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The Open Dentistry Journal, 2016, 10, 619-635 619
DOI: 10.2174/1874210601610010619
REVIEW ARTICLE
Diagnosis of Lingual Atrophic Conditions: Associations with Local
and Systemic Factors. A Descriptive Review
M. Erriu1,*, F.M.G. Pili1, S. Cadoni2 and V. Garau1
1
Department of Surgical Sciences, Cagliari University, Cagliari, Italy
2
Digestive Endoscopy Unit, S. Barbara Hospital, Iglesias (CA), Italy
Received: April 03, 2016 Revised: October 09, 2016 Accepted: October 15, 2016
Abstract: Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the
tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft
and smooth aspect.
Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently
considered to be a mirror of general health. Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral
involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental.
Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in
providing patients with a better prognosis.
Keywords: Atrophic tongue, Gastrointestinal disease, Infections, Nutritional deficiency, Systemic conditions.
1. INTRODUCTION
Due to its proximity to the respiratory tract and its continuity with gastrointestinal system, as well as its
participation in speech articulation, the oral cavity assumes a crucial role in many physiologic processes [1, 2].
Additionally, a great variety of systemic disorders have been associated with specific or nonspecific oral changes and,
in many circumstances, the oral cavity becomes an important diagnostic area. Oral involvement may precede systemic
manifestations and symptoms, providing clinicians with early diagnosis of an underlying condition. In particular, its
careful examination can reveal signs and symptoms of metabolic disorders, endocrinopathies, gastrointestinal diseases,
hematologic, autoimmune, and neoplastic pathologies [1, 3].
From this perspective, the systematic investigation of the oral mucosa and the dorsum of the tongue appears
fundamental. Any variation of oral anatomical structures may be indicative of a systemic disease and should be
thoroughly investigated. However, in order to generate differential diagnoses, since the aetiology of many oral
conditions remains unknown, defining a univocal classification system is still arduous and clinicians should firstly
discern local and generalized systemic conditions [1 - 5]. Afterwards, having collected all clinical findings and formed a
first opinion, clinicians should determine what additional tests might be necessary before establishing the definitive
therapy.
This article focuses mainly on local and systemic conditions associated with atrophy of the dorsum of the tongue,
currently considered a potential indicator of general health. At the same time other tongue conditions, determining a
clinical aspect similar to a atrophic glossitis, will be examined in order to give a guidance to the differential diagnosis
In this context, the differential diagnosis between primary atrophic glossitis and the conditions related to atrophic.
* Address correspondence to this author at the Cagliari University Via Ospedale, Cagliari Binaghi 4, 09121 Cagliari (CA), Italy; Tel: (+39)
070537429; E-mail: matteoerr@gmail.com
Fig. (1). Graphical representation of the tongue in physiological conditions. (A. Vallate papillae, B. Foliate papillae, C. Filiform
papillae, D. Fungiform papillae).
Throughout the years, numerous factors have been taken into consideration for the aetiology of AG. In particular,
papillary atrophy has been correlated to both local and generalized systemic conditions. Local lesions are more often
attributed to congenital or developmental affections, infections, neoplasia; or they may be idiopathic. Lesions of
systemic origins are more frequently associated to metabolic disorders, blood dyscrasias and immunological diseases [6,
7]. AG can also be correlated with protein deficiency and a hypocaloric diet; as well as deficiency of iron, vitamin B12,
folic acid, riboflavin, and niacin [3, 8, 9].
1.1. Methodology
A literature search was done to identify all reports specifically regarding a condition of atrophy of the papillae of the
tongue, regardless of their publication status. Medline, Pubmed and Cochrane Library were searched systematically for
all published literature from January 1975 (year of the first published paper regarding the AG) to April 2016, which
included the following terms in their titles, abstracts, or keyword lists: atrophic glossitis, benign migratory glossitis and
median romboid glossitis. Reviews, case reports, editorials, letters and commentaries were excluded, as well as articles
lacking an abstract preview or not written in English.
1.2. Results
The search strategy generated 50 records for the AG, 297 records for the benign migratory glossitis and 83 records
for the median romboid glossitis. After application of the inclusion/exclusion criteria and the analysis of full-text
articles, 40 records were discarded for AG, (Fig. 2), 278 for the benign migratory glossitis and 69 for the median
romboid glossitis. Finally, 10 studies for the AG, 19 studies for the benign migratory glossitis and 14 studies for the
median romboid glossitis were chosen to write the review. Due to the lack of articles that specifically deal with the
subject of this review, most of the data were taken from publications in which the observation of tongue atrophy
condition was secondary to the main outcome of the work. Additional sources were hand-searched, including:
bibliographies from previous reviews on the subject, bibliography of all publications cited in these articles and chapter
from various English textbooks regarding the oral pathology.
Diagnosis of Atrophic Tongue The Open Dentistry Journal, 2016, Volume 10 621
2. ASSOCIATIONS
The tongue is continuously exposed to chemical, mechanical and physical stimuli that, when too strong or chronic,
may cause atrophic lesions. Among these kind of aetiological factors are alcohol abuse, traumas and drug collateral
effects. At the same time, an incorrect diet with nutritional deficiency can determine atrophy of the dorsum of the
tongue leading to a diagnosis of AG.
2.2.1. Introduction
The association of nutritional deficiencies and AG was first described in 1975 in the first US National Health and
Nutritional Examination Survey, and it is considered the principal aetiological factor determining the atrophy of the
tongue mucosa [2, 5, 15]. Deficiency of various nutrients, usually several of them rather than one at a time, is described
to be correlated with AG [9, 16 - 19] (Table 1). Those recognised are riboflavin (vitamin B2), niacin (vitamin B3),
622 The Open Dentistry Journal, 2016, Volume 10 Erriu et al.
pyridoxine (vitamin B6), folic acid (vitamin B9), cobalamin (vitamin B12), iron and zinc [2, 5, 8, 9, 16, 17, 20 - 31]
(Table 2). Lately, mechanisms involving cellular oxygenation and/or the iron concentration in tongue's cells have been
associated to AG due to nutritional deficiencies. Deficiency of each one of the nutrients listed above determines one of
the conditions described, with a direct or an indirect mechanism (poor diet, malabsorption, excessive consumption).
Table 1. Literature analysis of articles focused on AG related to nutritional deficiency.
This causes poor absorption of nutrients determining a deficiency of vitamin B12, folic acid and iron [34]. Tongue
lesions related to celiac diseases are identified as indirect symptoms. The AG associated with celiac disease, when
accompanied by other signs or symptoms, has been recognized as a warning sign of the underlying intestinal pathology
[2, 4, 7, 34 - 37]. Pastore and Lo Muzio highlighted the importance of the recognition of AG to obtain the diagnosis of a
celiac disease. The authors cited the National Institutes of Health consensus statement on celiac disease: “the single
most important step in diagnosing celiac disease is to first consider the disorder by recognizing its myriad clinical
features” [6, 38]. AG has also been described as the only clinical sign leading to suspect the diagnosis of celiac disease
[7].
In 2014, a paper by Park JM et al. described a case of Plummer-Vinson syndrome associated with Crohn's disease.
Further works will be needed to confirm this data [39].
specific, and often single, microbial strain accompanied by clinical manifestations. Atrophic condition of the tongue has
been described in association with candidiasis, colonization of Helicobacter pylori and as consequence of Treponema
pallidum infection [2, 12, 79 - 81].
Table 3. Drugs that could be related to the development of an atrophic condition of the tongue.
2.6.5. Psoriasis
Psoriasis is a skin and joint disease affecting between 1 and 2% of the population of the United States [3]. The
clinical pattern is represented by an increased proliferation of keratinocytes due to an autoimmune reaction, with
activation of T lymphocytes, abnormal production of cytokines, altered molecular adhesion, chemotactic mechanisms
and grow factors productions [3]. Specific oral lesions have been associated with this pathology. In particular, fissured
tongue and geographical tongue have been observed as consequence of the immunological disorder [106]. Oral mucosal
lesion may be associated with psoriasis, but it is not clear if these can be considered pathognomonic of this systemic
disease [104].
addiction to food intolerance determining malabsorption [113 - 116]. The tongue can develop fissures, edema,
paresthesia, erosions or taste alteration [3, 111, 112]. For the reasons explained previously, in addition to the therapy
with corticosteroid, clinicians often suggest a specific diet, with the addition of B vitamins. Therefore, the application of
tests to determine food allergies will make it easier to identify and eliminate particular foods from a given patient’s diet
[113].
2.6.8. Diabetes
Diabetes mellitus is a disease that causes an alteration in the production of insulin or that determines a tissue
resistance to insulin effects [3]. It is divided into two different clinical patterns (Type I and type II). Only type I diabetes
is related to oral manifestation through autoimmune aetiology. Oral manifestations are periodontitis, diabetic
sialoadenosis, oral candidiasis, xerostomia, fissured tongue and benign migratory glossitis [3, 14, 117 - 119].
Candida infections, in particular the development of a median rhomboid glossitis, are strongly associated with
diabetes mellitus, with an incidence up to 30% of patients [3, 70, 79].
Fissured tongue and benign migratory glossitis were described as common finding in diabetic patients, but a definite
correlation has never been recognized [3, 117, 120, 121].
3. DIAGNOSTIC HINTS
The diagnosis of an atrophic condition of the tongue is complicated by the similar, local expression of different
clinical presentations. It is usually composed of three different clinical patterns, such as atrophic glossitis, geographic
tongue (benign migratory glossitis) and the median rhomboid glossitis (Table 4).
Table 4. Summary of the different kind of atrophic disease of the tongue.
4. DISCUSSION
The tongue can be considered as a mirror of oral and/or systemic health. An oral medicine expert can be the first to
observe the lingual status, and should be familiar with the different diagnoses of these conditions, for example being
able to link lingual abnormalities with specific etiologic causes. Recognition of alterations relative to tongue’s
morphology, in the presence of a negative anamnesis, should lead to more accurate investigations, in order to ascertain
if they are manifestations of an underlying systemic condition [1, 12].
Among tongue diseases, AG has the most complex differential diagnosis, because it is associated with several
conditions. Atrophy of the filiform papillae, not directly attributable to mechanical damages of the mucosa, can occur in
systemic or local conditions. Although seemingly simple, sometimes the recognition of a “real AG” can be very hard.
Many local conditions, such as median rhomboid glossitis, of glossite migrans, mediated by infective and idiopathic
etiological factors, as well as neoplastic or congenital factors, can complicate the diagnosis. Reamy et al. described and
analyzed the most frequent lingual diseases, with a particular attention to the atrophic conditions [2]. They summarized
the etiologic conditions responsible for the development of AG; among them it was discovered that nutritional
deficiencies and drug reactions are the most frequently encountered. Unfortunately, while drug interactions are almost
always detectable with anamnesis, nutritional deficiencies can be related to various and different systemic conditions,
and sometimes the etiological factor may be difficult to identify. A typical example is anaemia, in which the cause may
be acute or chronic. In some circumstances, however, the outbreak of other symptoms in association with the casual
discovery of tongue lesions, as in case of celiac disease, can be decisive for the diagnosis [7].
The clinician has to identify the clinical and anamnestic conditions that will lead to the diagnosis of the AG and also
identify a possible related systemic disease. During the first observation of the lesion it is necessary to apply a strict
protocol to achieve the right diagnosis. First of all, after the anamnesis, the clinician has to identify if the lingual
condition can be associated with medication taken by the patient (Table 2) or with some already recognised systemic
disease (chapter 2.3). In case of a negative anamnesis, it is fundamental to verify if the AG changes during the 12-24
hours after the first observation in order to reject the hypothesis of a geographic tongue (chapter 3.2). If the lesion
shows no variation in this time-span, the clinician needs to perform a microbiological analysis of the lingual dorsum to
exclude or find a candida infection (that can be classified as primary or secondary to the AG). The presence of a
candidiasis is not necessarily the diagnostic answer, because the AG can easily be infected by both local and systemic
conditions. It is important to remember that the clinical picture associated with a primary candidiasis is the median
rhomboid glossitis (chapter 3.3), while condition such as nutritional deficiencies, diabetes, xerostomia and ph
alterations can easily lead to a secondary infection. Anyway, in case of positivity of the microbiological test, it is
necessary to treat the infection and to revaluate the patient after the therapy, repeating the microbiological analysis in
order to observe possible remission of the atrophic condition (in case of primary candidiasis). If the lesion is still
observable after the antimicrobic therapy, or in case the microbiological test was negative, the clinician needs to
evaluate specific blood tests (chapter 3.1). Following the results of the blood tests, the pathologist should be able to
identify the aetiology of the atrophic condition and to treat it, or ask for a consultation. In the case of unknown or
unidentified aetiology, the observation has to be repeated to identify the appearance of other signs (local or systemic).
CONCLUSION
The early recognition of signs and symptoms relative to systemic conditions through careful analysis of oral
anatomical structures appears essential in the perspective of achieving a better prognosis. Atrophic anomalies are
related to several conditions, both local and systemic, that clinicians have to know and identify. For these reasons,
knowledge of oral diseases and their aetiology is important, requiring a continuous professional education as well as
interaction with other medical specialists when necessary.
CONFLICT OF INTEREST
The authors confirm that this article content has no conflict of interest.
ACKNOWLEDGEMENTS
Authors are thankful to Laura Armosini for the picture on tongue anatomy.
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