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Adv Biomed Res 2023,  12:107

The relationship between white tongue and gastroesophageal reflux disease

1 Research Development Center, Sina Hospital; Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Internal Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Internal Medicine, Eisenhower Medical Center, California, USA
4 Dental Research Center, Dental Research Institute, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

Date of Submission05-Mar-2022
Date of Acceptance02-Aug-2022
Date of Web Publication27-Apr-2023

Correspondence Address:
Dr. Arsia Jamali
Department of Internal Medicine, Eisenhower Medical Center, 39000 Bob Hope Dr, Rancho Mirage, California, 92270
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abr.abr_78_22

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How to cite this article:
Jamali R, Goodarzi N, Jamali A, Moslemi N. The relationship between white tongue and gastroesophageal reflux disease. Adv Biomed Res 2023;12:107

How to cite this URL:
Jamali R, Goodarzi N, Jamali A, Moslemi N. The relationship between white tongue and gastroesophageal reflux disease. Adv Biomed Res [serial online] 2023 [cited 2023 Jun 7];12:107. Available from:

To the Editor,

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that adversely affects the patients' quality of life.[1] It imposes a huge economic burden on the health care system. It seems that the signs of disease are limited; therefore, the monitoring of treatment efficacy is mainly based on patients' self-expressed symptoms.

Following lodgment of food debris, sluffed epithelial cells, and bacteria between inflamed tongue papilla, the whitish discoloration of tongue surface occurs. The reflux of gastric secretions into the oral cavity could affect the tongue epithelium causing white tongue (WT) or coated tongue appearance. Oral cavity infections, inflammations and cancers, dry mouth (xerostomia), poor oral hygiene, vitamin deficiencies, pregnancy, irritant foods, specific medications, alcohol consumption, smoking, and chewing tobacco are the common situations that damage the epithelium and induce a coated tongue.[2] Considering the limitations in the signs of GERD, we aimed to assess WT as a physical finding can discriminate individuals with GERD from healthy participants. Therefore, we conducted a case–control observational on 100 consecutive individuals with GERD and the same number of the healthy accompanies of patients without GERD symptoms. An expert dentist examined the oral cavity for the determination of conditions that might cause WT. A reliable questionnaire was applied to evaluate the severity of symptoms in GERD.[3] Individuals with GERD were classified in three groups of mild, moderate, and severe symptoms. The mild group consisted of individuals that do not feel symptoms if they do not think about them. The moderate group included those who feel the symptoms even if they do not think about them. The severe group feels symptoms that interfere with their quality of life. A single gastroenterologist assessed presence of the WT for all participants that were defined as white discoloration of the tongue surface in adherence to the study of Lundgren et al.[4] The WT diagnosis was confirmed a week after by the same assessor. Intra-observer agreement between two separate observations of WT was almost perfect (Kappa = 0.93 [±0.03]; P < 0.01). The extension of WT was measured based on the approximate white discoloration of the tongue surface. It was graded as grade 0 (if no tongue coating present), grade 1 (if less than 33% tongue coating present), grade 2 (if tongue coating was between 33 and 66%), and grade 3 (if tongue coating was more than 66%) according to the grading system used by the previous study.[4]

We found that the prevalence of WT is considerably greater in individuals with GERD compared to those of control group. Furthermore, we observed a positive correlation between the severity of WT and severity of the symptoms in individuals with GERD. To the best of our knowledge, this is the first study that evaluated the association between GERD and WT. There are similar observations that emphasize on the role of tongue examination in discrimination of subjects' general health. Wang et al.[5] expressed that examination of the tongue with regard to color, spirit, shape, coating, and moisture by a specialist would determine the patient's health status. Wu et al.[6] showed the greater amount of saliva and thicker tongue fur (especially in the spleen and stomach area) in individuals with GERD compared to controls. They concluded that inspection of tongue could be a non-invasive method for GERD diagnosis. Meanwhile, Wang et al.[7] studied changes in tongue manifestations and clinical outcomes of gastric ulcer disease. The tongue fur was significantly thinner with discoloration to white, while sublingual blood vessels improved with blood clotting and stagnation after Helicobacter pylori wound healing and eradication. The study proposed that tongue observation could potentially be used as a complementary non-invasive diagnostic method and as an indicator for the clinical outcome of patients with this disease.

Our survey was conducted in those GERD patients who were diagnosed based on typical GERD symptoms; therefore, the results could not be generalized to all GERD subjects. Another limitation of this study was the method used for determination of WT extension. We reported WT extension according to the clinician's inspection. It is suggested to take standard photographs from the top surface of the tongue and measure the extent of white discoloration via an appropriate software.

In conclusion, it seems that WT can be considered as a sign of GERD. Considering the association between the severity of the symptoms in participants with GERD and the severity of WT in this observation, we recommend evaluating the severity of WT as an objective assessment for monitoring the response to treatment in individuals with GERD.


The authors would like to appreciate Dr. Ayat Ahmadi and Dr. Mahin Ahmadi Pishkuhi, Sina Hospital Research Development Center for their supervision on biostatistical analysis.

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of the Research Deputy, Tehran University of Medical Sciences (registration number: IR.TUMS.SINAHOSPITAL.REC.1399.041).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Karimian M, Nourmohammadi H, Salamati M, Hafezi Ahmadi MR, Kazemi F, Azami M. Epidemiology of gastroesophageal reflux disease in Iran: A systematic review and meta-analysis. BMC Gastroenterol 2020;20:297.  Back to cited text no. 1
Wu TC, Wu KL, Hu WL, Sheen JM, Lu CN, Chiang JY, et al. Tongue diagnosis indices for upper gastrointestinal disorders: Protocol for a cross-sectional, case-controlled observational study. Medicine (Baltimore) 2018;97:e9607.  Back to cited text no. 2
Nasseri-Moghaddam S, Razjouyan H, Alimohamadi SM, Mamarabadi M, Ghotbi MH, Mostajabi P, et al. Prospective Acid Reflux Study of Iran (PARSI): Methodology and study design. BMC Gastroenterol 2007;7:42.  Back to cited text no. 3
Lundgren T, Mobilia A, Hallström H, Egelberg J. Evaluation of tongue coating indices. Oral Dis 2007;13:177-80.  Back to cited text no. 4
Wang PL, Kaneko A. Introduction to Kampo medicine for dental treatment-Oral pharmacotherapy that utilizes the advantages of Western and Kampo medicines. Jpn Dent Sci Rev 2018;54:197-204.  Back to cited text no. 5
Wu TC, Lu CN, Hu WL, Wu KL, Chiang JY, Sheen JM, et al. Tongue diagnosis indices for gastroesophageal reflux disease: A cross-sectional, case-controlled observational study. Medicine (Baltimore) 2020;99:e20471.  Back to cited text no. 6
Wang HH, Pan CH, Wu PP, Luo SF, Lin HJ, Wu CH. Alteration of the tongue manifestation reflects clinical outcomes of peptic ulcer disease. J Altern Complement Med 2012;18:1038-44.  Back to cited text no. 7


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