Anatomy of tongue/endodontic courses

Anatomy of Tongue
&
its disorders
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.iniandentalacademy.com

Contents
• Introduction
• Embryology
• External features & Papillae of the tongue
• Muscles of the tongue
• Arterial, Venous and Lymphatic Drainage
• Nerve supply
• Functions
• Disorders
• Investigations
• Conclusion
• References

Introduction
• Tongue is highly muscular & vascular organ of
deglutition, taste and speech.
• It is partly oral and partly pharyngeal in
position.
• It is attached by its muscle to hyoid bone ,
mandible, styloid process, soft palate and
pharyngeal wall.
• It has a root , apex, a curved dorsum and inferior
surface. (Gray’s)

Embryology
• Tongue appears in embryo at approximately 4th
week in utero.
• Anterior 2/3rd
of tongue develops in utero by
fusion of two lateral swelling a midline swelling
referred to as tuberculum impar.
• All these structure arises from first brachial arch.
• Lateral lingual swelling subsequently merge
with and grow over tuberculum impar.
• Posterior portion of tongue: 2nd
& 3rd
brachial
arch.

• The point of fusion between tubercular impar at
the anterior 2/3rd
& rudimentary posterior portion
of tongue corresponds to epithelial cells.
• That subsequently migrate to form thyroid gland .
• In adult this point is marked by foramen caecum.
• Foramen caecum & V shaped row of vallate
papillae that extends anteriorly & laterally from it
marks the separation at oral & pharyngeal portion
of tongue.

• Posterior part of fourth brachial arch marks
development of epiglottis.
• Immediately behind this swelling is laryngeal
orifice which is marked by archnoid swelling
• Since the mucosa covering the body of tongue
originates from first pharyngeal arch, sensory
nerve supply to this area is by mandibular branch
of trigeminal nerve .
• The body of the tongue is separated from
posterior third by V shaped groove, terminal
sulcus. www.iniandentalacademy.com

• Posterior part or root of tongue originates from
second , third, & part of fourth pharyngeal arch.
• Sensory nerve supply to this part of tongue is by
glossopharyngeal nerve, indicates that tissue of
third arch overgrows that of second.
• The epiglottis & extreme posterior part of tongue
are supplied by superior laryngeal nerve
reflecting their development from the fourth arch.
• Most of tongue muscles are derived from the
myoblasts originating in occipital somites.
• Thus tongue musculature is supplied by
hypoglossal nerve.

Embryology

Superficial features of anterior
2/3rd
• Mucosa – 1) Filiform papillae
2) Fungiform papillae
Filiform papillae-
• Slender connective tissue papillae with heavily
keratinized caps or tails
• Present approx.500/cm2
• Center of the dorsum
• Do not carry taste buds.
• Functions:
-Licking
-Convey food distally
-Modulating textural and pressure sensations on
the tongue. www.iniandentalacademy.com

Fungiform papillae :
• Anterior 2/3rd
of the tongue
• Mushroom-shaped structures have a rich
capillary network
• Identified as reddish dots
• Present approx 200 fungiform papillae per
tongue
• Carries about 0 to 20 taste buds (depends on
capillary blood flow)www.iniandentalacademy.com

Superficial features of posterior 3rd
• At the junction of the anterior 2/3rd
and posterior
3rd
of the tongue is found the V-or Y- shaped row
of vallate ( circumvallate papillae)
• It terminates on the lateral margins of the
tongue with a cluster of leaflets known as the
foliate papillae
• Each vallate papillae is surrounded by moat and
cuff

• Vallate and foliate papillae contain
-number of taste buds
-Non-keratinized epithelium
-specialized connective tissue cores
- numerous fine endings of 9th
cranial nerve.
- clusters of very prominent serous glands
(glands of von Ebner)
Glands of von Ebner :
- found below the row of vallate papillae &
adjacent to the foliate papillae.www.iniandentalacademy.com

Taste pathway
• Receptors:
- Type III cells of taste buds.
- Each taste buds is innervated by about
50 sensory nerve fibers .
- Each nerve fibre supplies at least 5 taste
buds through its terminals.

• First order neuron :
- These are in the nuclei of 3 different cranial
nerves.
- Dendrites of the neurons are distributed to
taste buds.
- After arising from taste buds , the fibers run
in the following nerves-
i) Chorda tympani fibers of facial nerve
ii) Glassopharyngeal nerve fibers
iii) Vagal fibers.www.iniandentalacademy.com

• Second order neuron :
- Are in nucleus of tractus solitarius.
- Axons of these neurons cross the midline ,
run through medial lemniscus & terminates in
posteroventral nucleus of thalamus.
• Third order neuron:
- Are in the posteroventral nucleus of thalamus.
- Axons of these neurons project into parietal
lobe of cerebral cortex.

• Taste centre:
- It is in the opercular insular cortex ( lower part of post
central gyrus , which receives cutaneous sensations from
face).
- Because of crossing of taste fibers , each side of tongue
is represented in the taste centre in parietal cortex of
opposite side.

Pathway for taste sensation

Muscles of tongue
• A middle fibrous septum divides the
tongue into right & left halves.
• Intrinsic muscles –
- superior longitudinal
- inferior longitudinal
- transverse
- vertical

• Extrinsic muscles-
- genioglossus
- hyoglossus
- styloglossus
- palatoglossus.

Arterial, Venous and Lymphatic
Drainage
• Tongue is supplied by right & left lingual
arteries .
• Near base of tongue lingual artery divides
into 3 branches –
Dorsal
Deep lingual artery
Sublingual artery
• Two venae comitantes accompany the lingual
artery, and one vena comitantes accompanies
the hypoglossal nerve.
• The deep lingual vein is the largest &
principal vein of the tongue.

Lymphatic drainage:
• The tip of the tongue drains bilaterally
to the submental nodes.
• The right & left halves of the remaining
part of the ant 2/3rd
of the tongue drain
unilaterally to the submandibular
nodes.
• The post 1/3rd
of the tongue drains
bilaterally to the jugulo-omohyoid
nodes.

Nerve supply
• Motor nerves :
- All the intrinsic & extrinsic muscles, except the
palatoglossus , are supplied by the hypoglossal nerve.
- The palatoglossus is supplied by the cranial root of
the accessory nerve through the pharyngeal plexus.
• Sensory nerves :
The lingual nerve is the nerve of general sensation and
the chorda tympani is the nerve of taste for the anterior
2/3rd
of the tongue except vallate papillae.

• The glassopharyngeal nerve is the nerve
for both general sensation and taste for the
posterior 1/3rd
of the tongue including the
circumvallate papillae.
• The posterior most part of the tongue is
supplied the vagus nerve through the
internal laryngeal branch.

Functions
a)Prehension and Ingestion:
- collecting liquid & solid food & propelling
the food to pharynx.
- licking, sucking, & other chewing movements
all involve coordinated muscular activity of
tongue , jaw, lips & cheeks.
b) Suckling:
-highly specialized form of ingestion
characteristics of infant.

c) Swallowing :
- Involves a physiological coordination analogous to
that in suckling.
- Involves sequential muscular activity in the tongue
& constrictor muscles of the pharynx to close palate
velum & epiglottis , allowing passage the bolus into
the esophagus without regurgitation into nose or
lower respiratory tract.
-Lack of this function in problems like hypoglossal
paralysis, localized but painful tongue lesion or
topical anesthesia of base of tongue & pharynx leads
to aspiration or choking .

c) Perception:
- Specialized mucosa , general & special
sensory nerve supply of tongue dorsum
provide sensitive assessment of
temperature ,texture, taste, pain & general
sensation.
- Proprioceptors in lingual muscles,
periodontal membrane and masticatory
muscles modulate spatial (stereotactic)
sensation.

d) Phonation
- adequate muscle strength and control
& an lingual sensory system are
needed.
e) Respiration
- Position of the jaw and tongue, by
contributing to lingual muscular
tonus, www.iniandentalacademy.com

Diseases of the tongue
Inherited ,Congenital and Developmental
Anomalies
i) Variations in tongue morphology & function
Partial ankyloglossia (tongue tie)
-Prevalence – 0.1 to 3.7 %
-Refers to congenital shortness to
lingual frenum or a frenal
attachment that extends nearly
to the tip of the tongue, binding
the tongue to the floor of mouth.

C/F:
- midline mandibular diastema,
- lingual mandibular periodontal defects,
-poor sucking or inability to chew some foods ,
-recurrent tongue biting ,
-speech defects( t, d, n & l, in sounds & words
such as ta, te , time, water, cat )
- inability to clean the teeth & lick the lips with
the tongue.

• Extreme degree of ankyloglossia occurs more
rarely
• It includes complete attachment of tongue to the
floor of the mouth or alveolar gingiva.
• Attachment of the tip of tongue to the hard
palate (glossopalatine ankylosis or
ankyloglossum superius syndrome) which is
often seen in association with cleft palate or in
which a lingual frenum is one of several
grossly hyperplastic fernum ( e.g. Orofacial
digital syndrome)www.iniandentalacademy.com

• It is also associated with
-Cleft lip-cleft palate,
-Congenital lip pit (Van der Woude’s
syndrome),
-Cryptophtalmos ( Fraser’s syndrome ),
- Trisomy 13 ( Patau syndrome),
- Fetal face (Robinow’s syndome),
- Meckel’s syndrome

ii) Variations in tongue movements
-Ability to curl up lateral borders of tongue into
tube is seen in 65 % of white people –
Autosomal dominant trait.
- Ability to fold back tip of extended tongue
without the aid of teeth- less frequent.
- Some individuals can voluntarily deform the tip
of tongue into clover leaf pattern ( trefoil
tongue)- no inheritance.
- Gorlin sign – unusual extendibility of tongue
both forward to touch the tip of nose and
backward into pharynx occurs in 8 % to 10 % of
general population but also in 50 % of patients
with Ehlers-Danlos syndrome-

- Extreme degree of extensibility noted in this syndrome
due to inherited defects in collagen metabolism
- Characteristics are hyperplastic skin, loose
jointenderness , and more severe cardiovascular and
gastrointestinal complications.
• Tongue in tuberous sclerosis – “long narrow and
cylinderical” as a consequence of hyperostosis and
thickening of the mandible.
• Epidermolysis bullosa – mobility of the tongue may be
severely restricted as a result of fibrous scars secondary
to blister formation.

Tongue thrusting
• Positioning of the tongue between the anterior
teeth during swallowing or at rest.
• Prevalence declines to approx 3% by 12 yrs of
age.
• Anterior open bite associated with
macroglossia, excessive epipharyngeal
lymphoid tissue, or cerebral palsy
• T/t : appliances and myofunctional therapy

Fissured , plicated or scrotal tongue
• Most commonly associated with institutionalized,
mentally retarded and psychotic individuals.
• Syndromes associated :
-Coffin – Lowry syndrome
-Cryptopthalamus ( fraser’s )syndrome
-Ectrodactyly –ectodermal –dysplasia- clefting
(EEC) syndrome
-Meckel’s syndrome
-Orofacial digital syndrome, type 1
( papillon – Leage – psaume) and type 2 (Mohr)
- Fetal face (Robinow’s) syndrome
-Trisomy 21(G1 Down ) syndromewww.iniandentalacademy.com

• Factors associated with increased
prevalence and degree of tongue fissuring
with age - salivary hypofunction and vit B
deficiency, candidiasis and chronic
(plaque like) lichenoid lesions.

Patent Thyroglossal ducts,
Thyroglossal duct cyst, and Lingual
thyroid
Thyroglossal duct cyst:
• Embryologically , as the thyroid gland descends
from base of tongue to its cervical location , it
brings with it a tract of epithelial tissue
( thyroglossal duct) that normally involutes by
10th
week of gestation.
• Remnants may remain , giving rise to cyst
formation in the base of the tongue.
• The lesion become very large or are secondarily
infected.

Lingual thyroid:
• Thyroid gland originates as a midline
endothelial outgrowth at the junction of
dorsal anterior 2/3rd
& base of the tongue in
the region of future foramen caecum.
• From there , thyroid tissue normally descends
through the tongue & cervical tissues to reach
its final position in the region of larynx.
• However this migration failed persistent
thyroid tissue may be found in the tongue.
• Firm , midline mass in the region of foramen
caecum. www.iniandentalacademy.com

• Symptoms- dysphagia ,
- difficulty with speech,
-a feeling of fullness in the throat.
• Investigation-
CT scan
Radioactive iodine uptake scan –for additional thyroid
tissue.
Biopsy not recommended - as only thyroid tissue present.
• T/t:
-No treatment for asymptomatic
-Partial or total excision- if mass causing functional
impairment
-Thyroid hormone supplementation.

Sagittal reconstruction of MRI scan of the neck,
showing the lingual thyroid at the base
of the tongue.
Lingual thyroid seen on
axial MRI scan of the neck.

Major inherited, congenital, and
developmental abnormalities
• Aglossia (Hypoglossia) :
- Associated with severe deformation of the
limbs and digits,
• Hypoglossia- hypodactylia,
• Oromandibular limb hypogenesis syndrome (only a
tiny nodule of tongue tissue develops from the copula)
• Ankyloglossum superius (glossopalatine ankylosis
syndrome)
• Lymph deficiency – splenogonadal fusion syndrome
• Hanhart’s syndrome
• Mobiu’s syndrome

Macroglossia
• is a component of numerous syndromes many of them
caused by inherited metabolic anomalies in which the
increase in tongue size is a manifestation of the
visceromegaly related to abnormal lysosomal storage
of carbohydrate macromolecules.
• Exomphalos –macroglossia –gigantism syndrome
( EMG or Beckwith- Widedemann)- genetically
determined endocrine abnormality.
- macroglossia , high birth weight, umbilical hernia,
enlargement of viscera, and linear indentations in ear
lobe are often complicated by hypoglycemia &
neoplasia. www.iniandentalacademy.com

• Neurofibromatosis type I: small localized nodule
to multiple & plexiform lesions that cause
massive enlargement of tongue.
• Hamartomatous syndrome ( Sturge –Weber)-
haemangiomas & lymphangiomas occur as a
localized lesions & tongue is massively involved
& enlarged.
• Hemangiomas restricted to tongue or in
continuity with a cystic hygroma of neck- most
common cause of congenital macroglossia.

• Surface of tongue is irregular & nodular.
• Altered patterns of blood or lymph flow can be
responsible for recurrent tongue enlargement.
( also seen in Down’s Syndrome)
• Large protruding tongues associated with happy
puppet ( Angelman syndrome) & congenital
hypothyroidism ( cretinism).
• Relative macroglosia( seen in Down’s syndrome)
– a normal sized tongue partially enclosed by a
small oral cavity due to maxillary retrusion & a
restricted nasopharynx.

• In adolescent , tongue enlargement can be
secondary to an epithelial inclusion cyst
( dermoid or epidermoid)
• In mature adult , macroglossia result from
acromegaly & may lead to distortion of
mandibular arch.
• Surgical reduction in case of congenital or
acquired macroglossia interferes with
oropharyngeal function or cosmetic
deformity. www.iniandentalacademy.com

Bald or Depapillated Tongues
• Atrophy of the filliform papillae (result of iron or
vitamin deficiency)
• Familial dysautonomia (Riley – Day syndrome) the
congenital absence of fungiform and vallate papillae
and a variety of autonomic, motor and sensory
dysfunctions result in vasomotor problems , absent
reflexes, feeding difficulties, and diminished pain and
taste sensation.
• Loss of papillae secondary to congenital anomalies
that result in scarring of the tongue dorsum occurs in
epidermolysis bullosa dyskeratosis congenita ,
endocrine candosis, and hyalinosis cutis et mucosae
syndromes.

Disorder of lingual mucosa
1. Changes in tongue papillae:
a. Geographic tongue ( benign migratory
glossitis) –
- irregularly shaped, reddish areas of
depapilation,& thinning of the dorsal tongue
epithelium that are usually surrounded by a narrow
zone of regenerating papillae i.e. whiter than the
surrounding tongue surface.
- often accompanied by fissured tongue, irregularities at
the junction of dorsal & ventral epithelium.www.iniandentalacademy.com

-histologically white and red areas show paillae of
variable height with some submucosal round cell
infiltration & areas of spongiotic epithelium with
localized intra epithelial infiltrate of poly
morphonuclear leucocytes so called intraepithelial
spongiotic pustules or Monro’s abscess.
• Ectopic geographic tongue, erythema circinata
migrans or annulus migrans (lesions occurred
elsewhere in the oral cavity )

• Etiology –immunologic reaction , atopic predisposition
( increased serum,IgE, associated hey fever,
asthma, eczematous dermatitis )
- Psychological stress
C/F : burning, stinging, & pain
T/t : topical local anesthetic agents of lidocaine ,
antihistamines such as 0.5 % aqueous diclonin hydrochloride
or diphenhydramine ,
administered as a mouth rinse over crushed ice before meals.

Coated or hairy tongue
• Heavily keratinized surface layers of the filliform papillae are
continuously desquamated through friction of the tongue with
food , the palate and the upper anterior teeth .
• During the illness or painful oral conditions , the filliform
papillae lengthen and becomes heavily coated with bacteria and
fungi.
• Longer papillae give the tongue a coated or hairy appearance
and retain debris and pigment from substances like food ,
tobacco –smoke and candy.
• Primarily affect the middorsum of the tongue.
• Extreme degree occurring in dehydrated debilitated , terminally
ill patients can lead to very thick leathery coatings on the tongue
referred to as ‘earthy’ or ‘encrusted’ tonguewww.iniandentalacademy.com

• Etiology : local and systemic
medication use ( systemic
antibiotics; topical oxidizing
agents such as H2O2 &
perborate & chlorhexidene used
in some mouth rinses)
• T/t : through cleaning and scraping of the
tongue
• Application of topical keratolytic agents &
yogurt or other lactobacillus acidophilus culture.www.iniandentalacademy.com

Non keratotic & keratotic white
lesion
Non keratotic white lesions
1. Thrush
( acute pseudomembronous candidiasis)
- prototype of oral infections with yeast like fungus -
candidia
-appears as classic pearly white , pin head ; sized flecks
scattered over dorsal surface of tongue.
- Composed of desquamated epithelial cells ,
inflammatory cells , fibrin, yeasts & mycelial elements.
- Etiology : medication , food debris other infectious
lesion , & where as oral cleansing mechanism are poor
(roof of mouth , mucobuccal fold, or retromoral region)www.iniandentalacademy.com

- Candida species are a normal
component of oral microbial flora
& become established their during
or soon after birth.
- Usually by direct spread from the mother genital tract , or
contact with contaminated skin or fomites.
- Typical lesions in infants are soft, white or bluish white ,
adherent patches on the oral mucosa.
- Intraoral lesions are generally painless and can be remove
with little difficulty but may leave a raw , bleeding
surface.
- In adults – inflammation , erythema and painful eroded
areas more seen.

Burns
• The thick, keratinized dorsal surface of the tongue
with an adherent coat of saliva is more resistant to
chemical and thermal burns than are thinner drier
areas of mucosa such as palate.
• Patients who scald or burns their tongues on hot
foods may experience some persistent pain and
hypersensitivity of the tongue.
• Severe burns caused by electric contacts and
ingestion of lye.
• Before sloughing of the dead tissue , the burned
area often becomes white and leathery.

Keratotic white lesions
• Lichen planus:
- lacelike, erosive and bullous
variety of this disorder may
affect the tongue
-Reticular lesion most common form
-In the papular form , 0.5- 1mm whitish elevated
lesion , or , plaques are seen.
-Chronic lichen planus often leads to
considerable
atrophy and scarring of the tongue dorsum.www.iniandentalacademy.com

Hairy leukoplakia
• Most common Ebstein Barr virus related
lesion in patients with AIDS is oral hairy
leukoplakia .
• Occurs on the lateral boarder of tongue &
range in appearance from faint white
vertical streaks to thickened & furrowed
area of leukoplakia exhibiting a shaggy
keratotic surface.

Depapillation and Atrophic
Lesions
• Localized or more extensive loss of the papillae
from the anterior 2/3rd
of the tongue may result
from a number of causes :
1) Chronic trauma:
- Localized area of depapillation associated with
Jagged teeth or rough margins of restorations.
-Contact of the tongue with dental medicaments
such as phenol.
2) Nutritional deficiencies and hematologic
abnormalities:
-Several vitamin B deficiency – niacin (pellagra)
riboflavin (ariboflavinosis), pyridoxine, folic acid
and vitamin B12 (pernicious anemia, sprue)www.iniandentalacademy.com

• Specific deficiency may result from malabsorption
syndrome (pernicious anaemia , sprue) or from drug
– conditioned deficiency (isoniazid and pyridoxine
deficiency), excessive loss of iron as well as deficient
intake involved in iron deficiency states.
• “raw”, “beefy” “magenta” or “bright red” , “Hunter’s
glossitis” – atrophic glossitis.
• Sideropenic anaemia: atrophic glossitis, angular
chelitis, generalized atrophic oral mucosa, oral
ulcerations, and secondary candidiasis.
• Plummer- Vinson syndromewww.iniandentalacademy.com

3) Medications:
Antibiotics
Cancer chemotherapeutic agents
Anticholinergic agents
4)Median rhomboid glossitis
- a rounded or roughly lozenge-shaped , raised area
that occurs in the midline of the tongue dorsum just
anterior to the vallate papillae
- the affected area is devoid of filiform or other papillae
,although it may be fissured or lobulated.

Tertiary syphilis and Interstitial
Glossitis
• Common in males
• Gumma formation or a more diffuse chronic
granulomatous lesion - Interstitial Glossitis
• Tongue – exhibit non ulcerating ,irregular
indurations with an asymmetric pattern of
grooves alternating with leucoplakia and smooth
(atrophic) fields covering the entire dorsum.
• Initially the tongue is often enlarged but later can
undergo marked shrinkage.
• Approx 25% of patients with carcinoma of the
tongue had positive test for syphilis. ( VDRL,
RPR)

Pigmentation
• Endogenous pigmentation-
- rarely identifiable but jaundice apparent
under thinner ventral mucosa.
-associated with
primary adrenal deficiency (Addison’s
disease), Peutz – Jeghers & Albright’s
syndromes, acanthosis nigricans , & some
cases of neurofibromatosis &
hemochromatosis.

• Exogenous pigmentation-
- of filiform papillae are common & due to microbial
growth & metabolic products, food debris, dyes from
candy & mouth rinses.
-tattooing of lateral margins & ventral surface of tongue
is common as a result of deposits of amalgam & other
metals from lacerations during dental treatment.
• Medications – doxorubicin , alpha-methyl dopa ,
tricyclic antidepressant (nortryptiline) & zidovudine.

Traumatic Injuries, Ulcers, &
infectious disease
• Ulcerations results from variety of physical
agents & infectious agents acting on normal
mucosa or mucosa that has been already
damaged by atrophic changes , vesiculobullous
disease or immunologic reactions.
• Mobility of tongue & its proximity to dentition
& dental prostheses contribute to its
susceptibility to physical trauma; this along with
mixed flora results in to all type of ulcer.

• Rough surfaces on restorations & jagged , broken
cusps rapidly cause ulcerations .
• Benign overgrowth ( fibroma) develops on dorsal
or ventral surfaces of tongue as a response of
chronic irritation, ulceration or biting trauma.
• Fimbriated folds on either side of lingual frenum
& openings of the submandibular & sublingual
glands are especially liable to be aspirated during
dental procedure with resultant ulceration &
ecchymosis. www.iniandentalacademy.com

• Ulcers on lingual frenum in neonates is due to
abrasion by lower incisors during sucking –
Riga’s ulcers or Riga – Fede disease.
• Shallow but persistent tongue ulcer especially
along posterior ventral surfaces- lichen planus,
various nutritional deficiencies, hematological
problems & in patients with xerostomia.
• The persistence of ulcers in these locations will
often cause cancers about the possibility of
carcinomatous change.

• Severe ulcers ; in nature of lacerations &
contusions are produced by sudden biting
trauma ( epilepsy) or a result of sudden blow to
jaw while the tongue lies between upper &
lower teeth.
• More chronic type seen in patients with
uncontrolled grinding & chewing movements as
result of ischaemic or brain damage.
• Special “ tongue –depressing splints” needed.
• Both ulcerative & prolifeartive lesions occur in
chronic granulomatosis.

• Tuberculosis of tongue- as a chronic ulcer on
posterior ventral surface or pharyngeal surface.
• Similar ulcers seen in disseminated
histoplasmosis, blastomycosis, cryptococosis,
sporotrichosis, & mucormycosis
• Extragenital chancre of primary syphilis & oral
lesion of Lymphogranuloma Venerum seen on
anterior third of tongue.
• Mucous patch of secondary syphilis may involve
tongue & other part of oral mucosa.
• In primary herpes simplex gingivostomatitis ,
the dorsum ,ventral surface & lateral margins of
tongue may be ulcerated.www.iniandentalacademy.com

• Recurrent herpes simplex
infections occurs intra orally
much less frequent & it affects
palate , attached gingiva & tongue
dorsum.
• Herpes zoster affects the lingual branch of madibular
division of 5th
cranial nerve & produce a series of
ulcers along the anterior 3rd
of the tongue on one side.

• In infections with erythrogenic
toxin producing S.pyogens
(scarlet fever), the classic sign
of ‘strawberry tongue’.
• ‘Baked tongue’- the dry , brown, coated tongue
described in typhoid fever.
• ‘Parrot tongue’- the dry , horney, immobile tongue
seen in chronic low grade fever.

• Multiple pseudomembranous ulceration
of the tongue & palate with septicemia
caused by Capnocytophaga sp.in
granulocytopenic patients.

Superficial vascular changes
• Lingual varicosities-
- purplish blue spots, nodules & ridges
usually on the anterior ventral surface of
the tongue & around the submandibular -
sublingual gland orifices .
- increases in number with age.
-sublingual varicosities also referred to as
‘caviar spots’.
-petechial hemorrhages & telangiectases
present on the ventral aspect of the tongue.www.iniandentalacademy.com

Haemangioma : can be classified as
a) congenital – common vascular tumor of infancy that
gradually involutes during adolescence.
b) Vascular malformations- present at birth but never
regress.
- this type occurs in the tongue.
-lingual vascular malformations appears as a distinctly
reddish, purplish, or bluish lesion that blanches when
compressed.
Small lesions – require no treatment
Lesions causing function problems or that are at risk of
injury- surgical management.www.iniandentalacademy.com

Hemangioma of the lateral aspect of the tongue in an 82 year-old man.

Disorders affecting
lingual mucosal glands
• Lingual mucosal glands
are affected in Sjogren’s
syndrome & pansialadenites.
• Large cyst of the sublingual glands that
often distend the overlying floor the
mouth & displace the tongue referred
to as ranula.
Dorsal tongue in primary Sjögren's
syndrome patient showing central
depapillation, dryness and erythema.

Diseases affecting body of tongue
1)Amyloidosis
• refers to a miscellaneous group of
conditions in which an amorphous
material with characteristic staining
properties is deposited extracellularly
in either a single organ or many organs.
• The tongue may be diffusely enlarged,
(macroglossia) thickened can affect the dentition ,
chewing, swallowing , and speaking.

2)Infections
• Result from contaminated traumatic injuries that
have been sutured superficially with inadequate
debridement of the deeper parts of the wound.
A) Ludwig’s angina (acute phelegmonous bacterial
infection of the tissue spaces)
• Characterized by an indurated swelling of the
whole floor of the mouth and base of the
tongue ,which pushes the tongue upward and
prevents the patient from closing the mouth.
• Dysphagia and upper airway obstruction-
common complication of all enlargements of the
base of the tongue.

B) Actinomyces species isolated from
tongue abscess especially where deep
lacerations of the tongue have been
contaminated with calculus and tooth
fragments.
• Chronic actinomycosis of the tongue with
induration and multiple draining sinuses-
so called wooden tongue of cattle..rare.

3)Neuromuscular disorders :
- of central , peripheral or muscular origin produce
symptoms of dysphagia and choking as well as speech
and masticatory problems.
• Dysphagia caused by weakness of the tongue muscles
referred to as oropharyngeal dysphagia.
- Symptoms - inability of the tongue to move the
bolus of food into the pharynx .
Speech problems caused by neuromuscular disorders
involving the tongue are severe and be the first
symptom noted by the patient (dysarthria)

Dystonia i.e. abnormally increased muscular
tone that results in a fixed abnormal posture;
the problem may be localized to a small
group of muscles( focal dystonia) or involve
major postural abnormality.
• Includes lingual or palatal muscular dystonia
(parkinsonism, athetosis)
• Involving the tongue and oropharyngeal
muscles may occur with levodopa,
neuroleptic medications (prochlorperazine)
and other phenothiazines.www.iniandentalacademy.com

• Dyskinesia i.e. any repetative uncontrolled
muscular activity but restricted to a disorder
,tardive dyskinesia( head, jaws,tongue or lips)
• Symptoms include rapid repetitive movements
of the tongue , jaws and lips.
• Fine tremors and fasiculations of the tongue –
“vermicular movements”; rapid , darting
movements of the tongue as “fly-catcher’s
tongue”or “bon-bon” sign .

• Weakness of the tongue can occur in
polymyositis , multiple sclerosis- the
flaccid small tongue that cannot be
extended and that falls backward in the
mouth blocking the airway.

Benign Tumors:
• Benign tumours are uncommon compared with
malignant sq. cell carcinoma.
• Haemangioma
• Papilloma
• Lymphangioma
• Lipoma
• Neurofibroma
• Osteoma

Malignant tumours of the
tongue
Squamous cell carcinoma of tongue:
uncommon below the age of 50 yrs
(50-70 years) used to be common
in men than women
Predisposing causes:
Chronic irritation by smoking,
sepsis, spices and spirits (alcohol).
o Pre-cancerous lesions which
o include syphilis, ch. Superficial
o glossitis, dental ulcers and
o papilloma.
• Poor oral hygiene and mal nutrition.
• Betel chewing.

Spread of carcinoma of the tongue:
• Local (direct to the floor of the mouth,
gums and pharynx).
• Lymphatic spread.
• Blood spread (very rare)

Investigation
1. Cineradiographic studies:
• Of the oral cavity & pharynx during drinking,
chewing, sucking , phonation & other activities have
added immesurably to our understandimg position &
shape of the tongue in motion & help diagnosis
abnormalities of swallowing , phonation & other
functions associated with congenital & surgically
induced defects.
2. Computer assisted tomography( CT Scan):
• Used to identify space occupying lesions & muscular
atrophy secondary to hypoglossal nerve damage,
where the lesion was deep in the base of tongue & not
detectable by other approaches.

3.Pulsed ultrasound:
• Used to study the characteristic of arterial
blood flow in the tongue and abnormal
pulse waves have been noted in the
lingual arteries of individuals with
evidence of compromised flow in other
branches of carotid arterial tree.

• Real time (gray scale , B mode) ultrasound: it is
adaptable for study of tongue provided the probe of
sufficiently small cross- sectional diameter are available
for exploring the ventral surface of the tongue . This
approach can be used an image of cyst or other lesion
within tongue and also to estimate tongue size.
• Isotope scanning techniques: it is useful in cases where
a mass in the tongue is composed of specialized
secretory tissue as thyroid, which selectively
concentrates intravenously administered radioactive
131I or 99 Tc- concentrate.

• Electromyography:
- Used for many years to study action potentials in
actively contracting muscles & has contributed to
an understanding of lingual & masticatory muscle
function.
- Recently , noninvasive techniques using surface
electrodes (earlier technique that requires a thin
needle electrode inserted in muscle to be studied )
has been introduced with considerable success.

• The scanning electron microscope (SEM):
- Is well established as a tool for studying
the surface topography of tongue
dorsum , the character & morphology of
different types of tongue papillae, and the
distribution and morphology of bacteria
on the papillated areas of the dorsum.

• Transmission electron microscopy (TEM):
-Used to study of tongue biopsies of patients with
various taste complaints .
-Helps to establish the nature of granular cells
found in tongue.
- Direct microscopic examination of tongue papillae
and the capillary blood flow the fungiform papillae
in particular is possible with intravenously
administered fluorescein dye.though there is
possibility of anaphylactic or other untoward
allergic reaction to the dye , it has been used to
demonstrate changes in the taste papillae, as well
as localized areas of decreased blood flow on the
tongue secondary to diabetic angiopathy.

• Psychophysical evaluation of lingual
sensory function
• Includes various methods for evaluating
taste function ( taste testing with a series of
concentrations of sweet, sour , bitter and
salty solutions; electrogustometry; and
regional “tongue mapping” for localized
taste dysfunction); tactile sensation testing
by means of von Frey fibers, a single or two
– point esthesiometer.

Conclusion
• The tongue is not only the site of variety of local lesion,
but it also reflects the presence of number of systemic
diseases
• The location of lesion & its physical characteristics can
also be essential factors in determining its diagnosis &
possible etiology.
• Mouth is the mirror that reflects the entire body health,
The tongue's villi may become discolored if a person
smokes or chews tobacco, eats certain foods, or has
colored bacteria growing on the tongue....
• Brushing the tongue with a toothbrush or scraping it
with a tongue scraper is very useful to maintain the oral
hygiene.

References
1.Malcolm A.Lynch, Vernon,J.Brightman, Martin S. Greenberg. Burket’s Oral
Medicine , Diagnosis and treatment 8th
edi.,J.B.Lippincott Company
Philadelphia 1984.
2. Malcolm A.Lynch, Vernon,J.Brightman, Martin S. Greenberg. Burket’s Oral
Medicine , Diagnosis and treatment 9th
edi.,J.B.Lippincott Company
Philadelphia 1994.
3.B.D.Chourasia.Human Anatomy Regional & Applied Dissection and clinical
volume 3 Head,Neck and brain fourth edition 2004:249-254
4.Daniel M.Laskin, James A. Giglio,Eric T.Rippert :Differtial diagnosis of
tongue lesions.J.Quintessence International ;3;3;2003:15-26
5.K Sembulingam, Prema Sembulingam. Essentials of Medical Physiology 3rd
edi.,2004:841
6.Willium G.Shafer, Maynard K.Hine, Barnet M.Levy. A textbook of Oral
Pathology 4th
edi.,2000:24-25.
7. http://www.entusa.com

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