1GOOD MORNING

2

Presented by:

Dr. Ratna . SamudrawarPg 1 year

DISEASES OF TONGUE

Introduction Development of tongue Anatomy of tongue Examination of tongue Function of tongue Classification Diseases of tongue Applied aspects Conclusion References

CONTENTS:

INTRODUCTION

Tongue is a muscular organ situated in the floor of mouth.

It forms the part of floor of the oral cavity and part of

anterior wall of oropharynx.

It is attached to the inner surface of the mandible near the

midline and gains support below from the hyoid bone.

Comprises of voluntary skeletal muscle.

5

Parts of tongue

BODY

TIP

ROOT

Curved upper surface / dorsum

Inferior surface Oral partPharyngeal part

ROOT : It is attached to styloid process and soft palate above and to mandible and hyoid bone below.

6

• Because of these attachments tongue doesn’t falls back to block the oropharynx.(airway obstruction)

• In between mandible and hyoid bone , it is related to geniohyoid and mylohyoid muscle.

7

TIP : It forms the anterior free end which , at rest, lies behind the upper incisor teeth.

8

BODY :1.Dorsum : convex in all directions.a.Oral Part : anterior 2/3 b.Pharyngeal part : posterior 1/3 They are divided by faint V shaped groove

called sulcus terminalis Two limbs of V meet at median pit named as

foramen caecum

9

10

2. Inferior surface: is covered with a smooth mucous membrane , which shows a median fold called the ‘ frenulum linguae’ .

On either side of frenulum , there is a prominence produced by deep lingual veins.

More laterally there is a fold called plica fimbricata

11

12

INFERIOR SURFACE

Pharyngeal part or lymphoid part of tongue:• It lies behind the palatoglossal arches and

sulcus terminalis • Its posterior posterior surface (base of tongue)

forms anterior wall of oropharynx.• The mucous membrane has no papillae but has

many lymphoid follicles that collectively constitute the lingual tonsil.

13

14

Development of Tongue Starts in 4th week of intrauterine life.

Develops in relation to pharyngeal arches in the

floor of the developing mouth.

Each pharyngeal arch-

i. Grows as a mesodermal thickening in the lateral

wall of foregut.

ii. Grows ventrally to become continuous with the

corresponding arch of the opposite side.

16

Medial most part of mandibular arches proliferate to form two lingual swellings.

The lingual swelling are partially separated from each other by another swelling that appears in the midline called tuberculum impar.

Immediately behind the tuberculum impar, the epithelial proliferates to form a down growth thyroglossal duct from which the thyroid gland develops.These site is marked by a depression called Foramen Caecum.At the end of 2nd and 4th week- Midline swelling develop known as Hypobranchial Eminence.

In 2nd & 3rd week Hypobranchial eminence divide into-i.Cranial part(Copula)-2nd & 3rd archii.Caudal part-4th arch( forms the Epiglottis )

Anterior 2/3rd of tongue is formed by fusion of:1.Tuberculum impar2.2 lingual swelling

20

POSTERIOR 1/3RD : formed by 3rd arch mesoderm.•Formed from cranial part of hypobranchial eminence(copula).

•In this situation, the second arch mesoderm get buried below the surface.

•The 3rd arch mesoderm grows over it to fuse with the mesoderm of 1st arch.

•POSTERIORMOST PART: 4th arch.

22

•MUSCLES : Develop from Occipital myotomes

•EPITHELIUM:

• Formed First by single layers of cell.

• Later- Stratified and papillae become evident.

• Taste buds are formed in relation to the terminal

branches of innervating nerve fibers.

•CONNECTIVE TISSUE:• Develop from local mesenchyme

PAPILLAE OF TONGUE : These are projections of mucous membrane (or) corium which give the anterior 2/3rd of tongue its characteristic roughness They are - Filliform papillae ( conical / thread shape) - Fungiform papillae (mushroom shape) - Circumvallate / vallate papillae ( ring or circle shape ) - Foliate papillae ( leaf shape )

-

24

FILIFORM PAPILLAE : (thread shape or conical papillae)

• Numerous pinpoint cone-shaped projections of the mucosa that ends in one or more points.

• Gives velvety appearance to the tongue.

• They are smallest papillae.

• Each papilla is pointed & covered with keratin.

• Apex is often split into filamentous process.

FUNGIFORM PAPILLAE:(mushroom shape)

•They are numerous near the tip and margins of

tongue

•Few are scattered over dorsum of the tongue

•They are smaller than vallate papillae but larger

than filiform papillae

•Each papilla consists of narrow pedicle & a large

rounded head.

•They are distinguished by their bright red colour.

•Color is derived from rich capillary network

visible through the thin epithelium.•29/cm² at tip,

7-8 /cm² in the middle of tongue

CIRCUMVALATE PAPILLAE: ( circular or ringed

shape )

•They are larger in size i.e 1-2 mm in diameter .

•Situated immediately in front of V- shaped sulcus

terminals.

•8-12 in number.

•The walls of papillae have taste buds

•They are associated with ducts of Von Ebner's glands.

•Each papilla is a cylindrical projection surrounded by

a circular sulcus.

FOLIATE PAPILLAE:

(leaf shape)

•Scattered over the mucous membrane of the mouth and tongue at irregular intervals

•Occur specially in the sides of the vallate papillae

•Abundant at side of the base of the tongue•Bounded by narrow fold of mucous membrane

TASTE BUDS• Small ovoid barrel shaped intrapapillary organ 40μm thick.•They are modified epithelial cells arranged in a flask – shaped form.•Also called as gustatory calyculli.•Found in maximum numbers on circumvallate and fungiform papillae•Outer surface- covered by few flat epithelial cells which is surrounded by small opening called taste pores•Taste buds may have one or more taste pores

• Taste buds contain the receptors for taste.

• They are located around the small structures on the upper surface of the tongue, soft palate, upper esophagus and epiglottis, which are called papillae

• These structures are involved in detecting the five (known) elements of taste perception: salty, sour, bitter, sweet, and savory (or umami).

• Via small openings in the tongue epithelium, called taste pores, parts of the food dissolved in saliva come into contact with taste receptors.

30

• These are located on top of the taste receptor cells that constitute the taste buds.

• The taste receptor cells send information detected by clusters of various receptors and ion channels to the gustatory areas of the brain via the seventh, ninth and tenth cranial nerves.

• On average, the human tongue has 2,000–8,000 taste buds

31

32

STRUCTURE OF TASTE BUD

• Central process passes toward the deep extremity of the bud, and there ends in single or bifurcated varicosities.

• The nerve fibrils after losing their medullary sheaths enter the taste bud, and end in fine extremities between the gustatory cells

• other nerve fibrils ramify between the supporting cells and terminate in fine extremities.

• these, however, are believed to be nerves of ordinary sensation and not gustatory.

• The peripheral end of the cell terminates at the gustatory pore in a fine hair filament, the gustatory hair.

33

34

35

TASTE PATHWAY :

• Taste from anterior 2/3rd of tongue except vallate papilla is carried by chordatymphani branch of facial nerve till the geniculate ganglion.

• The central processes go to tractus solitarius in the medulla

• Taste from posterior 1/3rd of tongue including the circumvallate papilla is carried by glossophayngeal nerve till the inferior ganglion.

36

• The central processes go to tractus solitarius in the medulla

• Taste from posterior most part of tongue and epiglottis travels through vagus nerve till the inferior ganglion of vagus.

• These central processes also reach tractus solitarius.

• After rely in the tractus solitarius , solitario thalamic tract is formed which becomes a part of trigeminal lemniscus and reaches posterio-ventro medial nucleus of thalamus of opposite side

• Another relay here, taken them to lowest part of post central gyrus , which is area for TASTE

37

38

39

Taste pathway

40

Taste sensation at different regions

Sweet – Taste bud of fungiform at tip of tongue.

Sour – Taste bud of foliate papillae on palate and posterior part of

tongue.

Bitter – Taste buds of vallate papillae in middle part of tongue.

Salty – Taste buds of fungiform papillae at lateral border of tongue.

Taste areas of tongue

Taste is extremely sensitive to bitter flavours which could be a possible protective mechanism as many poisonous substances have a bitter i.e. unpleasant flavour.

The experience of taste depends on internal state (like hunger), on past experiences (familiarity with food), and genes (different sensitivities to certain tastes).

It also depends on smell and texture (touch)

Intrinsic muscles • Inferior longitudinal• Superior longitudinal• Transverse• Vertical

Muscles of tongue:•Tongue is made of intrinsic and extrinsic muscles •Divided into right & left by median sagittal septum of connective tissue.

Extrinsic muscles: •Genioglossus•Hyoglossus•Styloglossus•Palatoglossus

INTRINSIC MUSCLES :

They occupy the upper part of the tongue and are attached to the submucous fibrous layer & to the median fibrous septum

Function : alter the shape of tongue

43

44

SUPERIOR LONGITUDINAL MUSCLE:Lies beneath the mucous membraneOrigin: sub mucosal connective tissue at the back of the tongue and from the median septum of tongue.

Insertion: muscle fiber pass forward and obliquely to sub mucosal connective tissue and mucosa on margin of tongue.

Innervation: Hypoglossal nerve.

Function: shorten tongue. curl apex and sides of tongue.

INFERIOR LONGITUDINAL:Is a narrow band lying close to the Inferior surface of the tongue b/w genioglossus & hyoglosssusOrigin: root of tongueInsertion: Apex of tongue.Innervation: Hypoglossal nerve.Function: Shorten tongue. Uncurls apex and turn it downward.

TRANSVERSE:Origin: median septum of tongueInsertion: submucosal connective tissue on lateral margin of tongue.Innervation: hypoglossal nerveFunction: narrow and elongates tongue

VERTICAL:Origin: submucosal connective tissue on dorsum of tongue.Insertion: connective tissue in ventral region of tongue.Innervation: Hypoglossal nerve.Function: Flattens and widens tongue.

EXTRINSIC MUSCLES

49

The tongue is attached to hyoid bone, mandible, styloid process & the palate through the 4 extrinsic muscles.

Extrinsic musclesGENIOGLOSSUS:• Fan shaped•Occur in either side of midline septum that separates right and left halves of tongue.Origin: Superior mental tubercles on the posterior surface of mandibular symphsis immediately superior to the origin of geniohyoid.

Insertion: Body of hyoid, entire length of tongue

51

Innervation: hypoglossal nerveFunction: Protrude the tongue, depress the central part of tongue.

HYOGLOSSUS:•Thin quadrangular muscle lateral to the genioglossus muscle.Origin: Greater horn and adjacent part of body of hyoid bone.Insertion: lateral surface of tongue.Innervation: hypoglossal nerveFunction: depress the tongue.

STYLOGLOSSUS:Origin: Anterolateral surface of styloid process.Insertion: Lateral surface of tongue.Innervation: Hypoglossal nerve.Function: Elevates and retracts the tongue.

PALATOGLOSSUS:Origin: inferior surface of palatine aponeurosis.Insertion: lateral margin of tongue.Innervation: vagus nerve via pharyngeal plexus.Function: depress tongue, elevates back of tongue.

55

Arterial supply

Mainly by lingual artery which is a branch of external carotid artery.

The root is also supplied by tonsillar artery which is a branch of facial artery & ascending pharyngeal artery.

Due to the median fibrous septum of tongue, there is no anastomosis of arteries between 2 sides.

56

VENOUS DRAINAGEThe deep lingual veins are largest & principle veins. Seen along the inferior surface of tongue.

2 veins accompany the lingual artery & 1 vein is seen alongside hypoglossal nerve.

These veins unite at posterior border of hyoglossal muscle & form the Lingual Vein.

This lingual vein drains into common facial or internal jugular vein

57

Lymphatic drainage:

Tip: drains bilaterally to submental nodes

The right & left halves of remaining part of the anterior 2/3rd of tongue drain unilaterally to submandibular nodes.

A few central lympahtics drain bilaterally to the deep cervical nodes.

• Posterior most part & posterior 1/3rd of tongue dain bilaterally into upper deep cervical lymph nodes including jugulodiagastric.

• The whole lymph finally drains into “jugulo omohyoid nodes”

• These are known as lymph nodes of tongue.

58

59

NERVE SUPPLY:Motor – all intrinsic & extrinsic muscles, except the palatoglossus muscle is supplied by HYPOGLOSSAL NERVE ( XII) .Palatoglossus is supplied by – cranial root of accessory nerve through the pharyngeal plexus.

Sensory – 1.Lingual nerve is the nerve of general sensation2.Chorda tympani is the nerve of taste for anterior 2/3rd of tongue except circumvallate papillae

3. Glossophayngeal nerve is the nerve for both general sensation & taste for the posterior 1/3rd of tongue including circumvallate papillae

4. Posterior most part of tongue is supplied by vagus nerve through the internal laryngeal branch.

61

63

Nerve supply

Ingestion Suckling Swallowing Taste Perception Phonation Jaw Development

FUNCTIONS OF TONGUE :

Mastication & deglutition

• The functions of tongue in chewing & swallowing are well known.

• Gibbons in 1898 was the first to state that apart from swallowing, the tongue also aids in mixing of bolus as well as separating out the undesirable food particles.

• Various radiographic studies were done to observe the pattern of tongue movement during chewing & swallowing of food by coating the tongue with barium milk. (Harris 1957)

65

The normal sequence of mastication & deglutition are as follows:1) The preparatory stage: The tongue from its resting position in

the floor of mouth prepares itself for receiving the food by becoming trough like, so as to collect food on its dorsum.

66

2) The throwing stage: the anterior 2/3rd of the tongue having collected the foodstuff twists over on one side which throws the food on the lower grinding teeth.

3) The guarding stage : the tongue & buccinator muscle of the same side press against the teeth together to prevent the food from slipping into the vestibules.

67

4) The sorting out stage: this stage begins after a series of chewing movements. The buccinator pushes the food medially onto the dorsum of tongue so as to separate any larger food particles that remain. This cycle continues till all the food particles are crushed to a homogenous small size.

5) The stage of bolus formation: this stage partly overlaps the last. The tongue makes rapid & jerky side to side movements to mix the food particles with saliva & form a bolus.

6) Stage of deglutition: in the first step the tip of tongue presses against the posterior surface of the upper central incisors & palate.

68

7) With a wave like rippling motion the bolus is pushed backwards. The hyoid bone is pulled up quickly & the back of tongue contacts the soft palate. This seal is maintained to avoid the return of bolus into the mouth, thus completing the oral stage of deglutition.

The right side muscles of tongue help throw the food onto the left molars. Hence it is observed that in cases of hemipelgia the patient is forced to chew on the paralyzed side.

69

- Part played by tongue in mastication & deglutition, Shafik Abd-El-Malek, J Anat. 1955 April; 89(Pt 2): 250–254.1

SPEECH:• It is a co-ordinated movement of lips, tongue, cheeks, teeth &

palate.

• Tongue is considered to play an important role due to its ability to affect rapid changes in its movement & shape.

• The tongue impedes & selectively restricts air channels with precise contact against teeth and palate to articulate speech.

70

• Some examples of speech articulation by tongue are:• Linguo-velar contacts: K,G• Linguo-alveolar contact: T,D,N• Linguo-palatal contact: J, CH• Linguo-dental contact: TH• Apertures of wind created by tongue also produce certain

sounds like• Lateral aperture: L• Central aperture: R• Wide aperture: Y• In “S” and “Z” sounds there is not an actual contact of tongue

with teeth but a very thin space.• “SH” sounds have a larger space between the tongue and teeth.

71

• Some speech difficulties can be observed in certain types of malocclusions. Infact, these can be an aid in diagnosis of malocclusions.

1) Ant. Open bite, large gap b/w incisors – S, Z Sibilants not

pronounced correctly

2) Irregular Incisors – T, D ( Linguoalveolar stops)

3) Anterior Open Bite with Skeletal Class III – TH, SH, CH

(Linguodental)

72

DEVELOPMENTATION :• The form and stability of dental relationship is determined by

the buccinator and the tongue.

• Equilibrium of forces between buccinator, tongue and lips is important to maintain arch form.

• Large tongue – wider arch forms

• Small tongue – narrow arch forms.

73

TASTE:• The special sensation of ‘taste’ is provided by the taste buds

present on the dorsum of the tongue.• Taste can be defined as detection & perception of liquid phase

stimuli.• Until recently 4 basic tastes were  categorized i.e. Salty, Sweet,

Bitter & Sour. A new taste called “Umami” has been added.

• Taste is extremely sensitive to bitter flavours which could be a possible protective mechanism as many poisonous substances have a bitter i.e. unpleasant flavour.

• The experience of taste depends on internal state (like hunger), on past experiences (familiarity with food), and genes (different sensitivities to certain tastes).

74

APPLIED ASPECTSELATED TO TONGUAPPLIED ASPLATED TO TONGGag reflex: Posterior most part of the tongue when touched produces gagging. IX and X nerves are responsible for muscular contraction of each side of pharynx.

When the genioglossus muscle is paralyzed, the tongue has a tendency to fall posteriorly obstructing the airway and creating the risk of suffocation.

Total relaxation of the genioglosuss muscle occurs during G.A therefore the tongue of an anesthetized patient must be prevented from relapsing by inserting an airway.

75

Sublingual absorption of drugs possible due to thin mucosa & rich vasculature

Trauma such as fractured mandible may injure the hypoglossal N. resulting in paralysis an eventual atrophy of one side of the tongue.

The tongue deviated to the paralyzed side during protrusion because of the action of unaffected genioglosuss muscles on the other side.

Injury on both sides causes tongue to be motionless.

76

In many elderly patients, there is nodular enlargement of superficial veins on the ventral surface of the tongue. The presence of such lingual varicosities (varicose tongue) is not of special significance and should not be regarded as evidence of disease of blood vessels.Snoring may be reduced by anterior displacement of the tongue with the intention to compensate inadequate pharyngeal muscle activity. Direct anterior displacement of the tongue leads to an amplification of the airway space, but is difficult to achieve with clinical manoeuvres at night. However, the use of tongue retaining devices & tongue repositioning manouvre has been reported to reduce the time of loud snoring during sleep (Cartwright et al, 2002)- Wilfried Engelk, Wolfgang Engelhart, Oscar Decco, Functional treatment of snoring based on the tongue-repositioning manoeuvre, Eur J Orthod (2010) 32 (5): 490-495. doi: 10.1093/ejo/cjp135

77

EXAMINATION OF TONGUE

78

79

EXAMINATION OF TONGUE

Inspection• Inspect the dorsum of the tongue at rest for variation in size, color,

and texture.

• Observe and note – the distribution of papillae, – margins of the tongue.– depapillated areas, – fissures, ulcers, and keratotic areas.

• Note frenal attachment

• Any deviations as the patient protrudes tongue and attempts to move it to the right and left.

• Note tongue thrust on swallowing.• Wrap a piece of gauze (4 x 4 cm) around the tip of the protruded

tongue to steady it

80

CINERADIOGRAPHY : It is the making of a motion picture record of successive images appearing on a fluoroscopic screen.

• Eg: use cineradiographic images to investigate tongue movement during deglutition in anterior open bite patients with tongue thrust.

• Each subject had semi-spherical lead markers attached to the tip and dorsal surface of the tongue and was asked to swallow 5 ml of diluted liquid barium.

• Tongue movement during deglutition was recorded in the mid-sagittal plane with an X-ray VTR system. ( video tape recorder)

81

A CINERADIOGRAPHIC STUDY OF DEGLUTITIVE TONGUE MOVEMENT IN PATIENTS WITH ANTERIOR OPEN BITE, M. KAWAMURA et al. Bull. Tokyo dent. Coll., Vol. 44, No. 3, pp.133139, August 2003

• The deglutition process was divided into 6 stages to analyze the movements of the tip and dorsal surface of the tongue in each stage

• In open bite patients, both the tip and dorsum of the tongue were positioned anteriorly and inferiorly at rest and during the buildup of negative intraoral pressure.

• The dorsum of the tongue tended to move and be positioned anteriorly as the tongue tip protruded and pushed the maxillary and mandibular anterior teeth.

• The tongue tip traveled a significantly smaller distance from the stage of tongue rest position to that of most retruded tongue tip position and a significantly larger distance from the stage of most retruded tongue tip position to that of tongue tip fixation in open bite patients than in controls.

82

Pulsed (Doppler) Ultrasound

Ultrasound is a form of mechanical acoustic pressure waveat frequencies above the limit of human hearing that whentransmitted through biological tissues can produce differentbiological effects.

Noninvasive ultrasound technique has recently been applied study laryngeal activity, pharyngeal wall displacement and tongue movements.

Two types of echo ultrasound equipment can be used to monitor tongue movements in speech, A scan and sector scan.

83

In the A scan method, ultrasound pulses are passed from a transducer positioned below the chin, through the skin and the muscular tissue of the tongue, and are reflected in proportion to changes in acoustic impedance, at transitions in tissue density in the tongue body, at the interface between the tongue dorsum and the ambient air, and at the oral cavity walls.

The most widely used applications in medicine areoperative (usually has a frequency that ranges between2-8 K Hz), therapeutic (usually has a frequency that rangesbetween 20 K Hz-3 M Hz either in continuous or pulsedmodes), and diagnostic (usually has a frequency that rangesbetween 1.6-12 M Hz).3

84

It has been used to study the characteristics of arterialblood flow in the tongue, and abnormal pulse waves havebeen noted in the lingual arteries of individuals withevidence of compromised flow in other branches of thecarotid arterial tree.

Karen M. Hiiemae and Jeffrey B. Palmer in 2003 reviewed tongue moments in feeding and speech through ultrasound and stated that it is clear that new and very sophisticated ultrasound technology can generate the data to produce 3D models of the tongue surface

85

Computer-Assisted Tomography:• The CT system was invented in 1972 by Godfrey Newbold

Hounsfield of EMI Central Research Laboratories.• In this X-ray slice data is generated using an X-ray source that

rotates around the object, X-ray sensors are positioned on the opposite side of the circle from the X-ray source.

• Many data scans are progressively taken as the object is gradually passed through the gantry.

• They are combined together by the mathematical procedure known as tomographic reconstruction.

• It can be used to identify space occupying lesions and muscular atrophy secondary to hypoglossal nerve damage, in cases where the lesion is deep in the base of the tongue and not detectable by other approaches

86

Isotopic Scanning Techniques:• The principle of obtaining diagnostic information from a

visual image of isotope distribution is based on the fact that the uptake of an isotope by abnormal tissue often differs from that by normal, healthy tissue.

• Sometimes it is more, in some other cases less. Present techniques offer a two dimensional image, somewhat similar to the appearance of X-ray absorption as seen on an X-ray picture.

• It can be used when a mass in the tongue is composed of specialized secretory tissue or other tissue, such as thyroid, which selectively concentrates intravenously administered radioactive 131I or 99Tc-pertechnetate.

87

• Gallium 67Ga scanning and tumor labeling with radioactive

indium and cobalt–bleomycin chelates also have been used to

outline the extent of lingual and other oral tumors with varying

success.

• Bathi, Taneja and Rao reported a case ofasymptomatic tissue

growth on dorsal surface of the tongue,isotopic scanning with

99mTc04 was done to evaluate the type of tissue mass.

88

Electromyography:• Electromyography is a test to study the muscle functions.

• It has been used for many years to study the action potentials in actively contracting muscles and has contributed to an understanding of lingual and masticator muscular function and also in detecting uncoordinated muscular movements in diseases like dyskinesia, dystonia, and various neuromuscular disorders.

• It is a noninvasive technique.

• Use of surface electrodes (in earlier techniques thin-needle electrode inserted in the muscle to the studied) have been introduced with considerable success

89

According to Cheng et al movement of the tongue during normal breathing in awake healthy humans with electromyography and suggested that the patterns of local movement vary between subjects.

There is anterior movement of the genioglossus muscle at the level of the epiglottis during inspiration with limited movement in nearby tissue including the geniohyoid, and hence even during respiration tongue behaves as a muscular hydrostat.

90

Magnetic Resonance Imaging:MRI used as an alternative to imaging modalities involving radiation. It has proven to be vastly superior in the detail it provides, of soft-tissue structures, such as the tongue and oropharynx.

MRI has the ability to provide, direct coronal or sagittal scanning sections, which allows accurate delineation of the lingual musculature and the extent of tumor infiltration.

MRI has serious limitations as a research tool for studies of speech or deglutition because of supine position of the patient which causes difficulty in feeding and also MRI data acquisition is slow when compared with normal feeding and deglutition

91

Scanning Electron Microscope:The SEM uses a focused beam of high energy electrons togenerate a variety of signals at the surface of solid specimens.

SEM is a well-established tool for in vitro study of the surface topography of tongue dorsum, the character and morphology of the different types of tongue papillae and distribution and morphology of bacteria on the papillated areas of the dorsum.

Many studies have been performed in different animals but in human more studies are required to know the efficacy of SEM on tongue.

92

93

Video Microscopy:Video microscopy is useful for observation of the surface of tongue papillae.Negoro et al in 2004 conducted a study in 10 individuals for observation of tongue papillae by video microscopy and contact endoscopy to investigate their correlation with taste function and concluded that in the normal taste group, round-shaped papillae and clear blood vessels were observed with both microscopy and contact endoscopy.In the taste disorder group, flat and irregular papillae were observed with microscopy. Blood vessel flow of the papillae was observed to be poor with contact endoscopy. It can be used in vivo for visualization of tongue papillae, their capillary network, and taste pores.

94

Stereo Microscopy:• A stereo microscope is an optical microscope fitted with two

sets of lenses, each positioned to view an object from a slightly different angle.

• The result is a three-dimensional image. In order to produce a clear, functional three dimensional image, a stereo microscope relies on reflected, exterior light sources to illuminate its subject, instead of the brighter plate lights that shine through the specimen on a standard microscopy.

• It is similar to video microscopy and can be used to study the

tongue papillae, their capillary network, and taste pores.

95Review and Update: Advanced Investigation Methods for Diagnosis of Tongue Lesions. Neeraj Taneja et al The Journal of Contemporary Dental Practice, March-April 2013;14(2):365-369

96

TONGUE AND ITS DISEASES PART II

CLASSIFICATION:

INHERITED, CONGENITAL AND DEVELOPMENTAL ANAMOLIES:

1. Variations in tongue morphology and function A. Partial Ankyloglossia B. Complete Ankyloglossia

2.Variations in tongue movements3. Fissured, Plicated or Scrotal tongue 4. Patent Thyroglossal Ducts5. Lingual Thyroid

(Burket’s Oral Medicine Diagnosis and (Burket’s Oral Medicine Diagnosis and Treatment, 9th edition: Diseases of Treatment, 9th edition: Diseases of tongue)tongue)

MAJOR INHERITED, CONGENITAL AND DEVELOPMENTAL ANAMOLIES:

1. Cleft, Lobed, Bifurcated and Tetrafurcated tongue2. Aglossia(Hypoglossia)3. Macroglossia4. Depapillated tongue5. Localised enlargement and Papillomatosis

DISORDERS OF LINGUAL MUCOSA:A - CHANGES IN LINGUAL PAPILLAE: 1.Geographic Tongue 2. Coated or Hairy Tongue

B - NONKERATOTIC AND KERATOTIC WHITE LESIONS:

i NON-KERATOTIC:

1. Thrush 2. Burns 3. White Sponge Nevus 4. Pachyonychia Congenita 5. Vesiculobullous and other Desquamating Disorders

II KERATOTIC : 1. Lichen Planus 2. Leukoplakia 3. Hairy Leukoplakia 4. Depapillation 5. Atrophic lesions 6. Chronic traumaC - Nutritional deficiencies and hematologic

abnormalitiesD - MedicationsE - Peripheral vascular disease

F - Chronic candidiasis and median rhomboid glossitisG - Tertiary syphilis and interstitial glossitisH - PigmentationI - Traumatic injuries, ulcers and infectionsJ - Superficial vascular lesions

DISORDERS AFFECTING LINGUAL MUCOUS GLANDS:

1. Sjogren’s syndrome 2. Ranula 3. Cysts and Sialolithiasis

DISEASES AFFECTING THE BODY OF TONGUE: 1. Amyloidosis 2. Infections 3. Neuromuscular Disorders 4. Obstructive Sleep Apnoea and Glossoptosis 5. Temporomandibular Joint Dysfunction Syndrome 6. Neck-Tongue Syndrome 7. Vascular disease of the body of tongue 8. Angioneurotic Edema

MALIGNANT TUMOURS OF TONGUE 1. Squamous Cell Carcinoma

BENIGN TUMOURS OF TONGUE

SIMULATING EPIDERMOID CARCINOMA: 1. Pseudoepitheliomatous Hyperplasia 2. Papilloma 3. Irritational Fibroma

•Complete absence of tongue•It is a rare congenital anomaly •Manifested by presence of a small or rudimentary tongue.

Clinical Features:•Difficulty in speech and mastication.•High arched palate, narrow constricted mandible•Missing lower incisors•There may be airway obstruction, due to negative pressure generated by deglutition and inspiration

AGLOSSIA OR MICROGLOSSIA :

Hall's classification (Oromandibular limb hypogenesis syndrome)

Type-IA HypoglossiaB Aglossia

Type-IIA Hypoglossia - hypodactyliaB Hypoglossia - hypomeliaC Hypoglossia – hypodactylomelia

Type-IIIA Glossopalatine ankylosis (Ankylossum Superius syndrome)B With hypoglossiaC With hypoglossia - hypodactyliaD With hypoglossia - hypomeliaE With hypoglosia - hypodactylomelia

Type-IVA Intraoral bands and fusionB With hypoglossiaC With hypoglossia - hypodactyliaD With hypoglossia - hypomeliaE With hypoglossia –hypodactylomelia

Type-VA. The Hanhart syndromeB.Pierre-Robin syndromeC.Mobius syndrome

Rasool A et al. Isolated aglossia in a six year old child presenting with impaired speech: a case report. Cases Journal .2009. 2:7926;1-3

Treatment and prognosis

•  Depends on the nature and severity of the condition

• Surgery and orthodontics may improve oral function

• Speech development is quite good but depends on tongue size

109

Pierre Robin anomalad

Cleft palate , retrognathia , glossoptosis

110

Variable degrees of limb hypogenesis.Strabismus, micrognathia, mask-like facies. Small tongue

Moebius syndrome

111

Hanhart’s syndrome

Rare birth defect. Hypoglossia , hypodactylia , peromelia (malformed arms /legs & micrognathia

•Tongue enlargement which leads to functional and cosmetic problems.Classification:1.True macroglossia -congenital -Acquired

Congenital causes:•Idiopathic muscle hyperthrophy•Hemangioma•Lymphangioma•Neurofibromatosis•Gargoylism

MACROGLOSSIA :

Aquired causes: Metabolic• Hypothyroidism• Cretinism• Diabetes

Inflammatory:• Syphilis• Rheumatic fever• Typhoid• Tuberculosis• pellagra

Systemic/medical condition• Uremia• Myxedema• Hypertrophy• Acromegaly• Iatrogenic macroglossia Traumatic• Surgery• Hemorrhage• Direct trauma(bitting)

Neoplastic• Lingual thyroid• Carcinoma• PlasmacytomaInfiltrative• Amyloidosis• Sarcoidosis

2.Pseudomacroglossia- maybe due to severe retrognathic maxilla or mandible.

Clinical features:• Age: more common in infants• Symptoms: tongue protrusion, which exposes the

tongue to trauma.• Other symptoms include swallowing difficulties,

airway obstruction, drooling and failure to thrive.

• Signs: displacement of teeth and malocclusion• Crenation or scalloping of lateral borders of tongue

• Associated sndrome:i. Beckwith’s- Wiedemann syndromeii. Down syndromeiii.Behmel syndromeiv.Laband syndrome

Treatment:• Removal of primary cause• Majority of cases are treated surgically.

118

•It is a condition when the inferior frenulum attaches to the bottom of tongue and subsequently restricts free movement of the tongue.

•Types: Complete Ankyloglossia (fusion of tongue to the floor of the mouth)

ANKYLOGLOSSIA(Tongue-Tie)

Partial Ankyloglossia-Tongue tie is usually defined on the basis of inability to extend the tip of the tongue beyond the vermillion border of the lip.

CATEGORIES OF ANKYLOGLOSSIA (Figs lato le)•Clinically acceptable, normal range of free tongue :greater than 16mm•Class I: Mild ankyloglossia: 12 to 16 mm•Class II: Moderate ankyloglossia: 8 to 11 mm•Class III: Severe ankyloglossia: 3 to 7 mm•Class IV: Complete ankyloglossia: less than 3 mmLawrence A. Kotlow.Ankyloglossia (tongue-tie):A diagnostic and treatment quandary.Quintessence International 1999;30:259-262

Hazelbaker Assessment Tool for Lingual Frenulum Function

AppearanceAppearance of tongue when lifted• 2: Round or square• 1: Slight cleft in tip apparent• 0: Heart- or V-shapedElasticity of frenulum• 2: Very elastic• 1: Moderately elastic• 0: Little or no elasticityLength of lingual frenulum when lifted• 2: >1 cm• 1: 1 cm• 0: <1 cm

Ballard J L et al. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad. Pediatrics.2002:110 (5);1-6

Attachment of lingual frenulum to tongue• 2: Posterior to tip• 1: At tip• 0: Notched tipAttachment of lingual frenulum to inferior alveolar ridge• 2: Attached to floor of mouth or well below ridge• 1: Attached just below ridge• 0: Attached at ridge

Ballard J L et al. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad. Pediatrics.2002:110 (5);1-6

Clinical features: Symptoms: limit the movement of tongue.•Recurrent tongue biting

Severe degree-- Inability to lick the lips-Inability to pronounce certain words t, d, as, ta, n ,l etc.

Signs:•Where there is an attempt to stick the tongue out, there may be a V-shaped notch at the tip. •midline mandibular diastema, lingual mandibular periodontal defects.•anterior open bite

Superior (Glossopalatine ankylosis)•Rare - congenital adherence of tongue to the palate•Usually combined with other congenital anomalies in the maxillofacial region and extremities (superior syndrome)•Causes suckling and respiratory dysfunction

Syndrome associated : Orofacial digital syndromeCleft lip and palate

Treatment:Mild cases- no treatment.Some degree of Ankyloglossia is managed by speech therapist.Surgical correction of frenum.

Fissured/ plicated /scrotal tongue

• It is characterized by grooves that vary in depth and are noted along the dorsal and lateral aspect of the tongue.

Clinical features:• In elderly, mentally retarded & psychotic individuals.• Deep furrows – food lodgement- symptomatic

Associated syndrome: -Melkersson - Rosenthal syndrome - Down’s syndrome

Treatment: no definative t/t.-oral hygiene- soft bristle brush, mouthwash/dil H2O2.

127

Melkerssonrosenthal syndrome

 rare neurological disorder characterized by recurring facial paralysis, swelling of the face and lips (usually the upper lip), and the development of folds and furrows in the tongue

MEDIAN RHOMBOID GLOSSITIS• It is defined as the central papillary atrophy of the

tongue.

• MRG is typically located around the midline of the

dorsum of the tongue.

• It occurs as a well-demarcated, symmetric, depapillated area arising anterior to the circumvallate papillae.

• sometimes appears in the paramedial location.•  The surface of the lesion can be smooth or lobulated.

• Clinical Features:• Most cases are not diagnosed until the middle

age of affected patient.• 3:1 male predlection• Present in the posterior midline of dorsum of

tongue.• Depapillation of tongue.• Asymptomatic in most cases• Patients may complain of persistent pain,

irritation, or pruritus.

• When MRG is concomitant with a palatal inflammation, which is called the kissing lesion.

• Lesions are typically less than 2cm in dimension

Treatment: • Asymptomatic- No treatment• In candidal infection- antifungal agent

CLEFT OR BIFID TONGUE• It ie a condition in which there is Cleavage of the tongue due to lack of fusion of lateral lingual swellings of the tongue.

• Partial cleft tongue is more common and is manifest as a deep groove in the midline of the dorsum of tongue.

Symptoms: food debris and microorganisms may collect in the base of cleft and cause irritation.

Associated syndrome: oro-facial-digital syndrome

133

Orofacial digital syndrome /papillon league/psaume syndrome

In 1954 papillon described a syndrome characterised by congenital anomaliesof face , oral cavity and digits.Its X- linked dominantPossibility in 1 in 250,000C/F – frontal bossing, alopecia, cleft in palate , lip , supernumerary teeth hypoplasia of malar bones , broad nasal root, syndactyly, polydactyl intracerebral cysts, polycystic kidney disease.

LINGUAL VARICES (lingual or sublingual varicosities)

•A varix is a dilated, tortuous vein, most commonly a vein which is subjected to increased hydrostatic pressure.•These veins are poorly supported by surrounding tissue.

• Appearance: red or purple slotlike clusters of vessels on the ventral and lateral surface of tongue as well as in the floor of mouth.

• Other part: upper and lower lip, buccal mucosa, and commissure.

• Strongly associated with portal hypertension, aging & leg Varicosities.

Gomes C C et al. Mucosal varicosities: case report treated with monoethanolamine oleate. Med Oral Patol Oral Cir Bucal 2006;11:E44-6.

LINGUAL THYROID NODULE• It is an anomalous condition in which follicles of

thyroid tissue are found in the tongue, arising from remnants of thyroid that may fail to migrate to its predestinated position or from remnants that became detached and were left behind.

Etiology:• Functional insufficiency of chief thyroid gland in neck.• Failure of primitive thyroid analogue to descend.

Clinical features: • Females are more commonly affected than males• 4:1 ratio• Site: manifest as a nodular mass in or near the base

of tongue, in vicinity of foramen caecum.• Symptoms: dysphagia, dysphonia, dyspnea,

hemorrhage with pain, or felling of tightness or fullness in throat.

Treatment and prognosis• Most cases require no treatment and biopsy should be

considered with caution because of the potential for hemorrhage, infection or release of large amounts of hormone into the vascular system (thyroid storm).

• Occasional patients with parathyroid tissue associated with their lingual thyroid have developed tetany after their inadvertent removal.

• Surgical excision or radioiodine therapy(no treatment should be attempted until an 131iodine radioisotope scan has determined that there is adequate thyroid tissue in the neck).  

Baughman RA. Lingual thyroid and lingual thyroglossal tract remnants. A clinical and histopathologic study with review of the literature. Oral Surg Oral Med Oral Pathol 1972; 34:781-99.

• Patients lacking thyroid tissue in the neck, the lingual thyroid can be excised .

• Thyroid carcinoma arising in the mass have been reported, almost always in males

• An enlarged lingual thyroid is more likely to reflect a normal compensatory response to thyroid hypofunction

Baughman RA. Lingual thyroid and lingual thyroglossal tract remnants. A clinical and histopathologic study with review of the literature. Oral Surg Oral Med Oral Pathol 1972; 34:781-99.

• Absence of papillae

Syndromes associated with Bald and Depapillated tongue

• Familial dysautonomia: congenital absence of fungiform and vallate papillae

• Dyskeratosis congenita

Depapillation of Tongue

140

141

Dyskeratosis congenita/Zinsser-Cole-Engman syndrome

•X-linked recessive

•develop between ages 5 and 15 years,

•male-to-female ratio is approximately 3:1,

• hyperpigmentation of the skin, nail dystrophy, leukoplakia occurs in approximately 80% of patients, typically involves the buccal mucosa, tongue, and oropharynx. 

VARIATIONS IN TONGUE MOVEMENTS

Variations in tongue movement

Variations in Tongue Movements

Gorlin’s SignEDS Syndrome

144

Hyperextensibility of tongue

RED AND WHITE LESIONS

The tongue may traumatized by mechanical, thermal, electrical or chemical means.

The tongue may develop scalloping on the lateral margins, sometimes termed crenated tongue.

This appearance is the result of indentations of the teeth where the tongue is habitually pressed against the teeth (“tongue thrusting”, and example of oral parafunction).

A lesion similar to morsicatio buccarum can occur on the tongue (sometimes called morsicatio linguarum), caused by chronic chewing on the tongue.

146

Morsicatio linguarum. Thickened, rough areas of white hyperkeratosis of the lateral border of the tongue on the left side.

Oral leukoplakia and Erythroplakia :• A comprehensive global review points at a prevalence

of 2.6%.• Most oral leukoplakias are seen in patients over the

age of 50• Leukoplakia is more common in men• Oral erythroplakia is not as common as oral

leukoplakia,• and the prevalence has been estimated to be in the

range of 0.02 to 0.1%.56• The gender distribution is equal.

148Burkitt 11/E

• Oral leukoplakia may be found at all sites of the oral mucosa.

• Nonsmokers have a higher percentage of leukoplakias at the border of the tongue compared with smokers.

• The floor of the mouth and the lateral borders of the tongue are high-risk sites for malignant transformation

149

Leukoplakia

Verrucous leukoplakia

Large, diffuse, and corrugated white lesions of the buccal mucosa and tongue.

Erythroleukoplakia

Hairy leukoplakia• Most common HIV lesion• Also associated with:– Immunosuppressive

drugs Cancer chemotherapy

– Organ transplantation

• Etiology: EBV with low CD4+ T lymphocytes

153

HAIRY TONGUE•Also called as Lingua nigra, Lingua villosa, Lingua villosa nigra, Black hairy tongue.

•Commonly observed condition of defective desquamation of the filiform papillae.

•Lesion can also appear brown, white, green, pink, or any of a variety of hues depending on the specific etiology and secondary factors.

154

ETIOLOGY:-

•Hypertrophy of the filliform papillae on the dorsal surface of the tongue.

•Often occurs in individuals with poor oral hygeine.

•Contributory factors can be numerous including tobacco use and coffee or tea drinking, general debilitation, history of radiation therapy to head and neck.

155

CLINICAL FEATURES:-

Affects the mid line just anterior to circumvallate papilla.

Filliform papillae more than 15mm in length

Male predilection…no racial predilection

In HIV positive patients, drug users

Asymptomatic…Candida albicans may result in glossopyrosis.

Tickling sensation in soft palate, oropharynx may occur.

156

157

Thrush / Acute pseudomembraneous Candidiasis

The erythematous form of candidiasis was previously referred to as atrophic oral Candidiasis.

The lesion has a diffuse border whichhelps distinguish it from erythroplakia, which has a sharper demarcation.

The infection is predominantly encountered in the palate and the dorsum of the tongue of patients who are using inhalation steroids.

Oral Candidiasis Associated with HIV

161

Erythematous candidiasis at the central part of the tongue in an AIDS patient. Hairy leukoplakia at the right lateral border.

The most common types of oral candidiasis in conjunction with HIV are pseudomembranousCandidiasis, erythematous candidiasis, angular cheilitis, and chronic hyperplastic candidiasis.

Oral submucous fibrosis

162

Etiology and Pathogenesis:Areca nuts contain alcaloids, of which arecoline seems to be a primary

Etiologic factor. Arecoline has the capacity to modulate matrix metalloproteinases, lysyl oxidases, and collagenases, all affecting the metabolism of collagen, which leads to an increased fibrosis

Epidemiology:The global incidence of submucous fibrosis is estimatedat 2.5 million individuals.93 The prevalence in Indian populationsis 5% for women and 2% for men

Clinical Findings:The first sign is erythematous lesions sometimes in conjunction with petechiae, pigmentations, and vesicles.These initial lesions are followed by a paler mucosa, which may comprise white marbling like appearance.The most prominent clinical characteristics will appear later in the course of the disease and include fibrotic bands located beneath an atrophic epithelium. Increased fibrosis eventually leads to loss of resilience which interferes with speech, tongue mobility, and a decreased ability to open the mouth. The atrophic epithelium may cause a smarting sensation and inability to eat hot and spicy food.

163

164

Normal mesioincisal angle of upper central incisor to the tip of the tongue when maximally extended•Males 5 to 6 cm•Females 4.5 to 5.5 cm

Oral submucous fibrosis

The buccal mucosa has a marbling appearance.

Pachyonychia congenita:• Pachyonychia congenita type I - known as "Jadassohn–

Lewandowsky syndrome" is an autosomal dominant keratoderma that principally involves the plantar surfaces, but also with nails changes that may be evident at birth but more commonly develop within the first few months of life.

• Pachyonychia congenita type II - known as "Jackson–Lawler pachyonychia congenita," and "Jackson–Sertoli syndrome" is an autosomal dominant keratoderma presenting with a limited focal plantar keratoderma that may be very minor, with nails changes that may be evident at birth, but more commonly develop within the first few months of life.

165

Signs and symptoms:

Excess keratin in nail beds and thickening of the nailsHyperkeratosis on hands and feetOral lesions that look like thick white plaquesSteatocystoma multiplexPainBlisters

166

Described by Jamieson in 1873, and coined by Pringle in 1899, steatocystoma multiplex (SM) is an uncommon disorder of the pilosebaceous unit characterized by the development of numerous sebum-containing dermal cysts. 

Pachyonychia Congenita

Thickened white plaques involve the lateral margins and dorsal surface of the tongue. callous like lesions

Nail changes

Dyskeratosis congenita / Zinsser-Cole-Engman syndrome. Rare progressive congenital disorder  Clinical features: develop between ages 5 and 15 years male-to-female ratio is approximately 3:1 characterized by cutaneous pigmentation, premature graying, dystrophy of the nails, leukoplakia of the oral mucosa

Mucosal leukoplakia occurs in approximately 80% of patients and typically involves the buccal mucosa, tongue, and oropharynx. The leukoplakia may become verrucous, and ulceration may occur.

168

Dyskeratosis congenita

Atrophy and hyperkeratosis of the dorsal tongue mucosa

Dysplastic nail changes.

ULCERATIVE AND VESICULLOBULOUS LESIONS

Herpes simplex virus:

The herpesviridae family of viruses contains nine different viruses that are pathogenic in humans.

1.Herpes simplex virus 12.Herpes simplex virus 23.Varicella-zoster virus Varicella (chickenpox) Zoster (shingles) 4.Cytomegalovirus5.Epstein-Barr virus 6.Human herpesvirus 67.Human herpesvirus 78.Human herpesvirus 8 9.Simian herpesvirus B

171

HSV-1, an a-herpesvirus, is a ubiquitous virus• In general, infections above the waist are caused by HS V-1

and those below the waist by HS V-2

Oral findings:• Within a few days of the prodrome, erythema and clusters of

vesicles and/or ulcers appear on the keratinized mucosa of the hard palate, attached gingiva and dorsum of the tongue, and the non keratinized mucosa of the buccal and labial mucosa, ventral tongue, and soft palate

Recrudescent Oral HSV Infection:• Reactivation of HSV may lead to asymptomatic shedding of

HSV, in the saliva and oral secretions, an important risk factor for transmission; it may also cause ulcers to form.

172

• Recrudescent HSV on the lips is called recurrent herpeslabialis (RHL) and occurs in 20 to 40% of the young adult population.

• Intraoral recrudescent HSV in the immunocompetent host occurs chiefly on the keratinized mucosa of the hard palate, attached gingiva, and dorsum of the tongue.

• Such lesions are called recurrent intraoral HSV (RIH ) infection.

• They present as 1 to 5 mm single or clustered painful ulcers with a bright erythematous border

173

174

HERPES SIMPLEX

Bright erythematous border

HIV-associated recurrent herpetic infection .

RIH infection may occur at any site intraorally and may form atypical-appearing ulcers that may be several centimeters in sizeand may last several weeks or months if undiagnosed anduntreated . They appear slightly depressed with raised borders, yellowish circinate border.

Recurrent Aphthous Stomatitis (RAS):

RAS is a disorder characterized by recurring ulcers confined to the oral mucosa in patients with no other signs of disease.

RAS affects approximately 20% of the general population.

RAS is classified according to clinical characteristics: minor ulcers, major ulcers and herpetiform ulcers.

176

Minor ulcers, which comprise over 80% of RAS cases, are less than 1 cm in diameter and heal without scars.

Major ulcers are over 1 cm in diameter take longer to heal and often scar.

Herpetiform ulcers are considered a distinct clinical entity that manifests as recurrent crops of dozens of small ulcers throughout the oral mucosa.

177

ETIOLOGY AND PATHOGENESIS:• The major factors presently linked to RAS include - genetic factors, hematologic deficiencies (particularly of

serum iron, folate, or vitamin B12, appears to be an etiologic factor in a small subset of patients with RAS), immunologic bnormalities, and local factors, such as trauma and smoking. although the specific defect remains unknown.

Clinical findings:• The first episodes of RAS most frequently begin during the

second decade of life.• The lesions are confined to the oral mucosa and begin with

prodromal burning any time from 2 to 48 hours before an ulcer appears.

178

• During this initial period,a localized area of erythema develops.

• Within hours, a small white papule forms, ulcerates, and gradually enlarges over the next 48 to 72 hours.

• The individual lesions are round, symmetric and shallow.

• The buccal and labial mucosae are most commonly involved.

179

A 42-year-old woman with a recent increase in severityof recurrent aphthous ulcers. Iron deficiency was detected, and the ulcersresolved when this deficiency was corrected

Recurrent Apthous ulcer

Traumatic ulcers

Traumatic ulceration of tongue: hyperkeratotic rolled border encircling mucosal surface on ventral side of tongue

Most common cause of ulceration of tongue is due to dentition

Riga-Fede disease

Riga-Fede disease. Newborn with traumatic ulceration of anterior ventral surface of the tongue. Mucosal damage occurred from contact of tongue with adjacent tooth during breast-feeding.

PHYSICAL AND CHEMICAL INJURIES

Intentional injury. Tongue pierced with a jewellery item known as a "dumbbell

Contact stomatitis from cinnamon flavoring of left lateral border of the tongue demonstrating linear rows of hyperkeratosis that resemble oral hairy leukoplakia .

Nutritional deficiency Iron deficiency anemia Plummer vinson syndrome Pernicious anemia Niacin deficiency Folic acid defieciency

Iron deficiency anemia: (microcytic hypochromic anemia) Iron deficiency is defined as a reduction in total body iron toan extent that iron stores are fully exhausted and some degreeof tissue iron deficiency is present.

Epidemiology:A moderate degree of iron-deficiency anemia affected approximately 610 million people worldwide or 8.8% of the population. It is slightly more common in female

•causes of iron deficiency anemia are conveniently classified into two major categories: physiologic and pathologic.

The most common cause is physiologic and relates to nutritional deficiency. 188

Pathologic iron deficiency anemia is invariably due to excessive blood loss. In the vast majority of patients, the source of bleeding is the gastrointestinal tract from hemorrhoids, peptic ulcers, esophageal varices, or carcinoma or from excess uterine bleeding in women.

Clinical manifestations:The most important clinical symptom is chronic fatigue

Other findings such as pallor of the conjunctivae, lips, and oral mucosa; brittle nails with spooning, cracking, and splitting of nailbeds; and palmar creases.

Other findings may include palpitations, shortness of breath, numbness and tingling in fingers and toes, and bone pain

189

Oral Manifestations:

Glossitis and stomatitis are recognized oral manifestations ofanemia.

Oral manifestations of iron deficiency anemia include angular cheilitis , glossitis with different degrees of atrophy of fungiform and filliform papillae , pale oral mucosa , oral candidiasis , recurrent aphthous stomatitis, erythematous mucositis , and burning mouth for several months to 1 year’s duration.

Clinically evident atrophic changes of the tongue occurs , giving a smooth red tongue appearance, in patients with iron deficiency anemia

190

191

atrophic changes of the tongue, giving a smooth red tongue appearance

TREATMENT:The treatment of iron deficiency should always be initiated with oral iron supplementation.

Ferrous sulfate is the preferredform of oral iron because of low cost and high Bioavailability,typically administered at 325 mg (60 mg iron) orallythree times daily.

Removal of underlying causes.

Plummer-Vinson Syndrome:also called Paterson-Kelly syndrome or sideropenic dysphagia

Etiopathogenesis:

Etiopathogenesis of Plummer-Vinson syndrome is unknown; however, the most important possible etiologic factor is iron deficiency.

Other possible factors include malnutrition, genetic predisposition, or autoimmune processes.

192

Clinical features:It usually affects middle-aged white women in the fourth to seventh decade of life.

It shows the classic triad of dysphagia, iron deficiency anemia, and upper esophageal webs or strictures.

The dysphagia may be intermittent or progressive over years, is usually painless and limited to solids, and sometimes is associated with weight loss.

Other Symptoms like Anemia, glossitis, angular cheilitis, and koilonychia are.

193

194

Splenomegaly and enlargement of the thyroid and upper alimentary tract cancers may also be found.

Radiologic examination of the pharynx shows the presence of webs

Esophageal web

Depapillation of tongue

Pernicious anemia: (megaloblastic anemia)•Megaloblastic or pernicious anemia is an autoimmunedisease resulting from autoantibodies directed againstintrinsic factor (a substance needed to absorb vitamin B12from the gastrointestinal tract) and gastric parietal cells.

•Pernicious anemia is more common among people of Celtic and Scandinavian descent and is diagnosed at the age of60 years

•Deficiency in production of intrinsic factor mayresult from chronic gastritis or surgical removal of thestomach.

195

Oral manifestations:•Burning sensation in the tongue, lips, buccalmucosa, and other mucosal sites.•Tongue and mucosa shows smooth or patchy areas of erythema.• Dysphagia and taste alteration.

Diagnosis:based on measurement of serum vitamin B12 levels.A more sensitive method of screening for vitaminB12 deficiency is measurement of serum methylmalonic acidand homocysteine levels, which are increased early in vitaminB12 deficiency.

196

197

Tongue appears to be smooth and erythematous

Treatment:

Treatment has traditionally been weekly intramuscular injections of 1,000 μg of vitamin B12 for the initial 4 to 6 weeks, followed by 1,000 μg per week indefinitely.

INFECTIOUS DISEASES

Syphilis:caused by T. pallidum, spirochete.

Syphilis has an incubation period of 10 to 90 days (average 3 weeks) and is characterized by four main clinical stages: primary, secondary, tertiary, and late or quaternary.

199

Syphilis

Chancre of primary syphilis. Ulceration of the dorsal surface of the tongue on the left side .

Characteristic slightly raised, grayishwhite, glistening patches ‘mucous patches,’ of the tongue

201

Atrophic glossitis of tertiary syphilis. Dorsal surface of the tongue exhibiting loss of filiform papillae and areas of epithelial atrophy and hyperkeratosis

Common site of gumma (tertiary syhpilis)Is hard palate.

Tuberculosis:It is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs. It is transmitted from person to person via droplets.

Epidemiology:India is the country with the highest burden of TB with World Health Organisation (WHO) statistics for 2013 giving an estimated incidence figure of 2.1 million cases of TB for India out of a global incidence of 9 million. The estimated TB prevalence figure for 2013 is given as 2.6 million.

It is estimated that about 40% of the Indian population is infected with TB bacteria, the vast majority of whom have latent rather than active TB.

202Courtesy: TB facts.org

Tuberculosis

Chronic mucosal ulceration of the ventral surface of the tongue

Scarlet fever: (called as scarlatina in older literature)• Caused by bacterium Streptococcus pyogenes (group A

streptococcus)

Epidemiology: most common in children ages 5– 15Both the gender are equally affected

Clincal features:• Sore throat • Fever• Bright red tongue with a "strawberry" appearance

204

•Forchheimer spots (fleeting small, red spots on the soft palate)

•Paranoia (false illusions )

•Hallucinations

•The rash is the most striking sign of scarlet fever. It usually appears first on the neck and face

•The rash is fine, red, and rough-textured

205

Blanches  upon pressure ,appears 12–72 hours after the fever starts generally begins on the chest and armpits and behind the ears. On the face, often shows as red cheeks with a characteristic pale area around the mouth (circumoral pallor)

206

Red cheeks and pale area around the mouth in scarlet fever

Begins to fade three to four days after onset and desquamation (peeling) begins. "This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later." Peeling also occurs in the axilla , the groin, and the tips of fingers and toes

Scarlet fever

Strawberry tongue is a characteristic of scarlet fever.

Strawberry tongue (also called raspberry tongue),refers to glossitis which manifests with hyperplastic  (enlarged) fungiform papillae , giving the appearance of a strawberry. 

Early in the infection, the tongue may have a whitish or yellowish coating.

After 4–5 days,  red strawberry tongue occurs 

NEUROLOGICAL DISORDERS

Neurological disorders

Dyskinesias are involuntary movement that have no purpose and are not fully controllable by the patient. Some are random, some rhythmic, most are very odd looking and socially stigmatizing. 

Fly Catcher Tongue:The intermittent in and out darting of tongue which is cahracteristic of tardive dyskinesia,(Tardive Dyskinesia (TD) is by definition a neuroleptic, Latin - "seize the neuron” ) a complication of antpsychotic drug therapy. Mainly by risperidone

Risperidone is used to treat schizophrenia  and symptoms of bipolar disorder manic depression)

210

Bon bon sign:Involuntary pushing of tongue against the inside of the cheek. Bon bon sign is said to be typical of the stereotypic orolingual movements.

211

Gustatory disorders of the tongue

Gustatory disorders

• Stimulated dysgeusia- Distortion in perception of taste.

• Unstimulated dysgeusia/ phantogeusia- perception of taste in absence of any recognized stimulus.

• Hypergeusia: Increased sensitivity for all taste stimuli.

BENIGN LESIONS

FIBROMA (IRRITATION FIBROMA; TRAUMATIC FIBROMA; FOCAL FIBROUS HYPERPLASIA; FIBROUS NODULE)

Most common "tumor" of the oral cavity.

It is doubtful that it represents a true neoplasm in most instances; rather, it is a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma.

215

Clinical Features

4-6 decade of life, F>M

Most common - buccal mucosa along the occlusal line. The labial mucosa, tongue and gingiva also are common sites.

Smooth-surfaced pink nodule that is similar in color to the surrounding mucosa.

In some cases, the surface may appear white as a result of hyperkeratosis from continued irritation.

.

216

Most fibromas are sessile, although some are pedunculated. Few millimeters to large masses.

Asymptomatic, unless secondary traumatic ulceration of the surface has occurred.

Treatment and Prognosis

Conservative surgical excision; recurrence is extremely rare.

217

Traumatic fibroma

NEUROFIBROMA•The tongue and buccal mucosa are the most common intraoral sites. •Solitary tumors are most common in young adults and present as slow-growing, soft, painless lesions that vary in size from small nodules to larger masses. •The skin is the most frequent location for neurofibromas, but lesions of the oral cavity are not uncommon

219

Neurofibromatosis

Granular cell tumor of the tongue:In 1926 Arbikossoff described a tumor of the tongue composed of granular cells derived from striated muscles and termed it as granular cell myoblastoma, theory that was subsequently abandoned.

Granular cell tumor (GCT) is a benign lesion characterized by the accumulation of plump cells with abundant granular cytoplasm.

A wide variety of cell types have been proposed as the cells of origin, including histiocytes, fibroblasts, myoblasts, neural sheath cells, neuroendocrine cells, and undifferentiated mesenchymal cells

221

Granular cell tumor of the tongue: Report of a case, D. Alka et al. J Oral Maxillofac Pathol. 2013 Jan-Apr; 17(1): 148.

• GCTs can affect any part of the body, however, in head and neck area it predominates by 45% to 65%.

• Of the head and neck cases, 70% of lesions are located intraorally (tongue, oral mucosa, hard palate).

• GCTs are typically small, solitary lesions; rarely do they exceed 3 cm in size.

• Both benign and malignant lesions have been reported; although malignancy occurring is rare, comprising of 2% of all GCTs

222

Granular Cell Tumor

LIPOMA:The tumor is asymptomatic and often has been

noted for many months or years before diagnosis.

Most are less than 3 cm in size, but occasional lesions can become much larger. Although a subtle or more obvious yellow hue often is detected clinically, deeper examples may appear pink.

224

Lipoma

HEMANGIOMA

• Hemangiomas are endothelial tumors with a unique biologic behavior—they grow rapidly, regress slowly, and never recur.

• The three stages in the life cycle of a hemangioma,• (1) the proliferating phase (0–1 year of age),• (2) the involuting phase (1–5 years of age),

• (3) the involuted phase (>5 years of age).

226

227

Most hemangiomas of the tongue are asymptomatic, they could sometimes cause significant bleeding, pain or difficulty in chewing, speaking, and  even swallowing, if they are large enough

LYMPHANGIOMALymphangiomas are benign, hamartomatous tumors of lymphatic vessels.

Oral lymphangiomas may occur at various sites but are most frequent on the anterior two thirds of the tongue, where they often result in macroglossia

228

Pebbly, vesicle- like appearance of a tumor of the right lateral tongue.

MALIGNANT TUMOR OF TONGUE

Squamous cell carcinoma

Anterior 2/3 of tongue

Squamous cell carcinoma

Posterior 1/3 of tongue

METASTASES TO THE ORAL SOFT TISSUES

•The most common site for oral soft tissue metastases is the gingiva, which accounts for slightly more than 50% of all cases. •This is followed by the tongue, which is the site for 25% of cases.•The lesion usually appears as a nodular mass that often resembles a hyperplastic or reactive growth, such as a Pyogenic granuloma. •Occasionally, the lesion appears as a surface ulceration.

232

233

Metastatic renal carcinoma. Nodular mass of the left lateral border of the tongue.

An accessory tongue (Kumar S et al) Singapore Med J 2009; 50(5) : e172

An accessory tongue is a rare anomaly. In the literature, only a few case reports have been cited. The patient was treated with a simple surgical excision.

234

Taste disorders:• Taste disorders are distressing for patients. • Taste disturbances can range from a total loss of taste to the

constant presence of phantom tastes, such as a bitter or metallic taste in the absence of any offending substance in the mouth.

• Such disturbances and associated dietary alterations can lead to malnutrition (possibly resulting in death), obesity or other health issues, such as hypertension.

• Despite the discomfort and profound effect on quality of life caused by alteration or loss of taste, few definitive treatments for taste disturbances exist, partly because of the complexity of the taste system and partly because of a lack of substantive research on the topic.

235

• Taste disturbances can be classified into 4 main categories:

Hypogeusia (decreased sensitivity to taste

modalities), Dysgeusia (taste confusion), Phantogeusia (phantom taste) and Ageusia (loss of taste).

Total loss of taste is rare.

236

• Taste disturbances may occur secondary to autoimmune disease, inflammation, hormone imbalance, nerve related damage, psychological problems (e.g., anorexia), medication therapy or malignancy; they may also occur as a result of natural aging.

• In communicating their symptoms, patients often confuse taste changes with flavour changes.

TREATMENT :Treat the underline cause. In communicating their symptoms, patients often confuse taste

changes with flavour changes.• In previous studies, zinc gluconate (50 mg 3 times daily) had a

positive effect on taste disorders in a zinc deficient population and also in patients with idiopathic taste loss regardless of serum zinc level

237

• Alphalipoic acid, an important coenzyme and antioxidant in many cellular pathways within the body, has also been suggested for treating idiopathic dysgeusia.

• Femiano and colleagues36 found that 91% of patients with idiopathic dysgeusia who took αlipoic acid (200 mg every 8 hours) showed some improvement, and 46% experienced total resolution.

• These authors suggested that αlipoic acid may mitigate or

reverse the neuropathic changes related to idiopathic dysgeusia.

238

Journal of cannadian dental association; Taste Disorders: A Review,Nan Su, BSc; Victor Ching, BSc, RN; Miriam Grushka, MSc, DDS, PhDverse the neuropathic changes related to idiopathic dysgeusia , September 17, 2013

The tongue is an important organ of the body.

Any pathology concerning its boundaries may spread to distant areas of the body… via its lymphatic and vascular supply.

Correct and an early diagnosis during the examination of tongue

Differential diagnosis of the lesions need the knowledge, the skill and the experience of the clinician.

CONCLUSION

REFERENCES

1. Drake L R, Vogl W, Mitchell A W M. Gray’s anatomy for student. International Edition.

2. Sinnatamby C S. Last’s anatomy regional and applied. 11th edition.3. Sadler T W. Langman’s medical embryology.9th edition.4. Berkovitz B K B, Holland G K, Moxham B J. oral anatomy,

histology and embryology. 3rd edition.5. Nanci A. Ten Cate’s Oral histology. Development, structure and

function. 7th edition. 6. Singh I, Pal G P. Human embryology. 7th edition.7. Kumar G S. Orban’s oral histology and embryology. 12th edition.8. Greenberg, Glick, Ship. Burket’s Oral Medicine. 9, 10,11 edition.9. Textbook of Human physiology- Guyton

9. Greenberg, Glick, Ship. Burket’s Oral Medicine. 12 edition.10. R Rajendran, B Sivapathasundharam. Shafer’s textbook of Oral Pathology.

5th edition.11. R Rajendran, B Sivapathasundharam. Shafer’s textbook of Oral Pathology.

6th edition.12. Ballard J L et al. Ankyloglossia: Assessment, Incidence, and Effect of

Frenuloplasty on the Breastfeeding Dyad. Pediatrics.2002:110 (5);1-613. Lawrence A. Kotlow.Ankyloglossia (tongue-tie):A diagnostic and

treatment quandary.Quintessence International 1999;30:259-26214. Segal L M et al.Clinical Review Prevalence, diagnosis, and treatment of

ankyloglossia Methodologic review. Canadian Family Physician. 2007:53;1027-33

15. Gomes C C et al. Mucosal varicosities: case report treated with monoethanolamine oleate. Med Oral Patol Oral Cir Bucal 2006;11:E44-6.

16. Baughman RA. Lingual thyroid and lingual thyroglossal tract remnants. A clinical and histopathologic study with review of the literature. Oral Surg Oral Med Oral Pathol 1972; 34:781-99.

243 THANK YOU