Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the. Strawberry tongue, initially pale with red spots, changing to bright red after a Characterised by areas of depapillation; Area migrates with time. Download scientific diagram | Depapillation of the tongue. from publication: Arresting rampant dental caries with silver diamine fluoride in a young teenager.
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Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft and smooth aspect. Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently considered to be a mirror of general health.
Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental. Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in providing patients with a better prognosis.
Due to its proximity to the respiratory tract and its continuity with gastrointestinal system, as well as its participation in speech articulation, the oral cavity assumes a crucial role in many physiologic processes [ 12 ]. Additionally, a great variety of systemic disorders have been associated with specific or nonspecific oral changes and, in many circumstances, the oral cavity becomes an important diagnostic area. Oral involvement may precede systemic manifestations and symptoms, providing clinicians with early diagnosis of an underlying condition.
In particular, its careful examination can reveal signs and symptoms of metabolic disorders, endocrinopathies, gastrointestinal diseases, hematologic, autoimmune, and neoplastic pathologies [ 13 ]. From this perspective, the systematic investigation of the oral mucosa and the dorsum of the tongue appears fundamental. Any variation of oral anatomical structures may be indicative of a systemic disease and should be thoroughly investigated.
However, in order to generate differential diagnoses, since the aetiology of many oral conditions remains unknown, defining a univocal classification system is still arduous and clinicians should firstly discern local and generalized systemic conditions [ 1 – 5 ]. Afterwards, having collected all clinical findings and formed a first opinion, clinicians should determine what additional tests might be necessary before establishing the definitive therapy.
This article focuses mainly on local and systemic conditions associated with atrophy of the dorsum of the tongue, currently considered a potential indicator of general health. At the same time other tongue conditions, determining a clinical aspect similar to a atrophic glossitis, will be examined in order to give a guidance to the differential diagnosis In this context, the differential diagnosis between primary atrophic glossitis and the conditions related to atrophic.
The ordinary texture and appearance of the dorsal tongue are related to the protrusion of a large number of papillae, which are responsible for the roughness of the surface, Fig. Absence of filiform or fungiform papillae on the dorsal surface of the tongue produces a soft and smooth aspect, known as atrophic glossitis AG [ 2 ].
Graphical representation of the tongue in physiological conditions. Throughout the years, numerous factors have been taken into consideration for the aetiology of AG.
In particular, papillary atrophy has been correlated to both local and generalized systemic conditions. Local lesions are more often attributed to congenital or developmental affections, infections, neoplasia; or they may be idiopathic.
Lesions of systemic origins are more frequently associated to metabolic disorders, blood dyscrasias and immunological diseases [ 67 ]. AG can also be correlated with protein deficiency and a hypocaloric diet; as well as deficiency of iron, vitamin B12, folic acid, riboflavin, and niacin [ 389 ].
Differential diagnoses – Conditions affecting the tongue
A literature search was done to identify all reports specifically regarding a condition of atrophy of the papillae of the tongue, regardless of their publication status. Medline, Pubmed and Cochrane Library were ddpapillation systematically for all published literature from January year of off first published paper regarding the AG to Aprilwhich included the following terms in their titles, abstracts, or keyword lists: Reviews, case reports, editorials, letters and commentaries were excluded, as well as articles lacking an abstract preview or not written in English.
The search strategy generated 50 records for the AG, records for the benign migratory glossitis and 83 records for the median romboid glossitis. Finally, 10 studies for the AG, 19 studies for the benign migratory glossitis and 14 studies for the median romboid glossitis were chosen to write the review. Due to the lack of articles that specifically deal with the subject of this review, most of the data were taken from publications in which the observation of tongue atrophy condition was secondary to the main outcome of the work.
Additional sources were hand-searched, including: The tomgue is continuously exposed to chemical, mechanical and depapillaation stimuli that, when too strong or chronic, may cause atrophic lesions.
Among these kind of aetiological factors are alcohol abuse, traumas and drug collateral effects. At the same time, an incorrect diet with nutritional deficiency can determine atrophy of the dorsum dpapillation the tongue leading to a diagnosis of AG.
Typically AG is not a physiological condition; despite this, it has been associated with another tongue disease such as the fissured tongue, also in the absence of a systemic disease [ 10 ]. The depapiloation clinical manifestation of this condition, that is not always associated with an atrophy of the lingual dorsum, is the presence of grooves with varying degree of depth along the dorsal surface of the tongue [ 1014 ].
The fissured tongue is usually asymptomatic, unless a secondary inflammation was determined by a low-grade infection, bacterial overgrowth or trapped food debris. Other than being correlated with older age, this is a condition observed in patients affected by Down’s syndrome, Acromegaly, Sjogren syndrome, Psoriasis and Melkersson-Rosenthal syndrome [ 2512 ].
The association of nutritional deficiencies and AG was first described in in the first US National Health and Nutritional Examination Survey, and it is considered the principal aetiological factor determining the atrophy of the tongue mucosa [ 2515 ].
Deficiency of each one of the nutrients listed above determines one of the conditions described, with a direct or an indirect mechanism poor diet, malabsorption, excessive consumption.
Gastrointestinal diseases are the most common conditions associated with the development of an atrophy of the tongue’s mucosa related to a nutritional aetiology. Among them, celiac disease CD is considered one of the main causes in determining the nutritional deficiencies described above [ 1 ]. Celiac disease is caused by an autoimmune intolerance to gliadin, a protein contained in gluten [ 3233 ].
The main target of this intolerance is represented by the mucosa of the small intestine, with the development of histological lesions characterized by various degrees of villous atrophy, crypt hyperplasia, damage to the surface epithelium, an increased number of lymphocytes and other inflammatory cells in the lamina propria [ 732 – 34 ]. This causes poor absorption of nutrients determining a deficiency of vitamin B12, folic acid and iron [ 34 ].
Tongue lesions related to celiac diseases are identified as indirect symptoms.
The AG associated with celiac disease, when accompanied by other signs or depapillatino, has been recognized as a warning sign of the underlying intestinal pathology [ 24734 – 37 ]. Pastore and Lo Muzio highlighted the importance of the recognition of AG to obtain the diagnosis of a celiac disease.
Differential diagnoses – Conditions affecting the tongue | GPonline
The authors cited the National Institutes of Health consensus statement on celiac disease: AG has also been described as the only clinical sign leading to suspect the diagnosis of celiac disease [ 7 ]. Ina paper by Park JM et al. Further works will be needed to confirm this data [ 39 ]. Alcoholic tongue atrophy can be related to two possible explanations: Malnutrition is a typical condition of an alcoholic patient.
This contradiction is due to an alteration in hepatic enzyme levels, meaning that patients can show symptoms or signs of vitamin B12 deficiency even if its levels are normal [ 41 ]. InCunha S. They observed a statistically significant correlation between atrophic glossitis and reduced anthropometric measures, anemia and hypoalbuminemia. They also identified alterations in serum levels of vitamins A, E and B12, but were not been able to determine a correlation with an atrophic condition of depxpillation tongue [ 42 ].
Direct damage of depapillaion tissues caused by alcohol has been analyzed by several authors.
Everything You Need to Know About Glossitis
InValentine J. The authors studied the histology of tongue specimens taken from corpses of patients with a history of abuse of tobgue within 5 years before death.
Their results showed that epithelial atrophy was frequently present on the lingual dorsum, with an increase in basal cells size and also a decrease in superficial cells [ 43 ]. InMaier H. Alcohol consumption determined a reduction of epithelial thickness associated to increased cellular proliferation in the basal layer.
Alcohol determined a cytotoxic effect, with atrophy of the oral mucosa followed by an hyper-regeneration. All if effects have been associated with an increased susceptibility to carcinogenic substances [ 4445 ]. Drugs determine an AG through several different mechanisms. The AG could derive from drug usage principally in an indirect way, or as a symptom or consequence of a specific adverse reaction to a drug therapy [ 4647 ].
In fact, specific medicaments can determine a vitamin deficiency that leads to an AG through the mechanisms previously explained. The drugs with an adverse reaction leading to this tongye of consequence are very different. Each one of them could generate an AG related to a vitamin deficiency through two principal mechanisms of action: In addition, there are other mechanisms leading to an atrophic condition such as the development of candidiasis after antibiotic use, xerostomia related to antidepressant consumption or microcirculation alteration after use of chemotherapeutical drugs [ 67 – 73 ].
In addition, a review from described as a tongue dysesthesia can also be associated with multitargeted tyrosine kinase inhibitors TKIs and mammalian target of rapamycin inhibitors mTORIs [ 74 ]. Tongue crypts, along with tonsils and depapiillation sulcus, are considered important ecological niches of the oral cavity [ 75 ]. In these areas the balance between the environment and oral microorganisms is frail, and regulates the maintenance of the oral ecosystem equilibrium preventing environmental changes [ 76 – 78 ].
The tongue dorsum is always colonized by various microbial colonies without the development of a pathological condition. When the balance of the niches is altered, it is often possible to observe a pathological colonization due to a specific, and often single, microbial strain accompanied by clinical manifestations.
Atrophic condition of the tongue has been described in association with candidiasis, colonization of Helicobacter pylori and as consequence of Treponema pallidum infection [ 21279 – 81 ]. The development of an oral candidiasis is usually related to an imbalance of the normal oral microbial ecosystem. Determinants of an oral candidiosis o AIDS, organ transplant, chemotherapy or favourable environmental conditions i. Candida infection promotes different clinical manifestations on the tongue surface, both acute and chronic.
Among them, chronic erythematous candidiasis determines an atrophic lesion defined as median rhomboid glossitis [ 570 ], while an acute erythematous candidiasis can promote an a specific AG [ 79 ]. InGall-Troselj et al.
They tongye 87 patients with an AG looking for the presence of H. This statistically higher incidence lead the authors to suspect that H. Treponema pallidum is an anaerobic spirochete causing the sexually transmitted systemic disease named syphilis. Oral manifestations are uncommon but can be present in all the three stages of the disease. The importance of mouth examination for the diagnosis has been recognized long ago [ 92 ]. The review analyzing the literature from to about oral manifestation of syphilis, determined the atrophic condition of the tongue as the sign of a secondary and tertiary stages of the disease.
An atrophic condition of the tongue can be related to a systemic disorder that leads to nutritional deficiency, with the determination of an AG as described in 2.
There are several other systemic conditions or pathologies that can lead to the formation of an atrophic aspect of the tongue, not always classifiable as AG: Gastroesophageal reflux disease GERD is a pathological condition typically represented by the regurgitation of gastric acid with damage to the esophagus. Symptoms of GERD are distinguished into classic and extra-esophageal, the latter being the only symptoms in about fifty percent of cases [ 94 ]. Oral signs can be distinguished on the basis otngue their aetiological cause.
Deppapillation damage provoked by gastric acid reflux from the stomach is represented mainly by dental erosions [ 95 ]. Mucosal damages, in particular on the palatine mucosa, are often described as hyperaemic, erythematous areas along with an alteration in salivary gland functions.
Atrophic lesions of the tongue are frequently described in association with GERD. It is often difficult to determine if they are a direct consequence of the acid ph or if they are secondary to the alteration of the saliva often with a xerostomic condition leading to infection e.