The surface of the tongue may develop changes in color or texture because of intrinsic or extrinsic factors. Discolorations may be related to chewed, ingested, or topical products, or certain infections. It is important to be familiar with some of the more common, benign tongue abnormalities that may present in the pediatric patient so that reassurance and appropriate guidance may be given to families.

• Syphilis and lichen planus may be associated with white plaques on the tongue.

• The use of antibiotics, immunosuppressive agents, systemic steroids, or inhaled corticosteroids may predispose patients to oral thrush.

• Immunodeficiency, recent radiation, or cytotoxic therapy predisposes patients to oral thrush and oral hairy leukoplakia. Hairy leukoplakia is caused by Epstein–Barr virus and is seen more commonly in adults affected by human immunodeficiency virus (HIV), but is rare in children affected by HIV.

• White plaques associated with lichen planus are more common in patients with thyroid disease, particularly hypothyroidism.

• Geographic tongue is seen less commonly in smokers.

• Chewing betel leaf, which is common in some Southeast Asian countries, may stain the tongue red. Chewing betel quid, also known as betel paan (a mixture of betel leaf with or without tobacco, spices, areca nut, and slaked lime), is associated with oral leukoplakia.

• Medications, such as antibiotics, antifungal agents, antimalarial drugs (primarily on the hard palate), psychotropic agents (including selective serotonin reuptake inhibitors), phenothiazines, benzodiazepines, and phenytoin, may cause tongue discoloration.

• Argyria is an irreversible blue gray mucocutaneous staining caused by exposure to silver and includes ingestion of a silver-containing supplement known as colloidal silver.

• Use of coffee, tea, tobacco, and cola products may cause brown discoloration of the tongue.

• Ingestion of bismuth-containing products may lead to black tongue staining.

• Minocycline-associated pigmentary changes may persist for years.

• Darkly pigmented adults and children are more likely to have pigmented fungiform papillae of the tongue.

• Dark pigmentation of the fungiform papillae may be seen in iron deficiency.

• Hairy tongue, or elongated filiform papillae in the midline tongue, is associated with the following: tobacco, tea, coffee, antibiotics, griseofulvin, or certain mouthwashes containing an oxidizing agent, such as sodium perborate, sodium peroxide, or hydrogen peroxide.

• Hairy tongue has been linked to herbal tea ingestion in an infant.

• Fixed drug eruptions occur at the same location on the tongue with each exposure.

• Adult females are more prone to fixed drug eruptions on the tongue.

• Glossitis may be precipitated by the use of cytotoxic agents.

• A white plaque that wipes off easily may be due to milk or food. If it cannot be scraped off easily, bleeds, or leaves a denuded surface after scraping, the white plaque is usually the result of a fungal infection.

• Lichen planus, an immunological disorder, may cause lacy white plaques on the buccal mucosae and may coexist with oral candidiasis.

• White sponge nevus is a rare autosomal dominant condition that starts in childhood and is characterized by bilateral white plaques on the buccal mucosae, and sometimes on the lateral border of the tongue and other mucosal surfaces. The cornified layer may peel away from the underlying mucosa. It may be painful if secondarily infected.

• Linea alba is caused by repeated trauma from biting or chewing and appears as a thin white line on the lateral margins of the tongue (or the buccal mucosae) bilaterally.

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