Changes in tongue coating
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Tongue papillae.
Food debris.
Bacteria.
Desquamated epithelium.
The tongue coating
varies in different individuals.
Varies in the same individual during the day
It is continuously formed
it is marked in the morning since cleaning factors
are at rest. and is removed by:
1-Mechanical factors: speaking and chewing food.
2-Salivary flow
Tongue coating is in a continuous process of
removal and formation.
If removal exceeds formation  atrophy
If formation exceeds removal  increased tongue
coating.
A- Atrophy of tongue coating
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The cells forming the filiform papillae and
fungiform papillae are of high metabolic activity so
any disturbance in enzyme, circulation or nutrients
leads to atrophy.

During the process of atrophy: the filiform
papillae are affected first, followed by fungiform
papillae.

During regeneration: the fungiform papillae
regenerate first followed by regeneration of
filiform.
 Circumvallate and foliate are permanent structures
of the tongue coating , don’t participate in atrophy.
Atrophy of tongue coating
1- Deficient or impaired utilization of
nutrients
1Iron deficiency anemia.
2Pulmonary Vinson syndrome.
3Pernicious anemia.
4Anemia associated with parasitic infection
as ascaris and bilhariziasis.
5Malnutrition, malabsorption.
6Sprue .
7Chronic alcoholism.
8Vitamin B deficiency especially (vitamin
B2, B6, B12, folic acid and nicotinic acid).
2- Peripheral vascular disease
1- Angiopathy: Diabetes Mellitus.
2-Vasulitis: systemic lupus erythematosus.
3-Endarteritis obliterans: syphilitic glossitis.
4-Obliteration of small blood vessels: scleroderma,
submucous fibrosis.
5-Localized vascular insufficiency in elderly patients.
3-Therapeutic agents
1-Drugs that:
 Interfere with the growth and maturation of the
epithelium e.g cyclosporine.
 Induce candidosis e.g. antibiotic, steroid.
 Induce xerostomia e.g anticholinergic drugs,
radiotherapy.
4- Miscellaneous
1- Frictional irritation: atrophy at tip & lateral borders
of tongue.
2- Atrophic lichen planus.
3- Epidermolysis bullosa: ulceration healed by scar.
4- Long standing xerostomia.
5- Diabetes and chronic candidiasis may produce a
lesion called central papillary atrophy.
B- Increased tongue coating
 The filiform papillae which constitute the
keratinizing surface of the tongue are in
continuous state of growth and their height is
determined by the rate of desquamation process.
The later is induced by friction with food, palate
and the upper anterior teeth, during eating and
speech.
Increased tongue coating
Etiology:
 Basically the abnormal increase in tongue coating is
due to local environmental changes represented by
lack of function and/or changes in the oral flora and
these are attributed to:
1- Drugs
a- Topical and systemic use of antibiotics.
b- Antiseptic mouth washes.
c- Oxygen releasing mouth rinse.
Etiology cont…
 2- Febrile illness (general body dehydration,
decreased salivary flow, liquid diet and poor oral
hygiene).
 3-Stomach upset, vomiting associated with intestinal
or pyloric obstruction, debilitated or terminally ill
patient.
 4- Mouth breathing
Clinical features:
 The increased tongue coating may be stained
particularly on the mid dorsum by food, tobacco,
drugs or possibly by microorganisms.
 In debilitated, dehydrated and terminally ill patients
the increased tongue coating may be very thick and
has been described as leathery coating.
Treatment
 Consist of brushing the dorsal surface of the tongue
several times a day systemic antibiotic should not be
interrupted but antifungal agent should be used
locally. Topical antibiotic and mouth washes should
not be used. The condition usually regresses
spontaneously when the normal jaw and tongue
activity are restored.
Black hairy tongue
 Definition
It is a condition characterized by hypertrophy of
filiform papillae associated with growth of black
pigment producing micro organism.
Black hairy tongue
Etiology
1- Sodium perporate and sodium peroxide mouth
wash that stimulate growth of filiform papillae.
2-Topical and systemic antibiotics:
ex: penicillin, tetracycline, aureomycin.
3- Systemic disturbance: anemia, hyperacidity, peptic
ulcer.
4- Predisposition in some people.
Clinical features
May be asymptomatic or may cause gagging and
tickling.
Management
 Removal of the cause
 stop t0pical antibiotic.
 Brushing of the tongue.
 Systemic antibiotic should not be stopped, but
antifungal ointment is prescribed in additional to
the antibiotic.
 Pseudo black hairy tongue means discolouration
of tongue by food, smoking and drugs without
actual hypertrophy of filiform papillae.
Site:
the dorsum of the tongue.
 It is an irregularly outlined area, devoid of
filiform papillae, with red dots representing
fungiform papillae. {occasionally devoid of
fungiform}. The margin of the depapillated area
is raised with yellowish, whitish tinge.
 The margin of the lesion shifts as much as ¼
inch per day due to renewed of papillae in one
area and loss in another area.
 It occurs chiefly in children and young adults.
Geographic tongue
Geographic tongue
Clinical picture
 Females are frequently affected more than males.
 The patient may fell discomfort of pain specially
alcoholics and with highly seasoned food.
 The lesions are usually multiple.
 Identical lesion is seen in psoriasis and Reiter’s
syndrome.
Etiology:
Unknown but may be:
1- Associated with fissured tongue (attributed to
bacterial irritation).
2-Common in allergic persons (more frequent in
atopic patients).
3-Related to psychological factor (the exacerbation
has been associated with anxiety and depression.
4-Related to family history (several member of the
family may have the disease).
Differential diagnosis
Geographic tongue should be differential from
1- Atrophic lichen planus.
2-Fixed drug eruption.
The main characteristic features of geographic tongue is
the continuous daily migration of the lesion.
Treatment
No treatment is indicated as the lesion is self limiting
disease.
1- In apprehensive and cancerphobic patient reassurance
is required.
2-If the patient is suffering from burning or soreness,
benzydamine HCl mouth wash will offer good relief.
Identatoin marking of the tongue
Definition:
It is crenation marking seen along the tip and lateral
margins of the tongue where it rests against the
surfaces of the teeth.
Etiology
Local factors
1- Tongue pressure habit.
2-Macroglossia (acromegaly, gigantism, etc).
3-Acute inflammation: e.g. erythroma multiform,
metallic intoxication, Acute necrotizing ulcerative
gingivitis, acute herpetic gingivostomatitis.
Systemic factors
1- Vitamin B complex deficiency.
2-Diabetes mellitus due to decreased muscular tone
associated with vitamin B&C deficiency.
Sublingual varices
1- It is formed by enlarged tortuous veins in the
sublingual area.
2-It is asymptomatic, but trauma may result in bleeding
Etiology
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Idiopathic
Congential.
Found more in elderly people.
It may be associated with portal hypertension.
Glossopyrosis
Burning tongue
Glossodynia
painful tongue
Etiology
1- Local factors
2-Systemic factors
3-Psychogenic factors represents 75% of cases.
1- Local factors
1- Irritating calculus, caries, malposed teeth, sharp tooth
edge.
2-Electrogalvanic discharge between two dissimilar
metals.
3-Oral Candidosis.
4-Dryness of the mouth.
5-Allergic response to lipstick, dentifrices.
6-Excessive smoking.
7-Habit of rubbing the tongue against the teeth.
8-Excessive use of strong mouth wash.
9-Mouth breathing.
10- Highly spicy food.
Erosions on the dorsum of the tongue, caused by very hot food.
2- Systemic factors
 Anemia: iron deficiency anemia, pernicious
anemia.
 Vitamin B complex deficiency.
 Chronic alcoholism.
 Gonadal deficiency
 Diabetes mellitus.
 Drugs: fixed drug eruption.
 Low serum zinc level.
 Tongue tremors e.g. parkinsonism.
3-Psychogenic factors
12-
Post menopausal women with cancerphobia.
After death of close persons.
 Psychogenic factors result in glossodynia which is
characterized by:
1- No observable clinical cause.
2-Pain does not follow any anatomical distribution.
3-Pain does not interfere with eating or sleeping.
4-Pain intensity increases at the end of the day.
Treatment
1- Removal of the cause if possible.
2-If psychogenic.
 Reassurance of the patient that there is no malignancy.
 Valium 5-10 mg t.d.s may be of help.
 Resistant cases  refer to psychiatrist
6- Papillitis (painful foliate and
circumvallate papillae)
 It is the inflammation of foliate and / or the lateral
circumvallate papillae.
 The patient complains of pain at the posterolateral aspect
of the tongue.
Etiology
 Sharp distolingual cusp of lower second molar.
 Sharp edge of a denture.
The lesion arises as a result of rubbing or biting the tongue
against the teeth, or denture. Digital palpation may reveal a
rough or sharp tooth or restoration.
References:
 Martin Greenberg and Michel Glick & Jonathan A.
Ship. Burkett's Oral Medicine ,Diagnosis & Treatment ,
10th ed. 2008, BC Decker, Inc..
 George Laskaris, Pocket Atlas of Oral Diseases, 2nd
edition, 2006, Stuttgart , New York.