ORAL MEDICINE MINOR CASE FISSURED TONGUE

CHAPTER I INTRODUCTION

Tongue disorders are characterized by changes in the texture and appearance of the tongue's surface. People of all ages can experience several different types of tongues disorders due to poor oral hygiene, infection, genetic tendencies and various underlyi g n medical conditions. Although some tongue disorders are symptomatic meanwhile some are completely symptom free (John Hopkins, 2008). Following is the description of the patient. He is a male aged 19 years old, complained that his tongue has crack and groove on surface of his tongue. Patient said that he never had any discomfort or pain but he finds it difficult to clean and sometime there are white coatings on the tongue. The patient only brush his teeth as daily oral hygiene and do not use any mouthwashes. Patient has no history of previous disease or known systemic diseases. Patient also complaints of ulceration on right cheek. The ulcers form around 3 days ago. The patient did not recall any bitting or traumatizing at the ulcer location and not taking any medication for the ulcers. Through clinical examination, the diagnosis for the tongue disease is fissured tongue. The treatment for the ulcer is antibacterial mouthwash contains Chlorohexidine 0.2% and used twice daily with 30 to 60 seconds gargling. After 1 week, the lesions is evaluated to get the best result from the treatment given.

CHAPTER II PATIENT STATUS

2.1 Clinical Working Record y y y y y y Name Sex Age Religion Occupation Marital Status : Mr. R : Male : 19 years old : Muslim : Private : Single

2.2 Anamnesis The patient complained that his tongue has crack and groove on surface of his tongue. Patient said that he never had any discomfort or pain but he finds it difficult to clean and sometime there are white coatings on the tongue. The patient only brush his teeth as daily oral hygiene and do not use any mouthwashes. Patient has no history of previous disease or known systemic diseases. Patient also complaints of ulceration on right cheek. The ulcers form around 3 days ago. The patient did not recall any bitting or traumatizing at the ulcer location and not taking any medication for the ulcers. He decided to see a dentist to get the further treatment with the hope that the lesion can be reduced.

2.3 History of Systemic Disease y Heart disease : No

y y y y y y y

Hypertension Diabetes Mellitus Asthma/Allergy Hepatitis GIT disease Blood Abnormalities Others

: No : No : No : No : No : No : No

2.4 History of Previous Disease: No

2.5 General Condition y y y y y y General Condition Blood Pressure Consciousness Respiration Temperature Pulse : Good : 120/70 mmHg : Compos Mentis : 18 x minute : Normal : 84 x minute

2.6 Extra Oral Examination y Lymph nodes:

Submandibular

Right: Non palpable Left : Non palpable

Submental

Right: Non palpable Left: Non palpable

Cervical

Right: Non palpable Left: Non palpable

Others y y y y Lip Face Circum oral Others

: : Normal : Symmetry : Normal : Normal

2.7 Intra Oral Examination y o o o y y Oral hygiene (based on Plaque Indice (PI) by OLeary et al., 1972): Moderate Plaque Calculus Stain Gingiva Buccal Mucosa : : : + -

: Normal : Ulcer on buccal dextra reg 46 with diameter of

4mm with erythematous border and pseudomembranous layer base y y y y y Labial Mucosa Palatal Dorum Palatal Mole Frenulum Tongue : Normal : Normal : Normal : Normal : Fissured on the dorsm and lateral of tongue.

y y

Floor of The Mouth Teeth Caries Missing Filling Discoloration

: Normal

: 15 : 36 ::-

Fissure on the lateral side of the tongue (1st visit)

Fissure on the dorsum surface of the tongue (1st visit)

Ulcer on right buccal at area 46 (1st visit) 2.8 Diagnosis 1. 2. Fissured tongue Traumatic ulcer

2.9 Treatment Planning and Management Treatment planning involve communication and information about fissured tongue. The patient should be informed about the benign nature and the progression of this lesion with age. The patient was explained that this is normal. He is assured that good hygiene is

sufficient to manage fissured tongue. The patient is educated about the proper tooth brushing method and advised to use tongue scraper to clean his tongue. The patient was also prescribed chlorhexidine gargle to rinse the oral cavity 2x per day until the ulcer subsides. Patient is then asked to come for control after 1 week.

2.10 Evaluation After 1 week Patient came for control after 1 week. Based on patients memory, patient said that the ulcer was reduced and eventually disappeared after rinsing with the antibacterial mouthwash prescribed to the patient after 5 days from the first visit. Since that, patient always takes precaution by maintaining good oral hygiene making sure his tongue is clean.

2.10.2 Extra Oral y Lymph nodes Submandibular Submental Servikal y y y y Lip TMJ Face Oral Sirkum : Normal : Normal : Symmetry : Normal : Normal : Normal :Normal

2.10.3 Intra Oral y Oral Hygiene : Good

y y y y y y y y y y y y

Staining Gingiva Buccal Mucosa Labial Mucosa Palatum Durum Palatum Mole Frenulum Palate Tongue Floor of the mouth Tonsils Gingival

: Negative : Pinkish red : Normal : Normal : Normal : Normal : Normal : Normal : Fissured on the dorsm and lateral of tongue : Normal : Normal : Normal

Fissure on Dorsum of tongue (Control 1 week)

Fissure on lateral side of tongue (Control 1 week)

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CHAPTER III LITERATURE REVIEW

Anatom of tongue The tongue The tongue consists of a buccal and a pharyngeal portion separated by a V shaped groove on its dorsal surface, the sulcus terminalis. At the apex of this groove is a shallow depression, the foramen caecum, marking thethe sulcus lie a row of large vallate papilliae. The under aspect of the tongue bears the median frenulum linguae; the mucosa is thin on this surface and the lingual veins can thus be seen on either side of the frenulum. The lingual nerve and the lingual artery are medial to the vein but not visible. More laterally can be seen a fringed fold of mucous membrane termed the plica fimbriata. On either side of the base of the frenulum can be seen the orifice of the submandibular duct on its papilla. Inspect this in a mirror and note the discharge of saliva when you press on your submandibular gland just below the angle of the jaw. (Ellis, 2006)

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Structure The thick stratified squamous mucosa of the dorsum of the tongue bears papillae over the anterior two-thirds back as far as the sulcus terminalis. These papillae (particularly the vallate) bear the taste buds. The posterior one-third has no papillae but carries numerous lymphoid nodules which, with the palatine tonsils and adenoids, make up the lymphoid ring of Waldeyer. (Ellis, 2006) Small glands are scattered throughout the submucosa of the dorsum; these are predominantly serous anteriorly and mucous posteriorly.The tongue is divided by a median vertical fibrous septum, as indicated on the dorsum by a shallow groove. On each side of this septum are the intrinsic and extrinsic muscles of the tongue.The intrinsic muscles are disposed in vertical, longitudinal and transverse bundles; they alter the shape of the tongue. The extrinsic muscles move the tongue as a whole. They pass to the tongue from the symphysis of the mandible, the hyoid, styloid process and the soft palate, respectively the genioglossus, hyoglossus, styloglossus andpalatoglossus. The functions of the individual extrinsic muscles can be deduced from their relative positions. Genioglossus protrudes the tongue, styloglossus retracts it and hyoglossus depresses it. Palatoglossus is, in fact, a palatal muscle and helps to narrow the oropharynx in swallowing. (Ellis, 2006) The mucous membrane on the anterior part of the tongue is rough because of the presence of numerous small lingual papillae (Moore & Dalley, 2006): 1. Vallate papillae: large and flat topped, they lie directly anterior to the terminal sulcus and are arranged in a V-shaped row. They are surrounded by deep moatlike trenches, the walls of which are studded with taste buds. The ducts of the serous glands of the tongue open into the trenches.

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2. Foliate papillae: small lateral folds of the lingual mucosa. They are poorly developed in humans. 3. Filliform papillae: long and numerous, they contain afferent nerve endings that are sensitive to touch. These scaly, conical projections are pinkish gray and are arranged in V-shaped rows that are parallel to the terminal sulcus, except at the apex, where they tend to be arranged transversely. 4. Fungiform papillae: mushroom shaped pink or red spots, they are scattered among filliform papillae but are most numerous at the apex and margins of the tongue.

Blood supply Blood is supplied from the lingual branch of the external carotid artery. (Ellis, 2006)

Lymph drainage The drainage zones of the mucosa of the tongue can be grouped into three: (Ellis, 2006) 1 The tip drains to the submental nodes;

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The anterior two-thirds drains to the submental and submandibular nodes and thence to the lower nodes of the deep cervical chain along the carotid sheath;

The posterior one-third drains to the upper nodes of the deep cervical chain.

Nerve supply The anterior two-thirds of the tongue receives its sensory supply from the lingual branch of V which also transmits the gustatory fibres of the chorda tympani (VII). Common sensation and taste to the posterior one-third, including the vallate papillae, are derived from IX. Afew fibres of the superior laryngeal nerve (X) carry sensory fibres from the posterior part of the tongue.All the muscles of the tongue except palatoglossus are supplied by XII; palatoglossus, a muscle of the soft palate, is innervated by the pharyngeal branch of X (Ellis, 2006)

Fissured tongue Definition Fissured tongue (FT), also termed lingua fissurata, lingua plicata, scrotal tongue and grooved tongue is recognized clinically by an groove oriented anteroposteriorly, often with multiple branch fissures extending laterally. The frequency of FT increases with age and has been associated with psoriasis, acromegaly, and Sjogrens, Downs and MelkersonRosenthal syndromes (Zargari, 2005). The fissured tongue (FT) is a condition, either inherited or acquired, that manifests variable degrees of grooves or fissures on the tongue dorsum (Silverman et al, 2002). A tongue with fissures on the dorsum (Scully et al, 2010).

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Prevalence About 5% of population. Age mainly affected: More noticeable with increasing age. Gender mainly affected: M = F (Scully et al, 2010). It is unclear whether FT occurs more frequently in male or female patients. It has been reported in patients ranging in age from 15 to 84 years (Wood & Goaz, 1997).

Etiology The etiology is uncertain, because the time when the fissures first appeared cannot be documented with certainty. Whereas there has been some testimonial

association with nutritional and vitamin deficiencies, this has not been frequent or wellconfirmed (Silverman et al, 2002). For years median rhomboid glossitis (MRG) (central papillary atrophy of the tongue) has been considered a developmental and congenital defect causing a segment of the tuberculum impar to persist on the dorsal surface of the tongue, instead of being buried in normal embryonic development. However, the paucity of cases in children and some cases of remission has diminished support for this theory. It is thought that a chronic candidal infection plays a leading etiologic role and smoking may also act as a promoter. Conflicting reports concern a possible role by diabetes (Wood & Goaz, 1997). The etiology is unknown but hereditary plays a significant role. The condition may be congenital, present at birth, or may become apparent during childhood or later in life. Ajra examined clinical and genetic characteristics of histologically defined fissured tongue in a familial study and reported that fissured tongue with smooth-surfaced papillae was transmitted as a dominant characteristic with incomplete penetrance and was preceded by

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geographic tongue. The severity of fissured tongue changed with increasing age. Tongue fissuring with normal appearing filiform papillae was not familial and was not associated with geographic tongue. Fissuring with normal-appearing structure should be considered as variation of normal anatomy, whereas fissured tongue and geographical tongue are clinical and etiological disease entity. Aging and local environmental factors may also contribute to its development. Fissured tongue may present as an independent manifestation or associated with certain underlying syndromes or familial

conditions. Conditions associated with fissured tongue include Melkersson-Rosenthal syndrome, Down syndrome, acromegaly, Sjorgens syndrome, oro-facial granulomatosis, psoriasis and geographic tongue (Rathee et al, 2010).

Clinical findings Usually asymptomatic. However, it is often complicated by geographic tongue, or the tongue becomes sore for no apparent reason. Multiple fissures on the dorsum of the tongue. There is such a wide range of fissuring appearances that there is no standard classification or adequate description (Scully et al, 2010). Occasionally, when a patient notices a FT for the first time or feels that the fissures are increasing, there is concern over the significance. In some patients, there are complaints of discomfort, or coincidental tongue symptoms; these are eventually shown to be unrelated to the fissuring (Silverman et al, 2002). The lesion is located on the dorsal surface of the tongue in the midline and anterior to the circumvallate papillae. The surface is dusky red, completely devoid of filiform papillae, and usually smooth; however, nodular or fissured surfaces have been noted .

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Rarely, there may be some keratosis. The size and shape of the lesion are somewhat variable, at times causing confusion as to the diagnosis. The lesions are generally asymptomatic, but pain and ulceration have been reported (Wood & Goaz, 1997).

Fissured tongue is characterized by anteroposterior and multiple laterally fissures on the dorsal aspect of the tongue

Histology Microscopic examination of fissured tongue reveals hyperplasia of the rete ridges and loss of the keratin " hairs" on the surface of the filiform papillae. The papillae vary in size and often arc separated by deepgrooves. Polymorphonuclear leukocytes can be seen migrating into the epithelium. often forming microabscesses in the upper epithelial layers. A mixed inflammatory cell in filtrate is present in the lamin a propria. (Neville et al, 2002)

Diagnosis The diagnosis is made by clinical findings and history. If there are indications of a systemic disease or condition based on signs and symptoms, then the appropriate referral

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or laboratory tests should be carried out. By simply stretching the tongue with mild pressure, the epithelial-lined fissures become obvious (Silverman et al, 2002).

Treatment The prime treatment involves counseling the patient regarding the benign nature, the common occurrence, and the lack of association with infections or other conditions or diseases. Management is empirical, including optimal hygiene and mouthrinses. Rarely, when a fissure is deep and associated with debris and exudate, dbridement and closure of the defect is in order (Silverman et al, 2002). No treatment is indicated or available. (Scully et al, 2010)

Prognosis Excellent. (Scully et al, 2010)

Differential Diagnosis : Geographic tongue Definition Geographic tongue (benign migratory glossitis) is an entity of unknown cause and presents clinincally with loss of the filiform papillae on the dorsal and lateral surfaces of the tongue sometimes accompanied by an advancing white border with or without erythema (Rathee et al, 2010). GT, also known as benign migratory glossitis or glossitis areata migrans, is an inflammatory disorder of unknown aetiology caused by the local loss of filiform papillae. The condition usually presents as asymptomatic erythematous patches with serpiginous borders. The patches are irregular and sharply demarcated, resembling a

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map. These lesions characteristically have a migratory nature, and their colour and shape change over time. GT is usually an isolated abnormality but has been associated with psoriasis, atopic diathesis, diabetes mellitus, reactive bronchitis, anaemia, stress, hormonal disturbances, Reiters and Downs syndromes, and lithium therapy (Zargari,2005).

Prevalence Geographical tongue occurs in about 1% of general population, and 50% in association with fissured tongue (Rathee et al, 2010). The reported prevalence is approximately 1 per cent of the population and there is often a family history. The disorder occurs over a wide age range and presents both in children and adults. (Soames & Southam, 2005)

Etiology The cause has not been clearly identified. It is considered to be an allergic or hypersensitivity reaction to certain factors to which the tongue is exposed. This could be a germ that usually lives in the mouth or a foodstuff. This reaction causes excessive shedding of cells on the surface of the tongue (Scully et al, 2010).

Clinical findings Irregular, partially depapillated, red areas on the anterior two-thirds of the dorsal tongue surface and is associated with loss of the filiform papillae, the fungiform papillae remaining as shiny, dark-red eminences. The margins of the lesions are often outlined by a

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thin, white line or band and the disorder is frequently associated with fissured (scrotal) tongue . The affected areas may begin as small lesions only a few millimetres in diameter which, after gradually enlarging, heal and then reappear in another location. The condition may regress for a period and then recur. It is usually symptomless but there may be some irritation associated with acid and spicy foods. (Soames & Southam, 2005)

Geographical tongue. Note the atrophic red patches are sharply demarcated, resembling a map

Histology Histological examination shows the epithelium at the edges of the lesions to be acanthotic with a dense, neutrophil leucocyte infiltration throughout the epithelium and the lamina propria. In the centres of the lesions, the loose desquamating cells on the surface have been lost and there is underlying chronic inflammatory cell infiltration (Soames & Southam, 2005) Histologically, there is thinning of the epithelium in the centre of the lesion with mild hyperplasia and hyperkeratosis at the periphery. There are chronic inflammatory cells

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in the underlying connective tissue. The irregular areas of dekeratinized and desquamated filliform papillae which is red in colour are surrounded by elevated whitish or yellow margins due to acantholysis and hyperkeratosis. (Cawson & Odell, 2002)..

Pathophysiology Red patches develop and then over a few days coalesce to form rather large areas of raw-looking patches (Murtagh, 2010). In this condition, localized areas of filliform papillae are rapidly lost and replaced by uneven areas of smooth dorsal surface lingual mucosa that is often erythematous because of hyperemia (Sonis et al., 1995). The cause of lost papillae is still unknown. The fungiform papillae are exaggerated (Sonis et al., 1995). The papillae on the tongue surface rapidly regrow and the affected area returns to normal. The process moves around to other parts of the tongue with a major change occurring every three weeks. The process may then subside and go into remission that may be complete or partial. However, it may return at a later time (Murtagh, 2010).

Diagnosis The diagnosis is based upon clinical appearance and history. When there is clinical confusion because of a rather bizarre manifestation, or deep concern on the part of the patient, a biopsy can be performed. (Scully et al, 2010).

Treatment

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Most important, patients must be reassured that although this is a chronic or cyclic condition, GT does not represent a neoplastic, infectious, or contagious disease. Biopsy is elective. If a patient has generalized complaints or findings, then a physical examination should be suggested to rule out a coincidental systemic problem. When a patient is asymptomatic, no further treatment is necessary. Since some patients may be uncomfortable or experience considerable pain, identifiable irritants (mainly food types) should be avoided. Symptoms are treated empirically. Trials can include placebos (vitamins), mouthrinses, antianxiety medications, and anti-inflammatory drugs. The latter can include nonsteroidal anti-inflammatory drugs (NSAIDs) and topical or systemic corticosteroids. Analgesic agents are sometimes needed. There is no specific treatment, drug or process that makes it disappear. However, palliation in the form of sprays, ointments or rinses may be helpful in symptomatic cases (Sonis et al, 1995 ; Scully et al, 2010).

Prognosis There are no complications. Spontaneous resolution of the lesion in one area is not uncommon, but usually another lesion appears in another location. (Scully et al, 2010)

Ulcer Definition and Terminology Ulcerative lesions are a group of common oral mucosal disorders. The most common causes of these lesions are mechanical and reactive factors, infectious diseases, and neoplasms, as well as autoimmune and hematological disorders. The main clinical

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feature in all these conditions is an ulcer, which is defined as loss of all epithelial layers. In addition, the term erosion is used to defined a superficial loss of epithelium. However, at the clinical level, the terms ulcer and erosion are usually used interchangeably. In this chapter, only primary ulcerative lesions are discussed, and not lesions that arise secondarily fromrupture d bullae.(Laskaris, 2006) Ulceration is a breach in the oral epithelium, which typically exposes nerve endings in the underlying lamina propria, resulting in pain or soreness, especially when eating spicy foods or citrus fruits. Patients vary enormously in the degree to which they suffer and complain of soreness in relation to oral ulceration. It is always important to exclude serious disorders such as oral cancer or other serious disease, but not all patients who complain of soreness have discernible organic disease. Conversely, some with serious disease have no pain. Even in those with detectable lesions, the level of complaint can vary enormously. Some patients with large ulcers complain little; others with minimal ulceration complain bitterly of discomfort. Sometimes there is a psychogenic influence. (Scully, 2005) y Erosion which is the term used for superficial breaches of the epithelium. These often have a red appearance initially as there is little damage to the underlying lamina propria, but they typically become covered by a fibrinous exudate which has a yellowish appearance (Scully, 2005). y Ulcer which is the term usually used where there is damage both to epithelium and lamina propria. An inflammatory halo, if present, also highlights the ulcer with a red halo around the yellow or grey ulcer (Scully, 2005).

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Etiology (Scully, 2005) y y y y y y y Trauma Recurrent aphthous stomatitis (RAS) Microbial infections Mucocutaneous diseases Systemic disorders Drug therapy Squamous cell carcinoma

Clinical features Acute reactive ulcers of oral mucous membranes exhibit the clinical signs and symptoms of acute inflammation, including variable degrees of pain, redness, and swelling The ulcers are covered by a yellow-white fibrinous exudate and are surrounded by an erythematous halo. Chronic reactive ulcers may cause little or no pain. They are covered by a yellow membrane and are surrounded by elevated margins that may show hyperkeratosis. Induration, often associated with these lesions, is due to star formation and chronic inflammatory cell infiltration (Regezi, 2003).

Oral ulcer at right buccal

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Histology Acute ulcers show a loss of surface epithelium that is replaced by a fibrin network containing predominantly neutrophils. The ulcer base contains dilated capillaries and, with time, granulation tissue. Regeneration of the epithelium begins at the ulcer margins, with proliferating cells moving over the granulation tissue base and under the fibrin clot. Chronic ulcers have a granulation tissue base, with scar found deeper in the tissue. A mixed inflammatory cell infiltrate is seen throughout. Epithelial regeneration occasionally may not occur because of continued trauma or because of unfavorable local tissue factors. It has been speculated (hat these factors are related to inappropriate adhesion molecule expression (integrins) and/or inadequate extracellular matrix receptors for the keratinocyte integrins. In traumatic granulomas, tissue injury and inflammation extend into subjacent skeletal muscle. The term granuloma as used here reflects the large numbers of macrophages that dominate the infiltrate, but this is not a typical granuloma as seen in an infectious process, such as tuberculosis. (Regezi et al,2003) Histological examination shows an ulcer covered by a thick layer of fibrinous exudate with a dense, chronic inflammatory cell infiltrate in its base involving underlying damaged muscle. The deeper parts of the lesion are characterized by an infiltrate rich in histiocytes and eosinophils (Soames, 2005).

Treatment Management involves the elimination of the suspected cause and use of an antiseptic mouthwash (for example, 0.2 per cent chlorhexidine) or a simple covering agent such as Orabase). Ulcers of local cause usually heal spontaneously within 714 days if the

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cause is removed. Maintenance of good oral hygiene and the use of hot saline mouthbaths and 0.2% aqueous chlorhexidine gluconate mouthwash aid healing. Occasionally, particularly in self-induced trauma, mechanical protection with a plastic guard may help. Patients should be reviewed within three weeks to ensure healing has occurred. Any patient with a single ulcer lasting more than 23 weeks should be regarded with suspicion and investigated further; biopsy may be indicated. Most reactive ulcers of oral mucous membranes arc simply observed. If pain is considerable, topical treatment may be of benefit. This could be in the form of a topical corticosteroid (Regezi,2003; Scully, 2010 )

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CHAPTER IV DISCUSSION

The patient complained that his tongue has crack and groove on surface of his tongue. Patient said that he never had any discomfort or pain but he finds it difficult to clean and sometime there are white coatings on the tongue. Patient also complaints of ulceration on right cheek. The ulcers form around 3 days ago. The patient did not recall any bitting or traumatizing at the ulcer location and not taking any medication for the ulcers. Extraoral examination and anemnesis showed no underlying systemic disease of the patient that may manifest in the oral cavity. After intraoral examination, it is found that there are fissuring on the dorsum and lateral side of the tongue. According to the patient, the lesion never caused him any pain or discomfort but sometimes making cleaning the tongue hard. This is consistent with statement from Silverman et al (2001), Scully et al (2010), Wood & Goaz (1997) and Neville et al (2002) which state that fissure tongue are usually asymptomatic. The patient also revealed ulcerations on the buccal right. The ulcer healed 5 days after the first visit. According to Regezi and Scully,ulceration in oral mucosa usually heal spontaneously within 7-14 days. The patient was explained about his condition and the nature of fissure tongue. According to Scully, fissured tongue progress with age. The patient was informed about this progression of fissured tongue and was advised to not concern himself as long as the patient does not feel any discomfort or pain and practices good oral hygiene. The patient was reassure that good oral hygiene is a sufficient way to manage his treatment. The patient is instructed to maintain a good oral hygiene. In addition to daily brushing, the

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patient was instructed to scrape the tongue to ensure torough cleaning of the oral cavity. This is to make sure that food debris and microorgannism will not accumulate and reside between the groves and fissure. The treatment prescribed is antiseptic Chlorhexidine gluconate 0.2% mouthrinse as it has antimicrobial properties to fight against germs and bacteria. Antiseptic is a solution used to disinfect skin or other living tissue (Burton & Engelkirk, 1996). Antimicrobial agent is defined as an agent that can kill or inhibit microbial growth (Prescott, Harley & Klein, 2002). Chlorhexidine is used twice daily with 30 to 60 seconds gargling until the ulcer subsides.. This is also to make sure that there are no secondary infection at the ulcers. Chlorhexidine gluconate is only advised to be used for 714 days. It is known that prolonged usage or chlorhexidine can cause staining of tongue and change of oral microflora (Yagiela, Dowd & Neidle, 2007). Then, the lesion is examined again after 1 week. The ulcer on the buccal right already healed. The patient has no complaints and has been using tongue scrape to helps r with the cleansing of the tongue surface. There is no specific management and treatment for fissured tongue. The patient need optimal hygiene and mouthrinses in order to prevent any progress or occurance of infection (Silverman et al, 2002; Scully et al, 2010).

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CHAPTER V CONCLUSSION

Based on the anamnesis and clinical examination, all the patients symptoms and the clinical features of the lesion fulfill the criteria of diagnosing fissure tongue. According to literature, no specific treatment was stated, the patient was instructed to maintaine good oral hygine and encourage to scrape his tongue for a better removal of food debris. After a week the patient is called back for control and the patient didnt have any complaints.

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REFERENCES Better Health Channel, 2010. www.betterhealth.vic.gov.au. Tongue. P. 1-4. Available online at

Burton R and Engelkirk R;1996 Microbiology for the Health Sciences. 5th ed. Lippincott. p. 125-126 Cawson, R.A. & Odell, E.W., 2006. Essential Pathology and Oral Medicine. 7th edition. Churchill Livingstone. Ellis H. 2006.Clinical anatomy: applied anatomy for students and junior doctors .WileyBlackwell. John Hopkins, 2008. Symptoms and Remedies: The Complete Home Medical References. Remedy Health Media, LLC.Available online at http://www.johnshopkinshealthalerts.com Laskaris G, 2006, Pocket Atlas of Oral Diseases. Thieme Moore & Dalley, 2006. Clinically Oriented Anatomy. 5 th edition. Lippincott Williams & Wilkins Neville B.W. Douglas D. Damm. Terry A Day .2002. Oral and maxillofacial pathology. Saunders/Elsevier Prescott LM, Harley JP & Klein DA, 2002. Microbiology 5th Ed. Boston Mc Graw-Hill Higher Education. p. 806-812 Rathee M, A. Hooda & A. Kumar. 2010.Fissured Tongue: A Case Report and Review of Literature. The Internet Journal of Nutrition and Wellness. 10(1) Regezi, Sciubba, Jordan.2003.Oral Pathology: Clinical Pathologic Correlations 4th ed. Saunders Scully C. Oslei Paes de Almeida, Jose Bagan, Pedro Diz Dios, Adalberto Mosqueda Taylor. 2010. Oral Medicine and Pathology at a Glance .John Wiley and Sons. Scully C. Felix DH. 2005.Oral medicine Update for the dental practitioner Aphthous and other common ulcers, British Dental Journal ; 199:259264 Silverman S, Lewis R.E, Edmond L.T, 2002,Essentials of oral medicine. PMPH-USA Soames JV, Southam JC .2005.Oral Pathology - 4th Ed.

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Sonis, Fazio & Fang 1995, Principles and Practices of Oral Medicine, 2nd ed. W.B. Saunders Company. Wood NK, Goaz PW. 1997.Differential diagnosis of oral lesions. 5th ed. St. Louis: Mosby, Yagiela JA,Frank J. Dowd,Bart Johnson,Angelo Mariotti,and Enid A. Neidle,2007. Pharmacology and Therapeutics for Dentistry, 4th Edition Zargari O.2006. The prevalence and significance of fissured tongue and geographical tongue in psoriatic patients.Clinical and Experimental Dermatology, 31, 192195