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Changes in tongue coating


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1- Tongue papillae.2- Food debris.

3- Bacteria.

4- Desquamated epithelium.


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The tongue coatingvaries in different individuals.

Varies in the same individual during the day

It is continuously formedit is marked in the morning since cleaning factors

are at rest. and is removed by:

1- Mechanical factors: speaking and chewing food.2-Salivary flow


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Tongue coating is in a continuous process ofremoval and formation.

If removal exceeds formationatrophy

If formation exceeds removal

increased tonguecoating.


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A- Atrophy of tongue coating

The cells forming the filiform papillae andfungiform papillae are of high metabolic activity soany disturbance in enzyme, circulation or nutrientsleads to atrophy.

During the process of atrophy: the filiformpapillae are affected first, followed by fungiformpapillae.

During regeneration: the fungiform papillaeregenerate first followed by regeneration offiliform.

Circumvallate and foliate are permanent structuresof the tongue coating , dont participate in atrophy.


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Atrophy of tongue coating


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1- Deficient or impaired utilization of

nutrients

1- Iron deficiency anemia.2- Pulmonary Vinson syndrome.3- Pernicious anemia.

4- Anemia associated with parasitic infectionas ascaris and bilhariziasis.

5- Malnutrition, malabsorption.6- Sprue .

7- Chronic alcoholism.8- Vitamin B deficiency especially (vitamin

B2, B6, B12, folic acid and nicotinic acid).


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2- Peripheral vascular disease

1- Angiopathy: Diabetes Mellitus.

2-Vasulitis: systemic lupus erythematosus.

3- Endarteritis obliterans: syphilitic glossitis.4-Obliteration of small blood vessels: scleroderma,

submucous fibrosis.

5-Localized vascular insufficiency in elderly patients.


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3-Therapeutic agents1-Drugs that:

Interfere with the growth and maturation of theepithelium e.g cyclosporine.

Induce candidosis e.g. antibiotic, steroid.

Induce xerostomia e.g anticholinergic drugs,radiotherapy.


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4- Miscellaneous

1- Frictional irritation: atrophy at tip & lateral bordersof tongue.

2- Atrophic lichen planus.

3- Epidermolysis bullosa: ulceration healed by scar.

4- Long standing xerostomia.5- Diabetes and chronic candidiasis may produce a

lesion called central papillary atrophy.


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B- Increased tongue coating The filiform papillae which constitute the

keratinizing surface of the tongue are incontinuous state of growth and their height is

determined by the rate of desquamation process.The later is induced by friction with food, palateand the upper anterior teeth, during eating andspeech.


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Increased tongue coating


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Etiology:

Basically the abnormal increase in tongue coating isdue to local environmental changes represented bylack of function and/or changes in the oral flora andthese are attributed to:

1- Drugs

a- Topical and systemic use of antibiotics.

b- Antiseptic mouth washes.

c- Oxygen releasing mouth rinse.


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Etiology cont 2- Febrile illness (general body dehydration,

decreased salivary flow, liquid diet and poor oralhygiene).

3-Stomach upset, vomiting associated with intestinalor pyloric obstruction, debilitated or terminally illpatient.

4- Mouth breathing


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Clinical features:

The increased tongue coating may be stainedparticularly on the mid dorsum by food, tobacco,drugs or possibly by microorganisms.

In debilitated, dehydrated and terminally ill patientsthe increased tongue coating may be very thick andhas been described as leathery coating.


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Treatment Consist of brushing the dorsal surface of the tongue

several times a day systemic antibiotic should not beinterrupted but antifungal agent should be used

locally. Topical antibiotic and mouth washes shouldnot be used. The condition usually regressesspontaneously when the normal jaw and tongueactivity are restored.


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Black hairy tongue

Definition

It is a condition characterized by hypertrophy of

filiform papillae associated with growth of blackpigment producing micro organism.


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Black hairy tongue


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Etiology

1- Sodium perporate and sodium peroxide mouthwash that stimulate growth of filiform papillae.2-Topical and systemic antibiotics:ex: penicillin, tetracycline, aureomycin.3- Systemic disturbance: anemia, hyperacidity, peptic

ulcer.4- Predisposition in some people.

Clinical features

May be asymptomatic or may cause gagging andtickling.


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Management Removal of the cause stop t0pical antibiotic. Brushing of the tongue. Systemic antibiotic should not be stopped, but

antifungal ointment is prescribed in additional tothe antibiotic.

Pseudo black hairy tongue means discolourationof tongue by food, smoking and drugs withoutactual hypertrophy of filiform papillae.


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Site:the dorsum of the tongue.It is an irregularly outlined area, devoid of

filiform papillae, with red dots representing

fungiform papillae. {occasionally devoid offungiform}. The margin of the depapillated areais raised with yellowish, whitish tinge.

The margin of the lesion shifts as much as

inch per day due to renewed of papillae in onearea and loss in another area.

It occurs chiefly in children and young adults.


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Geographic tongue


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Geographic tongue


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Clinical pictureFemales are frequently affected more than males.

The patient may fell discomfort of pain speciallyalcoholics and with highly seasoned food.

The lesions are usually multiple.

Identical lesion is seen in psoriasis and Reiterssyndrome.


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Etiology:Unknown but may be:

1- Associated with fissured tongue (attributed tobacterial irritation).

2-Common in allergic persons (more frequent inatopic patients).

3- Related to psychological factor (the exacerbationhas been associated with anxiety and depression.

4-Related to family history (several member of thefamily may have the disease).


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Differential diagnosis Geographic tongue should be differential from

1- Atrophic lichen planus.2-Fixed drug eruption.

The main characteristic features of geographic tongue isthe continuous daily migration of the lesion.


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Treatment

No treatment is indicated as the lesion is self limitingdisease.

1- In apprehensive and cancerphobic patient reassuranceis required.

2-If the patient is suffering from burning or soreness,benzydamine HCl mouth wash will offer good relief.


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Etiology

Local factors

1- Tongue pressure habit.

2-Macroglossia (acromegaly, gigantism, etc).3- Acute inflammation: e.g. erythroma multiform,

metallic intoxication, Acute necrotizing ulcerativegingivitis, acute herpetic gingivostomatitis.


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Systemic factors

1- Vitamin B complex deficiency.

2-Diabetes mellitus due to decreased muscular toneassociated with vitamin B&C deficiency.


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Sublingual varices

1- It is formed by enlarged tortuous veins in thesublingual area.

2-It is asymptomatic, but trauma may result in bleeding


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Etiology

Idiopathic

Congential.

Found more in elderly people. It may be associated with portal hypertension.


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Glossopyrosis Glossodynia

Burning tongue painful tongue


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Etiology

1- Local factors

2-Systemic factors3- Psychogenic factors represents 75% of cases.


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1- Local factors1-

Irritating calculus, caries, malposed teeth, sharp toothedge.2-Electrogalvanic discharge between two dissimilar

metals.3- Oral Candidosis.

4-Dryness of the mouth.5- Allergic response to lipstick, dentifrices.6-Excessive smoking.7- Habit of rubbing the tongue against the teeth.8-Excessive use of strong mouth wash.9-Mouth breathing.10- Highly spicy food.


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Erosions on the dorsum of the tongue, caused by very hot food.


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2- Systemic factors Anemia: iron deficiency anemia, pernicious

anemia.Vitamin B complex deficiency. Chronic alcoholism. Gonadal deficiency Diabetes mellitus.

Drugs: fixed drug eruption. Low serum zinc level.

Tongue tremors e.g. parkinsonism.


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3-Psychogenic factors

1- Post menopausal women with cancerphobia.2- After death of close persons.

Psychogenic factors result in glossodynia which is

characterized by:1- No observable clinical cause.

2-Pain does not follow any anatomical distribution.

3- Pain does not interfere with eating or sleeping.

4-Pain intensity increases at the end of the day.


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Treatment

1- Removal of the cause if possible.

2-If psychogenic.

Reassurance of the patient that there is no malignancy.Valium 5-10 mg t.d.s may be of help.

Resistant casesrefer to psychiatrist


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6- Papillitis (painful foliate and

circumvallate papillae) It is the inflammation of foliate and / or the lateral

circumvallate papillae.

The patient complains of pain at the posterolateral aspect

of the tongue.Etiology

Sharp distolingual cusp of lower second molar.

Sharp edge of a denture.

The lesion arises as a result of rubbing or biting the tongueagainst the teeth, or denture. Digital palpation may reveal arough or sharp tooth or restoration.


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References: Martin Greenberg and Michel Glick & Jonathan A.

Ship. Burkett's Oral Medicine ,Diagnosis & Treatment ,10thed. 2008, BC Decker, Inc..

George Laskaris, Pocket Atlas of Oral Diseases, 2ndedition, 2006, Stuttgart , New York.

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