oral medicine

Editor.
JAMES W. LITTLE, D.M.D., M.S.D.
School of Dentistry
University of Minnesota
515 S.E. Delaware St.
Minneapolis, Minn. 55455

Candidal infection of the tongue with

nonspecific inflammation of the palate
Louis ZG Touyz, B.D.S., M.Sc. (Dent.), M. Dent. (P.O.M.),* and
Edmund Peters, D.D.S., M.Sc., ** Johannesburg, South Africa

UNIVERSITY OF THE WITWATERSRAND

A retrospective study of ten patients with median rhomboid glossitis (MRG) revealed the presence of a
nonspecific inflammatory reaction of varying degrees of severity in the overlying palatal mucosa. Clinical
records and photographs indicated that the palatal reactions physically approximated the underlying
glossal lesions, suggesting a relationship between these entities. The nature of the relationship is
uncertain, but it may involve a localized infection of the palatal mucosa by Candida species, from the MRG.
Alternatively, irritation by soluble, possibly Candida-related factors from the MRG that are applied
repeatedly to the palatal mucosa during swallowing may be responsible.
(ORAL SURG. ORAL MED. ORAL PATHOL. 1987;63:304-8)

S everal studies have indicated that median rhom-

boid glossitis (MRG) may represent a localized form
of glossal candidal infection rather than a develop-
mental defect.le4 This article analyzes the clinical
features of 10 cases of MRG with specific reference
to palatal observations and proposes that these dis-
tinctive cases of candidal infection of the tongue can
be associated with nonspecific inflammation of the
contiguous overlying palatal mucosa.
MATERIALS AND METHODS
Sixteen cases diagnosed as MRG were found
after a search of records from 1953 to 1986 in the
Departments of Oral Medicine and Periodontics, and
Oral Pathology at the University of the Witwaters-
rand. Six of these cases were excluded from analysis
since adequate records were not available. The
remaining case records were analyzed to determine
*Department of Oral Medicine and Periodontics.
**Department of Oral Pathology, School of Pathology.
304
each patient’s age, sex, race, and dentate state;
descriptions of mucosal surfaces including the tongue
and palate were recorded. In most cases, the diagnosis
had been made on the basis of the distinctive clinical
appearance of MRG; however, in one case (Case 4),
results of a biopsy were available to confirm the
diagnosis, and in six cases (Cases 5 to lo), smears of
the MRG and the palatal mucosa had been taken. In
one other case (Case 6), results of a biopsy of the
overlying palatal mucosa were available.
RESULTS
Table I gives the clinical data of the ten cases of
MRG for which adequate records were available. An
age range of 9 to 57 years, with a mean of 42.6 years,
was determined. Table II summarizes the clinical
notes describing the palate taken from the record
cards of the patients listed in Table I; all of these
indicate a concomitant palatal inflammatory change
of varying degrees of severity. In one case (Case 4)
the patient wore a complete upper denture during the
daytime, which may have been related to the inflam-
Volume 63 Candidal tongue infection with nonspeci$c inflammation of palate 305
Number 3

Fig. 1. Case10.A, Inflammatory palatal reaction-highly erythematous.B, Opposingmedianrhomboid

glossitisis present.

Fig. 2. Case 7. A, Inflammatory palatal reaction-poorly defined areas characterized by multiple

petechiae.B, Opposingmedianrhomboidglossitisis present.

mation. There were no apparent predisposing factors
in the other cases. Figs. 1, 2, and 3 illustrate three
cases that were photographed.
Glossal smears generally confirmed previous work
indicating that MRG is a site of candidal infection;
however, the palatal smears were negative for candi-
da1 hyphae in all but one case.
Fig. 4 shows the histologic appearance of a biopsy
specimen from the palatal lesion illustrated in Fig. 3.
Despite features suggestive of candidiasis, candidal
306 Touyz and Peters Oral Surg.
March, 1987

Table I. Data from the charts of median rhomboid glossitis cases involving patients with palatal lesions
-
No. Year Age Sex Race Dentate state Smears for Candida

T P
1973 42 F W D
2 1974 31 M A D
3 1974 49 F W D
4 1975 56 F W E
5 1983 9 M W D -ve -ve
6 1984 45 F B D +ve -ve
7 1984 54 F B D +ve +ve
8 1985 51 F W E* +ve -ve
9 1985 45 M W D +ve -ve
10 1986 38 F W D +ve -ve

W = White: B = black: A = Asian; T = tongue; P = palate; D = dentthus. E = edentulous.

*Case 8. Patient did not wear dentures.

Table II. Summary of palatal notes taken from analyzed, and particularly the geographic congru-
records of the corresponding patients listed in ence of these reactions with the glossal lesions,
Table I suggests a relationship between these entities. This
relationship is probably initiated by juxtaposition of
1 Soft palate, has some telangiectatic spots
the palatal and glossal mucosae during swallowing,
2 Palate-junction of hard and soft palate;
reddish an event that can occur as often as 590 times per
3 Palate-IT center; reddish base, white day.’ The pathogenic nature of these multiple tran-
peripheral area sient contacts is uncertain, but it is unlikely that
4 Palate-sore midline inflamed area repeated contiguity of the MRG and the stress-
5 Palate-inflamed swollen area
adapted palatal mucosa could result in a purely
6 Inflamed area, junction-hard and soft
palate; central depression, circular, mechanical irritation. A more likely explanation
peripheral pigmentation; median rhom- implicates the Candida albicans infecting the MRG.
boid glossitis fits into this area Possibly, localized infection of the palate by the
7 Palate, midline erythematous area with subjacent tongue lesion causes some of the inflam-
petechiae, about 2 cm in diameter,
matory reactions. However, candidal hyphae were
opposes tongue lesion
8 Hard palate, patchy areas of inflamma- not present in the single palatal biopsy specimen
tion, anterior third unaffected, posterior available for study and were found in only one of the
two thirds hard palate, midline palatal smears. Difficulties in demonstrating hyphae
involved may indicate simply the ephemeral nature of numer-
9 Inflamed red area, palate; touches tongue
ous reinfections. Alternatively, soluble factors from
lesion when swallowing
IO Midline area, hard palate; stops behind candidal hyphae may be implicated. According to this
incisal papilla; tapers posteriorly; reasoning, the palatal inflammation would be caused
tongue lesion fits into palatal lesion on by candidotoxins derived from the infected MRG
swallowing being applied repeatedly to the palatal mucosa.
Evidence supporting this suggestion is found in
experimental attempts to produce candidiasis by
hyphae were not demonstrable, even after examina- placing aqueous suspensions of Candida species in
tion of multiple levels of the specimen and special the hamster cheek pouch. These topical applications
staining with periodic acid-Schiff/diastase. A benign consistently produced a highly inflamed mucosa
epithelial melanocytic hyperplasia was also without infestation by hyphae, indicating that the
present peripherally, as was a heavy melanin incon- inflammation is mediated by factors produced by
tinence in the subjacent lamina propria. These fea- Candida species? Such factors may include toxins or
tures have been noted in mucosa subjected to irrita- hydrolytic enzymes that are derived from some
tion.5*6 pathogenic strains of C. albicans.9 The pathogenic
mechanism could involve a direct toxic action or a
DISCUSSION hypersensitivity response.
An unexplained palatal inflammatory reaction in The frequency with which a palatal reaction
at least nine of the ten cases of MRG that were occurs in patients with MRG cannot be stated from
Volume 63 Candidal tongue infection with nonspecific injammation of palate 307
Number 3

Fig. 3. Case6. A circinate erythematous,slightly depressed palatal lesionis evident; radially oriented
lineardepressions
extendto the periphery,which is demarcatedby pigmentation.The lesionfit preciselyinto
subjacentmedianrhomboidglossitis(not photographed).

Fig. 4. Case 6. Biopsy photomicrographof lesion shown in Fig. 3. A mixed acute and chronic
inflammatory cell infiltrate, including occasionaleosinophils,is presentwithin the juxtaepithelial lamina
propria. Overlying epitheliumexhibits spongiosisand a heavyexocytosisof acute inflammatorycells.It was
not possibleto demonstratecandidal hyphae. (Hematoxyhn and eosinstain. Magnification, x250.)

our findings. Our results indicate that such a reac-
tion is not uncommon, but inadequate records of the
six patients who were not included in our analysis
may reflect the absence of any other noteworthy soft
tissue lesions. One study of 28 patients with MRG’O
noted the presence of atrophic patches and petechial
lesions on the palate in four cases; ten of the patients
in this study wore full dentures, which would have
protected their palates. A further possibility-that
both the palatal lesions and the MRGs were second-
ary to fellatio-was suggested. In another study of
32 patients with chronic multifocal candidiasis, 12 of
15 patients with glossal lesions had concomitant
palatal lesions, both of which were ascribed to
candidal infection.”
Red lesions on the posterior portion of the palate
308 Touyz and Peters Oral Surg.
March, 1987

may be seen accompanying diverse conditions such 5. Goode RK, Crawford BE, Callihan MD, Neville BW. Oral
melanoacanthoma. ORAL SURG ORAL MED ORAL PATHOI.
as erythroplakia, blood dyscrasias, infectious mono- I983;56:622-628.
nucleosis, lymphonodular pharyngitis, herpangina, 6. Page LR, Corio RL, Crawford BE, Giasanti JS, Weathers
denture sore mouth, or traumatic lesions secondary DR. The oral melanotic macule. ORAL SURG ORAL MED ORAL
PATHOL 1977;44:219-226.
to fellatio. The distinguishing features have been 7. Jenkins GN. The physiology and biochemistry of the mouth.
adequately discussed elsewhere.12 This study illus- 4th ed. Oxford: Blackwell Scientific Publications, 1978:501-
trates the further possibility that nonspecific inflam- 541.
8. McMillan MD, Cowell VM. Experimental candidiasis in the
mation related to candidal infection in the form of hamster cheek pouch. Arch Oral Biol 1985;30:249-255.
MRG should also be considered in the differential 9. Chattaway FW, Odds FC, Barlow AJE. An examination of
diagnosis of lesions in this area. The acronym CZT- the production of hydrolytic enzymes and toxins by pathoge-
netic strains of Candida albicans. J Gen Microbial
NIP syndrome (candidal infection of the tongue with I97 1;67:255-263.
nonspecific inflammation of the palate) is proposed 10. Farman AG, van Wyk CW, Staz J, Hugo M, Dreyer WP.
to describe the association of these lesions. Central papillary atrophy of the tongue. ORAL SURG ORAL
MED ORAL PATHOL 1977;43:48-58.
11. Pindborg JJ. Diseases of the oral mucosa. 4th ed. Copenha-
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