Is COVID Tongue a Real Symptom?

First it was a loss of smell and taste, then it was COVID toes, then it was delirium and hallucinations. Altogether, these unusual symptoms of COVID-19 were a part of a growing list that seemed to change on a weekly basis with patients experiencing new and undiagnosed problems.  

Can we add COVID tongue to that list, too? Some people with COVID have been experiencing changes to their tongue, such as inflammation and swelling, and have turned to the internet for answers. But are these complications coincidental or is there any evidence to tie it specifically to the coronavirus? This blog will help address those questions. 

What is COVID tongue?

There doesn’t seem to be any debate on if a minority of COVID patients are experiencing symptoms related to their mouth and tongue. The bigger question is if the coronavirus is the culprit. 

The first mention of COVID tongue came in 2021 when a British professor of genetic epidemiology tweeted about tongue changes – mainly inflammation – and an increased presence of mouth ulcers among COVID patients. The insight came from an app called the ZOE COVID Symptom Study, which tracks the varying symptoms associated with the coronavirus. 

That same professor estimated that about 1 in 500 patients experience COVID tongue. However, one study published in the British Journal of Dermatology found COVID caused some type of oral cavity findings in 10 percent of patients. 

In either case, the true nature of tongue-related symptoms associated with COVID largely remains unknown. A single study of under 1,000 people is too small of a sample size to draw any meaningful conclusions. On the other hand, some COVID symptoms, especially minor ones, tend to be underreported. There is also the possibility that doctors don’t see many cases up close for two reasons: patients wear masks and most of the focus is on respiratory or heart health – not the mouth. 

As a result of the ambiguity, the Centers for Disease Control and Prevention doesn’t list problems with your tongue among its laundry list of COVID-19 symptoms. Further, the American Academy of Oral and Maxillofacial Pathology released a statement in 2021 indicating the oral lesions in the study were common oral conditions not specific to COVID-19 infection. 

What’s causing these tongue changes? 

In general, many common tongue issues such as cold sores, canker sores, oral thrush or hairy tongue are caused by viral or bacterial infections. Even poor oral hygiene can contribute to problems with your tongue. However, there are several possible explanations – both direct and indirect – as to why tongue changes can coincide with a COVID infection.  

Your tongue and mouth (oral mucosa and tongue epithelium) have many angiotensin-converting enzyme 2 (ACE2 receptors), which are the proteins the coronavirus attaches to. One theory is the virus may concentrate in the mouth region and cause swelling and inflammation. The virus may also affect the salivary glands, reducing the amount of saliva and leading to dry mouth. 

Another theory indirectly tied to the coronavirus is a byproduct of certain patients who are hospitalized. There have been a few reports of macroglossia, a disorder in which the tongue is larger than normal, in people who were intubated because of COVID. People who are intubated for weeks are often put on the stomachs to increase oxygen flow. Macroglossia is a rare side effect of being in this position for an extended period of time. 

In other cases, oral symptoms, such as oral thrush, may be a side effect of medications provided to treat COVID. Typically, the fungus that causes oral thrush remains dormant, but steroids or inhaled medications to treat inflammation can weaken your immune system to a point where oral thrush rapidly grows. 

There’s also the belief that COVID’s attack on your immune system leaves it susceptible to other secondary viruses from activating and becoming symptomatic. For example, the herpes simplex virus (HSV-1), which is mainly acquired during childhood through non-sexual contact with saliva (sharing toothbrushes, drinks, toys, etc.) can become symptomatic from a viral infection and cause cold sores. 

The reality is these oral complications may be entirely coincidental. After all, stress, anxiety and poor oral hygiene – all of which have been present during the pandemic – can exacerbate these conditions.  

What are COVID tongue symptoms?

In that same British study by the British Journal of Dermatology, the following symptoms were noted: 

• Lingual papillitis (inflammation of the small bumps on the tongue’s surface) 
• Glossitis with indentations (swollen or inflamed tongue) 
• Aphthous ulcers (mouth ulcers) 
• Glossitis with patchy depapillation (tongue inflammation that creates a pattern, also called geographic tongue) 
• Mucositis (inflammation and swelling of moist tissue called mucosa) 

It’s important to note these symptoms shouldn’t be used to diagnose COVID. For example, these tongue and mouth issues may be present with other viral infections. Instead, discussion of these symptoms is more of an indicator of how widespread COVID’s reach is. 

Is there a treatment for COVID tongue?

If your tongue problems are in fact a direct symptom of a COVID illness, the most appropriate course of action is treating symptoms – not the virus – since there isn’t a cure for COVID yet. 

Here are some treatment options for various tongue complications:

• Black hairy tongue: This is an overgrowth of bacteria that occurs on the surface of the tongue, also called hyperkeratosis. Most often, this is due to poor oral hygiene. Brushing your tongue or using a tongue scraper can help remove the food and bacteria. More advanced treatment options include antifungal medications, mouthwashes or retinoids (derived from vitamin A). 
• Cold sores: The virus that causes cold sores is usually present from an early age, meaning your body has built up antibodies to lessen the severity of symptoms. Still, cold sores can be painful. Most will go away in 7 to 10 days on their own without treatment. Over-the-counter gels and antiseptic mouth rinses can provide temporary relief. In more severe cases, anti-viral treatments can help. 
• Dry mouth: Staying hydrated is the easiest way to keep a dry mouth moist. You should also avoid sugary drinks, caffeine, tobacco and salty or spicy foods as these can make dry mouth worse. A dentist may also suggest artificial saliva to moisten your mouth. 
• Geographic tongue: There is no treatment for this tongue condition. Most cases of geographic tongue don’t cause pain. In the event they do, over-the-counter gels and antiseptic mouth rinses can provide temporary relief. 
• Glossitis: Inflammation or swelling of the tongue caused by a viral, bacterial or fungal infection will be treated with medications to get rid of the infection. For symptomatic treatment, anti-inflammatory or pain-relieving mouthrinse and over-the-counter anti-inflammatory medications, such as ibuprofen or naproxen, can provide relief. 
• Oral thrush: A type of yeast infection known as candidiasis, oral thrush occurs in adults when the immune system is suppressed or when antibiotics or inhaled steroids disrupt the good bacteria in your mouth. Treatment for oral thrush includes antifungal medications that come in the form of lozenges, tablets or a mouth rinse. 

If you had a recent COVID-19 diagnosis and are experiencing issues with your tongue, contact your primary care physician. They can help you treat your infection or refer you to an otolaryngologist (ENT).