The tongue: False findings and referral

What stains and what erases

Half an hour before the appointment can completely change what you see. Asking takes five seconds and prevents an entire wrong diagnosis.

Coffee, tea and wine

darken the layer

Sweets and soft drinks

stain it yellow or other colours

Scraping the tongue

erases the layer completely

Antibiotics and steroids

alter both layer and flora

Common mistake: Diagnosing a yellow coating in someone who has just had a white coffee and a croissant.

What is not a sign: it is a reason to refer

Some findings in the mouth do not belong to this map and require medical assessment. Recognising them and saying so plainly is part of a serious practice.

An ulcer that does not close in two weeks

refer

A white patch that does not scrape off

refer

A lump or induration on the border

refer

Sudden deviation of the tongue

emergency

Common mistake: Reading a persistent lesion as «damp» and treating it session after session.

What do you do with each finding?

• A dark brown layer in someone who has just had breakfastIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer
• A thick white coating in a fasting patient with loose stoolsIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer
• An ulcer on the border that has not closed in a monthIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer
• A very red tongue after ten minutes with the mouth openIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer
• A firm white patch that does not scrape offIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer
• Tooth marks in someone with fatigue and weak digestionIt is an artefact: repeat the observationIt is a sign: interpret itIt is a reason to refer

A 60-year-old smoker has a firm white patch on the lateral border that does not scrape off and has been there for months. What do you do?

1. Read it as chronic damp and treat the Spleen
2. Say so plainly, recommend medical assessment, and carry on treating what is yours
3. Not mention it, so as not to alarm them

Order what to do with a tongue finding that fits nothing.

1. Rule out staining, scraping and recent medication↑↓
2. Repeat the observation another day, fasting↑↓
3. Check whether the finding persists unchanged↑↓
4. Assess whether it meets referral criteria↑↓
5. Communicate it without drama and carry on with what is appropriate↑↓

What can tongue observation NOT do?

1. Diagnose or rule out a specific disease
2. Confirm the nature of a picture you already suspected
3. Serve to follow a treatment's progress