Treating Geographic Tongue
Median rhomboid glossitis usually presents as a painless, reddened, sharply demarcated area of depapillation in the centre of the dorsum of the tongue anterior to the foramen caecum. In some cases the area is nodular or grooved. It was originally thought to be due to the persistence of the developmental eminence called the tuberculum impar, but now most cases are believed to be candidal in origin 180, 188 . Predisposing factors include smoking, wearing dentures, diabetes and using steroid inhalers. Sometimes there is a kissing lesion in the palate. Fig. 3.5. Median rhomboid glossitis showing extensive epithelial Fig. 3.6. Eosinophilic ulcers showing plump histiocytic nuclei hyperplasia and fusing of rete processes and eosinophils Fig. 3.5. Median rhomboid glossitis showing extensive epithelial Fig. 3.6. Eosinophilic ulcers showing plump histiocytic nuclei hyperplasia and fusing of rete processes and eosinophils
Geographic tongue is a relatively common idiopathic condition typically characterised by migrating areas of depapillation on the dorsum of the tongue 6 . In many cases it is associated with fissuring. There is loss of filiform papillae often surrounded by a slightly raised yellowish-white and crenellated margin. These areas of depapillation tend to heal centrally and spread cen-trifugally. Occasionally, the ventrum is involved and in that site lesions consist of an area of erythema completely or partially surrounded by a circinate whitish halo. Identical lesions can occasionally be seen elsewhere in the mouth and have been called ectopic geographical tongue , although geographical stomatitis or benign migratory stomatitis would be more appropriate terms 81 . The majority of cases of geographical tongue are painless, but some patients complain bitterly of soreness and discomfort, which may or may not be associated with specific foods. Geographical tongue is usually obvious clinically...
Symptoms are attributable primarily to anemia, although glossitis, jaundice, and splenomegaly may be present. Vitamin B12 deficiency may cause decreased vibratory and positional sense, ataxia, paresthesias, confusion, and dementia. Neurologic complications may occur in the absence of anemia and may not resolve completely despite adequate treatment. Folic acid deficiency does not result in neurologic disease.
Interstitial glossitis due to late stage syphilis with squamous cell carcinoma at the left tip of the tongue (Collection of J.J. Pindborg, M.D., Copenhagen). Fig. 4.19 Syphilis. Interstitial glossitis due to late stage syphilis with squamous cell carcinoma at the left tip of the tongue (Collection of J.J. Pindborg, M.D., Copenhagen).
Median rhomboid glossitis typically forms a patch of papillary atrophy near the midline of the dorsum of the tongue at the junction of the anterior two thirds and posterior third in the region of the embryological foramen caecum. It is no longer thought to be a developmental defect but the result of chronic candidal infection 719,2825 .
There are few diseases that will cause chronic swelling of one or both lips other than cheilitis granulomatosa or Miescher's cheilitis. This form of cheilitis combined with fissured tongue and facial nerve paralysis constitutes the Melkersson-Rosenthal syndrome. Although labial swelling is the most common presentation, no orofacial tissue is immune. Facial skin, gingiva, buccal mucosa, tongue, and palate may be affected. The term orofacial granulomatosis recognizes the disparate forms of this condition. Females are more often affected than are males and the mean age of onset is 33 years. It is ushered in by cycles of unexplained edema and resolution that ultimately lead to swelling without remission. Examination of biopsy material reveals non-caseating, epithelioid granulomas devoid of foreign material and
Pemphigus vegetans is considerably less common in the mouth than pemphigus vulgaris 15 . It usually presents clinically as serpiginous ulcers that are most frequent on the dorsum of the tongue and lips 187 . The lingual lesions closely resemble those of erythema migrans. The papillomatous, proliferative lesions that characterise cutaneous pemphigus vegetans can sometimes be seen at the angles of the mouth. As in pemphigus vulgaris, drugs, particularly ACE inhibitors, have been invoked as possible causative agents in some cases 12, 137 .
The striking feature is the presence of polymorphonuclear leukocytic mi-croabscesses in the upper stratum spinosum (Fig. 3.11). These spongiform pustules are not pathognomonic of geographical tongue and can be seen in oral psoriasis, acute and chronic candidosis, Reiter syndrome and plasma cell gingivostomatosis. Some describe elongation of the rete ridges, but this is by no means a consistent observation. However, occasionally there may be psoriasi-form hyperplasia in geographical tongue and it may be difficult or impossible to distinguish from psoriasis. Indeed, geographical tongue and migratory stomatitis are 4-5 times more common in patients with psoriasis and some believe that geographical tongue is the oral ho-mology of psoriasis 179, 194 . The presence of spon-giform pustules in oral biopsies should always prompt the search for candidal hyphae with a PAS or Grocott stain. These are not usually seen in geographical tongue and their presence...
Oral lesions may precede, or accompany, bowel symptoms, but in a significant number of cases intestinal disease is subclinical. In patients with active bowel disease there may be atrophic glossitis secondary to malabsorption of the haematinics iron, vitamin B12 or folate. OFG may be part of a spectrum of diseases that includes Melkersson Rosenthal syndrome (MRS) and cheilitis granulomatosa (Miescher's syndrome). MRS, in its complete form, is a triad of fissured tongue, labial or facial swelling due to granulomatous inflammation, and facial nerve palsy, which may be the first indication of the disease 192 . Cheilitis granulomatosa is probably merely an isolated manifestation of OFG.
Relatively few side effects are associated with the usual antimalarial dosages. However, signs of toxicity are evident at higher dosages, particularly those used in the management of toxoplasmosis. Many of these reactions reflect the interference of pyrimethamine with host folic acid metabolism, especially that occurring in rapidly dividing cells. Toxic symptoms include anorexia, vomiting, anemia, leukopenia, thrombocytopenia, and atrophic glossitis. CNS stimulation, including convulsions, may follow an acute overdose.The side effects associated with the pyrimethamine-sulfadoxine combination include those associated with the sulfonamide and pyrimethamine alone. In addition, there is evidence of a greater incidence of allergic reactions, particularly toxic epidermal necroly-sis and Stevens-Johnson syndrome, with the combination. This carries an estimated mortality of 1 11,000 to 1 25,000 when used as a chemoprophylactic.
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