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The tongue is essentially a complex muscular organ covered by specialized mucous membrane. The mucous membrane is composed of different types of papillae, these are:

1. Circumvallate papillae:

2. Fungiform papillae:

3. Filifom papillae:

4. Foliate papillae:

The tongue is essentially a complex muscular organ covered by specialized mucous membrane. The mucous membrane is composed of different types of papillae, these are:
Circumvallate papillae:
At the junction of the anterior two third and posterior third of the tongue as V shaped row. They are vascularized and they contain a large number of taste buds. They do not participate in the atrophic changes of the tongue. They are usually 8 to 12 in number.
Fungiform papillae:
These mushroom-shaped structure are found only on the anterior two third of the tongue mostly near the tip and lateral margins. They have a rich capillary network that makes them easily identifiable as reddish dots against a carpet of filiform papillae they are participate in the inflammatory and atrophic changes of the tongue. Their number is about 100/cm2 on the tip and 5o/ cm2 in the middle.
Filifom papillae:
The are slender or hair like papillae with heavily keratinized caps that are found in rows radiating anteroposteriorly over the anterior two third. It is calculated about 500/cm2.
Foliate papillae:
These are found mostly in the lateral margin of the posterior part of the tongue. They do not participate in the atrophic changes of the tongue.
5. Papillae simplices:
It is a connective tissue papillae present beneath the tongue surfaces.


1.Ankyloglossia (tongue tie):Is a congenital shortness of the lingual frenum that extends nearly to the tip of the tongue, binding the tongue to the floor of the mouth and restricting its extension. It may be associated with microglossia. Contrary to popular opinion, there is no evidence that ankyloglossia interferes with speech, although patient may find that restricted mobility interferes with the mechanical cleansing action of the tongue.

2.Fissured tongue (Grooved or Scrotal tongue or plicated tongue or lingua dissecta ):Occurs as a normal variation affecting less than 10% of the population. Food debris accumulation in these fissures cause mild inflammation and discomfort to the patient with burning sensation.Treatment of painful symptoms:Irrigation with 3% H2O2.Mild antibacterial agent on the inflamed area.Warm mouthwash.Chlorhexidine mouthwash.The appearance of an irregular border of the tongue (often said to resemble a “pie-crust edge”) is known as crenated tongue and can be one of the features of bruxism in some patients.

4.Median rhomboid glossitis: Described as a rhomboid, diamond or rounded area of depapillation in the midline anterior to V-shaped circumvallate papillae. It may have a red, white, or yellow appearance.Median rhomboid glossitis has for long been considered to be developmental abnormality in some way connected with the site of the embryonic tuberculum impar. It has now been recognized that these lesions are often associated with the presence of candida.Treatment:In asymptomatic cases reassurance of the patient is required.In symptomatic cases (burning sensation) antifungal agent (nystatin)Observation is required to detect any enlargement of the area but a need for biopsy is unlikely.

Macroglossia (Large tongue): Is a component of numerous syndromes, most of them associated with sever metabolic anomalies in which the increase in tongue size is caused by deposit of lipid or CHO.In all cases, other abnormalities accompany the macroglossia.The most common causes of macroglossiaCretinism.Mongolism (Down’s syndrome)Myxedema.Haemangioma.Generalized amyloidosis.Feature of acromegaly. Amyloidosis is an important cause of macroglossia since it is usually associated with life-threading disease, particularly multiple myeloma. Amyloidosis is the deposition of an abnormal protein in the tissue. It can result from overproduction of immunoglobulin light chains, usually by multiple myeloma. In over 20% of such cases, amyloid is deposited in the mouth, particularly the tongue and macroglossia can be so gross as to protrude from the mouth.

3.Hamartomas & dermoids:The tongue may be distorted or enlarged by the presence of a variety of tumor-like growths of developmental origin like hamartomas (neorofibromas, hemangioma) or by epithelial inclusion cyst (dermoids, branchial cleft cysts).

4.Blad or depapillated tongue:Absence of papillae may be caused by a congenital anomaly or develop as a secondary feature to congenital anomalies that result in scarring of the tongue dorsum. e.g epidermolysis bullosa.

A.Changes in the tongue papillae: 1.Geographic tongue (Benign migratory glossitis or erythema migrans or wandering rash or glossitis areata exfoliativa.)Refers to irregularly shaped, redish areas of depapillation that are usually surrounded by a narrow zone of regenerating papillae that is whiter than the surrounding tongue surface. Spontaneous development and regeneration of affected areas account for the term wandering rash or migratory glossitis.It is not restricted to the tongue and similar irregular lesion occurring elsewhere in the oral cavity are referred to as ectopic geographic tongue, erythema migrans or annular migrans.The etiology remains obscure, but an immunologic reaction has been proposed on the basis of the associated inflammatory infiltrate. Some cases occur due to zinc deficiency.

D.D:1. Pustular psoriatic dermatitis. +ve skin lesion2. Reiter’s syndrome. skin ,occular,urethral & arthritis.3. Dermatitis herpetiformis.4. Lichen planus. Annular type5. Anaemia.

TreatmentThere is no specific curative treatment for this self-limiting condition. Treatment are attempted for the control of chronic burning pain by:Most patients learn to avoid foodstuffs that irritate their tongue.Application of topical local anaesthetic agents.Mouth rinse by aqueous antihistamineTopical corticosteroidTopical application of Tretinoin.Some authorities have suggested the use of zinc supplement.

2.Coated or hairy tongue or lingua nigra or lingua villosa.In health, the heavily keratinized surface layers of the filiform papillae are continuously desquamated through friction of tongue with food, the palate and the upper anterior teeth and are replaced by new epithelial cells from bellow. When illness or painful oral condition limits tongue movement, the filliform papillae lengthen and become heavily coated with bacteria and fungi. The longer papillae give the tongue a coated or hairy appearance and retain debris and pigments from food, drink, or tobacco smoke.Extreme degree of coated tongue occurring in dehydrated, debilitated, terminally ill patients. The hairy tongue is increased with use of systemic antibiotics or topical H2O2 probably as result of changes in the oral microbial flora.Treatment Thorough cleaning and scraping of tongue or application of topical keratolytic agents.

3.Non keratotic white lesionsa.thrushb. chemical or thermal burnc.white spongy nevusd.vesiculo-bullous & other desequamativing disorders (benign mucous membrane pemphigoid, lichen planus, epidermolysis bullosa). 4.Keratotic white lesionse.g leukoplakia

B.Depapillation & atrophic lesions1.Chronic trauma2.Nutritional deficiencies & hematologic abnormalitiesRedness, loss of papillae & painful swelling of the tongue are found in deficiency of several B vitamins and in iron deficiency.3.Medicationsdepapillation of the tongue occur as side effect of a number of medications (like antibiotics, cancer chemotherapeutic agents, anticholinergic agents). In these cases inhibition of epithelial reproduction, secondary candidiasis & the effect of chronic xerostomia are probably involved.

4.Periphral vascular diseaseDiabetes:Decrease nutritional status of the lingual papillae as a result of vascular changes affecting the lingual vessels is underlies the atrophic glossitis.SclerodermaFibrosis of the submucosal tissues secondary to obliteration of small vessels by an autoimmune process is responsible for the scarred, shrunked & atrophic appearance of tongue.Lupus erythematosusIsolated, irregular areas of lingual mucosal atrophy & ulceration are caused by the arteritis.5. Chronic candidiasis6.Tertiary syphlis & interstitial glossitisDue to the obliteration of the wall of blood vessels which is called obliterative endarteritis and this will lead to vascular insufficiency and nutritional deficiency and atrophy of the papillae of the tongue.7.Atrophic lichen planus

C.PigmentationEndogenous is rarely identifiable on the dorsum because of the thickness of the epithelium but jaundice may be apparent under the thinner ventral mucosa.Exogenous pigmentation of filiform papillae of the normal and coated or hairy tongue is very common.D.Superficial vascular changesLingual varicositisAs prominent purplish blue spots, nodules and ridges usually on the anterior ventral surface of the tongue and around the submandibular and sublingual glands. They are rarely symptomatic. They are usually increase in number with age.HaemangiomesPetechial hemorrhage telangictases

Examination of the tongue

The tongue is believed to be the mirror of the stomach or the window of the digestive system. Its examination includes:
1.Shape
2.Color.
3.Relative number and distribution of its papillae.
4.Evaluation of its muscular tone.
5.Any lesion on its surface.
The color: is orange-red best examined when tongue is relaxed in the floor of the mouth to avoid change of color due to venous congestion when tongue is protruded out side.
Tongue coating is examined when tongue is protruded to see number and shape of papillae.
Muscular tone of the tongue is examined digitally or bimanually. We can find: .Less muscular tone in secondary anemia and muscular dystrophy.
.Diffuse fibrous consistency in interstitial glossitis of syphilis.
.Localized scarred area in cases of epilepsy.
The tongue most be palpated to detect silent lesions, also examine the lateral and ventral surfaces of the tongue for malignant ulcers, they are commonly occur there.

NORMAL VARIATION IN TONGUE MORPHOLOGY & FUNCTION

1.Ankyloglossia (tongue tie):

2.Fissured tongue (Grooved or Scrotal tongue):

3.Patent thyroglossal duct,thyroglossal duct cyst & Lingual thyroid.

4.Median rhomboid glossitis:

MAJOR INHERITED, CONGENITAL & DEVELOPMENTAL ABNORMALITIES:

1.Cleft, lobed, bifurcated & tetrafurcated tongue

2.Aglossia, hypoglossia & macroglossia

3.Hamartomas & dermoids:

4.Blad or depapillated tongue:
The most common causes of macroglossia
.Cretinism.
.Mongolism (Down’s syndrome)
.Myxedema.
.Haemangioma.
.Generalized amyloidosis.
.Feature of acromegaly.

DISORDER OF THE LINGUAL MUCOSA

A.Changes in the tongue papillae:
1.Geographic tongue (Benign migratory glossitis)
2.Coated or hairy tongue
3.Non keratotic white lesions
4.Keratotic white lesions
B.Depapillation & atrophic lesions
1.Chronic trauma
2.Nutritional deficiencies & hematologic abnormalitie
3.Medications
4.Periphral vascular disease
5. Chronic candidiasis
6.Tertiary syphlis & interstitial glossitis
7.Atrophic lichen planus
8.Early leukoplakia
C.Pigmentation
D.Superficial vascular changes



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