1. Fordyce’s Granules 2. Leukoedema 3. Microglossia 4. Macroglossia 5. Ankyloglossia 6. Lingual Thyroid 7. Hairy Tongue 8.

Fissured Tongue

DEFINITION:
A Fordyce granule is a developmental anomaly characterized by heterotrophic collection of sebaceous glands at various sites in the oral cavity which is covered with intact mucosa.

Yellow papules on the vermilion of the upper lip

PATHOGENESIS:
The occurrence of sebaceous glands in the mouth may result from the inclusion in the oral cavity of ectoderm having some of the potentialities in the course of the development of the maxillary and mandibular processes during embryonic life.

CLINICAL FEATURES:
 Appearance : appears as a multiple yellow or yellowish – white papular lesions.  Common site : on the buccal mucosa and lateral portion of the vermilion of the upper lip.
Occasionally – retromolar area and anterior tonsillar pillar.

 Age : adults > children Sex : Male> Female

 Non ulcerated smooth surface with sharply delineated.  Consistency : slightly cheesy consistency.  Increases rapidly in number at puberty as a result of hormonal factor.

HISTOPATHOLOGIAL FEATURES :  Consists of submucosal clusters of sebaceous acini which are communicating with the oral epithelium through a central duct.  Aciner tubules – polygonal sebaceous cells with centrally located nuclei and abundant foamy cytoplasm.  Fordyce’s granules are similar to normal sebaceous glands in the skin except for the absence of hair follicles.
Multiple sebaceous glands below the surface epithelium

TREATMENT:
 No treatment  If it causes disfigurement – surgical removal can be done.

DEFINITION:
It is a common oral mucosal condition which clinically resembles early leukoplakia.

ETIOLOGY:
 Use of tobacco  Racial  Poor oral hygiene

White, wrinkled appearance of the buccal mucosa

CLINICAL FEATURES:  Age : 15-35 years.  Sex : Male>Female -2:1  Most common site – buccal mucosa and lip  Bilateral lesions  Appearance : diffuse, grayish-white, milky, opalescent appearance of the mucosa. Mucosa retains the normal softness and flexibility with folded surface appearance resulting in wrinkles or whitish streaks.  It can be easily diagnosed clinically because the white appearance greatly diminishes when the cheek is everted and stretched and re-establishes itself almost immediately.

diffuse white appearance of the buccal mucosa

Whiteness disappears when the cheek is stretched

HISTOPATHOLOGICAL FEATURES:  Frequently parakeratinized epithelium  Increased in thickness of epithelium ; Broad, elongated rete pegs and Intracellular edema of spinous layer.  Large vacuolated Cells at the surface are flattened and may retain pyknotic nuclei that contain glycogen.

Parakeratosis and intracellular edema of the spinous layer

DIFFERENTIAL DIAGNOSIS:

Leukoplakia

Cheek biting lesion

White sponge nevus

Hereditary benign intraepithelial dyskeratosis

MANAGEMENT:  No treatment

DEFINITION: AGLOSSIA: It is the complete absence of the tongue at birth. MICROGLOSSIA : it is the presence of abnormally small rudimentary tongue.

CAUSES  Usually occurs in syndromes such as (1) Hypoglossiahypodactylia syndrome (2) Pierre robin syndrome.  Also associated with cleft lip, cleft palate, intraoral bands, situs inversus.

CLINICAL FEATURES:  Difficulty in eating and speaking  high arched palate and a narrow constricted mandible  frequently associated with hypoplasia of the mandible and lower incisors may be missing.  May be an airway obstruction, due to negative pressure generated by deglutition and inspiration.

Abnormally small tongue associated with constricted mandibular arch.

MANAGEMENT : Depends on the nature and severity of the condition  Surgery and orthodontics – may improve oral function  Non surgical techniques such as positioning, naso-gastric intubation and temporary endotracheal intubation-to prevent airway obstruction.

DEFINITION: It is an uncommon condition characterized by enlargement of the tongue.

CLASSIFICATION
Congenital Acquired Relative macroglossia Apperent macroglossia

Hypertrophic

Inflammatory

Neoplastic

ETIOLOGY
Neoplastic Traumatic tuberculosis Muscular hypertrophy Metabolic

Inflammatory Congenital

hemangioma lymphangioma

dental irritation hematoma post operative edema

myxodema amyloidosis

actinomycosis

lingual thyroid

syphilitic gumma Ranula

acromegaly

CLINICAL FEATURES:  Commonly occurs in children  Symptoms: noisy breathing, drooling, difficulty in eating, swallowing difficulties, lisping speech, airway obstruction.  Signs - crenation or scalloping of the lateral borders of the tongue - malocclusion : open bite - mandibular prognathism.  If the tongue constantly protrudes from the mouth, it may ulcerate and become secondarily infected or necrosis.  Syndromes associated – beckwith’s hypoglycemic syndrome - fetal visceromegaly - postnatal somatic gigantism

Large tongue in a patient with Down syndrome

MANAGEMENT :  Depends on the cause and severity of the condition - in symptomatic patients : reduction glossectomy. - if speech is affected : speech therapy - for dental arch deformity: orthodontic treatment

DEFINITION: It is a developmental anomaly of the tongue characterized by a short, thick lingual frenum, resulting in limitation of the tongue movement. TYPES: 1. complete : fusion of tongue and the floor of mouth 2. partial : short lingual frenum.

CLINICAL FEATURES : Symptoms :  limitation of the tongue movement  recurrent tongue biting, poor sucking and inability to food chewing.  Speech abnormalities like lisping and inability to pronounce certain sounds and words viz t, d, n, i, as, ta, te, time etc.  In extreme cases : nursing and feeding problems can occur.

Abnormal attachment of the lingual frenum, limiting tongue mobility

Signs :  ‘V’ shaped notch at the tip of the tongue  short or anteriorly placed lingual frenum  midline mandibular diestema  Inability to clean the teeth Syndromes associated :  Ankyloglossum superious syndrome  Rainbow’ syndrome  Fraser’s syndrome  Orofacial digital syndrome MANAGEMENT : Frenectomy

DEFINITION : The lingual thyroid is an anomalous condition in which follicles of thyroid tissue are found between the foramen caecum and epiglottis or in the substance of the tongue, possibly arising from a thyroid anlage that failed to migrate to its predestinated position. ETIOLOGY :

 Failure of the primitive thyroid anlage to descend.

CLINICAL FEATURES :

 Age : birth to 6th decade  Sex : Female > Male - Occurs during puberty, adolescence, pregnancy or menopause.  Appearance : appears as a small asymptomatic remnants of thyroid tissue on the posterior dorsal tongue.  Common clinical symptoms - dysphagia - dysphonia - dyspnea - haemorrhage with pain or feeling of tightness

Nodular mass of the posterior dorsal midline of the tongue

HISTOLOGICAL FEATURES :

 resemble either normal or an embryonal type of thyroid tissue.  characteristically has an incomplete or poorly defined capsules.

DIAGNOSIS :

 thyroid scan using iodine isotopes or technetium 99m.  computed tomography scan.  magnetic resonance imaging.
MANAGEMENT :

 thyroxin – to reduce the size of the swelling.  if it causing difficulty to patient – excision or ablation with radioiodine – 131.

DEFINITION : Hairy tongue is characterized by marked accumulation of keratin on the filiform papillae of the dorsal tongue, resulting in a hairlike appearance. ETIOLOGY :  heavy smoking

 oral use of certain drugs – sodium perborate - sodium peroxide - antibiotics 1. penicillin 2. auremycin

 poor oral hygiene.  general debilitation.  extensive x-ray radiation therapy.  over growth of fungal organisms like candida albicans and systemic disturbances i.e. anaemia, gastric upset.  use of oxidizing mouthwashes or antacids.  delayed shadding of the horny layer of the filiform papillae
CLINICAL FEATURE :

 lesion involves the dorsum, particularly the midline of the middle and posterior 1/3 . sparing the lateral and anterior borders.  Elongated papillae are usually yellowish-white to brown or black depending upon the growth of pigment producing bacteria or staining from tobacco and food.

 Asymptomatic condition, occasionally gagging sensation or bad taste in the mouth.  Hypertrophy of filiform papillae, the papillae may reach a length of 2cm..

Elongated, black-staining filiform papillae on the posterior dorsal tongue

Marked elongation and brown staining of the filiform papillae, resulting in a hairlike appearance

HISTOPATHOLOGICAL FEATURES :

 Marked elongation and hyperkeratosis of the filiform papillae.  External colonization of the papillae by basophilic microbial colonies.

Elongation and marked hyperkeratosis of the filiform papillae, with bacterial accumulation on the surface

TREATMENT :

 Predisposing factors such as tobacco, antibiotics or mouthwashes should be eliminated.  Excellent oral hygiene should be encouraged.  Desquamation of the hyperkeratotic papillae-by periodic scraping or brushing with a toothbrush or tongue scraper twice daily for 2 min.  Application of topical keratolytic agents such as podophyllin or other lactobacillus acidophilus cultures.

DEFINITION : Fissured tongue is relatively common condition characterized by presence of numerous grooves, or fissures on the dorsal tongue surface. TYPES : 1. foliaceus 2. cerebriform 3. plicated

ETIOLOGY :

 Genetically determined  Mentally retarded and psychotic individuals  Extrinsic factors like chronic trauma or vitamin deficiency.
CLINICAL FEATURES :

 Multiple grooves or furrows on the surface of the tongue ranging from 2-6 mm in depth, often radiating out from the central groove along the midline of the tongue.  Usually, asymptomatic. Occasionally mild burning or soreness due to irritation. - Prevalence and severity increases with age. - Associated with Melkersson Rosenthal syndrome

Extensive fissuring involving the entire dorsal tongue surface

Moderate fissuring of the dorsal tongue

HISTOPATHOLOGICAL FEATURES :

 Hyperplasia of the rete pags.  Loss of the keratin “hairs” on the surface of the filiform papillae.  Polymorphonuclear leucocytes seen migrating into the epithelium, often forming microabscesses in the upper epithelial cells.  A mixed inflammatory cells present in the lamina propria.

TREATMENT :

 Clean the debris with brush to tongue.

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