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Symptomatic Benign Migratory Glossitis: Report of Two Cases

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Symptomatic Benign Migratory Glossitis: Report of Two Cases Symptomatic benign migratory glossitis: CASE REPORTS report of two cases and literature review MichaelJ. Sigal, DDS,MSC, Dip Paed, MRCD(C) DavidMock, DDS, PhD, FRCD(C) Abstrac~ Benign migratory glossitis (geographic tongue) is a commonclinical finding in routine pediatric dentistry. The condition usually is discoveredon routine clinical examination,appearing as an asymptomatic, ulcer-like region on the dorsumof the tongue. The lesion mayrecur at different sites on the tongue, creating a migratory appearance, and in manycases, will resolve completely. The presentation of symptomatic geographictongue in children is rare. This article presents two cases of symptomaticgeographic tongue. Both children presented with a chief complaintof significant oral pain which wasaffecting daily activity, eating, and sleeping. Both patients presentedwith a classical clinical presentationof ulcer-like regions on the dorsum of the tongue in which the filiform papillae were denuded.Successful managementwas achieved with topical and systemic antihistamine. The clinician should be aware that this condition may be symptomatic fn children. (Pediatr Dent 14:392-96, 1992) Introduction Benign migratory glossitis (BMG)is a condition re- account for the increased prevalence observed, since ferred to in the literature by a variety of names,such as: BMGmay be seen more often in children with associ- geographic tongue, erythema migrans, annulus migrans, ated major illnesses. Both articles also suggested that and wandering rash of the.tongue. 1-4 This inflamma- the increased incidence mayreflect the different racial/ tory condition first was reported by RayerI in 1831. ethnic backgrounds of the samples examined.12, 13 ~. I~is a benign, inflammatory disorder occurring most The etiology of geographic tongue is still unknown. ff6mmonly on the .dorsum of the tongue, possibly ex- Someconsider the condition to be a congenital anomaly tending onto the lateral borders..The characteristic ap- and others believe it to represent an acute inflammatory pearance’includesmultifocal, circinate; irregular reaction. Attempts have been made to demonstrate an erythematous patches bounded by a slightly elevated, association between various systemic and/or psycho- keratotic band or line. The erythematous patches repre- logical conditions and BMG.These conditions include sent loss of filif0rm papillae and a thinning of the psoriasis,7, 14, Reiter’s syndrome,14 anemia, gastro- epithelium. The white border is composedof regenerat- intestinal disturbances, nutritional disturbances, ing filiform papillae and a mixture of keratin and neu- c a ndid’asis,~ lichen planus, hormonalimbalance,10 psy- trophils. The surface is nonulcerated, but appears ulcer- chological upsets, l~and allergies. 16 A definitive causal ated due to the loss of the surface papillae and keratin. relationship has not been established. These well-defined, elliptical lesions vary in size from a Heredity may play a role in the etiology of BMG. few millimeters to several centimeters. The location and Redman17 postulated a polygenic mode of inheritance pattern undergo change over time, thereby accounting for geographic tongue. Eidelman et al. 18 determined for the name "migratory." This apparent migration is that the prevalence of BMGin parents and sibling com- due to a concurrent epithelial desquamation at one binations was significantly higher than that observed in location5-8 and proliferation at another site. the general population. They concluded that geographic The prevalence of BMGin the general population is tongue was a familial condition in which heredity plays between 1.0 and 2.5%.2-4, 9 Various age groups can be a significant role. affected with no apparent racial predilection; however, Marks and Tait 19 provided additional support for a the condition appears to be more commonin females genetic basis of BMGby demonstrating an increased with reported female-to-male ratios of 5:3 and 2:1.1,2,10 incidence of tissue type HLA-B15in atopic patients Redman11 observed a 1% prevalence of BMGin with geographic tongue. Wysocki and Daley5 investi- schoolchildren, with an equal distribution between gated the prevalence of BMGin patients with juvenile males and females. A similar finding was noted in an diabetes, because it is known that HLA-B15occurs investigation4 of university students by Meskin. more frequently in insulin-dependent diabetic pa- Very high rates of occurrence of BMGin children in tients. 20 They discovered a prevalence of 8%for BMGin Japan (8%) and Israel (14%), with a peak age of diabetic patients and concluded that BMGmay be a years, were reported in studies conducted on hospital- clinical marker for insulin-dependent diabetes mellitus.5 ized pediatric patients. 12, 13 This sampling bias could 392 PEDIATRlC"DENTISTRY" NOVEMBER/DECEMBER, 1992 ~ VOLUME14, NUMBER6 Marks and Simons21 discovered a significantly in- with migration of polymorphonuclear leukocytes and creased frequency of atopy among patients with geo- lymphocytes toward the zone of epithelial degenera- graphic tongue, as compared to the normal population. tion. Munroabscesses also may be seen. The advancing In a study of atopic patients with a history of asthma margin is outlined clearly by a dense, polymorpho- and/or rhinitis, Marks and Czarny16 found a 50%preva- nuclear infiltration of the acanthotic epithelium and lence of BMG.They also observed that the frequency of corium. The border may demonstrate a zone of geographic tongue increased significantly in the control hyperkeratinization (parakeratosis). Tissues which were group with no clinical history of atopy, but who had a affected previouslly show a chronic inflammatory reac- positive skinprick test to commoninhalant allergens. tion.8, 10, 26, 27 Geographic tongue is characterized by They concluded that a positive association between periods of exacerbation and remission. During remis- geographic tongue and atopy exists, and further postu- sion, lesions resolve without residual scar formation. lated that geographic tongue and asthma/rhinitis may Whenlesions recur, they tend to occur in a new loca- have a similar pathogenesiso Both conditions are recur- tion, thus producing the migration effect. rent, inflammatory, and can be initiated by contact with Since BMGis asymptomatic in most cases, no treat- external environmental irritants. Geographic tongue is ment is required other than patient reassurance of the probably a sign commonto those individuals who have benign and self-limiting nature of the disorder. If symp- a tendency to develop a recurrent acute inflammatory toms are present, the patient should be instructed to reaction on surfaces which are in contact with the exter- avoid any knownirritants, such as hot, spicy, or acidic nal environment. foods. If treatment is warranted, it should be palliative/ Psoriasis, a cutaneous dermatological condition, ap- symptomatic care using topical anesthetic rinses or pears to be related to an accelerated rate of epithelial gels, antihistamines, or steroids. 6, 8, 10, 25, 28 A psycho- turnover, resulting in epithelial hyperplasia and is seen logical component may contribute to the development clinically as erythematous papules and/or white scaly of BMG,and tranquilizers maybe considered in patient plaques. 7 BMGhas been suggested as an oral manifes- management.25 tation of psoriasiso7, 22, 23 A review of the literature on BMGfailed to produce The association between fissured tongue and BMG a reported case of symptomatic BMGin children. This supports a genetic basis for the development of the article presents two cases of therapeutic management conditiono18 The fissures mayact as stagnation areas on of children with symptomatic BMG. the tongue surface in which glossitis maybegin. 8 Geo- graphic tongue appears to be associated with geographic Case Reports stomatitis 6, 8 which has a clinical and histological ap- Case One pearance similar to BMGbut occurs on an extraglossal A 4-year-old Caucasian boy was seen with a chief intraoral24 site. complaint of oral discomfort and increased salivation. The diagnosis of BMGusually is based solely on the history and clinical presentation which would include Review of his medical history revealed an innocent heart murmur, sleep apnea until the age of 9 months, characteristic migratory pattern and chronic nature. and recurrent otitis media which required placement of The vast majority are asymptomatic and noticed during myringotomytubes at the age of 1 year. At the initial the course of a routine oral examination, or self-exami- nation.6, 8,10, 25 Only Cooke8 reported that a significant visit there was no history of allergy to medications or environmental factors. number of patients complained of some oral sensitivity The patient’s mother reported that approximately or discomfort, most often described as a "burning sen- one month earlier, her son began to experience oral sation." No oral sensitivity associated with cases of discomfort, evidenced by crying, placing objects in his BMGin pediatric populations has been reported. mouth, and a marked increase in salivation and expec- If a patient presents with suspected BMG,a differen- toration. The child reported that his mouth had an tial diagnosis based on adult studies should include "awful taste." atrophic candidiasis, psoriasis, Reiter’s syndrome, atro- He was placed on nystatin (Mycostatin ®, Bristol- phic lichen planus, systemic luaus erythematosus, Myers Squibb Canada, Montreal Quebec, Canada), leukoplakia, and drug reaction. 6, 25 100,000 units, three
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