Tongue Coating: Or something else? Differential Diagnosis

Blood, hematopoietic organs – immune system (D50-D90).

  • Iron deficiency anemia – anemia caused by iron deficiency; tongue appears rather pale; burning of the tongue [see below iron deficiency anemia].
  • Immunodeficiency / immune deficiency → candidiasis (synonyms: candidasis, candidosis).
  • Pernicious anemia – anemia (anemia) caused by a deficiency of vitamin B12 or, less commonly, by a deficiency of folic acid; smooth, red inflamed tongue and burning tongue (“Hunter’s glossitis”) [see below megaloblastic anemia].
  • Plummer-Vinson syndrome (synonyms: sideropenic dysphagia, Paterson-Brown-Kelly syndrome) – combination of several symptoms caused by mucosal atrophy in the upper gastrointestinal tract (oral cavity to stomach); the disease leads to difficulty swallowing and tongue burning due to mucosal atrophy in the mouth; furthermore, there are: Mucosal defects, oral rhagades (tears in the corner of the mouth), brittle nails and hair and dysphagia (difficulty swallowing) due to larger mucosal defects; the disease is a risk factor for the development of esophageal cancer (esophageal cancer).

Endocrine, nutritional, and metabolic diseases (E00-E90).

  • Diabetes mellitus (→ candidiasis)
  • Iron deficiency
  • Folic acid deficiency
  • Vitamin B12 deficiency

Cardiovascular system (I00-I99)

  • Osler-Weber-Rendu disease (synonyms: Osler disease; Osler syndrome; Osler-Weber-Rendu disease; Osler-Rendu-Weber disease; hereditary hemorrhagic telangiectasia, HHT) – autosomal-dominant inherited disorder in which telangiectasias (abnormal dilation of blood vessels) occur. These can occur anywhere, but are found especially in the nose (leading symptom: epistaxis (nosebleed)), mouth, face, and the mucous membranes of the gastrointestinal tract (GI tract). Because the telangiectasias are very vulnerable, it is easy to tear and therefore bleeding.

Skin and subcutaneous (L00-L99).

  • Lichen ruber planus (nodular lichen) – description of small flat, slightly scaly nodules here: Lichen ruber mucosae oris; burning tongue pain may occur before the appearance of visible changes.

Infectious and parasitic diseases (A00-B99).

  • Candidiasis – infectious diseases caused by fungi (fungi sprouts) of the genus Candida (here: inflammation of the oral mucosa, including the tongue).
  • Scarlet fever (childhood disease); initially white coated tongue, later red colored tongue with enlarged tongue poplars (so-called “raspberry tongue”) [see below scarlet fever].
  • Typhoid fever (tropical disease): centrally gray-white / yellow occupied tongue with free reddish edges (so-called typhoid tongue) [see below typhoid fever].

Liver, gallbladder and bile ducts – pancreas (pancreas) (K70-K77; K80-K87).

  • Liver disease? → yellowish tongue coating? [significance is controversial]
  • Liver cirrhosis – irreversible (non-reversible) damage to the liver and a pronounced remodeling of liver tissue; endpoint of many liver diseases characterized by a slowly progressive (progressive) course over decades; lacquer tongue (especially red and uncoated tongue) and lacquer lips (smooth, lacquer-red lips) [see below liver cirrhosis].

Mouth, esophagus (esophagus), stomach, and intestines (K00-K67; K90-K93).

  • Gastritis (gastritis) → white (to dirty-white) tongue coating [see below gastritis].
  • Gingivostomatitis ulcerosa/ulcerous inflammation of the gums and oral mucosa (forms: Plaut-Vincent due tomixed bacterial infection; agranulocytosis/absence or severe decrease of granulocytes in the blood due tointolerance reactions).
  • Glossitis (inflammation of the tongue) → red tongue coating [see below glossitis].
  • Glossitis mediana rhombica: oval painless change in the middle third of the dorsum of the tongue, which is not covered by papillae; unknown cause.
  • Lingua geographica (map tongue): harmless change in the tongue surface; constitutional anomaly; the tongue gets its typical appearance by repulsion of the epithelium of the filiform papillae of the tongue surface (papillae filiformes); whitish and reddish districts resembling a map appear; spectrum of complaints ranges from asymptomatic to a burning sensation or burning pain.
  • Lingua plicata (wrinkle tongue; synonyms: Folded tongue, notched tongue, furrowed tongue, lingua fissurata, lingua scrotalis, lingua dissecta, lingua cerebelliformis): autosomal dominant inherited variant of tongue surface texture; increased longitudinal and/or transverse wrinkling; has no disease value; partial symptom in Melkersson-Rosenthal syndrome; also frequently found in patients with trisomy 21 (Down syndrome).
  • Periodontitis – disease of the periodontium (periodontium) → occupied tongue of different color and thickness.
  • Black hair tongue (Lingua pilosa nigra; Nigrities linguae; Lingua villosa nigra (simplified also Lingua nigra)): a disease value in the actual sense should not have the hair tongue. Occurrence: 3-5% of the normal population, mainly in men; caused by the elongation of certain papillae (hyperplasia of the papillae filiformes) of the tongue, which form a hairy and usually dark coating on the back of the tongue.
  • Xerostomia (dry mouth) [see below xerostomia].
  • Tongue fissure (mucous membrane tear in the tongue), usually painless.

Musculoskeletal system and connective tissue (M00-M99).

  • Kawasaki syndrome – acute, febrile, systemic illness characterized by necrotizing vasculitis of small and medium-sized arteries); red raspberry tongue and brittle patent lips [see vasculitis/Kawasaki syndrome below].
  • Sjögren’s syndrome – autoimmune disease from the group of collagenoses, which leads to a chronic inflammatory disease or destruction of the exocrine glands, with the salivary and lacrimal glands most often affected; often shows a typical red, shiny lacquer tongue (especially red and uncoated tongue) [see below Sjögren’s syndrome]

Neoplasms (C00-D48)

  • Leukoplakia of the oral mucosa – predominantly white change that cannot be characterized clinically or histopathologically as any other definable mucosal change.

Medications

Medications that may cause discoloration of the tongue.

Medications that can cause xerostomia (dry mouth).

Drugs that can cause burning of the mouth

  • Mouthwashes
  • Reserpine

Further

  • Behavioral causes
    • Nutrition
      • Predominantly liquid diet (e.g. fasting) → white (to dirty white) tongue coating.
    • Consumption of stimulants → black tongue coating.
    • Poor oral hygiene → white (to dirty white) tongue coating.