|Year : 2015 | Volume
| Issue : 1 | Page : 113-116
Asymptomatic reversible lesion on tongue: A case series in pediatric patients
Vela D Desai, Swati Phore, Pallavi Baghla
Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan, India
|Date of Web Publication||13-Apr-2015|
Vela D Desai
Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Tongue is a sensitive organ of the oral cavity that is responsible for many vital functions like taste, swallowing, speech, mastication, speaking and breathing. Geographic tongue is a frequently encountered oral condition with a controversial etiology. Since it is an asymptomatic condition known to resolve completely on its own, it is usually discovered during routine clinical examinations. Furthermore, it warrants treatment only when it becomes symptomatic. It can be present on any surface of the tongue but the commonest site is dorsal surface, where it characteristically presents with a migratory pattern that changes in location. This case report describes the uncommon occurrence of the tongue lesion diagnosed in children which is seldom reported in the pediatric literature.
Keywords: Asymptomatic, geographic, glossitis, migratory, tongue
|How to cite this article:|
Desai VD, Phore S, Baghla P. Asymptomatic reversible lesion on tongue: A case series in pediatric patients. Arch Med Health Sci 2015;3:113-6
| Introduction|| |
Benign migratory glossitis (BMG) is a condition referred to by a variety of names, such as geographic tongue, erythema migrans, annulus migrans, and wandering rash of tongue. This condition was first reported by Rayer in 1831.  Geographic tongue is an asymptomatic inflammatory condition of the dorsum of tongue sometimes extending toward the lateral borders.  Its clinical presentation can be solitary/multiple, and intermittent/continuous, usually characterized by periods of remission and exacerbation of varying durations.  During remission, the condition resolves without any residual scar formation.  The location and pattern undergo change over time, thereby accounting for the name "migratory". This apparent migration is due to a concurrent epithelial desquamation at one location and proliferation at another site.  Clinically it comprises irregular erythematous circinate patches surrounded by white hyperkeratotic border. It is usually asymptomatic but occasionally presents with burning sensation and sensitivity to hot and spicy food. 
Here, the authors present three cases of geographic tongue in young children which is rarely reported.
| Case Reports|| |
A 5-year-old [Figure 1] female patient with chief complaint of decayed upper front teeth, reported to the department of oral medicine and radiology. Medical history, family history and general physical examination were non contributory. On clinical examination, maxillary central and laterals were carious. Filiform papillae were absent but an irregularly erythematous patch with a red and white lesion surrounded by white circinate borders was present on the entire dorsal surface of tongue [Figure 2]. According to the patient's mother, it was present from last 1month but not associated with any discomfort. On routine investigation, hemoglobin was found to be 12.5 gm% and total RBC was 2.8 ml/mm 3 . A smear was done to rule out candidal superimposition after a written consent was obtained from the patient's mother. Diagnosis of caries in relation to 51,52,61,62 and geographic tongue was made. Patient was advised to go for extraction of anterior teeth after radiographic evaluation and reassurance for the tongue lesion. Patient was recalled for regular follow-up.
|Figure 2: Case I: Absence of filliform papilla and erythematous patch surrounded by white circinate boders on the tongue|
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A 5-year-old boy came with a chief complaint of dirty looking teeth since 2-3 months to the department of Oral Medicine and Radiology. Intraoral examination showed good oral hygiene. There was an irregularly erythematous, asymptomatic lesion extending from the tip of tongue to the right lateral border of tongue surrounded by an elevated thick white border [Figure 3]. Filiform papillae were absent. After obtaining an informed consent from the patient's parent, a smear was made which came out to be negative for candidal infection. Blood investigations were within normal limits and no known allergen was reported by the parents. As there were no predisposing factors evident, only counseling the parents for proper oral hygiene maintenance especially of the tongue was recommended. At 15 day follow-up visit the lesion showed drastic healing [Figure 4].
|Figure 3: Case II: Irregular, erythmatous lesion on right lateral border and dorsum of tongue|
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|Figure 4: Case II: Complete remission of the lesion on tongue after 15 days|
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A 4-year-old boy [Figure 5] reported to our OPD with a chief complaint of dirty looking teeth since 1 month. On intraoral examination, the dorsum of tongue showed large denuded areas representing atrophy of papillae [Figure 6] with no white circinate borders surrounding the lesion. Smear was negative for fungal infection. A provisional diagnosis of geographic tongue was made. In this case also since no etiological factor was evident, only oral hygiene instructions were recommended for the follow-up visits.
|Figure 6: Case III: Denuded areas with atrophy of papilla on dorsum of tongue|
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None of the above presented cases had any relevant systemic and/or family history and their general physical examination was not contributory either. There were no associated skin lesions in these patients. No positive history of any drug intake or allergy was documented. And in all the subjects there were no symptoms associated with the lesion. Smear was done to rule out candidal superimposition. The patients and their parents were instructed for proper oral hygiene maintenance. Also reassured for the tongue lesion which is self healing and observed for any reoccurrence. Only the second patient reported with remarkable response. The other two patients follow-up was not possible as their contacts were lost.
| Discussion|| |
Geographic tongue is a condition represented as areas of multifocal, circinate, irregular erythematous patches bounded by a slightly elevated, white or cream-colored keratotic band or line. The central erythematous patch represents atrophy of the filiform papillae. The white border is composed of regenerating filiform papillae and a mixture of keratin.  These patches are of various sizes and shapes. Some consider the condition to be a congenital anomaly and others believe it to represent an acute inflammatory reaction.
Percentage of reported cases among children in India is 0.89% and overall prevalence is 1-2.5% in general population. In school children its prevalence was observed to be 1% by Redman.  Similar prevalence was calculated in investigation of university students by Meskin.  High prevalence in children was found in Japan (8%), Israel (14%) with peak age of 2-3 years. 
Females are more commonly affected unlike in this case series, where two were males and one was a female child patient.
Etiology of geographic tongue is not clear but in children it can be associated with environmental allergies.  Other causes like Vitamin B deficiency, a trigger from certain foods such as cheese, congenital anomaly, asthma, rhinitis, systemic diseases like psoriasis, anemia, gastrointestinal disturbances, candidiasis, lichen planus, hormonal imbalance, spicy food, emotional stress, psychological disturbances, etc., have been suggested in the literature. ,,,
If history and clinical examination is not helpful in diagnosis then blood investigation should be obtained to differentiate neutropenia. 
Wysocki et al. investigated the prevalence of geographic tongue in patients with juvenile diabetes as it is known that HLA-B15 occurs more commonly in insulin dependent diabetic patients. They found a prevalence of 8% in type 1 diabetes patients. They concluded that geographic tongue might be a clinical marker for insulin dependent diabetes mellitus. , Geographic tongue is reported to occur in association with fissured tongue. 
Histologically, there is a loss of filiform papillae leaving a flattened mucosal surface with irregular rete pegs. There is epithelial degeneration with an absence of stratum corneum. Beneath the epithelium there is infiltration of inflammatory cells and migration of polymorphonuclear leukocytes and lymphocytes. 
The diagnosis of geographic tongue is based on its characteristic history of migration, its circinate appearance, and a lack of significant pain (opposed to burning) as a subjective complaint. 
The differential diagnosis in children should include psoriasis and other rarities like atrophic candidiasis, drug-induced reactions, etc. Redman et al. found a strong tendency for familial occurrence of geographic tongue. ,
BMG is capable of producing symptoms in children that are significant enough to require management. But in 75.5% of the cases it's asymptomatic as also seen in the presented cases.  Since geographic tongue is usually asymptomatic, patients do not require any significant treatment except proper oral hygiene maintenance with cleaning of the tongue to prevent candidal superimposition. 
The clinical diagnosis of geographic tongue is typical and hence confirmatory. However, to rule out any systemic causes, blood investigations should be indicated for every patient and smear to rule out superimposed fungal infection. As it is a self-limiting lesion, only reassurance is required; but if symptomatic, an avoidance of known irritants is advised along with bland diet, plenty of fluids and palliative care like anesthetic rinses. If there is recurrence of these lesions, antihistamines (Benadryl) rinse 12.5-2.5 mg is required for a few minutes, three to four times a day for 1 week. For recalcitrant lesions steroid (Betamethasone) rinse 500 microgram twice daily for 1-2 weeks is given.  Masaya et al. introduced topical Tacrolimus ointment for 2 weeks and there was an improvement without any side effects. 
| Conclusion|| |
The etiology of geographic tongue is unknown till date and the literature reports varied predisposing factors. So far there is no difference (clinical or symptom related) reported between geographic tongue in children and adult patient. Careful examination and investigations are recommended to rule out probable etiological factor. Reassurance and follow-up of both young and adult patients is mandatory, so that unnecessary treatment protocol is not undertaken. Also long-term follow-up studies should be initiated to know the course, duration of the disease and probable outcome of different treatment modalities in future.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]