Differential diagnosis of tongue lesions
Daniel M. Laskin, DDS, MSVJames A. Giglio, DDS, MEd^/Eric T. Rippert,
This article reviews the clinical characteristics ot the numerous iocai and systemic conditions that fre-
quently involve ttie tongue and presents ciassitications based on their appearance and common iocations
ttiat can aid dentists in their eariy recognition and clinicai diagnosis. (Quintessence int 2003;34-331-342)
Key words: congenital tongue lesions, lingual cysts, systemic linguai conditions, tongue infections, tongue
lesions, traumatic tongue lesions, tumors of ttie tongue
he tongue is not only the site of a variety of iocai
T lesions, but it also refieets tbe presence of a num-
ber of systemie diseases. Because tbe dentist will most
often be tbe first to observe tbese conditions, it is es-
sential tbat he or she be familiar with their diagnosis.
This is particuiariy important because some of these
conditions can have serious consequences, and the
prognosis is greatly improved by early recognition and
treatment. This article is designed to belp the clinician
make a correct and early diagnosis of the more com-
mon forms of lingual pathology and to distinguish
these iesions from some of the congenital and devei-
opmental disorders that can also involve this organ.
Although it is recognized that there may be cbanges in
the tongue associated witb a number of conditions not
included in the present article, this discussion focuses
mainly on those tongue lesions that are either the oniy
site of the pathology or in which they piay an impor-
tant diagnostic role.
'Professor and Chairrran Emeritus. Department ot Oral and Maxillofacial
Surgery, Virginia Commonwealth University, School ot Dentistry,
Richmond, Virginia.
^Prolessoi, Department ot Oral and Maxillofacial Surgery, Virginia
Commonwealth Llniversily, School of Dentistry, Rielimord, Virginia
¥ormeily. Associate Professor, Department of Oral and Maxrilofaciai
Surgery, Virginia Commonwealth University, School cf Dentistry,
Richmond. Virginia; currently. Associate Professer. Department ol Oral
and Maxillotactal Surgery, School cf Dentistry. Medical College oí Georgia.
Augusta, Georgia.
Reprint requests: Dr Daniel ful. Laskin, Department of Oral and Maxil-
lofacial Surgery, Virginia Commonwealth University, Scheel of Dentistry.
Box 980566, Richmcnd, VA 23298-0566. E-mail: DMLASKIN®
VCU.EDU
Quintessence International
Though there have been various classifications of
tongue lesions proposed,'"' tbe fact that the etiology of
certain conditions remains a mystery makes it impos-
sible to deveiop a uniform system. From a clinicai
standpoint, it Is best to begin the differential diagnosis
by determining whether the condition is localized or
part of a generalized systemic disease. Most local le-
sions can then be categorized as congenital or devel-
opmentai, traumatic, infectious, neoplastie, or idio-
pathie, and oral lesions of systemic origin can be
divided into tbose that are related to infections, biood
dyscrasias, metabolic diseases, and immunologie dis-
orders. Use of sucb a classification is helpful because it
aids the clinician in ordering the diagnostic process,
forming an initial impression based on the clinical
findings, and determining what additional tests may be
necessary before deciding on the definitive therapy.^
LOCALIZED LINGUAL CONDITIONS
Congenital and developmental problems
Fissured tongue. Fissured tongue, also referred to as
"scrotai tongue" or "plicated tongue," is a develop-
mental condition of unknown etiology affecting the
tongue's dorsal surface. It is found in approximately
5% of tbe general population but is also a cbaracteris-
tic of Down's syndrome and Meikersson-Rosentbal
syndrome. The multiple fissures generally brancb off a
eentral groove in tbe midline of tbe tongue. The con-
dition is not painful unless the furrows are deep and
become irritated and inflamed from food debris
trapped in tbe crevices (Fig 1}. Use of a soft-bristled
331
 La skin et al
Fig 1 Patient with a deeply tisaured Fig 2 Lingual thyrmd This is sometimes
tongye. The gtooves can trap lood particles the oniy thyroid tissue present.
and become secondariiy inlected.
toothbrush and commercially available effervescent
mouthwashes or diluted hydrogen peroxide rinses^ will
improve oral hygiene and minimize the inflammation.
Lingual thyroid. The thyroid gland originates as a
midline endothelial outgrowth at the junction of the
dorsal anterior two thirds and the base of the tongue
in the region of the future foramen caecum. From
there, the thyroid tissue normally descends through
the tongue and cervical tissues to reach its final posi-
tion in the region of the larynx. However, when this
migration fails, persistent thyroid tissue may he found
in the tongue (Fig 2), It generally appears as a firm,
midline mass in the region of the foramen caecum.
Symptoms, when present, include dysphagia, difficulty
with speech, and a feehng of fullness in the throat.
Because this may be the only thyroid tissue present,
biopsy is not recommended. Instead, a radioactive io-
dine uptake scan can be used to establish the diagno-
sis and to determine if additional thyroid tissue is
present.' Unless there are symptoms, no treatment is
necessary. However, if the mass is causing functional
impairment, partial or total excision and thyroid hor-
mone supplementation may be necessary,
Thyroglossal duct cyst. Embryologically, as the
thyroid gland decends from the base of the tongue to
its cervical location, it brings with it a tract of epithe-
lial tissue (thyroglossal duct) that normally involutes
by the 10th week of gestation. However, remnants may
remain, giving rise to cyst formation in the base of the
tongue. The lesions are generally asymptomatic unless
they become very large or are secondarily infected,
Dermoid cyst. Entrapment of epithelium during de-
velopment of the tongue can give rise to subsequent
cyst formation. The lesion is usually located in the
body of the tongue more anterior than the thyroglossal
duct cyst, but it may otherwise be indistinguishable ex-
cept on histologie examination. More commonly, der-
332
Fig 3 Large lymphangioma of the tongue
with a pap i i Ic m ato us appearance.
mal cysts originate in the anterior floor of the mouth,
but their proximity to the tongue may make it difficult
to distinguish the exaet location.
Lymphangioma. Lymphangiomas commonly arise
from a proliferation of lymphatic vessels and appear at
birth. They are therefore actually a hamartoma or vas-
cular malformation rather than a neoplasm. The su-
perficial lesions are papillomatous in nature and may
have a relatively normal mucosal covering or a red-
dish to purpie hue (Fig 3}, The deeper iesions are dif-
fuse and appear as grapelike structures covered by
normal colored mucosa," Unless the lesion is causing
functional problems, no treatment is necessary.
Hemangioma. The hemangioma can be classified
into two types: the congenital hemangioma, which is a
common vascular tumor of infancy that gradually invo-
lutes during adolescence, and the vascular malforma-
tion, which also is present at birth but never regresses,'
The latter is the type that occurs in the tongue.
The lingual vascular malformation appears as a dis-
tinctly reddish, purplish, or bluish lesion that blanches
when compressed. The iatter characteristic is useful in
distinguishing it from pigmented nonvascular lesions.
It has an elevated, sessile appearance, and the overly-
ing mucosa is smooth and hypervascular in some
areas and pebbly in others,^'
Small lesions may require no treatment, but those
causing functional problems, or that are at risk of in-
jury and causing profuse bleeding, require surgical
management.
Median rhomboid glossitis. This lesion, located in
the midline of the posterior dorsum, was originally
considered to be a developmental condition resulting
from the tuberculum impar failing to retract and then
becoming trapped by fusion of the two lateral halves of
the developing tongue. Currently, however, it is consid-
ered by many authors to be either a primary, localized
Volume 34, Numbet 5, 2003

Fig 4 (iefi) Midiine dorsai iesion ol the
tongue showing the characteristics cl me-
dian rhomboid glossitis.
Fig 5 (rigiit) Traumatic uicer cl the pos-
te roíate ral aspect of the tongue resembiing
a squamous ceii carcincma. Note the sharp
edges cn Ihe adjacent teeth.
form of cartdidiasis, or that Candida albicans is a sec-
ondary invader'" {see page 334), Ciinicaiiy, the lesion is
characterized as a smooth or granular, red, flat, slightly
elevated or lobulated area located just anterior to the
foramen caecutn (Fig 4), When candidiasis is sus-
pected, it should be treated with one of the antifungal
agents.
Traumatic iesions
Traumatic ulcer. Because of its iocation, the tongue is
a frequent site of acute trauma. The diagnosis of such
an injury can usually be made on the basis of patient
history. However, there are often instances of irrita-
tion of the lateral borders of the tongue from sharp
areas on teeth or restorations that can cause chronic
ulcers, hut the patient is unaware of these causes. In
such cases, the lesion may resemble a neoplasm, and
an early differential diagnosis is essential (Fig 5), If a
local source of irritation can be identified and re-
moved, the lesion can be observed for a week to see if
healing occurs. If healing does not take place follow-
ing removal of any irritation, a biopsy is indicated to
establish the diagnosis,
Pyogenic granuloma. Although traumatic uicers
can occur on the dorsum of the tongue as well as the
margins, in some cases of dorsal trauma there appears
to be a hyper-response, and a pyogenic granuloma
forms. The lesion may be sessile or pedunculated, and
the surface characteristics can vary from smooth to ir-
regular and lobulated. Often there is central ulcéra-
tion. The lesion is usually painless, but it tends to
bleed easily. Treatment consists of surgical excision.
Focal fibrous hyperpiasia (fibroma, irritation fi-
broma, traumatic fibroma). This lesion frequently de-
velops in regions of tbe tongue susceptible to trauma,
such as the anterior and lateral dorsal surfaces. It is
Laskin et ai
raised, often pedunculated, smooth, nonpainful, and
usually has an apparent etiology. Patients should be
questioned concerning habits such as rubbing the
tongue against sharp or irregular surfaces on the den-
tition,^ The lesion often appears similar to other more
serious iesions, so biopsy is indicated to confirm the
clinical diagnosis.
Neuroma (traumatic neuroma). This lesion repre-
sents a reactive hyperpiasia caused by injury to a
nerve rather than a true neoplasm, it is most often lo-
cated on the dorsal surface, where it appears as a cir-
cumscribed, sessile nodule covered by a smooth, pink
mucosa. Usually, the patient will relate a history of in-
jury to the area. In contrast to the true neurogenic tu-
mors (neurilemmoma, neurofibroma), manipulation of
a traumatic neuroma will often result in pain at the
site or in the region innervated by the involved nerve,-
Treatment consists of surgical excision,
Muccus extravasation cyst. These pseudocysts re-
sult from injury to an excretory duct of a minor salivary
gland leading to the accumulation of mucous in the ad-
jacent connective tissue. In the tongue, they are usually
associated witb the glands of Blandin and Nuhn and
are located on the ventral surface near the tip,"
INFECTIONS
Herpes simplex infection. Primary herpetic gingivo-
stomatitis is typically a childhood disease character-
ized by the formation of vesicles that rupture and form
generalized, small, shallow, punctate, yellowish ulcers
with an erythematous halo located on the oral mucosa
and tongue. However, adults can also be affected. In
more severe forms of the disease, the lesions coalesce
to form ulcers that may appear similar to major aph-
thous ulcers. However, in contrast to aphthous ulcers.
333
 Laskin et ai
a primary herpetic outbreak is usually accompanied by
fever, malaise, and lymphadenopathy. When the dis-
ease deveiops in immunocompromised patients, the
lesions are deeper and are present longer than in
heaithy patients.'
Recurrent (secondary) herpes develops in adults
with a history of primary herpes simplex infection due
to reactivation of the virus. It often occurs after dental
treatment or injeetion of a locai anesthetic. Aithough
these lesions are most often found on the lip, palate,
and attached gingiva, the lateral border of the tongue
can also be affeeted.'
Treatment of herpes simplex infections involves a
soft, bland diet, adequate fluid intake, an antipyretic
analgésie for pain, and chiorhexidine mouthrinses.
Antiviral agents, such as acyclovir, vidarabine, or idox-
uridine ean he used in severe eases to speed up the
healing, but they are not curative.
Aphthous ulcers (recurrent aphthous stomatitis,
canker sores). Although the etioiogy of the aphthous
ulcer is unknown, it is important to consider it along
with the inflammatory lesions of the tongue heeause of
its resemblance to the lesions caused by the herpes
simplex infection. The aphthous ulcer can be divided
into minor and major forms. Minor aphthous ulcers
most commonly develop on unattached mucosal sur-
faces. Those that form on the tongue often appear on
the ventral and lateral surfaces. They ehnically present
as shaliow, whitish-yeiiow-based craters surrounded
by an erythematous border. The lesions are dispropor-
tionately painful to their size. They appear as multiple
or single lesions usually iess than 10 mm in diameter.
Each lesion lasts approximately 10 to 14 days and
heals without scar formation. Major aphthous ulcers
range from 5 to 20 mm or more in size, occur in fewer
numbers than aphthous minor ulcers, and are most
often located on the labial/bueeai tnucosa and soft
palate/anterior tonsillar pillars, but also may develop
on the dorsum of the tongue (Fig 6). Aphthous ulcers,
along with oeular ulcérations and anogenital aphthous
334
Fig 6 (ieft) Patient with two iarge aphthous
ulcers on the iaterai borders of the tongue.
Fig 7 (right) Patient with inflamed folliate
papulae (arrow) causing pain in the posfero-
iaterai aspect of tne tongue.
minorlike lesions, form a triad of clinical signs that are
usually diagnostic of Behcet's syndrome. Other cotn-
ponents of this syndrome are arthralgia, phlebitis, skin
lesions, and central nervous system involvetnent.'''*'^
Aphthous minor ulcers usually respond to palliative
treatment in the form of topical anesthetics, topicai
steroids, cautery, or tetracyeline or chiorhexidine
rinses. Aphthous major ulcers or patients with Behcet's
syndrome usually require systemic steroids in additioti
lo the palliative measures,
Folliate papillitis. Folliate papulae are a series of
ridges or lobular, rounded projections located on the
posterolateral aspect of the tongue. The core of these
papillae consists of lymphoid tissue that has been re-
ferred to as the lingual tonsil. This tissue, plus the
paired palatine tonsils and the pharyngeal tonsil (ade-
noids), form the triad of oropharyngeal lymphoid tis-
sue known as Waldeyer's ring. Because of their appear-
ance and location, the folliate papillae are sotrtetimes
mistaken for a malignancy by the patient. The fact that
they are biiateral and have a similar appearance on
both sides helps to rule out this possihihty.
The folliate papillae may sometimes become enlarged
as part of a regionai lymphoid tissue reaction to an upper
respiratory infection, or due to mechanical irritation, and
hccome slightly painful and tender. This has been termed
faliiate papillitis (Fig 7). The condition requires no treat-
ment other than use of a chiorhexidine mouthrinse, re-
moval of any irritating factors, and reassurance to the
patient that the lesion is not a malignancy,
Candidiasis (moniliasis, thrush). Candida alU-
cans is a normal component of the oral flora.
However, it is an opportunistic organism that can in-
vade the oral tissues when there is a change in the en-
vironment brought about by uncontrolled diabetes,
poor orai hygietie, chronic irritation, or the prolonged
use of broad spectrurn antibiotics: immunosuppression
resuiting from chemotherapy, long-term use of
steroids, or infection with the autoimmune deficiency
syndrome (AIDS) virus^^
Voiume 34, Number 5, 2003

Oral manifestations of candidiasis can be classified
as acute or cbronic. Acute candidiasis can take a
pseudomembranous or erytbematous form, Tbe acute
pseudomembranous form (tbrusb) is usually seen in
infants and young cbildren and appears as creamy,
white patches resembling milk curds located on the
dorsum of tbe tongue, as well as the huccal mucosa,
Tbe lesions, whicb consist of a tangled mass of fungal
hyphae, can be scraped off leaving a raw, bleeding sur-
face. The acute erytbematous form is usually seen in
adults. It consists of varying-sized, painful, red, at-
rophie areas on tbe dorsum of tbe tongue and palate,
Cbronic candidiasis disease is most commonly seen
on the palate of elderly edentulous patients who wear
a maxillary denture, appearing as a bright red lesion
with a velvety or pebbly surface (cbronic atropbic can-
didiasis, denture sore moutb). However, a cbronic by-
perplastic form can occur on the tongue, appearing as
persistent, firm, wbite plaques (candidal leukoplakia)
located anywhere on the tongue or as a loealized le-
sion in tbe midline of the posterior dorsum referred to
as median rhomboid glossitis (see page 332),
The management of oral candidiasis consists of
treating the predisposing cause and using antifungal
drugs sticb as nystatin, ampbotericin, ketoconazole, or
fluconazole.
Benign tumors
Benign tumors of epitbelium, connective tissue, muscle,
and nerve can all occur in the tongue. Thus, one will
see papillomas, lipomas, rhabdomyomas, leiomyomas,
neuril em momas, and neurofibromas. Many of these le-
sions sbare similar clinical characteristics and can only
be distinguished from eacb other and from occasional,
more serious conditions by excisional biopsy.
Papilloma. Papillomas may have a pebblelike,
warty surface or consist of hyperkeratotic fingerlike
projections, Tbey can be eitber sessile or pedunculated
and bave a pink to white color, depending on the de-
gree of epithelial keratinization.
Lipoma. Lipomas are generally located on the bor-
ders of tbe tongue. They are soft, sessile iesions that
bave a yellowish color,
Rhabdomyoma. Although the tongue is a muscular
organ, benign muscle tumors are extremely rare in this
region. When present, they appear as an asymptomatic
submucosal mass witb no distinguishing clinical char-
acteristics,
Leiomyoma. This benign neoplasm can occasion-
ally occur on the tongue, where it originates from the
smooth muscle in the walls of blood vessels or the cir-
cumvalate papulae. They usually present as small, sin-
gle or multiple, circumscribed lesions that may be in-
distinguishable from an irritation fibroma.
• Irffirnatianal
Lasiíin et al
Fig 8 Large, firm, yeilow, suomucosai
mass in the iaterai aspect of (he tongue di-
agnosed on biopsy as a granuiar celi tumor.
Neurilemmoma (Schwannoma). This circum-
scribed, slow-growing lesion, wbicb arises from the
Scbwann cells surrounding peripberal nerves, usually
appears as a firm, submucosal mass iocated anywhere
on the tongue. Although generally painless, tbis lesion
may he painful,
Neurofibroma. Altbougb the neurofibroma may be
a solitary lesion, more often it is part of the neuro-
fibromatosis of von Recklinghausen's disease, Tbe
tongue may sbow multiple nodules or tbere may be a
more diffuse involvement causing unilateral macro-
glossia. Single neurofibromas can be surgically re-
moved. However, this may not be possible in patients
witb neurofihromatosis. In such cases, surgical inter-
vention is only indicated when tbere is functional im-
pairment. Patients with von Recklingbausen's disease
need to be observed at regular intervals because of the
risk of malignant transformation of these lesions,'
Granular cell tumor (granuiar ceil myoblastoma).
This lesion, which was at one time thought to he of
muscle origin, is now considered to be of neurogenic
origin,'^ Although it can occur in other regions of the
body, most of the lesions are located in the tongue,
where they appear as painless, firm, submucosal nod-
ules with a yellowish or pinkish color (Fig 8), Treat-
ment consists of conservative surgical removal, and re-
currence is rare.
Malignant tumors
About one tbird of oral malignancies occur in fbe
tongue, Aithough most of these tumors are squamous
cell carcinomas, malignant minor sahvary gland tu-
mors, sarcomas, and metastatic lesions may also be
seen. Because of the seriousness of these tumors, early
diagnosis is important.
335
• Laskin et ai

Fig 9 Lriigr; i,lci";ínlr;r: r,r|L..n,TiDi.í; er
cinomn of the tongue
Fig 10 Meiastatic bronctiogenic carci-
noma of the tip oí tiie tongue. Ttiis is an un-
usuai location, witii most metastatic lesions
being located in the base of the tongue.
Fig 11 Benign migratory glossitis. The
condition is often referred to as geographic
tongue because the pattern resembies a
map The pattern changes as areas of
desquamation heal and new areas deveiop.

Squamous cell carcinotna. Oral carcinomas com-
prise approximately 5% of ali malignaneies and 80%
to QO^/n of ali malignant oral tumors.'* The tongue is a
common site for such lesions. Heavy use of alcohol
and tobacco are recognized as major comorbidity fac-
tors for this disease.
Squamous cell carcinoma presents as a surface le-
sion on the tongue with a predilection for the lateral
borders, particularly on tbe middle and posterior seg-
ments (Fig 9). Tbe lesion is often initially painless and
usually has an ulcerated appearance with rolled bor-
ders around a neerotie center. It frequently resembles
a traumatic ulcer. If a possible traumatic etiology is
suspected, ie, sbarp cusp or fractured restoration, tbis
sbouid be treated first. If tbe lesion does not show
signs of bealing within 1 week, a biopsy sbouid be per-
formed.
Malignant salivary gland tumors. Tbe location of
tbese tumors is determined by tbe anatomic location
of salivary gland tissue in the tongue. Tbus, tbe most
common sites are in tbe glands of Biandin and Nubn
in tbe ventral tip of tbe tongue and in the posterior
part of the dorsum and base of the tongue. The lesions
begin as slow-growing, asymptomatie, submueosal
masses, but may ulcerate in tbe later stages. Although
the lesions can be bistologically classified as mucoepi-
demoid tumors, acinic cell tumors, and adenocarcino-
mas, they cannot be distinguished elinieally.
Sarcoma. Sarcomas of the tongue are extremely
rare, with only sporatic cases of fibrosarcoma,'' be-
mangiopericytoma,'*' alveolar soft-part sarcoma," h-
posarcoma,"' rbabdomyosarcoma," leiomyosarcomaj^"
synovial sarcoma,^' cbondrosarcoma,^^ and neuro-
genic sarcoma" being reported. Because of tbe paucity
of such eases, there are no distinguishing characteris-
tics that have been described, and the definitive diag-
nosis is made from the biopsy.
A previously rare oral sarcoma that is now being
seen more frequently is Kaposi's sarcoma, a malignant
neoplasm of the retieulocndothelial system. Occurring
mainiy in immunocompromised patients, it is now as-
sociated mainly witb patients baving AIDS.'^' The le-
sions begin as painless reddish or bluisb macules tbat
then coalesce to form purplish nodules, which ulti-
mately become ulcerated. Altbougb most commonly
seen on tbe palate, lesions may also occur on tbe
tongue. A biopsy is indicated when tbe diagnosis is
not obvious and a human immunodeficiency virus
(HIV) test is confirmatory.
Metastatic tumors. Metastatic lesions to tbe tongue
bave been reported from primary malignancies in the
kidney, stomach, breast, thyroid, and lungs.^^ However,
the oral lesions are rarely the first evidence of
metastatic disease.
Most lingual métastases are located in the base of
the tongue, altbough a few eases involving tbe tip bave
also been reported {Fig 10).=^ Lesions in tbe base of
the tongue may produce pain and, when large, can
cause dysphagia. Because of their location and late
onset, most lingual métastases are treated palliatively.
Idiopathic lesions
Hairy tongue. This condition is characterized by a lack
of normal papillary desquamation resulting in hyper-
trophy of the filiform papillae, wbich gives the dorsum
of the tongue a hairy appearatiee. The color will vary
from yellowish-white to brown or black depending on
the extrinsic staining. Among the contributing factors
are tobacco; certain foods, beverages, and medieations-

336 Volume 34. Number 5,

and various chromogenic organisms. It may also occur
as the result of xerostomia in patients who have under-
gone radiation therapy. The condition is treated by
brushing the tongue, proper oral hygiene, and elimina-
tion of any identifiable contributing factors.
Benign migratory glossitis (geographic tongue,
erythema migrans). The etiology of this condition re-
mains unknown, although a relationship to emotional
stress or an atopic form of allergy has been proposed,"
The lesions appear as one or more irregularly shaped,
reddish areas of depapillation surrounded by a nar-
row, whitish zone of regenerating papillae. As the
papillae reform and the area heals, new lesions de-
velop in other sites (Fig 11), The condition is generaiiy
painless and requires no treatment other than assuring
the patient that it is not a malignancy.
LINGUAL CHANGES ASSOCIATED
WITH SYSTEMIC DISEASES
The tongue can be involved in a variety of systemic
diseases and thus has often been referred to as a mir-
ror of one's general health. These conditions can be
divided into systemic infections, blood dyscrasias,
metabolic disorders, and immunoiogic disorders.
Systemic infections
Syphilis. With the recent increase In the incidence of
venereal disease, dentists need to have greater aware-
ness of the oral manifestations of syphilis. The tongue
can be involved in any of the three stages of this dis-
ease. Half of the extragenital chancres, the primary
stage of syphilis, are located in the oral mucosa, and
the tongue is among the common sites. The lingual
chancre is a solitary, painless, slightly raised, well-de-
marcated ulcer associated with the presence of en-
larged, painless, regional lymph nodes. A smear of the
lesion examined by dark-field illumination will reveal
the causative organism, the spirochete Treponema pal-
lidum. However, the sérologie examination does not
become positive until 4 to 5 weeks after the initial in-
fection. The lesion generally heals spontaneously
within 3 to 12 weeks.
Second stage lesions develop from 6 weeks to 6
months after the primary infection, and can present
with involvement of both tbe skin and mucous mem-
branes. However, they may be limited only to the oral
cavity, making the diagnosis more difficult The mu-
cous patches are slightly raised, grayish-white, and
usually surrounded by a red halo. If the lesion is
scraped, it leaves a raw, bleeding surface. The mucous
patch is highly contagious because of the high spiro-
chete content.
Quintessence International
Because of the effective treatment for syphilis, ter-
tiary stage lesions are quite rare. Lesions involving the
tongue can be single or multiple. The gumma appears
as a painless, elastic mass that subsequently undergoes
central necrosis and ulcération. The tongue may also
undergo chronic interstitial changes characterized by
atrophy of the papillae and a bald appearance. This
so-called syphilitic glossitis is also frequently associ-
ated with leukopiakia, which has a tendency to un-
dergo malignant transformation (Fig 12).
Tuberculosis. Because the oral mucosa of persons
with pulmonary tuberculosis is constantly bathed with
sputum containing tubercle bacilli, there may be sec-
ondary lesions in the oral cavity. Although rare, pri-
mary lesions have also been reported.'" The most com-
mon site of oral tuberculosis is the dorsum of the
tongue. The tuberculous ulcer is usually painful, has
an irregular outline and undulated borders, and is cov-
ered with a yellowish-gray, fibrinous layer (Fig 13).
The diagnosis is generally confirmed by culture and
biopsy.
Acquired immunodeficiency syndrome (AIDS).
The lingual manifestafions of AIDS inciude herpes in-
fections (see page 333), candidiasis (see page 334),
aphthous ulcers (see page 334), Kapasi's sarcoma (see
page 336), and hairy leukoplakia. Hairy leukoplal<ia
represents an opportunistic infection caused by the
Epstein-Barr virus. Although it occurs mainly In pa-
fients with AIDS, it has been reported in persons with
other forms of immunosuppression.'' The lesions pre-
sent as well-demarcated, unilateral or bilateral, corru-
gated, white areas on the lateral borders of the tongue
(Fig 14). They are asymptomatic uniess secondarily in-
fected with Candida albicaus. The presence of these
lesions has been associated with a depletion of the pe-
ripheral CD4 cells and is considered a prognosticator
of the development of the more serious clinical mani-
festafions of AIDS.^^
Scarlet fever (scarlatina). This condition occurs
predominately in children, and is caused by a group A
streptococcal infection. It is characterized by fever,
malaise, headache, pharyngitis, and regional lym-
phadenopathy, as well as a red skin rash. The most
common oral manifestations invoive the tongue, which
initially has a heavy gray-white coating and shows en-
largement of the fungiform papillae, which appear as
multiple red dots (strawberry tongue). Later, the coat-
ing is lost, giving the tongue a bee^ red appearance.
Blood dyscrasias
Anemia. Lingual changes are the most common oral
manifestations of iron deficiency anemia, which pre-
dominately aftects women. The tongue becomes red,
painful, and smooth (Fig 15). The atrophie changes in
337
• Laskin et ai
Fig 12 Patient with tertiary syphilis si^ow- Fig 13 Tuberculous ulcer of the Icngue.
ing atrophy o( Ihe tcngue papiliae and sec- Rather than having firm, raised margins like
ondary leukoplakia characteristic ol a squamojs ceii carcinoma (see Fig 9), the
syphiiitic glossitis. tuberculous uicer is flat and less firm.
the papillae usually begin on the tip and lateral bor-
ders, and then involve the remainder of the dorsum.
Angular cheilitis is a commonly associated finding.
The anemic patient often complains of weakness and
dyspnea on exertion, and the skin tends to he pale.
Oral complaints of pernicious (vitamin B-12 defi-
ciency) anemia also involve mainly the tongue, which
becomes a fiery red because of papillary atrophy.
However, rather than being smooth, as in iron defi-
ciency anemia, the tongue often has a lobulated ap-
pearance (Fig 16), Pain and a burning sensation gener-
ally are present early, and there may also be a
disturbance in taste. The skin may have a yellow tinge,
Plummer-Vinson syndrome, also known as
sideropenic dysphagia, is a hypochromic, microcytic
form of anemia. It is characterized mainly by difficulty
in swallowing, but there is also atrophy of the papillae
in SO^/o to 70% of the cases, giving rise to a painful, red
or pale tongue, Fissuring of the tongue may also be
present, as well as lingual leukoplakia, which is con-
sidered a precancerous lesion in these patients.
Leukemia. Patients with a chronic form of
leukemia, which usually occurs in adults, may show
few clinical oral signs and symptoms in the early
stages of the disease. In the later stages, superficial ul-
cérations of the tongue as well as the oral mucosa are
seen, and areas of ecchymosis may also be present.
Patients with acute forms of leukemia have more
frequent oral manifestations than those with chronic
leukemia. Because the tongue is often exposed to
trauma, it is prone to develop ulcérations from even
minor types of injury due to the altered body defense
mechanisms, Leukemic ceil infiltrations may also be
present in the tongue of these patients, causing an ir-
regular enlargement.
338
Fig 14 Hsiry ieukupiakia in a patient with
AiDS.
Metaboiic diseases
Diabetes mellitus. In the diabetic with orai manifesta-
tions, the presence of changes in the tongue is second
only to periodontai disease, A feeling of burning and
dryness are the earliest lingual symptoms. Central lin-
gua! papillary atrophy may occur and almost half of
all uncontrolled diabetic patients will show evidence
of candidiasis (see page 334),
Hypothyroidism. Patients with hypothyroidism not
only can have dry mouth, but there may also be
macroglossia caused by infiltration of the tongue with
mucoproteins and mucopolysaccharides (myxedema).
The enlargement of the tongue can sometimes cause
difficulties in eating and speaking, and may even lead
to protrusion is some patients.
Acromegaly. Macroglossia occurs in about 50% of
persons with acromegaly due to an increase in the size
of the muscle fibers, as well as byperplasia of the ep-
ithelium and connective tissue. When the tongue is
greatly enlarged, it presses against the teeth causing
lingual indentations and spacing and labial tilting of
the teeth.
Vitamin B deficiency. Although deficiencies in six
of the 12 B-complex vitamins can be associated with
lingual changes, only niacin and folie acid deficiencies
are generally encountered clinically. The lingual
changes in niacin deficiency (pellegra) are among the
earliest manifestations noted. First, the tip and mar-
gins of the tongue become red and swollen. Then, in
the more advanced cases, tbe papillae are lost, and the
red color becomes even more intense. As swelling of
the tongue increases, indentations of the teeth may be
seen along the lateral margins. The signs and symp-
toms of folie acid deficiency are similar to tbose of
niacin deficiency except that neuroiogic symptoms do
Voiume 34, Number 5, 2003

Fig 15 Ttie painful, red, smooth tongue of Fig 16 Red, iobulated tongue in a patient
a patient with severe iron deficiency anemia, with pernicious anemia.
not occur. Thus, the tongue becomes fiery red,
swollen, and shows atrophy of both the filliform and
fungiform papillae.
Amyloidosis. Amyioidosis is characterized by the
accumulation of a fibriliar protein in various organs
and tissues. An enlarged tongue is one of the frequent
features of the disease. The resultant decrease in lin-
gual mobility due to infiltration with amyloid can give
rise to difficulty in chewing, swallowing, and spealiing.
In addition to the generalized induration, yellowish
nodules may be present along the lateral borders of
the tongue (Fig 17).
Immunoiogic disorders
Pemphigus. Manifestations of pemphigus are oñen
found in the oral cavity, with it being the initial site in
more than half the patients. The lesions on the tongue
generally take the form of bullae, which rupture soon
after formation to produce ulcers (pemphigus vui-
garis). Sometimes, fungoid vegetations develop on the
base of these ulcers. This has been termed pemphigus
vegetans.
Benign mucous membrane pemphigoid. This auto-
immune disease afleets primarily women over the age
of 50. About two thirds of these patients will initially
have oral manifestations. These involve the formation
of yellow or hemorrhagic bullae on an erythematous
background. Within a few days, the bullae rupture
leaving a fihrin-covered ulcération. Although the most
common locations for these lesions are the palate,
huccal mucosa, and gingiva, the tongue is also often
involved.
Erythema multiforme (Stevens-Johnson syn-
drome). Although in about 50% of the cases, the cause
of this disorder is an infectious disease (herpes sim-
Quintessenceinfernatlonai
• LasKin ef ai
Fig 17 Multipie yeilowistinoduies on the
iaterai borders ol the tongue characteristic
ot arnyioidosis.
Fig 18 Iviuitipie erosr ie n= e
tongue of a patient with erythema muiti
forme The tongue also has a heavy, white
coating resuiting from secondary candidia-
sis and the iack of epithelial desquamation
associated with poor masticatory function.
plex, coxsackie virus) or drug therapy, in other pa-
tients, no cause can be found. It occurs primarily in
young adults, especially men. The oral lesions are lo-
cated in all areas of the mouth, including the tongue.
They appear initially as a small, erythematous plaque
that then becomes a vesicle. These quickly rupture and
become confluent, shallow erosions covered by a
pseudomembrane of necrotic tissue (Fig 18). Although
these are generally associated skin lesions, the disease
may occur solely on the oral mueosa.
Lichen planus. Oral liehen planus may cause retic-
ular, erosive, atrophie, or plaquelike lesions. Early lin-
gual lichen planus usually appears as depapillated
areas with an irregular, whitish border located on the
dorsum. Because of the papillae on the tongue, the
reticular form does not aiways have the typical lacy
339
• Laskin étal

TABLE 1 Conditions commorily found in specific

form may be seen in conjunction with the reticular or
regions of the tongue erosive types and appears as smooth red patches witb
very fine white striae. The plaquelike lesions appear as
Dorsum (anterior, posterior, midline) raised white areas resembling leukoplakia, from which
Traumatic ulcers it can only be distinguisbed bistologically,
Lichen plan us
Altbough most cases of lieben planus represent a
-Candidiasis (median rhomboid glossitis)
Tuberculosis
systemic immunologie reaction mediated by T-lympho-
Scar i et teuer "strawberry tongue" cytes, lichen planuslike (lichenoid) lesions may occur
Second stage syphilis (mucous patches] that are drug induced (antihypertenslves, antidiabetics,
Tertiary stage syphilis (gumma) nonsteroidal anti-inflammatory agents, gold salts, ariti-
Geographic tongue (benign migratory giossitis) malarials), represent a reaction to amalgam or gold, or
Vitamin B deficiency develop as part of graft-versus-host disease, HIV infec-
Anemia tion, or bepatitis C virus infection. It is often difticult
Leukemia to distinguisb true lichen planus from tbe licbenoid le-
Diabetes mellitus sions on a clinical basis.
Pyogenic granuloma Asymptomatic lichen planus may require no treat-
Papule m a
ment once tbe diagnosis bas been confirmed by
Fibroma
Neuroma
biopsy. The erosive form, which can be very painful,
Ne jrofi broma may respond to topical corticosteroids. Recalcitrant le-
Neurolemmoma sions may be managed by intralesional steroid injec-
Leiomyoma tions. Good oral bygiene and stopping smoking also
Granular ceil tumor belp improve the symptoms. Systemic immunosup-
Salivary giand tumors (postenor) pressant agents bave been used for severe lieben
Fissured tongue planus unresponsive to otber forms of therapy. It is
Lingual thyroid (posterior midline) important to examine patients with erosive and at-
Lymphangioma rophie lichen planus on a regular basis because it bas
Hemandioma been suggested that these lesions may undergo malig-
Thyroglossal duct cyst (postenor midiine)
nant transformation,'°
Dermoid cysts
Median rfiomboid giossitis (candidiasis)
Licbenoid lesions due to a drug or metal usually re-
Metastafic tumor (posterior) solve on discontinuation or removal of fbe oftending
Laterai borders (anterior, posterior) agent, Tbose liebenoid lesions due to other causes will
Apthous ulcers require management of tbe primary disease.
Recurrent herpes simpiex
Traumatic uicers Estabiishing the final diagnosis
Foliate papiilitis (posterior)
Papilloma The history related by the patient is often the single
Fibroma most significant factor in determining the diagnosis,
Neurcfi broma
Tbe patient's chief complaint, the duration of the
Neuroiemmoma
Squamous celi carcinoma (posterior)
problem, and any positive medical bistory are all im-
Amyioidosis portant bits of information tbat can belp determine
Ventral the nature of the condition. However, establishing the
Apthous ulcers diagnosis may be more difficult when an asympto-
Mucous extravasation cyst matic lesion is discovered during a routine oral exami-
Salivary gland tumor nation and tbe patient is unaware of Its presence.
Generalized As noted previously, one of the most important deci-
Mucous membrane pemptiigoid sions in making a final diagnosis is determining
Pemphigus vulgaris whetber the lesion(s) is of local origin or a part of a
Primary herpes simplex
more generalized systemic disorder. Sometimes this de-
Erythema muitiforme
cision can be made on the basis of a history of similar
lesions in other areas of the body or the findings on
physical examination, but other times it is more diffi-
appearance seen in otber parts of the oral cavity. The cult when only oral lesions are observed, tbe patient re-
erosive form occurs on the lateral borders, as well as lates a negative medical history, and there are no other
tbe dorsum of tfie tongue, and is characterized by significant pbysical findings. In tbe latter instance it
painful ulcers with a yellowisb base. The atrophie may be necessary to use laboratory tests to rule out

340 Volume 34, Number 5 2003

 Laskin et ai

TABLE 2 Classification of lingual lesions TABLE 3 Benign and malignant neoplasms of the
according to their clinical characteristics tongue
Lesion/etiology Usuai iocation Neoplasm Usuai location
I.Vesiculo-bullous Benign
Primary herpes simplex Generalized Fibroma Dorsal/lateral
Recurrent herpes simplex Lateral borders Papilloma Dorsai/ialeral
Erythema multitorme Generalized Lipoma Any surface
Mucous membrane pemphigoid Generalized Rh ab do myoma Any surface
Pemphigus vulgaris Generalized Leiomyoma Any surface
2. Utoerative Neuroma Dorsal
Squamous cell carcinoma Posterior laterai border Neurofibroma Dorsal/lateral
Pyogenic granuloma Dorsal Neurilenimoma Dorsal/lateral
Traumatio uicer Laterai/dorsai Granular cell tumor Dorsal
Aphthcus ulcer Latera i/vent ral Malignanl
Erythema multiforme Generalized Squamous cell carcinoma Posterior lateral border
Lichen planus Dorsal Salivary gland tumor Posterior dorsal/base;
Primary herpes simplex Generalized ventral lip
Recurrent herpes simplex Lateral border Sarcoma Any surface
Mucous membrane pemphigoid Generalized Metastatic tumor Dorsal (posterior)
Pemphigus vuigaris Generalized
Tuberculosis Dorsal
Leukemia Dorsal/lateral TABLE 4 Congenital and developmental tongue
Primary syphilis (chancre) Dorsal lesions
Tertiary syphilis (gumma) Dorsal
3. Atrophie Lesion Usual location
Chronic candJdiasis Dorsal Fissured tongue Dorsal
(median rhomboid glossitis) Lingual thyroid Dorsal (posterior midline)
Benign migratory glossitis Dorsai Lymphangioma Dorsal
(geographic tongue) Hemangioma Dorsal
Vitamin B deficiency Dorsal Median rhomboid glossitis Dorsal
Anemia Dorsal (Candid i as is)
Diabetes mellitus Dorsal
Lichen planus Dorsal
4. Cystic
Thyroglossal duct cyst Dorsal (posterior midline)
Mucous extravasation cyst Ventral
Derm oid cyst Dorsal (midline)

specific infections, metabolic disorders, or blood
dyscrasia as an etiologic factor. Tbe order in whicb
tbese tests should be done wili depend on the ciini-
cian's index of suspicion.
The location of a lesion and its physical characteris-
tics can also be essentiai factors in determining its di-
agnosis and possible etiology. Certain lesions tend to
be found most often in specific areas because of
anatomic considerations, greater exposure of tbe site
to irritation or trauma, or for undetermined reasons
(Table 1). Most lingual lesions can aiso be classified as
vesiculobulious, ulcerative, atropbic, cystic, or neo-
plastic in character (Tables 2 and 3), or they may rep-
resent congenital and developmental malformations
(Table 4). Dividing lesions into local and systemic con-
ditions, and then further classifying them in the previ-
ous manner, narrows the diagnostic speetrum and
makes the final determination easier.
When the diagnosis cannot be definitively estab-
iisbcd on tbe basis of tbe history and clinical findings,
a biopsy is indicated. This is particuiariy important
wbcn there is a possibility that the lesion may be ma-
lignant. A useful rule is to consider every lesion sus-
pected of being neopiastic as a malignancy until
proven otherwise by bistologic examination.
REFERENCES
1. Lynch DP. Ulcérations of the tongue. Postgrad Med 1984;
75:191-203.
2. Newland RI Benign lingual lesions of intrinsic origin.
Postgrad Med 19S4;75:152-163.
3. Dolan EA, Mason RM. Lesions of the tongue: A review. Int
JOrofacMyoI 1988;14:9-n.
4. McNally MA, Langlais RP. Conditions peculiar to the
tongue. Dermatol Clin 1996; 14:257-272.

International 341
Laskin et al
5. Rousseau A, Mock D, Lutnps of the tongue. Ont Dent 1997;
74:20-24.
6. Bawer T. Teaching rounds: Differential diagtiosis of neck
tnasses. Hosp Med 1980,22:66-75.
7. Sapp |P, Eversole LR, Wysocki GP. Contetnpory Oral and
Maxiliofaciai Pathology. St Louis: Mosby, 1997:200,221,
231,247-249,295,307
8. Litzow T], Lash H. Lymphangioma of the tongue. Mayo
Clin Proc 1961;36:229-234.
9. Kaban L, Mullikcn J. Vascular malformations of the max-
iliofaciai region. J Oral Maxillofac Surg 1986;44:203-213.
10. Walker DM, Arendorf T, Candidat leukoplakia, chronic
multifocal candidosis and median rhomboid glossitis. In:
Samaranayake LP, McFarlane TW (eds]. Oral Candidosis.
Bristol, United Kingdom: Wright, 1990:184-199.
11. Sugerman PB, Savage NW, Young WG. Mucocele of the an-
terior lingual salivary glands (glands of Blanditi and Nuhn):
Report of 5 cases. Oral Surg Orai Med Oral Pathol 2000;
90:478-482.
12. Lewis MAO, Satnaranayake LP, Lamey P-J. Diagnosis and
treattnent of oral candidosis, ] Oral Maxillofac Surg 1991;
49:996-1002.
13. Baden E, Divaris M, Quillard ]. A light microscopic and im-
munohistochemical study of a multiple granular cell tumor
and review of the literature. J Oral Maxillofac Surg 1990;
48:1093-1099.
14. van der Waal I, Pindborg JJ. Diseases of the Tongue.
Chicago: Quintessence, 1985:167-168.
15. Nagi LT. Fibrosarcoma of Ihe tongue. Int ) Oral Surg 1973;
2:303-306.
16. Brockbank ]. Hemangiopericytoma of the oral cavity:
Report of a case and review of the literature. J Oral Surg
1979;57:659-664.
342
17 Komori A, Takeda Y, Kabiichi T Alveolar soft part sarcoma
of the tongue. Oral Surg 1984;57:532-539,
18. Wescott WB, Correli RW. Multiple recurrences of a lesion at
the base of the tongue. J Am Dent Assoc 1984;108:231-232.
19. Rao TV, Satyanaryana CV. Rhabdomyosaracoma. Indian J
Pediatr 1977 ;44:377-380,
20. Farman AG, Kay S. Oral (eiomyosarcoma. Oral Surg
1977,43:402-409.
21. Carrillo R, El-Naggar AK, Rodriguez-Peral to JL, Batsakis
JG. Synovica! sarcoma of the longue: Case report and re-
view of the literature. J Oral Maxillofac Surg 1992;50:
904-906.
22. Zagrebin VM. Chondrosarcoma of the root of the tongue.
Arkh Patol 1977;39:78-80.
23. Rapoport A, Pinheiro de Lima CP, de Andrade Sobrinho J,
do Qucriroz Costa F. Neurogenic sarcoma (neurofibrosar-
coma] ofthe tongue, Int Surg 1973;58:738-739.
24. McDaniel RK. Linguai malignancies. Postgrad Med 1984"
75:178-185.
25. Oikarinen VJ, Calonius PEB, Sainio P, Metastatic tumors to
the oral region, 1. An analysis of cases in the literature. Proc
Finn Dent Soc 1975;71:58-65,
26. Koper A, Skinner G, Calcaterra TC. Carcinoma of the blad-
der metastatic to the tongue. Br J Urol 1975;47:644.
27 Regezi JA, Sciubba JJ. Oral Pathology: Clinical Pathologic
Correlations, ed 3. Philadelphia: Saunders, 1999:97,100-101.
28. Hashimoto Y, Tanioka H. Primary tuburculosis of the
tongue. J Oral Maxiilofac Surg 1989;47:744-746.
29. Eversole LR. Clinical Oulline of Oral Pathoiogy, ed 3,
Philadelphia: Lea & Pebiger, 1992:21-22.
30. Silverman S Jr Ora) lichen planus: A potentially premalig-
nant lesion. ] Oral Maxillofac Surg 2ü00;58:1286-1288.
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