Tongue in health and disease

1. TONGUE IN
HEALTH AND
DISEASES
CHAIR PERSON – DR PRAVEEN KUSUBI
STUDENT – DR RAVIKIRAN

2. The tongue is a complex set of sensory papillae and muscles.
3 forms of taste buds:
• Fungiform (anterior)
• Circumvallate (posterior dorsum)
• Foliate papillae (posterior lateral)
The filiform papillae - devoid of sensory fibers and are not true
taste buds.

3. APPEARANCE
MOISTURE
SIZE
PIGMENTATION
ULCERS
TREMORS
DEVELOPMENTAL ANOMALIES

4. COLOUR
PALE/WHITE TONGUE
Iron deficiency anaemia
 Leukoplakia
 Excessive furring
 Irritant substances-mercury bichloride, carbolic acid, sulphuric
acid

5. PALE TONGUE

6. RED BEEFY TONGUE IN VIT B12
DEFICIENCY

7. SCARLET RED TONGUE
Niacin deficiency
Acute glossitis
Irritants – sodium or potassium hydroxide
Acute infections like scarlet fever

8. SCARLET RED TONGUE

9. RIBOFLAVIN DEFICIENCY
• Involvement of angle of mouth ( chielosis or perleche), buccal
mucosa and conjunctiva are early.
• When tongue involved, MAGENTA coloured tongue seen

10. MAGENTA COLOURED TONGUE

11. PURPLE TONGUE
Polycythemia

12. BLUE TONGUE
Central Cyanosis
YELLOW TONGUE
Jaundice(rarely)
Acute hepatic necrosis( a yellowish brown fur)
Irritants- nitric or hydrochloric acid

13. CYANOSED TONGUE

14. YELLOW TONGUE

15. HAIRY TONGUE
• AKA- furred tongue
• It is the result of retention hyperkeratosis of the filiform papillae
on the anterior 2/3 of the dorsal aspect of the tongue.

16. HAIRY TONGUE

17. HAIRY TONGUE
• poor oral hygiene, smokers, drug users, mouth breathers, low
fiber diets, and febrile patients.
• HIV infections, graft-versus host disease (GVHD), or internal
malignancies.
• drugs - most common being antibiotics.
• atypical antipsychotics, antidepressants, and anti-cholinergics.

18. BLACK HAIRY TONGUE
• Black HT, seen in the spectrum of HT, occurs when bacteria are
trapped in the filiform papillae and produce pigments causing a
brown/black color.
• The presence of other microbes, such as candida, can exacerbate
this condition.

19. BLACK HAIRY TONGUE

20. PSEUDO HAIRY BLACK TONGUE -
BISMUTH SALICYLATE

21. DD OF HAIRY TONGUE
• Pseudo-hairy black tongue,
• Oral hairy leukoplakia
• Premalignant leukoplakia
• Squamous cell carcinoma
• Acanthosis nigricans
• Hypertrophic herpes simplex virus infections

22. WORKUP FOR HAIRY TONGUE
• Unless there are stigmata of underlying disease or symptoms,
such as pain, no additional workup is needed.
• In refractory or atypical cases, a biopsy and cultures or PCR for
bacteria, fungus, and HSV may be warranted.

23. TREATMENT OF HAIRY TONGUE
• Regular brushing of the tongue with using 1.5% hydrogen peroxide
(5 to 10 strokes daily) with a hard toothbrush.
• Topical retinoids, antifungals, and keratolytics.
• Oral therapy with antifungals, antibiotics and antivirals for
refractory cases with positive cultures.
• When the disease is refractory or persistent, an alternative
diagnosis, an associated systemic disease, or oral malignancy
should be considered.

24. BROWN TONGUE
Uraemia

25. STRAWBERRY TONGUE
In scarlet fever with progression of epithelial exfoliation, all the
papillae appear as large red knobs giving the appearance of
stawberry tongue
Also seen in ,
 toxic shock syndrome
 kawasaki disease

26. STRAWBERRY TONGUE

27. SCARLET FEVER

28. LEUKOPLAKIA
• Hypertrophy and cornification of epithelial surfaces leading to
formation of thick , white and pearly raised plaques giving whitish
appearance of part of tongue.
• Predisposing factors
• Spices, betel nut chewing
• Smoking, tobacco chewing
• Infective or mechanical (dental irritation)

29. LEUKOPLAKIA

30. ERYTHROPLAKIA

31. ORAL HAIRY LEUKOPLAKIA
• Seen on lateral margins of tongue as several white areas
• Immuno-compromised patients
• Associated with Epstein Barr virus
• The plaques are asymptomatic and cannot be
• Wiped off with gauze.

32. ORAL HAIRY LEUKOPLAKIA

33. OHL
• OHL is asymptomatic, has no malignant potential.
• First line topical treatment of OHL includes topical retinoids,
podophyllin, and acyclovir, Anti candida agents.
• the underlying HIV infection should be treated or the
immunosuppressed states should be modified.

34. PIGMENTATION OF
TONGUE
Dark brown or black patches on tongue may be due to
1. Addisons
2. Nelsons syndrome
3. Peutz jeghers
4. Malabsorption
5. Chronic cachxia

35. ADDISON’S DISEASE

36. SURFACE
• Fissured tongue
• Scarred tongue
• Cobblestone tongue
• Crocodile skin tongue
• Smokers patch
• Geographic tongue
• Median rhomboid glossitis
• Oral candidiasis

37. FISSURED TONGUE

38. FISSURED TONGUE
• A normal variant seen in up to 20% to 30% of the population
• Characterized by an increased number of fissures and grooves at
the central and lateral aspects of the tongue.
• More severe fissuring is often referred to as “lingua plicata.”

39. FISSURED TONGUE
• FT is more common in individuals with geographic tongue and
psoriasis( 1/3rd).
• Other associations include:
• Down’s syndrome
• Melkersson-Rosethenal syndrome
• Pernicious anemia
• Macroglossia
• Pachyonychia congenita
• Cowden’s syndrome

40. FISSURED TONGUE- MX
• Good oral hygiene with brushing deep into the fissures in order to
remove debris, lessen the microbial burden, and reduce halitosis.
• If pain is present- therapy should be targeted at reducing
inflammation or eradication of the infection.

41. COBBLESTONE TONGUE
• Ariboflavinosis(with magenta colour)
• Syphilis(with leukoplakia)
CROCODILE SKIN TONGUE
• In sjogren’s syndrome there is dorsal papillary atrophy &
furring of the tongue

42. COBBLESTONE TONGUE

43. SMOKER’S PATCH
• Small, raised, smooth, congested area frequently covered with
a crust on the dorsum of tongue
• White umbilicated papules with a central brown spot on
palatal mucosa
LEPROTIC NODULES
• May develop on anterior 2/3rd of tongue especially near tip
EHLERS DANLOS SYNDROME
• Corlin’s sign-tongue is extensible to touch the nose

44. EHLER DANLOS SYNDROME

45. BENIGN MIGRATORY GLOSSITIS
• AKA geographic tongue & annular transient patches of the
tongue.
• Benign, inflammatory condition that affects all age groups.
• 1 to 2% of the population ,more common in young patients.
• BMG is more common in psoriasis, up to 14%, and some argue
that BMG is an oral manifestation of psoriasis

46. BMG (GEOGRAPHIC TONGUE)
• BMG is characterized by an annular arrangement of alternating
raised, hyper keratotic plaques and smooth, atrophic patches.
• Filiform papillae are absent in the atrophic, red patches.
• Dynamic and change over time creating a “migratory pattern”
• BMG often has a waxing and waning course.

47. GEOGRAPHIC TONGUE

48. TREATMENT OF GEOGRAPHIC TONGUE
• BMG is often asymptomatic .
• Few individuals experiencing burning pain or sensitivity to
foods.
• Mainstay of treatment for symptomatic BMG is with potent
topical corticosteroids as well as topical calcineurin inhibitors.

49. MEDIAN RHOMBOID GLOSSITIS
Red depapillated area in the centre of tongue dorsum
Believed to be associated with candidiasis
Biopsy may show pseudo-epitheliomatous hyperplasia
May respond to antifungal treatment

50. MEDIAN RHOMBOID GLOSSITIS

51. CANDIDIASIS

52. ORAL CANDIDIASIS
• Oral Candidiasis into acute and chronic types with further sub-
dvisions.
Acute:
• Acute Pseudomembranous Oral Candidiasis (Thrush)
• Acute Atrophic Oral Candidiasis (Erythematous)

53. Chronic:
Chronic Hyperplastic Oral Candidiasis
(Candidal Leukoplakia)
Chronic Atrophic Oral Candidiasis ( Angular Cheilitis)

54. ORAL CANDIDIASIS
1. Pseudomembranous type (“thrush”):
Creamy white curdlike patches that reveal a raw, bleeding surface when
scraped.
• Sick infants
• Debilitated elderly patients
• Receiving high-dose glucocorticoids broad-spectrum antibiotics
• Patients with AIDS

55. THRUSH
(PSEUDOMEMBRANOUS )

56. ACUTE ERYTHEMATOUS TYPE
(ATROPHIC TYPE)
Flat, red, sometimes sore areas .

57. CANDIDAL LEUKOPLAKIA
(CHRONIC HYPERPLASTIC CANDIDIASIS)

58. CHRONIC ATROPHIC ORAL CANDIDIASIS
( ANGULAR CHEILITIS)

59. MOISTURE
DRYNESS
• Prolonged fever
• Dehydration
• After haemorrhage
• Dyspnoea
• Mouth breathing
• Uraemia
• Belladona or atropine effect
• Anxiety state
• Sjogrens syndrome
• Sarcoidosis

60. DRY TONGUE

61. MACROGLOSSIA
• Acromegaly
• Hypothyroidism
• Cretinism
• Down’s syndrome
• Hurler’s syndrome
• Mucopolysaccharidosis
• Beckwith–Wiedemann syndrome
• Amyloidosis
• Glycogen storage disease
• Angio edema
• Acute inflammation of tongue/abscess
• Haemangioma,lymphangioma

62. MACROGLOSSIA

63. MICROGLOSSIA
• Starvation
• Atrophic glossitis
• Bilateral or unilateral paralysis
• Pseudobulbar palsy

64. MICROGLOSSIA

65. ULCERS
SINGLE
• Carcinomatous
• TB
• Syphilitic
• Dental

66. CARCINOMATOUS ULCER
• Usually single
• Common on side or tip of tongue
• Hard, indurated
• Irregular ,deep, raised everted margins
• Associated with slough
• Impaired mobility of tongue
• Regional lymphnode enlargement

67. TONGUE MALIGNANCY

68. TUBERCULOUS ULCER
• Usually at or near tip
• Painful
• Small with a granulated base
• Thin undermined edges

69. MULTIPLE ULCERS
• Dyspepsia
• Ulcerative stomatitis
• Secondary syphilis
• Herpes
• Chickenpox
• Eczema
• Vit B complex deficiency

70. MULTIPLE ULCERS

71. RECURRENT ULCERS
• Aphthous ulcer
• Leukaemia
• Lichen planus, pemphigus, pemphigoid, eythema multiforme
• SLE
• Behcet’s syndrome (mouth ulcers, genital ulcers, uveitis)

72. MOVEMENTS OF THE TONGUE
TREMOR
• Parkisons disease
• Delirium tremens
• Bulbar palsy
• Involvement of hypoglossal nerve or nucleus
• Multiple sclerosis
• Chronic alcoholism
• Thyrotoxicosis

73.  LIZARD TONGUE(Jack-in-box tongue)
• Rheumatic chorea
 CHEWING TONGUE
• Athetosis
 Fasiculation
• Motor neuron diseases

74. DEVIATED TONGUE
• Involvement of hypoglossal nerve
• Malignant infiltration of the tongue
• Scarification after burns
• Severe ulceration

75. DEVIATED TONGUE

76. DEVELOPMENTAL ANOMALIES
• Tongue tie
• Congenital macroglossia
• Microglossia
• Aglossia
• Bifid or trifid

77. AGLOSSIA

78. BIFID TONGUE

79. TONGUE TIE

80. MISCELLANEOUS CONDITIONS
AMYLOID TONGUE
• Appears enlarged & presents a mottling of dark purple
areas with translucent matter
ALLIGATOR TONGUE
• Dry, thick, furrowed & irregular tongue in diabetes
CAVIAR TONGUE
• Varicosities of the sublingual veins on the under surface
of the tongue

81. CAVIAR TONGUE

82. REFRENCES
• A text book of symptoms and physical diagnosis. ASPI F
GOLWALLA - 5TH Edition
• HARRISON’S Principles of Internal Medicine - 20th edition
• DAVIDSON principles and practice of medicine - 23rd edition
• Mangold Aaron R., Torgerson Rochelle R., Rogers Roy S.,
Diseases of the Tongue, Clinics in Dermatology (2016)

83. THANK YOU