3. Introduction
Development of tongue
Anatomy of tongue
Examination of tongue
Function of tongue
Classification
Diseases of tongue
Applied aspects
Conclusion
References
CONTENTS:
4. INTRODUCTION
Tongue is a muscular organ situated in the floor of mouth.
It forms the part of floor of the oral cavity and part of
anterior wall of oropharynx.
It is attached to the inner surface of the mandible near the
midline and gains support below from the hyoid bone.
Comprises of voluntary skeletal muscle.
6. ROOT : It is attached to styloid process and soft
palate above and to mandible and hyoid
bone below.
6
7. • Because of these attachments tongue doesn’t falls
back to block the oropharynx.(airway obstruction)
• In between mandible and hyoid bone , it is related to
geniohyoid and mylohyoid muscle.
7
8. TIP : It forms the anterior free end which , at
rest, lies behind the upper incisor teeth.
8
9. BODY :
1.Dorsum : convex in all directions.
a.Oral Part : anterior 2/3
b.Pharyngeal part : posterior 1/3
They are divided by faint V shaped groove
called sulcus terminalis
Two limbs of V meet at median pit named as
foramen caecum
9
11. 2. Inferior surface: is covered with a smooth
mucous membrane , which shows a median
fold called the ‘ frenulum linguae’ .
On either side of frenulum , there is a
prominence produced by deep lingual veins.
More laterally there is a fold called plica
fimbricata
11
13. Pharyngeal part or lymphoid part of tongue:
• It lies behind the palatoglossal arches and
sulcus terminalis
• Its posterior posterior surface (base of tongue)
forms anterior wall of oropharynx.
• The mucous membrane has no papillae but has
many lymphoid follicles that collectively
constitute the lingual tonsil.
13
15. Development of Tongue
Starts in 4th
week of intrauterine life.
Develops in relation to pharyngeal arches in the
floor of the developing mouth.
Each pharyngeal arch-
i. Grows as a mesodermal thickening in the lateral
wall of foregut.
ii. Grows ventrally to become continuous with the
corresponding arch of the opposite side.
17. Medial most part of
mandibular arches proliferate
to form two lingual swellings.
The lingual swelling are
partially separated from each
other by another swelling that
appears in the midline called
tuberculum impar.
18. Immediately behind the
tuberculum impar, the epithelial
proliferates to form a down
growth thyroglossal duct from
which the thyroid gland
develops.
These site is marked by a
depression called Foramen
Caecum.
At the end of 2nd
and 4th
week-
Midline swelling develop known
as Hypobranchial Eminence.
19. In 2nd
& 3rd
week Hypobranchial eminence divide into-
i.Cranial part(Copula)-2nd
& 3rd
arch
ii.Caudal part-4th
arch( forms the Epiglottis )
Anterior 2/3rd
of tongue is formed by fusion of:
1.Tuberculum impar
2.2 lingual swelling
21. POSTERIOR 1/3RD
: formed by 3rd
arch mesoderm.
•Formed from cranial part of
hypobranchial eminence(copula).
•In this situation, the second
arch mesoderm get buried below the surface.
•The 3rd
arch mesoderm grows over it to fuse with the
mesoderm of 1st
arch.
•POSTERIORMOST PART: 4th
arch.
23. •MUSCLES : Develop from Occipital myotomes
•EPITHELIUM:
• Formed First by single layers of cell.
• Later- Stratified and papillae become evident.
• Taste buds are formed in relation to the terminal
branches of innervating nerve fibers.
•CONNECTIVE TISSUE:
• Develop from local mesenchyme
24. PAPILLAE OF TONGUE :
These are projections of mucous
membrane (or) corium which give the anterior
2/3rd
of tongue its characteristic roughness
They are - Filliform papillae ( conical /
thread shape)
- Fungiform papillae (mushroom
shape)
- Circumvallate / vallate papillae (
ring or circle shape )
- Foliate papillae ( leaf shape )
-
24
25. FILIFORM PAPILLAE : (thread shape
or conical papillae)
• Numerous pinpoint cone-shaped
projections of the mucosa that ends in
one or more points.
• Gives velvety appearance to the tongue.
• They are smallest papillae.
• Each papilla is pointed & covered with
keratin.
• Apex is often split into filamentous
process.
26. FUNGIFORM PAPILLAE:(mushroom shape)
•They are numerous near the tip and margins of
tongue
•Few are scattered over dorsum of the tongue
•They are smaller than vallate papillae but larger
than filiform papillae
•Each papilla consists of narrow pedicle & a large
rounded head.
•They are distinguished by their bright red colour.
•Color is derived from rich capillary network
visible through the thin epithelium.
•29/cm² at tip,
7-8 /cm² in the middle of tongue
27. CIRCUMVALATE PAPILLAE: ( circular or ringed
shape )
•They are larger in size i.e 1-2 mm in diameter .
•Situated immediately in front of V- shaped sulcus
terminals.
•8-12 in number.
•The walls of papillae have taste buds
•They are associated with ducts of
Von Ebner's glands.
•Each papilla is a cylindrical projection surrounded
by a circular sulcus.
28. FOLIATE PAPILLAE:
(leaf shape)
•Scattered over the mucous
membrane of the mouth and tongue
at irregular intervals
•Occur specially in the sides of the
vallate papillae
•Abundant at side of the base of the
tongue
•Bounded by narrow fold of mucous
membrane
29. TASTE BUDS
• Small ovoid barrel shaped intrapapillary organ 40μm thick.
•They are modified epithelial cells arranged in a flask – shaped
form.
•Also called as gustatory calyculli.
•Found in maximum numbers on circumvallate and fungiform
papillae
•Outer surface- covered by few flat epithelial cells which is
surrounded by small opening called taste pores
•Taste buds may have one or more taste pores
30. • Taste buds contain the receptors for taste.
• They are located around the small structures on the upper
surface of the tongue, soft palate, upper esophagus and
epiglottis, which are called papillae
• These structures are involved in detecting the five (known)
elements of taste perception: salty, sour, bitter, sweet, and
savory (or umami).
• Via small openings in the tongue epithelium, called taste
pores, parts of the food dissolved in saliva come into contact
with taste receptors.
30
31. • These are located on top of the taste receptor cells that
constitute the taste buds.
• The taste receptor cells send information detected by clusters
of various receptors and ion channels to the gustatory areas of
the brain via the seventh, ninth and tenth cranial nerves.
• On average, the human tongue has 2,000–8,000 taste buds
31
33. STRUCTURE OF TASTE BUD
• Central process passes toward the deep extremity of the bud,
and there ends in single or bifurcated varicosities.
• The nerve fibrils after losing their medullary sheaths enter the
taste bud, and end in fine extremities between the gustatory
cells
• other nerve fibrils ramify between the supporting cells and
terminate in fine extremities.
• these, however, are believed to be nerves of ordinary sensation
and not gustatory.
• The peripheral end of the cell terminates at the gustatory pore
in a fine hair filament, the gustatory hair.
33
36. TASTE PATHWAY :
• Taste from anterior 2/3rd
of tongue except vallate papilla is
carried by chordatymphani branch of facial nerve till the
geniculate ganglion.
• The central processes go to tractus solitarius in the medulla
• Taste from posterior 1/3rd
of tongue including the circumvallate
papilla is carried by glossophayngeal nerve till the inferior
ganglion.
36
37. • The central processes go to tractus solitarius in the medulla
• Taste from posterior most part of tongue and epiglottis travels
through vagus nerve till the inferior ganglion of vagus.
• These central processes also reach tractus solitarius.
• After rely in the tractus solitarius , solitario thalamic tract is
formed which becomes a part of trigeminal lemniscus and
reaches posterio-ventro medial nucleus of thalamus of
opposite side
• Another relay here, taken them to lowest part of post central
gyrus , which is area for TASTE
37
40. 40
Taste sensation at different regions
Sweet –
Taste bud of fungiform at tip of tongue.
Sour –
Taste bud of foliate papillae on palate and posterior part of
tongue.
Bitter –
Taste buds of vallate papillae in middle part of tongue.
Salty –
Taste buds of fungiform papillae at lateral border of tongue.
41. Taste areas of tongue
Taste is extremely sensitive to
bitter flavours which could be a
possible protective mechanism as
many poisonous substances have a
bitter i.e. unpleasant flavour.
The experience of taste depends
on internal state (like hunger), on
past experiences (familiarity with
food), and genes (different
sensitivities to certain tastes).
It also depends on smell and
texture (touch)
42. Intrinsic muscles
• Inferior longitudinal
• Superior longitudinal
• Transverse
• Vertical
Muscles of tongue:
•Tongue is made of intrinsic and extrinsic muscles
•Divided into right & left by median sagittal septum of
connective tissue.
Extrinsic muscles:
•Genioglossus
•Hyoglossus
•Styloglossus
•Palatoglossus
43. INTRINSIC MUSCLES :
They occupy the upper part
of the tongue and are
attached to the submucous
fibrous layer & to the median
fibrous septum
Function : alter the shape of
tongue
43
45. SUPERIOR LONGITUDINAL MUSCLE:
Lies beneath the mucous membrane
Origin: sub mucosal connective tissue at the back of the
tongue and from the median septum of tongue.
Insertion: muscle fiber pass forward and obliquely to sub
mucosal connective tissue and mucosa on margin of
tongue.
Innervation: Hypoglossal nerve.
Function: shorten tongue.
curl apex and sides of tongue.
46. INFERIOR LONGITUDINAL:
Is a narrow band lying close to the Inferior surface of the
tongue b/w genioglossus & hyoglosssus
Origin: root of tongue
Insertion: Apex of tongue.
Innervation: Hypoglossal nerve.
Function: Shorten tongue.
Uncurls apex and turn it downward.
TRANSVERSE:
Origin: median septum of tongue
Insertion: submucosal connective tissue on lateral margin of
tongue.
Innervation: hypoglossal nerve
Function: narrow and elongates tongue
47. VERTICAL:
Origin: submucosal connective tissue on dorsum of
tongue.
Insertion: connective tissue in ventral region of tongue.
Innervation: Hypoglossal nerve.
Function: Flattens and widens tongue.
48. EXTRINSIC MUSCLES
49
The tongue is
attached to hyoid
bone, mandible,
styloid process & the
palate through the 4
extrinsic muscles.
49. Extrinsic muscles
GENIOGLOSSUS:
• Fan shaped
•Occur in either side of midline
septum that separates right and
left halves of tongue.
Origin: Superior mental
tubercles on the posterior surface
of mandibular symphsis
immediately superior to the
origin of geniohyoid.
Insertion: Body of hyoid, entire
length of tongue
51. Innervation: hypoglossal nerve
Function: Protrude the tongue, depress the central part of
tongue.
HYOGLOSSUS:
•Thin quadrangular muscle lateral
to the genioglossus muscle.
Origin: Greater horn and adjacent
part of body of hyoid bone.
Insertion: lateral surface of tongue.
Innervation: hypoglossal nerve
Function: depress the tongue.
52. STYLOGLOSSUS:
Origin: Anterolateral surface of styloid process.
Insertion: Lateral surface of tongue.
Innervation: Hypoglossal nerve.
Function: Elevates and retracts the tongue.
53. PALATOGLOSSUS:
Origin: inferior surface of palatine aponeurosis.
Insertion: lateral margin of tongue.
Innervation: vagus nerve via pharyngeal plexus.
Function: depress tongue, elevates back of tongue.
54. 55
Arterial supply
Mainly by lingual artery
which is a branch of external
carotid artery.
The root is also supplied by
tonsillar artery which is a
branch of facial artery &
ascending pharyngeal artery.
Due to the median fibrous
septum of tongue, there is no
anastomosis of arteries between
2 sides.
55. 56
VENOUS DRAINAGE
The deep lingual veins are
largest & principle veins. Seen
along the inferior surface of
tongue.
2 veins accompany the lingual
artery & 1 vein is seen alongside
hypoglossal nerve.
These veins unite at posterior
border of hyoglossal muscle &
form the Lingual Vein.
This lingual vein drains into
common facial or internal
jugular vein
56. 57
Lymphatic drainage:
Tip: drains bilaterally to submental nodes
The right & left halves of remaining part of the
anterior 2/3rd
of tongue drain unilaterally to
submandibular nodes.
A few central lympahtics drain bilaterally to the deep
cervical nodes.
57. • Posterior most part & posterior 1/3rd
of tongue dain
bilaterally into upper deep cervical lymph nodes
including jugulodiagastric.
• The whole lymph finally drains into “jugulo
omohyoid nodes”
• These are known as lymph nodes of tongue.
58
59. NERVE SUPPLY:
Motor – all intrinsic & extrinsic muscles, except the
palatoglossus muscle is supplied by
HYPOGLOSSAL NERVE ( XII) .
Palatoglossus is supplied by – cranial root of
accessory nerve through the pharyngeal plexus.
Sensory –
1.Lingual nerve is the nerve of general sensation
2.Chorda tympani is the nerve of taste for anterior
2/3rd
of tongue except circumvallate papillae
60. 3. Glossophayngeal nerve is the nerve for both general
sensation & taste for the posterior 1/3rd
of tongue
including circumvallate papillae
4. Posterior most part of tongue is supplied by vagus
nerve through the internal laryngeal branch.
61
62. Ingestion
Suckling
Swallowing
Taste Perception
Phonation
Jaw Development
FUNCTIONS OF TONGUE :
63. Mastication & deglutition
• The functions of tongue in chewing & swallowing are well
known.
• Gibbons in 1898 was the first to state that apart from
swallowing, the tongue also aids in mixing of bolus as well as
separating out the undesirable food particles.
• Various radiographic studies were done to observe the pattern
of tongue movement during chewing & swallowing of food by
coating the tongue with barium milk. (Harris 1957)
65
64. The normal sequence of mastication & deglutition are as follows:
1) The preparatory stage: The tongue from its resting position in
the floor of mouth prepares itself for receiving the food by
becoming trough like, so as to collect food on its dorsum.
66
65. 2) The throwing stage: the anterior 2/3rd of the tongue having
collected the foodstuff twists over on one side which throws
the food on the lower grinding teeth.
3) The guarding stage : the tongue & buccinator muscle of the
same side press against the teeth together to prevent the food
from slipping into the vestibules.
67
66. 4) The sorting out stage: this stage begins after a series of
chewing movements. The buccinator pushes the food medially
onto the dorsum of tongue so as to separate any larger food
particles that remain. This cycle continues till all the food
particles are crushed to a homogenous small size.
5) The stage of bolus formation: this stage partly overlaps the
last. The tongue makes rapid & jerky side to side movements
to mix the food particles with saliva & form a bolus.
6) Stage of deglutition: in the first step the tip of tongue presses
against the posterior surface of the upper central incisors &
palate.
68
67. 7) With a wave like rippling motion the bolus is pushed
backwards. The hyoid bone is pulled up quickly & the back of
tongue contacts the soft palate. This seal is maintained to
avoid the return of bolus into the mouth, thus completing the
oral stage of deglutition.
The right side muscles of tongue help throw the food onto the
left molars. Hence it is observed that in cases of hemipelgia
the patient is forced to chew on the paralyzed side.
69
- Part played by tongue in mastication & deglutition, Shafik Abd-El-Malek,
J Anat. 1955 April; 89(Pt 2): 250–254.1
68. SPEECH:
• It is a co-ordinated movement of lips, tongue, cheeks, teeth &
palate.
• Tongue is considered to play an important role due to its
ability to affect rapid changes in its movement & shape.
• The tongue impedes & selectively restricts air channels with
precise contact against teeth and palate to articulate speech.
70
69. • Some examples of speech articulation by tongue are:
• Linguo-velar contacts: K,G
• Linguo-alveolar contact: T,D,N
• Linguo-palatal contact: J, CH
• Linguo-dental contact: TH
• Apertures of wind created by tongue also produce certain
sounds like
• Lateral aperture: L
• Central aperture: R
• Wide aperture: Y
• In “S” and “Z” sounds there is not an actual contact of tongue
with teeth but a very thin space.
• “SH” sounds have a larger space between the tongue and
teeth.
71
70. • Some speech difficulties can be observed in certain types of
malocclusions. Infact, these can be an aid in diagnosis of
malocclusions.
1) Ant. Open bite, large gap b/w incisors – S, Z Sibilants not
pronounced correctly
2) Irregular Incisors – T, D ( Linguoalveolar stops)
3) Anterior Open Bite with Skeletal Class III – TH, SH, CH
(Linguodental)
72
71. DEVELOPMENTATION :
• The form and stability of dental relationship is determined by
the buccinator and the tongue.
• Equilibrium of forces between buccinator, tongue and lips is
important to maintain arch form.
• Large tongue – wider arch forms
• Small tongue – narrow arch forms.
73
72. TASTE:
• The special sensation of ‘taste’ is provided by the taste buds
present on the dorsum of the tongue.
• Taste can be defined as detection & perception of liquid phase
stimuli.
• Until recently 4 basic tastes were categorized i.e. Salty,
Sweet, Bitter & Sour. A new taste called “Umami” has been
added.
• Taste is extremely sensitive to bitter flavours which could be a
possible protective mechanism as many poisonous substances
have a bitter i.e. unpleasant flavour.
• The experience of taste depends on internal state (like hunger),
on past experiences (familiarity with food), and genes
(different sensitivities to certain tastes). 74
73. APPLIED ASPECTSELATED TO TONGUAPPLIED
ASPLATED TO TONG
Gag reflex: Posterior most part of the tongue when touched
produces gagging. IX and X nerves are responsible for
muscular contraction of each side of pharynx.
When the genioglossus muscle is paralyzed, the tongue has
a tendency to fall posteriorly obstructing the airway and
creating the risk of suffocation.
Total relaxation of the genioglosuss muscle occurs during G.A
therefore the tongue of an anesthetized patient must be
prevented from relapsing by inserting an airway.
75
74. Sublingual absorption of drugs possible due to thin mucosa
& rich vasculature
Trauma such as fractured mandible may injure the
hypoglossal N. resulting in paralysis an eventual atrophy of
one side of the tongue.
The tongue deviated to the paralyzed side during protrusion
because of the action of unaffected genioglosuss muscles on
the other side.
Injury on both sides causes tongue to be motionless.
76
75. In many elderly patients, there is nodular enlargement of
superficial veins on the ventral surface of the tongue. The
presence of such lingual varicosities (varicose tongue) is not of
special significance and should not be regarded as evidence of
disease of blood vessels.
Snoring may be reduced by anterior displacement of the
tongue with the intention to compensate inadequate pharyngeal
muscle activity. Direct anterior displacement of the tongue leads
to an amplification of the airway space, but is difficult to
achieve with clinical manoeuvres at night. However, the use of
tongue retaining devices & tongue repositioning manouvre
has been reported to reduce the time of loud snoring during
sleep (Cartwright et al, 2002)
- Wilfried Engelk, Wolfgang Engelhart, Oscar Decco, Functional treatment of snoring based on the
tongue-repositioning manoeuvre, Eur J Orthod (2010) 32 (5): 490-495. doi: 10.1093/ejo/cjp135
77
78. Inspection
• Inspect the dorsum of the tongue at rest for variation in size,
color, and texture.
• Observe and note
– the distribution of papillae,
– margins of the tongue.
– depapillated areas,
– fissures, ulcers, and keratotic areas.
• Note frenal attachment
• Any deviations as the patient protrudes tongue and attempts
to move it to the right and left.
• Note tongue thrust on swallowing.
• Wrap a piece of gauze (4 x 4 cm) around the tip of the
protruded tongue to steady it 80
79. CINERADIOGRAPHY : It is the making of a motion picture
record of successive images appearing on a fluoroscopic
screen.
• Eg: use cineradiographic images to investigate tongue
movement during deglutition in anterior open bite patients
with tongue thrust.
• Each subject had semi-spherical lead markers attached to the
tip and dorsal surface of the tongue and was asked to swallow
5 ml of diluted liquid barium.
• Tongue movement during deglutition was recorded in the mid-
sagittal plane with an X-ray VTR system. ( video tape
recorder)
81
A CINERADIOGRAPHIC STUDY OF DEGLUTITIVE TONGUE MOVEMENT IN PATIENTS
WITH ANTERIOR OPEN BITE, M. KAWAMURA et al. Bull. Tokyo dent. Coll., Vol. 44, No. 3, pp.133139,
August 2003
80. • The deglutition process was divided into 6 stages to analyze
the movements of the tip and dorsal surface of the tongue in
each stage
• In open bite patients, both the tip and dorsum of the tongue
were positioned anteriorly and inferiorly at rest and during the
buildup of negative intraoral pressure.
• The dorsum of the tongue tended to move and be positioned
anteriorly as the tongue tip protruded and pushed the maxillary
and mandibular anterior teeth.
• The tongue tip traveled a significantly smaller distance from
the stage of tongue rest position to that of most retruded
tongue tip position and a significantly larger distance from the
stage of most retruded tongue tip position to that of tongue tip
fixation in open bite patients than in controls.
82
81. Pulsed (Doppler) Ultrasound
Ultrasound is a form of mechanical acoustic pressure wave
at frequencies above the limit of human hearing that when
transmitted through biological tissues can produce different
biological effects.
Noninvasive ultrasound technique has recently been applied
study laryngeal activity, pharyngeal wall displacement and
tongue movements.
Two types of echo ultrasound equipment can be used to
monitor tongue movements in speech, A scan and sector scan.
83
82. In the A scan method, ultrasound pulses are passed from a
transducer positioned below the chin, through the skin and the
muscular tissue of the tongue, and are reflected in proportion to
changes in acoustic impedance, at transitions in tissue density
in the tongue body, at the interface between the tongue dorsum
and the ambient air, and at the oral cavity walls.
The most widely used applications in medicine are
operative (usually has a frequency that ranges between
2-8 K Hz), therapeutic (usually has a frequency that ranges
between 20 K Hz-3 M Hz either in continuous or pulsed
modes), and diagnostic (usually has a frequency that ranges
between 1.6-12 M Hz).3 84
83. It has been used to study the characteristics of arterial
blood flow in the tongue, and abnormal pulse waves have
been noted in the lingual arteries of individuals with
evidence of compromised flow in other branches of the
carotid arterial tree.
Karen M. Hiiemae and Jeffrey B. Palmer in 2003 reviewed
tongue moments in feeding and speech through ultrasound and
stated that it is clear that new and very sophisticated ultrasound
technology can generate the data to produce 3D models of the
tongue surface
85
84. Computer-Assisted Tomography:
• The CT system was invented in 1972 by Godfrey Newbold
Hounsfield of EMI Central Research Laboratories.
• In this X-ray slice data is generated using an X-ray source
that rotates around the object, X-ray sensors are positioned on
the opposite side of the circle from the X-ray source.
• Many data scans are progressively taken as the object is
gradually passed through the gantry.
• They are combined together by the mathematical procedure
known as tomographic reconstruction.
• It can be used to identify space occupying lesions and
muscular atrophy secondary to hypoglossal nerve damage, in
cases where the lesion is deep in the base of the tongue and
not detectable by other approaches
86
85. Isotopic Scanning Techniques:
• The principle of obtaining diagnostic information from a
visual image of isotope distribution is based on the fact that
the uptake of an isotope by abnormal tissue often differs from
that by normal, healthy tissue.
• Sometimes it is more, in some other cases less. Present
techniques offer a two dimensional image, somewhat similar
to the appearance of X-ray absorption as seen on an X-ray
picture.
• It can be used when a mass in the tongue is composed of
specialized secretory tissue or other tissue, such as thyroid,
which selectively concentrates intravenously administered
radioactive 131I or 99Tc-pertechnetate.
87
86. • Gallium 67Ga scanning and tumor labeling with radioactive
indium and cobalt–bleomycin chelates also have been used to
outline the extent of lingual and other oral tumors with varying
success.
• Bathi, Taneja and Rao reported a case ofasymptomatic tissue
growth on dorsal surface of the tongue,isotopic scanning with
99mTc04 was done to evaluate the type of tissue mass.
88
87. Electromyography:
• Electromyography is a test to study the muscle functions.
• It has been used for many years to study the action potentials
in actively contracting muscles and has contributed to an
understanding of lingual and masticator muscular function and
also in detecting uncoordinated muscular movements in
diseases like dyskinesia, dystonia, and various neuromuscular
disorders.
• It is a noninvasive technique.
• Use of surface electrodes (in earlier techniques thin-needle
electrode inserted in the muscle to the studied) have been
introduced with considerable success
89
88. According to Cheng et al movement of the tongue during
normal breathing in awake healthy humans with
electromyography and suggested that the patterns of local
movement vary between subjects.
There is anterior movement of the genioglossus muscle at the
level of the epiglottis during inspiration with limited
movement in nearby tissue including the geniohyoid, and
hence even during respiration tongue behaves as a muscular
hydrostat.
90
89. Magnetic Resonance Imaging:
MRI used as an alternative to imaging modalities involving
radiation. It has proven to be vastly superior in the detail it
provides, of soft-tissue structures, such as the tongue and
oropharynx.
MRI has the ability to provide, direct coronal or sagittal scanning
sections, which allows accurate delineation of the lingual
musculature and the extent of tumor infiltration.
MRI has serious limitations as a research tool for studies of speech
or deglutition because of supine position of the patient which
causes difficulty in feeding and also MRI data acquisition is slow
when compared with normal feeding and deglutition
91
90. Scanning Electron Microscope:
The SEM uses a focused beam of high energy electrons to
generate a variety of signals at the surface of solid specimens.
SEM is a well-established tool for in vitro study of the surface
topography of tongue dorsum, the character and morphology
of the different types of tongue papillae and distribution and
morphology of bacteria on the papillated areas of the dorsum.
Many studies have been performed in different animals but in
human more studies are required to know the efficacy of SEM
on tongue.
92
92. Video Microscopy:
Video microscopy is useful for observation of the surface of
tongue papillae.
Negoro et al in 2004 conducted a study in 10 individuals for
observation of tongue papillae by video microscopy and contact
endoscopy to investigate their correlation with taste function
and concluded that in the normal taste group, round-shaped
papillae and clear blood vessels were observed with both
microscopy and contact endoscopy.
In the taste disorder group, flat and irregular papillae were
observed with microscopy. Blood vessel flow of the papillae
was observed to be poor with contact endoscopy.
It can be used in vivo for visualization of tongue papillae, their
capillary network, and taste pores.
94
93. Stereo Microscopy:
• A stereo microscope is an optical microscope fitted with two
sets of lenses, each positioned to view an object from a
slightly different angle.
• The result is a three-dimensional image. In order to produce a
clear, functional three dimensional image, a stereo microscope
relies on reflected, exterior light sources to illuminate its
subject, instead of the brighter plate lights that shine through
the specimen on a standard microscopy.
• It is similar to video microscopy and can be used to study the
tongue papillae, their capillary network, and taste pores.
95
Review and Update: Advanced Investigation Methods for Diagnosis of Tongue Lesions. Neeraj Taneja et al
The Journal of Contemporary Dental Practice, March-April 2013;14(2):365-369
96. INHERITED, CONGENITAL AND
DEVELOPMENTAL ANAMOLIES:
1. Variations in tongue morphology and function
A. Partial Ankyloglossia
B. Complete Ankyloglossia
2.Variations in tongue movements
3. Fissured, Plicated or Scrotal tongue
4. Patent Thyroglossal Ducts
5. Lingual Thyroid
(Burket’s Oral Medicine Diagnosis and(Burket’s Oral Medicine Diagnosis and
Treatment, 9th edition: Diseases ofTreatment, 9th edition: Diseases of
tongue)tongue)
97. MAJOR INHERITED, CONGENITAL AND
DEVELOPMENTAL ANAMOLIES:
1. Cleft, Lobed, Bifurcated and Tetrafurcated tongue
2. Aglossia(Hypoglossia)
3. Macroglossia
4. Depapillated tongue
5. Localised enlargement and Papillomatosis
DISORDERS OF LINGUAL MUCOSA:
A - CHANGES IN LINGUAL PAPILLAE:
1.Geographic Tongue
2. Coated or Hairy Tongue
98. B - NONKERATOTIC AND KERATOTIC WHITE LESIONS:
i NON-KERATOTIC:
1. Thrush
2. Burns
3. White Sponge Nevus
4. Pachyonychia Congenita
5. Vesiculobullous and other Desquamating Disorders
99. II KERATOTIC :
1. Lichen Planus
2. Leukoplakia
3. Hairy Leukoplakia
4. Depapillation
5. Atrophic lesions
6. Chronic trauma
C - Nutritional deficiencies and hematologic
abnormalities
D - Medications
E - Peripheral vascular disease
100. F - Chronic candidiasis and median rhomboid
glossitis
G - Tertiary syphilis and interstitial glossitis
H - Pigmentation
I - Traumatic injuries, ulcers and infections
J - Superficial vascular lesions
DISORDERS AFFECTING LINGUAL MUCOUS
GLANDS:
1. Sjogren’s syndrome
2. Ranula
3. Cysts and Sialolithiasis
101. DISEASES AFFECTING THE BODY OF TONGUE:
1. Amyloidosis
2. Infections
3. Neuromuscular Disorders
4. Obstructive Sleep Apnoea and Glossoptosis
5. Temporomandibular Joint Dysfunction Syndrome
6. Neck-Tongue Syndrome
7. Vascular disease of the body of tongue
8. Angioneurotic Edema
103. •Complete absence of tongue
•It is a rare congenital anomaly
•Manifested by presence of a small or rudimentary tongue.
Clinical Features:
•Difficulty in speech and mastication.
•High arched palate, narrow constricted
mandible
•Missing lower incisors
•There may be airway obstruction, due to negative
pressure generated by deglutition and inspiration
AGLOSSIA OR MICROGLOSSIA :
104. Hall's classification (Oromandibular limb hypogenesis
syndrome)
Type-I
A Hypoglossia
B Aglossia
Type-II
A Hypoglossia - hypodactylia
B Hypoglossia - hypomelia
C Hypoglossia – hypodactylomelia
Type-III
A Glossopalatine ankylosis (Ankylossum Superius
syndrome)
B With hypoglossia
C With hypoglossia - hypodactylia
D With hypoglossia - hypomelia
E With hypoglosia - hypodactylomelia
105. Type-IV
A Intraoral bands and fusion
B With hypoglossia
C With hypoglossia - hypodactylia
D With hypoglossia - hypomelia
E With hypoglossia –hypodactylomelia
Type-V
A. The Hanhart syndrome
B.Pierre-Robin syndrome
C.Mobius syndrome
Rasool A et al. Isolated aglossia in a six year old child presenting with impaired speech: a case report.
Cases Journal .2009. 2:7926;1-3
106. Treatment and prognosis
• Depends on the nature and severity of the condition
• Surgery and orthodontics may improve oral function
• Speech development is quite good but depends on
tongue size
113. Neoplastic
• Lingual thyroid
• Carcinoma
• Plasmacytoma
Infiltrative
• Amyloidosis
• Sarcoidosis
2.Pseudomacroglossia- maybe due to severe
retrognathic maxilla or mandible.
114. Clinical features:
• Age: more common in infants
• Symptoms: tongue protrusion, which exposes the
tongue to trauma.
• Other symptoms include swallowing difficulties,
airway obstruction, drooling and failure to thrive.
• Signs: displacement of teeth and malocclusion
• Crenation or scalloping of lateral borders of tongue
115. • Associated sndrome:
i. Beckwith’s- Wiedemann syndrome
ii. Down syndrome
iii.Behmel syndrome
iv.Laband syndrome
Treatment:
• Removal of primary cause
• Majority of cases are treated surgically.
117. •It is a condition when the inferior frenulum attaches to
the bottom of tongue and subsequently restricts free
movement of the tongue.
•Types:
Complete Ankyloglossia (fusion of tongue to the floor
of the mouth)
ANKYLOGLOSSIA(Tongue-Tie)
118. Partial Ankyloglossia
-Tongue tie is usually defined on the basis of inability to
extend the tip of the tongue beyond the vermillion border
of the lip.
CATEGORIES OF ANKYLOGLOSSIA (Figs lato le)
•Clinically acceptable, normal range of free tongue
:greater than 16mm
•Class I: Mild ankyloglossia: 12 to 16 mm
•Class II: Moderate ankyloglossia: 8 to 11 mm
•Class III: Severe ankyloglossia: 3 to 7 mm
•Class IV: Complete ankyloglossia: less than 3 mm
Lawrence A. Kotlow.Ankyloglossia (tongue-tie):A diagnostic and treatment quandary.Quintessence
International 1999;30:259-262
119. Hazelbaker Assessment Tool for Lingual Frenulum Function
Appearance
Appearance of tongue when lifted
• 2: Round or square
• 1: Slight cleft in tip apparent
• 0: Heart- or V-shaped
Elasticity of frenulum
• 2: Very elastic
• 1: Moderately elastic
• 0: Little or no elasticity
Length of lingual frenulum when lifted
• 2: >1 cm
• 1: 1 cm
• 0: <1 cm
Ballard J L et al. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding
Dyad. Pediatrics.2002:110 (5);1-6
120. Attachment of lingual frenulum to tongue
• 2: Posterior to tip
• 1: At tip
• 0: Notched tip
Attachment of lingual frenulum to inferior alveolar ridge
• 2: Attached to floor of mouth or well below ridge
• 1: Attached just below ridge
• 0: Attached at ridge
Ballard J L et al. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding
Dyad. Pediatrics.2002:110 (5);1-6
121. Clinical features:
Symptoms: limit the movement of tongue.
•Recurrent tongue biting
Severe degree-
- Inability to lick the lips
-Inability to pronounce certain words t, d, as, ta, n ,l etc.
122. Signs:
•Where there is an attempt to stick the tongue out, there may
be a V-shaped notch at the tip.
•midline mandibular diastema, lingual mandibular
periodontal defects.
•anterior open bite
Superior (Glossopalatine ankylosis)
•Rare - congenital adherence of tongue to the palate
•Usually combined with other congenital anomalies in the
maxillofacial region and extremities (superior syndrome)
•Causes suckling and respiratory dysfunction
123. Syndrome associated :
Orofacial digital syndrome
Cleft lip and palate
Treatment:
Mild cases- no treatment.
Some degree of Ankyloglossia is managed by speech
therapist.
Surgical correction of frenum.
124. Fissured/ plicated /scrotal tongue
• It is characterized by grooves that vary in depth and
are noted along the dorsal and lateral aspect of the
tongue.
Clinical features:
• In elderly, mentally retarded & psychotic individuals.
• Deep furrows – food lodgement- symptomatic
Associated syndrome:
-Melkersson - Rosenthal syndrome
- Down’s syndrome
Treatment: no definative t/t.
-oral hygiene- soft bristle brush,
mouthwash/dil H2O2.
125. 127
Melkerssonrosenthal syndrome
rare neurological disorder characterized by recurring
facial paralysis, swelling of the face and lips (usually the
upper lip), and the
development of folds and furrows in the tongue
126. MEDIAN RHOMBOID GLOSSITIS
• It is defined as the central papillary atrophy of the
tongue.
• MRG is typically located around the midline of the
dorsum of the tongue.
• It occurs as a well-demarcated, symmetric, depapillated
area arising anterior to the circumvallate papillae.
• sometimes appears in the paramedial location.
• The surface of the lesion can be smooth or lobulated.
127. • Clinical Features:
• Most cases are not diagnosed until the middle
age of affected patient.
• 3:1 male predlection
• Present in the posterior midline of dorsum of
tongue.
• Depapillation of tongue.
• Asymptomatic in most cases
• Patients may complain of persistent pain,
irritation, or pruritus.
128. • When MRG is concomitant with a palatal
inflammation, which is called the kissing lesion.
• Lesions are typically less than 2cm in dimension
Treatment:
• Asymptomatic- No treatment
• In candidal infection- antifungal agent
129. CLEFT OR BIFID TONGUE
• It ie a condition in which there is
Cleavage of the tongue due to lack of
fusion of lateral lingual swellings of the
tongue.
• Partial cleft tongue is more common and is manifest as
a deep groove in the midline of the dorsum of tongue.
130. Symptoms: food debris and microorganisms may collect in
the base of cleft and cause irritation.
Associated syndrome: oro-facial-digital syndrome
131. 133
Orofacial digital syndrome /papillon league/psaume syndrome
In 1954 papillon described a
syndrome characterised by congenital
anomalies
of face , oral cavity and digits.
Its X- linked dominant
Possibility in 1 in 250,000
C/F – frontal bossing, alopecia, cleft
in palate , lip , supernumerary teeth
hypoplasia of malar bones , broad
nasal root, syndactyly, polydactyl
intracerebral cysts, polycystic kidney
disease.
132. LINGUAL VARICES (lingual or sublingual varicosities)
•A varix is a dilated, tortuous vein, most commonly a
vein which is subjected to increased hydrostatic
pressure.
•These veins are poorly supported by surrounding
tissue.
133. • Appearance: red or purple slotlike clusters of
vessels on the ventral and lateral surface of
tongue as well as in the floor of mouth.
• Other part: upper and lower lip, buccal mucosa,
and commissure.
• Strongly associated with portal hypertension,
aging & leg Varicosities.
Gomes C C et al. Mucosal varicosities: case report treated with monoethanolamine oleate. Med Oral Patol
Oral Cir Bucal 2006;11:E44-6.
134. LINGUAL THYROID NODULE
• It is an anomalous condition in which follicles of
thyroid tissue are found in the tongue, arising from
remnants of thyroid that may fail to migrate to its
predestinated position or from remnants that became
detached and were left behind.
Etiology:
• Functional insufficiency of chief thyroid gland in neck.
• Failure of primitive thyroid analogue to descend.
135. Clinical features:
• Females are more commonly affected than males
• 4:1 ratio
• Site: manifest as a nodular mass in or near the base
of tongue, in vicinity of foramen caecum.
• Symptoms: dysphagia, dysphonia, dyspnea,
hemorrhage with pain, or felling of tightness or
fullness in throat.
136. Treatment and prognosis
• Most cases require no treatment and biopsy should be
considered with caution because of the potential for
hemorrhage, infection or release of large amounts of hormone
into the vascular system (thyroid storm).
• Occasional patients with parathyroid tissue associated with their
lingual thyroid have developed tetany after their inadvertent
removal.
• Surgical excision or radioiodine therapy(no treatment should be
attempted until an 131
iodine radioisotope scan has determined
that there is adequate thyroid tissue in the neck).
Baughman RA. Lingual thyroid and lingual thyroglossal tract remnants. A clinical and histopathologic study with
review of the literature. Oral Surg Oral Med Oral Pathol 1972; 34:781-99.
137. • Patients lacking thyroid tissue in the neck, the
lingual thyroid can be excised .
• Thyroid carcinoma arising in the mass have
been reported, almost always in males
• An enlarged lingual thyroid is more likely to
reflect a normal compensatory response to
thyroid hypofunction
Baughman RA. Lingual thyroid and lingual thyroglossal tract remnants. A clinical and histopathologic study with
review of the literature. Oral Surg Oral Med Oral Pathol 1972; 34:781-99.
138. • Absence of papillae
Syndromes associated with Bald and
Depapillated tongue
• Familial dysautonomia: congenital absence of
fungiform and vallate papillae
• Dyskeratosis congenita
Depapillation of Tongue
140
139. 141
Dyskeratosis congenita/Zinsser-Cole-Engman syndrome
•X-linked recessive
•develop between ages 5 and 15
years,
•male-to-female ratio is
approximately 3:1,
• hyperpigmentation of the skin, nail
dystrophy, leukoplakia occurs in
approximately 80% of patients,
typically involves the buccal mucosa,
tongue, and oropharynx.
144. The tongue may traumatized by mechanical, thermal, electrical
or chemical means.
The tongue may develop scalloping on the lateral margins,
sometimes termed crenated tongue.
This appearance is the result of indentations of the teeth where
the tongue is habitually pressed against the teeth (“tongue
thrusting”, and example of oral parafunction).
A lesion similar to morsicatio buccarum can occur on the tongue
(sometimes called morsicatio linguarum), caused by chronic
chewing on the tongue.
146
146. Oral leukoplakia and Erythroplakia :
• A comprehensive global review points at a prevalence
of 2.6%.
• Most oral leukoplakias are seen in patients over the
age of 50
• Leukoplakia is more common in men
• Oral erythroplakia is not as common as oral
leukoplakia,
• and the prevalence has been estimated to be in the
range of 0.02 to 0.1%.56
• The gender distribution is equal.
148
Burkitt 11/E
147. • Oral leukoplakia may be found at all sites of
the oral mucosa.
• Nonsmokers have a higher percentage of
leukoplakias at the border of the tongue
compared with smokers.
• The floor of the mouth and the lateral borders
of the tongue are high-risk sites for malignant
transformation
149
151. Hairy leukoplakia
• Most common HIV lesion
• Also associated with:
– Immunosuppressive
drugs Cancer
chemotherapy
– Organ transplantation
• Etiology: EBV with low CD4+
T lymphocytes
153
152. HAIRY TONGUE
•Also called as Lingua nigra, Lingua villosa, Lingua villosa
nigra, Black hairy tongue.
•Commonly observed condition of defective desquamation of
the filiform papillae.
•Lesion can also appear brown, white, green, pink, or any of a
variety of hues depending on the specific etiology and secondary
factors.
154
153. ETIOLOGY:-
•Hypertrophy of the filliform papillae on the dorsal surface of
the tongue.
•Often occurs in individuals with poor oral hygeine.
•Contributory factors can be numerous including tobacco use
and coffee or tea drinking, general debilitation, history of
radiation therapy to head and neck.
155
154. CLINICAL FEATURES:-
Affects the mid line just anterior to circumvallate papilla.
Filliform papillae more than 15mm in length
Male predilection…no racial predilection
In HIV positive patients, drug users
Asymptomatic…Candida albicans may result in glossopyrosis.
Tickling sensation in soft palate, oropharynx may occur.
156
158. The erythematous form of candidiasis
was previously referred to as atrophic
oral Candidiasis.
The lesion has a diffuse border which
helps distinguish it from erythroplakia,
which has a sharper demarcation.
The infection is predominantly
encountered in the palate and the
dorsum of the tongue of patients who
are using inhalation steroids.
159. Oral Candidiasis Associated with HIV
161
Erythematous candidiasis
at the central part of the
tongue in an AIDS
patient. Hairy
leukoplakia at the right
lateral border.
The most common types of oral
candidiasis in conjunction with HIV are
pseudomembranous
Candidiasis, erythematous candidiasis,
angular cheilitis, and chronic
hyperplastic candidiasis.
160. Oral submucous fibrosis
162
Etiology and Pathogenesis:
Areca nuts contain alcaloids, of which arecoline seems to be a
primary
Etiologic factor.
Arecoline has the capacity to modulate matrix metalloproteinases,
lysyl oxidases, and collagenases, all affecting the metabolism of
collagen, which leads to an increased fibrosis
Epidemiology:
The global incidence of submucous fibrosis is estimated
at 2.5 million individuals.93 The prevalence in Indian populations
is 5% for women and 2% for men
161. Clinical Findings:
The first sign is erythematous lesions sometimes in
conjunction with petechiae, pigmentations, and vesicles.
These initial lesions are followed by a paler mucosa, which
may comprise white marbling like appearance.
The most prominent clinical characteristics will appear later
in the course of the disease and include fibrotic bands located
beneath an atrophic epithelium.
Increased fibrosis eventually leads to loss of resilience which
interferes with speech, tongue mobility, and a decreased ability
to open the mouth.
The atrophic epithelium may cause a smarting sensation and
inability to eat hot and spicy food.
163
162. 164
Normal mesioincisal angle of upper
central incisor to the tip of the
tongue when maximally extended
•Males 5 to 6 cm
•Females 4.5 to 5.5 cm
Oral submucous fibrosis
The buccal mucosa has a
marbling appearance.
163. Pachyonychia congenita:
• Pachyonychia congenita type I - known as "Jadassohn–
Lewandowsky syndrome" is an autosomal dominant
keratoderma that principally involves the plantar surfaces, but
also with nails changes that may be evident at birth but more
commonly develop within the first few months of life.
• Pachyonychia congenita type II - known as "Jackson–Lawler
pachyonychia congenita," and "Jackson–Sertoli syndrome" is
an autosomal dominant keratoderma presenting with a limited
focal plantar keratoderma that may be very minor, with nails
changes that may be evident at birth, but more commonly
develop within the first few months of life.
165
164. Signs and symptoms:
Excess keratin in nail beds and thickening of the nails
Hyperkeratosis on hands and feet
Oral lesions that look like thick white plaques
Steatocystoma multiplex
Pain
Blisters
166
Described by Jamieson in 1873, and coined by Pringle in 1899,
steatocystoma multiplex (SM) is an uncommon disorder of the
pilosebaceous unit characterized by the development of
numerous sebum-containing dermal cysts.
166. Dyskeratosis congenita / Zinsser-Cole-Engman syndrome.
Rare progressive congenital disorder
Clinical features:
develop between ages 5 and 15 years
male-to-female ratio is approximately 3:1
characterized by cutaneous pigmentation, premature
graying, dystrophy of the nails, leukoplakia of the oral mucosa
Mucosal leukoplakia occurs in approximately 80% of patients
and typically involves the buccal mucosa, tongue, and
oropharynx. The leukoplakia may become verrucous, and
ulceration may occur.
168
169. Herpes simplex virus:
The herpesviridae family of viruses contains nine different viruses
that are pathogenic in humans.
1.Herpes simplex virus 1
2.Herpes simplex virus 2
3.Varicella-zoster virus Varicella (chickenpox) Zoster (shingles)
4.Cytomegalovirus
5.Epstein-Barr virus
6.Human herpesvirus 6
7.Human herpesvirus 7
8.Human herpesvirus 8
9.Simian herpesvirus B
171
170. HSV-1, an a-herpesvirus, is a ubiquitous virus
• In general, infections above the waist are caused by HS V-1
and those below the waist by HS V-2
Oral findings:
• Within a few days of the prodrome, erythema and clusters of
vesicles and/or ulcers appear on the keratinized mucosa of the
hard palate, attached gingiva and dorsum of the tongue, and
the non keratinized mucosa of the buccal and labial mucosa,
ventral tongue, and soft palate
Recrudescent Oral HSV Infection:
• Reactivation of HSV may lead to asymptomatic shedding of
HSV, in the saliva and oral secretions, an important risk factor
for transmission; it may also cause ulcers to form.
172
171. • Recrudescent HSV on the lips is called recurrent herpeslabialis
(RHL) and occurs in 20 to 40% of the young adult population.
• Intraoral recrudescent HSV in the immunocompetent host
occurs chiefly on the keratinized mucosa of the hard palate,
attached gingiva, and dorsum of the tongue.
• Such lesions are called recurrent intraoral HSV (RIH )
infection.
• They present as 1 to 5 mm single or clustered painful ulcers
with a bright erythematous border
173
173. HIV-associated recurrent
herpetic infection .
RIH infection may occur at any site
intraorally and may form atypical-
appearing ulcers that may be
several centimeters in size
and may last several weeks or
months if undiagnosed and
untreated .
They appear slightly depressed with
raised borders, yellowish circinate
border.
174. Recurrent Aphthous Stomatitis (RAS):
RAS is a disorder characterized by recurring ulcers confined
to the oral mucosa in patients with no other signs of disease.
RAS affects approximately 20% of the general population.
RAS is classified according to clinical characteristics: minor
ulcers, major ulcers and herpetiform ulcers.
176
175. Minor ulcers, which comprise over 80% of RAS cases, are
less than 1 cm in diameter and heal without scars.
Major ulcers are over 1 cm in diameter take longer to heal and
often scar.
Herpetiform ulcers are considered a distinct clinical entity that
manifests as recurrent crops of dozens of small ulcers
throughout the oral mucosa.
177
176. ETIOLOGY AND PATHOGENESIS:
• The major factors presently linked to RAS include -
genetic factors, hematologic deficiencies (particularly of
serum iron, folate, or vitamin B12, appears to be an etiologic
factor in a small subset of patients with RAS), immunologic
bnormalities, and local factors, such as trauma and smoking.
although the specific defect remains unknown.
Clinical findings:
• The first episodes of RAS most frequently begin during the
second decade of life.
• The lesions are confined to the oral mucosa and begin with
prodromal burning any time from 2 to 48 hours before an ulcer
appears.
178
177. • During this initial period,a
localized area of erythema
develops.
• Within hours, a small white papule
forms, ulcerates, and gradually
enlarges over the next 48 to 72
hours.
• The individual lesions are round,
symmetric and shallow.
• The buccal and labial mucosae are
most commonly involved.
179
A 42-year-old woman with a
recent increase in severity
of recurrent aphthous ulcers.
Iron deficiency was detected,
and the ulcers
resolved when this deficiency
was corrected
179. Traumatic ulcers
Traumatic ulceration of tongue:
hyperkeratotic rolled border encircling
mucosal surface on ventral side of tongue
Most common cause
of ulceration of
tongue is due to
dentition
180. Riga-Fede disease
Riga-Fede disease. Newborn with traumatic ulceration of
anterior ventral surface of the tongue. Mucosal damage
occurred from contact of tongue with adjacent tooth during
breast-feeding.
183. Contact stomatitis from
cinnamon flavoring of left
lateral border of the tongue
demonstrating linear rows of
hyperkeratosis that resemble
oral hairy leukoplakia .
185. Iron deficiency anemia: (microcytic hypochromic anemia)
Iron deficiency is defined as a reduction in total body iron to
an extent that iron stores are fully exhausted and some degree
of tissue iron deficiency is present.
Epidemiology:
A moderate degree of iron-deficiency anemia affected
approximately 610 million people worldwide or 8.8% of the
population. It is slightly more common in female
•causes of iron deficiency anemia are conveniently classified
into two major categories: physiologic and pathologic.
The most common cause is physiologic and relates to
nutritional deficiency. 188
186. Pathologic iron deficiency anemia is invariably due to excessive
blood loss. In the vast majority of patients, the source of bleeding is
the gastrointestinal tract from hemorrhoids, peptic ulcers,
esophageal varices, or carcinoma or from excess uterine bleeding in
women.
Clinical manifestations:
The most important clinical symptom is chronic fatigue
Other findings such as pallor of the conjunctivae, lips, and oral
mucosa; brittle nails with spooning, cracking, and splitting of nail
beds; and palmar creases.
Other findings may include palpitations, shortness of breath,
numbness and tingling in fingers and toes, and bone pain 189
187. Oral Manifestations:
Glossitis and stomatitis are recognized oral manifestations of
anemia.
Oral manifestations of iron deficiency anemia include angular
cheilitis , glossitis with different degrees of atrophy of fungiform
and filliform papillae , pale oral mucosa , oral candidiasis ,
recurrent aphthous stomatitis, erythematous mucositis , and
burning mouth for several months to 1 year’s duration.
Clinically evident atrophic changes of the tongue occurs , giving
a smooth red tongue appearance, in patients with iron
deficiency anemia
190
188. 191
atrophic changes of the tongue, giving
a smooth red tongue appearance
TREATMENT:
The treatment of iron deficiency
should always be initiated with
oral iron supplementation.
Ferrous sulfate is the preferred
form of oral iron because of low
cost and high Bioavailability,
typically administered at 325 mg
(60 mg iron) orally
three times daily.
Removal of underlying causes.
189. Plummer-Vinson Syndrome:
also called Paterson-Kelly syndrome or sideropenic dysphagia
Etiopathogenesis:
Etiopathogenesis of Plummer-Vinson syndrome is unknown;
however, the most important possible etiologic factor is iron
deficiency.
Other possible factors include malnutrition, genetic
predisposition, or autoimmune processes.
192
190. Clinical features:
It usually affects middle-aged white women in the fourth to
seventh decade of life.
It shows the classic triad of dysphagia, iron deficiency anemia,
and upper esophageal webs or strictures.
The dysphagia may be intermittent or progressive over years, is
usually painless and limited to solids, and sometimes is associated
with weight loss.
Other Symptoms like Anemia, glossitis, angular cheilitis, and
koilonychia are.
193
191. 194
Splenomegaly and enlargement of the
thyroid and upper alimentary tract
cancers may also be found.
Radiologic examination of the
pharynx shows the presence of webs
Esophageal web
Depapillation of tongue
192. Pernicious anemia: (megaloblastic anemia)
•Megaloblastic or pernicious anemia is an autoimmune
disease resulting from autoantibodies directed against
intrinsic factor (a substance needed to absorb vitamin B12
from the gastrointestinal tract) and gastric parietal cells.
•Pernicious anemia is more common among people of Celtic and
Scandinavian descent and is diagnosed at the age of
60 years
•Deficiency in production of intrinsic factor may
result from chronic gastritis or surgical removal of the
stomach.
195
193. Oral manifestations:
•Burning sensation in the tongue, lips, buccal
mucosa, and other mucosal sites.
•Tongue and mucosa shows smooth or patchy areas of erythema.
• Dysphagia and taste alteration.
Diagnosis:
based on measurement of serum vitamin B12 levels.
A more sensitive method of screening for vitamin
B12 deficiency is measurement of serum methylmalonic acid
and homocysteine levels, which are increased early in vitamin
B12 deficiency.
196
194. 197
Tongue appears to be smooth
and erythematous
Treatment:
Treatment has traditionally been weekly
intramuscular injections of 1,000 μg of
vitamin B12 for the initial 4 to 6 weeks,
followed by 1,000 μg per week
indefinitely.
196. Syphilis:
caused by T. pallidum, spirochete.
Syphilis has an incubation period of 10 to 90
days (average 3 weeks) and is characterized
by four main clinical stages: primary,
secondary, tertiary, and late or quaternary.
199
197. Syphilis
Chancre of primary syphilis.
Ulceration of the dorsal surface of
the tongue on the left side .
Characteristic slightly raised, grayish
white, glistening patches ‘mucous
patches,’ of the tongue
198. 201
Atrophic glossitis of tertiary
syphilis. Dorsal surface of the
tongue exhibiting loss of
filiform papillae and areas of
epithelial atrophy and
hyperkeratosis
Common site of gumma
(tertiary syhpilis)
Is hard palate.
199. Tuberculosis:
It is an infectious bacterial disease caused by Mycobacterium
tuberculosis, which most commonly affects the lungs.
It is transmitted from person to person via droplets.
Epidemiology:
India is the country with the highest burden of TB with World
Health Organisation (WHO) statistics for 2013 giving an
estimated incidence figure of 2.1 million cases of TB for India
out of a global incidence of 9 million. The estimated TB
prevalence figure for 2013 is given as 2.6 million.
It is estimated that about 40% of the Indian population is
infected with TB bacteria, the vast majority of whom have latent
rather than active TB.
202Courtesy: TB facts.org
201. Scarlet fever: (called as scarlatina in older literature)
• Caused by bacterium Streptococcus pyogenes (group A
streptococcus)
Epidemiology:
most common in children ages 5– 15
Both the gender are equally affected
Clincal features:
• Sore throat
• Fever
• Bright red tongue with a "strawberry" appearance
204
202. •Forchheimer spots (fleeting small, red spots on the soft palate)
•Paranoia (false illusions )
•Hallucinations
•The rash is the most striking sign of scarlet fever. It usually
appears first on the neck and face
•The rash is fine, red, and rough-textured
205
203. Blanches upon pressure ,appears 12–72 hours after the fever
starts generally begins on the chest and armpits and behind the
ears.
On the face, often shows as red cheeks with a characteristic pale
area around the mouth (circumoral pallor)
206
Red cheeks and pale area around
the mouth in scarlet fever
Begins to fade three to four days
after onset and desquamation
(peeling) begins. "This phase
begins with flakes peeling from
the face. Peeling from the palms
and around the fingers occurs
about a week later." Peeling also
occurs in the axilla , the groin,
and the tips of fingers and toes
204. Scarlet fever
Strawberry tongue is a
characteristic of scarlet fever.
Strawberry tongue (also called raspberry
tongue),refers to glossitis which manifests
with hyperplastic (enlarged) fungiform papillae ,
giving the appearance of a strawberry.
Early in the infection, the tongue may have a
whitish or yellowish coating.
After 4–5 days, red strawberry tongue occurs
207. Dyskinesias are involuntary movement that have no purpose
and are not fully controllable by the patient. Some are random,
some rhythmic, most are very odd looking and socially
stigmatizing.
Fly Catcher Tongue:
The intermittent in and out darting of tongue which is
cahracteristic of tardive dyskinesia,(Tardive Dyskinesia (TD) is
by definition a neuroleptic, Latin - "seize the neuron” ) a
complication of antpsychotic drug therapy. Mainly by
risperidone
Risperidone is used to treat schizophrenia and symptoms
of bipolar disorder manic depression)
210
208. Bon bon sign:
Involuntary pushing of tongue against the inside of the cheek.
Bon bon sign is said to be typical of the stereotypic orolingual
movements.
211
210. Gustatory disorders
• Stimulated dysgeusia- Distortion in perception
of taste.
• Unstimulated dysgeusia/ phantogeusia-
perception of taste in absence of any
recognized stimulus.
• Hypergeusia: Increased sensitivity for all taste
stimuli.
212. FIBROMA (IRRITATION FIBROMA;
TRAUMATIC FIBROMA; FOCAL
FIBROUS HYPERPLASIA; FIBROUS
NODULE)
Most common "tumor" of the oral cavity.
It is doubtful that it represents a true neoplasm
in most instances; rather, it is a reactive
hyperplasia of fibrous connective tissue in
response to local irritation or trauma.
215
213. Clinical Features
4-6 decade of life, F>M
Most common - buccal mucosa along the occlusal line. The
labial mucosa, tongue and gingiva also are common sites.
Smooth-surfaced pink nodule that is similar in color to the
surrounding mucosa.
In some cases, the surface may appear white as a result of
hyperkeratosis from continued irritation.
.
216
214. Most fibromas are sessile, although some are
pedunculated. Few millimeters to large masses.
Asymptomatic, unless secondary traumatic ulceration
of the surface has occurred.
Treatment and Prognosis
Conservative surgical excision; recurrence is
extremely rare.
217
216. NEUROFIBROMA
•The tongue and buccal mucosa are the most
common intraoral sites.
•Solitary tumors are most common in young
adults and present as slow-growing, soft,
painless lesions that vary in size from small
nodules to larger masses.
•The skin is the most frequent location for
neurofibromas, but lesions of the oral cavity are
not uncommon
219
218. Granular cell tumor of the tongue:
In 1926 Arbikossoff described a tumor of the tongue composed
of granular cells derived from striated muscles and termed it as
granular cell myoblastoma, theory that was subsequently
abandoned.
Granular cell tumor (GCT) is a benign lesion characterized by
the accumulation of plump cells with abundant granular
cytoplasm.
A wide variety of cell types have been proposed as the cells of
origin, including histiocytes, fibroblasts, myoblasts, neural
sheath cells, neuroendocrine cells, and undifferentiated
mesenchymal cells
221
Granular cell tumor of the tongue: Report of a case, D. Alka et al.
J Oral Maxillofac Pathol. 2013 Jan-Apr; 17(1): 148.
219. • GCTs can affect any part of the body, however, in head and
neck area it predominates by 45% to 65%.
• Of the head and neck cases, 70% of lesions are located
intraorally (tongue, oral mucosa, hard palate).
• GCTs are typically small, solitary lesions; rarely do they
exceed 3 cm in size.
• Both benign and malignant lesions have been reported;
although malignancy occurring is rare, comprising of 2% of all
GCTs
222
221. LIPOMA:
The tumor is asymptomatic and often has been
noted for many months or years before
diagnosis.
Most are less than 3 cm in size, but occasional
lesions can become much larger. Although a
subtle or more obvious yellow hue often is
detected clinically, deeper examples may
appear pink.
224
223. HEMANGIOMA
• Hemangiomas are endothelial tumors with a unique biologic
behavior—they grow rapidly, regress slowly, and never recur.
• The three stages in the life cycle of a hemangioma,
• (1) the proliferating phase (0–1 year of age),
• (2) the involuting phase (1–5 years of age),
• (3) the involuted phase (>5 years of age).
226
224. 227
Most hemangiomas of the tongue are asymptomatic, they
could sometimes cause significant bleeding, pain or difficulty in
chewing, speaking, and even swallowing, if they are large
enough
225. LYMPHANGIOMA
Lymphangiomas are benign, hamartomatous tumors of
lymphatic vessels.
Oral lymphangiomas may occur at various sites but are most
frequent on the anterior two thirds of the tongue, where they
often result in macroglossia
228
Pebbly, vesicle- like
appearance of a tumor of
the right lateral tongue.
229. METASTASES TO THE ORAL SOFT TISSUES
•The most common site for oral soft tissue metastases is the
gingiva, which accounts for slightly more than 50% of all cases.
•This is followed by the tongue, which is the site for 25% of
cases.
•The lesion usually appears as a nodular mass that often
resembles a hyperplastic or reactive growth, such as a Pyogenic
granuloma.
•Occasionally, the lesion appears as a surface ulceration.
232
231. An accessory tongue (Kumar S et al)
Singapore Med J 2009; 50(5) : e172
An accessory tongue is a rare anomaly. In the literature, only a
few case reports have been cited. The patient was treated with a
simple surgical excision.
234
232. Taste disorders:
• Taste disorders are distressing for patients.
• Taste disturbances can range from a total loss of taste to the
constant presence of phantom tastes, such as a bitter or
metallic taste in the absence of any offending substance in the
mouth.
• Such disturbances and associated dietary alterations can lead
to malnutrition (possibly resulting in death), obesity or other
health issues, such as hypertension.
• Despite the discomfort and profound effect on quality of life
caused by alteration or loss of taste, few definitive treatments
for taste disturbances exist, partly because of the complexity
of the taste system and partly because of a lack of substantive
research on the topic.
235
233. • Taste disturbances can be classified into 4
main categories:
Hypogeusia (decreased sensitivity to taste
modalities),
Dysgeusia (taste confusion),
Phantogeusia (phantom taste) and
Ageusia (loss of taste).
Total loss of taste is rare.
236
234. • Taste disturbances may occur secondary to autoimmune
disease, inflammation, hormone imbalance, nerve related
damage, psychological problems (e.g., anorexia), medication
therapy or malignancy; they may also occur as a result of
natural aging.
• In communicating their symptoms, patients often confuse taste
changes with flavour changes.
TREATMENT :
Treat the underline cause.
In communicating their symptoms, patients often confuse taste
changes with flavour changes.
• In previous studies, zinc gluconate (50 mg 3 times daily) had a
positive effect on taste disorders in a zinc deficient population
and also in patients with idiopathic taste loss regardless of
serum zinc level 237
235. • Alphalipoic acid, an important coenzyme and antioxidant in
many cellular pathways within the body, has also been
suggested for treating idiopathic dysgeusia.
• Femiano and colleagues36 found that 91% of patients with
idiopathic dysgeusia who took αlipoic acid (200 mg every 8
hours) showed some improvement, and 46% experienced total
resolution.
• These authors suggested that αlipoic acid may mitigate or
reverse the neuropathic changes related to idiopathic
dysgeusia.
238
Journal of cannadian dental association; Taste Disorders: A Review,
Nan Su, BSc; Victor Ching, BSc, RN; Miriam Grushka, MSc, DDS, PhDverse the
neuropathic changes related to idiopathic dysgeusia , September 17, 2013
236. The tongue is an important organ of the body.
Any pathology concerning its boundaries may spread to
distant areas of the body… via its lymphatic and vascular
supply.
Correct and an early diagnosis during the examination of
tongue
Differential diagnosis of the lesions need the knowledge,
the skill and the experience of the clinician.
CONCLUSIO
N
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