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Glossitis

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Glossitis

ETIOLOGY AND PATHOPHYSIOLOGY

para>Many patients with glossitis caused by nutritional deficiencies are postmenopausal or elderly.

Varies; usual reported range: 1-14%; higher with nutritional deficiencies

Familial history may be present with BMG.

Initial Tests (lab, imaging)

Serum B12, folic acid, CBC with differential, ferritin, rapid plasma reagin (RPR), thyroid-stimulating hormone (TSH)

Vary according to underlying causes

Some symptoms of glossitis have no organic cause. Treat symptoms and reevaluate if no improvement.

Admission Criteria/Initial Stabilization

If glossitis is secondary to a severe primary condition, attend to any acute needs of the primary problem.

Revisit periodically when needed until healing occurs.

Prompt improvement when cause can be identified and treated.

11 Terai H, Shimahara M. Atrophic tongue associated with Candida. J Oral Pathol Med. 2005;34(7):397-400.22 Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627-634.33 Byrd JA, Bruce AJ, Rogers RSIII. Glossitis and other tongue disorders. Dermatol Clin. 2003;21(1):123-134.44 Tarakji B, Umair A, Babaker Z, et al. Relation between psoriasis and geographic tongue. J Clin Diagn Res. 2014;8(11):ZE06-ZE07.55 Nelson BL, Thompson L. Median rhomboid glossitis. Ear Nose Throat J. 2007;86(10):600-601.66 Codreanu F, Jarlot S, Astier C, et al. An apple a day . . . chronic glossitis in a 4-year-old boy. Eur Ann Allergy Clin Immunol. 2012;44(2):86-88.77 Assimakopoulos D, Patrikakos G, Fotika C, et al. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113(9):751-755.88 Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol. 2002;29(5):400-410.

  • SystemicNutritional deficiencies (e.g., vitamin B12, folic acid, ascorbic acid)Anemia (pernicious, iron deficiency)HIV (opportunistic infections such as candidiasis, herpes simplex virus [HSV]; or HIV-associated changes such as loss of papillae)Broad-spectrum antibioticsTopical or inhaled corticosteroidsVarious other medications (e.g., captopril, clarithromycin, enalapril, lansoprazole, lithium, metronidazole, NSAIDs)
  • LocalInfections (e.g., HSV, Epstein-Barr virus, candidiasis)Trauma (ill-fitting dentures, piercings, burns, convulsive seizures)Primary irritants (alcohol, tobacco, hot foods, spices, excessive peppermint, citrus)Sensitization with chemical irritants (e.g., dyes, mouthwash, toothpaste, systemic drugs)Malignancy (95% are squamous cell)
  • TongueAG: atrophy of filiform papillaeBMG: erythematous, yellow-white lesions (dorsum)MRG: atrophic filiform, plaque-like lesions (midline)HGG: linear fissures (dorsum)
  • Nutritional deficiencies (e.g., vitamin B12, folic acid, ascorbic acid)
  • Anemia (pernicious, iron deficiency)
  • HIV (opportunistic infections such as candidiasis, herpes simplex virus [HSV]; or HIV-associated changes such as loss of papillae)
  • Broad-spectrum antibiotics
  • Topical or inhaled corticosteroids
  • Various other medications (e.g., captopril, clarithromycin, enalapril, lansoprazole, lithium, metronidazole, NSAIDs)
  • Infections (e.g., HSV, Epstein-Barr virus, candidiasis)
  • Trauma (ill-fitting dentures, piercings, burns, convulsive seizures)
  • Primary irritants (alcohol, tobacco, hot foods, spices, excessive peppermint, citrus)
  • Sensitization with chemical irritants (e.g., dyes, mouthwash, toothpaste, systemic drugs)
  • Malignancy (95% are squamous cell)
  • AG: atrophy of filiform papillae
  • BMG: erythematous, yellow-white lesions (dorsum)
  • MRG: atrophic filiform, plaque-like lesions (midline)
  • HGG: linear fissures (dorsum)

RISK FACTORS

  • Poor nutrition
  • Dentures
  • Piercings
  • Allergic background (e.g., asthma, eczema, hay fever)
  • Smoking, smokeless tobacco
  • Alcoholism
  • Anxiety, stress
  • Depression
  • Hormonal disturbances
  • Oral contraceptives
  • Advancing age
  • Immunocompromised state

GENERAL PREVENTION

  • Evaluation of nutritional status, including vitamin B deficiencies, anemias
  • Cessation of tobacco use (including smokeless)
  • Assess for irritation from teeth, dentures, or piercings.

COMMONLY ASSOCIATED CONDITIONS

  • Fissured tongue (BMG)
  • HIV infection (rare)
  • Reiter syndrome (rare)
  • Down syndrome (rare)
  • Crohn disease (rare)
  • Celiac disease (possible correlation)
  • Psoriasis (possible correlation)

DIAGNOSIS

  • Many cases are asymptomatic.
  • BMG symptoms tend to wax and wane.

HISTORY

  • Oral discomfort
  • Burning sensation on tongue (often associated with nutritional deficiency)
  • Sensitivity to hot or spicy foods
  • Sensation of foreign body in the mouth
  • Paroxysmal ear pain
  • Swollen or painful submandibular lymph nodes

PHYSICAL EXAM

  • AG: smooth, glossy, red or pink tongue (1,2)[B]
  • BMG: erythematous and white patches on the dorsum of tongue; lesions may lack papillae; irregular (map-like) and migratory lesions (3)[B]
  • MRG: erythematous, shiny, rhomboid-shaped plaque in middle of tongue; hypertrophic or atrophic surface changes (2,3)[B]
  • HGG: linear fissures on dorsal tongue; geometric pattern is common; herpetic lesions usually are absent on other mucosal surfaces (3)[B].
  • A detailed oral exam is recommended for psoriatic patients (4)[A].

DIFFERENTIAL DIAGNOSIS

  • Irritation fibroma
  • Mucocele
  • Granular cell tumor
  • Tertiary syphilis
  • Drug reaction
  • Lichen planus
  • Candidiasis
  • Squamous cell carcinoma (rarely) (5)
  • Scurvy (6)

DIAGNOSTIC TESTS & INTERPRETATION

  • AG: Test for vitamin B12, folic acid, iron deficiency (1)[B].
  • BMG: none (3,7)[B]
  • MRG: viral culture, fungal smear (3)[B]
  • HGG: viral culture, Tzanck smear (3)[B]
  • Biopsy solitary lesions that do not respond to treatment (3,7)[B]
  • Examine scrapings with 10% potassium hydroxide for suspected candidiasis (1).

Differential diagnosis includes local trauma and severe neutropenia (7).

TREATMENT

GENERAL MEASURES

  • Usually outpatient
  • Avoid any possible sensitizing irritants or agents (such as acidic or spicy foods and drinks).
  • Analgesics when needed
  • Request dental evaluation.
  • Scrupulous oral hygiene

MEDICATION

  • AGVitamin B12, folic acid, iron (if deficient)For candidiasis: nystatin oral suspension 100,000 units/mL swish and spit 5 mL QID ORclotrimazole 1 to 2 troches 4 to 5 times a day (3)[B]
  • BMG (usually no treatment if asymptomatic)The following agents may be used to reduce tongue sensitivity or if lesions recur: antihistamines such as diphenhydramine liquid: Rinse with 5 to 10 mL, holding it over the tongue for a few minutes and then swallowing, 3 to 4 times a day (may also dilute in a 1:4 ratio with water) (2,7)[B] OR miracle mouthwash: swish and spit 5 mL, 3 to 4 times a day, OR topical steroid gels such as 0.1% triamcinolone oral dental paste (Oralone) (2)[B].
  • MRG (usually no treatment if asymptomatic)Topical antifungals (nystatin oral suspension or clotrimazole troches) may provide temporary improvement (3)[B].
  • HGGOral antivirals such as acyclovir 200 mg 5 times daily (3)[B]
  • Contraindications:Nystatin oral suspension: hypersensitivity to nystatin productsClotrimazole troche: hypersensitivity to clotrimazoleDiphenhydramineHypersensitivity to diphenhydramineNewborns or premature infantsNursing mothersAcyclovir (oral): hypersensitivity to acyclovir or valacyclovirTriamcinolone (oral paste): corticosteroid hypersensitivity
  • Precautions:Clotrimazole troche: hepatic impairmentDiphenhydramineMay cause excitation in young childrenConcurrent monoamine oxidase inhibitor (MAOI) therapyConcurrent use of CNS depressantsDecreases mental alertness and psychomotor performanceOlder adults are more susceptible to side effects.Bladder neck obstructionSymptomatic prostatic hypertrophyNarrow-angle glaucomaHistory of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertensionAcyclovir (oral)Maintain adequate hydration.Geriatric patients (due to age-related decline in renal function)Renal impairmentTriamcinolone (oral paste): infections or sores in the mouth
  • Significant possible interactions:Diphenhydramine: alcohol (increased sedation)Acyclovir (oral): meperidine (increased risk of CNS stimulation and seizures)
  • Adverse effects:Clotrimazole trocheNausea, vomiting, or diarrheaMild elevations in serum glutamic-oxaloacetic transaminase (SGOT) levelsDiphenhydramineSedationDizzinessUrinary retentionAcyclovir (oral)Nausea, vomiting, and diarrheaMyalgiaTransient renal impairmentTriamcinolone (oral paste)BurningItchingIrritation
  • Vitamin B12, folic acid, iron (if deficient)
  • For candidiasis: nystatin oral suspension 100,000 units/mL swish and spit 5 mL QID ORclotrimazole 1 to 2 troches 4 to 5 times a day (3)[B]
  • The following agents may be used to reduce tongue sensitivity or if lesions recur: antihistamines such as diphenhydramine liquid: Rinse with 5 to 10 mL, holding it over the tongue for a few minutes and then swallowing, 3 to 4 times a day (may also dilute in a 1:4 ratio with water) (2,7)[B] OR miracle mouthwash: swish and spit 5 mL, 3 to 4 times a day, OR topical steroid gels such as 0.1% triamcinolone oral dental paste (Oralone) (2)[B].
  • Topical antifungals (nystatin oral suspension or clotrimazole troches) may provide temporary improvement (3)[B].
  • Oral antivirals such as acyclovir 200 mg 5 times daily (3)[B]
  • Nystatin oral suspension: hypersensitivity to nystatin products
  • Clotrimazole troche: hypersensitivity to clotrimazole
  • DiphenhydramineHypersensitivity to diphenhydramineNewborns or premature infantsNursing mothers
  • Acyclovir (oral): hypersensitivity to acyclovir or valacyclovir
  • Triamcinolone (oral paste): corticosteroid hypersensitivity
  • Hypersensitivity to diphenhydramine
  • Newborns or premature infants
  • Nursing mothers
  • Clotrimazole troche: hepatic impairment
  • DiphenhydramineMay cause excitation in young childrenConcurrent monoamine oxidase inhibitor (MAOI) therapyConcurrent use of CNS depressantsDecreases mental alertness and psychomotor performanceOlder adults are more susceptible to side effects.Bladder neck obstructionSymptomatic prostatic hypertrophyNarrow-angle glaucomaHistory of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertension
  • Acyclovir (oral)Maintain adequate hydration.Geriatric patients (due to age-related decline in renal function)Renal impairment
  • Triamcinolone (oral paste): infections or sores in the mouth
  • May cause excitation in young children
  • Concurrent monoamine oxidase inhibitor (MAOI) therapy
  • Concurrent use of CNS depressants
  • Decreases mental alertness and psychomotor performance
  • Older adults are more susceptible to side effects.
  • Bladder neck obstruction
  • Symptomatic prostatic hypertrophy
  • Narrow-angle glaucoma
  • History of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertension
  • Maintain adequate hydration.
  • Geriatric patients (due to age-related decline in renal function)
  • Renal impairment
  • Diphenhydramine: alcohol (increased sedation)
  • Acyclovir (oral): meperidine (increased risk of CNS stimulation and seizures)
  • Clotrimazole trocheNausea, vomiting, or diarrheaMild elevations in serum glutamic-oxaloacetic transaminase (SGOT) levels
  • DiphenhydramineSedationDizzinessUrinary retention
  • Acyclovir (oral)Nausea, vomiting, and diarrheaMyalgiaTransient renal impairment
  • Triamcinolone (oral paste)BurningItchingIrritation
  • Nausea, vomiting, or diarrhea
  • Mild elevations in serum glutamic-oxaloacetic transaminase (SGOT) levels
  • Sedation
  • Dizziness
  • Urinary retention
  • Nausea, vomiting, and diarrhea
  • Myalgia
  • Transient renal impairment
  • Burning
  • Itching
  • Irritation
  • Topical antifungal/steroid agent: triamcinolone acetonide 0.1% in nystatin suspension (8)[B]
  • Alkaline saline mouth rinse (8)[B]
  • Topical anesthetics/coating agents: 1:1 mixture of diphenhydramine liquid and Maalox (8)[B]

Topical antifungal/steroid agent: triamcinolone acetonide 0.1% in nystatin suspension (8)[B]

Alkaline saline mouth rinse (8)[B]

Topical anesthetics/coating agents: 1:1 mixture of diphenhydramine liquid and Maalox (8)[B]

INPATIENT CONSIDERATIONS

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

PATIENT MONITORING

DIET

PATIENT EDUCATION

  • Proper diet and nutrition
  • Avoid irritants such as cigarette smoking and acidic or spicy foods.
  • Maintain good oral hygiene.

PROGNOSIS

COMPLICATIONS

  • Recurrence: Evaluate for systemic etiology.
  • Chronicity: If not healing, biopsy is indicated.

REFERENCES

ADDITIONAL READING

  • Demir N, DoÄŸan M, Ko § A, et al. Dermatological findings of vitamin B12 deficiency and resolving time of these symptoms. Cutan Ocul Toxicol. 2014;33(1):70-73.

SEE ALSO

CODES

ICD10

  • K14.0 Glossitis
  • K14.4 Atrophy of tongue papillae
  • K14.1 Geographic tongue
  • K14.2 Median rhomboid glossitis

ICD9

  • 529.0 Glossitis
  • 529.4 Atrophy of tongue papillae
  • 529.1 Geographic tongue
  • 529.2 Median rhomboid glossitis

SNOMED

  • Glossitis (disorder)
  • Atrophy of tongue papillae (disorder)
  • Geographic tongue (disorder)
  • Persistent tuberculum impar (disorder)
  • Acute glossitis (disorder)
  • Chronic glossitis (disorder)

CLINICAL PEARLS

  • An acute or chronic inflammation of the tongue, either as primary disease or a symptom of systemic disease
  • The most common forms are as follows:AG or Hunter glossitis: smooth, glossy, red or pink tongueBMG or geographic tongue or erythema migrans: erythematous and white patches on the dorsum of tongue; lesions may lack papillae; irregular (map-like) and migratory lesionsMRG: erythematous, shiny, rhomboid-shaped plaque in middle of tongue; hypertrophic or atrophic surface changesHGG: linear fissures on dorsal tongue; geometric pattern is common; herpetic lesions usually are absent on other mucosal surfaces.
  • Testing: serum B12, folic acid, CBC with differential, ferritin, RPR, TSH
  • AG or Hunter glossitis: smooth, glossy, red or pink tongue
  • BMG or geographic tongue or erythema migrans: erythematous and white patches on the dorsum of tongue; lesions may lack papillae; irregular (map-like) and migratory lesions
  • MRG: erythematous, shiny, rhomboid-shaped plaque in middle of tongue; hypertrophic or atrophic surface changes
  • HGG: linear fissures on dorsal tongue; geometric pattern is common; herpetic lesions usually are absent on other mucosal surfaces.