Tongue and systemic diseases

Tongue and systemic diseases

1. TONGUE AND SYSTEMIC DISEASES Chairperson – Dr. GAYATRI B H Student – Dr. SUMANT BALGANDI

2. INTRODUCTION The tongue is a complex set of sensory papillae and muscles. 3 forms of taste buds : Fungiform (edges and tip) Circumvallate ( posteriorly in V shape ) Foliate papillae ( posterolateral ) The filiform papillae - devoid of sensory fibers and are not true taste buds.

3. APPEARANCE AND COLOUR SURFACE SIZE ULCERS MOVEMENTS OF TONGUE DEVELOPMENTAL ANOMALIES MISCELLANEOUS CONDITIONS

4. APPEARANCE AND COLOUR

5. Dry tongue

6. Prolonged fever Dehydration Mouth breathing Belladona or atropine effect Anxiety state Sjogrens syndrome-Bone dry tongue Sarcoidosis

7. Excessive moist tongue( sialorrhea ) Organophosphorous poisoning Post encephalitic parkinsonism Drugs- pilocarpine,clozapine Heavy metals- mercury,copper,arsenic GERD Rabies

8. BALD TONGUE Iron deficiency anemia B12 deficiency Folate deficiency Riboflavin deficiency Pellagra Tropical sprue Syphilis- sclerosing glossitis

9. SCARLET RED TONGUE Niacin deficiency Irritants – sodium or potassium hydroxide Acute infections like scarlet fever

10. SCARLET RED TONGUE

11. MAGENTA COLOUR TONGUE R iboflavin deficiency BLUE TONGUE Central Cyanosis Methhemoglobinemia sulphemoglobinemia YELLOW TONGUE Jaundice Irritants- nitric or hydrochloric acid

12. WHITE TONGUE Centrally coating Leukoplakia Irritant substances-mercuric bichloride,carbolic acid,sulphuric acid BROWN TONGUE Uremia Acute liver necrosis PURPLE TONGUE polycythemia

13. EXCESSIVE COATED TONGUE(FURRED TONGUE) Mouth breathing Tobacco consumption Acute exanthematous fever Cirrhosis liver CENTRAL FURRING Enteric fever

14. BLACK TONGUE Iron supplements Bismuth Charcoal Liquorice actinomycosis Antibiotics like penicillin

15. MAGENTA COLOUR TONGUE

16. BLUE TONGUE

17. HAIRY TONGUE(lingua villosa ) Also called as furred tongue Defective desquamation of the filiform papillae leading to the retention hyperkeratosis.

18. HAIRY TONGUE Poor oral hygiene Smokers Mouth breathers low fiber diets Febrile patients . HIV infection Radiation treatment to head and neck Graft-versus host disease Drugs - most common being antibiotics- tetracyclines atypical antipsychotics antidepressants anti- cholinergics .

19. BLACK HAIRY TONGUE Black hairy tongue seen as the complication of hairy tongue Occurs when bacteria are trapped in the filiform papillae and produce pigments causing a brown/black colour . The presence of other microbes such as candida, can exacerbate this condition .

20. Black hairy tongue

21. Pseudo black hairy tongue - bismuth salicylate

22. DD of Hairy tongue Pseudo-hairy black tongue, Oral hairy leukoplakia Premalignant leukoplakia Squamous cell carcinoma Acanthosis nigricans Hypertrophic herpes simplex virus infections

23. Workup for hairy tongue Unless there are stigmata of underlying disease or symptoms, such as pain, no additional workup is needed . In refractory or atypical cases, a biopsy and cultures or PCR for bacteria, fungus, and HSV may be warranted.

24. TREATMENT OF HAIRY TONGUE Regular brushing of the tongue using 1.5% hydrogen peroxide ( 5 to 10 strokes daily) with a hard toothbrush. T opical retinoids , antifungals , and keratolytics . Oral therapy with antifungals , antibiotics and antivirals for refractory cases with positive cultures .

25. STRAWBERRY TONGUE Hypertrophy of fungiform papillae and then desquamation Papillae appear as large red knobs giving the appearance of stawberry tongue( rasberry tongue) Seen in Scarlet fever Toxic shock syndrome Kawasaki disease

26. Strawberry tongue

27. Scarlet fever

28. LEUKOPLAKIA It is a white patch in the mucosa of oral cavity that cannot be characterised clinically or pathologically to any other diseases. It is a premalignant condition Dysplasia and of dyskeratosis leading to formation of thick , white and pearly raised plaques giving whitish appearance of part of tongue. Predisposing factors Spices, betel nut chewing Smoking, tobacco chewing Infective or mechanical (dental irritation)

29. Leukoplakia

30. Erythroplakia

31. ORAL HAIRY LEUKOPLAKIA Seen on lateral margins of tongue as several white areas Cannot be wiped off with gauze. Immuno -compromised patients-AIDS Associated with Epstein Barr virus

32. Oral Hairy leukoplakia

33. It is painless Has no malignant potential. First line topical treatment includes topical retinoids , podophyllin , and acyclovir The underlying HIV infection should be treated or the immunosuppressed states should be modified.

34. PIGMENTATION OF TONGUE Dark brown or black patches on tongue Addisons Nelsons syndrome Peutz jeghers Malabsorption Acanthosis nigricans

35. YELLOWISH WHITE PATCHES Leucoplakia xanthelasma

36. Addison’s disease

37. SURFACE

38. Fissured Tongue(scrotal tongue) A normal variant seen in up to 20% to 30% of the population Characterized by an increased number of fissures and grooves at the central and lateral aspects of the tongue . Very severe fissuring is often referred to as “lingua plicata .”

39. Fissured tongue Down’s syndrome Acromegaly Melkersson -Rosenthal syndrome Pernicious anemia Pachyonychia congenita Cowden’s syndrome Idiopathic

40. Fissured tongue

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

42. COBBLESTONE TONGUE Due to hyperemic and hypertrophied papillae with thickened epithelium Ariboflavinosis (with magenta colour) Syphilis CROCODILE SKIN TONGUE In Sjogren’s syndrome, there is dorsal papillary atrophy & furring of the tongue

43. Cobblestone tongue

44. SMOKER’S PATCH Small, raised, smooth, congested area frequently covered with a crust on the dorsum of tongue White umbilicated papules with a central brown spot on palatal mucosa LEPROTIC NODULES May develop on anterior 2/3 rd of tongue especially near tip

45. CORLIN SIGN- Ehler danlos syndrome

46. Benign Migratory Glossitis = GEOGRAPHIC TONGUE. Benign, inflammatory condition Prevalence-1 to 2% of the population ,more common in young patients. Etiology-rapid loss and regrowth of filiform papillae leading to denuded red patches wandering across the tongue surface. It is more common in Psoriasis (14%) , and some argue that it is an oral manifestation of psoriasis

47. It is characterized by an annular arrangement of alternating raised, hyper keratotic plaques and smooth, atrophic red patches. Red- atrophic filiform papillae White- hypertophic filiform papillae Dynamic and change over time creating a “migratory pattern”

48. Geographic tongue

49. Treatment of geographic tongue Generally no treatment required. If burning pain or sensitivity to foods present -topical corticosteroids as well as topical calcineurin inhibitors.

50. MEDIAN RHOMBOID GLOSSITIS Red depapillated area in the centre of dorsum of tongue Believed to be associated with candidiasis and a marker of underlying immunosuppression . Biopsy may show pseudo- epitheliomatous hyperplasia Responds to antifungal treatment

51. Median rhomboid glossitis

52. Oral candidiasis C reamy white curdlike patches that reveal a raw, bleeding surface when scraped. Debilitated elderly patients High-dose glucocorticoids , broad-spectrum antibiotics Patients with AIDS

53. Candidiasis

54. SIZE

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

56. Macroglossia

57. MICROGLOSSIA Starvation Atrophic glossitis Motor neuron disease Pseudobulbar palsy Cerebral diplegia

58. Microglossia

59. ULCERS

60. SINGLE ULCER Carcinomatous TB Syphilitic Ill fitted dentures Aphthous ulcer

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

62. Tongue malignancy

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

64. MULTIPLE ULCERS Dyspepsia Ulcerative stomatitis Secondary syphilis Herpes Chickenpox Eczema Vit B complex deficiency

65. Multiple ulcers

66. RECURRENT ULCERS Aphthous ulcer Lichen planus , pemphigus , eythema multiforme SLE Behcet’s syndrome (mouth ulcers, genital ulcers, uveitis)

67. MOVEMENTS OF TONGUE

68. TREMOR Parkisonson disease Delirium tremens Thyrotoxicosis Anxiety neurosis

69. LIZARD TONGUE(Jack-in-box tongue) chorea CHEWING TONGUE Athetosis FASCICULATION Motor neuron diseases Syringobulbia

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

71. Deviated tongue

72. DEVELOPMENTAL ANOMALIES

73. TONGUE TIE(ANKYLOGLOSSIA) Pierre Roboin syndrome Oral facial digital syndrome Meckel syndrome Patau syndrome Beckwith widerman syndrome

74. BIFID OR TRIFID TONGUE Orofacialdigital syndrome Klippel feil anomaly AGLOSSIA Pierre robin syndrome Moebius syndrome Aglossia adactyly syndrome

75. Aglossia

76. Bifid tongue

77. Tongue tie

78. MISCELLANEOUS CONDITIONS AMYLOID TONGUE Appears enlarged & presents as mottling of dark purple areas with translucent matter MUCOSAL NEUROMA OF TONGUE MEN II b syndrome ALLIGATOR TONGUE Dry, thick, furrowed & irregular tongue Seen in Diabetes mellitus CAVIAR TONGUE Varicosities of the sublingual veins on the under surface of the tongue Seen in Cirrhosis liver, Superior vena cava syndrome

79. Caviar tongue

80. REFRENCES A text book of symptoms and physical diagnosis. ASPI F GOLWALLA - 5 TH Edition HARRISON’S Principles of Internal Medicine - 20 th edition DAVIDSON principles and practice of medicine - 23 rd edition Manual of Practical medicine by R.Alagappan 4 th edition SRB’s manual of surgery 4 th edition Mangold Aaron R., Torgerson Rochelle R., Rogers Roy S., Diseases of the Tongue, Clinics in Dermatology (2016) Internet