Common Tongue Conditions in Primary Care - American Family Physician

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Mar 1, 2010 Issue

Common Tongue Conditions in PrimaryCare

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B"IA# &. "EAM'( C$)( *SAF( MC+ "IC%A"D DE"B'( )T C$)( *SAF( MC+ an,C%"IST$P%E" -. B*#T( CAPT( *SAF( MC( *ni or/e, Services *niversity o the %ealthSciences( Bethes,a( Marylan,

Am Fam Physician. 0121 Mar 2+324567809:8;ths

• Burning Tongue

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• Anato/ic Tongue A nor/alities

• "e erral

• "e erences

Although easily examined, abnormalities of the tongue an !resent a diagnosti andthera!euti dilemma for !hysi ians" Re ognition and diagnosis re#uire a thorough history,in luding onset and duration, ante edent sym!toms, and toba o and al ohol use"Examination of tongue mor!hology and a areful assessment for lym!hadeno!athy are alsoim!ortant" $eogra!hi tongue, fissured tongue, and hairy tongue are the most ommontongue !roblems and do not re#uire treatment" %edian rhomboid glossitis is usuallyasso iated &ith a andidal infe tion and res!onds to to!i al antifungals" Atro!hi glossitisis often lin'ed to an underlying nutritional defi ien y of iron, foli a id, (itamin ) *+,ribofla(in, or nia in and resol(es &ith orre tion of the underlying ondition" Oral hairyleu'o!la'ia, &hi h an be a mar'er for underlying immunodefi ien y, is aused by the

E!stein )arr (irus and is treated &ith oral anti(irals" Tongue gro&ths usually re#uirebio!sy to differentiate benign lesions -e"g", granular ell tumors, fibromas, lym!hoe!ithelialysts. from !remalignant leu'o!la'ia or s#uamous ell ar inoma" )urning mouth

syndrome often in(ol(es the tongue and has res!onded to treatment &ith al!ha li!oi a id,lona/e!am, and ogniti(e beha(ior thera!y in ontrolled trials" Se(eral trials ha(e alsoonfirmed the effe ti(eness of surgi al di(ision of tongue tie -an'yloglossia., in the ontext

of o!timi/ing the su ess of breastfeeding om!ared &ith edu ation alone" Tongue lesions of un lear etiology may re#uire bio!sy or referral to an oral and maxillofa ial surgeon, headand ne ' surgeon, or a dentist ex!erien ed in oral !athology"

"ecognition an, ,iagnosis o tongue a nor/alities re?uire e@a/ination o tongue /orphology

an, a thorough history( inclu,ing onset an, ,uration( antece,ent sy/pto/s( an, to acco an,alcohol use. A co/plete hea, an, nec e@a/ination( >ith care ul assess/ent orly/pha,enopathy( is essential.

0ie&1Print Table

SORT2 3E4 RECO%%EN5ATIONS 6OR PRACTICE

Clinical recommendation Evidencerating References

*lcerative lichen planus can e treate, >ith topicalsteroi,s( such as clo etasol4Te/ovate6 or luocinoni,e,ental paste.

B 09

So/e oral leu opla ias /ay eco/e /alignant+ there ore( iopsy an, /icroscopicanalysis shoul, e consi,ere,.

C ;2 ;;

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$nly alpha:lipoic aci,(clonazepa/ 4 lonopin6( an,cognitive ehavior therapyhave een sho>n to re,ucesy/pto/s o urning tongue.

B ithtongue:tie 4an yloglossia6>ho have reast ee,ing,i iculties.

B


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Me,ian rho/ oi, glossitis is characterize, y a s/ooth( shiny( erythe/atous( sharplycircu/scri e,( asy/pto/atic( pla?ue:li e lesion on the ,orsal /i,line o the tongue 4 Figure ) 6.Men are a ecte, three ti/es /ore o ten than >o/en. 0 Most persons >ith the con,ition areasy/pto/atic( ut urning or itching is possi le. ; Me,ian rho/ oi, glossitis is co//onlyassociate, >ith a can,i,al in ection an, respon,s to anti ungals 4e.g.( nystatin( luconazole

Di lucan ( clotri/azole6 ,elivere, as a suspension or oral troche.< 8

Candida can e con ir/e,>ith a scraping or culture. $ther sur aces o the /outh are characteristically spare,. %o>ever(the presence o palatal in la//ation /ay e in,icative o i//unosuppression( an, hu/ani//uno,e iciency virus 4%I&6 in ection shoul, e consi,ere,. 0

0ie&1Print 6igure

6igure *"Me,ian rho/ oi, glossitis. Can,i,al in ection can e con ir/e, y a scraping ro/ in la/e, area.

ATROP7IC $LOSSITISAtrophic glossitis is also no>n as s/ooth tongue ecause o the s/ooth( glossy appearance>ith a re, or pin ac groun,. The s/ooth ?uality is cause, y the atrophy o ili or/ papillae.Atrophic glossitis is pri/arily a /ani estation o un,erlying con,itions 4 %a!le * 2(8(96 an, >arrantsthorough ,iagnostic evaluation. #utritional ,e iciencies o iron( olic aci,( vita/in B 20(ri o lavin( an, niacin are co//on causes. 0(; (3( $ther etiologies inclu,e syste/ic in ection 4e.g.(syphilis6( localize, in ection 4e.g.( Candida 6( a/yloi,osis( celiac ,isease( protein:calorie/alnutrition( an, @erosto/ia triggere, y so/e /e,ications an, SGHgren syn,ro/e .0(3(21 20 Atrophic glossitis cause, y nutritional ,e iciency o ten causes a pain ul sensation in the tongue.

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Treat/ent inclu,es replace/ent o the /issing nutrient or treat/ent o the un,erlyingcon,ition. 22 2;

0ie&1Print Table

Ta le 0.Conditions Asso iated &ith $lossitis

A/yloi,osis

Celiac ,isease

Che/ical irritants

Drug reactions

)ocal in ections 4especially can,i,iasis6

#utritional ,e iciencies 4e.g.( iron( olic aci,( vita/in B 20( ri o lavin( niacin6

Pernicious ane/iaProtein:calorie /alnutrition

Sarcoi,osis

SGHgren syn,ro/e

Syste/ic in ections 4e.g.( syphilis6

&esiculoerosive ,iseases 4e.g.( pe/phigoi,( pe/phigus vulgaris( erythe/a /ulti or/e( Stevens:!ohnson syn,ro/e6

+n ormation rom re erences ) , , and .

6ISS8RE5 TON$8E-ith issure, tongue 4 Figure * 6( ,eep grooves can ,evelop ,ue to physiologic ,eepening onor/al tongue issures. These typically occur >ith aging an, re?uire no treat/ent( unlesstrapping o oo, an, acteria lea,s to in la//ation o the issures. 0 =entle rushing o thetongue is use ul in persons >ith sy/pto/atic in la//ation. Fissure, tongue has een associate,>ith Do>n syn,ro/e( acro/egaly( psoriasis( an, SGHgren syn,ro/e. 0(2< Mel ersson:"osenthalsyn,ro/e is a rare ,isor,er o unclear etiology that is characterize, y a tria, o severe issuring(relapsing oro acial e,e/a( an, acial nerve palsy. 25

0ie&1Print 6igure

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6igure +"Fissure, tongue. Fissures /ay trap oo, an, acteria( causing localize, in la//ation. Changes o geographic tongue are alsonote,.

$EO$RAP7IC TON$8E=eographic tongue 4 Figure 6( also no>n as enign /igratory glossitis or erythe/a /igrans(a ects 2 to 2< percent o the *.S. population an, is o un no>n etiology .2(0(28 Although previousresearch pointe, to associations >ith ,ia etes( psoriasis( se orrheic ,er/atitis( an, atopy( recentanalysis o population ,ata ro/ *.S. patients ,oes not support these in,ings. 0(2hite an, lac persons co/pare, >ith Me@ican A/ericans( an, ithas an association >ith issure, tongue an, an inverse association >ith cigarette s/o ing. 01

0ie&1Print 6igure

6igure 9"=eographic tongue. Sharply ,e ine, ,e/arcation o in la//ation is characteristic.

-ith geographic tongue( the ,orsal tongue ,evelops areas o papillary atrophy that appears/ooth an, are surroun,e, y raise, serpiginous or,ers. These regions o atrophyspontaneously resolve an, /igrate( giving the tongue a variegate, appearance. The con,ition is

enign an, localize,( generally re?uiring no treat/ent e@cept reassurance. So/e patients /ayhave sensitivity to hot or spicy oo,s. 28(02 Topical steroi, gels 4e.g.( tria/cinolone ,ental paste

$ralone 6 an, antihista/ine /outh rinses 4e.g.( ,iphenhy,ra/ine eli@ir Banophen ( 20.5 /g per 5 /) ,ilute, in a 27< ratio >ith >ater6 can re,uce tongue sensitivity.


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Accu/ulation o e@cess eratin on the ili or/ papillae o the ,orsal tongue lea,s to theor/ation o elongate, stran,s that rese/ le hair. The color o the tongue can range ro/ >hite

or tan to lac . Dar er coloration results ro/ the trapping o ,e ris an, acteria in the elongate,stran,s 4 Figure / 6. This occurs /ost co//only in s/o ers an, in persons >ith poor oralhygiene. ; (0; (0< %airy tongue has een associate, >ith use o certain anti iotic /e,ications. 0ith a tongue scraper or so t tooth rush can re/ove eratinize,tissue. 0(0<

0ie&1Print 6igure

6igure :"%airy tongue. The ,ar coloration is cause, y the trapping o ,e ris an, acteria( >hich is >orsene, y s/o ing an, poor oralhygiene.

ORAL 7AIR4 LE83OPLA3IA$ral hairy leu opla ia 4 Figure 0 6 ,i ers ro/ hairy tongue in its location an, association >ithi//unosuppression. The con,ition is characterize, y >hite( hairy appearing lesions localize, tothe lateral /argins o the tongue( in a unilateral or ilateral ashion. It is cause, y Epstein:Barrvirus in ection. 0(08 I oral hairy leu opla ia occurs in the a sence o a no>ni//unoco/pro/ising con,ition( %I& testing shoul, e consi,ere,. Antiviral /e,ications suchas acyclovir 4 ovira@+ 311 /g ive ti/es per ,ay6 or ganciclovir 4211 /g three ti/es per ,ay6 or one to three >ee s /ay e use,( although recurrence is co//on. 0(08

0ie&1Print 6igure

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6igure ;"$ral hairy leu opla ia. The lateral tongue location ,i erentiates this con,ition ro/ hairy tongue. Biopsy is nee,e, i s?ua/ouscell carcino/a is suspecte,.

LIC7EN PLAN8S)ichen planus is an i//unologic con,ition that a ects s in or /ucosal sur aces( such as the/outh an, tongue 4 Figure 6. T>o /ani estations o lichen planus have een ,escri e,7 areticular( >hite( lacy pattern that a ects the uccal /ucosa o the tongue an, an erosive or/ thatappears as shallo> ulcerations. Candida can coe@ist >ith lichen planus an, re?uires treat/ent>ith an anti ungal agent. "eticular lichen planus ,oes not re?uire treat/ent. *lcerative lichen

planus can e treate, >ith topical steroi,s( such as luocinoni,e ,ental paste or clo etasol gel4Te/ovate6 applie, t>ice per ,ay or t>o to three >ee s. 09 Biopsy is in,icate, i the ,iagnosis isunclear.

0ie&1Print 6igure

6igure


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S>8A%O8S CELL CARCINO%A"is actors or s?ua/ous cell carcino/a inclu,e ol,er age( to acco use( an, alcohol use. ;< Intraoral s?ua/ous cell carcino/a co//only involves the lateral sur ace o the tongue 4 Figure16. Patients younger than ho ,evelop intraoral s?ua/ous cell carcino/a o ten ,o nothave ris actors. ;< (;5 Initially( lesions appear as a slight thic ening over a re, or >hite ase. This

/ay lea, to no,ularity or ulceration( causing pain an, ,isco/ ort. Biopsy is critical to con ir/the ,iagnosis an, allo> or pro/pt treat/ent e ore e@tensive local invasion occurs. Treat/enttypically re?uires surgery an, ra,iation therapy .;8

0ie&1Print 6igure

6igure ?"S?ua/ous cell carcino/a. The lac o an erythe/atous halo an, its rough sur ace help ,i erentiate this con,ition ro/ an

aphthous ulcer.LIN$8AL T74ROI5 NO58LEAl/ost 1 percent o ectopic thyroi, tissue is associate, >ith the ,orsu/ o the tongue. Ittypically appears as a s/ooth no,ular /ass o tissue locate, in the /i,line o the posterior ,orsalsur ace o the tongue. ;9 The presence o a lingual thyroi, re lects the lac o ,escent o thyroi,tissue ,uring ,evelop/ent. *p to 91 percent o patients >ith a lingual thyroi, havehypothyroi,is/. ;3 So/e patients have a sensation o a lu/p or ,i iculty s>allo>ing. Sy/pto/sare /ore co//on ,uring increase, /eta olic ,e/an,( such as in a,olescence or pregnancy. ; Ihypothyroi,is/ is present( thyroi, replace/ent can ,ecrease the size o the lingual thyroi, an,i/prove o structive sy/pto/s. Surgical e@cision is o ten a,vise, or patients >ith a lingualthyroi, an, nor/al thyroi, unction+ ho>ever( this /ay lea, to a nee, or postoperative thyroi,

replace/ent ecause the lingual thyroi, is usually the only unctioning thyroi, tissue in these patients. ;3

L4%P7OEPIT7ELIAL C4STS)y/phoepithelial cysts are yello>ish no,ules locate, on the ventral sur ace o the tongue(tonsillar region( or loor o the /outh. They are enign an, thought to arise ro/ the entrap/ento salivary epitheliu/ in ly/phoi, aggregates ,uring e/ ryogenesis.


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PAPILLO%AS?ua/ous papillo/a is one o the /ore co//on oral lesions( occurring in up to 2 percent oa,ults. It is generally associate, >ith hu/an papillo/avirus type 8 or 22 in ection. ith inger:li e proGections. Treat/entinvolves surgical e@cision or laser a lation.

)urning TongueJump to section A urning sensation o the tongue can represent a pri/ary syn,ro/e( or it can e secon,ary to acon,ition that lea,s to the ,enu,ation o the nor/al tongue sur ace 4e.g.( can,i,al in ection(vita/in ,e iciency6. Burning tongue has an un no>n etiology an, see/s to a ect >o/en seventi/es /ore o ten than /en. ith Do>n syn,ro/e( hypothyroi,is/(tu erculosis( sarcoi,osis( a/yloi,osis( /ultiple /yelo/a( neuro i ro/atosis( in ection 4e.g.(syphilis6( an, angioe,e/a or allergic reaction. 0(< It is i/portant to consi,er /acroglossia as asign o an un,erlying ,isor,er an, procee, >ith ocuse, ,iagnostic testing( inclu,ing possi le

iopsy. Treat/ent shoul, e ,irecte, at the un,erlying ,isor,er.

ReferralJump to section Patients >ith a tongue lesion o unclear etiology can e re erre, to an oral an, /a@illo acialsurgeon( hea, an, nec surgeon( or a ,entist e@perience, in oral pathology.

http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b41http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b41http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b43http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b44http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b44http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b45http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b44http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b46http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b46http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b7http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b7http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b47http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b47http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b48http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b2http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b2http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b2http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b49http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b41http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b43http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b44http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b45http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b44http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b42http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b46http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b7http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b47http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b48http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b2http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b2http://www.aafp.org/afp/2010/0301/p627.html#afp20100301p627-b49


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The Authorssho> all author in oB"IA# &. "EAM'( C$)( *SAF( MC( is a pro essor in an, chair o the Depart/ent o Fa/ily

Me,icine at the *ni or/e, Services *niversity o the %ealth Sciences( Bethes,a( M,....

Figures * through 1 provi,e, y Craig B. Fo>ler( DDS.

RE6ERENCESsho> all re erences2. Shul/an !D( Beach MM( "ivera:%i,algo F. The prevalence o oral /ucosal lesions in *.S.a,ults7 ,ata ro/ the Thir, #ational %ealth an, #utrition E@a/ination Survey( 2 33 2


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/aterial an, /ay use that printout only or his or her personal( non:co//ercial re erence. This/aterial /ay not other>ise e ,o>nloa,e,( copie,( printe,( store,( trans/itte, or repro,uce, inany /e,iu/( >hether no> no>n or later invente,( e@cept as authorize, in >riting y the AAFP.Contact a pservKaa p.org or copyright ?uestions an,Lor per/ission re?uests.

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*lcerative lichen planus can e treate, >ith topical

steroi,s( such as clo etasol4Te/ovate6 or luocinoni,e,ental paste.

B 09

So/e oral leu opla ias /ay eco/e /alignant+there ore( iopsy an,/icroscopic analysis shoul,

e consi,ere,.

C ;2 ;;

$nly alpha:lipoic aci,(clonazepa/ 4 lonopin6( an,cognitive ehavior therapyhave een sho>n to re,ucesy/pto/s o urningtongue.

B ithtongue:tie 4an yloglossia6>ho have reast ee,ing,i iculties.

B


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Me,ian rho/ oi, glossitis. Can,i,al in ection can e con ir/e, y a scraping ro/ in la/e,area.

Ta le 0.Conditions Asso iated &ith $lossitis

A/yloi,osis

Celiac ,isease

Che/ical irritants

Drug reactions

)ocal in ections 4especially can,i,iasis6

#utritional ,e iciencies 4e.g.( iron( olic aci,( vita/in B 20( ri o lavin( niacin6

Pernicious ane/ia

Protein:calorie /alnutrition

Sarcoi,osis

SGHgren syn,ro/e

Syste/ic in ections 4e.g.( syphilis6

&esiculoerosive ,iseases 4e.g.( pe/phigoi,( pe/phigus vulgaris( erythe/a /ulti or/e(Stevens:!ohnson syn,ro/e6

+n ormation rom re erences ) , , and .

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6igure +"

Fissure, tongue. Fissures /ay trap oo, an, acteria( causing localize, in la//ation. Changeso geographic tongue are also note,.

6igure 9"

=eographic tongue. Sharply ,e ine, ,e/arcation o in la//ation is characteristic.

6igure :"


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%airy tongue. The ,ar coloration is cause, y the trapping o ,e ris an, acteria( >hich is>orsene, y s/o ing an, poor oral hygiene.

6igure ;"

$ral hairy leu opla ia. The lateral tongue location ,i erentiates this con,ition ro/ hairytongue. Biopsy is nee,e, i s?ua/ous cell carcino/a is suspecte,.

6igure


55/55

6igure ="

Trau/atic i ro/a. Biopsy is necessary to ,i erentiate ro/ other neoplas/s.

6igure ?"

S?ua/ous cell carcino/a. The lac o an erythe/atous halo an, its rough sur ace help,i erentiate this con,ition ro/ an aphthous ulcer.