Common Causes and Patient Case Study

Through: Jeffrey W. Horowitz, DMD, FAGD, D-ABDSM, D-ASBA

A scalloped tongue is characterized by wavy or ruffled edges along the sides.

Scalloped tongues are usually not a cause for concern, but if left untreated, they can cause additional complications and symptoms that can harm your dental health.

Identifying bad oral habits and diagnosing certain medical conditions can also be made easier by a scalloped tongue.

Scalloped Tongue: Case Study

Let’s look at a patient case I had with a scalloped tongue to help you diagnose and treat future patients.

Patient information:

  • 38-year-old white man presents for first dental examination
  • Medical history is positive for hypertension and GERD
  • Dental/Perio exam negative for pathology
  • Archform is narrow with a high palate vault
  • Soft tissue examination positive for oropharyngeal inflammation/oedema

3 Primary Reasons for Tongue Shells

  1. A large tongue (Macroglossia)
  2. Small dental arches / malformed teeth (may be developmental or iatrogenic)
  3. A combination of the above

These patients are at higher risk of airway obstruction and further assessment of the airway is indicated.

Narrow arches, high palate

  • The tongue may be normal in size but is forced to function within an undersized dental/skeletal arch.
  • Archforms may be underdeveloped due to poor tongue position during childhood/adolescence. This is often initiated by early respiratory failure.
  • Archforms may be undersized by reductive orthodontic therapies (extraction/IPR) to correct crowding or by space closure

big tongues; Tongue level can be assessed

Type 1 – Tongue at rest with side edge BELOW mandibular occlusal plane
Type 2 – Tongue at rest with side edges LEVEL WITH mandibular occlusal plane
Type 3 – Tongue at rest with side edges REST ON occlusal surfaces of mandibular teeth
Type 4 – Tongue at rest with side edge ENTIRE COVERAGE occlusal surfaces of mandibular teeth

Pictured above: Tongue level 3 when tongue at rest covers the occlusal surfaces of the lower molars without completely covering the occlusal surfaces (type 4). Type 3 and Type 4 tongues are risk factors for sleep-disordered breathing.

Compromised tongue space can lead to a compromised airway!

Further airway assessment is indicated, including evaluation of other oropharyngeal structures. (soft palate, lateral pharyngeal walls, uvula, tonsils and skeletal patterns.

Subjective questions about snoring, panting, sleep quality, and daytime sleepiness should be considered.

With any concern about respiratory disease, referral to a well-trained sleep physician/dentist can reduce medical risk and save lives. Once a sleep study is performed, breathing sleep disturbances can be confirmed or ruled out.


The patient was confirmed to have severe sleep apnea after a home sleep study was diagnosed by a board-certified sleep physician.

The patient was successfully treated with a Mandibular Repositioning Appliance

A scalloped tongue is just one of many anatomical presentations that can be easily recognized by dental professionals as a risk factor for sleep disturbances when breathing.

Next: The Importance of an Infection Control Coordinator

photo by Andrea Piacquadio

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