Geographic Tongue (Figure 1) is a condition of a unknown cause and is more prevalent among whites and blacks than Mexican Americans, and it is strongly associated with fissure tongue but is inversely associated with cigarette smoking. In a few patients, emotional stress may enhance the process. Geographic tongue has been associated, coincidentally, with several different conditions, including psoriasis, seborrheic dermatitis, Reiter’s syndrome, and atopy.
Psoriasis is a common, chronic, relapsing/remitting, immune-mediated systemic disease characterized by skin lesions including red, scaly patches, papules, and plaques, which usually itch. The skin lesions seen in psoriasis may vary in severity from minor localized patches to complete body coverage (Figure 2).
Seborrhoeic Dermatitis is a chronic, relapsing and usually mild dermatitis (inflammation of the skin). In infants seborrheic dermatitis is called cradle cap.
Seborrheic dermatitis (Figure 3) is an inflammatory skin disorder affecting the scalp, face, and torso. Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin. It particularly affects the sebaceous-gland-rich areas of skin. In adolescents and adults, seborrhoeic dermatitis usually presents as scalp scaling similar to dandruff or as mild to marked erythema of the nasolabial fold.
The topical antifungal medications ketoconazole and ciclopirox are both effective for the condition. It is unclear if other antifungals are equally effective as this has not been studied.
Reiter’s Syndrome or Reactive arthritis (Figure 4) is classified as an autoimmune condition that develops in response to an infection in another part of the body.
The arthritis often is coupled with other characteristic symptoms; this is called Reiter’s syndrome.
The manifestations of reactive arthritis include the following triad of symptoms: an inflammatory arthritis of large joints, inflammation of the eyes in the form of conjunctivitis or uveitis, and urethritis in men or cervicitis in women.
Atopy or atopic syndrome is a predisposition toward developing certain allergic hypersensitivity reactions. Atopy may have a hereditary component, although contact with the allergen must occur before the hypersensitivity reaction can develop (Figure 5).
- Clinical features
Geographic tongue is seen in approximately 2% of the U.S population and affects women slightly more often than men. It is more prevalent in the young, in nonsmokers, and in allergic or atopic individuals. Children between infancy and 10 years of age may be affected in up to 18% of cases. Geographic tongue is characterized initially by the presence of atrophic (waste away body tissue) patches surrounded by elevated keratotic (is a growth of whitish keratin on the skin or on mucous membranes) margins. The desquamated (come off in scales or flakes) areas appear red and maybe slightly tender (Figure 6 to 8).
When followed over a period of days or weeks, the pattern changes, appearing to move across the dorsum of the tongue. A strong association has been noted between geographic tongue and
fissured (plicated) tongue (Figure 9).
The significance of this association is unknown, although symptoms may be more common when fissured tongue is present, presumably because of secondary fungal infection in the base of the fissures.
Rarely, similar alterations have been described in the floor of the mouth, the buccal mucosa, and the gingiva. Red atrophic lesions and white keratotic margins mimic the lingual counterparts.
Although most patients with geographic tongue are asymptomatic, patients occasionally report irritation or tenderness, especially in relation to the consumption of spicy foods and alcoholic beverages. The severity of symptoms varies over time and is often an indicator of the intensity of lesional activity. Lesions periodically disappear and recur for no apparent reason.
- Differential Diagnosis (is the distinguishing of a particular disease or condition from others that present similar symptoms)
Based on clinical appearance, geographic tongue is usually diagnostic. Only rarely might a biopsy be required for a definitive diagnosis. In equivocal cases, clinical differential diagnosis might include candidiasis, leukoplakia, lichen planus, and lupus erythematosus.
Candidiasis is a fungal infection due to any type of Candida (a type of yeast). When it affects the mouth, it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the mouth and throat. Other symptoms may include soreness and problems swallowing (Figure 10).
Leukoplakia normally refers to a condition where areas of keratosis appear as firmly attached white patches on the mucous membranes of the oral cavity (Figure 11).
Leukoplakia in the mouth (oral leukoplakia), is defined as “a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion”. However, this definition is inconsistently applied, and some refer to any oral white patch as “leukoplakia”. Leukoplakia is a descriptive clinical term that is only correctly used once all other possible causes have been ruled out (a diagnosis of exclusion). As such, leukoplakia is not a specific disease entity, and the clinical and histologic appearance are variable, i.e. the term has no specific histologic implications. Leukoplakia may be confused with other common causes of white patches in the mouth, such as oral candidiasis or lichen planus. The lesions of leukoplakia cannot be rubbed off, as would be the case in pseudomembraneous candidiasis (oral thrush).
Oral leukoplakia more commonly occurs in those who smoke, but often the cause is unknown (hence the name idiopathic leukoplakia). Chewing tobacco is also associated with this type of lesion. Leukoplakia is a premalignant lesion, i.e. “a morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart”. The chance of transformation into oral squamous cell carcinoma (OSCC, a type of oral cancer) varies from almost 0% to about 20%, and this may occur over 1 – 30 years. The vast majority of oral leukoplakias will not turn malignant, however some subtypes hold greater risk than others. No interventions have been proven to reduce the risk of cancer developing in an area of leukoplakia, but people are generally advised to stop smoking and limit alcohol consumption to reduce their risk. Sometimes the white patch will shrink and eventually disappear after stopping smoking, but this may take up to a year. In many cases, areas of leukoplakia will slowly expand, become more white and thicken if smoking is not stopped. Management usually involves regular review of the lesion to detect any possible malignant change early, and thereby significantly improve the prognosis, which normally is relatively poor for OSCC.
Lichen Planus is a disease of the skin and/or mucous membranes that resembles lichen (Figure 12). The cause is unknown, but it is thought to be the result of an autoimmune process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used to control the symptoms.
Lupus Erythematosus is a name given to a collection of autoimmune diseases in which the human immune system becomes hyperactive and attacks normal, healthy tissues. Symptoms of these diseases can affect many different body systems, including joints, skin (Figure 13), kidneys, blood cells, heart, and lungs.
- Treatment and prognosis
Because of the self-limiting and usually asymptomatic nature of this condition, treatment is not required. However, when symptoms occur, treatment is empirical. Considerable benefit may be gained by keeping the mouth clean using a mouth rinse composed of sodium bicarbonate in water. Topical steroids, especially those containing an antifungal agent, may be helpful in reducing symptoms. Reassuring patients that this condition is totally benign and does not portend more serious disease helps relieve anxiety.
- Etiology: Unknown
- Clinical Features: usually discovered as incidental finding on oral examination. Common; 2% of U.S population affected. Appears as red atrophic patches surrounded by hyperkeratotic (white) margins. Dorsum and lateral surfaces of tongue usually affected; rarely other mucosal sites. Pattern changes with time. Often seen in company with fissured tongue. Spontaneous regression/worsening. Usually asymptomatic, but might be slightly painful.
- Treatment: Usually none. When painful, baking soda rinses, antifungals, or topical corticosteroids may help.
Reference: Oral Pathology, Sixth Edition, By Regezi, Sciubba, & Jordan.
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Haider Maitham, DDS