Continuing Education Activity

Glossitis refers to inflammation of the tongue and has numerous potential etiologies. While most causes are benign or idiopathic, glossitis can be the presenting symptom of more serious systemic conditions.

Objectives:

• Review the potential etiologies for glossitis.
• Outline the best current practice in the management of each type of glossitis.
• Summarize the risk factors associated with glossitis.
• Summarize the importance of an interprofessional team in the management of glossitis.

Introduction

The tongue is readily visible to patients who may present for assessment of a variety of incidentally noted disorders or may present as a referral from the dentist. The examination of the tongue and oral mucosa is a crucial part of the complete physical exam, and numerous systemic medical conditions can have oral manifestations or symptoms. Glossitis is an overarching term denoting inflammation of the tongue. The condition may present clinically as a painful tongue, as a change in the surface appearance of the tongue (changes in texture and or color), or both.[1] 

Anatomy       

The tongue is a muscular organ in the oral cavity, which is essential for normal swallowing and speech.[2] Embryologically, the tongue derives from a medial triangular elevation on top of the mandibular arch called the median lingual swelling.[3] It is comprised of skeletal muscle. Motor innervation is via the hypoglossal nerve (except for the palatoglossus muscle, which is supplied by the vagus nerve), while sensory innervation of the anterior two-thirds of the tongue receives innervation from two nerves: the lingual nerve supplying general sensation and the chorda tympani, which provides taste sensation—the posterior one-third of the tongue receives innervation via the accessory nerve.

The median sulcus divides the tongue centrally, beginning at the apex of the tongue tip and extending to the foramen cecum, which creates the apex of a V-shaped groove, which is called the sulcus terminalis. The papillae are tiny protuberances on the dorsal tongue, especially on the anterior two-thirds, classified into three types. The first group called filiform papillae, which are the most common papillae uniformly distributed on the dorsum. They are thin papillae 1- to 2-mm without taste buds. The second type of papillae is called pointed filiform papillae, which morphologically give a rugged texture and promote the mechanical function of licking and chewing.

The fungiform papillae are the third type distributed mostly on the dorsum of the anterior tongue. They are recognized clinically by their dome shape and red color. The posterior tongue contains lymphoid tissue (the lingual tonsils). The ventral tongue contains the lingual veins and the lingual frenulum, attaching the ventral tongue to the anterior floor of the mouth. The submandibular (Wharton's) ducts course parallels to the lingual frenulum along the anterior floor of the mouth.[1]

Etiology

There are numerous potential etiologies for glossitis. These include:

1-Anemia:

• Iron-deficiency anemia
• Pernicious anemia[4]

2-Vitamin B deficiencies:

• Vitamin B1
• Vitamin B2
• Vitamin B3
• Vitamin B6
• Vitamin B9
• Vitamin B12[5]

3-Infections:

• Viral: herpes viruses, as well as post-herpetic glossitis
• Bacterial: rare in immunocompetent patients[6] 
• Fungal: most commonly Candida species[7]
• Parasite: malaria, spirochetes [8][9]

4-Medications:

• ACE inhibitors
• Albuterol 
• Organosulfur antimicrobial drugs such as (sulphanilamide, sulphathiazole)[10]
• Oral contraceptive pills[11]
• Lithium carbonate[11]

5-Others:

• Psychological factors (conversion disorders, anxiety)
• Exposure to irritants, for example, alcohol, spicy food, and tobacco.
• Normal familial variants (fissured tongue, geographic tongue)
• Mechanical irritation (burns, chronic dental trauma)
• Poor hydration
• Down syndrome
• Psoriasis and other autoimmune conditions
• Burning mouth syndrome

Epidemiology

Precise epidemiological statistics are lacking, largely owing to the diverse nature of potential causes of glossitis. Various vitamin deficiencies are endemic in some regions of the world and may fluctuate with the overall nutritional status of the population. Glossitis caused by a vitamin deficiency or infection will often resolve with treatment of the underlying condition. Infectious glossitis will likewise resolve with the eradication of the causative organism. Medication-induced glossitis will typically resolve with discontinuation of the offending agent.

Per to the Third National Health and Nutrition Examination Survey III (NHANES III) that performed oral mucosal examinations on 17,235 adults 27.9 % of them had a total of 6,003 clinically oral lesions, 14.2% of the mucosal lesions were on the dorsum of the tongue, while 1.3% only on the lateral border of the tongue. Overall, the prevalence ranges of geographic tongue (benign migratory glossitis) were 1.41 to 2.29%, and 0.46 to 0.30% for median rhomboid glossitis.[12]

Pathophysiology

The precise pathogenesis of geographic tongue is poorly understood. Stress is a well-documented exacerbating factor, and patients may report worsening of symptoms with exposure to particular foods (acidic and spicy foods, classically).[13]

History and Physical

History

When evaluating a patient with glossitis, a thorough history is an absolute necessity. Specifics include an overall nutritional status and any dietary restrictions, tobacco, and alcohol use, and any fluctuation of symptoms with food or environmental exposure. A thorough past medical history should include concurrent immunosuppressive conditions, cancer history, as well as any autoimmune or endocrine conditions.

The patient's daily medications should also have a review, and any medication changes should undergo evaluation concerning changes in the patient's glossitis symptoms. The most common symptoms of glossitis include pain in the tongue, redness, swelling of the tongue, loss of papillae of the tongue, or any new visible tongue lesions. The clinician should also obtain a family history of geographic tongue.

Physical Exam

The examination of the tongue is an essential part of the physical examination and is a component of the overall oral cavity examination. The examiner should note the appearance of the tongue surface (dorsal and ventral), as well as the character of the mucosa (wet, dry, erythematous, leukoplakia, etc.). Any lesions visible on the tongue should be noted, as well as the overall dental health. Chronic friction from jagged teeth can lead to mucosal changes and even ulcerations of the tongue that the examiner must distinguish from primary tongue pathology. The language and floor of mouth should be palpated to assess for tenderness or palpable lesions. A thorough head and neck exam are also necessary to note any lymphadenopathy.

Atrophic glossitis [14]:

• Erythematous tongue
• Lack of the lingual papillae and a smooth, shiny, dry appearance
• Atrophic tongue

Median rhomboid glossitis:

• Central rhomboid-shaped hyperkeratotic areas. These classically appear as erythematous plaque-like lesions and may be tender to palpation. Classically present in the central dorsum of the mobile tongue.  

Benign migratory glossitis: 

• Areas of smooth tongue with loss of papillae that may have a surrounding white border; these may change position (migrate) over time and may be sensitive to touch or specific foods.
• Must be differentiated from a stable leukoplakic or erythroleukoplakic lesion which is more worrisome for malignancy

 Geometric glossitis: 

• Painful linear fissures throughout the mobile tongue

 Strawberry tongue [15]:

•   Red denuded appearance on the dorsal of the tongue.
•   Persistent hypertrophic fungiform papillae.

Evaluation

The history and physical examination are the most important evaluations in a patient with glossitis. Additional studies may be required depending upon the suspected etiology of the glossitis.

Biopsy

• May be helpful to diagnose bullous disease (pemphigus vulgaris, bullous pemphigoid)
• Indicated for any stable or worrisome lesion to rule out malignancy[1]

Laboratory Studies

• Vitamin levels can be obtained if primary deficiency is suspected or in endemic/high-risk areas.
• Rheumatologic studies (rheumatoid factor, anti-ro, anti-la, erythrocyte sedimentation rate, c-reactive protein, others) may be indicated if autoimmune conditions such as scleroderma are suspected.
• Complete blood count and HIV testing are necessary if immunosuppression is suspected or in the setting of opportunistic infections.
• Endocrine studies such as hemoglobin A1c and thyroid function tests may be helpful if diabetes or thyroid disease is suspected.

Imaging

• Routine imaging is not required.
• Suspected or known malignancy should receive imaging with computed tomography of the neck with IV contrast.

Treatment / Management

Most causes of glossitis are self-limiting and require no treatment. Symptomatic relief is possible with good oral hygiene and mouth rinses (various formulations of "magic mouthwash" contain corticosteroids and lidocaine that can soothe acute exacerbations of migratory glossitis). Some additional specific treatments include:

Atrophic glossitis:

• Intramuscular injections of vitamin B12.

Median rhomboid glossitis:

• Antifungals only if symptomatic (nystatin swish and swallow)

Benign migratory glossitis:

• Reassurance only, with mouth rinses, as described above, for acute exacerbations.

Geometric glossitis:

• Reassurance. Acute episodes have been treated with antivirals with limited success.

Strawberry tongue:

• Vitamin B12 supplementation

Medication-induced:

• Discontinue offending medication

Infectious:

• Treat acute or chronic infection.
• Immunology workup for any opportunistic infections and control of diabetes

Differential Diagnosis

The differential diagnosis for glossitis is extremely broad, and can be slightly narrowed down according to the physical exam findings:

Normal-appearing tongue:

• Burning mouth syndrome
• Diabetic neuropathy
• Post-herpetic glossitis
• Acid reflux

Atrophic glossitis:

• Protein-calorie malnutrition
• Vitamin B12 deficiency
• Bullous disease
• Candidiasis
• Xerostomia[16]

Median rhomboid glossitis:

• Haemangioma
• Geographic tongue
• Amyloidosis
• Candidiasis
• Squamous cell carcinoma[17]

Strawberry tongue:

• Yellow fever
• Kawasaki disease
• Toxic shock syndrome[15]

Geographic Tongue:

• Oral lichen planus
• Chemical or inhalational irritant (smoking)
• Dehydration
• Candidiasis
• Connective tissue disease
• Bullous disease
• Leukoplakia[18]

Prognosis

The overall prognosis depends on the cause of the glossitis. While generally a benign condition, it can be chronic or lifelong with periodic flare-ups (i.e., geographic tongue). Some patients are extremely sensitive to and bothered by the visual appearance and/or physical symptoms. Anxiolytics can be employed. Many causes of glossitis are reversible with treatment of the underlying condition. If there is any question of malignancy, the area should be promptly biopsied not to delay treatment.

Complications

The most common complication is anxiety due to the appearance of the tongue, and reassurance can be challenging. In this situation, a biopsy to further reassure the patient and provider that there is no underlying malignancy may be prudent.

Deterrence and Patient Education

Glossitis is often a benign condition of the dorsum of the tongue and does not require treatment beyond the education of the patient. Symptomatic treatment is possible with anti-inflammatory and pain-relieving mouth rinses. Any chronic or unchanging tongue or mouth lesion should have a biopsy to rule out malignancy. Good overall oral hygiene may minimize symptoms.[1]

Enhancing Healthcare Team Outcomes

An interprofessional team approach to diagnose and treat glossitis can help achieve the best possible patient outcomes. Physicians, nurses, dentists, oncologists, and pathologists can all play a role in determining the etiology of glossitis.