Geographic Tongue

 What Is Geographic Tongue?

[dropcap]G[/dropcap]eographic tongue is a painful alteration in tongue tissue that is characteristic of riboflavin (vitamin B2) deficiency.¹

Q: How does the tongue surface appear?

A: Areas of inflamed tissue with flattened papillae develop among areas of normal tissue, giving a map-like appearance to the tongue surface. There are often swollen papillae that hurt or sting, such as is seen in the photo to the left.

A diet that does not provide adequate amounts of riboflavin and any condition that 1) interferes with riboflavin absorption from the gut, 2) depletes the vitamin from the body, 3) overuses the vitamin in the body, or 4) adversely affects its use in the body will result in riboflavin deficiency causing geographic tongue.

Riboflavin is essential for converting foodstuffs into energy, maintaining the normal lifespan of red blood cells and maintaining healthy skin, eyes, hair, and nervous system. Riboflavin is converted into its active forms, flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN). These enzymes are primarily involved as co-factors in oxidation reduction reactions that are essential for cellular energy production and respiration.

Riboflavin is required for the conversion of pyridoxine (vitamin B6) to its functional form and the production of niacin (vitamin B3) from the amino acid tryptophan. Riboflavin has a role in antioxidant status by activating glutathione reductase, which regenerates used glutathione, a powerful antioxidant.

Respiratory infection, exercise, certain diseases, drugs and hormones can adversely influence riboflavin status.² Stress is a major depleter of riboflavin.

What Is Geographic Tongue In Celiac Disease and/or Gluten Sensitivity?

• Geographic tongue is a classic feature of riboflavin (vitamin B2) deficiency caused by malabsorption in celiac disease.
• Riboflavin deficiency itself can cause conditioned deficiency of vitamin B6 (pyridoxine). Mucous membrane lesions observed in these two vitamins deficiencies could be due to impaired collagen maturity. Collagen is the major fibrous protein in connective tissue that makes up skin and mucous tissue. About a third of body protein is collagen.²
• Frequently, riboflavin deficiencies overlap with niacin (vitamin B3) or iron deficiencies. There is no specific name for riboflavin deficiency disease.³
• Riboflavin status in the body is not dependent exclusively on absorption. Certain non-dietary factors can modify riboflavin status by their effect on riboflavin metabolism,  especially those factors that increase the need for energy production such as stress (emotional, physical, mental), fever and inflammation.⁴

How Prevalent Is Geographic Tongue In Celiac Disease and/or Gluten Sensitivity?

Geographic tongue has increased frequency in patients with untreated celiac disease.⁵

What Are The Symptoms Of Geographic Tongue?

Geographic tongue symptoms:

• Sore, inflamed areas of atrophied, or flattened, papillae among normal tissue, giving a map-like appearance to the tongue.
• Magenta colored, swollen tongue surface.
• Swollen, or hypertrophied, papillae hurt or sting.
• Opportunistic invasion by candida albicans yeast shows as a white coating on the tongue which can be seen in the above photo.

Other symptoms of riboflavin deficiency include:

• Low strength.
• Sensitivity of eyes to light, itching or teary eyes, blurry vision.
• Sores at corners of mouth.
• Burning and redness of lips that may develop tiny fissures which may scar.
• Anxiety.

More severe symptoms of riboflavin deficiency are these:

• Seborrhea dermatitis (red, itching and burning skin followed by greasy, scaly accumulations that may appear on sides of nose, ears, eyelids, perineum in females, and scrotum in males).
• Inflammation of eye conjunctiva.
• Importantly, digestive symptoms include constipation, indigestion, gas, and abdominal pain which are hallmarks of celiac disease.

Prolonged deficiency leads to these problems:

• Depression.
• Normocytic and normochromic anemia with pallor and dizziness.
• In infants and children, growth retardation may occur.

How Does Geographic Tongue In Celiac Disease and/or Gluten Sensitivity Develop?

• Geographic tongue results from malabsorption causing riboflavin deficiency in celiac disease.
• Stress, inflammation, fever and excessive exercise worsen the damage to tongue tissues due to increased need for this vitamin which depletes already inadequate levels.

Does Geographic Tongue Respond to Gluten-Free Diet?

Yes. Celiac disease-related geographic tongue responds to a gluten free diet containing riboflavin.

6 Steps To Improve Geographic Tongue In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both geographic tongue and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁶
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁷
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁷
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁷.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁷
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁷
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁷[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

 

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]Certain prescription drugs deplete riboflavin causing geographic tongue. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTIBIOTICS  disrupt intestinal permeability.

• Gentomycin®, Neomycin®, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins and others.
• Tetracyclines deplete Vitamin B2 (riboflavin).

FEMALE HORMONES disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B2 and many others.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin B2 and many others.

ANTI-DEPRESSANTS

• Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete Vitamin B2 and others.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Riboflavin as part of B-complex supplement or as prescribed by a doctor to correct deficiency.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Geographic Tongue In Celiac Disease and/or Gluten Sensitivity?

“Glossodynia in patients with nutritional deficiencies.” Various types of nutritional deficiencies can produce glossodynia and associated signs of inflammation. Changes such as swelling of the tongue, papillary atrophy, and surface ulceration are possible in most of the deficiency states. To further complicate the clinical picture, the patient commonly will suffer from multiple nutritional deficiencies. Therefore, it is not advisable to diagnose a specific nutritional deficiency on clinical impression alone. To establish iron, folate, or vitamin-B12 deficiency, a hematologic screening that includes complete blood count, red-cell, serum iron, B12, and folate levels should be performed. Although they are rarely required, specific tests for suspected niacin, pyridoxine, and riboflavin deficiency are available. Although glossodynia related to nutritional deficiency is statistically uncommon, it is easily curable with replacement therapy. Identification of a vitamin deficiency through early oral symptoms can forestall development of serious and irreversible systemic and neurologic damage.⁸

Sources:

1. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
2. Lakshmi AV. Riboflavin metabolism–relevance to human nutrition. Indian J Med Res. 1998 Nov;108:182-90. [↩] [↩]
3. Kathleen Mahan and Sylvia Escott-Stump, ed. Krause’s Food, Nutrition & Diet Therapy, 10th Edition. Philadelphia, PA. USA: W.B. Saunders Company, 2000. [↩]
4. Lakshmi AV. Riboflavin metabolism–relevance to human nutrition. Indian J Med Res. 1998 Nov;108:182-90. [↩]
5. Murray JA, the widening spectrum of celiac disease. American Journal of Clinical Nutrition. Mar 1999; 69(3):354-365. [↩]
6. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
7. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
8. Huber MA, Hall EH. Glossodynia in patients with nutritional deficiencies. Ear Nose Throat J. 1989 Oct;68(10):771-5. [↩]