Tongue disorders

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Tongue disorders
Changes in tongue coating
Dr/ Maha Mahmoud Assistant professor, Faculty of
Dentistry, Umm Al-Qura University, Makkah, KSA
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Tongue coating is formed of

• 1- Tongue papillae.
• 2- Food debris.
• 3- Bacteria.
• 4- Desquamated epithelium.

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The tongue coating

• varies in different individuals.
• Varies in the same individual during the day
• It is continuously formed
• it is marked in the morning since cleaning
  factors are at rest. and is removed by
• 1- Mechanical factors speaking and chewing food.
  
• 2-Salivary flow

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• Tongue coating is in a continuous process of
  removal and formation.
• If removal exceeds formation ? atrophy
• If formation exceeds removal ? increased tongue
  coating.

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A- Atrophy of tongue coating

• The cells forming the filiform papillae and
  fungiform papillae are of high metabolic activity
  so any disturbance in enzyme, circulation or
  nutrients leads to atrophy.
• During the process of atrophy the filiform
  papillae are affected first, followed by
  fungiform papillae.
• During regeneration the fungiform papillae
  regenerate first followed by regeneration of
  filiform.
• Circumvallate and foliate are permanent
  structures of the tongue coating , dont
  participate in atrophy.

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Atrophy of tongue coating
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Etiology
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1- Deficient or impaired utilization of nutrients

• 1- Iron deficiency anemia.
• 2- Pulmonary Vinson syndrome.
• 3- Pernicious anemia.
• 4- Anemia associated with parasitic infection as
  ascaris and bilhariziasis.
• 5- Malnutrition, malabsorption.
• 6- Sprue .
• 7- Chronic alcoholism.
• 8- Vitamin B deficiency especially (vitamin B2,
  B6, B12, folic acid and nicotinic acid).

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2- Peripheral vascular disease

• 1- Angiopathy Diabetes Mellitus.
• 2-Vasulitis systemic lupus erythematosus.
• 3- Endarteritis obliterans syphilitic glossitis.
  
• 4-Obliteration of small blood vessels
  scleroderma, submucous fibrosis.
• 5-Localized vascular insufficiency in elderly
  patients.

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3-Therapeutic agents

• 1-Drugs that
• Interfere with the growth and maturation of the
  epithelium e.g cyclosporine.
• Induce candidosis e.g. antibiotic, steroid.
• Induce xerostomia e.g anticholinergic drugs,
  radiotherapy.

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4- Miscellaneous

• 1- Frictional irritation atrophy at tip
  lateral borders of tongue.
• 2- Atrophic lichen planus.
• 3- Epidermolysis bullosa ulceration healed by
  scar.
• 4- Long standing xerostomia.
• 5- Diabetes and chronic candidiasis may produce a
  lesion called central papillary atrophy.

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B- Increased tongue coating

• The filiform papillae which constitute the
  keratinizing surface of the tongue are in
  continuous state of growth and their height is
  determined by the rate of desquamation process.
  The later is induced by friction with food,
  palate and the upper anterior teeth, during
  eating and speech.

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Increased tongue coating
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Etiology

• Basically the abnormal increase in tongue coating
  is due to local environmental changes represented
  by lack of function and/or changes in the oral
  flora and these are attributed to
• 1- Drugs
• a- Topical and systemic use of antibiotics.
• b- Antiseptic mouth washes.
• c- Oxygen releasing mouth rinse.

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Etiology cont

• 2- Febrile illness (general body dehydration,
  decreased salivary flow, liquid diet and poor
  oral hygiene).
• 3-Stomach upset, vomiting associated with
  intestinal or pyloric obstruction, debilitated or
  terminally ill patient.
• 4- Mouth breathing

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Clinical features

• The increased tongue coating may be stained
  particularly on the mid dorsum by food, tobacco,
  drugs or possibly by microorganisms.
• In debilitated, dehydrated and terminally ill
  patients the increased tongue coating may be very
  thick and has been described as leathery coating.
  

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Treatment

• Consist of brushing the dorsal surface of the
  tongue several times a day systemic antibiotic
  should not be interrupted but antifungal agent
  should be used locally. Topical antibiotic and
  mouth washes should not be used. The condition
  usually regresses spontaneously when the normal
  jaw and tongue activity are restored.

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Black hairy tongue

• Definition
• It is a condition characterized by hypertrophy
  of filiform papillae associated with growth of
  black pigment producing micro organism.

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Black hairy tongue
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Etiology

• 1- Sodium perporate and sodium peroxide mouth
  wash that stimulate growth of filiform papillae.
• 2-Topical and systemic antibiotics
• ex penicillin, tetracycline, aureomycin.
• 3- Systemic disturbance anemia, hyperacidity,
  peptic ulcer.
• 4- Predisposition in some people.
• Clinical features
• May be asymptomatic or may cause gagging and
  tickling.

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Management

• Removal of the cause
• stop t0pical antibiotic.
• Brushing of the tongue.
• Systemic antibiotic should not be stopped, but
  antifungal ointment is prescribed in additional
  to the antibiotic.
• Pseudo black hairy tongue means discolouration of
  tongue by food, smoking and drugs without actual
  hypertrophy of filiform papillae.

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Geographic tongue (benign migratory glossitis
(wendering rash)
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Site

• the dorsum of the tongue.
• ? It is an irregularly outlined area, devoid of
  filiform papillae, with red dots representing
  fungiform papillae. occasionally devoid of
  fungiform. The margin of the depapillated area
  is raised with yellowish, whitish tinge.
• ? The margin of the lesion shifts as much as ¼
  inch per day due to renewed of papillae in one
  area and loss in another area.
• ? It occurs chiefly in children and young adults.
  

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Geographic tongue
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Geographic tongue
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Clinical picture

• ? Females are frequently affected more than
  males.
• ? The patient may fell discomfort of pain
  specially alcoholics and with highly seasoned
  food.
• ? The lesions are usually multiple.
• ? Identical lesion is seen in psoriasis and
  Reiters syndrome.

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Etiology

• Unknown but may be
• 1- Associated with fissured tongue (attributed to
  bacterial irritation).
• 2-Common in allergic persons (more frequent in
  atopic patients).
• 3- Related to psychological factor (the
  exacerbation has been associated with anxiety and
  depression.
• 4-Related to family history (several member of
  the family may have the disease).

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Differential diagnosis

• Geographic tongue should be differential from
• 1- Atrophic lichen planus.
• 2-Fixed drug eruption.
• The main characteristic features of geographic
  tongue is the continuous daily migration of the
  lesion.

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Treatment

• No treatment is indicated as the lesion is self
  limiting disease.
• 1- In apprehensive and cancerphobic patient
  reassurance is required.
• 2-If the patient is suffering from burning or
  soreness, benzydamine HCl mouth wash will offer
  good relief.

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Indentatoin marking of the tongue
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Identatoin marking of the tongue

• Definition
• It is crenation marking seen along the tip
  and lateral margins of the tongue where it rests
  against the surfaces of the teeth.

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Etiology

• Local factors
• 1- Tongue pressure habit.
• 2-Macroglossia (acromegaly, gigantism, etc).
• 3- Acute inflammation e.g. erythroma multiform,
  metallic intoxication, Acute necrotizing
  ulcerative gingivitis, acute herpetic
  gingivostomatitis.

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• Systemic factors
• 1- Vitamin B complex deficiency.
• 2-Diabetes mellitus due to decreased muscular
  tone associated with vitamin BC deficiency.

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Sublingual varices
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Sublingual varices

• 1- It is formed by enlarged tortuous veins in the
  sublingual area.
• 2-It is asymptomatic, but trauma may result in
  bleeding

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Etiology

• ? Idiopathic
• ? Congential.
• ? Found more in elderly people.
• ? It may be associated with portal hypertension.

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Burning tongue painful tongue
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Glossopyrosis Glossodynia

• Burning tongue painful tongue

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Etiology

• 1- Local factors
• 2-Systemic factors
• 3- Psychogenic factors represents 75 of cases.

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1- Local factors

• 1- Irritating calculus, caries, malposed teeth,
  sharp tooth edge.
• 2-Electrogalvanic discharge between two
  dissimilar metals.
• 3- Oral Candidosis.
• 4-Dryness of the mouth.
• 5- Allergic response to lipstick, dentifrices.
• 6-Excessive smoking.
• 7- Habit of rubbing the tongue against the teeth.
  
• 8-Excessive use of strong mouth wash.
• 9-Mouth breathing.
• 10- Highly spicy food.

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Erosions on the dorsum of the tongue, caused by
very hot food.
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2- Systemic factors

• Anemia iron deficiency anemia, pernicious
  anemia.
• Vitamin B complex deficiency.
• Chronic alcoholism.
• Gonadal deficiency
• Diabetes mellitus.
• Drugs fixed drug eruption.
• Low serum zinc level.
• Tongue tremors e.g. parkinsonism.

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3-Psychogenic factors

• 1- Post menopausal women with cancerphobia.
• 2- After death of close persons.
• ? Psychogenic factors result in glossodynia which
  is characterized by
• 1- No observable clinical cause.
• 2-Pain does not follow any anatomical
  distribution.
• 3- Pain does not interfere with eating or
  sleeping.
• 4-Pain intensity increases at the end of the day.

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Treatment

• 1- Removal of the cause if possible.
• 2-If psychogenic.
• ? Reassurance of the patient that there is no
  malignancy.
• ? Valium 5-10 mg t.d.s may be of help.
• ? Resistant cases ? refer to psychiatrist

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6- Papillitis (painful foliate and circumvallate
papillae)

• ? It is the inflammation of foliate and / or the
  lateral circumvallate papillae.
• ? The patient complains of pain at the
  posterolateral aspect of the tongue.
• Etiology
• ? Sharp distolingual cusp of lower second molar.
• ? Sharp edge of a denture.
• The lesion arises as a result of rubbing or
  biting the tongue against the teeth, or denture.
  Digital palpation may reveal a rough or sharp
  tooth or restoration.

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References

• Martin Greenberg and Michel Glick Jonathan A.
  Ship. Burkett's Oral Medicine ,Diagnosis
  Treatment , 10th ed. 2008, BC Decker, Inc..
• George Laskaris, Pocket Atlas of Oral Diseases,
  2nd edition, 2006, Stuttgart , New York.