DISEASES & DISORDERS OF THE

TONGUE
The tongue is essentially a complex muscular organ covered by a
specialized mucous membrane. This mucous membrane
:composed of different types of papillae, including

Circumvallate papillae 2. Fungiform papillae .1

Filifom papillae 4. Foliate papillae .3

Circumvallate papillae: 8-12 dome shaped structures .1

located at the junction of the anterior 2/3 and posterior 1/3 of
the tongue as a V shaped row. They are vascularized and
contain a large number of taste buds. They do not participate in
the atrophic changes of the tongue. 2. Abnormal keratinization
of non-keratinized epithelial surfaces (metaplasia) such as
keratinization of non-masticatory (lining) mucous membrane of
.the oral cavity

Fungiform papillae: These mushroom-shaped structures .2

found only on the anterior 2/3 of the tongue mostly near the tip
and lateral margins. They have a rich capillary network that
makes them easily identifiable as reddish dots against a carpet
of filiform papillae, they participate in the inflammatory and
atrophic changes of the tongue. Their number is about 100/cm2
.on the tip and 5o/cm2 in the middle (or 200 and 400 in total)

Filifom papillae: They are slender or hair like papillae with .3

heavily keratinized caps that are found in rows radiating antero-
posteriorly over the anterior 2/3 of the tongue. They count
around 500/cm2. They participate in the inflammatory and
.atrophic changes of the tongue

Foliate papillae: These are found mostly on the lateral .4

margins of the posterior part of the tongue. They do not
.participate in the atrophic changes of the tongue

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:Examination of the tongue

The tongue is believed to be the mirror of the stomach or the

:window of the digestive system. Its examination includes

Shape .1

Color .2

.Relative number and distribution of its papillae .3

.Evaluation of its muscular tone .4

.Any lesion on its surface .5

The color is light pink or pinkish-red (light white coating maybe

accepted and considered normal) best examined when tongue is
relaxed in the floor of the mouth to avoid change of color due to
.venous congestion when tongue is protruded outside

Tongue coating is examined when tongue is protruded to see

number and shape of papillae, and any abnormal coating of the
.tongue as well

Muscular tone of the tongue is examined digitally or bimanually.

:We can find

Less muscular tone in secondary anemia and muscular *

.dystrophy

.Diffused fibrous consistency in interstitial glossitis of syphilis *

.Localized scarred area in cases of epilepsy *

The tongue must be palpated to detect any mass or nodule, silent

or hidden lesions, also examine the lateral and ventral surfaces of
the tongue for any premalignant lesion or malignant ulcer, as they
.commonly occur there

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:Examples of changes in color of the tongue

Red: A red tongue can indicate the presence of an infectious

disease or simply be part of an inflammatory process. Glossitis is
the inflammation of the tongue that leads to increased blood flow
.to the organ and result in a red appearance

This color may also result from an acute mechanical or chemical

.injury or an infection from bacteria entering a cut on the tongue

Bright red: If the red coloring becomes much brighter, you could
be looking at heart disorders or blood diseases. Bright red tongue
also occur with iron & vitamin B12 deficiencies, and sore
.mouth/throat

Yellow: Yellow discoloration is uncommon but could be a sign of

jaundice which is associated with liver problems. Additionally, a
.yellowish color can be noted with persistent stomach problems too

Most likely, a yellow tongue is the start of the gradual development

of a disease and the color changes to brown and then black. Poor
oral hygiene, smoking and certain medications can cause this
.color too

Purple: A purple tongue indicates blood stasis which may be a

sign of heart complications (blood is not flowing in a regular way or
.it’s impaired)

On the other hand, this may indicate lung problems because a lack
.of oxygen in the blood will cause a bluish-purple tint to appear

Blue: If the tongue has a bluish color this could be an indication of

cyanosis, which is a condition caused when there is not enough
oxygen supply to tissues. This can be caused by blood disorders,
diseased blood vessels, kidney disease, and respiratory
.insufficiency

Pale: An obviously pale-colored tongue most likely indicate

nutritional deficiency and should be easily rectified with diet
.changes

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White: A white tongue is most commonly caused by dehydration
and can easily be corrected by drinking more water. Additionally,
.white tongue can indicate a fungal infection, such as oral thrush

Gray: A gray-colored tongue can indicate long-term digestive or

intestinal problems. Typically, the gray color comes from a
coating caused by bacterial build up associated with digestive
.issues

:Examples of changes in the tongue coating

A normal, healthy tongue will have a light white coating which

can easily be brushed away. Anything thicker or varying in
color beyond this can indicate serious health problems requiring
.immediate attention

Thick white coating: While a thick, white coating can form as a

result of drinking too much alcohol (intoxication), it can also
indicate an infectious disease. Oral thrush is one such disease
caused by an overgrowth of Candida hyphae. A white coating
can also appear as a result of bacteria or dead cells getting
.trapped between the papillae

Brown coating: Drinking a lot of tea & coffee along with

smoking can lead to a brown discoloration of the tongue. More
seriously, however, a permanent brown coating can be an
indication of lung problems and is often seen in chronic
smokers. With time and no treatment, this brown coating can
turn black and we may notice a distinctively hairy feeling across
.the surface of the tongue (black hairy tongue)

Yellow coating: A thick, yellow coating indicates digestive

disorders, specifically problems with the stomach, gallbladder,
or even the liver. There are also some foods that can cause a
temporary yellowish coating, so there is only cause for concern
.should the coating be thick and remain for a long time

Gray coating: Gastric disorders and possible peptic ulcers are

generally the cause for a gray coating to appear on the tongue.
Often it may not be obvious that there is a coating and the
.tongue will just have a gray tint only
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NORMAL VARIATION IN TONGUE MORPHOLOGY &
FUNCTION

.Ankyloglossia (tongue tie) .1

.Fissured tongue (Grooved or Scrotal tongue) .2

Patent thyroglossal duct, thyroglossal duct cyst & .3

.Lingual thyroid

.Median rhomboid glossitis .4

:Ankyloglossia (tongue tie) .1

Is a congenital shortness of the lingual frenum that extends

nearly to the tip of the tongue, binding the tongue to the floor of
the mouth and restricting its extension. It may be associated
with microglossia. Contrary to popular opinion, there is no
evidence that ankyloglossia interferes with speech, although
patient may find that restricted mobility interferes with the
.mechanical cleansing action of the tongue

:Fissured tongue (Grooved or Scrotal tongue) .2

Occurs as a normal variation affecting less than 10% of the

population. Food debris accumulation in these fissures may
cause mild inflammation and discomfort to the patient with
.burning sensation
:Treatment of painful symptoms

Irrigation with 3% H2O2 *

Mild antibacterial agent on the inflamed area *

Warm mouthwash (salty mouth wash) *

Chlorhexidine mouthwash (avoid if the patient is sensitive or *

.irritated)

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:Lingual thyroid .3

Lingual thyroid is an abnormal mass of ectopic thyroid tissue

seen in the base of the tongue due to embryological aberrancy
in development of the thyroid gland. Most of the ectopic tissue
is seen in the tongue. Its’ identification and proper management
is essential since it may be the only functioning thyroid tissue
.occurring in the body

:Median rhomboid glossitis .4

Described as a rhomboid, diamond or rounded area of

depapillation in the midline anterior to V-shaped circumvallate
.papillae. It may have a red, white, or yellow appearance

Median rhomboid glossitis has for long been considered to be

developmental abnormality in some way connected with the site
of the embryonic tuberculum impar. It has now been recognized
that these lesions are often associated with the presence of
.candida

:Treatment

.In asymptomatic cases reassurance of the patient is required *

In symptomatic cases (burning sensation) antifungal agent *

.(nystatin)

Observation is required to detect any enlargement of the area

.but a need for biopsy is unlikely

:Note

The appearance of an irregular border of the tongue (often *

said to resemble a “pie-crust edge”) is known as crenated
tongue or scalloped tongue and can be one of the features of
.bruxism in some patients (indentation pattern of the tongue)

Tongue Thrust: protruding or pressing the tongue against the *

teeth may also result in scalloped tongue with anterior open
.bite

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MAJOR INHERITED, CONGENITAL & DEVELOPMENTAL
ABNORMALITIES

Cleft, lobed, bifurcated & tetrafurcated tongue .1

Aglossia, hypoglossia, microglossia & macroglossia .2

Hamartomas & dermoids .3

Bald or depapillated tongue .4

:Cleft tongue (bifid tongue) .1

Completely cleft tongue is a rare condition caused by a failure

of the lateral lingual swellings to merge. More common is an
incompletely cleft tongue, appearing as midline deep fissure.
This is normally classed as fissured tongue (see fissured
.tongue)

Aglossia: Complete absence of the tongue at birth .2

Hypoglossia: Congenitally short tongue

Microglossia: Small size tongue

Macroglossia: Large size tongue, usually it’s a component of

numerous syndromes, most of them associated with severe
metabolic anomalies in which the increase in tongue size is
caused by deposition of lipid, carbohydrate, or amyloid. In all
.cases, other abnormalities may accompany macroglossia

:The most common causes of macroglossia are

Mongolism (Down’s syndrome) .

Cretinism (congenital hypothyroidism) .

Myxedema (hypothyroidism) .

.Hemangioma .

.Generalized amyloidosis .

.Feature of acromegaly .
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Amyloidosis: Is an important cause of macroglossia since it is
usually associated with life-threatening disease, particularly
multiple myeloma. Amyloidosis is the deposition of an abnormal
protein in the tissue. It can result from overproduction of
immunoglobulin light chains, usually by multiple myeloma. In
over 20% of such cases, amyloid is deposited in the mouth,
particularly the tongue and macroglossia can be so gross as to
.protrude from the mouth

:Hamartomas & dermoids .3

The tongue may be distorted or enlarged by the presence of a

variety of tumor-like growths of developmental origin like
hamartomas (neurofibromas, hemangioma) or by epithelial
.inclusion cyst (dermoids, branchial cleft cysts)

:Bald or depapillated tongue .4

Absence of papillae may be caused by a congenital anomaly or

develop as a secondary feature to congenital anomalies that
result in scarring of the tongue dorsum. e.g. Epidermolysis
bullosa (which is a group of genetic conditions that result in
.easy blistering of the skin and mucous membranes)

DISORDERS OF THE LINGUAL MUCOSA

:A. Changes in the tongue papillae

Geographic tongue (Benign migratory glossitis) .1

Coated or hairy tongue .2

Non-keratotic white lesions .3

Keratotic white lesions .4

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B. Depapillation & atrophic lesions

Chronic trauma .1

Nutritional deficiencies & hematologic abnormalities .2

Medications .3

Peripheral vascular disease .4

Chronic candidiasis .5

Tertiary syphilis & interstitial glossitis .6

Atrophic lichen planus .7

Early leukoplakia .8

C. Pigmentation

D. Superficial vascular changes

:A. Changes in the tongue papillae

Geographic tongue (Benign migratory glossitis or .1

erythema migrans linguae or wandering rash or glossitis
.areata exfoliativa)

Refers to irregularly shaped, reddish areas of depapillation that

are usually surrounded by a narrow zone of regenerating
papillae that is whiter than the surrounding tongue surface.
Spontaneous development and regeneration of affected areas
.account for the term wandering rash or migratory glossitis

It is not restricted to the tongue and similar irregular lesion

occurring elsewhere in the oral cavity are referred to as ectopic
.geographic tongue, erythema migrans or annular migrans

Etiology remains obscure, but an immunologic reaction has

been proposed on the basis of the associated inflammatory
.infiltrate. Some cases occur due to zinc deficiency

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 :D.D

Psoriasis .1

Anemia and nutritional deficiency such as Vitamin B2 .2

.deficiency (ariboflvinosis)

Reports linked the condition with various human leukocyte .3

antigens, such as increased incidence of HLA-DR5, HLA-DRW6
.and HLA-Cw6 and decreased incidence in HLA-B51

Reiter’s syndrome (also known as reactive arthritis, is the .4

classic triad of conjunctivitis, urethritis, and arthritis occurring
after an infection, particularly those in the urogenital or
.gastrointestinal tract “cross-reactivity”)

.Dermatitis herpetiformis .5

Other oral inflammatory diseases and conditions such as oral .6

lichen planus, erythematous candidiasis, leukoplakia, lupus
.erythematosus, glossitis, and chemical burns

:Treatment

There is no specific curative treatment for this self-limiting

condition. Treatment attempt to control the chronic burning pain
:(symptomatic treatment) by

Most patients advised to avoid food stuffs that irritate their .1

.tongue (such as spicy or citrus or acidic food)

.Application of topical local anesthetic agents .2

.Mouth rinse by aqueous antihistamine .3

.Topical corticosteroids .4

.Topical application of Tretinoin .5

.Zinc supplement .6

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Coated or hairy tongue or lingua villosa (coated tongue) .2
.or lingua villosa nigra (black hairy tongue)
In health, the heavily keratinized surface layers of the filiform
papillae are continuously desquamated through friction of
tongue with food, the palate and the upper anterior teeth and
are replaced by new epithelial cells from bellow. When illness or
painful oral condition limits tongue movement, the filliform
papillae lengthen and become heavily coated with bacteria and
fungi. The longer papillae give the tongue a coated or hairy
appearance and retain debris and pigments from food, drink, or
.tobacco smoke
Extreme degree of coated tongue occurring in dehydrated,
debilitated, terminally ill patients. The hairy tongue is increased
with use of systemic or topical antibiotics probably as result of
.changes in the oral microbial flora (more anaerobic bacteria)

:Treatment
Thorough cleaning and scraping of tongue or application of
topical keratolytic agents. H2o2 mouth wash is also useful for
.its’ frothing action and killing anaerobic microorganisms

Non-keratotic white lesions .3

a. Thrush

b. Chemical or thermal burn

c. White spongy nevus

d. Vesiculo-bullous & other desquamative disorders

(benign mucous membrane pemphigoid, lichen planus,
.epidermolysis bullosa)

Keratotic white lesions .4

e.g. Leukoplakia

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B. Depapillation & atrophic lesions
Chronic trauma .1

Nutritional deficiencies & hematologic abnormalities: .2

Redness, loss of papillae & painful swelling of the tongue are
found in deficiency of several vitamin B derivatives and in iron
.deficiency anemia

Medications: Depapillation of the tongue occur as side effect .3

of a number of medications (such as antibiotics, cancer
chemotherapeutic agents, anticholinergic agents). In these
cases inhibition of epithelial reproduction, secondary
candidiasis & the effect of chronic xerostomia are probably
.involved

:Periphral vascular diseases .4

Diabetes: Decreased nutritional status of the lingual papillae as
a result of vascular changes affecting the lingual vessels
.underlies the atrophic glossitis
Scleroderma: Fibrosis of the submucosal tissues secondary to
obliteration of small vessels by an autoimmune process is
responsible for the scarred, shrunken & atrophic appearance of
.tongue
Lupus erythematosus: Isolated, irregular areas of lingual
.mucosal atrophy & ulceration are caused by the arteritis

Chronic candidiasis .5

Tertiary syphilis & interstitial glossitis: Due to the .6

obliteration of the wall of blood vessels which is called
obliterative endarteritis and this will lead to vascular
insufficiency and nutritional deficiency and atrophy of the
.papillae of the tongue

Atrophic lichen planus 8.Early leukoplakia .7

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:C. Pigmentation
Endogenous pigmentation is rarely identifiable on the dorsum
of the tongue because of the thickness of the epithelium but
.jaundice may be apparent under the thinner ventral mucosa
Exogenous pigmentation of the filiform papillae of the normal
.and coated or hairy tongue is very common

:D. Superficial vascular changes

Lingual varicosities (or lingual varices)
Appear as prominent purplish-blue spots, nodules or ridges
usually on the anterior ventral surface of the tongue and around
the submandibular and sublingual glands. They are rarely
.symptomatic. They usually increase in number with age

Hemangiomes

Petechial hemorrhage & telangiectasia (telangiecteses)

 

Note: Consider that some of the diseases, disorders

& lesions discussed in this lecture were mentioned
in previous lectures (Vesiculobullous diseases,
.White & Red lesions & Oral Ulcers)

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