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Glossodynia
GLOSSODYNIA
Jam es II. Q uinn, D D S, N ew Orleans
Clinical experience w ith 54 patients with glossodynia indicates that, in the absence of systemic disease, cause of burning tongue m ay be attributed to local irrita tion and to anxiety resulting in tonguethrusting and tooth-clenching. In this series of patients, there were 42 tonguethrusters, m any of whom, also were toothclenchers. N ineteen o f the patients had cancerphobia; 11 had foliate papillitis. M anagem ent o f patients w ith glossodynia varies according to the cause. Instruction and exercises are used to help patients overcome tongue-thrusting and toothclenching habits. Use o f an anesthetic m outhwash m ay help relieve pain. Ger micidal, anesthetic m outhwashes and top ical application of germicidal agents are used to treat patients with inflam m ation of the foliate papillae.
Burning tongue, a com plaint of tense p a tients— predom inantly m iddle-aged and older women—has long been a puzzling phenomenon. N o lesions are seen on the tongues of these patients, and there is no
detectable systemic cause for the pain. M any investigators believe the pain is psychogenic. From a study of 54 patients w ith glossodynia, I have concluded th a t the pain is real and is caused prim arily by local irritation and secondarily by anx iety. Thirty-six of m y patients were women, and 18 were m en; 49 were older th an 40 years. C AUSE
Ziskin and M oulton1 m ade a psychiatric an d endocrinologic study of 14 women of postmenopausal age w ithout observable tongue disease. Ziskin h ad postulated th at atrophy of the mucosa caused burning of the tongue in women of postmeno pausal age. Tissue responded favorably to horm onal therapy, b u t the glossodynia persisted. Because these patients had m any emotional conflicts, sexual m alad justm ents and cancerphobia, M oulton concluded th a t the symptom was pri m arily psychogenic. Schroff2 attributed the burning to inflam m ation of the foli ate papillae, caused by irritation of the teeth. Such irritation seems anatomically impossible because the foliate papillae of the tongue reside in the pharynx when the tongue is a t rest. Local factors, such
Q u in n : G L O S S O D Y N IA • 1419
as calculi, m alposed teeth, dentures, tongue-thrusting because of tension, ciga rette smoking, excessive use of alcoholic beverages, highly seasoned foods and possible allergy to dentifrices, lipsticks, mouthwashes an d dentures have been incrim inated.3 K utscher an d C hilton4 com pared the cutaneous pain threshold in 15 patients w ith idiopathic glossodynia with th at in 15 patients who served as controls. T h e average cutaneous pain threshold an d the ability to discrim inate these thresholds consistently were the same for both groups.
S calloping (cre n a tio n m arkings) o f tip and late ral borders o f ton gue caused by prolong ed tonguethrusting
SY M PTO M S
M ost patients com plain of alm ost con stant burning of the tongue and, perhaps, of the entire oral cavity. T h e pain rarely awakens them from sleep. T h e tongue usually feels better on awakening, but pain becomes worse during the day until the burning reaches greatest intensity by bedtime. Some patients will reveal, on questioning, th a t the p ain began shortly after a relative or close friend died of can cer of the tongue or oral cavity, or th a t it began after some other em otionally dis turbing experience. N ineteen patients in this series h ad cancerphobia. O n exam ination, no lesions are found. Scalloping (crenation) of the tip and lateral borders of the tongue (illustra tion) strongly suggests a tongue-thrusting habit. This m arking is caused by pressure of the tongue against the teeth, w ith re sulting protrusion of the tissue into the interproxim al spaces, the tongue actually taking an impression of the lingual aspect of the teeth. Scalloping was noted in eight patients in this series. T h e fungiform papillae may be som ew hat redder th an usual, which indicates some irritation. O ther contributing factors, such as malposed teeth, partial d en tu re clasps, lingual bars and calculi in lower incisors m ay be present. M ost patients whom I have seen with burning tongue have a persistent habit of tongue-thrusting; 42 of the 54
patients studied were tongue-thrusters. M any are tooth clenchers as well. Anyone can produce a burning sensation in the tongue simply by pressing it forcibly against the edge of the lower incisors and m aintaining pressure for approxi m ately 30 seconds. In some patients, the foliate papillae, which are composed of lym phoid follicles, are inflamed and m ay produce pain. Bac teria can collect in the folds, m uch as they do in the tonsillar crypts, and pro duce inflam m ation. Eleven patients in the present series h a d foliate papillitis. W hether this condition is a source of pain can be determ ined rapidly by anesthetiz ing this region w ith 5 per cent lidocaine ointm ent or some related topical anes thetic. In my opinion, most instances of bu rn ing tongue are the result of tension, w hich produces oral habits, such as tongue-thrusting against the teeth for long periods, and tooth clenching. Such problems as sharp cusps, m alposed teeth, prosthetic appliances and calculi simply increase the irritation to the tongue. I t is postulated th a t these patients do not have an actual lesion, because the tongue is so sensitive to sensory stimuli th a t a burning sensation will occur before the tissue is sufficiently dam aged to ulcerate. For ex am ple, one rarely, if ever, sees any ab
1420 • J . A M ER . DENT. ASSN.: V o l. 70, June 1965
norm ality of the tongue after it has been burned w ith hot food. Consequently, the p atien t becomes conscious of the irrita tion, and he will stop tongue-thrusting until the level of irritation is decreased and then will begin all over again. I t is this hypersensitivity of the tongue th at actually protects it and prevents tissue de struction. TREATM ENT
B urning caused by tongue-thrusting can be relieved by explaining to the patient the basic mechanism involved. If the anxiety is produced by cancerphobia, the patien t often can be helped by strong reassurance th a t there is no evidence of cancer in the oral cavity. M uscle relaxants and tranquilizers m ay have to be prescribed. Sharp cusps, prosthetic appli ances, calculi and the like should be changed or removed if they are causing the trouble. Scalloping of the tongue, w hen present, should be shown to the patient. O cclusal disharmonies can be a factor in increasing the patient’s tendency to clench the teeth. They produce abnorm al proprioceptive stimuli, w hich result in increased muscle spasm. This problem in creases the existing anxiety state until it is co rrected by judicious, cautious grind ing or by construction of indicated resto rations. Schwartz5 showed th a t muscle spasm can produce interceptive occlusal contact on the affected side and, when the muscle spasm is relieved, interceptive contacts disappear. This finding strongly suggests th a t muscle spasms should be ruled out before an attem p t is m ade to correct apparent interceptive contacts. Occlusal disharmonies should be cor rected w hen they exist. T h e patient should be told to make a conscientious effort to stop clenching the teeth, because this habit confines the tongue muscle, which presses persistently against the teeth, and com pounds the problem. T h e patient should be instructed in how to m aintain the rest position of
the mandible. H e should exercise the suprahyoid muscles, which are the a n tagonists of the elevators of the mandible, particularly the masseter muscle. These exercises6 are done by placing the fist under the symphysis of the m andible with the arm at the side m aintaining constant upw ard pressure and the head in a fixed forw ard position. T hen the m outh is opened and closed slowly so th a t the depressor muscles rem ain contracted throughout the exercise. T h e elevator muscles of the m andible are relaxed and stretched during these movements. This exercise is done until the contracting muscles are completely exhausted; it is necessary to do this m ovem ent for the muscle to grow rapidly in size and strength. T he exercises should be repeated at least three or four times daily or when it is noticed th at clenching is occurring. Strengthening the depressors of the m an dible results in better muscle balance be tween these opposing groups of muscles in tonic contraction, thereby facilitating assumption of the rest position. Chronic tooth clenchers have shortened, hyper trophied elevator muscles. U n d er such circumstances, the rest position feels forced rather th a n relaxed and natural. For an extremely painful tongue, anes thetic m outhwashes may be helpful. Inflam m ation of the foliate papillae may be relieved by use of germicidal a n esthetic m outhwashes an d application of germicidal agents, such as povidoneiodine solution, directly to the papillae. Persistent inflam m ation caused by bac teria collecting in the crevices may re quire excision of the foliate papillae. Patients who smoke excessively should be advised to stop smoking. In the rare case caused by allergy to a dentifrice, m outhwash or lipstick, treatm ent is avoid ance of these substances. C O N C L U S IO N
Glossodynia not caused by systemic dis ease is the result of local irritants and is
Q u in n : G L O S S O D Y N IA • 1421
not im aginary. T h e prim ary cause is tongue-thrusting, a habit produced by underlying tension. This habit m ay be ac com panied by tooth clenching. Purely psychogenic glossodynia is ex tremely rare. T h e condition m ay be con sidered partially psychogenic because em otional stresses cause the tongue-thrust ing habit. Local factors th a t m ay produce a burning tongue include m alposed teeth, partial denture clasps and lingual bars, calculi, foliate papillitis and allergic re actions.
Are you going to th e a n n u a l session in Las V egas this N ovem ber? If so, one of th e m any interesting sights you m ay w a n t to see is the fam ed J a in E ast In d ia n tem ple, exhibited on the g rounds of th e Castaw ays H otel.
From the d e p a rtm e n t o f o ra l surgery, O chsner C lin ic , 1514 Jefferson H ighw ay, N ew O rleans, 70121. 1. Ziskin, D. E., and M o u lto n , Ruth. G lossod ynia: a study o f id io p a th ic o ro lm g u a l pain. J A D A 33:1422 N ov. I, 1946. 2. Schroff, Joseph. Painful (b u rn in g ) to n g u e o f fo lia te p a p illa (ly m p h o id f o llic le ) . J . O ra l Surg., A n esth. & H o sp. D. Serv. 18:207 M ay I960. 3. F a b ric a n t, N . D. The bu rn in g , p a in fu l to n g u e . Eye Ear Nose T h ro a t M o n th ly 41:546 J u ly 1962. 4. Kutscher, A . H ., and C h ilto n , N . W . D o lo rim e tric ev a lu a tio n o f id io p a th ic glossodynia. N ew Y ork State D. J . 18:31 Jan. 1952. 5. Schwartz, Laszlo, and others. D isorders o f th e te m p o ro m a n d ib u la r jo in t; diagnosis, m anage m ent, re la tio n to occlusion o f te e th . P h ila d e lp h ia , W . B. Saunders C o., 1959, p . 53-60. 6. Schwartz, Laszlo, and others. Disorders o f th e te m p o ro m a n d ib u la r jo in t; diagnosis, m anage m ent, re la tio n to occlusion o f te e fh . P h ila d e lp h ia , W . B. Saunders C o., 1959, p. 223-225.
Jam es II. Q uinn, D D S, N ew Orleans
Clinical experience w ith 54 patients with glossodynia indicates that, in the absence of systemic disease, cause of burning tongue m ay be attributed to local irrita tion and to anxiety resulting in tonguethrusting and tooth-clenching. In this series of patients, there were 42 tonguethrusters, m any of whom, also were toothclenchers. N ineteen o f the patients had cancerphobia; 11 had foliate papillitis. M anagem ent o f patients w ith glossodynia varies according to the cause. Instruction and exercises are used to help patients overcome tongue-thrusting and toothclenching habits. Use o f an anesthetic m outhwash m ay help relieve pain. Ger micidal, anesthetic m outhwashes and top ical application of germicidal agents are used to treat patients with inflam m ation of the foliate papillae.
Burning tongue, a com plaint of tense p a tients— predom inantly m iddle-aged and older women—has long been a puzzling phenomenon. N o lesions are seen on the tongues of these patients, and there is no
detectable systemic cause for the pain. M any investigators believe the pain is psychogenic. From a study of 54 patients w ith glossodynia, I have concluded th a t the pain is real and is caused prim arily by local irritation and secondarily by anx iety. Thirty-six of m y patients were women, and 18 were m en; 49 were older th an 40 years. C AUSE
Ziskin and M oulton1 m ade a psychiatric an d endocrinologic study of 14 women of postmenopausal age w ithout observable tongue disease. Ziskin h ad postulated th at atrophy of the mucosa caused burning of the tongue in women of postmeno pausal age. Tissue responded favorably to horm onal therapy, b u t the glossodynia persisted. Because these patients had m any emotional conflicts, sexual m alad justm ents and cancerphobia, M oulton concluded th a t the symptom was pri m arily psychogenic. Schroff2 attributed the burning to inflam m ation of the foli ate papillae, caused by irritation of the teeth. Such irritation seems anatomically impossible because the foliate papillae of the tongue reside in the pharynx when the tongue is a t rest. Local factors, such
Q u in n : G L O S S O D Y N IA • 1419
as calculi, m alposed teeth, dentures, tongue-thrusting because of tension, ciga rette smoking, excessive use of alcoholic beverages, highly seasoned foods and possible allergy to dentifrices, lipsticks, mouthwashes an d dentures have been incrim inated.3 K utscher an d C hilton4 com pared the cutaneous pain threshold in 15 patients w ith idiopathic glossodynia with th at in 15 patients who served as controls. T h e average cutaneous pain threshold an d the ability to discrim inate these thresholds consistently were the same for both groups.
S calloping (cre n a tio n m arkings) o f tip and late ral borders o f ton gue caused by prolong ed tonguethrusting
SY M PTO M S
M ost patients com plain of alm ost con stant burning of the tongue and, perhaps, of the entire oral cavity. T h e pain rarely awakens them from sleep. T h e tongue usually feels better on awakening, but pain becomes worse during the day until the burning reaches greatest intensity by bedtime. Some patients will reveal, on questioning, th a t the p ain began shortly after a relative or close friend died of can cer of the tongue or oral cavity, or th a t it began after some other em otionally dis turbing experience. N ineteen patients in this series h ad cancerphobia. O n exam ination, no lesions are found. Scalloping (crenation) of the tip and lateral borders of the tongue (illustra tion) strongly suggests a tongue-thrusting habit. This m arking is caused by pressure of the tongue against the teeth, w ith re sulting protrusion of the tissue into the interproxim al spaces, the tongue actually taking an impression of the lingual aspect of the teeth. Scalloping was noted in eight patients in this series. T h e fungiform papillae may be som ew hat redder th an usual, which indicates some irritation. O ther contributing factors, such as malposed teeth, partial d en tu re clasps, lingual bars and calculi in lower incisors m ay be present. M ost patients whom I have seen with burning tongue have a persistent habit of tongue-thrusting; 42 of the 54
patients studied were tongue-thrusters. M any are tooth clenchers as well. Anyone can produce a burning sensation in the tongue simply by pressing it forcibly against the edge of the lower incisors and m aintaining pressure for approxi m ately 30 seconds. In some patients, the foliate papillae, which are composed of lym phoid follicles, are inflamed and m ay produce pain. Bac teria can collect in the folds, m uch as they do in the tonsillar crypts, and pro duce inflam m ation. Eleven patients in the present series h a d foliate papillitis. W hether this condition is a source of pain can be determ ined rapidly by anesthetiz ing this region w ith 5 per cent lidocaine ointm ent or some related topical anes thetic. In my opinion, most instances of bu rn ing tongue are the result of tension, w hich produces oral habits, such as tongue-thrusting against the teeth for long periods, and tooth clenching. Such problems as sharp cusps, m alposed teeth, prosthetic appliances and calculi simply increase the irritation to the tongue. I t is postulated th a t these patients do not have an actual lesion, because the tongue is so sensitive to sensory stimuli th a t a burning sensation will occur before the tissue is sufficiently dam aged to ulcerate. For ex am ple, one rarely, if ever, sees any ab
1420 • J . A M ER . DENT. ASSN.: V o l. 70, June 1965
norm ality of the tongue after it has been burned w ith hot food. Consequently, the p atien t becomes conscious of the irrita tion, and he will stop tongue-thrusting until the level of irritation is decreased and then will begin all over again. I t is this hypersensitivity of the tongue th at actually protects it and prevents tissue de struction. TREATM ENT
B urning caused by tongue-thrusting can be relieved by explaining to the patient the basic mechanism involved. If the anxiety is produced by cancerphobia, the patien t often can be helped by strong reassurance th a t there is no evidence of cancer in the oral cavity. M uscle relaxants and tranquilizers m ay have to be prescribed. Sharp cusps, prosthetic appli ances, calculi and the like should be changed or removed if they are causing the trouble. Scalloping of the tongue, w hen present, should be shown to the patient. O cclusal disharmonies can be a factor in increasing the patient’s tendency to clench the teeth. They produce abnorm al proprioceptive stimuli, w hich result in increased muscle spasm. This problem in creases the existing anxiety state until it is co rrected by judicious, cautious grind ing or by construction of indicated resto rations. Schwartz5 showed th a t muscle spasm can produce interceptive occlusal contact on the affected side and, when the muscle spasm is relieved, interceptive contacts disappear. This finding strongly suggests th a t muscle spasms should be ruled out before an attem p t is m ade to correct apparent interceptive contacts. Occlusal disharmonies should be cor rected w hen they exist. T h e patient should be told to make a conscientious effort to stop clenching the teeth, because this habit confines the tongue muscle, which presses persistently against the teeth, and com pounds the problem. T h e patient should be instructed in how to m aintain the rest position of
the mandible. H e should exercise the suprahyoid muscles, which are the a n tagonists of the elevators of the mandible, particularly the masseter muscle. These exercises6 are done by placing the fist under the symphysis of the m andible with the arm at the side m aintaining constant upw ard pressure and the head in a fixed forw ard position. T hen the m outh is opened and closed slowly so th a t the depressor muscles rem ain contracted throughout the exercise. T h e elevator muscles of the m andible are relaxed and stretched during these movements. This exercise is done until the contracting muscles are completely exhausted; it is necessary to do this m ovem ent for the muscle to grow rapidly in size and strength. T he exercises should be repeated at least three or four times daily or when it is noticed th at clenching is occurring. Strengthening the depressors of the m an dible results in better muscle balance be tween these opposing groups of muscles in tonic contraction, thereby facilitating assumption of the rest position. Chronic tooth clenchers have shortened, hyper trophied elevator muscles. U n d er such circumstances, the rest position feels forced rather th a n relaxed and natural. For an extremely painful tongue, anes thetic m outhwashes may be helpful. Inflam m ation of the foliate papillae may be relieved by use of germicidal a n esthetic m outhwashes an d application of germicidal agents, such as povidoneiodine solution, directly to the papillae. Persistent inflam m ation caused by bac teria collecting in the crevices may re quire excision of the foliate papillae. Patients who smoke excessively should be advised to stop smoking. In the rare case caused by allergy to a dentifrice, m outhwash or lipstick, treatm ent is avoid ance of these substances. C O N C L U S IO N
Glossodynia not caused by systemic dis ease is the result of local irritants and is
Q u in n : G L O S S O D Y N IA • 1421
not im aginary. T h e prim ary cause is tongue-thrusting, a habit produced by underlying tension. This habit m ay be ac com panied by tooth clenching. Purely psychogenic glossodynia is ex tremely rare. T h e condition m ay be con sidered partially psychogenic because em otional stresses cause the tongue-thrust ing habit. Local factors th a t m ay produce a burning tongue include m alposed teeth, partial denture clasps and lingual bars, calculi, foliate papillitis and allergic re actions.
Are you going to th e a n n u a l session in Las V egas this N ovem ber? If so, one of th e m any interesting sights you m ay w a n t to see is the fam ed J a in E ast In d ia n tem ple, exhibited on the g rounds of th e Castaw ays H otel.
From the d e p a rtm e n t o f o ra l surgery, O chsner C lin ic , 1514 Jefferson H ighw ay, N ew O rleans, 70121. 1. Ziskin, D. E., and M o u lto n , Ruth. G lossod ynia: a study o f id io p a th ic o ro lm g u a l pain. J A D A 33:1422 N ov. I, 1946. 2. Schroff, Joseph. Painful (b u rn in g ) to n g u e o f fo lia te p a p illa (ly m p h o id f o llic le ) . J . O ra l Surg., A n esth. & H o sp. D. Serv. 18:207 M ay I960. 3. F a b ric a n t, N . D. The bu rn in g , p a in fu l to n g u e . Eye Ear Nose T h ro a t M o n th ly 41:546 J u ly 1962. 4. Kutscher, A . H ., and C h ilto n , N . W . D o lo rim e tric ev a lu a tio n o f id io p a th ic glossodynia. N ew Y ork State D. J . 18:31 Jan. 1952. 5. Schwartz, Laszlo, and others. D isorders o f th e te m p o ro m a n d ib u la r jo in t; diagnosis, m anage m ent, re la tio n to occlusion o f te e th . P h ila d e lp h ia , W . B. Saunders C o., 1959, p . 53-60. 6. Schwartz, Laszlo, and others. Disorders o f th e te m p o ro m a n d ib u la r jo in t; diagnosis, m anage m ent, re la tio n to occlusion o f te e fh . P h ila d e lp h ia , W . B. Saunders C o., 1959, p. 223-225.