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Nonpainful, erythematous, circinate lesions of a protean nature on a fissured tongue
D IA G N O SIN G ORAL DISEASE
Nonpainful, erythematous, circinate lesions of a protean nature on a fissured tongue
R alph W. Correll, D D S W illiam B. W escott, DM D, M S Jerald L. Jensen, D D S, M S
A 70-year-old white man was referred to the dental clin ic for evaluation of multiple tongue lesions, which, accord ing to the patient, had been present for several months and had caused him no discomfort. He stated that the red areas on his tongue tended to heal at varying rates, causing the pattern to appear to “move around.” He was not overly concerned about the lesions because they were not painful. He did, however, ask about the significance of the grooves in the surface of his tongue. C linical examination showed numer ous annular, erythematous lesions that w ere w ell d elin e ated by p rom in en t yellowish-white borders, involving the dorsal, lateral, and ventral surfaces of the patient’s tongue (Fig 1-3). The dorsum of his tongue also contained several rela tively deep grooves or fissures that ex tended generally in an anteroposterior di rection (Fig 3). The m edical history included periph eral vascular atherosclerosis, left ven tricular hypertrophy, hypertension, and acute bronchitis. There was no history of skin disease. The clinical impression for the tongue changes was explained to the patient and treatment was not recom mended. Follow-up examinations were scheduled and conducted for three years. The well-circumscribed, annular red le sions rem ained during the follow -up period; however, they did change in loca tion, size, and shape. The lingual grooves and fissures remained unchanged.
Diagnosis The well-circumscribed, annular red le sions with conspicuous yellowish-white 9 0 ■ JADA, Vol. 109, July 1984
Fig 1 ■ Several discrete, ovoid, erythematous lesions on anterior surface of tongue. Yellowish-white lesional borders are readily apparent.
Fig 2 ■ Involvement of lateral border of tongue by well-circumscribed, red lesions.
Fig 3 ■ Several deep, anteroposterior grooves in dorsal surface and tip of tongue.
D IA G N O SIN G
borders were characteristic of benign mi gratory glossitis. The grooves on the dor sal aspect of the tongue were believed to represent fissured or scrotal tongue. Benign migratory glossitis has been re ferred to by several names, including geographic tongue, glossitis areata migrans, wandering rash of the tongue, ery thema migrans linguale, and exfoliatio areata linguae. We use the term benign migratory glossitis (BMG) in this paper. BMG is usually diagnosed on the basis of the clinical appearance and history of the lesions. Clinicians, however, should be aware that other conditions, especially psoriasis and Reiter’s syndrome and oc casionally atrophic lichen planus and anemia, can cause tongue changes similar to those found in BMG. Some mouth washes have also been reported to cause similar lesions.1 If the characteristic changes are con fined to the tongue, it is most probable that the condition is BMG; however, if the p a tien t has sk in m a n ife sta tio n s of psoriasis, the lesions on the tongue may be the intraoral counterpart of this dermatologic condition. Reiter’s syndrome should be suspected in patients who, in addition to the characteristic tongue le sions of BMG, have conjunctivitis, ure thritis, arthritis, and skin involvement. In som e in stan ces, the tongue changes found in atrophic lichen planus resemble the lesions of BMG. It is, however, un common for only the tongue to be in volved in lichen planus, and the tongue lesions of atrophic lichen planus usually do not have the raised white to yellow borders seen in the lesions of BMG. Occa sion ally, anem ia can cause intraoral changes that appear similar to BMG, but usually, as in lichen planus, these lesions do not migrate nor do they have the characteristic yellow ish-w hite borders that are so common in BMG.
Characteristics
squamation and healing causes the ap parent migratory nature of the lesions that are seen as maplike areas on the lingual m ucosa (hence, the name geographic tongue). The lesions not uncommonly w ill change appearance rather rapidly. Zegarelli and others6 performed sequen tial photographs of tongue lesions every 15 minutes and demonstrated a complete change in lesional configurations after 2 hours. The dorsal surface of the tongue is most frequently affected; however, the lateral margins and ventral surface also may be involved. On rare occasions, other areas of the oral mucosa are similarly affected (a condition that has been referred to as stomatitis areata migrans or ectopic geo graphic tongue).7,8 BMG generally devel ops rapidly and persists for variable times, from weeks to years. It usually has a characteristic migratory clinical ap pearance; however, some cases have been reported to remain static for a prolonged period (sometimes referred to as glossitis areata perstans). It is unclear from the literature whether BMG has a gender predilection. The majority of reports indicate that females and patients older than 40 years of age are more susceptible to the condition. The lesions are usually asymptomatic, but some patients complain of a slight burn ing sensation. In approximately 40% of reported cases of BMG, the patients have also had a fissured tongue. The histologic appearance of lesions of BMG is similar to lesions of the derma tologie disease, psoriasis, and the skin a n d o ra l m u c o sa le s io n s o f th e oculom ucocutaneous disease, Reiter’s syndrome. Because of their histologic and clinical similarity, these diseases have been referred to as psoriasiform lesions. Weathers and others9 have discussed the similarities, differences, and possible re lationship of these diseases. Treatment of BMG essentially consists of identification of the disease and reas surance of the patient of its benign nature, especially if cancerphobia is present. Some investigators suggest eliminating p oten tially irritating factors such as smoking or spicy foods10; others favor sym ptom atic treatm ent w ith mouthrinses, topical anesthetics, and some times vitamin B complex. Most practitio ners consider actual treatment of the le sions unnecessary. Banoczy and others11 concluded that treatment of BMG did not influence the lesions or the subjective complaints of the patients.
BMG is a common but unusual inflamma tory condition affecting the tongue in 1% to 3% of the population.2'4 The cause is unknown. However, a psychosomatic re lationship has been suggested.5 BMG ap pears as polymorphic clinical changes characterized by a chronic process of de squamation and healing of the filiform papillae in m ultiple, irregular-shaped areas. These circinate or ovoid zones of desquamation are characteristically sur rounded by elevated, yellow ish-w hite borders. The central portions of the le sions are smooth and erythematous, and conspicuous fungiform papillae usually Summary appear as elevated red dots. This sometimes rapid process of de We have presented a case of BMG with
ORAL
D IS E A S E
concomitant fissured tongue, a not un common association for two rather com mon oral diseases. BMG is relatively sim ple to recognize, and the diagnosis most commonly is based on clinical appear ance and history of the presence of the lesions. Clinicians should be aware, how ever, of the similarity, clinically and histologically, of lesions of BMG with other, more serious diseases such as psoriasis and Reiter’s syndrome. Patients with characteristic lesions of BMG should be ev a lu a te d c lo s e ly for s ig n s and symptoms of these other diseases. gA_ A _____________________________ J r n O A i T he publication of this series is coordinated by the Veterans Administration Dental Education Center, W est Los Angeles VA M edical Center, Los Angeles, and is supported in part by the Veterans Administra tion and by the Am erican Dental Association. The opinions and assertions contained herein are those of the authors and are not to be construed as official or necessarily representing the views of the Veterans Administration. Dr. Correll is associate director, Veterans A dminis tration Dental Education Center, W est Los Angeles VA M edical Center, Los Angeles, and clin ical assis tant professor, department of pathology, University of Southern California School of Dentistry, Los Angeles. Dr. W escott is director, Veterans Administration Den tal Education Center, Los A ngeles; professor, depart ment of oral diagnosis, radiology, and pathology, Loma Linda University of School of Dentistry; and ad ju n ct professor, departm ent o f oral diagnosis, m edicine, and pathology, School of Dentistry, Uni versity of California, Los Angeles. Dr. Jensen is an oral pathologist, Veterans Administration M edical Cen ter, Long Beach, and clin ical associate professor, de partment o f pathology, University of Southern Cali fornia School of Dentistry, Los Angeles. Address re quest for reprints to Dr. Correll, VA Dental Education Center (161), W est Los Angeles VA M edical Center, Los Angeles, 90073. 1. Kowitz, G.M.; Lucatorto, F.M .; and Cherreck, H.M. Effects of mouthwashes on the oral soft tissues. J Oral Med 3 1 (2 ):4 7 -5 0 ,1976. 2. Halperin, V., and others. O ccurrence of Fordyce spots, benign migratory glossitis, median rhomboid glossitis, and fissured tongue in 2,478 dental patients. Oral Surg 6:1072-1077, 1953. 3. M eskin, L.H.; Redman, R.S.; and Gorlin, R.J. In cidence o f geographic tongue among 3,668 students at the University of Minn. J Dent Res 4 2 :8 9 5 ,1 9 6 3 . 4 . R ich a rd so n , E.R . In c id e n c e of geo g rap h ic tongue and median rhomboid glossitis in 3,319 negro college students. Oral Surg 26:623-625, 1968. 5. Redman, R.S., and others. Psychological com ponent in the etiology of geographic tongue. J Dent Res 45:1403-1408, 1966. 6. Zegarelli, E.V., and others. Geographic tongue: relation o f changes in appearance to tim e. J South Calif Dent Assoc 31:11-13, 1963. 7. Sapiro, S.M ., and Shklar, G. Stom atitis areata migrans. Oral Surg 36:28-33, 1973. 8. Cooke, B.E. Erythema m igrans affecting the oral mucosa. Oral Surg 8:164-167, 1955. 9. Weathers, D.R., and others. Psoriasiform lesions of the oral m ucosa (with emphasis on “ectopic geo graphic tongue”). Oral Surg 37:872-888, 1974. 10. Cooke, B.E. M edian rhomboid glossitis and be nign glossitis migrans. Br Dent J 1 1 2:389-393,1962. 11. Banoczy, J., and others. Migratory glossitis. A clinical-histologic review of seventy cases. Oral Surg 39:113-121, 1975.
JADA, Vol. 109, July 1984 ■91
Nonpainful, erythematous, circinate lesions of a protean nature on a fissured tongue
R alph W. Correll, D D S W illiam B. W escott, DM D, M S Jerald L. Jensen, D D S, M S
A 70-year-old white man was referred to the dental clin ic for evaluation of multiple tongue lesions, which, accord ing to the patient, had been present for several months and had caused him no discomfort. He stated that the red areas on his tongue tended to heal at varying rates, causing the pattern to appear to “move around.” He was not overly concerned about the lesions because they were not painful. He did, however, ask about the significance of the grooves in the surface of his tongue. C linical examination showed numer ous annular, erythematous lesions that w ere w ell d elin e ated by p rom in en t yellowish-white borders, involving the dorsal, lateral, and ventral surfaces of the patient’s tongue (Fig 1-3). The dorsum of his tongue also contained several rela tively deep grooves or fissures that ex tended generally in an anteroposterior di rection (Fig 3). The m edical history included periph eral vascular atherosclerosis, left ven tricular hypertrophy, hypertension, and acute bronchitis. There was no history of skin disease. The clinical impression for the tongue changes was explained to the patient and treatment was not recom mended. Follow-up examinations were scheduled and conducted for three years. The well-circumscribed, annular red le sions rem ained during the follow -up period; however, they did change in loca tion, size, and shape. The lingual grooves and fissures remained unchanged.
Diagnosis The well-circumscribed, annular red le sions with conspicuous yellowish-white 9 0 ■ JADA, Vol. 109, July 1984
Fig 1 ■ Several discrete, ovoid, erythematous lesions on anterior surface of tongue. Yellowish-white lesional borders are readily apparent.
Fig 2 ■ Involvement of lateral border of tongue by well-circumscribed, red lesions.
Fig 3 ■ Several deep, anteroposterior grooves in dorsal surface and tip of tongue.
D IA G N O SIN G
borders were characteristic of benign mi gratory glossitis. The grooves on the dor sal aspect of the tongue were believed to represent fissured or scrotal tongue. Benign migratory glossitis has been re ferred to by several names, including geographic tongue, glossitis areata migrans, wandering rash of the tongue, ery thema migrans linguale, and exfoliatio areata linguae. We use the term benign migratory glossitis (BMG) in this paper. BMG is usually diagnosed on the basis of the clinical appearance and history of the lesions. Clinicians, however, should be aware that other conditions, especially psoriasis and Reiter’s syndrome and oc casionally atrophic lichen planus and anemia, can cause tongue changes similar to those found in BMG. Some mouth washes have also been reported to cause similar lesions.1 If the characteristic changes are con fined to the tongue, it is most probable that the condition is BMG; however, if the p a tien t has sk in m a n ife sta tio n s of psoriasis, the lesions on the tongue may be the intraoral counterpart of this dermatologic condition. Reiter’s syndrome should be suspected in patients who, in addition to the characteristic tongue le sions of BMG, have conjunctivitis, ure thritis, arthritis, and skin involvement. In som e in stan ces, the tongue changes found in atrophic lichen planus resemble the lesions of BMG. It is, however, un common for only the tongue to be in volved in lichen planus, and the tongue lesions of atrophic lichen planus usually do not have the raised white to yellow borders seen in the lesions of BMG. Occa sion ally, anem ia can cause intraoral changes that appear similar to BMG, but usually, as in lichen planus, these lesions do not migrate nor do they have the characteristic yellow ish-w hite borders that are so common in BMG.
Characteristics
squamation and healing causes the ap parent migratory nature of the lesions that are seen as maplike areas on the lingual m ucosa (hence, the name geographic tongue). The lesions not uncommonly w ill change appearance rather rapidly. Zegarelli and others6 performed sequen tial photographs of tongue lesions every 15 minutes and demonstrated a complete change in lesional configurations after 2 hours. The dorsal surface of the tongue is most frequently affected; however, the lateral margins and ventral surface also may be involved. On rare occasions, other areas of the oral mucosa are similarly affected (a condition that has been referred to as stomatitis areata migrans or ectopic geo graphic tongue).7,8 BMG generally devel ops rapidly and persists for variable times, from weeks to years. It usually has a characteristic migratory clinical ap pearance; however, some cases have been reported to remain static for a prolonged period (sometimes referred to as glossitis areata perstans). It is unclear from the literature whether BMG has a gender predilection. The majority of reports indicate that females and patients older than 40 years of age are more susceptible to the condition. The lesions are usually asymptomatic, but some patients complain of a slight burn ing sensation. In approximately 40% of reported cases of BMG, the patients have also had a fissured tongue. The histologic appearance of lesions of BMG is similar to lesions of the derma tologie disease, psoriasis, and the skin a n d o ra l m u c o sa le s io n s o f th e oculom ucocutaneous disease, Reiter’s syndrome. Because of their histologic and clinical similarity, these diseases have been referred to as psoriasiform lesions. Weathers and others9 have discussed the similarities, differences, and possible re lationship of these diseases. Treatment of BMG essentially consists of identification of the disease and reas surance of the patient of its benign nature, especially if cancerphobia is present. Some investigators suggest eliminating p oten tially irritating factors such as smoking or spicy foods10; others favor sym ptom atic treatm ent w ith mouthrinses, topical anesthetics, and some times vitamin B complex. Most practitio ners consider actual treatment of the le sions unnecessary. Banoczy and others11 concluded that treatment of BMG did not influence the lesions or the subjective complaints of the patients.
BMG is a common but unusual inflamma tory condition affecting the tongue in 1% to 3% of the population.2'4 The cause is unknown. However, a psychosomatic re lationship has been suggested.5 BMG ap pears as polymorphic clinical changes characterized by a chronic process of de squamation and healing of the filiform papillae in m ultiple, irregular-shaped areas. These circinate or ovoid zones of desquamation are characteristically sur rounded by elevated, yellow ish-w hite borders. The central portions of the le sions are smooth and erythematous, and conspicuous fungiform papillae usually Summary appear as elevated red dots. This sometimes rapid process of de We have presented a case of BMG with
ORAL
D IS E A S E
concomitant fissured tongue, a not un common association for two rather com mon oral diseases. BMG is relatively sim ple to recognize, and the diagnosis most commonly is based on clinical appear ance and history of the presence of the lesions. Clinicians should be aware, how ever, of the similarity, clinically and histologically, of lesions of BMG with other, more serious diseases such as psoriasis and Reiter’s syndrome. Patients with characteristic lesions of BMG should be ev a lu a te d c lo s e ly for s ig n s and symptoms of these other diseases. gA_ A _____________________________ J r n O A i T he publication of this series is coordinated by the Veterans Administration Dental Education Center, W est Los Angeles VA M edical Center, Los Angeles, and is supported in part by the Veterans Administra tion and by the Am erican Dental Association. The opinions and assertions contained herein are those of the authors and are not to be construed as official or necessarily representing the views of the Veterans Administration. Dr. Correll is associate director, Veterans A dminis tration Dental Education Center, W est Los Angeles VA M edical Center, Los Angeles, and clin ical assis tant professor, department of pathology, University of Southern California School of Dentistry, Los Angeles. Dr. W escott is director, Veterans Administration Den tal Education Center, Los A ngeles; professor, depart ment of oral diagnosis, radiology, and pathology, Loma Linda University of School of Dentistry; and ad ju n ct professor, departm ent o f oral diagnosis, m edicine, and pathology, School of Dentistry, Uni versity of California, Los Angeles. Dr. Jensen is an oral pathologist, Veterans Administration M edical Cen ter, Long Beach, and clin ical associate professor, de partment o f pathology, University of Southern Cali fornia School of Dentistry, Los Angeles. Address re quest for reprints to Dr. Correll, VA Dental Education Center (161), W est Los Angeles VA M edical Center, Los Angeles, 90073. 1. Kowitz, G.M.; Lucatorto, F.M .; and Cherreck, H.M. Effects of mouthwashes on the oral soft tissues. J Oral Med 3 1 (2 ):4 7 -5 0 ,1976. 2. Halperin, V., and others. O ccurrence of Fordyce spots, benign migratory glossitis, median rhomboid glossitis, and fissured tongue in 2,478 dental patients. Oral Surg 6:1072-1077, 1953. 3. M eskin, L.H.; Redman, R.S.; and Gorlin, R.J. In cidence o f geographic tongue among 3,668 students at the University of Minn. J Dent Res 4 2 :8 9 5 ,1 9 6 3 . 4 . R ich a rd so n , E.R . In c id e n c e of geo g rap h ic tongue and median rhomboid glossitis in 3,319 negro college students. Oral Surg 26:623-625, 1968. 5. Redman, R.S., and others. Psychological com ponent in the etiology of geographic tongue. J Dent Res 45:1403-1408, 1966. 6. Zegarelli, E.V., and others. Geographic tongue: relation o f changes in appearance to tim e. J South Calif Dent Assoc 31:11-13, 1963. 7. Sapiro, S.M ., and Shklar, G. Stom atitis areata migrans. Oral Surg 36:28-33, 1973. 8. Cooke, B.E. Erythema m igrans affecting the oral mucosa. Oral Surg 8:164-167, 1955. 9. Weathers, D.R., and others. Psoriasiform lesions of the oral m ucosa (with emphasis on “ectopic geo graphic tongue”). Oral Surg 37:872-888, 1974. 10. Cooke, B.E. M edian rhomboid glossitis and be nign glossitis migrans. Br Dent J 1 1 2:389-393,1962. 11. Banoczy, J., and others. Migratory glossitis. A clinical-histologic review of seventy cases. Oral Surg 39:113-121, 1975.
JADA, Vol. 109, July 1984 ■91