dev disturbances of gingiva and tongue

8/6/2019 Dev Disturbances of Gingiva and Tongue

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Developmentallesions

of face


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Classification Broadly classified into

Developmental disturbances of tongue

Developmental disturbances of gingiva

Developmental disturbances of lips and palate

Developmental disturbances of oral lymphoid tissue

Developmental disturbances of salivary glands

Developmental disturbances of oral mucosa

Developmental cysts of the oral region


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DevelopmentalDevelopmentaldisturbances ofdisturbances of

tonguetongue


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Developmental disturbances of tongueBroadly classified into

Microglossia

Macroglossia

AnkyloglossiaCleft tongue

Fissured tongue

Median rhomboid glossitis

Geographic tongue

Hairy tongueLingual varices

Lingual thyroid nodule


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MicroglossiaSmall or rudimentary tongue

C/FUncommon developmental condition

Aglossia rareOften associated with one of a group of the overlapping

conditions known as Oromandibular limb hypogenesissyndrome

Limb anomalies hypodactylia (absence of digits)

Hypomelia hypoplasia of part or all of a limb

Some patients associated with cleft palate, intra oral bands

Also frequently associated with hypoplasia of mandible


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Microglossia


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MicroglossiaTreatment and prognosis

Depends on the nature and severity of the

conditionSurgery and orthodontics may improve oral

function

Speech development is quite good but depends

on tongue size


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MacroglossiaEnlargement of the tongue

Caused by a wide variety of conditions

including both congenital malformations andacquired diseases

True macroglossia tongue enlargement

Relative macroglossia insufficient space inthe oral cavity


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MacroglossiaC/F:

Most common in children

Degree of macroglossia Mild to severe

Infants manifest noisy breathing, drooling, difficulty ineating, lispy speech

Pressure of tongue against mandible and teeth produce Crenated lateral borders of tongue

Open bite

Mandibular prognathism

Constant protrusion produces ulceration

If severe, airway obstruction can be produced


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macroglossia


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MacroglossiaFeature ofBeckwith-Wiedemann syndrome

Visceromegaly

GigantismNeonatal hypoglycemia

(Prone to Wilms tumor, Adenocarcinoma and

Hepatoblastoma)


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MacroglossiaFacial features include,

Nevus of forehead and eyelids

Linear indentations of the ear lobes

Maxillary hypoplasia

AD inheritance

Hypothyroid macroglossia enlargement issmooth, diffuse and generalized

Amyloidosis, neurofibromatosis and MEN IIBsyndrome produce nodulartype of enlargement


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MacroglossiaH/P:

Microscopy depends on the cause

Downs and edentulous patients normal

Amyloidosis shows abnormal proteins

Tumors show abnormal proliferation

Beckwith shows muscular enlargement

Ttt and Prognosis:

Mild no surgery, speech therapy

Severe Partial glossectomy


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Ankyloglossia/Tongue tieDevelopmental anomaly

Characterized by short, thick lingual frenum

Complete fusion between tongue and floorof the mouth

Partial tongue tie short lingual frenumattached to the tip of the tongue

Occur in 1.7 to 4.4% of neonates

Four times more common in boys than girls


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ankyloglossia


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Ankyloglossia/Tongue tieC/F:

Speech difficulties due to restricted tongue movement

High mucogingival attachment cause periodontal problems

Some investigators say ankyloglossia cause open bite due

to abnormal swallowing pattern

Ankyloglossia associated with upward and forward

displacement of epiglottis resulting in dyspnoea.


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Ankyloglossia/Tongue tieA. superior (Glossopalatine ankylosis)

Rare - congenital adherence of tongue to thepalate

Usually combined with other congenital anomaliesin the maxillofacial region and extremities (A.superior syndrome)

Causes suckling and respiratory dysfunction

(JOMFS,95 53:588-589)


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Ankyloglossia superior


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Ankyloglossia/Tongue tie

Ttt and prognosis:

Most cases do not exhibit any clinical problem

and ttt is not requiredIn children, mostly self corrective

If functional and periodontal problems develop,

frenectomy to allow free tongue movement

A.superior requires surgical separation


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Cleft tongue / Bifid tongue

Complete cleft:

Is a rare condition

Caused due to lack of merging of lateral lingual swellings

Partial cleft:

Is more common

Manifested as a deep groove in the midline on the dorsal

tongue

Results due to incomplete merging and failure of groove

obliteration by the underlying mesechymal proliferation


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Cleft tongue / Bifid tongueFeature ofOro-facial-digital syndrome in

association with

Thick, fibrous lower anterior mucobuccalfold and

clefting of the mandibular alveolar process

Rarely associated with epignathus

teratoma, cleft palate, median glossal

salivary mass(Mills et al, JOMFS,2004 379-383)


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Bifid tongue with median glossal salivary mass


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Cleft tongue / Bifid tongueTtt and Prognosis:

No clinical significance except

collection of food debris andmicroorganisms at the base of the

cleft, which may cause irritation

If marked surgery


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Fissured tongue

Relatively common anomaly

Presents as numerous grooves or fissures

Etiology is uncertain

Different etiology is suggestedAging and vitamin deficiency (Halperin et al)

Hereditary AD

Children with extra oral congenital anomalies

Children with a history of allergy (Bessa et al JOPOM2004:17-

22)


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Fissured tongue

Based on clinical appearance,classified as

Foliaceous,Cerebriform and

Transverse.


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Fissured tongue

C/F:

Prevalence 2-5% of population

Groove depth is 2-6mm

Seen in children and adults

Prevalence increase with age

Mild to severe

Mild shallow fissures only on the dorsum of tongue

Severe numerous fissures covering the entire dorsum anddividing the tongue papillae into multiple separate islands


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Fissured tongue


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Fissured tongue

Some patients have fissures extendingdorsolaterally

Some have large central fissures withradiating fissures

Usually asymptomatic except mild sorenessor burning sensation

Strong correlation between Fissured tongueand Geographic tongue


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Fissured tongue


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Fissured tongue

H/P:

Hyperplasia of rete ridges

Loss of keratin on the surface of filiform papillaePapillae vary in size and separated by deep

grooves

PMN migrate into the epithelium forming micro-

abscesses in the upper epithelial layers.Mixed inflammatory cell infiltrate in the lamina

propria


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Fissured tongue

Ttt & Prognosis:

Usually no specific ttt

Patient encouraged to brush the tongue toremove the entrapped food debris in the grooves

which may act as a source of infection


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Median Rhomboid Glossitis

Also known as Central Papillary Atrophy oftongue

Described classically as congenital anomalyoccurring due to failure of tuberculum imparto retract or withdraw before fusion of thelateral half of the tongue

Hence the structure devoid of papillae isinterposed between them


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The possibility of candidal infection is

suggested,

As there is no report in childrenMore common in diabetics

Hyphae demonstrated in some histologic sections

Lesion resolves on antifungals

Prevalence is 2-3%. Three times more

frequent in mentally retarded


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C/F:

Ovoid, diamond or rhomboid shaped

Reddish patch or plaque likeLocated on the dorsal surface of tongue

immediately anterior to the circumvallate papillae

De-papillated no filiform papillae

Obvious clinically, often asymptomatic

Smooth or lobulated


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Median rhomboid glossitis


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When MRG occurs with oral candidiasis inother sites erythematous candidiasis termed as Chronic multifocal candidiasis

Carcinomatous change has been reported

When a lesion in the location of MRGaccompanied with induration, soreness or

pain, a neoplastic origin should besuspected. Biopsy is then mandatory.

(Drosky et al,JOMFS, 1993: 51-798-800)


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H/P: Loss of papillae with varying degrees of hyperkeratosis

Proliferation of spinous layer with elongation of rete ridges

Lymphocytic infiltrate within the connective tissueNumerous blood vessels and lymphatics are seen

Degeneration and hyalinization within the underlying muscle

Fungal hyphae in the Parakeratin or very superficial spinouslayer or both.

Best seen by PAS stain Ttt:

No specific ttt

Some lesions regress with/without antifungal ttt


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Benign migratory glossitisKnown as Geographic tongue

Common benign condition

Incidence is 1-3%

More common in females


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Benign migratory glossitisSeveral etiologies suggested

Hypersensitivity Marks et al

Hormonal OCP, Waltimo et al

Heredity Multifactorial mode of transmission associatedwith environmental factors

Relationship between HLA complex and GT (DR5, DRW6raised)

Increased incidence of GT & FT in patients with psoriasis

Psoriasis also shows increase in HLA antigen GT & Psoriasis share same HLA CW6T

(Redman, Fenarali, Pindborg et al)


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Benign migratory glossitisC/F:

Characteristically seen in anterior two thirds of tongue

Appear as multiple, demarcated zones of erythema on the

tip and lateral borders of the tongue

Erythema is due to atrophy of filiform papillae

Atrophic areas typically surrounded by slightly elevated,

yellowish white, serpentine or scalloped borders

Lesion persists for short time in one areaNew lesion develops in other sites of the tongue


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Geographic tongue


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Benign migratory glossitisRarely lesions similar to GT may occur in

other sites of oral cavity called Ectopic GT

Associated with GTUsually asymptomatic

Occasionally patient may experience

burning sensation


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Benign migratory glossitisD/D:

Candidiasis

Lichen planusCicatricial pemphigoid

Pernicious anemia

Leukoplakia


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Benign migratory glossitisInvestigations:

Full blood examination and vit B12 assay to rule

out pernicious anemia and IDASaliva for candida culture

Immunofluorescence to rule out pemphigoid


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Benign migratory glossitisH/P:

Loss of filiform papillae

Margin of the lesion shows hyperparakeratosis, spongiosis,acanthosis, elongation of rete ridges

Center of the lesion shows desquamated Para keratin

Migration of PMN and lymphocytes into the epitheliumproducing degeneration of epithelial cells and microabscesses.

As this features are reminiscent of psoriasis, it is called

psoriasiform mucositis. Inflammatory cells in underlying CT chiefly neutrophils,

lymphocytes and plasma cells


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Benign migratory glossitisTtt & Prognosis:

Generally no ttt

Reassurance of patient is sufficientPatients with intolerable burning sensation, topical

corticosteroids may be given

Zinc supplementation may be effective


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Hairy tongue

Etiology:

Uncertain

Affected people are mostly heavy smokers

Other possible factors include,

Antibiotic therapy

Poor oral hygiene

General debilitation

Radiation therapy Oxidising mouthwash or antacids

Overgrowth of fungal or bacterial organisms


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Hairy tongue

C/F:

Mostly affects midline just anterior to CVP, sparing the

lateral and anterior borders

Elongated papillae brown, black or yellow depending onthe pigment producing bacteria, staining from tobacco and

food

Sometimes most dorsum affected matted appearance

Asymptomatic occasionally pt complains of gaggingsensation and bad taste


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Hairy tongue


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Hairy tongue

H/P:Marked elongation and hyperparakeratosis of the filiform

papillae

Numerous bacteria seen growing on the epithelial surfaceTtt & Prognosis:

Benign condition hence no serious sequelae

Major concerns are esthetic appearance and bad breath

Predisposing factors should be eliminated

Excellent oral hygiene should be maintained

Desquamation promoted by periodic scraping or brushing


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H/P of hairy tongue


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Lingual varices

Abnormally dilated or tortuous veins

Common in old adults and rare in children

Etiology:Age related degeneration loss of CT zone supporting the

blood vessels

Not associated with systemic hypertension or cardiac

diseases

Sometimes, patients with varicose veins of legs are likely

to have varicosities of the tongue


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Lingual varices

C/F:Sublingual varices is most common

Multiple, bluish-purple, elevated, papular blebs

Ventral and lateral borders of the tongue

Usually asymptomatic except when secondary thrombosisoccurs

Less frequently solitary varices occur in other parts of themouth like lips and buccal mucosa

Usually noticed after becoming thrombosed.

Thrombosed varix present as firm, non-tender, bluish-purple nodule


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Lingual varices


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Lingual varices

H/P:Reveals a dilated vein

Walls show little smooth muscle and poorly developedelastic tissue

If secondary thrombosis occurs, lumen show Lines of Zahn

Organization and recanalization

Older thrombi exhibit dystrophic calcification Phlebolith

Ttt & Prog:No ttt required for asymptomatic sublingual varices

Solitary varices can be removed surgically to confirm thediagnosis and for esthetic reasons.


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Lingual thyroid

Condition in which follicles of thyroid tissue arefound in the substance of the tongue

90% between F.caecum and epiglottis

Arising from thyroid analage that failed to migrateto its predestined position or from analageremnants that become detached and left behind

Etiology:Enlargement due to functional insufficiency of the chief

thyroid glandPatients residing in a goitrous area


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Lingual thyroid

C/F:Asymptomatic remnants on posterior dorsal tongue in

about 10%

Symptomatic thyroid - more common in femalesFound anywhere between CVP to epiglottis

Symptoms often develop during puberty, pregnancy andmenopause

In 70% patients, these ectopic glands is the only functional

thyroid glandHypo - thy occur in 33% of patients


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Lingual thyroid


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L

ingual thyroidSmall nodules to large masses

Most clinical symptoms are,Dysphagia

DysphoniaDyspnoea

Hemorrhage and pain

Fullness of throat

Lesions usually vascular and smooth3% - thyroid carcinoma


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L

ingual thyroidDiagnosis:

Best by thyroid scan using I131 and Tc99M

CT and MRI helpful in delineating the lesion

Due to brisk bleeding, biopsy is better avoided

Investigations:

Hormone level estimation (T3,T4, TSH)

Ultrasonography

I131 uptake study

Scintigraphy


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L

ingual thyroidTtt & Prog:

Asymptomatic follow up without ttt

Symptomatic supplemental thyroid hormonesNo response surgery

As malignant transformation more common in

men, some advocate prophylactic excision in men

older than 30 yrs


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Developmental disturbances of

gingivaIt includes

Fibromatosis gingivae

Retrocuspid papilla


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F

ibromatosis gingivaeDiffuse fibrous overgrowth of the gingival

tissue

Mostly hereditary ADFamilial also occur with Hypertrichosis,

epilepsy, mental retardation, sensori-neural

deafness, hyperthyroidism and growth

hormone deficiency


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F

ibromatosis gingivaeC/F:

Manifested as dense, diffuse, smooth or nodularovergrowth

In older patients, surface has numerous papillaryprojections

Occur in one or both dental arches but Mostcommon in maxilla

Appear at the time of eruption of permanentincisors

Mostly before the age of 20


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Fibromatosis gingivae


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F

ibromatosis gingivaeC/F:

Gingiva not inflamed

Firm, normal colorPrevent normal eruption of teeth

Not painful and no tendency for hemorrhage

Localized cases involve a group of teeth

May remain stable or may spread to othersegments


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F

ibromatosis gingivaeH/P:

Dense hypocellular and hypovascular collagenous tissue

Appear to run in all directions as interlacing bundles

Epithelial thickening with elongated rete ridges

Mild inflammatory infiltrate

Sometimes dystrophic calcifications seen

EM reveals mixture of fibroblasts and myofibroblast like

cells


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F

ibromatosis gingivaeTtt and Prognosis:

Gingivectomy and oral hygiene measures

Follow up required because of itstendency to recur

Severe cases selective extraction and

gingivectomy


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Retrocuspid papilla


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Retrocuspid papilla

Histopathology

Mild hyperorthokeratosis or

hyperparakeratosis,with or without acanthosis

Connective tissues sometimes highly

vascularised and show large stellate fibroblasts

Occasionally epithelial rests also seen

Tmt and prognosisRegress with age no treatment necessary

dev disturbances of gingiva and tongue

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