Glossitis

para>Many patients with glossitis caused by nutritional deficiencies are postmenopausal or elderly.
Prevalence
Varies; usual reported range: 1-14%; higher with nutritional deficiencies

ETIOLOGY AND PATHOPHYSIOLOGY

Systemic
- 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)
Local
- 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)
Tongue
- AG: atrophy of filiform papillae
- BMG: erythematous, yellow-white lesions (dorsum)
- MRG: atrophic filiform, plaque-like lesions (midline)
- HGG: linear fissures (dorsum)

Genetics
Familial history may be present with BMG.

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

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

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]

Diagnostic Procedures/Other

Biopsy solitary lesions that do not respond to treatment (3,7)[B]
Examine scrapings with 10% potassium hydroxide for suspected candidiasis (1).

Test Interpretation
Vary according to underlying causes
Pediatric Considerations

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

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

AG
- 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]
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].
HGG
- Oral antivirals such as acyclovir 200 mg 5 times daily (3)[B]
Contraindications:
- Nystatin oral suspension: hypersensitivity to nystatin products
- Clotrimazole troche: hypersensitivity to clotrimazole
- Diphenhydramine
  - Hypersensitivity to diphenhydramine
  - Newborns or premature infants
  - Nursing mothers
- Acyclovir (oral): hypersensitivity to acyclovir or valacyclovir
- Triamcinolone (oral paste): corticosteroid hypersensitivity
Precautions:
- Clotrimazole troche: hepatic impairment
- Diphenhydramine
  - 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
- 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
Significant possible interactions:
- Diphenhydramine: alcohol (increased sedation)
- Acyclovir (oral): meperidine (increased risk of CNS stimulation and seizures)
Adverse effects:
- Clotrimazole troche
  - Nausea, vomiting, or diarrhea
  - Mild elevations in serum glutamic-oxaloacetic transaminase (SGOT) levels
- Diphenhydramine
  - Sedation
  - Dizziness
  - Urinary retention
- Acyclovir (oral)
  - Nausea, vomiting, and diarrhea
  - Myalgia
  - Transient renal impairment
- Triamcinolone (oral paste)
  - Burning
  - Itching
  - Irritation

Pediatric Considerations

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

Admission Criteria/Initial Stabilization
If glossitis is secondary to a severe primary condition, attend to any acute needs of the primary problem.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

If lesions do not heal, biopsy is indicated.

PATIENT MONITORING

Revisit periodically when needed until healing occurs.

DIET

Bland or liquid diet

PATIENT EDUCATION

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

PROGNOSIS

Prompt improvement when cause can be identified and treated.

COMPLICATIONS

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

REFERENCES

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.

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.

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 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.
Testing: serum B12, folic acid, CBC with differential, ferritin, RPR, TSH

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