Do you have a scalloped tongue or know someone who does?

We know that it can be a challenge to find a summary of the available information for scalloped tongue and we would like to help you.

This informational post was written by an ear, nose and throat surgeon.

In order to make this more helpful and as part of the research for this information guide, we searched the internet for frequently asked questions.

First, this information post provides general information about scalloped tongues.

Second, because a scalloped tongue is often related to snoring and obstructive sleep apnea, we also provide a sleep and breathing perspective.

Finally, scattered throughout the post you will find frequently asked questions that were identified on the internet.

This post provides illustrations that provide examples of the grades of mild, moderate, severe and extreme scalloping of the tongue.

Scalloped tongue, severity grading scale. Top left: mild. Top right: moderate. Bottom left: severe. Bottom right: extremely severe. CamachoMD.com
Scalloped tongue, severity grading scale. Top left: mild. Top right: moderate. Bottom left: severe. Bottom right: extremely severe.

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Summary:

Scalloped tongues occur when the side of the tongue has teeth marks.

Other names for scalloped tongue include: crenated tongue, wavy tongue, pie-crust tongue, rippled tongue, lingua indentata or tooth-marked tongue.

A scalloped tongue means that the tongue is either enlarged or the lower jaw is relatively too small, or both.

Background information about scalloped tongue:

What is a scalloped tongue?

Scalloped tongue, graded as extremely severe. Note the teeth marks which are present and are extreme, even when the patient leaves the tongue out. CamachoMD.com
Scalloped tongue, graded as extremely severe. Note the teeth marks which are present and are extreme, even when the patient leaves the tongue out.
Scalloped tongue, graded as severe. Note the teeth marks which are present and are severe even when the patient leaves the tongue out. CamachoMD.com
Scalloped tongue, graded as severe. Note the teeth marks which are present and are severe even when the patient leaves the tongue out.
Scalloped tongue, graded as moderate. Note the teeth marks which are present and are still present, but it is moderate even when the patient leaves the tongue out. You can still feel the ridges and you can see the indentations. CamachoMD.com
Scalloped tongue, graded as moderate. Note the teeth marks which are present and are still present, but it is moderate even when the patient leaves the tongue out. You can still feel the ridges and you can see the indentations.
Scalloped tongue, graded as mild. Note that the scalloping resolves when the tongue is out. There is however, a trace amount of scalloping that can be seen. CamachoMD.com
Scalloped tongue, graded as mild. Note that the scalloping resolves when the tongue is out. There is however, a trace amount of scalloping that can be seen.

A scalloped tongue, also known as a crenated tongue, wavy tongue, pie-crust tongue, rippled tongue, lingua indentata or tooth-marked tongue is due to the tongue being large relative to the size of the lower jaw (mandible) and possible also the upper jaw (maxilla).

What causes a scalloped tongue?

By definition the fact that the tongue has markings from the teeth pressing against it means that the tongue is too big for the lower jaw.

So, there are three possible scenarios:

The tongue is large (also called macroglossia) while their jaw is normal sized,  

The tongue is normal sized and the lower jaw is smaller than normal, or

The tongue is larger than normal and the jaw is smaller than normal.

What disorders can cause the tongue to enlarge?

Temporary enlargement of the tongue can be due to an allergic reactions, such as when exposed a person is exposed to certain foods they may be allergic to, certain medications, and insect or animal bites.

Temporary enlargements of the tongue due to an allergic reaction can be life threatening and immediate healthcare should be sought in order to avoid airway complications. If in doubt call 911 or your local emergency hotline.

Permanent enlargement of the tongue (macroglossia) may be from fat deposits (if the person is overweight or obese), enlargement of the muscles of the tongue, enlargement of the tonsils of the back of the tongue (base of tongue tonsil hypertrophy).

Dental crowding with narrow upper jaw and narrow lower jaw. CamachoMD.com
Dental crowding with narrow upper jaw and narrow lower jaw.
Dental crowding with narrow upper jaw and narrow lower jaw with blue pointer showing crooked and overlapping teeth. The blue pointer demonstrates the dental crowding (crooked teeth). CamachoMD.com
Dental crowding with narrow upper jaw and narrow lower jaw with blue pointer showing crooked and overlapping teeth. The blue pointer demonstrates the dental crowding (crooked teeth).

Other disorders that can are associated with macroglossia include acromegaly, Beckwith-Wiedemann syndrome, sarcoidosis, amyloidosis, multiple myeloma, neurofibromatosis, infection, hypothyroidism, tuberculosis, lymphangioma, cystic hygroma, hemangioma, glycogen storage diseases, neurofibromatosis, actinomycosis, echinococcosis and Down syndrome.[1,2]

If a reason cannot be figured out, then the tongue scalloping is called “idiopathic” (the medical term for unknown).

What disorders cause a small lower jaw?

A small lower jaw is called micrognathia.

Profile view of a girl with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw. CamachoMD.com
Profile view of a girl with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw.

There are various categories for small lower jaw.

For example, a person might have minimal, mild, moderate, severe or even extremely small lower jaws. 

Usually, the higher the severity of the micrognathia, the more likely that it will be identified and addressed earlier in childhood or infancy.

One of the well-known syndromes associated with a small lower jaw is Pierre Robin sequence, in which the child has the following findings:

Micrognathia,

Profile view of a girl with normal upper jaw, but her lower jaw is smaller than normal in the vertical dimension. This will move the tongue back because there is not enough room in the lower jaw. CamachoMD.com
Profile view of a girl with normal upper jaw, but her lower jaw is smaller than normal in the vertical dimension. This will move the tongue back because there is not enough room in the lower jaw.

A tongue that moves back and can obstruct the airway or pharynx (glossoptosis), and

Usually also has a cleft palate.[3]

Is a scalloped tongue a sign that a person snores or has obstructive sleep apnea?

A scalloped tongue doesn’t necessarily mean that a person snores or has obstructive sleep apnea, but it is one of the many signs that they might be at risk.

Scalloped tongues are a sign that the tongue is too big for the lower jaw, so with the mouth closed during sleep, the tongue is more likely to obstruct the airway than if the tongue was normal sized since it doesn’t take as much backward movement to close off the throat.

A study from Japan (Tomooka and colleagues) found that a scalloped tongue was associated with a higher chance that a person has moderate or severe obstructive sleep apnea.[4]

Additionally, Tomooka and colleagues found that the breathing problems during sleep were noted more in overweight patients.[4]

Given that the world as a whole is becoming more overweight and obese, it is important to at least think of snoring and obstructive sleep apnea as a possible disorder in people who have a scalloped tongue.

Because of the smaller lower jaw, Pierre Robin sequence children are predisposed to obstructive sleep apnea, and moving the lower jaw forward helps to improve their breathing significantly.[5]

The syndrome provides an extreme example of what can happen when there is a small jaw and the tongue is relatively too big for the size of the jaw.

How can you tell if the lower jaw (mandible) is too small for the persons face?

If a person’s lower jaw is too small for their facial structure, then there may be a crowding of the teeth (dental crowding) or the person may have a lower jaw that is set back relative to the upper jaw (known as overjet).

Side view of the face of a girl with normal proportions. CamachoMD.com
Side view of the face of a girl with normal proportions.
Profile view of a girl with normal upper jaw, but her lower jaw is smaller than normal in the vertical dimension. This will move the tongue back because there is not enough room in the lower jaw. CamachoMD.com
Profile view of a girl with normal upper jaw, but her lower jaw is smaller than normal in the vertical dimension. This will move the tongue back because there is not enough room in the lower jaw.
Profile view of woman with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw. CamachoMD.com
Profile view (zoomed in) of a girl with normal upper jaw, but her lower jaw is set back more than normal (retrognathia). This will move the tongue back because the tongue is attached to the lower jaw.

Is a scalloped tongue caused by bruxism?

A case study by Vinod and colleagues reported that there was no other cause for tongue scalloping in a patient aside from nocturnal bruxism.[6]

The authors reported she had no hypothyroidism, no atopy, no snoring or excessive sleepiness, no abnormality in her blood labs, no abnormalities in a chest x-ray, no abnormalities in heart and thyroid function testing.[6]

Her tongue was not large and the only cause they could find for the scalloping was nocturnal bruxism.[6]

The readers should interpret case studies with caution.

There are many case studies on many topics, and it does not provide causality.

In order to make generalizations, a finding should be noted in multiple patients and when possible should be researched using the scientific method.

We are not completely discounting the possibility that bruxism can contribute to scalloped tongue, but there is currently not much written about it in the medical literature.

Is a scalloped tongue a sign of a thyroid problem?

Hypothyroidism has been shown to be associated with an enlargement of the tongue in some patients.[7]

Your healthcare provider might order labs to check for abnormalities, if they deem it necessary.

Is a scalloped tongue a sign of dehydration?

Dehydration is when there is a decrease in the amount of fluid in the body.

It is not clear why dehydration might cause the tongue to become scalloped.

A search on PubMed/MEDLINE for scalloped tongue and dehydration or scalloped tongue and dehydration yields two articles that are not relevant.

Do stress or anxiety cause a scalloped tongue?

Stress and anxiety in and of themselves do not cause a tongue to become scalloped.

However, if there are behaviors that involve the person to move the tongue toward the teeth, such as sucking their tongue toward their cheeks, then yes, the behavior can lead to teeth marks and subsequent tongue scalloping.

In this case, dealing with the stress or anxiety and seeking psychological help to retrain the patient so they no longer do the behavior that causes stress and anxiety can help.

Additionally, seeking help from a practitioner of myofunctional therapy can also help, as one of the main goals of a myofunctional therapist is to help patients learn to properly position their tongues in their mouths.

Is a scalloped tongue caused by a sexually transmitted disease?

It is quite rare, but syphilis has been found to have tongue involvement in some patients as a result of the formation of gummas.[2]

Tongue gummas would be the result of not treating tertiary syphilis which can develop over the period of about 10 years if the patients don’t receive appropriate antibiotic treatment.[2]

Is scalloped tongue a sign of cancer?

Although cancer can make a tongue enlarge in certain areas, it is rare for a patient to have tongue cancer without other features, such as ulcerations, pain, bleeding, pain with swallowing, difficulty swallowing and other problems.

The abnormal deposits of a protein called amyloid can build up in tissues and organs throughout the body and when it does, it is called amyloidosis.[8]

One type of amyloidosis is local (one area) and the second type is when the amyloid deposits at multiple sites throughout the body.[8]

In children a rare cancer is rhabdomyosarcoma, which makes up about 20% of the rhabdomyosarcomas that occur in the head and neck area.[2]

Because there are many disorders that can cause an enlarged tongue, you should bring it up to your healthcare provider the next time you see them.

How does a scalloped tongue affect patients according to Chinese Medicine?

Qi deficiency syndrome has been studied in Traditional Chinese Medical literature. 

One study found that shortness of breath (or lack of desire to speak, sweating spontaneously, swollen tongue and indentations of the tongue with teeth marks showing on the sides (consistent with a scalloped tongue), deficient/weak pulse, fatigue and health status were associated with qi deficiency syndrome rather than increasing age.[9]

Is there a problem with having a scalloped tongue?

A scalloped tongue is a sign that there is not enough room for the tongue to sit well in the lower jaw.

Given that fact, the tongue could move back during sleep and this can lead to snoring and in some cases can lead to obstructive sleep apnea.

A study evaluating scalloped tongue and sleep problems found that there is an association with sleep disordered breathing (snoring and obstructive sleep apnea).[10]  

In the same study, the researchers evaluated 61 patients with physical exam and 77% of them had a history of snoring and 44% patients had known or newly diagnosed obstructive sleep apnea.[10]  

The presence of a scalloped tongue was 70% specific for an abnormal apnea-hypopnea index (>5 events per hour of sleep).[10]  

Interestingly, all three patients with severe tongue scalloping had obstructive sleep apnea.[10]    

How can a scalloped tongue cause snoring or obstructive sleep apnea?

A scalloped tongue can fall back during sleep and this can narrow the airway. If the airway is partially blocked, then the tongue might vibrate back and forth, and this vibration could cause snoring.

For obstructive sleep apnea, if the upper airway is partially obstructed then it is a hypopnea and if the upper airway is completely obstructed, then this is known as an apnea.

Events that last 10 seconds or more and the blockage is enough to cause airflow to be restricted and either the patient awakens or has a drop in oxygen levels.

Scalloped tongue, severity grading scale. Top left: mild. Top right: moderate. Bottom left: severe. Bottom right: extremely severe. CamachoMD.com
Scalloped tongue, severity grading scale. Top left: mild. Top right: moderate. Bottom left: severe. Bottom right: extremely severe.

What is the treatment for a scalloped tongue?

The only way to know if there is a disorder causing tongue scalloping is to have a healthcare provider evaluate the patient.

It is possible that the tongue is too large and it is possible that the lower jaw is just too small.
Because there are many other reasons, and some of them include disorders such as amyloidosis, hypothyroidism and several other disorders, a patient should be evaluated by a healthcare provider.

It is possible that a scalloped tongue is normal in size, but the lower jaw is just too small, so in that case, the healthcare provider may choose to evaluate for snoring and obstructive sleep apnea.

If the healthcare provider evaluates the patient and finds that there is a problem with sleep breathing (snoring and/or obstructive sleep apnea), then they might not do anything about the tongue itself, rather they may pursue further evaluation and treatment for the sleep disorders.

So, the first step is to find out whether there are sleep problems is to find out if there is snoring.

Bedpartners should provide information about whether or not there is snoring.

Second, sleepiness can be a sign of obstructive sleep apnea.

There are several other signs of obstructive sleep apnea such as:

  • Morning headache,
  • Fatigue,
  • Tiredness,
  • High blood pressure,
  • Frequently urinating at night,
  • Pauses or gasps during sleep,
  • Choking during sleep, and
  • Fogginess in thought (neurocognitive dysfunction).

A sleep study at a sleep lab will provide answers.

During the sleep study, the lab technician will connect the equipment which attached from the head down to the legs.

Areas that are evaluated include the eyes, brain, breathing, heartbeat, breathing movements (belts over the chest and abdomen), oxygen sensors, leg leads to check for movements during sleep and video monitoring.

If you have a sleep study at home (home sleep test), then the study will be performed without most of the above attachments.

If you are found to have obstructive sleep apnea, then the common treatment is tonsillectomy, if you have large tonsils or continuous positive airway pressure (CPAP or APAP) depending on your anatomy.

If you have very bad obstructive sleep apnea and are not able to ever adapt to CPAP or other medical treatment modalities, then you may be referred to a surgeon for additional treatment.

Surgeons might use sleep endoscopy to evaluate your airway.

If your tongue is enlarged (consistent with the tongue scalloping), then a tongue reduction might be recommended.

If you have a small mandible, then your surgeons might consider a moving your lower jaw (or upper and lower jaw) forward if that is what is best in your situation.

Can moving the lower jaw forward help treat obstructive sleep apnea in children and adults?

Yes, moving the lower jaw forward (mandibular advancement) has been found to significantly improve obstructive sleep apnea in children (reduction of apnea-hypopnea index by 89%)[5] and in adults (reduction of apnea-hypopnea index by 87%).[11]

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.            Byrd JA, Bruce AJ, Rogers RS, 3rd. Glossitis and other tongue disorders. Dermatol Clin. 2003;21(1):123-134.

2.            Rizer FM, Schechter GL, Richardson MA. Macroglossia: etiologic considerations and management techniques. Int J Pediatr Otorhinolaryngol. 1985;8(3):225-236.

3.            Giudice A, Barone S, Belhous K, et al. Pierre Robin sequence: A comprehensive narrative review of the literature over time. J Stomatol Oral Maxillofac Surg. 2018;119(5):419-428.

4.            Tomooka K, Tanigawa T, Sakurai S, et al. Scalloped tongue is associated with nocturnal intermittent hypoxia among community-dwelling Japanese: the Toon Health Study. J Oral Rehabil. 2017;44(8):602-609.

5.            Noller MW, Guilleminault C, Gouveia CJ, et al. Mandibular advancement for pediatric obstructive sleep apnea: A systematic review and meta-analysis. J Craniomaxillofac Surg. 2018;46(8):1296-1302.

6.            Vinod KV, Reddy P, Pillai VM. Scalloped tongue: A rare finding in nocturnal bruxism. Natl Med J India. 2017;30(5):296.

7.            Melville JC, Menegotto KD, Woernley TC, Maida BD, Alava I, 3rd. Unusual Case of a Massive Macroglossia Secondary to Myxedema: A Case Report and Literature Review. J Oral Maxillofac Surg. 2018;76(1):119-127.

8.            Xavier SD, Bussoloti IF, Muller H. Macroglossia secondary to systemic amyloidosis: case report and literature review. Ear Nose Throat J. 2005;84(6):358-361.

9.            Zhang Y, Zhang L, Zhao X, et al. Symptom characteristics and prevalence of qi deficiency syndrome in people of varied health status and ages: A multicenter cross-sectional study. Journal of Traditional Chinese Medical Sciences. 2015;2(3):173-182.

10.          Weiss TM, Atanasov S, Calhoun KH. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Otolaryngol Head Neck Surg. 2005;133(6):966-971.

11.          Noller MW, Guilleminault C, Gouveia CJ, et al. Mandibular advancement for adult obstructive sleep apnea: A systematic review and meta-analysis. J Craniomaxillofac Surg. 2017.