Tongue in health and disease

Tongue in health and disease

1. TONGUE IN HEALTH AND DISEASES Chair person – Dr praveen kusubi Student – dr ravikiran

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

3. APPEARANCE MOISTURE SIZE PIGMENTATION ULCERS TREMORS DEVELOPMENTAL ANOMALIES

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

5. Pale tongue

6. Red beefy tongue in vit B12 deficiency

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

8. SCARLET RED TONGUE

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

10. MAGENTA coloured tongue

11. PURPLE TONGUE Polycythemia

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

13. Cyanosed tongue

14. Yellow tongue

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

16. Hairy tongue

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

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

19. Black hairy tongue

20. Pseudo hairy black tongue - bismuth salicylate

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

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

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

24. BROWN TONGUE Uraemia

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

26. Strawberry tongue

27. Scarlet fever

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

29. Leukoplakia

30. Erythroplakia

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

32. Oral Hairy leukoplakia

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

34. Pigmentation of tongue Dark brown or black patches on tongue may be due to Addisons Nelsons syndrome Peutz jeghers Malabsorption Chronic cachxia

35. Addison’s disease

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

37. fissured tongue

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

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

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

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

42. Cobblestone tongue

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

44. Ehler danlos syndrome

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

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

47. Geographic tongue

48. Treatment of geographic tongue BMG is often asymptomatic . Few individuals experiencing burning pain or sensitivity to foods. Mainstay of treatment for symptomatic BMG is with potent topical corticosteroids as well as topical calcineurin inhibitors.

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

50. Median rhomboid glossitis

51. Candidiasis

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

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

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

55. Thrush ( Pseudomembranous )

56. Acute Erythematous type (atrophic type) Flat , red, sometimes sore areas .

57. Candidal Leukoplakia (Chronic Hyperplastic Candidiasis )

58. Chronic Atrophic Oral Candidiasis ( Angular Cheilitis )

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

60. Dry tongue

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

62. Macroglossia

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

64. Microglossia

65. ULCERS SINGLE Carcinomatous TB Syphilitic Dental

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

67. Tongue malignancy

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

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

70. Multiple ulcers

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

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

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

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

75. Deviated tongue

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

77. aglossia

78. Bifid tongue

79. Tongue tie

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

81. Caviar tongue

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

83. Thank you