Glossitis

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Glossitis [1]
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Glossitis in a person with scarlet fever ("red strawberry tongue").
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Glossitis can mean soreness of the tongue, or more usually inflammation with depapillation of the dorsal surface of the tongue (loss of the lingual papillae), leaving a smooth and erythematous (reddened) surface, [2] [3] (sometimes specifically termed atrophic glossitis). In a wider sense, glossitis can mean inflammation of the tongue generally. [4] Glossitis is often caused by nutritional deficiencies and may be painless or cause discomfort. Glossitis usually responds well to treatment if the cause is identified and corrected. Tongue soreness caused by glossitis is differentiated from burning mouth syndrome, where there is no identifiable change in the appearance of the tongue, and there are no identifiable causes. [5]

Contents

Symptoms

Patchy depapillation of filiform papillae with prominence of the fungiform papillae. Glossite.jpg
Patchy depapillation of filiform papillae with prominence of the fungiform papillae.

Depending upon what exact meaning of the word glossitis is implied, signs and symptoms might include:

Depending upon the underlying cause, there may be additional signs and symptoms such as pallor, oral ulceration and angular cheilitis. [2]

Causes

Anemias

Iron-deficiency anemia is mainly caused by blood loss, such as may occur during menses or gastrointestinal hemorrhage. This often results in a depapilled, atrophic glossitis, giving the tongue a bald and shiny appearance, along with pallor (paleness) of the lips and other mucous membranes a tendency towards recurrent oral ulceration, [6] and cheilosis (swelling of the lips). [7] The appearance of the tongue in iron deficiency anemia has been described as diffuse or patchy atrophy with tenderness or burning. [8] One cause of iron deficiency anemia is sideropenic dysphagia (Plummer–Vinson or Paterson–Brown–Kelly syndrome) which is also characterized by esophageal webbing and dysphagia. [6]

Pernicious anemia is usually caused by autoimmune destruction of gastric parietal cells. Parietal cells secrete intrinsic factor which is required for the absorption of vitamin B12. Vitamin B12 deficiency results in megaloblastic anemia and may present as glossitis. The appearance of the tongue in vitamin B12 deficiency is described as "beefy" or "fiery red and sore". [6] There may be linear or patchy red lesions. [2]

Vitamin B deficiencies

Vitamin B1 deficiency (thiamine deficiency) can cause glossitis. [7] Vitamin B2 deficiency (ariboflavinosis) can cause glossitis, along with angular cheilitis, cheilosis, peripheral neuropathy and other signs and symptoms. [7] The glossitis in vitamin B2 deficiency is described as magenta. [9] Vitamin B3 deficiency (pellagra) can cause glossitis. [7] Vitamin B6 deficiency (pyridoxine deficiency) can cause glossitis, along with angular cheilitis, cheilosis, peripheral neuropathy and seborrheic dermatitis. [7] Folate deficiency (vitamin B9 deficiency) can cause glossitis, along with macrocytic anemia, thrombocytopenia, leukopenia, diarrhea, fatigue and possibly neurological signs. [7] Apart from pernicious anemia discussed above, any other cause of vitamin B12 deficiency can cause glossitis, which tends to be painful, smooth and shiny. [7]

Infections

Bacterial, viral or fungal infections can cause glossitis. Chronic Candida infections of the tongue can cause an atrophic glossitis known as median rhomboid glossitis. [10]

Syphilis is now relatively rare, but the tertiary stage can cause diffuse glossitis and atrophy of lingual papillae, termed "syphilitic glossitis", [2] "luetic glossitis" or "atrophic glossitis of tertiary syphilis". [8] It is caused by Treponema pallidum and is a sexually transmitted infection.

Other causes

Many conditions can cause glossitis via malnutrition or malabsorption, [7] which creates the nutritional deficiencies described above, although other mechanisms may be involved in some of those conditions listed.

A painful tongue may be an indication of an underlying serious medical condition and nearly always merits assessment by a physician or dental surgeon.

Diagnosis

Classification

Median rhomboid glossitis Glossitis.jpg
Median rhomboid glossitis
Geographic tongue (benign migratory glossitis) Landkartenzunge 005.jpg
Geographic tongue (benign migratory glossitis)

Glossitis could be classified as a group of tongue diseases or gastrointestinal diseases. [4] It may be primary, where there is no underlying cause, or secondary where it is a sign or symptom of another condition. [3] It can be acute or chronic. [4] Generally speaking, there are several clinical patterns of glossitis, some more common than others.

Atrophic glossitis

Atrophic glossitis, also known as bald tongue, [3] smooth tongue, Hunter glossitis, Moeller glossitis, or Möller-Hunter glossitis, [14] is a condition characterized by a smooth glossy tongue that is often tender/painful, [15] caused by complete atrophy of the lingual papillae (depapillation). [3] The dorsal tongue surface may be affected totally, or in patches, and may be associated with a burning sensation, pain and/or erythema. [16] Atrophic glossitis is a non-specific finding, [16] and has a great many causes, usually related to iron-deficiency anemia, pernicious anemia, B vitamin complex deficiencies, [16] unrecognized and untreated celiac disease (which often presents without gastrointestinal symptoms), [17] [18] [19] or other factors such as xerostomia (dry mouth). Although the terms Möller and Hunter glossitis were originally used to refer to specifically the glossitis that occurs in vitamin B12 deficiency secondary to pernicious anemia, they are now used as synonyms for atrophic glossitis generally. [14] In this article, the term glossitis, unless otherwise specified, refers to atrophic glossitis.

Candidiasis may be a concurrent finding or an alternative cause of erythema, burning, and atrophy.

Median rhomboid glossitis

This condition is characterized by a persistent erythematous, rhomboidal depapillated lesion in the central area of the dorsum of the tongue, just in front of the circumvallate papillae. [2] [15] Median rhomboid glossitis is a type of oral candidiasis, and rarely causes any symptoms. It is treated with antifungal medication. Predisposing factors include use of corticosteroid sprays or inhalers or immunosuppression.

Benign migratory glossitis

Geographic tongue, also termed benign migratory glossitis, is a common condition which usually affects the dorsal surface of the tongue. It is characterized by patches of depapillation and erythema bordered by a whitish peripheral zone. These patches give the tongue the appearance of a map, hence the name. Unlike glossitis due to nutritional deficiencies and anemia, the lesions of geographic tongue move around the tongue over time. [20] This is because in geographic tongue, new areas of the tongue become involved with the condition whilst previously affected areas heal, giving the appearance of a moving lesion. [3] The cause is unknown, [21] and there is no curative treatment. Rarely are there any symptoms associated with the lesions, but occasionally a burning sensation may be present, which is exacerbated by eating hot, spicy or acidic foodstuffs. Some consider geographic tongue to be an early stage of fissured tongue, since the two conditions often occur in combination. [22]

Geometric glossitis

Geometric glossitis, also termed herpetic geometric glossitis, [4] is a term used by some to refer to a chronic lesion associated with herpes simplex virus (HSV) type I infection, [23] in which there is a deep fissure in the midline of the tongue, which gives off multiple branches. [8] The lesion is usually very painful, and there may be erosions present in the depths of the fissures. Similar fissured lesions which are not associated with HSV, as may occur in fissured tongue, do not tend to be painful. [23] The name comes from the geometric pattern of the fissures which are longitudinal, crossed or branched. [24] It is described as occurring in immunocompromized persons, e.g. who have leukemia. However, the association between herpes simplex and geometric glossitis is disputed by some due to a lack of gold standard techniques for diagnosis of intraoral herpetic lesions, and the high prevalence of asymptomatic viral shedding in immunocompromized individuals. [8] Treatment is with systemic aciclovir. [23]

Strawberry tongue

Distinct strawberry tongue with "parched" lips as seen in a young child with Kawasaki disease. Kawasaki symptoms B.jpg
Distinct strawberry tongue with "parched" lips as seen in a young child with Kawasaki disease.

Strawberry tongue, or raspberry tongue, [25] is glossitis which manifests with hyperplastic (enlarged) fungiform papillae, giving the appearance of a strawberry. White strawberry tongue is where there is a white coating on the tongue through which the hyperplastic fungiform papillae protrude. Red strawberry tongue is where the white coating is lost and a dark red, erythematous surface is revealed, interspaced with the hyperplastic fungiform papillae. White strawberry tongue is seen in early scarlet fever (a systemic infection of group A β- hemolytic streptococci), [26] and red strawberry tongue occurs later, after 4–5 days. [8] Strawberry tongue is also seen in Kawasaki disease (a vasculitic disorder primarily occurring in children under 5), [27] [28] and toxic shock syndrome. [29] It may mimic other types of glossitis or Vitamin B12 deficiency. [30]

Treatment

The goal of treatment is to reduce inflammation. Treatment usually does not require hospitalization unless tongue swelling is severe. Good oral hygiene is necessary, including thorough tooth brushing at least twice a day, and flossing at least daily. Corticosteroids such as prednisone may be given to reduce the inflammation of glossitis. For mild cases, topical applications (such as a prednisone mouth rinse that is not swallowed) may be recommended to avoid the side effects of swallowed or injected corticosteroids. Antibiotics, antifungal medications, or other antimicrobials may be prescribed if the cause of glossitis is an infection. Anemia and nutritional deficiencies (such as a deficiency in niacin, riboflavin, iron, or Vitamin E) must be treated, often by dietary changes or other supplements. Avoiding irritants (such as hot or spicy foods, alcohol, and tobacco) may minimize the discomfort. In some cases, tongue swelling may threaten the airway, a medical emergency that needs immediate attention.

Epidemiology

One review reported overall prevalence ranges of 0.1–14.3% for geographic tongue, 1.3–9.0% for "atrophy tongue" (atrophic glossitis), and 0.0–3.35% for median rhomboid glossitis. [31]

Related Research Articles

<span class="mw-page-title-main">Anemia</span> Medical condition

Anemia or anaemia is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, the symptoms are often vague, such as tiredness, weakness, shortness of breath, headaches, and a reduced ability to exercise. When anemia is acute, symptoms may include confusion, feeling like one is going to pass out, loss of consciousness, and increased thirst. Anemia must be significant before a person becomes noticeably pale. Symptoms of anemia depend on how quickly hemoglobin decreases. Additional symptoms may occur depending on the underlying cause. Preoperative anemia can increase the risk of needing a blood transfusion following surgery. Anemia can be temporary or long term and can range from mild to severe.

<span class="mw-page-title-main">Mouth ulcer</span> Medical condition

A mouth ulcer (aphtha) is an ulcer that occurs on the mucous membrane of the oral cavity. Mouth ulcers are very common, occurring in association with many diseases and by many different mechanisms, but usually there is no serious underlying cause. Rarely, a mouth ulcer that does not heal may be a sign of oral cancer. These ulcers may form individually or multiple ulcers may appear at once. Once formed, an ulcer may be maintained by inflammation and/or secondary infection.

<span class="mw-page-title-main">Pernicious anemia</span> Anemia caused by vitamin B12 deficiency

Pernicious anemia is a type of vitamin B12 deficiency anemia, a disease in which not enough red blood cells are produced due to the malabsorption of vitamin B12. Malabsorption in pernicious anemia results from the lack or loss of intrinsic factor needed for the absorption of vitamin B12. Anemia is defined as a condition in which the blood has a lower than normal amount of red blood cells or hemoglobin. The onset can be gradual and no changes can be observed for a period of time.

<span class="mw-page-title-main">Iron-deficiency anemia</span> Medical condition

Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, short of breath, or having decreased ability to exercise. Anemia that comes on quickly often has more severe symptoms, including confusion, feeling like one is going to pass out or increased thirst. Anemia is typically significant before a person becomes noticeably pale. Children with iron deficiency anemia may have problems with growth and development. There may be additional symptoms depending on the underlying cause.

<span class="mw-page-title-main">Oral candidiasis</span> Fungal infection

Oral candidiasis, also known as oral thrush among other names, is candidiasis that occurs in the mouth. That is, oral candidiasis is a mycosis of Candida species on the mucous membranes of the mouth.

<span class="mw-page-title-main">Plummer–Vinson syndrome</span> Medical condition

Plummer–Vinson syndrome is a rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs. Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the oesophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Aphthous stomatitis</span> Common condition involving ulceration of the oral mucosa.

Aphthous stomatitis, or recurrent aphthous stomatitis (RAS), is a common condition characterized by the repeated formation of benign and non-contagious mouth ulcers (aphthae) in otherwise healthy individuals. The informal term canker sore is also used, mainly in North America, although it may also refer to other types of mouth ulcers. The cause is not completely understood but involves a T cell-mediated immune response triggered by a variety of factors which may include nutritional deficiencies, local trauma, stress, hormonal influences, allergies, genetic predisposition, certain foods, dehydration, some food additives, or some hygienic chemical additives like SDS.

Ageusia is the loss of taste functions of the tongue, particularly the inability to detect sweetness, sourness, bitterness, saltiness, and umami. It is sometimes confused with anosmia – a loss of the sense of smell. Because the tongue can only indicate texture and differentiate between sweet, sour, bitter, salty, and umami, most of what is perceived as the sense of taste is actually derived from smell. True ageusia is relatively rare compared to hypogeusia – a partial loss of taste – and dysgeusia – a distortion or alteration of taste.

<span class="mw-page-title-main">Stomatitis</span> Medical condition

Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration.

<span class="mw-page-title-main">Geographic tongue</span> Tongue disorder

Geographic tongue, also known by several other terms, is a condition of the mucous membrane of the tongue, usually on the dorsal surface. It is a common condition, affecting approximately 2–3% of the general population. It is characterized by areas of smooth, red depapillation which migrate over time. The name comes from the map-like appearance of the tongue, with the patches resembling the islands of an archipelago. The cause is unknown, but the condition is entirely benign, and there is no curative treatment. Uncommonly, geographic tongue may cause a burning sensation on the tongue, for which various treatments have been described with little formal evidence of efficacy.

<span class="mw-page-title-main">Herpetic gingivostomatitis</span> Medical condition

Gingivostomatitis is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva. Herpetic gingivostomatitis is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis which is often the subsequent presentations. Primary herpetic gingivostomatitis is the most common viral infection of the mouth.

<span class="mw-page-title-main">Angular cheilitis</span> Cheilitis characterized by inflammation of one or both of the corners of the mouth

Angular cheilitis (AC) is inflammation of one or both corners of the mouth. Often the corners are red with skin breakdown and crusting. It can also be itchy or painful. The condition can last for days to years. Angular cheilitis is a type of cheilitis.

Burning mouth syndrome (BMS) is a burning, tingling or scalding sensation in the mouth, lasting for at least four to six months, with no underlying known dental or medical cause. No related signs of disease are found in the mouth. People with burning mouth syndrome may also have a subjective xerostomia, paraesthesia, or an altered sense of taste or smell.

<span class="mw-page-title-main">Cheilitis</span> Inflammation of the lips

Cheilitis is a medical condition characterized by inflammation of the lips. The inflammation may include the perioral skin, the vermilion border, or the labial mucosa. The skin and the vermilion border are more commonly involved, as the mucosa is less affected by inflammatory and allergic reactions.

<span class="mw-page-title-main">Tongue disease</span> Medical condition

Tongue diseases can be congenital or acquired, and are multiple in number. Considered according to a surgical sieve, some example conditions which can involve the tongue are discussed below. Glossitis is a general term for tongue inflammation, which can have various etiologies, e.g. infection.

<span class="mw-page-title-main">Plasma cell gingivitis</span> Medical condition

Plasma cell gingivitis is a rare condition, appearing as generalized erythema (redness) and edema (swelling) of the attached gingiva, occasionally accompanied by cheilitis or glossitis. It is called plasma cell gingivitis where the gingiva (gums) are involved, plasma cell cheilitis, where the lips are involved, and other terms such as plasma cell orifacial mucositis, or plasma cell gingivostomatitis where several sites in the mouth are involved. On the lips, the condition appears as sharply outlined, infiltrated, dark red plaque with a lacquer-like glazing of the surface of the involved oral area.

<span class="mw-page-title-main">Median rhomboid glossitis</span> Medical condition

Median rhomboid glossitis is a condition characterized by an area of redness and loss of lingual papillae on the central dorsum of the tongue, sometimes including lesions of the tongue and palate. It is seen in patients using inhaled steroids and smokers, and is usually a kind of chronic atrophic oral candidiasis, but hematinic deficiency and diabetes should be excluded.

<span class="mw-page-title-main">Lingual papillae</span> Structure giving the tongue its characteristic rough texture

Lingual papillae are small structures on the upper surface of the tongue that give it its characteristic rough texture. The four types of papillae on the human tongue have different structures and are accordingly classified as circumvallate, fungiform, filiform, and foliate. All except the filiform papillae are associated with taste buds.

References

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