6.  Diseases of the tongue and lips

Q. 2. Describe the appearance of tongue in geographic tongue.

Or

Describe briefly about benign migratory glossitis.

Ans.

Geographic tongue is a psoriasiform mucositis of the dorsum of the tongue. It is also known as benign migratory glossitis.

Its dominant characteristic is a constantly changing pattern of serpiginous white lines surrounding areas of smooth, depapillated mucosa.

The changing appearance with depapillated areas have reminded of continental outlines on globe, hence popular with the term geographic tongue.

Clinical presentation and pathogenesis

Benign migratory glossitis is usually noted as an incidental examination finding or by patient recognition. Although all surfaces of the tongue may be involved, the dorsum is the most common.

Adults are affected more than children and women slightly more than men.

The tongue will show alternating areas of normal texture and a whitish colour due to filiform papillae and surface keratinization, contrasted with smooth red areas where the filiform papillae have flattened and a dekeratinization of the surface has occurred.

The confluent borders of these two areas are usually elevated, rolled, and more intensely white. The pattern and areas of involvement will change over a period of days.

At times the tongue will revert to a normal texture and appearance, and at times it will exhibit almost a bald denudation. Usually the appearance will be somewhere in between.

The lesions are innocuous and asymptomatic except on occasions when spicy foods or acidic citrus products are consumed.

A small percentage of benign migratory glossitis cases will be accompanied by constant burning pain, known as the glossopyrosis.

These cases are usually related to invasive candidiasis and occasionally to erosive lichen planus. In fact, candida colonization rather than true invasive infection may be the stimulus for benign migratory glossitis.

Although the disease is often referred to as ‘geographic tongue’, it does occasionally appear in the floor of the mouth or buccal mucosa as a benign migratory stomatitis.

Histologically

Biopsy should be taken from a prominent serpiginous lines at the periphery of a depapillated patch.

A thickened layer of keratin is infiltrated with neutrophils, these inflammatory cells often produces small micro-abscesses, called as Monro’s abscess, in keratin and spinous layers.

Chronic inflammatory cells can be seen in variable numbers within the stroma.

Silver and PAS staining will demonstrate candida hyphae or spores in the superficial layers of the epithelium.

Differential diagnosis

Surface tongue lesions that are generally asymptomatic include candidiasis, lichen planus, and perhaps lesions related to both systemic lupus erythematosus and discoid lupus erythematosus. In addition, the clinician must be aware of the possibility of premalignant dysplasia.

Diagnostic work-up

Benign migratory glossitis is a diagnosis of clinical recognition. If clinical doubt exists or a burning tongue sensation accompanies the lesion, a biopsy is indicated to rule out the other entities on the differential list.

A PAS stain is recommended to rule out Candida organisms.

Treatment

No specific treatment is indicated in asymptomatic cases.

Symptomatic lesions can be treated with topical prednisolone and a topical or systemic antifungal medication can be tried if infected secondary with candidiasis.

Symptomatic cases respond well to nystatin oral suspension, 100,000 U/mL given as 5 mL (1 teaspoon) oral swish and expectorate 4 times daily, alone or combined with clotrimazole troches (Mycelex, Alza), 10 mg as a lozenge three times daily. Response to such therapy suggests the presence of Candida organisms.

Emphasis on the innocuous nature of the condition and the fact that it is not malignant or premalignant is recommended.


Q. 3. Describe the appearance of tongue in:

a. Amyloidosis

b. Hunter glossitis

Ans.

Amyloidosis

Amyloidosis is fundamentally a disorder of protein misfolding.

It is a condition associated with a number of inherited and inflammatory disorders in which extracellular deposits of fibrillar proteins are responsible for tissue damage and functional compromise.

This abnormal proteinaceous substance that is deposited between cells and organs of the body in a variety of clinical disorders is referred to as an amyloid.

Of the more than 20 biochemically distinct forms of proteins, three are most common. They are:

i. the amyloid light chain (AL)

ii. the amyloid associated (AA), and

iii. a β-amyloid.

Any organ can be involved but the most commonly affected organs are kidneys, heart, gastrointestinal tract, liver and spleen.

Amyloidosis is generally irreversible condition.

Amyloid deposition in tongue results in macroglossia and gingiva is also commonly affected.

Amyloidosis may or may not be apparent on macroscopic examination, but when the suspected organ is painted with iodine and sulphuric acid, a peculiar mahogany brown staining of amyloid deposits is revealed.

If large amount of amyloid is accumulated, the affected organ is frequently enlarged and the tissue appears grey with a waxy firm consistency.

Histologically, the deposition always begins between the cells and eventually surrounds and destroy the trapped native cells.

The diagnosis of amyloidosis is established by demonstration of the characteristic emerald-green birefringence of tissue specimens stained with Congo red and examined by polarizing microscopy.

There is no specific therapy for primary amyloidosis.

Hunter glossitis

Pernicious anaemia is rare before the age of 30 years and increases in frequency with advancing age.

The disease is often characterized by the presence of a triad of symptoms: generalized weakness, a sore, painful tongue and numbness or tingling of the extremities.

Glossitis is one of the more common symptoms of pernicious anaemia.

The patients complain of painful and burning lingual sensations.

The tongue is generally inflamed, often described as ‘beefy red’ in colour, either in entirety or in patches scattered over the dorsum and lateral borders.

In some cases, small and shallow ulcers—resembling aphthous ulcers—occur on the tongue.

Characteristically, with the glossitis, glossodynia and glossopyrosis, there is gradual atrophy of the papillae of the tongue that eventuates in a smooth or bald tongue, which is often referred to as Hunter glossitis or Moeller glossitis.

Loss or distortion of taste is sometimes reported accompanying these changes.

The fiery red appearance of the tongue may undergo periods of remission, but recurrent attacks are common.

On occasion, the inflammation and burning sensation extend to involve the entire oral mucosa but, more frequently, the rest of the oral mucosa exhibits only the pale yellowish tinge noted on the skin.

Commonly the oral mucous membranes in patients with this disease become intolerant to dentures.

Treatment

Regardless of the aetiology of vitamin B12 deficiency, high-dose oral supplementation (l,000−2,000 mcg daily for 2 weeks), followed by 1,000 mcg daily for maintenance is currently recommended.

Historically pernicious anaemia was treated with intramuscular vitamin B12 supplementation.

Management for folic acid deficiency consists of administration of oral folic acid (5 mg/day), which is given for a period of 4 months. The differentiation of B12 deficiency and folic acid deficiency is crucial as folic acid supplements may correct the anaemia but will not stop the neurological manifestations.


Q. 4. How the clinical examination of the tongue can be carried out? Describe glossodynia and mention the treatment plan in brief.

Ans.

Clinical examination of tongue

Inspect the dorsum of the tongue while it is at rest for any swelling, ulcers, coating or variation in size, colour and texture.

Observe the margins of the tongue and note the distribution of filiform and fungiform papillae, crenations and fasciculations, depapillated areas, fissures, ulcers and keratotic areas.

Note the frenal attachment and any deviations as the patient pushes out the tongue and attempts to move it to the right and left.

Wrap a piece of gauze (4 cm × 4 cm) around the tip of the protruding tongue to steady it, and lightly press a warm mirror against the uvula to observe the base of the tongue and vallate papillae, note any ulcers or significant swellings.

Holding the tongue with the gauze, gently guide the tongue to the right and retract the left cheek to observe the foliate papillae and the entire lateral border of the tongue for ulcers, keratotic areas, and red patches.

Repeat for the opposite side, and then have the patient touch the tip of the tongue to the palate to display the ventral surface of the tongue and floor of the mouth. Note any varicosities, tight frenal attachments, stones in Wharton ducts, ulcers, swellings and red or white patches. Gently palpate the muscles of the tongue for nodules and tumours, extending the finger onto the base of the tongue and pressing forward if this has been poorly visualized or if any ulcers or masses are suspected.

Note tongue thrust on swallowing.

Burning mouth syndrome (Glossodynia)

Burning mouth syndrome is a common dysaesthesia (i.e., distortion of a sense) typically described by the patient as a burning sensation of the oral mucosa in the absence of any clinically apparent alterations.

The cause of BMS remains unknown, but a number of factors have been suspected, including hormonal and allergic disorders, salivary gland hypofunction, chronic low-grade trauma, and psychiatric abnormalities.

In addition to burning sensation patient also experience mucosal pain often described as ‘rawness’ (stomatodynia, glossodynia).

The so-called scalded mouth syndrome is an apparently unrelated immune response to certain medications, especially angiotensin-converting enzyme (ACE) inhibitors.

Burning mouth syndrome affect postmenopausal women. Women experience symptoms of BMS seven times more frequently than men.

Mean age is 40 years for men.

It has typical abrupt onset, although may be gradual.

Dorsum of tongue develops a burning sensation, usually in the anterior third of the tongue.

Mucosal changes are seldom visible, if dorsum of tongue is significantly erythematous and smooth, an underlying systemic or local infectious process, such as anaemia or erythematous candidiasis, should be suspected.

Other oral sites affected are hard palate and the lips.

Salivary levels of various proteins, immunoglobulins and phosphates may be elevated, and there may be a decreased salivary pH or buffering capacity.

There, will be mild discomfort on awakening, with increasing intensity throughout the day. Contact with hot food or liquid often intensifies the symptoms.

Chronically affected patients demonstrates psychological dysfunction, usually depression, anxiety or irritability.

The discomfortness reduces as the painful condition reduces or disappears.

Treatment

Underlying local or systemic causes should be identified and eliminated.

Counselling and reassurance may be adequate management for individuals with mild burning sensations, but patients with symptoms that are more severe often require drug therapy.

The drug therapies that have been found to be the most helpful are low doses of TCAs, such as amitriptyline and doxepin, or clonazepam (a benzodiazepine derivative).

Mood altering drugs such as chlordiazepoxide. Additional therapies used are clonazepam alpha lipoic acid, amitriptyline, transcutaneous electric nerve stimulation, analgesics, antibiotics, antifungals, vitamin B complex and placebo-controlled trial.

Burning of the tongue that results from parafunctional oral habits may be relieved with the use of a splint covering the teeth and/or the palate.

Short essays

Q. 1. Pernicious anaemia—tongue lesions.

Or

Glossitis.

Ans.

The pernicious anaemia is often characterized by the presence of a triad of symptoms: generalized weakness, a sore, painful tongue and numbness or tingling of the extremities.

In some cases, the lingual manifestations are the first sign of the disease.

Other typical complaints are easy fatigability, headache, dizziness, nausea, vomiting, diarrhoea, loss of appetite, shortness of breath, loss of weight, pallor and abdominal pain.

Patients with severe anaemia exhibit a yellowish tinge of the skin.

Oral manifestations

Glossitis is one of the more common symptoms of pernicious anaemia.

The patients complain of painful and burning lingual sensations.

Pernicious anaemia is rare before the age of 30 years and increases in frequency with advancing age.

The tongue is generally inflamed, often described as ‘beefy red’ in colour, either in entirety or in patches scattered over the dorsum and lateral borders.

In some cases, small and shallow ulcers—resembling aphthous ulcers—occur on the tongue.

Characteristically, with the glossitis, glossodynia and glossopyrosis, there is gradual atrophy of the papillae of the tongue that eventuates in a smooth or bald tongue, which is often referred to as Hunter glossitis or Moeller glossitis.

Loss or distortion of taste is sometimes reported accompanying these changes.

The fiery red appearance of the tongue may undergo periods of remission, but recurrent attacks are common.

On occasion, the inflammation and burning sensation extend to involve the entire oral mucosa but, more frequently, the rest of the oral mucosa exhibits only the pale yellowish tinge noted on the skin.

Commonly the oral mucous membranes in patients with this disease become intolerant to dentures.

Treatment

Regardless of the aetiology of vitamin B12 deficiency, high-dose oral supplementation (l,000–2,000 mcg daily for 2 weeks), followed by 1,000 mcg daily for maintenance is currently recommended.

Historically pernicious anaemia was treated with intramuscular vitamin B12 supplementation. However, several studies have demonstrated that high doses of oral vitamin B12 are just as effective as, and are better tolerated than intramuscular cyanocobalamin in patients with B12 malabsorption.

Management for folic acid deficiency consists of administration of oral folic acid (5 mg/day), which is given for a period of 4 months. The differentiation of B12 deficiency and folic acid deficiency is crucial as folic acid supplements may correct the anaemia but will not stop the neurological manifestations.


Q. 2. Angular cheilitis.

Ans.

Angular cheilitis is one of the clinical types of oral candidiasis.

Associated factors are: idiopathic, immunosuppression, loss of vertical dimension, iron deficiency, vitamin B12 deficiency.

Infection with Candida albicans and in some cases with a mixture of other microorganisms such as Staphylococcus aureus seems to represent a major cause.

Angular cheilitis is usually a reddish ulcerative or proliferative condition marked by one or a number of deep fissures spreading from the corners of the mouth.

The lesions are most often bilateral, usually do not bleed, and are restricted to the vermilion and skin surface

Resolution is relatively easily obtained if angular cheilitis is an isolated finding.

If it is part of a generalized oral/systemic candidal infection, it may be very deep seated and resistant to eradication. These lesions usually persist even though the predisposing factors have been eliminated, unless they are treated with an antifungal ointment such as nystatin in conjunction with an S. aureus agent or metronidazole.

The major priority of treatment must be directed to the main reservoir of infection in the body.


Q. 3. Glossopyrosis and glossodynia.

Or

Burning mouth syndrome.

Ans.

Burning mouth syndrome is a common dysaesthesia (i.e., distortion of a sense) typically described by the patient as a burning sensation of the oral mucosa in the absence of any clinically apparent alterations.

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Apr 11, 2016 | Posted by in Orthodontics | Comments Off on 6.  Diseases of the tongue and lips
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