Glossitis

Glossitis is inflammation of the tongue characterised by change in colour, surface texture and size of the tongue, often with papillary atrophy (smooth, red, "bald" tongue). It is a sign with many causes rather than a single disease. Acute forms follow infection, trauma, burns, allergy or angioedema; chronic forms follow nutritional deficiency, chronic infection, systemic disease and drugs.

Nutritional causes account for most chronic atrophic glossitis: iron deficiency (Plummer-Vinson syndrome with dysphagia and oesophageal web), vitamin B12 deficiency (Hunter glossitis, with pernicious anaemia), folate deficiency, riboflavin (B2), niacin (B3, pellagra), pyridoxine (B6), and zinc deficiency.

Other causes: oral candidiasis, syphilis (tertiary interstitial glossitis), Sjogren syndrome, coeliac disease, Crohn disease, HIV, diabetes, hypothyroidism, amyloidosis, lichen planus, geographic tongue, irritants (tobacco, alcohol, spices), medicines (ACE inhibitors causing angioedema, antibiotics, chemotherapy), poorly fitting dentures, and radiotherapy. Malabsorption is a prominent cause in Kenyan patients with HIV and chronic diarrhoea. Most nutritional glossitis reverses with replacement within 1 to 2 weeks.

• Smooth, shiny, red, swollen or beefy tongue with loss of papillae; sore, burning pain, especially with spicy foods; altered taste; difficulty chewing, swallowing and speaking.
• Iron deficiency: pale smooth tongue, angular cheilitis, koilonychia, dysphagia.
• B12 or folate deficiency: beefy red, painful tongue, pallor, jaundice, paraesthesia, neuropsychiatric signs (B12).
• Pellagra: red swollen tongue with dermatitis and diarrhoea.
• Acute glossitis from angioedema: rapid tongue swelling with airway compromise.
• Candidal glossitis: patchy white plaques over the red base.
• Red flags: rapid swelling with stridor, drooling, indurated mass or ulcer lasting over 3 weeks, associated weight loss, neurological signs.

• Clinical examination of the tongue and mouth, nutritional and drug history, signs of anaemia and neurological signs.
• Full blood count and film (macrocytosis in B12 or folate deficiency, microcytosis in iron deficiency), ferritin (below 15 micrograms/L indicates iron deficiency), vitamin B12 (below 200 ng/L deficient), red cell or serum folate, zinc, glucose or HbA1c, thyroid function.
• Intrinsic factor and parietal cell antibodies for pernicious anaemia; coeliac serology (tissue transglutaminase IgA with total IgA); HIV test; syphilis serology.
• Swab or smear for Candida species.
• Anti-Ro and anti-La antibodies and Schirmer test for Sjogren syndrome.
• Upper endoscopy for iron deficiency with dysphagia (web, malignancy).
• Biopsy for chronic non-healing or indurated lesions.
• Exclude geographic tongue, median rhomboid glossitis, leukoplakia, lichen planus, carcinoma, and amyloid macroglossia.

• Treat the cause; replace deficient nutrients.
• Iron deficiency: ferrous sulfate 200 mg (65 mg elemental iron) orally once or twice daily for 3 to 6 months (continue 3 months after correction of haemoglobin); intravenous iron (iron sucrose 200 mg on 5 occasions over 14 days) for malabsorption or intolerance; investigate and treat the cause of blood loss.
• Vitamin B12 deficiency: hydroxocobalamin 1 mg intramuscularly on alternate days for 2 weeks, then 1 mg every 3 months for life in pernicious anaemia; oral cyanocobalamin 1 to 2 mg daily for dietary deficiency.
• Folate deficiency: folic acid 5 mg orally once daily for 4 months (after excluding B12 deficiency).
• Riboflavin 10 mg orally once daily; nicotinamide 100 mg orally 3 times daily for pellagra for 3 to 4 weeks; pyridoxine 50 mg daily; zinc sulfate 220 mg daily for 8 weeks.
• Candidal glossitis: miconazole oral gel 20 mg/g, 2.5 mL four times daily for 14 days, or fluconazole 50 to 100 mg daily for 7 to 14 days.
• Symptomatic relief: benzydamine 0.15 percent rinse 15 mL every 3 hours as needed; avoid irritants (tobacco, alcohol, spicy foods, hot drinks); soft diet; chlorhexidine 0.2 percent mouthwash 10 mL twice daily for 7 to 14 days.
• Acute allergic or ACE inhibitor angioedema of the tongue: adrenaline 0.5 mg intramuscularly (0.5 mL of 1 mg/mL), repeat every 5 minutes as needed; hydrocortisone 200 mg intravenously; chlorphenamine 10 mg intravenously; secure the airway; stop the ACE inhibitor permanently.
• Syphilitic glossitis: benzathine benzylpenicillin 2.4 million units intramuscularly once weekly for 3 weeks (late disease).
• Sjogren syndrome: pilocarpine 5 mg three times daily and saliva substitutes.
• Follow up: recheck blood counts at 4 to 8 weeks, tongue recovery within 2 to 4 weeks; persistent glossitis needs biopsy.
• Counselling: dietary advice, regular dental care, and no tobacco.