appearance and ability to scrape off white plaques 1
• Fungal culture or KOH preparation confirms diagnosis when uncertain 1
• Microscopic demonstration of fungal hyphae on PAS smear or biopsy is highly diagnostic 4

Treatment Algorithm

First-Line Topical Therapy (for mild to moderate cases in immunocompetent patients):

• Nystatin oral suspension 100,000 units swish and swallow four times daily for 7-14 days 3, 1
• Clotrimazole troches 10 mg dissolved slowly in mouth five times daily for 7-14 days 3
• Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1

First-Line Systemic Therapy (for moderate to severe cases, immunocompromised patients, or topical therapy failures):

• Fluconazole 100-200 mg orally once daily for 7-14 days is superior to topical therapy and should be used as first-line treatment in HIV-infected patients and those with severe disease 3, 5
• Loading dose of 200 mg on day 1, then 100 mg daily achieves steady-state concentrations rapidly 5
• Itraconazole solution 200 mg daily for 7-14 days is comparable in efficacy to fluconazole 3

Second-Line Therapy (for azole-refractory infections):

• Itraconazole solution at doses >200 mg/day is effective in approximately two-thirds of fluconazole-refractory cases 3
• Amphotericin B oral suspension 1 mL four times daily (100 mg/mL suspension) for topical effect 3
• Intravenous amphotericin B 0.3 mg/kg/day reserved for severe azole-refractory infections 3
• Caspofungin or other echinocandins for refractory cases 3

Special Considerations

• Fluconazole mouthrinse (2 mg/mL) used as rinse-and-spit three times daily achieved 94% clinical cure in patients with xerostomia or swallowing difficulties 6
• Suppressive therapy with fluconazole is effective for preventing recurrent infections but should be reserved for frequent or disabling recurrences to minimize resistance development 3
• In HIV-infected patients, symptomatic relapses occur sooner with topical therapy than with fluconazole 3
• Denture-related candidiasis requires thorough disinfection of the denture for definitive cure 3

Common Pitfalls

• Avoid chronic use of petroleum-based products on oral mucosa as they promote mucosal dehydration and increase secondary infection risk 7, 1
• Do not use glycerin or lemon-glycerin swabs or alcohol-based mouthwashes as they dry the mouth and worsen symptoms 1
• Oropharyngeal fungal cultures are of little benefit since many individuals have asymptomatic colonization 3
• Treatment duration must be adequate (minimum 7-14 days) to prevent recurrence 3

Angular Cheilitis

Angular cheilitis presents as erythema, cracking, and fissuring at the mouth corners and requires treatment addressing both infection and underlying mechanical factors.

Non-Infected Angular Cheilitis Management

• Apply white soft paraffin ointment every 2 hours during acute phase to protect skin barrier 7
• Transition to beeswax, cocoa butter, or lanolin for maintenance after initial healing 7
• Apply topical antifungal-corticosteroid combination to address subclinical Candida colonization 7
• Clobetasol propionate 0.05% mixed with Orabase applied daily for severe inflammation 7

Addressing Underlying Causes

• Evaluate and correct ill-fitting dentures or loss of vertical dimension 7
• Consider occlusal vertical dimension restoration in appropriate cases 7
• Clean affected area daily with warm saline mouthwashes 7
• Use 0.2% chlorhexidine digluconate mouthwash twice daily if bacterial colonization suspected 7

Treatment Duration

• Reassess after 2 weeks if no improvement to confirm diagnosis and evaluate compliance 7
• Immunocompromised patients require more aggressive and prolonged therapy 7

White Tongue (Non-Candidal Causes)

Oral Hygiene-Related White Coating

• Daily tongue cleaning with soft toothbrush or tongue scraper on dorsal surface 1
• Brush teeth twice daily with mild fluoride toothpaste 1
• Rinse mouth with alcohol-free mouthwash at least four times daily 1
• Avoid smoking, alcohol, spicy foods, and hot beverages 1

Dehydration-Related Changes

• Address underlying dehydration with adequate fluid intake 1
• Maintain good oral hygiene protocol as above 1

Geographic Tongue (Benign Migratory Glossitis)

While not explicitly covered in the provided guidelines, this benign inflammatory condition presents as irregular, smooth red patches with white borders that migrate across the tongue surface. It typically requires no treatment beyond reassurance, though symptomatic cases may benefit from topical corticosteroids.

Median Rhomboid Glossitis

• Many investigators accept this as a form of chronic oral candidiasis 4
• Presents as a smooth, red, rhomboid-shaped area on the midline dorsum of the tongue 4
• Treatment follows oral candidiasis protocols with antifungal therapy 4

Hairy Tongue (Black Hairy Tongue)

While not detailed in the provided evidence, this condition involves elongation of filiform papillae and typically responds to improved oral hygiene, tongue brushing, and elimination of predisposing factors (tobacco, poor oral hygiene, certain medications).

Kawasaki Disease (Pediatric Consideration)

In children with fever ≥5 days and strawberry tongue, consider Kawasaki disease as this requires urgent treatment to prevent coronary artery complications.

Diagnostic Criteria

• Fever persisting at least 5 days 3
• Strawberry tongue with erythema and prominent fungiform papillae 3
• Erythema, cracking, and bleeding of lips 3
• Diffuse erythema of oropharyngeal mucosae 3
• Must have at least 4 of 5 principal features for diagnosis 3

Critical Distinction

• Oral ulcerations and pharyngeal exudates are NOT seen in Kawasaki disease 3
• This distinguishes it from infectious causes of strawberry tongue 3