An Atlas of Lingual Lesions, Part 3
Alexander K. C. Leung, MD
Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada
Benjamin Barankin, MD
Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada
Kin Fon Leong, MD
Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
Amy Ah-Man Leung, MD
Resident Physician, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
Leung AKC, Barankin B, Leong KF, Leung AA-M. An atlas of lingual lesions, part 3. Consultant. 2019;59(7):210-213.
EDITOR’S NOTE: This article is part 3 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Part 1 was published in the May 2019 issue (https://www.consultant360.com/article/consultant360/atlas-lingual-lesions-part-1), and part 2 was published in the June 2019 issue (https://www.consultant360.com/article/consultant360/atlas-lingual-lesions-part-2). Parts 4 and 5 will be published in upcoming issues of Consultant.
Aphthous stomatitis (also known as aphthous ulcers, aphthae, or canker sores) is characterized by painful solitary or multiple ulcers with well-defined erythematous margins and an ulcerated center covered by a yellowish gray fibrinous pseudomembrane.1,2 Prodromal sensations such as stinging, burning, or paresthesia may precede the appearance of the lesions.1,3,4 The lesions usually develop on the nonkeratinized oral mucosa such as the buccal and labial mucosa, the floor of the mouth, the soft palate, and the lateral and ventral surface of the tongue (Figure).1-7 They are rarely seen on the dorsum of the tongue, the hard palate, or the gingiva.5 Stretching the lesion may cause the ulcer to break down and bleed.2 Aphthous lesions are rarely documented as a single episode in the clinical history of patients; recurrence is the hallmark of the disease, hence the term recurrent aphthous stomatitis.2,8 Fever, headache, rash, and lymphadenopathy are characteristically absent.6
Aphthous stomatitis can be classified by the clinical characteristics of the ulcers: minor, major, and herpetiform.2,8,9 Minor aphthae represent the most common variety, accounting for 80% to 85% of all aphthae.4,8 Minor aphthous ulcers are superficial in nature, small in size (<1 cm in diameter), few in number (<3), and heal without scarring within 10 days.1,10 Major aphthae (Mikulicz aphthae, Sutton aphthae, periadenitis mucosa necrotica) are deeper and larger (≥1 cm) than minor aphthae and may have irregular raised borders.3,6-10 These lesions have a predilection for the lips, soft palate, and fauces.7,11 Major aphthae often take weeks or months to heal and may heal with scar formation.6 Herpetiform aphthae are the least common variety and are characterized by multiple recurrent crops of 10 or more small ulcers of 1 to 3 mm in diameter that may coalesce into larger ulcers with an irregular contour.1,8,9 Healing time for an individual lesion is 7 to 10 days with no scar formation.12
The prevalence of aphthous stomatitis is approximately 20% of the general population.1,6 The onset is typically during childhood, peaks during adolescence and young adulthood, and becomes less common with advancing age.6,8,13 The condition is slightly more common in females.8
Most cases of aphthous stomatitis are idiopathic.5,7 While the exact etiology is not known, it is likely multifactorial with various precipitating factors. A genetic predisposition is present, as shown by an increased frequency of certain human leukocyte antigen (HLA) subtypes and a positive family history in some affected patients.11,12 The most common precipitating factors are emotional/physiological stress and local trauma.2,3,6 Other predisposing factors that might account for recurrent aphthous stomatitis in a minor subset of patients include allergy, food sensitivity, hormonal changes during the menstrual cycle (related to the onset of menstruation or the luteal phase of the menstrual cycle), hematinic (iron, vitamin B6, vitamin B12, folic acid) deficiencies, and drugs (eg, chemotherapeutic agents, nonsteroidal anti-inflammatory drugs, β-blockers, angiotensin-converting enzyme inhibitors).1,3,6,9,13 Medical conditions associated with recurrent aphthous stomatitis include Behçet syndrome, Crohn disease, ulcerative colitis, celiac disease, and systemic lupus erythematosus.1
Aphthous stomatitis can cause considerable pain and may interfere with talking, eating, and swallowing.7,8 The major complication, albeit uncommon, is dehydration from poor fluid intake.
Alleviating pain, expediting resolution of ulcers, and preventing dehydration are the goals of treatment. Predisposing factors should be eliminated if possible. Patients should avoid alcohol, carbonated beverages, and foods that are hard, acidic, spicy, or salty.13 Simple measures to maintain good oral hygiene are important for symptom relief.7 Chlorhexidine gluconate mouthwash has been used to decrease mucosal pain and to prevent secondary infection of the ulcers. Topical corticosteroids, typically in a paste or ointment vehicle, such as triamcinolone acetonide and clobetasol propionate, have a very safe profile when used for a short period and are the mainstay of treatment.5,11,14 Triamcinolone acetonide with carboxymethylcellulose paste (Kenalog in Orabase, 0.1%) is the drug of choice, since the tissue adhesive prevents it from being rapidly washed away, thereby increasing its therapeutic efficacy.15 Topical analgesics such as lidocaine, polidocanol, or benzocaine can be used for pain relief. If necessary, oral ibuprofen or acetaminophen can also be used to relieve the pain.
- Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent Clin North Am. 2014;58(2):281-297.
- Hargitai IA. Painful oral lesions. Dent Clin North Am. 2018;62(4):597-609.
- Cui RZ, Bruce AJ, Rogers RS III. Recurrent aphthous stomatitis. Clin Dermatol. 2016;34(4):475-481.
- Edens MH, Khaled Y, Napeñas JJ. Intraoral pain disorders. Oral Maxillofac Surg Clin North Am. 2016;28(3):275-288.
- Scully C. Aphthous ulceration. N Engl J Med. 2006;355(2):165-172.
- Plewa MC, Chatterjee K. Aphthous stomatitis. StatPearls. http://knowledge.statpearls.com/chapter/0/17766/. Updated June 12, 2019. Accessed June 17, 2019.
- Leung AKC. Aphthous stomatitis. Consultant. 2011;51(11):817-819.
- Femiano F, Lanza A, Buonaiuto C, et al. Guidelines for diagnosis and management of aphthous stomatitis. Pediatr Infect Dis J. 2007;26(8):728-732.
- Edgar NR, Saleh D, Miller RA. Recurrent aphthous stomatitis: a review. J Clin Aesthet Dermatol. 2017;10(3):26-36.
- Bruce AJ, Rogers RS III. Acute oral ulcers. Dermatol Clin. 2003;21(1):1-15.
- Jurge S, Kuffer R, Scully C, Porter SR. Recurrent aphthous stomatitis. Oral Dis. 2006;12(1):1-21.
- Natah SS, Konttinen YT, Enattah NS, Ashammakhi N, Sharkey KA, Häyrinen-Immonen R. Recurrent aphthous ulcers today: a review of the growing knowledge. Int J Oral Maxillofac Surg. 2004;33(3):221-234.
- Shah K, Guarderas J, Krishnaswamy G. Aphthous stomatitis. Ann Allergy Asthma Immunol. 2016;117(4):341-343.
- Rodríguez M, Rubio JA, Sanchez R. Effectiveness of two oral pastes for the treatment of recurrent aphthous stomatitis. Oral Dis. 2007;13(5):490-494.
- Eisenberg E. Diagnosis and treatment of recurrent aphthous stomatitis. Oral Maxillofac Surg Clin North Am. 2003;15(1):111-122.
Geographic tongue, also known as benign migratory glossitis, is an inflammatory disorder of the mucosa of the tongue.1,2 The condition is characterized by a maplike distribution of one or more irregular bright red patches on the dorsum of the tongue due to the absence of filiform papillae.3,4 The lesion is usually surrounded by a slightly elevated, pale-yellow to white, circinate linear border.2
The estimated prevalence ranges from 1% to 2.5% in the general population.1,2,5 The condition occurs more commonly in children (Figure 1) but may also occur in adults (Figure 2).1,2,5 While some studies have shown a female to male ratio of 1.5 to 2:1,1,5 other studies have reported similar rates by sex.6
The exact etiology is not known and most cases are idiopathic.1 There is a genetic predisposition to the condition.6 Several conditions associated with geographic tongue have been reported, including allergy, fissured tongue, psoriasis, type 1 diabetes mellitus, seborrheic dermatitis, hormonal disturbances, pregnancy, use of oral contraceptives, anxiety, emotional stress, alcoholism, Crohn disease, Down syndrome, Aarskog syndrome, and Reiter syndrome.1,3,6,7
Clinically, geographic tongue presents on the dorsum of the tongue as multifocal, circinate or irregular, smooth, well-demarcated, erythematous patches that represent atrophy or loss of filiform papillae and a thinning of the epithelium.1,4 Typically, the erythematous patch is surrounded by a serpiginous, slightly raised, white or pale-yellow, hyperkeratotic border (Figures 1 and 2).1,2,4 The white border is composed of regenerating filiform papillae and a mixture of keratin and neutrophil aggregates within the epithelium.6 These lesions tend to change in shape, size, and location over time, giving the tongue a variegated appearance. They heal spontaneously but reappear at another site, thereby accounting for the name “migratory.”2,4
The condition is usually asymptomatic and is often discovered during routine oral examination.1,4 Affected individuals may experience discomfort, pain, stinging, or a burning sensation with hot, spicy, or acidic foods.4,8 The symptomatic areas tend to occur in the atrophic patches.
Typically, the lesions affect primarily the dorsal surface of the tongue.2,4 Similar lesions have been described in other areas of the oral mucosa, and these have been referred to as geographic stomatitis.2 In rare cases, lesions may involve the ventral surface of the tongue.8
The diagnosis is mainly clinical based on the history of a migrating pattern and the characteristic clinical appearance. No laboratory test is necessary.
The condition is benign and self-limiting. No treatment is required apart from reassurance.2-4 Typically, the lesion resolves spontaneously without sequelae but tends to recur.
- Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113(9):751-755.
- Leung AKC. Red patches on a 10-year-old’s tongue. Consultant Pediatricians. 2013;12(8):362-364.
- González-Álvarez L, García-Pola MJ, Garcia-Martin JM. Geographic tongue: predisposing factors, diagnosis and treatment. A systematic review. Rev Clin Esp. 2018;218(9):481-488.
- Leung AKC. Geographical tongue. In: Leung AKC, ed. Common Problems in Ambulatory Pediatrics: Specific Clinical Problems. Vol 2. New York, NY: Nova Science Publishers; 2011:121-124.
- Nandini DB, Bhavana SB, Deepak BS, Ashwini R. Paediatric geographic tongue: a case report, review and recent updates. J Clin Diagn Res. 2016;10(2):ZE05-ZE09.
- Khan S, Mujahid TA, Ishaq M, Bukhari SAR, Saeed I. Benign migratory glossitis. J Coll Physicians Surg Pak. 2018;28(2):175-176.
- Zadik Y, Drucker S, Pallmon S. Migratory stomatitis (ectopic geographic tongue) on the floor of the mouth. J Am Acad Dermatol. 2011;65(2):459-460.
- Menni S, Boccardi D, Crosti C. Painful geographic tongue (benign migratory glossitis) in a child. J Eur Acad Dermatol Venereol. 2004;18(6):737-738.
Lymphangioma is a hamartomatous malformation of the lymphatic vessels arising from sequestration of portions of the lymphatic tissue that has lost its communication with the other lymphatic tissue but has retained its embryonic growth potential.1-3
The incidence has been reported to be 1.2 to 2.8 per 1000 births.4 The male to female ratio is 2:1.3 Approximately 50% of cases are noted at birth, and 90% are diagnosed before the age of 2 years.3-5 The condition is more common in patients with trisomies, Noonan syndrome, Turner syndrome, familial pterygium colli, hydrops fetalis, and fetal alcohol syndrome.4
Approximately 50% to 75% of lymphangiomas occur in the head and neck region.3,6,7 However, lymphangiomas are rarely reported in the oral cavity.7-9 When lymphangiomas occur in the oral cavity, the most common location is the tongue, followed by the palate, buccal mucosa, gingiva, floor of the mouth, lips, and alveolar ridge of the mandible.3,8,10 If the tongue is affected, the most common site is the anterior two-thirds of tongue’s dorsal surface, as illustrated in the Figure.3,6,7,10
Clinically, lingual lymphangiomas often present as painless macroglossia.3 Superficial lesions typically present as nodules with a pebbly surface that resembles a cluster of translucent vesicles or “frog egg” or “tapioca pudding” appearance (Figure).4,8,9 At various times, the vesicles can appear pink, blue, purple, or red due to rupture of capillaries into the lymphatic inner spaces.1 Deeper lesions present as soft, diffuse nodules without significant change in surface texture or color.3,7
Lymphangioma-related complications include lingual protrusion, cosmetic disfigurement, bleeding associated with oral trauma, sialorrhea, chewing/swallowing/feeding difficulties, speech impairment, poor oral hygiene, halitosis, mandible deformities (eg, open-bite malocclusion, prognathism), dental cavities, and, if large enough, upper airway obstruction.5,7,9-11
The condition is benign, and the prognosis is usually good for most patients.2,3 Spontaneous regression, however, is rare.8 Surgical excision is the treatment of choice.3,10 Other treatment options include intralesional steroids, sclerotherapy, laser surgery, electrocautery, cryotherapy, embolization, radiofrequency tissue ablation, and ligation.4,10 Recurrence of lymphangiomas is common due to the noncapsulated and infiltrating nature of the lymphangioma.2,10
- Devi A, Narwal A, Yadav AB, Singh V, Gupta A. Classical cases of lymphangioma—as multiple vesicular eruptions. J Clin Diagn Res. 2016;10(6):ZD22-ZD23.
- Nagpal T, Shah D, Manjunatha BS, Mahajan A. Macroglossia associated with lymphangioma: surgical management of an interesting case. J Clin Diagn Res. 2015;9(11):ZD04-ZD06.
- Sunil S, Gopakumar D, Sreenivasan BS. Oral lymphangioma—case reports and review of literature. Contemp Clin Dent. 2012;3(1):116-118.
- Bhalla AP, Mehta S, Garg R. Anaesthetic management of a child posted for excision of lymphangioma of the tongue. Singapore Med J. 2012;53(3):e45-e48.
- Kayhan KB, Keskin Y, Kesimli MC, Ulusan M, Ünür M. Lymphangioma of the tongue: report of four cases with dental aspects. Kulak Burun Bogaz Ihtis Derg. 2014;24(3):172-176.
- Akyüz C, Ataş E, Varan A. Treatment of a tongue lymphangioma with sirolimus after failure of surgical resection and propranolol. Pediatr Blood Cancer. 2014;61(5):931-932.
- Usha V, Sivasankari T, Jeelani S, Asokan GS, Parthiban J. Lymphangioma of the tongue—a case report and review of literature. J Clin Diagn Res. 2014;8(9):ZD12-ZD14.
- Babu DB, Kumar BR, Boinepally NH, Gannepalli A. A case of intraoral lymphangioma circumscripta—a diagnostic dilemma. J Clin Diagn Res. 2015;9(10):ZD11-ZD13.
- Catalfamo L, Nava C, Lombardo G, Iudicello V, Siniscalchi EN, Saverio DPF. Tongue lymphangioma in adult. J Craniofac Surg. 2012;23(6):1920-1922.
- Bhayya H, Pavani D, Avinash Tejasvi ML, Geetha P. Oral lymphangioma: a rare case report. Contemp Clin Dent. 2015;6(4):584-587.
- Hong JP, Lee MY, Kim EK, Seo DH. Giant lymphangioma of the tongue. J Craniofac Surg. 2009;20(1):252-254.