The Tongue

By Andreas Filippi and Irène Hitz Lindenmüller

As the largest organ in the oral cavity, the tongue not only plays a primary role in masticatory and speech function—it is also a significant indicator of health, demonstrating signs of both oral pathologies and diseases that can affect the entire body. Because no health care provider gets the opportunity to examine a patient's tongue as often as the dentist, it is essential for dentists to recognize when there may be a problem with the tongue and what the problem is. In addition to an overview of tongue anatomy and general diagnosis and treatment recommendations, this book contains an atlas of more than 50 specific diseases and health concerns that may present signs and symptoms in the tongue. Each is outlined in a quick-reference table describing etiology, prognosis, and more and is accompanied by photographs of different ways the condition can present. A true diagnostic aid, this guide will allow clinicians to identify and address any abnormality a patient's tongue may exhibit.

• Language: English
• Publisher: Quintessence Publishing Co, Inc
• Release date: Oct 1, 2019
• ISBN: 9780867159028

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The Tongue

Library of Congress Cataloging-in-Publication Data

Names: Filippi, Andreas, editor. I Lindenmuller, Irene Hitz, editor.

Title: The tongue / [edited by] Andreas Filippi, Irene Hitz Lindenmuller.

Other titles: Zunge. English

Description: Batavia, IL : Quintessence Publishing Co, Inc, [2018] | Includes bibliographical references.

Identifiers: LCCN 2018033055 | ISBN 9780867157765 (hardcover) | eISBN 9780867159028

Subjects: | MESH: Tongue | Tongue Diseases | Atlases

Classification: LCC QL946 | NLM WI 17 | DDC 612.8/7--dc23

LC record available at https://lccn.loc.gov/2018033055

© 2019 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road

Batavia, IL 60510

www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Marieke Zaffron

Design: Sue Zubek

Production: Kaye Clemens

Printed in the USA

CONTENTS

Foreword

Contributors

1. INTRODUCTION

Andreas Filippi

2. ANATOMY AND PHYSIOLOGY OF THE TONGUE

Ralf J. Radlanski

Parts of the tongue

Development of the tongue

Internal structure of the tongue

Lingual mucosa

Filiform papillae

Fungiform papillae

Foliate papillae

Circumvallate papillae

Innervation of the tongue

Clinically relevant relationships

3. NORMAL VARIATIONS

Andreas Filippi

4. DIAGNOSTICS

Inga Mollen, Irène Hitz Lindenmüller

History taking and clinical examination

Glass spatula test (diascopy)

Fungal diagnostics

Blood tests

Iron deficiency

Vitamin B12 deficiency

Folic acid (vitamin B9) deficiency

Zinc deficiency

Hba1c (long-term blood sugar level)

Antinuclear autoantibodies and rheumatoid factors

Anti-desmoglein 1 and 3 autoantibodies

Bullous pemphigoid 180 and 230

Cytodiagnostics (brush biopsy)

Autofluorescence

Toluidine blue

Conventional biopsy

Direct immunofluorescence

Conclusion

5. CHANGES TO THE TONGUE

Michael M. Bornstein, Andreas Filippi, Jörg Halter, Irène Hitz Lindenmüller, Peter Itin, Sebastian Kühl, J. Thomas Lambrecht, Inga Mollen, Adrian Ramseier, Andrea Maria Schmidt-Westhausen, Richard Steffen, Valérie G. A. Suter, Branka Tomljenovic, Astrid Truschnegg, Tuomas Waltimo, Brigitte Zimmerli

Addison disease

Anemia

Ankyloglossia

Aphthae

Betel consumption

Black hairy tongue

Caviar tongue

Cheilitis granulomatosa

Cowden syndrome

Crohn disease

Ehlers-Danlos syndrome

Erythroplakia

Fibroma and fibrous hyperplasia

Fissured tongue

Focal epithelial hyperplasia

Foreign body in the tongue

Geographic tongue

Graft-versus-host disease

Hand, foot, and mouth disease

Hemangioma/vascular malformation

Hereditary hemorrhagic telangiectasia

Herpes zoster

Herpetic gingivostomatitis

Hyperkeratosis

Impressions caused by orthodontic appliance

Infectious mononucleosis

Leukoplakia

Lichenoid reaction

Lingual tonsil hypertrophy

Lipoma

Lymphangioma

Macroglossia

Median rhomboid glossitis

Melkersson-Rosenthal syndrome

Morsicatio linguarum

Multiple endocrine neoplasia

Neuroma

Neutropenia

Oral candidiasis

Oral hairy leukoplakia

Oral lichen planus

Oral verruca vulgaris

Papilloma

Pemphigus vulgaris (PV) and bullous pemphigoid (BP)

Piercing scars

Pyogenic granuloma

Salivary gland cysts

Scarlet fever

Sjögren syndrome

Split tongue

Syphilis

Systemic amyloidosis

Systemic lupus erythematosus

Tongue carcinoma

Tongue piercing

Tongue pigmentation

Tongue tattoo

Ulcer

Varicella (chicken pox)

6. TREATMENT

Irène Hitz Lindenmüller, Inga Mollen

Choice of oral care products

Avoidance of habits

Protective splint

Dietary guidance

Tobacco and alcohol

Diagnosing metallurgic reactions

Splinter test

Intraoral corrosion measurement with EC-pen

Retinoids

Immunosuppressants

Corticosteroids

Calcineurin inhibitors (tacrolimus)

Antifungals

Dental adhesive paste

Laser

CO2 laser

Diode laser

FOREWORD

Dental practitioners, pediatricians, otorhinolaryngology specialists, general practitioners, and dermatologists as well as dental hygienists, dental nurses, and dental assistants regularly look into the oral cavity or throat of their patients. The largest organ within this field of vision is the tongue, about which all of these specialties have relatively little detailed knowledge. Dentists in particular see their patients’ tongues regularly during the course of routine dental check-ups, whereas an ear, nose, and throat specialist or general practitioner only gets to see the tongue when examination of their patient requires it. The tongue not only exhibits a multitude of normal variations and pathologic changes, but it tends to reflect the general medical, internist, diet-related, and mental state of our patients.

In training as well as in continuing professional development, relatively little attention has so far been paid to the tongue. This is evident in everyday clinical practice from uncertainties about visible or sometimes invisible changes to the tongue (eg, burning tongue) that occasionally crop up. The aim of this book is to shed light on the tongue from the perspective of current academic literature. It was written by several authors with experience in the diagnosis and treatment of changes to the tongue. This volume is not designed as a textbook but as an illustrated atlas and reference work that aims to give all the relevant professional groups greater certainty when diagnosing and treating tongue changes. A further aim is to communicate the latest knowledge to students of dentistry and medicine for the benefit of their eventual patients.

The first four chapters deal with the importance of the tongue in dentistry, the anatomy and morphology of the tongue, the normal variations of the tongue, and diagnosis of changes to the tongue. In the fifth chapter, numerous possible changes to the tongue are presented in the form of brief, standardized, easy-to-read tables containing the most important information and illustrated with a number of clinical photographs. Treatment is first summarized in the tables and then described in more detail in chapter 6. Of course, there are different schools of thought and approaches, especially in the treatment of oral pathologic changes.

Many tongue lesions or changes appear in several chapters either because there are smooth transitions between normal variations and pathology or because individual diseases involve increased diagnostic and therapeutic efforts and complexity. The literature citations in all chapters have generally been kept to a minimum.

Acknowledgments

We express our special thanks to everyone involved in producing this book: our coauthors Michael M. Bornstein, Jörg Halter, Peter Itin, Sebastian Kühl, J. Thomas Lambrecht, Inga Mollen, Ralf J. Radlanski, Adrian Ramseier, Andrea Maria Schmidt-Westhausen, Richard Steffen, Valérie G. A. Suter, Branka Tomljenovic, Astrid Truschnegg, Tuomas Waltimo and Brigitte Zimmerli, Nicolas Lienert and Nicola Feola (as ever, for the excellent cover illustration), Inga Mollen for her outstanding commitment to the compilation of this book, Christoph Langerweder, Chantal Pfammatter, Fabio Saccardin, Silvio Schütz, Caroline Signorelli-Moret, Angela Stillhard, Paco Weiss, Christian Zedler, Melanie Zimmerli, and Marco Züger for providing their photographs, Anita Hattenbach from Quintessenz-Verlag for her kind and highly professional editing work, Johannes Wolters from Quintessenz-Verlag for years of trusting and always pleasant cooperation (even though we rather exceeded the deadline this time), and last but not least our families, without whose patience it would not have been possible to produce this book alongside all our professional commitments.

CONTRIBUTORS

Michael M. Bornstein, Prof Dr med dent

Associate Professor

Department of Oral Surgery and Stomatology

Bern University

Bern, Switzerland

Clinical Professor

Oral and Maxillofacial Radiology Department

University of Hong Kong

Pokfulam, Hong Kong

Andreas Filippi, Prof Dr med dent

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry

University of Basel

Basel, Switzerland

Jörg Halter, Dr med

Assistant Professor

Department of Hematology

University Hospital Basel

Basel, Switzerland

Irène Hitz Lindenmüller, Dr med dent

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry

University of Basel

Basel, Switzerland

Peter Itin, Prof Dr Med

Professor and Chair

Department of Dermatology

University Hospital Basel

Basel, Switzerland

Sebastian Kühl, Prof Dr med dent

Assistant Professor

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry

University of Basel

Basel, Switzerland

J. Thomas Lambrecht, Dr med, Prof Dr med dent

Professor and Chairman

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry

University of Basel

Basel, Switzerland

Inga Mollen, Dr med dent

Center of Dental Traumatology

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry

University of Basel

Basel, Switzerland

Ralf J. Radlanski, Dr med dent

Director

Department of Craniofacial Developmental Biology

Charité University Hospital Berlin

Berlin, Germany

Adrian Ramseier, Dr med, Dr med dent

Research Associate

Clinic for Preventive Dentistry and Oral Microbiology

University Center for Dentistry

University of Basel

Basel, Switzerland

Andrea Maria Schmidt-Westhausen, Dr med dent

Professor

Section of Oral Medicine, Dental Radiology, and Surgery

Charité University Hospital Berlin

Berlin, Germany

Richard Steffen, Dr med dent

Chief Physician

Department of Orthodontics and Pediatric Dentistry

Center for Dentistry

Zurich University

Zurich, Switzerland

Founder, Co-Owner, and Scientific Director

Medcem GmbH

Weinfelden, Switzerland

Valérie G. A. Suter, Dr med dent

Head of Dental Radiology and Stomatology

Department of Oral Surgery and Stomatology

Bern University

Bern, Switzerland

Branka Tomljenovic, Dr med dent

Department of Oral Surgery, Oral Radiology, and Oral Medicine

University Center for Dentistry Basel

Basel, Switzerland

Private Practice Brugg, Switzerland

Astrid Truschnegg, Dr med

Assistant Professor

Department of Dentistry and Oral Health

Medical University Graz

Graz, Austria

Tuomas Waltimo, Prof Dr odont

Head of Clinic for Preventive Dentistry and Oral Microbiology

University Center for Dentistry Basel

Basel, Switzerland

Brigitte Zimmerli, Dr med dent

Private Practice

Burgdorf, Switzerland

 1 

INTRODUCTION

Andreas Filippi

The tongue is by far the largest organ in the oral cavity. With its excellent innervation and mobility, it performs important functions for humans, such as touching, tasting, speaking, whistling, sucking, and cleaning the mouth. The tongue also fulfills an important role in mastication: It moves the food around in the mouth so that it can easily be chewed and lubricated with saliva. If one or more of these functions is restricted, quality of life is often greatly impaired. Many people suffering from advanced dysfunction or even complete loss of individual functions can also suffer from depression as a result. Articulation as well as the sense of touch and taste are so important to quality of life that patients who undergo radiotherapy to the head and neck area repeatedly report complaints. In addition to mucositis, they suffer severe impairment of their sense of taste (eg, things taste differently or blander than usual). In some cases, people develop aversions to particular foods and stop enjoying things that they used to like eating. Fortunately, these sensory disturbances usually go away after oncology treatment is finished.

The dorsal surface (ie, top) of the tongue is the only oral mucosa to have a microrough surface. This harbors more than half of all oral microorganisms, which live there in a highly organized biofilm that protects them against chemical and mechanical influences. Aerobes are more likely to be found on the surface and anaerobes in the depth of the tongue. The latter reside in the fissures of the strikingly rugged filiform papillae, which are only present on the dorsal surface of the tongue (Figs 1-1 and 1-2).

Fig 1-1 (a) The tongue surface is covered with filiform papillae. (b and c) As magnification increases, it becomes clear that the papillae are very rugged.

Fig 1-2 Difference between upper and lower surfaces of the tongue.

Treatment of the consequences of microbiologic diseases in the oral cavity (eg, caries, marginal periodontitis, apical periodontitis) is the most common type of work done in dental practices. Some causal microorganisms may reside on the teeth or in the sulcus or periodontal pockets, but a great many reside on the tongue. Even if great skill and effort is put into cleaning individual periodontal areas, this may not actually have a sustained impact on reinfection of the periodontium. Consider the current debate about the benefits of dental floss or the fact that the market introduces new toothbrushes each year that supposedly clean better than past toothbrushes. When it comes to caries prevention, clean teeth are only one consideration. In light of this growth of knowledge in prevention and therapy, modern medicine is fortunately focusing more and more on the largest site of oral microorganisms: the tongue. This is illustrated by examples such as full-mouth disinfection, modern halitosis treatment, and the idea of caries prevention by means of tongue cleaning. Furthermore, attempts are repeatedly being made to alter the oral biofilm (the largest of

which is located on the dorsal surface of the tongue) with the aid of probiotic medicines or probiotic foods to benefit oral health (Fig 1-3). There has been some success in relation to gut flora with certain changes or diseases, although attempts have not yet been successful in the oral cavity. However, in recent years there has been growing awareness of diagnostics of the tongue among dental practitioners and especially dental hygienists. This started with the extensive professional tongue diagnostics performed on halitosis patients, which is beyond the scope of this book but covered in other textbooks.³ Fundamentally, dentistry should not concentrate solely on the teeth. It is not without reason that universities in many countries have departments such as Oral Medicine, Oral Diagnostic Sciences, or Oral Health—a trend that should spread across the globe.

Fig 1-3 The largest oral biofilm is found on the tongue.

During a thorough dental examination, the borders, underside, and base of the tongue as well as the floor of the mouth should be inspected as a basic principle. If there are any visible or merely palpable changes, further diagnostic investigation should be discussed and—depending on the results—suitable treatment initiated. As well as visible and/or palpable changes, subjective complaints are playing a growing role in the aging population, who often require drug treatment in the general medical practice. The decrease in the saliva flow rate is a common problem that can lead to redness, inflammation, fungal infections, and a burning sensation of the tongue. This frequently demands an interdisciplinary approach to provide satisfactory help to patients whose quality of life is often impaired.

 2 

ANATOMY AND PHYSIOLOGY OF THE TONGUE

Ralf J. Radlanski

In its resting state when the mouth is closed, the tongue completely fills the oral cavity palatal to the rows of teeth (ie, the oral cavity proper). Because of its muscular core, the tongue is so variably mobile that the tip of the tongue is able to reach nearly every point in the mouth (Fig 2-1).¹ Only a shortened lingual frenulum (ie, ankyloglossia) would limit this mobility.

Fig 2-1 The tongue in lateral view (a) and ventral view (b). (Reprinted with permission from Radlanski.¹)

PARTS OF THE TONGUE

The median sulcus (ie, midline groove) divides the left and right half of the body of the tongue in the sagittal direction. The terminal sulcus runs in the transverse direction as a slightly V-shaped line (Fig 2-2) and divides the tongue into two parts. One part is the root or base, which lies in the pharynx. The second part comprises the body and tip, which lie within the oral cavity (Fig 2-3). The root accounts for roughly one-third of tongue volume, while the two anterior parts make up two thirds. The circumvallate papillae are on the body of the tongue, and the foramen cecum is located dorsally to the terminal sulcus (ie, on the root of the tongue).²–⁴

Fig 2-2 Macroscopic anatomy of the tongue in schematic diagram, cranial view.

Fig 2-3 Schematic diagram of the tongue in sagittal section.

DEVELOPMENT OF THE TONGUE

The pharyngeal arches have a major influence on the development of the face, including the tongue. The apex and body of the tongue develop from the first pharyngeal arch, and the root of the tongue develops from the third and fourth pharyngeal arches. The foramen cecum marks the endpoint of the thyroglossal duct and is evidence of the descent of the thyroid gland during the embryonic period of development.⁵

INTERNAL STRUCTURE OF THE TONGUE

The body of the tongue is permeated by intrinsic muscles that run in the sagittal, transverse, and vertical directions, partly interwoven with each other (Figs 2-4 to 2-6). The superior longitudinal muscle, the inferior longitudinal muscle, the genioglossus, and the geniohyoid muscles run sagittally; the transverse muscle runs transversally; and the vertical muscle runs vertically. Fasciae running in these directions appropriately compartmentalize the muscles. The lingual septum runs sagittally-vertically in the middle, and the lingual aponeurosis covers the dorsum of the tongue.³,⁴

Fig 2-4 Schematic diagram of the tongue in frontal section.

Fig 2-5 (a) Sagittal section through the tongue. Hematoxylin-eosin stain. (b) Tongue musculature cut longitudinally and transversally. (Reprinted with permission from Radlanski.¹)

Fig 2-6 Sagittal section through the floor of the mouth region of the tongue and its intrinsic musculature. The epithelium on the underside of the tongue is free of papillae, smooth and thin, like the epithelium on the floor of the mouth. In the submucosa of the floor of the mouth, the sublingual gland and the excretory duct of the submandibular gland are cut. Hematoxylin-eosin stain. (Reprinted with permission from Radlanski.¹)

The genioglossus, hyoglossus, palatoglossus, and styloglossus muscles radiate from outside into the tongue. Mediated by insertions of individual muscles onto the hyoid bone, these muscles afford support for tongue mobility. The lingual aponeurosis lies under the mucosa of the dorsum of the tongue (see Fig 2-3). The individual deforming movements of the body of the tongue that come from its intrinsic musculature are transmitted to the mucosa by the lingual aponeurosis.

LINGUAL MUCOSA

The epithelium on the dorsum of the tongue is keratinized. Underneath it is a relatively tough lamina propria that is rich in nerves and vessels. The