Tongue disorders

• The tongue is a complex muscular

organ that is anchored to hyoid
bone, styloid process, and genial
tubercles of mandible by the
hyoglossus, styloglossus and
genioglossus muscles.

• It is the most important organ of the

oral cavity with very important
functions
Examination
• a. Shape, color and size
• b. Papillae and taste buds
• c. Coating
• d. Tone (palpation)
• e. Lesions
Developmental Anomalies

• a. Aglossia
• b.Ankyloglossia
• c. Bifid tongue
• d. Macroglossia
• e. Fissured tongue/scrotal tongue
• f. Median rhomboid glossitis
• g. Thyroglossal duct cyst
• h. Microglossia
 Lesion Typical of Tongue
Changes in Coating (Atrophic)
• a. Benign migratory glossitis or
geographic tongue
• b. Nutritional deficiency—riboflavin,
niacin
• c. Iron deficiency anemia, pernicious
anemia
• d. Plummer-Vinson syndrome
• e. Sprue (malabsorption syndrome)
• f. Chronic alcoholism
• g. Endocrinal dysfunction—diabetes mellitus, chronic candidiasis
• h. Long-standing lichen planus, SMF, scleroderma,tertiary syphilis, SLE
• i. Long-standing xerostomia (drugs, radiotherapy, Sjögren’s syndrome)
B. Increased Coating on Tongue

• a. Black hairy tongue (true or pseudo)

• b. Altered oral physiology
• c. Chronic illness, liquid diet, stomatitis,
etc.
• d. Xerostomia
• e. Mouth breathing
• f. Constipation
• g. O2 liberating mouth washes
• h. Persistent vomiting of pyloric stenosis
C. Glossodynia

• Painful burning tongue

• a. With clinical observable changes
• Local—dental irritants
• • Food
• • Habits
• • Allergy
• Systemic—vit B complex deficiency
• • Anemia
• • Endocrinal disorders
• b. Without clinical changes—psychogenic
• d. Traumatic Injuries
• Falls, fight, epileptic attacks,
dental treatment
• (iatrogenic).
• e. Other Lesions
• a. Moeller’s glossitis
• b. Painful circumvallate and
foliate papilla
• c. Lingual varicosities—
senility, Sublingual
administration of drugs,
hypertension.
f. Atypical Lesions

• These lesions are not typical of the tongue and can also affect other
areas of the oral cavity.
• These are covered under relevant headings:
• a. Erythema multiforme
• b. Lichen planus
• c. Leukoplakia
• d. Carcinoma
• e. Haemangioma
Functions of the Tongue
• a. Prehension and ingestion of food and assists in mastication
• b. Swallowing, sucking
• c. Perception—taste, pain, temperature assessment, general
sensation
• d. Jaw development
• e. Respiration—hyoglossus and genioglossus
• f. Phonation
• g. Symbolic
Examination of Tongue

• Color of tongue is examined when tongue is

• lying passively in the floor of the mouth.
• Dark red in polycythemia and alcoholism and pale in anemia and SMF
• Patient is asked to protrude the tongue.
• If tremors are seen, it may be suggestive of
alcoholism or parkinsonism

• If tongue is deviated, it is suggestive of paralysis.

• If patient cannot protrude the tongue, SMF,

ankyloglossia or carcinoma may be suspected
Tongue Movement Variations
• Trefoil tongue: Ability to voluntarily deform tongue tip into clover leaf
pattern
• Unusual extensibility of tongue forward to touch the nose, backward
to touch the palate and pharynx—Gorlin’s sign which is positive in
Ehlers-Danlos syndrome.
• Tuberous sclerosis: Long and narrow tongue as a consequence of
hyperostosis and thickening of mandible.
• Reduced mobility due to scar formation secondary to blisters in
epidermolysis bullosa, healing of burn injury and SMF.
Specialized Examination Procedure
of Tongue
• CT scan
• Pulse Doppler ultrasound
• Real time ultrasound
• Isotopic (radionuclide) scanning techniques
• Electromyography
• MRI
• Direct microscope
• Electron microscope
Papilla and Taste Buds

• Fungiform Papillae
• Filiform Papillae
• Circumvallate Papillae (Lipoprotein lipase)
• Foliate Papillae

• 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
Aglossia
• (also known as “aglossia congenita”) means “absence of the
tongue” resulting from complete agenesis of the tongue
primordia
• Oromandibular limb hypogenesis syndrome (OLHS)

• The incidence of OLHS is very low (1/175,000 live births), and

most cases are actually hypoglossia rather than true aglossia
• a. Ankyloglossia:
Absent or shortened of lingual frenum

• Complications

• Treatment
• b. Bifid Tongue

• It is a rare anomaly due to failure of union of lateral halves of lingual

swelling. It is of no clinical significance
c. Macroglossia
• Macroglossia is feature of EMG
(exophthalmosmacroglossia- gigantism) syndrome
also known as Beckwith-Wiedeman syndrome
• 1. Cretinism
• 2. Mongolism
• 3. Amyloidosis
• 4. Hemangioma
• 5. Lymphangioma
• 6. Long-term edentulous area
• 7. In mature adults acromegaly and in adolescent
group dermoid–epidermoid cysts can cause
macroglossia.
In certain congenital disorders the tongue dorsum becomes
papillomatous or exhibits localised enlargements, described as cobble
stone, pebbled or lumpy

• Congenital lingual hemangiomas or lymphangiomas

• Neurofibromatosis
• Cowden’s syndrome
• Melkersson-Rosenthal syndrome
 d. Abnormally Fissured Tongue
• It normally goes un noticed unless patient gets
traumatized its described as scrotal, plicated or
cerebriform tongue.
• It may be associated with mild burning sensation.

• Factors which can contribute to increased prevalence of

fissured tongue with age include salivary hypofunction, vit
B deficiency, candidiasis and chronic lichenoid reactions.

Treatment
•?
Thyroglossal Duct Cyst
Changes in the Coating of the Tongue
• While depapillation of the tongue may be a result of metabolic
abnormality, there is no evidence that elongated filiform papillae and
the halitosis that often accompanies it is anything other than the
result of local environmental changes.
• The tongue coating is normally removed by salivary flow, mastication,
deglutition and speech. Any condition interfering with salivary flow,
mastication and deglutition will cause disturbance in tongue coating

• Black hairy tongue (lingua nigra)

• Pseudo Black Hairy Tongue

• Treatment
 BMG
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
prone to complain or verbalise discomfort”
• Allergic reaction
• BMG associated with increased frequency
of human leukocyte antigen (HLA) allele
B15
C.F
• Irregular lesions give a map-like appearance hence called geographic
tongue.
• Persistence of an everchanging painful (apparently) lesions on the
dorsum of tongue is frightening to the patient and he may develop
cancerophobia.
Differential Diagnosis—Median Rhomboid
Glossitis
Histologically
Treatment : Xylocaine, anti-histamine, Cortisone, keratinolytic
Depapillation of Tongue Caused
by Nutritional Deficiency and Anaemia
• Redness, loss of papillae and painful swelling of
tongue are characteristically found in deficiencies
of several B vitamins

• Niacin—pellagra (4D)
• Riboflavin
• Pyridoxine
• Folic acid and vit B12—pernicious anemia-G.C
• Similar changes are associated with iron
deficiency anaemia and malabsorption syndrome
• Various terms were used to describe—
atrophic glossitis, e.g. raw, beefy tongue,
magenta, bright red, hunters glossitis and in the
past the appearance was considered to be
specific for a particular vitamin deficiency.

• S.C
• Iron Deficiency Anemia

• Plummer-Vinson syndrome
Differential Diagnosis
Sjögren’s syndrome associated with ophthalmic
signs, rheumatoid arthritis, Hb may be normal.
(SJS more predisposed to lymphoma,
carcinoma more common in PV syndrome).
Pernicious Anemia
• In pernicious anaemia there is an autoantibody to the parietal cells/
intrinsic factor. It is also seen in connection with other autoimmune
disorders such as Graves’ disease and in patients with history of surgery of
fundus of stomach.

• Clinical Features
• 1. Patient complains of epigastric discomfort, diarrhea and constipation
• 2. Pallor, dyspnea and fatigue
• 3. Tingling, numbness and lack of coordination in movement of extremities,
i.e neurological symptoms (if present with anaemia)
Laboratory Findings
• RBCs show variation in size, macrocytic and normochromic
• Platelets are large
• WBCs are hypersegmented

Schillings test vs AB testings

Achlorhydria?
PERIPHERAL VASCULAR DISEASES

A. Decreased nutritional status of the lingual papillae in diabetes

mellitus could be due to:
• Vascular changes in the subpapillary dorsal capillary plexus or lingual
vessels supplying it.
• Chronic candidiasis and this could lead to atrophic glossitis.

b. Fibrosis of submucosal tissue secondary to obliteration of small

vessels suggestive of autoimmune process which is responsible for the
scarred shunken atrophic appearance of tongue in scleroderma, mixed
connective tissue diseases and in lupus erythematosus.
Tertiary Syphilis and Interstitial Glossitis
Non-ulcerating irregular indurations with an asymmetric pattern of
alternating grooves with leukoplakia and smooth (atrophic) fields
covering entire dorsum of the tongue. The tongue has been described as
upholstered tongue because of the scarring of the healed gummata.

Carcinoma of the dorsum of tongue associated with interstitial glossitis

is an exception to the general finding that carcinoma of the tongue is rare
on the dorsum.
Pigmentation of Tongue
1. Racial
2. Exogenous
• Microbial growth—pigment producingpathogens
• Food debris
• Candy dyes
• Beverages
• Mouth rinses
• Amalgam tattoo
3. Drugs: Doxorubicin hydrochloride
(cancer therapy)
• Alpha methyl dopa (antihypertensive)
• Nortryptyline (tricyclic antidepressant)
• Zidovudine (antiretroviral)
4. Endocrinal: Addison’s disease—primary
adrenal insufficiency
5. Peutz-Jeghers syndrome
6. Albright syndrome
7. Acanthosis nigricans
8. Neurofibromatosis
9. Hemochromatosis
Ulcerations of the tongue can result from
traumatic injuries, and infectious diseases:
1. Fine striated folds (fimbriae) and
Wharton’s duct opening on either sides
of lingual frenum is likely to be traumatized
during dental procedures because of aspiration
causing ulceration and ecchymosis.

2. Ulcers on tongue are seen in infectious

diseases and in riga fede disease in
neonates.
 Diseases Affecting Body of Tongue
1. Amyloidosis
2. Infections: Lingual abscess, Ludwig’s
angina, actinomycosis

Amyloidosis

a. Miscellaneous group of conditions in which

an amorphous material (amyloid) is deposited
extracellularly in a single organ
(localized) or many organs (systemic).
b. Nephrotic syndrome is the most common
clinical manifestation.
c. Macroglossia is the most common oral
manifestation.
Amyloidosis should be suspected in patients with tongue enlargement,
having a history of multiple myeloma, long standing tuberculosis,
rheumatoid arthritis, severe anemia.

Lingual abscess, Ludwig’s angina, actinomycosis

Neuromuscular Disorders
Neuromuscular disorders of central, peripheral or muscular origin
may produce
symptoms of dysphagia and choking and speech and masticatory
problems.
Dysphagia caused by the weakness of the tongue musculature is
referred to as oropharyngeal dysphagia and symptoms include:
• Aspiration while swallowing
• Nasal regurgitation
• Pain on swallowing
• Inability of the tongue to move the bolus of food into pharynx.
Other causes of dysphagia are SJS, PV syndrome, acute pharyngitis,
Vincent’s angina, glossitis, and retropharyngeal abscess
Dysarthria is the speech problem caused by the neuromuscular
disorders involving the tongue, in which defect is there in accurate
articulation and phrasing.

Dystonia refers to abnormally increased muscular tone results in fixed

abnormal posture

Dyskinesia: Repetitive uncontrolled muscular activity related to long-term

administration of phenothiazine, reserpine and other antipsychotic drugs.
Symptoms include:
• Rapid and repetitive movements of the tongue, jaw and lips
Myasthenia gravis is characterized by weakness
and easy fatiguability affecting facial,
oculomotor, laryngeal, pharyngeal, respiratory
muscles rather than lingual muscles
The term glossodynia is used to denote painful tongue and
glossopyrosis for burning sensation
of the tongue.

Glossodynia with observable clinical

changes –25% of cases
i. Local factors
• Traumatic lesions associated with sharp tooth, restorations, etc.
• Allergy to dentifrices, lipsticks, mouthwash
• Poor oral hygiene, candidiasis
• Painful red erosive lesions with inflamed papillae
Systemic factors
• Extensive generalised atrophy of lingual papillae and erosive
lesions— vit B complex deficiency
• Bald or depapillated tongue—iron deficiency anemia
• Reddish inflamed tongue—diabetes mellitus
• Depapillated tongue with dry shiny lobulated surface—
Sjögren’s syndrome
• Pernicious anemia tip and lateral borders bright and fiery red
Glossodynia without observable clinical changes –75% of
cases

1. Common in postmenopausal women

2. Patients also complain of disturbed taste, insomnia
3. Anxious and worried
4. Clinical examination fails to show any cause for
burning.
Lamey and Lewis in 1989 proposed the following
clinical classification for OD:
(a) type 1:
progressive pain throughout the day;
(b) type 2:
constant throughout the day; and
(c) type 3:
symptoms are intermittent and there are some
symptom-free days (Lamey and Lewis in 1989).
The essential feature of type 2 OD is a chronic
persistence of the oral pain without any circadian
fluctuation, probably due to psychogenic factors;

in type 1, burning symptoms show a typical daily

fluctuation with evening worsening, probably
due to systemic diseases, such as nutritional deficiencies,

while in type 3, burning symptoms are

intermittent, probably due to contact with oral allergens (Lopez-Jornet
et al. 2010).
Treatment plan
1- Patient Education

2- Oral Hygiene Optimization

(prevent xerostomia)
3- Alpha-lipoic Acid Supplementation

4- Neuropathic Treatments (Clonazepam )

1 mg tablets held intraorally near the sites of pain for 3 minutes
Without swallowing
Gabapentin may also be considered, starting at 300mg/ day,
with gradual titration up to 2400mg/day if necessary
 Traumatic Lesions

Unlike conventional traumatic ulcers, the traumatic granuloma

A traumatic ulcer occurs when injury to the oral mucosa results (traumatic ulcerative granuloma with stromal eosinophilia,
in a complete breach of the surface epithelium. Mechanical eosinophilic ulcer) is often slow to heal. It is characterized by a
injury is the most common cause, although chemical and exuberant inflammatory cell infiltrate that extends deeply into
thermal injuries also are possible the connective tissue and includes eosinophils
Other lesions caused by trauma
 Benign tumors

Granular Cell Tumor Papilloma

A slightly raised yellow nodule on the lateral border of the White papule with pointed surface projections on the anterio
tongue. dorsal tongue
Other benign tumors could be
found in the tongue
References
1- Color atlas of oral and maxillofacial diseases , Neville et al. 2019
2- Differential diagnosis of tongue lesions, Laskin et al.
Quintessence int 2003;34-331-342