Normal Tongue vs. Oral Thrush and Other Conditions

A normal tongue will look pink and be covered with tiny bumps called papillae (also known as "taste buds"). When your tongue is coated with creamy white patches or lesions, this is most likely due to a common fungal infection called oral candidiasis (oral thrush).

However, there are other possible explanations for a white tongue, some of which may be potentially more serious, like oral lichen planus and oral leukoplakia. Other things can also cause a whitish coating on the tongue, including geographic tongue, canker sores, and benign conditions called coated tongue and "milk tongue."

This article will describe a normal tongue versus one with oral thrush. It also lists other conditions that may be mistaken for thrush, including their symptoms, risk factors, and treatment options.

Signs of Oral Thrush

Oral thrush occurs when a fungus naturally found in the body—called Candida albicans—suddenly overgrows and causes creamy white patches on the tongue and other tissues in the mouth.

The condition, otherwise known as oral candidiasis, occurs when the body's immune system is weak, allowing the fungus to overgrow. It can also be caused by certain medications that suppress the immune system.

Oral thrush is not contagious but can cause serious harm if it spreads beyond the mouth into the throat, windpipe, lungs, and internal organs.

Risk Factors

Risk factors for oral thrush include:

• Having a compromised immune system (such as people with HIV and people on chemotherapy)
• Immunosuppressant drugs (such as those used in organ transplant recipients)
• Steroid drugs (including inhaled corticosteroids used in people with asthma or COPD)
• Diabetes
• Malnutrition (including iron or vitamin B12 deficiency)
• Wearing dentures

Symptoms

Symptoms of oral thrush include:

• A creamy white coating or patches on the tongue and inner surfaces of the mouth
• Red, inflamed sores when the white patches are scraped away
• Bleeding gums or tongue
• A burning sensation on the tongue
• Loss of taste
• Pain with eating
• Difficulty speaking
• Cracks at the corner of your mouth (angular cheilitis)

Treatment

Oral thrush is typically treated with prescription antifungal drugs, including:

• Oral antifungals like Diflucan (fluconazole) or Sporanox (itraconazole)
• Antifungal mouthwash containing nystatin
• Antifungal lozenges that contain clotrimazole
  

Geographic Tongue

Geographic tongue is a harmless condition in which the tongue has smooth, reddish patches surrounded by white borders. They can appear anywhere on the top, sides, and tip of the tongue.

Geographic tongue does not cause any long-term health problems, and it is not contagious. Most people have no symptoms or only mild symptoms, It is considered a cosmetic concern.

Risk Factors

It is not known exactly what causes geographic tongue, but risk factors include:

• A family history of geographic tongue
• Emotional stress
• Vitamin deficiencies (including zinc, iron, folic acid, vitamin B6, and vitamin B12)
• Diabetes (especially type 1 diabetes)
• Psoriasis (an autoimmune skin condition).
• Having atopic conditions (like eczema, hay fever, or asthma)
• Hormonal surges (such as during menstruation or when taking birth control pills)

Symptoms

Geographic tongue happens when parts of the upper layer of the tongue shed too quickly. Symptoms include:

• Irregular red patches that look like papillae have been stripped away (denuded)
• White or gray borders around the denuded patches
• Stinging, tingling, or burning sensations, especially while eating
• Similar red patches on the gums, top of the mouth, or inside the cheeks

The patches may come and go and change in size, shape, and location.

Treatment

Treatment for geographic tongue isn't necessary. If discomfort is significant, the following may be recommended:

• Avoidance of hot and spicy foods
• Saltwater rinses
• Topical analgesics (painkillers) applied directly to the tongue
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen)

Oral Lichen Planus

Oral lichen planus is a chronic (long-term) inflammatory condition of the mouth. It can also affect other areas of the skin and mucous membranes. Almost half of all people with oral lichen planus also have cutaneous (skin) lichen planus.

Oral lichen planus is not contagious.

Risk Factors

The cause of oral lichen planus is unclear. Some experts think that it is an autoimmune disorder in which the cells lining the inside of the mouth are attacked by the immune system. Others associate it with conditions that cause the excessive production of the stress hormone cortisol.

While anyone can get oral lichen planus, it occurs twice as often in females than in males. Oral lichen planus mostly affects adults 50 and older.

Other risk factors include:

• Diabetes
• Hepatitis B or C
• Anxiety or depression
• Medications like beta-blockers and NSAIDs

Symptoms

The symptoms of oral lichen planus differ by whether it is the reticular type or erosive type. The white lesion caused by both can be scraped off, leaving a raw, red surface underneath.

Symptoms of the reticular type include:

• White patches on the inside of the cheeks
• Slightly raised weblike threads
• Usually not painful unless scraped

Symptoms of the erosive type include:

• Bright red gums
• Ulcers inside the mouth or on the tongue
• Pain when eating or drinking spicy, hot, or acidic foods

Erosive oral lichen planus is more serious and associated with a higher risk of oral cancer. While rare, approximately 1% to 3% of people with oral lichen planus eventually develop oral cancer. People with erosive lichen planus should be routinely monitored by their healthcare providers every three to six months.

Treatment

Some cases of oral lichen planus resolve on their own without treatment. Severe cases may be treated with topical and oral medications, including:

• Lidocaine (topical)
• Tacrolimus (topical or oral)
• Steroids (topical or oral)
• Dapsone (oral)
• Cyclosporine (oral)

Occasional flare-ups are common.

Oral Leukoplakia

Oral leukoplakia involves white patches on the tongue and inside the mouth. caused by the overgrowth of cells called keratinocytes that produce a structural protein called keratin. It is caused by long-term irritation to tissues inside the mouth.

While leukoplakia isn't dangerous in and of itself, it can eventually turn into oral cancer. About 3% to 17.5% of people with leukoplakia will develop squamous cell carcinoma (a common type of skin cancer) within 15 years.

Risk Factors

Leukoplakia occurs most often in males between the ages of 50 and 70. It is rare in younger adults, with fewer than 1% of cases occurring in people less than 30 years of age.

Leukoplakia is often associated with:

• Smoking tobacco
• Chewing tobacco or snuff
• Chewing areca nut (betel nut)
• Heavy alcohol use

Symptoms

There are two main types of oral leukoplakia—homogenous and non-homogenous—each of which causes different symptoms. The oral lesions cannot be scraped off and are typically not painful.

Symptoms of homogenous leukoplakia include:

• White, evenly colored, thin patches
• Smooth, wrinkled, or ridged surfaces

Symptoms of non-homogenous leukoplakia include:

• White or speckled white-and-red patches
• Irregularly shaped
• May be flat, nodular (bumpy), or verrucous (wart-like)

Non-homogenous leukoplakia is seven times more likely to become cancerous than the homogenous type. This is especially true when the lesion has a verrucous surface (referred to as proliferative verrucous leukoplakia), with nearly every case eventually becoming cancerous.

Treatment

Treatment for oral leukoplakia is usually centered on preventing it from becoming cancerous. The efficacy of treatment can vary. The lesions may be removed, but they often return.

Treatment may involve:

• Oral retinoids (vitamin A derivatives)
• Accutane (isotretinoin) 
• Surgical removal
• Laser removal
• Photodynamic therapy (light-activated cancer therapy)
• Cryotherapy (removal with sub-zero temperatures)
• Electrocautery (removal with electrical current)
• Quitting cigarettes and other tobacco products
• Stopping alcohol

If patches are surgically removed, an examination every six to 12 months is recommended until there is no evidence of precancer, cancer, or other abnormal cellular changes for at least three years.

Aphthous Ulcers (Canker Sores)

Canker sores (also known as aphthous ulcers) are small, often painful open sores that develop on the lining of the mouth. While the exact cause is unknown, simple canker sores are believed to be caused by a minor injury to the inside of the mouth.

Risk Factors

Canker sores typically occur in people between the ages of 10 and 20, but anyone can get them.

Other risk factors include:

• Dental appliances like braces
• Poorly fitting dentures
• Eating acidic foods
• Frequent NSAID use
• Weakened immune systems
• Nutritional deficiencies (including vitamin B-12, zinc, folic acid, or iron)

Symptoms

Symptoms of canker sores include:

• A round white or yellow sore with a red border
• Located on the tongue, soft palate, or inner cheek
• Mouth pain, especially when eating or talking

Tingling or a burning sensation may develop before the sore appears

Treatment

Canker sores usually clear up on their own within a couple of weeks. To ease pain and promote healing, your healthcare provider may recommend:

• Over-the-counter topical painkillers like Kank-A, Zilactin, or Orajel
• Prescription antibacterial mouth rinse
• Oral corticosteroid ointment

Coated Tongue

Coated tongue, also known as hairy tongue, is a harmless condition caused by the lengthening of papillae on the tongue.

Papillae are composed of keratin. When the keratin is overproduced, the papillary layer on the tongue can thicken and take on a "hairy" appearance.

Risk Factors

Coated tongue is not contagious and commonly associated with conditions that either dry out mouth tissues or affect the natural shedding of keratin. These include:

• Dry mouth (xerostomia)
• Dehydration
• Certain medications (like antibiotics or chemotherapy)
• Cigarette smoking
• Alcohol-containing mouth rinses (which can dry the mouth)
• Eating a diet of soft foods (which reduces the shedding of keratin)
• Lack of eating

Symptoms

With coated tongue, the papillae will usually appear white but may also turn black or brown if stained by tobacco or food or discolored by mouth bacteria.

Most people with coated tongue have no symptoms other than a cosmetic concern. Some people experience mouth dryness or an unpleasant, stale, or abnormal taste in their mouths. Long papillae can cause pain and bleeding if you pick at it

Treatment

Coated tongue will usually resolve on its own once the underlying cause is resolved. Other ways to help include:

• Drinking water and staying hydrated
• Limiting caffeine
• Avoiding dehydrating mouth rinses
• Eating a balanced diet
• Gentle brushing of the tongue

Milk Tongue

A white tongue is common in young babies and doesn't always mean it's thrush.

Instead, it might be caused by a condition called milk tongue caused by the residue of milk that has been spit up. Milk tongue only affects the tongue, develops right after feeding, and is easily wiped away. It is not painful.

Milk tongue is normal and will go away once solid foods become a regular part of the baby's diet. The best way to manage a milk tongue is to practice good oral hygiene, including gently wiping the tongue after feeding.

Causes and Prevention

Each condition that causes a white tongue, including thrush, has unique causes, treatments, and prevention, but they also have some in common.

Ways to encourage oral health include:

• Stop smoking and using tobacco products (or never start).
• Avoid or limit alcohol consumption.
• Stay hydrated/drink more water (up to eight glasses a day).
• Practice good oral hygiene.
• Visit your dentist for a checkup and a teeth/tongue cleaning every six months.
• Brush your teeth at least twice a day with a soft toothbrush and a mild fluoride toothpaste that doesn’t contain sodium lauryl sulfate.
• Floss once a day.
• Use fluoride, alcohol-free mouthwash.
• Brush your tongue, or use a tongue scraper (or a turned-over teaspoon).
• Eat a healthy diet that includes lots of fruit and vegetables.
• Avoid food and drinks that are spicy, salty, acidic, very hot in temperature, or that otherwise irritate your mouth.
• See your healthcare provider for regular examinations.

Summary

Whether caused by oral thrush or another condition, a white tongue is a common symptom of a potential problem happening in your mouth.

While a white tongue is often harmless, it can signal a more serious health condition like oral lichen planus or oral leukoplakia. Other less serious conditions that mimic oral thrush are geographic tongue, canker sores, coated tongue, and "milk tongue."