- Email: [email protected]
Correlation between gross appearance and histopathology of the tongue
CORRELATION BETWEEN HISTOPATHOLOGY GEORCTE STEIN, M.D., D.M.D.,’
AND
GROSS APPEARANCE OF THE TONGUE HPMAN
COLD,
AND
M.D., NEW YORK, N. Y.
I
T HAS long been known that the mucous membranes of the oral cavity, especially of the tongue, of animals or man show abnormalities early in the course of nutritional deficiencies. This may be one of the reasons for the widespread use of the tongue examination as a diagnostic aid in internal diseases. The rate of desquamation and regeneration of the lingual epithelium is probably greater than that of other epithelial surfaces, possibly because of the tongue’s Henry, Mayer, Weinmann, and Schourl function in speech and mastication. have shown that the buccal epithelium of the rabbit regenerates completely in approximately 208 hours. A quick regeneration may also be assumed for the epithelium of the tongue. Deficiencies of nutritional factors, essedial for epithelial regeneration, may therefore be expected to manifest themselves on the tongue in their earlier stages. Experiments on animals have shown that hyperkeratosis and ulcers of the t,ongue can be induced by pantothenic acid-deficient diets,z and atrophy In man the factors of the tongue’s epithelium by diets deficient in protein.3 involved are more complex; however, a more complete knowledge of these factors would aid in the evaluation of the nutritional state of the organism as a whole. The literature on nutritional changes in the tongue furnishes very little data on the correlation between the clinical observations and the histologic findings. Therefore, as a first step in evaluating the effects of nutritional deficiency states on the tongue, it was felt necessary to compare gross observations with histologic appearance. Materials
and Methods
This study was conducted on cancer patients who were hospitalized for a prolonged period of time, permitting continuous follow-up examinat.ions and correlation of clinical and laboratory data on the nutritional state with findings in the oral cavity. Some of these patients were observed on the metabolic research ward at Montefiore Hospital, where dietary intake was determined and metabolic balances of nitrogen, phosphorus, sodium, potassium, ana calcium were measured. From the Division of Neoplastic Diseases and Dental Department, Monteflore Hospital, Columbia University School of Dental and Oral Surgery of the Faculty of Medicine. Presented at the meeting of the New York Institute of Clinical Oral Pathology on Feb. 15, 1952, and, in part, at the ninth annual meeting of the American Academy of Oral Pathology on Feb. 7, 1954. in Dentistry, Columbia University ; Research Adjunct, Dental *Research Associate Department. Monteflore Hospital. and
1165
The tongue was observed with a magnifying glass, and Kodachrome ~)icwere taken at regular intervals; l)iopsies and. mhenevcr possil)le, postmortem examinations of t tic tongue were pcrforrucd. Biopsies were ~~crformctl with I)lock ancstticsia, thereby avoiding injections The procedure cattscd only minimal discomfort near the area to br biopsietl. to t,he patient and usually the site of t&e biopsy could hardly be detected aftcr one week. The specimens were fixed in 10 per cent Formalin : paraffin sections were made, stained with hematosylin-eosin and trichrome. tnres
Fig. I.-Patient 9. L. a, section of the coated area. The of fungi, bacteria, desquamated
Coated tongue. flliform papillae cells and food
B, Biopsy of tongue shown in .4. Sagittal are elongated and embedded in a thick layer particles. (Magnification, xl 5 : reduced I,$. )
Since the appearance of the tongue varies considerably, even in areas which are not too far apart., Kodachrome photographs were taken immediately atIer each biopsy; t,his insured the proper coordination between gross and histologic examinations.
GROSS
APPEARANCE
ASD
I-IISTOPATHOLOt;Y
OF TONGUE
1167
Observations Six representative cases of tongue pathology will be presented. The dorsum of the normal tongue has a relvetliki? appearance and silver gray color due to the presence of hornificd filiform papillae which are densely distributed from the tip of the tongue to the \‘-shaped region of the circumvallate papillae. Thrre arc individual Mferences of the area covered by the filiform papillae. They extend, in some patients, OV(~I’the tip and lateral mar$ns of the tongue; in others, howewr, the\- ar(l almost complctclly absent in thrsc reg1011r;. Thcsc papillae are so dcnsrl~ arranged that thtl baw of the mucous mem branc from which they pro.jcct frccluently cannot be swn. The fun@form papillae are sparsely distributed over thtk dorsum and btwme mow numerous toward the tip of the tongue; frequently they c+an hardly be noticed. The circumvallate papillae are of motloratc~ siw alltl l)rojcV+t Y(‘1.y little. 01’ DOt at illl, over the surface of the tongucb. Coating.-+. I,. (JI. H. 4!JitiS), a 55.year-0111 woma~~, haul metastatic carcinoma of the breast and rheumatic heart disease. h weight loss of 25 pounds had been sustained in the year preceding admission. At the time of admission, her general nutritional condition was pool’, emaciation being noted. The patient was place11 on a high-calorie, low salt diet with supplementary multiple vitamin capsules, but her actual food intake was poor. -It the time of the l)iopsy her nutritional condition had not improved. papillae to When the biopsy was taken (Fig. 1, .A) the tongue showed the filiform be of normal length, rlistribution, and hornification at the tip of the tongue ; they were The elongatetl, coating was present in the central area of the mitl(lle third of the tongue. fungiform papillae were clearly Csible :IINI slightly The red at the tip of the tongue. Thr* other II~UCOUB mcwbranes of the oral cavity cirrumrallate papillae appeared large. were normal. The biopsy was taken f~xml tllr mi~ltllr thin1 of the tongue to the left of the midline in an area with heavy coating. ITi.stoZo~/y (Fig. 1, h’) : The reticular lzzyer of the Ianlima propria presented coarse The collagen fibers and moderate vascularization. There VW no increased cellularity. Ilernial papilIac> were well tleveloprd ; most of the retrl pegs were width. The stratum granulosum contained a motlerate number of coarse keratohyaline granules. Parakeratosis was noted in some places and normal keratinization in others. The filiform papillae were elongatrtl ant1 embedded in a thick layer of fungi, bac*tvri:l, tlrrc~uamated cells, and food particles. Shortened Filiform Papillae and Fusion.-11. G. (M. H. ;rlCiril)), a ‘ii-year-oltl man, had On admission, the patient was markedly emaciated, carcinoma of the scum with nwtastases. having sustainrtl a 30.pound wright loss in the preceding three months. Gross examination of the tongue (Fig. 2, .I) showed filiform papillae of almost normal toward the anterior third length but thinner than normal on the posterior two-thirds; of papillae, as well as increased redness and slight fissuring, were shortening and fusion* The fungiform papillae wew neither prominent nor red. The c~ircumrallate papillae evident. were enlarged. A biopsy was taken between the anterior ant1 mitl,lle thirds of the tongue to the right of the midline, including areas whc~rr the filiform papillae were of almost, normal length as well as :~re:w where the papillar were sllortcwetl nut1 suggeste(l fusiotl. Ei,~tolog!, (Fifj. 2, B) : The laniina proprin was thin with consideralde vascularizntion, l,ut \vitll only moderately inrreaaed vascularization of the ~lerrnal papillae. The rete pegs were mostly narrow, frequently pointed, and many of them new split into thin processes. papillae islands,
*the term fu~i~w is used” for a condition in which the site of the individual is recognized, hut no flliform papillae project in(lividually above the tongue of “fused”
papillae
develop
which
are
surrounded
by shallow
grooves.
filiform
surface:
c. Fig. Z.-Patient M. G. A, Thin Aliform papillae of almost normal length in posterio! B, Biopsy of tongue shown in A. Sagittal sectwo-thirds of tongue, fusion in anterior third. tion between the anterior and middle thirds of the tongue including areas of thinned flliform papillae of almost normal length toward the base of the tongue (left in the photomicrograph) (Magniflcaand area of fusion toward the tip of the tongue (right in the photomicrograph). tion. X15 ; reduced 45.) C, Higher-power view of B; left (posterior) part of the photomicrograph with thin flliform papillae of almost normal length embedded in a coating of fungi and bac9, Higher-power view of B; right (anterior) part of teria. (Magnitkation, X 85 ; reduced 2/j.) the photomicrograph presenting loss of papillae and “fusion.” E, Autops specimen of tongue Increased smoothness and development of co i: blestone two months after biopsy. appearance.
GROSS APPEARANCE
ASD
HIYTOPATHOLOGP
OP TONGUE
1169
A moderate number of lymphocytes and polymorphonuclear leukocytes were seen within the epithelial layer. In the posterior part of the specimen (left side of Fig. 2, B) upon higher magnification (Fig. 2, C) one can see that the filiform papillae were numerous, some of them The were very thin, and all mere embedded in a slight coating of fungi and bacteria. Keratinizastratum granulosum contained a considerable number of keratohyaline granules. 1-ion was normal in some areas and parakeratotic in others. The layers of keratin showed a tendency to separate. In the anterior part of the biopsy specimen in the area of fusion There were only a few scattered (right side of Fig. 2, B) the filiform papillae were missing. keratohyaline granules. The stratum granulosum was covered by a layer of nucleated cells This is two to three cells wide, which could not be definitely described as keratinized. illustrated in Fig. 2, U.
The patient gradually grew weaker and died t,wo months after the specimen just described was obtained. On post-mortem examination (Fig. 2, E), no filiform papillae were present. Their former sites were still marked by small projections, groups of which were separated by shallow grooves. Due to the absence of filiform papillae, separated islands appear smooth and represent early “cobblestone” appearance.
Dry, Red Tongue With Shortened Papillae and Fusion.-D. F. (31. H. 48090), a 40-year-old man, suffered from lymphosarcoma. At the time of admission to the hospital the patient was poorly nourished and moderately anemic. A 20-pound weight loss had occurred over the preceding one and one-half pears. The tongue, eight weeks before biopsy
Fig.
hornifiv,l
with
ra
tlrc~l~
Fig. 4.-A. .Sanx patient as in Wig. 3. Tongut cigllt \vwks after Fix:. 3 ; at the time of biopsy the tongue was dry and red, with shortened papillae uml “fusion.” R, liiopsy specithin lamina propria with numerous dilated capillaries; rudimenmen Of tongue in A, showing tary flliform papillae; rete pegs mostly thin; no stratum granulosum: no normal horniflcation. ( Magnification, X 15 ; reduced I,& ) C, Higher-power Numerous dilated capillaries view of B. visible in the dermal papillae. Corresponding to the tips of the dermal papillae were small caps of five to ten layers of flat nucleated cells. (Magnification, Xl 30 ; reduced !$. ) D, Autopsy specimen of tongue of patient D. P. (Fig. 3 ). Section through the serous glands (van Ebner’s glands) at the base of the tongue. Atrophy. (Magnification, X400 ; reduced I,$.)
(Fig. n), appeared fairly well hornified, with rather short filiform papillae somewhat, reduced Grooves rxtendcd from the midline to the margin, resembling in design the veins in number. No pcrli~+hc was present. l’hc patient was given a highcalorie diet and the of a leaf. food intake was fair al first and his weight remained stahlr. Supplementary liver extract ant1 multiple vitamins were also atlministered. lIespite all this, perlkhe developed five weeks later ant1 the tongue showed progrcssivc changes uutil it was dry and red with shortened, blunted papillae anti ‘Lfusion” at the time of l.lre l)iopsy (Fig. 1, A 1. .I Ijiopsy was taken fronr the anterior thirtl of tllc torlgm to tlm rigllt of the midline.
Histology (Fig. 4, B): ‘The lamina propria was thin. The collagen filers were of medium thickness; the capillaries were increasrti in numl)er and considerably dilated. The rete pegs were mostly narrow and split up into small, pointed project,ions. The basal cells were in regular arrangement with a moderate number of mitotic figures. The prickle cells appeared normal in shape and number of layers. There was no stratum granulosum and Filiform papillae were rudimentary. Corresponding to the tips no normal hornification. of the dermal papillae were small caps of five to ten layers of flat, nucleated cells, as seen on higher magnification in Fig. 4, C.
The patient failed rapidly thereafter and died less than one month after A post-mortem specimen of the tongue presented no essential changes from However, the serous (von Ebner’s) glands showetl marked atrophic changes (Fig.
the biopsy. the biopsy. 4, I)).
Effects of Therapy.--J. S. (M. H. 40%57), a 72.year-old man, had carcinoma of the On admission, four months before biopsy, the general condition of lung with metastases. the paGent was poor. At the time of the first biopsy (Fig. 5, A), the tongue was smooth and reddened on the anterior and middle thirds without prominent fungiform papillae. In
B.
Fig. 5.-Patient
J. S.
A,
Tongue
at the time
of biopsy;
smooth
and reddened
in the
anterior third: posteriorly there were some Aliform papillae and coating. B, Biopsy specimen of tongue shown in A. Numerous capillaries in the lamina propria; many rete pegs were broken up; no normal keratinization was present; t-here were no flliform papillae in the anterior part and only few and short papillae in the posterior part. (Magnification, X15 ; reduced j/5.)
the posterior third of the tongue a few short filiform papillae and some coating A biopsy was taken from the middle third to the right of the midline, including atrophic area and part of the coated area of the tongue.
were noted. part of the
Histology (Fig. 5, B): In the lamina propria were numerous dilated capillaries and precapillaries, but no cellular infiltration was noted. Some of the rete pegs were solid and Conwide; others were broken up with branches and projections into the dermal papillae.
GROSS APPEARANCE
ASD
HISTOPATHOLOGY
OF TONGUE
1173
The basal cells were in sequently, the dermal papillae had varying shapes and widths. The thickness of the prickle-cell regular arrangement with moderately numerous mitoses. layer over the tips of the dermal papillae was six to fifteen cells. There were only a few There were no filiform papillae in the anterior part of scattered keratohyaline granules. the biopsy specimen and only a few short papillae in the posterior part. In the posteriol part, where keratinization was present, it was parakeratotic. In the area where short filiform papillae were present they were embedded iu a coating of bacteria and fungi.
B. Fig. 6.-A, Appearance of tongue of patient J. S. (Fig. 5) six weeks later, after extensive vitamin and iron sulfate therapy. The color had changed toward normal color and numerous flliform papillae had reappeared. B, Biopsy of tongue shown in A, revealing less hyperemia in lamina propria. numerous Aliform papillae, increase in keratohyaline granules: keratinization still parakeratotic. (Magnification. X15. reduced $6.) Following the biopsy, iron sulfate by mouth and crude liver extract by injection were given, in addition to multiple vitamins. Although the patient’s general nutritional condition remained stationary, there was a marked improvement in the tongue’s appearance (Fig. Homification appeared on the previously smooth and red part of the tongue ana ‘4 A). In addition the redness decreased. A second biopsy short filiform papillae had developed. was taken one and one-half months after the first, from approximately the same area.
c’. .I
B, Biopsy taken from the anterior Fig. ‘I.-Patient B. S. A, Cobblestone appearance. LOSS of Aliform papillae: the rete pegs were part of the tongue to the right of the midline. Where more solid rete pegs mostly split into narrow projections into the dermal papillae. remained. grooves on the surface were present which, by their design, caused the cobblestone C, Photomicrograph of another case of cobblestone appearance. appearance.
GROSS APPEBRASCE
ANI)
HISTOPI1THOLO(:T
OF TOXGUE
1175
The histologic appearance paralleled the clinical improvement (Fig. 6, B). There were fewer and less dilated blood vcsxels in the laminx propria; the number of filiform Keratinization was still mostly pxrakeratotic with a moderate papillae was increased. increase of keratohyaline granules. A c+oating of lntc*tcbri:t au(I fuugi ~ovc~rc~l the rlougatett tiliform papillae. Fewer rete pegs apprared brokeu up. Cobblestone Appearance of the Tongue.-B. S. (M. H. 51X25), a TO-year-oltl man, the nutritiorml condition of the patient had carcinoma of the bladder. On admission, was considered to be fairly good despite a Wpound weight loss which had occurred over the preceding two years.
Fig. 8.-Patient J. H. A, Atrophic tongue with some coating. B, Biopsy of tongue sho\ving complete loss of flliform papillae on margins and tip of tongue and considerable reduction of dermal papillae. Coating with some flliform papillae in nikldle of tongue. Moderntc vascularization of Iarnimr propria : no kcratiniz:~tion in thr smooth ;)I’w. (Jl;u3rific:~tion. Xl 5 : reduced %r,.) Five months after admission (Fig. 7, .-I ), tin tongue was beefy red, the tiliform papillae were missing in the middle part, uud the marginal areas showed very short filiform papillae with poor hornifieation and a tendemy toward fusion. The tongue in general presented a “cobblestone” design and was dry. The fungiform papillar were visible, lmt
1176
STEIN
AND GOLD
not prominent. The circumvallate papillae were large. There was a slight suggestion of perli?che. A biopsy was taken at this time from the anterior third of the tongue to the right of the midline. Histology (Fig. 7, B): The collagen fibers of the lamina propria were roarse and well developed, being thinner in the dermal papillae. The cellularity was increased in the lamina propria close to the epithelium and consisted mostly of round cells and few polymorphonuclear cells. The rete pegs were mostly split up into narrow projections into the dermal papillae. Where more solid rete pegs remained, grooves on the surface were present which, by their design, caused the cobblestone appearance noted clinically. The basal cells Where there was rounilwere normal in arrangement, with a moderate number of mitoses. cell infiltration below the epithelium, there was also round-cell infiltration of the epithelium Keratohyaline extending toward the surface. There was no coherent granular layer. granules were missing except for a few areas where a small number of very fine granules were seen. There were numerous capillaries in the lamina propria, some of which were moderately dilated. No normal hornification was present; flat, nucleated cells with a tendency to separate into layers covered the surface. 1)ue to the absence of filiform papillae, the dermal papillae reached very close to the epithelial surface, sometimes covered by a layer of only three or four cells. Fig. 7, C, from another case of cobblestone formation, illustrates also the findings just described.
Atrophic Tongues-J. H. (M. H. 50370), a 6Y-year-old man, had carcinoma of the stomach. Food intake was poor and had to On admission the patient appeared cachetic. be supplemented by parenteral fluids and vitamins. Despite this, he continued to lose weight, rapidly and died one month after admission. At the time of biopsy, two weeks before death, his tongue was in an advanced stage of atrophy, especially at the margin and tip (Fig. 8, a). No filiform papillae were visible. Coating was present in The sites of the atrophic filiform papillae could not be distinguished. the central part of the tongue. The color of the tongue was almost normal. The biopsy was taken from the middle third to the left of the midline to include part of the coated area and part of the smooth area. Btitology (Fig. 8, B): The lamina propria was thin, showing moderate vascularization. The collagen fibers were fine. There were no well-developed dermal papillae or rete pegs under t,he smooth part of the tongue, while there were short and t,hin rete pegs with some short filiform papillae in the coated area. There were only a few scattered keratohyaline granules in the smooth part. They were increased in number where filiform papillae were present. The lamina propria wa,s fairly uniformly covered by a ten- to twenty-cell layer of epithelium. There was no keratinization in the smooth area and there ~a;_4 only a thin layer of keratin at the sites of the very few filiform papillae.
Discussion The material described in t,he precedin g section correlates the clinically observable changes of the tongue with their histologic appearance.
Changes in Hornifbation (Figs. lB, 2A, 2C, 4C, 7B, and 8B) .-The normal tongue surface appears silvery gray; the stratum granulosum is well developed; the cells contain coarse keratohyaline granules and are covered by a thick keratin layer. The silvery gray appearance may be caused, in part, by the reflection of light by t,hese coarse granules. Furthermore, the keratin layers, especially in hyperkeratosis, have a tendency to separate, creating spaces between these layers and thereby causing differences in light reflection. This ma- also contribute to Where poor hornification was observed the silvery gray surface appearance. grossly, as judged by the loss of the silvery gray surface appearance, the keratin
GROSS
APPEARANCE
AXD
HIRTOPATHOLOCT
OF TONGUE
1.177
layer was reduced in thickness or was absent, and keratohyaline granules were fewer in number and smaller in size. In the absence of these granules, the blood in the dermis causes a pinkish or reddish color, especially when the capillaries are increased in number and are dilat,cd. The reduction of hornification usually coincides with a shortening of the filiform papillae and the appearance of parakeratosis.
Shortening
and Fusion
of Filiform
Papillae
(Figs. 2B and 4B).-
The filiform papillae are shortened and, on gross examinat,ion, appear to bc blunt. The hornification is decreased. At a later stage the filiform papillae are represented only by a flat cap of five to ten layers of nucleated cells The above the tip of the dermal papillae, frequently showing parakeratosis. secondary dermal papillae increase in size and extend closer to the surface. In this stage the site of t.he filiform papillae can still be clearly distinguished on gross examination; no hornified papillae actually project above the surface and the impression is one of fusion of blunted filiform papillae. The word fusion, which is used in the literature to describe this condition, may thus be misleading, as it would suggest the presence of filiform papillae of normal length “fused” together.
Cobblestone Appearance (Figs. 7A, 7B, and 7C).-In some cases where gross observation reveals no filiform papillae, the tongue shows fairly deep, regular grooves resembling cobblestones. Histologically, t,he depths of these grooves correspond to solid epithelial pegs; in the area between two such grooves the rete pegs are reduced in size and width by numerous secondary dermal papillar reaching close to the surface. No filiform papillae are risible and the entire area between adjacent grooves bulges upward. Atrophy (Figs. 8A and 8B).-In completely smooth tongues, no papillar) design can be distinguished on gross observation. Histologically, the basal-cell layer is arranged in a fairly uniform, wavy line without rete pegs. The epithelial surface is smooth, with little or no keratinization. The original sites of the filiform papillae are not distinguishable. Shortening of filiform papillae, fusion, cobblestone appearance, and smooth tongue are progressive stages of atrophy. The first stage is the shortening of the filiform papillae which, however, still project over the surface of the tongue. In the second stage these papillae are still shorter and do not project over the surface, although their sites are still recognizable. Several of these atrophic papillae are grouped in islands separated by shallow grooves. Therefore, the often-used term fusion could be replaced by the term second stage of atrophy. If the grooves separating the islands of atrophic papillae are deeper, the cobblestone tongue develops. In the third, most advanced, stage of atrophy the former sites of filiform papillae are no longer visible and a smooth layer of the epithelium covers the tongue musculature, and the tongue shows none of the characteristics of its “specialized” epithelium.
Coating (Figs. 1A and 1B) .-The filit’orm papillar I’rcquentl~~ appc’ar C’IIIl)cdded in a coating consisting of hactcrin, fungi, food particles, and dcsquan~atc~tl papillae a~*( elongated : this el~ngakeratin and epithelial cc?lls. Tl~c filifonn tion may he tlnc lo a failllrc~ or llrc filiform ])it]~ill;l(~ lo lw slo1~~lrd oft’ in tllc B;ic*tc~r+;i ant1 I’ungi lllil!’ SrCtl IWtwWll thPW process of normal mastic3tion. elongated papillae and contrihulc to tlic, cdoalirrg. On the other hancl, conditions in the oral cavity may 1~~ favorahlc for cscrssivc growth of microorganisms which embed the filiform papillae, thus l)reventinp their desquamation. Redness.-Sereral factors (*ontrilmte to the al)llormaI’ redness of the tongue. Excessive vascularity in the lamina propria seems to he a major factor producing redness (Fig. 4, R). C’hanges in hornification or the absence of keratohyalinc granules can he responsible for a more reddish color of the mucous membrane. When atrophy of’ the filiform papillae is present, secondary dermal papillae may reach at some points close to the surface being covcrcd hp a two- to three-cell layer of eljithelium only. This may contrihutc to th(h red color of the t,ongue (Figs. 5, R and 7, C’). Atrophy of the epithelium alonca will not cause redness if there is no increased vascnlarity and if a sufficient numhcr of epithclial cells vovcr the latnina propria (F$. 8, I<). Dryness.--L)rying of the tongue has been related to various causes, such as dehydration and desiccation (sleeping with mouth open). However, there are experimental and clinical indications that in some cases the salivar: glands, especially the serous glands of the tongue, show degeneration or atrophic changes. The histologic section shown in Fig. 1, II, illustrates such atrophy of the serous glands in the postc+or part of the tongue (van Ehner’s gland).
Summary Some of t,he gross and hist,ologic changes of t,he tongue associated with in late stages of cancer have hcclr impaired nut,ritional st,ates occurring described. 11 correlation between gross and histologic findings has been attempted. We wish to express our appreciation to 1)r. Daniel Laszlo, Chief, Division of Neoplastic Ijiseases, Montefiore Hospital, for his continued interest and help, to Dr. David Tanchester, Attending Ijentist, Chief of Dental Service, Montefiore Hospital, and his staff for their wholehearted cooperation, and to Dr. Harry M. Zimmerman, Chief, Division of T,aboratories, 1lontefiorr Hospital, for his helpful advice.
References 1. Henry,
T. L., Mayer, T., Weinmann, J. P., and &hour, I.: Pattern of Mitotic Artirity in Oral Epithelium of Rabbits, A. M. A. Arch. Path. 54: 28, 1952. Oral, Gingival, and Periodontal 2. Ziskin, D. E., Stein, G., Gross, P., and Runne, IL: Pathology Induced in Rats on a Low Pantothenic Acid Diet by Toxic Doses of Zinc Carbonate, AM. J. ORTHODOKTI~~S AIW ORAL SURG. 33: 407, 1947. 3. Ziskin, I$. E., and Stein, G.: Epithelial Changes of the Tongue in Rats Fed a Protein Deficient Diet, J. D. Res. 27: 69, 191X. New York, 19.50, Paul 1. Jolliffe, N., Tisdall, F. F., and Cannon, P. R.: Clinical Nutrition, R. Hoeher, Inc., p. 80.
AND
GROSS APPEARANCE OF THE TONGUE HPMAN
COLD,
AND
M.D., NEW YORK, N. Y.
I
T HAS long been known that the mucous membranes of the oral cavity, especially of the tongue, of animals or man show abnormalities early in the course of nutritional deficiencies. This may be one of the reasons for the widespread use of the tongue examination as a diagnostic aid in internal diseases. The rate of desquamation and regeneration of the lingual epithelium is probably greater than that of other epithelial surfaces, possibly because of the tongue’s Henry, Mayer, Weinmann, and Schourl function in speech and mastication. have shown that the buccal epithelium of the rabbit regenerates completely in approximately 208 hours. A quick regeneration may also be assumed for the epithelium of the tongue. Deficiencies of nutritional factors, essedial for epithelial regeneration, may therefore be expected to manifest themselves on the tongue in their earlier stages. Experiments on animals have shown that hyperkeratosis and ulcers of the t,ongue can be induced by pantothenic acid-deficient diets,z and atrophy In man the factors of the tongue’s epithelium by diets deficient in protein.3 involved are more complex; however, a more complete knowledge of these factors would aid in the evaluation of the nutritional state of the organism as a whole. The literature on nutritional changes in the tongue furnishes very little data on the correlation between the clinical observations and the histologic findings. Therefore, as a first step in evaluating the effects of nutritional deficiency states on the tongue, it was felt necessary to compare gross observations with histologic appearance. Materials
and Methods
This study was conducted on cancer patients who were hospitalized for a prolonged period of time, permitting continuous follow-up examinat.ions and correlation of clinical and laboratory data on the nutritional state with findings in the oral cavity. Some of these patients were observed on the metabolic research ward at Montefiore Hospital, where dietary intake was determined and metabolic balances of nitrogen, phosphorus, sodium, potassium, ana calcium were measured. From the Division of Neoplastic Diseases and Dental Department, Monteflore Hospital, Columbia University School of Dental and Oral Surgery of the Faculty of Medicine. Presented at the meeting of the New York Institute of Clinical Oral Pathology on Feb. 15, 1952, and, in part, at the ninth annual meeting of the American Academy of Oral Pathology on Feb. 7, 1954. in Dentistry, Columbia University ; Research Adjunct, Dental *Research Associate Department. Monteflore Hospital. and
1165
The tongue was observed with a magnifying glass, and Kodachrome ~)icwere taken at regular intervals; l)iopsies and. mhenevcr possil)le, postmortem examinations of t tic tongue were pcrforrucd. Biopsies were ~~crformctl with I)lock ancstticsia, thereby avoiding injections The procedure cattscd only minimal discomfort near the area to br biopsietl. to t,he patient and usually the site of t&e biopsy could hardly be detected aftcr one week. The specimens were fixed in 10 per cent Formalin : paraffin sections were made, stained with hematosylin-eosin and trichrome. tnres
Fig. I.-Patient 9. L. a, section of the coated area. The of fungi, bacteria, desquamated
Coated tongue. flliform papillae cells and food
B, Biopsy of tongue shown in .4. Sagittal are elongated and embedded in a thick layer particles. (Magnification, xl 5 : reduced I,$. )
Since the appearance of the tongue varies considerably, even in areas which are not too far apart., Kodachrome photographs were taken immediately atIer each biopsy; t,his insured the proper coordination between gross and histologic examinations.
GROSS
APPEARANCE
ASD
I-IISTOPATHOLOt;Y
OF TONGUE
1167
Observations Six representative cases of tongue pathology will be presented. The dorsum of the normal tongue has a relvetliki? appearance and silver gray color due to the presence of hornificd filiform papillae which are densely distributed from the tip of the tongue to the \‘-shaped region of the circumvallate papillae. Thrre arc individual Mferences of the area covered by the filiform papillae. They extend, in some patients, OV(~I’the tip and lateral mar$ns of the tongue; in others, howewr, the\- ar(l almost complctclly absent in thrsc reg1011r;. Thcsc papillae are so dcnsrl~ arranged that thtl baw of the mucous mem branc from which they pro.jcct frccluently cannot be swn. The fun@form papillae are sparsely distributed over thtk dorsum and btwme mow numerous toward the tip of the tongue; frequently they c+an hardly be noticed. The circumvallate papillae are of motloratc~ siw alltl l)rojcV+t Y(‘1.y little. 01’ DOt at illl, over the surface of the tongucb. Coating.-+. I,. (JI. H. 4!JitiS), a 55.year-0111 woma~~, haul metastatic carcinoma of the breast and rheumatic heart disease. h weight loss of 25 pounds had been sustained in the year preceding admission. At the time of admission, her general nutritional condition was pool’, emaciation being noted. The patient was place11 on a high-calorie, low salt diet with supplementary multiple vitamin capsules, but her actual food intake was poor. -It the time of the l)iopsy her nutritional condition had not improved. papillae to When the biopsy was taken (Fig. 1, .A) the tongue showed the filiform be of normal length, rlistribution, and hornification at the tip of the tongue ; they were The elongatetl, coating was present in the central area of the mitl(lle third of the tongue. fungiform papillae were clearly Csible :IINI slightly The red at the tip of the tongue. Thr* other II~UCOUB mcwbranes of the oral cavity cirrumrallate papillae appeared large. were normal. The biopsy was taken f~xml tllr mi~ltllr thin1 of the tongue to the left of the midline in an area with heavy coating. ITi.stoZo~/y (Fig. 1, h’) : The reticular lzzyer of the Ianlima propria presented coarse The collagen fibers and moderate vascularization. There VW no increased cellularity. Ilernial papilIac> were well tleveloprd ; most of the retrl pegs were width. The stratum granulosum contained a motlerate number of coarse keratohyaline granules. Parakeratosis was noted in some places and normal keratinization in others. The filiform papillae were elongatrtl ant1 embedded in a thick layer of fungi, bac*tvri:l, tlrrc~uamated cells, and food particles. Shortened Filiform Papillae and Fusion.-11. G. (M. H. ;rlCiril)), a ‘ii-year-oltl man, had On admission, the patient was markedly emaciated, carcinoma of the scum with nwtastases. having sustainrtl a 30.pound wright loss in the preceding three months. Gross examination of the tongue (Fig. 2, .I) showed filiform papillae of almost normal toward the anterior third length but thinner than normal on the posterior two-thirds; of papillae, as well as increased redness and slight fissuring, were shortening and fusion* The fungiform papillae wew neither prominent nor red. The c~ircumrallate papillae evident. were enlarged. A biopsy was taken between the anterior ant1 mitl,lle thirds of the tongue to the right of the midline, including areas whc~rr the filiform papillae were of almost, normal length as well as :~re:w where the papillar were sllortcwetl nut1 suggeste(l fusiotl. Ei,~tolog!, (Fifj. 2, B) : The laniina proprin was thin with consideralde vascularizntion, l,ut \vitll only moderately inrreaaed vascularization of the ~lerrnal papillae. The rete pegs were mostly narrow, frequently pointed, and many of them new split into thin processes. papillae islands,
*the term fu~i~w is used” for a condition in which the site of the individual is recognized, hut no flliform papillae project in(lividually above the tongue of “fused”
papillae
develop
which
are
surrounded
by shallow
grooves.
filiform
surface:
c. Fig. Z.-Patient M. G. A, Thin Aliform papillae of almost normal length in posterio! B, Biopsy of tongue shown in A. Sagittal sectwo-thirds of tongue, fusion in anterior third. tion between the anterior and middle thirds of the tongue including areas of thinned flliform papillae of almost normal length toward the base of the tongue (left in the photomicrograph) (Magniflcaand area of fusion toward the tip of the tongue (right in the photomicrograph). tion. X15 ; reduced 45.) C, Higher-power view of B; left (posterior) part of the photomicrograph with thin flliform papillae of almost normal length embedded in a coating of fungi and bac9, Higher-power view of B; right (anterior) part of teria. (Magnitkation, X 85 ; reduced 2/j.) the photomicrograph presenting loss of papillae and “fusion.” E, Autops specimen of tongue Increased smoothness and development of co i: blestone two months after biopsy. appearance.
GROSS APPEARANCE
ASD
HIYTOPATHOLOGP
OP TONGUE
1169
A moderate number of lymphocytes and polymorphonuclear leukocytes were seen within the epithelial layer. In the posterior part of the specimen (left side of Fig. 2, B) upon higher magnification (Fig. 2, C) one can see that the filiform papillae were numerous, some of them The were very thin, and all mere embedded in a slight coating of fungi and bacteria. Keratinizastratum granulosum contained a considerable number of keratohyaline granules. 1-ion was normal in some areas and parakeratotic in others. The layers of keratin showed a tendency to separate. In the anterior part of the biopsy specimen in the area of fusion There were only a few scattered (right side of Fig. 2, B) the filiform papillae were missing. keratohyaline granules. The stratum granulosum was covered by a layer of nucleated cells This is two to three cells wide, which could not be definitely described as keratinized. illustrated in Fig. 2, U.
The patient gradually grew weaker and died t,wo months after the specimen just described was obtained. On post-mortem examination (Fig. 2, E), no filiform papillae were present. Their former sites were still marked by small projections, groups of which were separated by shallow grooves. Due to the absence of filiform papillae, separated islands appear smooth and represent early “cobblestone” appearance.
Dry, Red Tongue With Shortened Papillae and Fusion.-D. F. (31. H. 48090), a 40-year-old man, suffered from lymphosarcoma. At the time of admission to the hospital the patient was poorly nourished and moderately anemic. A 20-pound weight loss had occurred over the preceding one and one-half pears. The tongue, eight weeks before biopsy
Fig.
hornifiv,l
with
ra
tlrc~l~
Fig. 4.-A. .Sanx patient as in Wig. 3. Tongut cigllt \vwks after Fix:. 3 ; at the time of biopsy the tongue was dry and red, with shortened papillae uml “fusion.” R, liiopsy specithin lamina propria with numerous dilated capillaries; rudimenmen Of tongue in A, showing tary flliform papillae; rete pegs mostly thin; no stratum granulosum: no normal horniflcation. ( Magnification, X 15 ; reduced I,& ) C, Higher-power Numerous dilated capillaries view of B. visible in the dermal papillae. Corresponding to the tips of the dermal papillae were small caps of five to ten layers of flat nucleated cells. (Magnification, Xl 30 ; reduced !$. ) D, Autopsy specimen of tongue of patient D. P. (Fig. 3 ). Section through the serous glands (van Ebner’s glands) at the base of the tongue. Atrophy. (Magnification, X400 ; reduced I,$.)
(Fig. n), appeared fairly well hornified, with rather short filiform papillae somewhat, reduced Grooves rxtendcd from the midline to the margin, resembling in design the veins in number. No pcrli~+hc was present. l’hc patient was given a highcalorie diet and the of a leaf. food intake was fair al first and his weight remained stahlr. Supplementary liver extract ant1 multiple vitamins were also atlministered. lIespite all this, perlkhe developed five weeks later ant1 the tongue showed progrcssivc changes uutil it was dry and red with shortened, blunted papillae anti ‘Lfusion” at the time of l.lre l)iopsy (Fig. 1, A 1. .I Ijiopsy was taken fronr the anterior thirtl of tllc torlgm to tlm rigllt of the midline.
Histology (Fig. 4, B): ‘The lamina propria was thin. The collagen filers were of medium thickness; the capillaries were increasrti in numl)er and considerably dilated. The rete pegs were mostly narrow and split up into small, pointed project,ions. The basal cells were in regular arrangement with a moderate number of mitotic figures. The prickle cells appeared normal in shape and number of layers. There was no stratum granulosum and Filiform papillae were rudimentary. Corresponding to the tips no normal hornification. of the dermal papillae were small caps of five to ten layers of flat, nucleated cells, as seen on higher magnification in Fig. 4, C.
The patient failed rapidly thereafter and died less than one month after A post-mortem specimen of the tongue presented no essential changes from However, the serous (von Ebner’s) glands showetl marked atrophic changes (Fig.
the biopsy. the biopsy. 4, I)).
Effects of Therapy.--J. S. (M. H. 40%57), a 72.year-old man, had carcinoma of the On admission, four months before biopsy, the general condition of lung with metastases. the paGent was poor. At the time of the first biopsy (Fig. 5, A), the tongue was smooth and reddened on the anterior and middle thirds without prominent fungiform papillae. In
B.
Fig. 5.-Patient
J. S.
A,
Tongue
at the time
of biopsy;
smooth
and reddened
in the
anterior third: posteriorly there were some Aliform papillae and coating. B, Biopsy specimen of tongue shown in A. Numerous capillaries in the lamina propria; many rete pegs were broken up; no normal keratinization was present; t-here were no flliform papillae in the anterior part and only few and short papillae in the posterior part. (Magnification, X15 ; reduced j/5.)
the posterior third of the tongue a few short filiform papillae and some coating A biopsy was taken from the middle third to the right of the midline, including atrophic area and part of the coated area of the tongue.
were noted. part of the
Histology (Fig. 5, B): In the lamina propria were numerous dilated capillaries and precapillaries, but no cellular infiltration was noted. Some of the rete pegs were solid and Conwide; others were broken up with branches and projections into the dermal papillae.
GROSS APPEARANCE
ASD
HISTOPATHOLOGY
OF TONGUE
1173
The basal cells were in sequently, the dermal papillae had varying shapes and widths. The thickness of the prickle-cell regular arrangement with moderately numerous mitoses. layer over the tips of the dermal papillae was six to fifteen cells. There were only a few There were no filiform papillae in the anterior part of scattered keratohyaline granules. the biopsy specimen and only a few short papillae in the posterior part. In the posteriol part, where keratinization was present, it was parakeratotic. In the area where short filiform papillae were present they were embedded iu a coating of bacteria and fungi.
B. Fig. 6.-A, Appearance of tongue of patient J. S. (Fig. 5) six weeks later, after extensive vitamin and iron sulfate therapy. The color had changed toward normal color and numerous flliform papillae had reappeared. B, Biopsy of tongue shown in A, revealing less hyperemia in lamina propria. numerous Aliform papillae, increase in keratohyaline granules: keratinization still parakeratotic. (Magnification. X15. reduced $6.) Following the biopsy, iron sulfate by mouth and crude liver extract by injection were given, in addition to multiple vitamins. Although the patient’s general nutritional condition remained stationary, there was a marked improvement in the tongue’s appearance (Fig. Homification appeared on the previously smooth and red part of the tongue ana ‘4 A). In addition the redness decreased. A second biopsy short filiform papillae had developed. was taken one and one-half months after the first, from approximately the same area.
c’. .I
B, Biopsy taken from the anterior Fig. ‘I.-Patient B. S. A, Cobblestone appearance. LOSS of Aliform papillae: the rete pegs were part of the tongue to the right of the midline. Where more solid rete pegs mostly split into narrow projections into the dermal papillae. remained. grooves on the surface were present which, by their design, caused the cobblestone C, Photomicrograph of another case of cobblestone appearance. appearance.
GROSS APPEBRASCE
ANI)
HISTOPI1THOLO(:T
OF TOXGUE
1175
The histologic appearance paralleled the clinical improvement (Fig. 6, B). There were fewer and less dilated blood vcsxels in the laminx propria; the number of filiform Keratinization was still mostly pxrakeratotic with a moderate papillae was increased. increase of keratohyaline granules. A c+oating of lntc*tcbri:t au(I fuugi ~ovc~rc~l the rlougatett tiliform papillae. Fewer rete pegs apprared brokeu up. Cobblestone Appearance of the Tongue.-B. S. (M. H. 51X25), a TO-year-oltl man, the nutritiorml condition of the patient had carcinoma of the bladder. On admission, was considered to be fairly good despite a Wpound weight loss which had occurred over the preceding two years.
Fig. 8.-Patient J. H. A, Atrophic tongue with some coating. B, Biopsy of tongue sho\ving complete loss of flliform papillae on margins and tip of tongue and considerable reduction of dermal papillae. Coating with some flliform papillae in nikldle of tongue. Moderntc vascularization of Iarnimr propria : no kcratiniz:~tion in thr smooth ;)I’w. (Jl;u3rific:~tion. Xl 5 : reduced %r,.) Five months after admission (Fig. 7, .-I ), tin tongue was beefy red, the tiliform papillae were missing in the middle part, uud the marginal areas showed very short filiform papillae with poor hornifieation and a tendemy toward fusion. The tongue in general presented a “cobblestone” design and was dry. The fungiform papillar were visible, lmt
1176
STEIN
AND GOLD
not prominent. The circumvallate papillae were large. There was a slight suggestion of perli?che. A biopsy was taken at this time from the anterior third of the tongue to the right of the midline. Histology (Fig. 7, B): The collagen fibers of the lamina propria were roarse and well developed, being thinner in the dermal papillae. The cellularity was increased in the lamina propria close to the epithelium and consisted mostly of round cells and few polymorphonuclear cells. The rete pegs were mostly split up into narrow projections into the dermal papillae. Where more solid rete pegs remained, grooves on the surface were present which, by their design, caused the cobblestone appearance noted clinically. The basal cells Where there was rounilwere normal in arrangement, with a moderate number of mitoses. cell infiltration below the epithelium, there was also round-cell infiltration of the epithelium Keratohyaline extending toward the surface. There was no coherent granular layer. granules were missing except for a few areas where a small number of very fine granules were seen. There were numerous capillaries in the lamina propria, some of which were moderately dilated. No normal hornification was present; flat, nucleated cells with a tendency to separate into layers covered the surface. 1)ue to the absence of filiform papillae, the dermal papillae reached very close to the epithelial surface, sometimes covered by a layer of only three or four cells. Fig. 7, C, from another case of cobblestone formation, illustrates also the findings just described.
Atrophic Tongues-J. H. (M. H. 50370), a 6Y-year-old man, had carcinoma of the stomach. Food intake was poor and had to On admission the patient appeared cachetic. be supplemented by parenteral fluids and vitamins. Despite this, he continued to lose weight, rapidly and died one month after admission. At the time of biopsy, two weeks before death, his tongue was in an advanced stage of atrophy, especially at the margin and tip (Fig. 8, a). No filiform papillae were visible. Coating was present in The sites of the atrophic filiform papillae could not be distinguished. the central part of the tongue. The color of the tongue was almost normal. The biopsy was taken from the middle third to the left of the midline to include part of the coated area and part of the smooth area. Btitology (Fig. 8, B): The lamina propria was thin, showing moderate vascularization. The collagen fibers were fine. There were no well-developed dermal papillae or rete pegs under t,he smooth part of the tongue, while there were short and t,hin rete pegs with some short filiform papillae in the coated area. There were only a few scattered keratohyaline granules in the smooth part. They were increased in number where filiform papillae were present. The lamina propria wa,s fairly uniformly covered by a ten- to twenty-cell layer of epithelium. There was no keratinization in the smooth area and there ~a;_4 only a thin layer of keratin at the sites of the very few filiform papillae.
Discussion The material described in t,he precedin g section correlates the clinically observable changes of the tongue with their histologic appearance.
Changes in Hornifbation (Figs. lB, 2A, 2C, 4C, 7B, and 8B) .-The normal tongue surface appears silvery gray; the stratum granulosum is well developed; the cells contain coarse keratohyaline granules and are covered by a thick keratin layer. The silvery gray appearance may be caused, in part, by the reflection of light by t,hese coarse granules. Furthermore, the keratin layers, especially in hyperkeratosis, have a tendency to separate, creating spaces between these layers and thereby causing differences in light reflection. This ma- also contribute to Where poor hornification was observed the silvery gray surface appearance. grossly, as judged by the loss of the silvery gray surface appearance, the keratin
GROSS
APPEARANCE
AXD
HIRTOPATHOLOCT
OF TONGUE
1.177
layer was reduced in thickness or was absent, and keratohyaline granules were fewer in number and smaller in size. In the absence of these granules, the blood in the dermis causes a pinkish or reddish color, especially when the capillaries are increased in number and are dilat,cd. The reduction of hornification usually coincides with a shortening of the filiform papillae and the appearance of parakeratosis.
Shortening
and Fusion
of Filiform
Papillae
(Figs. 2B and 4B).-
The filiform papillae are shortened and, on gross examinat,ion, appear to bc blunt. The hornification is decreased. At a later stage the filiform papillae are represented only by a flat cap of five to ten layers of nucleated cells The above the tip of the dermal papillae, frequently showing parakeratosis. secondary dermal papillae increase in size and extend closer to the surface. In this stage the site of t.he filiform papillae can still be clearly distinguished on gross examination; no hornified papillae actually project above the surface and the impression is one of fusion of blunted filiform papillae. The word fusion, which is used in the literature to describe this condition, may thus be misleading, as it would suggest the presence of filiform papillae of normal length “fused” together.
Cobblestone Appearance (Figs. 7A, 7B, and 7C).-In some cases where gross observation reveals no filiform papillae, the tongue shows fairly deep, regular grooves resembling cobblestones. Histologically, t,he depths of these grooves correspond to solid epithelial pegs; in the area between two such grooves the rete pegs are reduced in size and width by numerous secondary dermal papillar reaching close to the surface. No filiform papillae are risible and the entire area between adjacent grooves bulges upward. Atrophy (Figs. 8A and 8B).-In completely smooth tongues, no papillar) design can be distinguished on gross observation. Histologically, the basal-cell layer is arranged in a fairly uniform, wavy line without rete pegs. The epithelial surface is smooth, with little or no keratinization. The original sites of the filiform papillae are not distinguishable. Shortening of filiform papillae, fusion, cobblestone appearance, and smooth tongue are progressive stages of atrophy. The first stage is the shortening of the filiform papillae which, however, still project over the surface of the tongue. In the second stage these papillae are still shorter and do not project over the surface, although their sites are still recognizable. Several of these atrophic papillae are grouped in islands separated by shallow grooves. Therefore, the often-used term fusion could be replaced by the term second stage of atrophy. If the grooves separating the islands of atrophic papillae are deeper, the cobblestone tongue develops. In the third, most advanced, stage of atrophy the former sites of filiform papillae are no longer visible and a smooth layer of the epithelium covers the tongue musculature, and the tongue shows none of the characteristics of its “specialized” epithelium.
Coating (Figs. 1A and 1B) .-The filit’orm papillar I’rcquentl~~ appc’ar C’IIIl)cdded in a coating consisting of hactcrin, fungi, food particles, and dcsquan~atc~tl papillae a~*( elongated : this el~ngakeratin and epithelial cc?lls. Tl~c filifonn tion may he tlnc lo a failllrc~ or llrc filiform ])it]~ill;l(~ lo lw slo1~~lrd oft’ in tllc B;ic*tc~r+;i ant1 I’ungi lllil!’ SrCtl IWtwWll thPW process of normal mastic3tion. elongated papillae and contrihulc to tlic, cdoalirrg. On the other hancl, conditions in the oral cavity may 1~~ favorahlc for cscrssivc growth of microorganisms which embed the filiform papillae, thus l)reventinp their desquamation. Redness.-Sereral factors (*ontrilmte to the al)llormaI’ redness of the tongue. Excessive vascularity in the lamina propria seems to he a major factor producing redness (Fig. 4, R). C’hanges in hornification or the absence of keratohyalinc granules can he responsible for a more reddish color of the mucous membrane. When atrophy of’ the filiform papillae is present, secondary dermal papillae may reach at some points close to the surface being covcrcd hp a two- to three-cell layer of eljithelium only. This may contrihutc to th(h red color of the t,ongue (Figs. 5, R and 7, C’). Atrophy of the epithelium alonca will not cause redness if there is no increased vascnlarity and if a sufficient numhcr of epithclial cells vovcr the latnina propria (F$. 8, I<). Dryness.--L)rying of the tongue has been related to various causes, such as dehydration and desiccation (sleeping with mouth open). However, there are experimental and clinical indications that in some cases the salivar: glands, especially the serous glands of the tongue, show degeneration or atrophic changes. The histologic section shown in Fig. 1, II, illustrates such atrophy of the serous glands in the postc+or part of the tongue (van Ehner’s gland).
Summary Some of t,he gross and hist,ologic changes of t,he tongue associated with in late stages of cancer have hcclr impaired nut,ritional st,ates occurring described. 11 correlation between gross and histologic findings has been attempted. We wish to express our appreciation to 1)r. Daniel Laszlo, Chief, Division of Neoplastic Ijiseases, Montefiore Hospital, for his continued interest and help, to Dr. David Tanchester, Attending Ijentist, Chief of Dental Service, Montefiore Hospital, and his staff for their wholehearted cooperation, and to Dr. Harry M. Zimmerman, Chief, Division of T,aboratories, 1lontefiorr Hospital, for his helpful advice.
References 1. Henry,
T. L., Mayer, T., Weinmann, J. P., and &hour, I.: Pattern of Mitotic Artirity in Oral Epithelium of Rabbits, A. M. A. Arch. Path. 54: 28, 1952. Oral, Gingival, and Periodontal 2. Ziskin, D. E., Stein, G., Gross, P., and Runne, IL: Pathology Induced in Rats on a Low Pantothenic Acid Diet by Toxic Doses of Zinc Carbonate, AM. J. ORTHODOKTI~~S AIW ORAL SURG. 33: 407, 1947. 3. Ziskin, I$. E., and Stein, G.: Epithelial Changes of the Tongue in Rats Fed a Protein Deficient Diet, J. D. Res. 27: 69, 191X. New York, 19.50, Paul 1. Jolliffe, N., Tisdall, F. F., and Cannon, P. R.: Clinical Nutrition, R. Hoeher, Inc., p. 80.