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What Your Tongue Says About Your Health

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What Your Tongue Says About Your Health Dr. Sahar Mafi, Assistant WHAT YOUR TONGUE SAYS ABOUT Professor, Oral Medicine Department, Dental School of YOUR HEALTH Kermanshah CASE A 17-year-old young woman underwent an initial examination at the dentist’s office during a routine checkup. Some caries were detected and also the need for an orthodontic consultation. The presence of an atrophy of filiform papillae of the dorsum of the tongue was observed. CASE No history of systemic disease or, in particular, any gastrointestinal symptoms. Tongue affection had started when she was five years old with no other symptoms and with intermittence. During her past medical history, no one had ever investigated these tongue lesions. DIFFERENTIAL DIAGNOSIS Glossitis Protein-calorie malnutrition Vitamin B12 deficiency Candidiasis Xerostomia LAB TESTS Test Normal range Patient’s value Hematologic tests showed a vitamin deficiency with positive results for Folic acid 3 to 17 ng/ml 1.65 antibody tests so a small intestine biopsy Vitamin b12 193 to 982 <150 was performed during a pg/ml gastroenterological consultation Transglutamin _ Positive ase (IgA) IgA- _ Positive endomysial antibody (EMA) DIAGNOSIS A diagnosis of Celiac Disease was made based on the findings from the biopsy sample; such as: the characteristic changes in intraepithelial lymphocytosis, crypt hyperplasia and … TREATMENT She was treated by excluding gluten- based-food from her diet (gluten-free diet). After five months she repeated the intraoral examination where it was possible to verify remission of the AG. GLOSSITIS Glossitis refers to inflammation of the tongue, and atrophic glossitis represents partial or complete loss of predominantly filiform papillae and minorly fungiform papillae on the dorsal surface of the tongue in addition to glossitis. ATROPHIC GLOSSITIS It is a condition characterized by a smooth glossy tongue that is often tender/painful The dorsal tongue surface may be affected totally, or in patches, and may be associated with a burning sensation, pain and/or erythema. CLASSIFICATION It may be primary, where there is no underlying cause, or secondary where it is a sign or symptom of another condition. Acute or chronic. Several clinical patterns SYMPTOMS Burning sensation and numbness due to loss of protection of dorsal surface mucosa of the tongue by filiform papillae and easy access of the free nerve ending in the atrophic dorsal surface mucosa of the tongue, respectively. CAUSES Deficiencies of some major nutrients including riboflavin, niacin, pyridoxine, folic acid, vitamin B12, iron, zinc, and vitamin E, protein-calorie malnutrition ANEMIA Patients with Hb deficiency have reduced capacity of the blood to carry oxygen to the dorsal surface mucosa of the tongue, finally resulting in AG. Iron-deficiency anemia is mainly caused by blood loss (menses or gastrointestinal hemorrhage). ANEMIA Giving the tongue a bald and shiny appearance, along with pallor (paleness) of the lips and other mucous membranes The appearance of the tongue in iron deficiency anemia has been described as diffuse or patchy atrophy with tenderness or burning VITAMIN B DEFICIENCY Vitamin B2 deficiency can cause glossitis(magenta), along with angular cheilitis, peripheral neuropathy B3 deficiency (Niacin) acts as a coenzyme for cellular oxidation reduction reactions and is involved in the DNA repair process VITAMIN B DEFICIENCY Pyridoxine is a cofactor in several enzymatic reactions involving the metabolism of amino acids, glucose and lipids. Vitamin B6 deficiency can cause glossitis, along with angular cheilitis, peripheral neuropathy and seborrheic dermatitis. VITAMIN B DEFICIENCY Vitamin B12 is involved in DNA synthesis, regulatory functions of nervous system, amino acid metabolism, and the maturation of developing red blood cells in the bone marrow. The appearance of the tongue in vitamin B12 deficiency is described as "beefy" or "fiery red and sore" VITAMIN B DEFICIENCY Folic acid plays a role in synthesis of DNA and RNA and in the prevention of genetic alterations. Folate deficiency (vitamin B9 deficiency) can cause glossitis, along with macrocytic anemia, thrombocytopenia, leukopenia, diarrhea, fatigue and possibly neurological signs OTHER NUTRIENT DEFICIENCY Zinc plays roles in various human biological functions including cell growth, wound healing, normal immune function, and taste function High blood homocysteine level may result in an elevated frequency of thrombosis in the feeding arterioles that supply the oral mucosal cells INFECTION The tongue dorsum is always colonized by various microbial colonies without the development of a pathological condition. When the balance of the niches is altered, it is often possible to observe a pathological colonization due to a specific, and often single, microbial strain accompanied by clinical manifestations. HELICOBACTER PYLORI Atrophic condition of the tongue has been described in association with candidiasis, colonization of Helicobacter pylori CANDIDIASIS Bacterial, viral or fungal infections can cause glossitis. Chronic Candida infections of the tongue can cause an atrophic glossitis known as median rhomboid glossitis and erythematous candidiasis TREPONEMA PALLIDUM Syphilis is now relatively rare, but the tertiary stage can cause diffuse glossitis and atrophy of lingual papillae, termed "syphilitic glossitis" CORONA VIROUS A clear relationship between Covid-19 and oral mucosal lesions has yet to be established. It is stated in few publications that only oral symptom associated with Covid-19 is taste impairment and other oral lesions arise as a result of decreased immunity due to viral infection, opportunistic or secondary infection or treatment for Covid-19 STRAWBERRY TONGUE White strawberry tongue is where there is a white coating on the tongue through which the hyperplastic fungiform papillae protrude. Red strawberry tongue is where the white coating is lost and a dark red, erythematous surface is revealed, interspaced with the hyperplastic fungiform papillae. STRAWBERRY TONGUE White strawberry tongue is seen in early scarlet fever (a systemic infection of group A β- hemolytic streptococci) and red strawberry tongue occurs later, after 4–5 days. Strawberry tongue is also seen in Kawasaki disease (a vasculitis disorder primarily occurring in children under 5), and toxic shock syndrome. AUTOIMMUNE Autoimmune conditions such as Sjögren syndrome can cause xerostomia, with resultant glossitis. MEDICATION Drugs for the treatment of type 2 diabetes, contraceptives, acid- lowering agents, anti-cancer medicaments, agents for the treatment of hypertension, neurologic drugs as well as others. MEDICATION Each one of them could generate an AG related to a vitamin deficiency through two principal mechanisms of action: firstly, they can determine a malabsorption of the nutrient; secondly, they can interfere in the metabolization of a specific vitamin. In addition, there are other mechanisms leading to an atrophic condition such as the development of candidiasis after antibiotic use, xerostomia related to antidepressant consumption or microcirculation alteration after use of chemotherapeutical drugs OTHER CAUSE Many conditions can cause glossitis via malnutrition or malabsorption Alcoholism Celiac disease Crohn’s disease Veganism and other specialized diets OTHER CAUSE Gastroesophageal reflux disease (GERD) irritants such as tobacco, spices Allergic reaction to toothpaste, mouthwash… Oral lichen planus Poor hydration and low saliva in the mouth Acquired immunodeficiency syndrome DIFFERENTIAL DIAGNOSIS Migratory glossitis The diagnosis of this condition is easy, because of the tendency of the lesions to change and “move” throughout the day. Two repeat visits in 12-24 hours will help in identifying with sufficient certainty the disease without the need for further tests A microbiological examination to rule out a Candida infection and a simple search for nutritional deficiencies is strongly recommended DIFFERENTIAL DIAGNOSIS Burning mouth syndrome Glossitis usually responds well to treatment if the cause is identified and corrected. Tongue soreness caused by glossitis is differentiated from burning mouth syndrome, where there is no identifiable change in the appearance of the tongue, and there are no identifiable causes LABORATORY TEST Complete blood count Serum levels of iron, Vitamin B12, Folic acid, Zinc Transglutaminase IgA (tTG-IgA) Test and IgA anti-endomysial Rheumatoid factor, anti-Ro, anti-La, erythrocyte sedimentation rate (ESR), CRP Gastric parietal cell antibody (GPCA) Fecal occult blood test (FOBT) , Calprotectin Homocysteine levels LABORATORY TEST GPCA can induce destruction of gastric parietal cells, can cause malabsorption of vitamin B12 IgA anti-endomysial antibodies remain the most specific test for coeliac disease The fecal occult blood test (FOBT) is a lab test used to check stool samples for hidden (occult) blood LABORATORY TEST Calprotectin is a stool (fecal) test that is used to detect inflammation in the intestines. Intestinal inflammation is associated with, for example, some bacterial infections and, in people with inflammatory bowel disease (IBD), it is associated with disease activity and severity. TREATMENT Good oral hygiene is necessary and Avoid irritants Corticosteroids such as prednisone may be given to reduce the inflammation of glossitis. For mild cases, topical applications (such as a prednisone mouth rinse that is not swallowed) may be recommended to avoid the side effects of swallowed or injected corticosteroids. Antibiotics, antifungal medications,
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