5

Tongue Lesions

DISEASES OF THE TONGUE d. Plummer-Vinson syndrome

e. Sprue (malabsorption syndrome)
The tongue is a complex muscular organ that
f. Chronic alcoholism
is anchored to hyoid bone, styloid process, and
genial tubercles of mandible by the hyo- g. Circulatory disturbances
glossus, styloglossus and genioglossus h. Endocrinal dysfunction—diabetes mellitus,
muscles. It is the most important organ of the chronic candidiasis
oral cavity with very important functions. i. Long-standing lichen planus, SMF, sclero-
derma, tertiary syphilis, SLE
I. Examination j. Long-standing xerostomia (drugs, radio-
a. Shape, color and size therapy, Sjögren’s syndrome)
b. Papillae and taste buds
B. Increased Coating on Tongue
c. Coating
a. Black hairy tongue (true or pseudo)
d. Tone (palpation)
b. Altered oral physiology
e. Lesions c. Chronic illness, liquid diet, stomatitis, etc.
II. Developmental Anomalies d. Xerostomia
a. Ankyloglossia e. Mouth breathing
b. Bifid tongue f. Constipation
c. Macroglossia g. O2 liberating mouth washes
d. Fissured tongue/scrotal tongue h. Persistent vomiting of pyloric stenosis
e. Median rhomboid glossitis C. Glossodynia
f. Thyroglossal duct cyst Painful burning tongue
g. Microglossia a. With clinical observable changes
h. Aglossia Local—dental irritants
• Food
III. Lesion Typical of Tongue
• Habits
A. Changes in Coating (Atrophic) • Allergy
a. Benign migratory glossitis or geographic Systemic—vit B complex deficiency
tongue • Anemia
b. Nutritional deficiency—riboflavin, niacin • Endocrinal disorders
c. Iron deficiency anemia, pernicious anemia b. Without clinical changes—psychogenic

86
 Tongue Lesions 87

D. Indentation on Tongue alcoholism or parkinsonism. If tongue is

a. Nutritional deviated, it is suggestive of paralysis. If patient
b. Vit B complex deficiency cannot protrude the tongue, SMF, ankylo-
c. Endocrinal—hypothyroidism (cretinism) glossia or carcinoma may be suspected.
d. Blood dyscrasias—anemia Tongue Movement Variations
e. ANUG, HSV, EM, etc. Trefoil tongue: Ability to voluntarily deform
E. Traumatic Injuries tongue tip into clover leaf pattern
Unusual extensibility of tongue forward to
Falls, fight, epileptic attacks, dental treatment
touch the nose, backward to touch the palate
(iatrogenic).
and pharynx—Gorlin’s sign which is positive
F. Other Lesions in Ehlers-Danlos syndrome.
a. Moeller’s glossitis Tuberous sclerosis: Long and narrow tongue
b. Painful circumvallate and foliate papilla as a consequence of hyperostosis and
c. Lingual varicosities—senility thickening of mandible.
Sublingual administration of drugs, hyper- Reduced mobility due to scar formation
tension. secondary to blisters in epidermolysis bullosa,
healing of burn injury and SMF.
G. Atypical Lesions
Specialized Examination Procedure
These lesions are not typical of the tongue and
of Tongue
can also affect other areas of the oral cavity.
These are covered under relevant headings: 1. Cine radiographic study of oral cavity and
pharynx is done during drinking, chewing,
a. Erythema multiforme
suckling and phonation. It helps to better
b. Lichen planus understand the position and shape of the
c. Leukoplakia tongue in motion, especially in congenital
d. Carcinoma and surgically induced defects. However,
e. Haemangioma due to the high radiation exposure involved
its use is limited.
Functions of the Tongue
2. CT scan causes increased radiation exposure
a. Prehension and ingestion of food and but still is used to identify
assists in mastication a. Space occupying lesions
b. Swallowing, sucking b. Muscular atrophy following hypoglossal
c. Perception—taste, pain, temperature nerve damage (deep lesions)
assessment, general sensation c. Tongue size may be estimated—allow
d. Jaw development D/D of macroglossia from muscular
e. Respiration—hyoglossus and genioglossus disturbance.
f. Phonation However, streak artifacts caused by metallic
g. Symbolic dental restorations lead to diminished
image clarity and is an unavoidable
Examination of Tongue
drawback of CT scan.
Color of tongue is examined when tongue is 3. Pulse Doppler ultrasound: Has been used to
lying passively in the floor of the mouth. Dark- study characteristics of arterial blood flow
red in polycythemia and alcoholism and pale in tongue. Abnormal pulse waves noted in
in anemia and SMF. lingual arteries of individual with evidence
Patient is asked to protrude the tongue. If of compromised blood supply or flow in
tremors are seen, it may be suggestive of other branches of carotid arterial tree.
 88 Concise Oral Medicine

Real time ultrasound (gray scale B mode ) 8. Scanning electron microscopy (SEM) to
with probes of small cross sectional study surface topography of tongue
diameter can be used to explore ventral dorsum and the character and morpho-
surface of tongue. This method can be used logy of tongue papillae.
to differentiate fluid filled cavity (cyst/ 9. Videomicroscopy and stereomicroscopy
abscess) from solid or vascular lesion. to visualize tongue papillae, capillary
4. Isotopic (radionuclide) scanning techniques networks and taste pores.
are used in lingual thyroid cases wherein
10. Psychophysical evaluation of lingual
radioactive iodine 131I is used.
sensory function.
Tc pertechnetate (Tc99m), gallium ( Ga67) and
tumor labeling with radioactive indium and Taste test—for evaluation of sweet, bitter,
cobalt-bleomycin chelates have been used sour and salty taste
to outline the extent of lingual and other Electrogustometry and tongue mapping
oral tumors with varying success. for localized taste dysfunction.
5. Electromyography: To understand lingual Tactile sensation testing by means of von
and masticatory muscle function. For this Frey fibers or a series of objects of graded
purpose, non-invasive technique with texture and testing for stereotactic activity
surface electrodes can be used as opposed by means of set of objects of different
to thin needle electrodes introduced in the shapes and other 3D objects. The latter
muscles in the past. approach is helpful in evaluating lingual
6. MRI function in speech disorders.
a. Excellent details of soft tissue such as
tongue and pharynx. Papilla and Taste Buds (Fig. 5.1)
b. CT scan has drawbacks of artifacts Filiform Papillae
caused by metallic restorations and also 500 cm2 in anterior two-thirds of the tongue.
the beam hardening effect because of
They have a small connective tissue core and
absorption of X-rays by the mandible.
elongated hair-like projections. They have
These drawbacks are minimized in MRI.
c. Direct coronal and sagittal sections are
seen—accurate delineation of lingual
muscles and extent of tumor infiltration.
d. Enhanced contrast of carcinoma, sarcoma,
inflamed salivary glandand normal
oropharyngeal structures can be observed
with gadolinium—diethylene triamine
penta-acetic acid (DTPA) enhancement
of MRI signed intensity.
e. Differentiation of fluid-filled and/or solid
lesions is possible as fluid appears hyper-
intense (bright) on T2-weighted images.
7. Direct microscopic examination of tongue
papilla and capillary blood flow in
fungiform papilla with IV fluorescein dye.
Similar to ophthalmic study of retinal blood
vessels. Helps in studying localized areas
of decreased blood flow secondary to
diabetic angiopathy. Fig. 5.1: Schematic diagram of tongue dorsum
 Tongue Lesions 89

arterial and venous supply and nerve endings von Ebner glands are strategically situated
like the conical papillae but carry no taste at a point where the milk is expressed
buds. Heavily concentrated in the centre of the during suckling.
dorsum. Function is to help in licking and
propagating the food distally. Foliate Papillae
Seen on the lateral border of the tongue
Fungiform Papillae posteriorly. They are conical in shape and
• Mushroom shaped, present on the anterior elongated resembling small leaves and hence
two-thirds of tongue. They are 200/cm2. called foliate (Fig. 5.3). Arranged in 2 to 3 rows.
They have vascular supply and nerve They get traumatized and inflamed often and
endings. They are identifiable as reddish the patients suddenly become conscious of
dots against a carpet of filiform and conical tender red areas with irregular surface and
papillae (Fig. 5.2). Sometimes the fungiform become apprehensive that it may be
papillae show small spots of melanin malignant. These patients become habitual
pigment. Taste pores of the papillae can be mirror watchers and keep on pulling out the
demonstrated in vivo on videomicroscopy tongue which gets traumatized by the lingual
by application of methylene blue stain. Each cusps of lower molars. This further aggravates
papilla has 0–20 taste buds. the problem.
• Both the filiform and fungiform papillae Such patients should be counselled and
take part in the atrophy of tongue. reassured that this is a normal feature of the
tongue and unlikely to turn malignant. Soft
Circumvallate Papillae acrylic tray for lower arch to be used as mouth-
• 10 to 20 in number arranged in the form of guard.
inverted V at the junction of anterior two- They do not take part in atrophic changes.
thirds and posterior one-third of the tongue. Taste buds are present.
• Do not take part in atrophic changes. Coating of the tongue is made of fungiform,
• These papillae are surrounded by a valley- filiform papilla enmeshed food debris,
like depression and hence called ‘circum- desquamated epithelial cells, bacteria and
vallate’ walls of the papilla contain von salivary proteins.
Ebner’s serous glands which secrete Posterior one-third of the tongue may be
lipoprotein lipase in neonates. This enzyme folded because of collected lymphoid tissue
is important for digestion of fat in milk. The called lingual tonsil.

Fig. 5.2: Tongue dorsum showing bulbous red

fungiform papillae with whitish filiform papillae Fig. 5.3: Foliate papillae
 90 Concise Oral Medicine

Tone of the Tongue

It is palpated bidigitally and is reduced in
pernicious anaemia and increased in SMF.
Anterior two-thirds of tongue: Devoid of
mucous or serous glands except directly under
the tip where small mucous glands of Blandin
and Nuhn are present.

Developmental Anomalies
a. Ankyloglossia
Absent or shortened lingual frenum (Fig. 5.4).
Tongue tie or ankyloglossia is a relatively
unimportant cause of defective speech. It Fig. 5.4: Partial ankyloglossia
causes difficulty in sucking and swallowing,
Macroglossia is feature of EMG (exophthalmos-
also recurrent traumatic ulcers. Also reduced
macroglossia-gigantism) syndrome also
self-cleansing capacity and inability to wet
known as Beckwith-Wiedeman syndrome.
lips.
If tongue tie is too severe and restricts the True macroglossia is rare, however, it is
mobility of tongue then it can be corrected by seen in:
frenectomy. Frenectomy is done only if there 1. Cretinism
is defective pronunciation of T, D, L, N. 2. Mongolism
3. Amyloidosis
b. Bifid Tongue
4. Hemangioma (Fig. 5.6)
It is a rare anomaly due to failure of union of
5. Lymphangioma (Fig. 5.7)
lateral halves of lingual swelling. It is of no
clinical significance (Fig. 5.5). 6. Long-term edentulous area
7. In mature adults acromegaly and in adole-
c. Macroglossia scent group dermoid–epidermoid cysts can
It is a component of numerous syndromes. In cause macroglossia.
these syndromes, the tongue enlargement is If tongue is large, slurred speech and defec-
caused by abnormal lysosomal storage of tive development of maxilla and mandible
carbohydrate macromolecules. with diastema will be present.

A B

Fig. 5.5: Examples of bifid tongue

 Tongue Lesions 91

A B

Fig. 5.6. Examples of macroglossia due to hemangioma

Congenital lingual hemangiomas or

lymphangiomas
Neurofibromatosis
Cowden’s syndrome
Epidermal nevus (ichthyosis hystrix
associated with papillomatosis) syndrome
Similar appearance of the tongue may be
seen in leprosy, Melkersson-Rosenthal
syndrome also.
d. Abnormally Fissured Tongue
It is a developmental variation in which no. of
Fig. 5.7: Lymphangioma deep fissures are seen on the dorsal surface of
tongue (Fig. 5.8). It normally goes un noticed
Lymphangioma of tongue with cystic unless patient gets traumatized its described
hygroma is the most common of congenital as scrotal, plicated or cerebriform tongue. It
macroglossia. Surface of tongue is nodular and may be associated with mild burning sensa-
irregular. Altered pattern of blood and lymph tion.
flow also can be responsible for recurrent Factors which can contribute to increased
tongue enlargement. Macroglossia associated prevalence of fissured tongue with age include
with storage disease—happy puppet (Angel-
man) syndrome and cretinism. Increased total
bulk of tongue. Often considered problem of
muscular control rather than true macroglossia.
Treatment
Surgery to reduce the tongue bulk may be
needed if congenital or acquired macroglossia
interferes with oropharyngeal function or is a
major cosmetic deformity.
In certain congenital disorders the tongue
dorsum becomes papillomatous or exhibits
localised enlargements, described as cobble
stone, pebbled or lumpy. Fig. 5.8: Fissured tongue
 92 Concise Oral Medicine

salivary hypofunction, vit B deficiency, Treatment

candidiasis and chronic lichenoid reactions. • Give reassurance to the patient.
Treatment • Antifungal ointment, nystatin or clotrima-
Clean fissures with H2O2 swab. zole.
Melkersson-Rosenthal syndrome: Fissured Thyroglossal Duct Cyst
tongue + psychosis (mental retardation) facial Seen as a round swelling at foramen cecum
palsy and hypoplasia of salivary gland. level, at times lingual thyroid is seen. Such a
Median Rhomboid Glossitis diagnosis can be made with radionuclide
Shows presence of rhomboidal or diamond- scanning-131I and Tc pertechnetate 99m and
shaped area in midline of tongue just anterior confirmed with biopsy.
to inverted V formed by circumvallate papilla Changes in the Coating of the Tongue
(Fig. 5.9). More common in males than in Coating of the tongue is made of fungiform,
females after the age of 30. filiform papillae, enmeshed food debris,
It may have: desquamated epithelial cells, bacteria and
1. Depapillated surface salivary proteins.
2. Tufted surface The changes in the coating of the tongue
3. Fissured surface are seen as the mirror of general health status
4. Lobulated surface in Western and Chinese medical traditions.
It was believed to be caused by failure of According to Brightman (Burket IXth Edn.)
tuberculum impar to retract before fusion of while depapillation of the tongue may be a
lateral halves and hypobranchial eminence so result of metabolic abnormality, there is no
that area devoid of papillae is present in the evidence that elongated filiform papillae and
midline. the halitosis that often accompanies it is
Recently, it is believed to have fungal origin, anything other than the result of local environ-
i.e. chronic candidiasis (coexistence of angular mental changes.
cheilitis, MRG and palatal erythematous The tongue coating is normally removed by
candidiasis), diabetes mellitus , impaired local salivary flow, mastication, deglutition and
blood supply due to atherosclerosis, impaired speech. Any condition interfering with salivary
local immune mechanism and reduced flow, mastication and deglutition will cause
concentration of Langerhans’ cells are the disturbance in tongue coating. Therefore,
other possible causative factors. tongue coating is increased in hospitalised,
dehydrated (nil by mouth) patients and those
with persistent vomiting. Patients using H2O2
mouthwash shows elongated filiform papillae
and subsequent increased coating of the
tongue.
Black hairy tongue (lingua nigra) is
characterized by elongation of the filiform
papillae and growth of black pigment
producing bacteria or other organism. Filiform
papillae may be 3 cm or longer which brush
against palate causing gagging. They appear
A B
as black hair as a result of pigment produced
Fig. 5.9: Examples of median rhomboid glossitis by fungi or micro-organisms (Fig. 5.10).
 Tongue Lesions 93

ded by a whitish margin of regenerating

filiform papillae overall resembling a map.
Etiology
Remains obscure it is suggested that it is
related to:
• Reduced activity of keratinase enzyme
system
• Immunological reaction
• Psychosomatic background
• Personality type: Patients who are “more
Fig. 5.10: Elongated and pigmented filiform papillae prone to complain or verbalise discomfort”
of black hairy tongue • Allergic reaction
Pseudo Black Hairy Tongue • BMG associated with increased frequency
of human leukocyte antigen (HLA) allele
When tongue appears black as a result of
B15
certain black-colored medications, food debris
and does not have pigment producing Clinical Features
organisms, it is called as pseudo black hairy 1. In early stage no symptoms are present and
tongue. Also seen after extensive oral surgery the lesion may not be noticed by patient.
when tongue is coated with blood pigments. But sometimes burning sensation may be
Treatment present and patient becomes conscious of
this condition.
Maintenance of proper oral hygiene and
cleaning tongue with brush and tongue blade 2. Lesions are multiple and appear as reddish
(podophyllin resin which is keratolytic). depapillated areas, irregular in shape
surrounded by erythematous halo which is
Benign Migratory Glossitis/ Geographic in turn surrounded by a raised whitish
Tongue/ Erythema Circinata Migrans/ margin of regenerating filiform papilla
Wandering Rash (Fig. 5.11).
As the name suggests typical BMG lesions are 3. These change their location within 3–7 days
reddish, irregular depapillated areas surroun- and hence called migratory.

A B

Fig. 5.11: Examples of benign migratory glossitis

 94 Concise Oral Medicine

4. Irregular lesions give a map-like appea- Depapillation of Tongue Caused

rance hence called geographic tongue. by Nutritional Deficiency and Anaemia
5. Persistence of an everchanging painful Redness, loss of papillae and painful swelling
(apparently) lesions on the dorsum of of tongue are characteristically found in
tongue is frightening to the patient and he deficiencies of several B vitamins.
may develop cancerophobia. • Niacin—pellagra
6. Ectopic geographic tongue is seen on • Riboflavin
ventral surface of tongue, lips, buccal • Pyridoxine
mucosa, palate and are called as erythema • Folic acid and vit B12—pernicious anemia
circinata migrans (Fig. 5.12).
Similar changes are associated with iron
Differential Diagnosis—Median Rhomboid deficiency anaemia and malabsorption syn-
Glossitis drome sprue.
Histologically: Papilla of variable height with Each of these factors involved in the
some submucosal round cell infiltrate and production of epithelial cells and RBCs and
areas of spongitic epithelium with localised manifestation of their deficiency affects other
intraepithelial infiltrates of polymorpho- mucosal surfaces, skin, RBCs, bone marrow,
nuclear leukocytes, so-called spongiotic and tongue papillae. Various changes occur
pustules or Monro’s abscesses. Clinically and in other organs also. Deficiency of one factor
histologically similar lesions also occur in rarely occurs alone because of dietary
Reiter’s syndrome, dermatitis herpetiformis, deficiency.
pustular psoriatic dermatitis. Specific deficiency may result from mal-
absorption syndrome causing pernicious
Treatment anaemia and sprue or drug induced defi-
The term ‘benign’ in BMG has therapeutic ciency, i.e. isoniazid leading to pyridoxine
value (since patient is worried that it is deficiency.
malignant). Various terms were used to describe—
Give assurance to the patient about the atrophic glossitis, e.g. raw, beefy tongue,
benign nature of the lesion. magenta, bright red, hunters glossitis and in
Xylocaine viscous mouth wash if burning the past the appearance was considered to be
is present. specific for a particular vitamin deficiency.
Cautious topical application of salicylic acid However, the atrophic appearance of the
and tretinoin recommended by some as an tongue depends on various factors such as
effective remedy. secondary candidiasis and in the absence of

A B

Fig. 5.12: Examples of erythema circinata migrans

 Tongue Lesions 95

hematologic evidence of anemia or vitamin

deficiency it is difficult to pinpoint the diag-
nosis.
Iron Deficiency Anemia
Patient will have pallor, dyspnea, fatigue, bald
tongue, angular cheilitis and koilonychia. First
oral symptom is that tip and sides of the A B

tongue become sore and sensitive to changes

in temperature.
O/E: Reddish, inflamed depapillated areas
seen. In advanced cases, entire tongue will be
involved and papilla totally disappear giving
a bald tongue (Fig. 5.13).
Plummer-Vinson syndrome: Paterson-Kelly
syndrome
1. Seen in middle aged patients with
anaemia caused by poor diet or blood loss.
2. Females more commonly affected than
males.
3. Thin narrow lips with narrow orifice. C D
4. Patient complains of dysphagia and pre-
sents with angular cheilitis and stomatitis Fig. 5.14: (A) Bald tongue and angular cheilitis;
and bald tongue (Fig. 5.14A). (B) conjunctival palor; (C) spoon-shaped nails;
5. Mucosa becomes pale dry, inelastic and (D) esophageal web—in barium swallow examination.
glazed. Plummer-Vinson syndrome
6. Brittle spoon-shaped nails (koilonychia),
dry skin with pallor (Fig. 5.14C). 9. This is a premalignant condition and may
7. Patient develops esophageal strictures and lead to oesophageal CA or post-cricoid
webs therefore barium swallow X-ray is CA, pharyngeal CA or oral CA (in
indicated (Fig. 5.14D). descending order).
8. Possibly dryness and atrophic changes in 10. Patients complain of spasm or food
conjunctiva (Fig. 5.14B), vaginal and anal sticking in throat, and may present with
mucosa. pagophagia (compulsive consumption of
cold drinks and ice).
11. Loss of teeth in early age.
Thin narrow lips with narrow orifice may
also be observed in Sjögren, scleroderma,
SMF.

Differential Diagnosis
Sjögren’s syndrome associated with ophthalmic
signs, rheumatoid arthritis, Hb may be normal.
A B
(SJS more predisposed to lymphoma,
Fig. 5.13: Examples of bald tongue carcinoma more common in PV syndrome).
 96 Concise Oral Medicine

Pernicious Anemia absorbed therefore less than 3% B12 excreted

It is caused by deficiency of intrinsic factor in urine.
secreted by the parietal cells of the fundus of After this the patient is given the intrinsic
stomach. In normal course this intrinsic factor factor along with radioactive B12, if patient still
combines with extrinsic factor, i.e. vit B12 and excretes less than 3% radioactive B 12 then
helps in iron synthesis after getting absorbed patient is having problem with absorption
through the ileum. In pernicious anaemia (malabsorption syndrome). Patients with
there is an autoantibody to the parietal cells/ pernicious anemia may also have achlor-
intrinsic factor. It is also seen in connection hydria.
with other autoimmune disorders such as Antibody test—Schilling’s test is now replaced
Graves’ disease and in patients with history by tests to check the presence of anti-parietal
of surgery of fundus of stomach. cell antibodies and antibodies to the intrinsic
Clinical Features factor. With both these tests results are more
accurate.
1. Patient complains of epigastric discomfort,
diarrhea and constipation Treatment
2. Pallor, dyspnea and fatigue Parenteral vit B12 throughout life.
3. Tingling, numbness and lack of co- Note: Since the hematologic changes in
ordination in movement of extremities, i.e pernicious anemia may be reversed by oral
neurological symptoms (if present with folic acid administration without the arrest of
anaemia), should raise the suspicion of neurological changes, one should not give
pernicious anemia multivitamins with folic acid to patients with
4. Tongue is bald or depapillated glossitis and pernicious anemia as anemia improves in
glossodynia these patients but serious neurological symp-
toms may worsen.
5. Red beefy tongue due to loss of filiform
papilla
PERIPHERAL VASCULAR DISEASES
6. Severe burning sensation
7. Loss of taste a. Decreased nutritional status of the lingual
papillae in diabetes mellitus could be due
Laboratory Findings to:
• RBCs show variation in size, macrocytic and • Vascular changes in the subpapillary
normochromic dorsal capillary plexus or lingual vessels
• Platelets are large supplying it.
• WBCs are hypersegmented • Chronic candidiasis and this could lead
Schillings test: Patient is given a measured to atrophic glossitis.
amount of radioactive B12 orally. After that a b. Fibrosis of submucosal tissue secondary to
flushing dose of parenteral Vit B12 (normal) is obliteration of small vessels suggestive of
given. Since the total dose of B12 exceeds renal autoimmune process which is responsible
threshold, excess B12 will appear in urine. for the scarred shunken atrophic appea-
Normal patient who has intrinsic factor will rance of tongue in scleroderma, mixed
show greater absorption of radioactive B12 connective tissue diseases and in lupus
through GI tract and therefore excrete 7 to 30% erythematosus.
radioactive B 12 in urine. In patients with c. Infarcts of the tongue may be associated
pernicious anemia, however, intrinsic factor with shrunken tongue with atrophic
is missing therefore radioactive B 12 not mucosal changes.
 Tongue Lesions 97

Tertiary Syphilis and Interstitial Glossitis 3. The ulcerative lesions affecting the tongue
Non-ulcerating irregular indurations with an and the oral mucosa are elaborated in the
asymmetric pattern of alternating grooves ulcerative lesion chapter.
with leukoplakia and smooth (atrophic) fields
covering entire dorsum of the tongue. The Diseases Affecting Body of Tongue
tongue has been described as upholstered The following diseases can cause swelling of
tongue because of the scarring of the healed the body of tongue:
gummata. 1. Amyloidosis
Carcinoma of the dorsum of tongue asso-
2. Infections: Lingual abscess, Ludwig’s
ciated with interstitial glossitis is an exception
to the general finding that carcinoma of the angina, actinomycosis, cysticercosis and
tongue is rare on the dorsum. trichinosis.

Pigmentation of Tongue Amyloidosis

1. Racial a. Miscellaneous group of conditions in which
2. Exogenous an amorphous material (amyloid) is
• Microbial growth—pigment producing deposited extracellularly in a single organ
pathogens (localized) or many organs (systemic).
• Food debris b. Nephrotic syndrome is the most common
• Candy dyes clinical manifestation.
• Beverages c. Macroglossia is the most common oral
• Mouth rinses manifestation. The enlarged tongue
• Amalgam tattoo protrudes between the teeth and presents
3. Drugs: Doxorubicin hydrochloride (cancer with indentations. Patients complain of
therapy) large, firm and immobile tongue which
• Alpha methyl dopa (antihypertensive) interferes with speech, mastication,
• Nortryptyline (tricyclic antidepressant) swallowing and affects the dentition.
• Zidovudine (antiretroviral) d. Amyloidosis should be suspected in
4. Endocrinal: Addison’s disease—primary patients with tongue enlargement, having
adrenal insufficiency a history of multiple myeloma, long
5. Peutz-Jeghers syndrome standing tuberculosis, rheumatoid arthritis,
6. Albright syndrome severe anemia.
7. Acanthosis nigricans e. Salivary gland involvement: Periductal and
8. Neurofibromatosis periacinar deposition of amyloid leads to
9. Hemochromatosis acinar atrophy.
Ulcerations of the tongue can result from f. Amyloid has characteristic staining pro-
traumatic injuries, and infectious diseases: perties, polarized light microscopy shows
1. Fine striated folds (fimbriae) and apple green birefringence in the tissue
Wharton’s duct opening on either sides stained with Congo red.
of lingual frenum is likely to be trauma-
tized during dental procedures because Infections
of aspiration causing ulceration and 1. Lingual abscess caused by contaminated
ecchymosis. injuries and streptococci and anaerobic
2. Ulcers on tongue are seen in infectious organisms are responsible. Drainage,
diseases and in riga fede disease in debridement under proper antibiotic cover
neonates. is essential.
 98 Concise Oral Medicine

2. Ludwig’s angina is actually not a lingual understands what he/she hears and has no
infection but elevates the tongue and difficulty in writing, if literate.
underlying spaces are involved, this very Dystonia refers to abnormally increased
dangerous rapidly spreading infection was muscular tone results in fixed abnormal
considered fatal in the preantibiotic era. posture. These are due to anatomic or bio-
Lingual cellulitis associated with Haemo- chemical lesions involving the basal ganglia
philus influenzae bacteremia can be fatal. and referred to as extra-pyramidal disorders;
3. Actinomycosis: Induration and multiple lingual and palatal muscular dystonia are seen
discharging sinuses, so called wooden patients with parkinsonism, athetoses, drug-
tongue of cattle is very rare. induced basal ganglia dysfunctions. Focal dys-
4. Larval stage of pork tapeworm taenia tonia of tongue and oropharyngeal muscles
solium (cysticercosis), roundworm and may occur with levodopa, prochlorperazine
gnathostomiasis infestation may affect the and other phenothiazines and antipsychotics.
tongue and is accompanied by other skeletal Spasmodic torticollis (wry neck syndrome):
muscle involvement leading to fever, Involuntary spasm of sternocleidomastoid,
generalized muscle tenderness and marked trapezius causing involuntary turning or
eosinophilia. Radiographically larvae of dipping of head.
cysticercosis are visualized as multiple Dyskinesia: Repetitive uncontrolled muscular
small oval opaque shadows in the soft activity related to long-term administration of
tissue. phenothiazine, reserpine and other anti-
Neuromuscular Disorders
psychotic drugs. Symptoms include:
• Rapid and repetitive movements of the
Neuromuscular disorders of central, peri- tongue, jaw and lips
pheral or muscular origin may produce • Fine tremors and fasciculation of tongue—
symptoms of dysphagia and choking and vermicular movements
speech and masticatory problems. • Rapid darting movements—fly catchers
Dysphagia caused by the weakness of the tongue, bon-bon sign
tongue musculature is referred to as oro- • Rabbit syndrome—involuntary mouthing,
pharyngeal dysphagia and symptoms include: chewing, smacking movements of lips with
• Aspiration while swallowing constant tremors
• Nasal regurgitation • Senile tremor associated with senile de-
• Pain on swallowing mentia has buccal-lingual-facial dyskinesia.
Newer drugs like clozapine have fewer
• Inability of the tongue to move the bolus of
complications of this type.
food into pharynx.
Myasthenia gravis is characterized by weak-
Other causes of dysphagia are SJS, PV ness and easy fatiguability affecting facial,
syndrome, acute pharyngitis, Vincent’s oculomotor, laryngeal, pharyngeal, respira-
angina, glossitis, and retropharyngeal abscess. tory muscles rather than lingual muscles.
Dysarthria is the speech problem caused by the This disorder is caused by decrease in the
neuromuscular disorders involving the number of available acetylcholinesterase
tongue, in which defect is there in accurate receptors at the myoneural junctions due to
articulation and phrasing. This condition is to antibody mediated autoimmune damage.
be distinguished from aphasia or dysphasia The defect is reversed by anticholinesterase
which are cerebral disorders in which the medications such as pyridostigmine. Improve-
ability to produce or comprehend spoken ment with thymectomy and immuno-
language is limited. The dysarthric patient suppression.
 Tongue Lesions 99

Amyotrophic Lateral Sclerosis (ALS) On EMG study of genioglossus, diaphragm

Steadily progressive disorder of motor neurons and other respiratory muscles, it was found
with clinical manifestation of muscle weakness, that genioglossus pulls the tongue forward
atrophy, spasticity with exaggerated reflexes. and opposes the tendency of pharynx to
The muscles supplied by the brainstem are collapse due to negative pressure during
affected resulting in weakness atrophy and inspiration. In OSAS, there is a weakness of
obvious fasciculation (persistent muscle genioglossus which fails to pull the tongue
twitches) in the tongue and facial muscles. forward leading to posterior and inferior
After the diagnosis of ALS is made, some positioning leading to interference in breathing.
patients develop an attitude of denial and seek Management of mild cases includes weight
opinions of many consultants. Such patients reduction, alcohol avoidance, increasing nasal
vainly hope that a new denture or tooth patency, altering sleep posture.
extraction or treatment of burning tongue Severe cases may require continuous nasal
will cure their symptoms. It is important that positive pressure, supplemental oxygen.
the dentist, through medical history and Surgical enlargement or tightening of
communication with the physician, become pharyngeal lumen, i.e. uvulopalatopharyngo-
aware of the diagnosis and undertake dental plasty.
treatment with the complete understanding of Surgical repositioning of mandible and
the reality of patients condition. occlusal splints, night guardin cases where
Obstructive Sleep Apnea Syndrome (OSAS) there is mandibular retrognathism.
1. Group of disorders characterized by Angioneurotic Edema
episodes of apnea (intermittent cessation of • It is a manifestation of allergy or anaphylaxis.
respiration) associated with regular sleep • Leads to transient painless swelling of
or hypersomnolence. tongue, lips.
2. Underventilation of pulmonary alveoli— • Angioedema of larynx in anaphylaxis can
alveolar hypoxemia and hypercapnia be life-threatening.
3. Primary disorder of alveolar hypoventila- • Angioedema of the lips and tongue can
tion or secondary to alcohol or barbiturate be managed by avoiding the allergen,
intoxication or respiratory centre damage antihistaminics, steroids. Treatment of
(from bulbar poliomyelitis or brainstem anaphylaxis is covered in Chapter 2—
infarcts) Ulcerative Vesiculobullous Lesions.
4. Obstructive sleep apnea results from the Various Appearances of the Tongue
blockage of the pharyngeal airway by the • Pellagra: Niacin (vit. B3) deficiency ‘5Ds’
tongue: (dark-red tongue, diarrhea, dermatitis,
a. Congenital deformity Pierre Robin dementia, and death)
syndrome and severe retrognathism of • Riboflavin deficiency: Magenta red tongue
other causes. • Strawberry tongue: Scarlet fever—prominent
b. Adenotonsillar hypertrophy, macro- red fungiform papillae against pinkish
glossia white tongue coating
c. Pickwickian syndrome/fat boy • Baked tongue: Dry/brown-typhoid fever
syndrome—morbid obesity, hyper- • Parrot tongue: Dry/horny/immobile—
somnolescence, periodic breathing with chronic low grade fever
hypoventilation, weakness or altered • Fly catchers tongue: Dyskinesia tarda—rabbit
tonus of genioglossus muscles. syndrome
100 Concise Oral Medicine

• Wooden tongue of cattle: Actinomycosis— inflammatory changes, if the symptom persists

induration and multiple draining sinuses. then deep seated/neurological/psychological
causes are suspected. Subsequent and
Glossodynia/Glossopyrosis
adequate treatment of the etiological factor.
The term glossodynia is used to denote painful
b. Glossodynia without observable clinical
tongue and glossopyrosis for burning sensation
changes –75% of cases
of the tongue. This symptom is most annoying
to the patient, the physician and the dentist. 1. Common in postmenopausal women
Unfortunately for the patients, quite often 2. Patients also complain of disturbed taste,
(75% of cases) there are no clinically observ- insomnia
able changes. In the remaining patients 3. Anxious and worried
observable clinical changes are seen and are 4. Clinical examination fails to show any cause
related to either local or systemic factors. for burning.
a. Glossodynia with observable clinical Before labelling their symptoms as psychogenic, it
changes –25% of cases is important to rule out
i. Local factors • Diabetes mellitus (fasting and postprandial
• Traumatic lesions associated with sharp blood sugar)
tooth, restorations, etc. • Anemia
• Allergy to dentifrices, lipsticks, mouth- • Lymphoid tissue infection at the base of the
wash tongue
• Poor oral hygiene, candidiasis • Glossopharyngeal neuralgia
• Chronic edentulous condition with
• Painful red erosive lesions with inflamed
decreased vertical intermaxillary space
papillae
compressing the tongue.
ii. Systemic factors
Treatment
• Extensive generalised atrophy of
lingual papillae and erosive lesions— • Patients should be handled with diplomacy
vit B complex deficiency and care.
• Bald or depapillated tongue—iron • Never tell the patients that the pain is
deficiency anemia imaginary.
• Reddish inflamed tongue—diabetes • Assurance to the patient that there is no
mellitus evidence of malignancy.
• Depapillated tongue with dry shiny • Diazepam 5 mg 1 bedtime for 10–15 days
lobulated surface—Sjögren’s syndrome (or tricyclic antidepressant).
• Pernicious anemia tip and lateral • Patients who are hysterical are referred to
borders bright and fiery red. psychiatrist.
The above appearances are characteristically Suggested Reading
indicative but not pathognomonic
Management: Identification of the causative 1. Burket’s Oral Medicine, 8th, 9th editions.
factor. 2. Oral and Maxillofacial Pathology by
The patients are prescribed local anesthetic Neville, 3rd edition.
gel/mouth wash—if the symptom disappears 3. Shafer’s Textbook of Oral Pathology, 6th
then the cause is related to local erosive/ edition.