Are You Confident of the Diagnosis?
What you should be alert for in the history
Geographic tongue is a benign condition, named for its classic clinical appearance of migratory color and texture variations over the dorsal and lateral surfaces of the tongue, creating a map-like appearance. The majority of patients with geographic tongue are asymptomatic and only alarmed by the appearance. Unfortunately, some patients experience an associated pain or burning. This can be a constant discomfort or one induced by spicy foods, acidic foods, salty foods, extremes of temperature, or oral care products.
Characteristic findings on physical examination
The pattern seen on exam is caused by variations in the filiform papillae. Red islands of atrophied papillae are surrounded by white-to-yellowish borders of hyperkeratotic papillae (Figure 1). The shape, size, extent, and intensity of the pattern is dynamic and can change from day to day. It can even normalize for a period of time and resume at a later date. Areas of the mouth other than the tongue may rarely be affected.
Expected results of diagnostic studies
The diagnosis is clinical and no studies are indicated. If a biopsy is performed, the histology is similar to that seen in pustular psoriasis (Figure 2). If a fungal culture is performed, it should be interpreted in light of a 50% commensal rate in the population.
The differential diagnosis includes candidiasis, lichen planus, contact stomatitis, reactive arthritis, erythema multiforme, oral hairy leukoplakia, and bullous dermatoses. These entities may be differentiated by potassium hydroxide (KOH) examination (candidiasis), biopsy (lichen planus, bullous dermatoses, erythema multiforme, oral hairy leukoplakia), and patch testing (contact stomatitis).
Who is at Risk for Developing this Disease?
Geographic tongue affects males and females of all ages but is more common in adults than children, and occurs more in women than men. It is estimated that 1%-3% of the population will experience geographic tongue at some point. Some patients report a family history of geographic tongue. Patients with psoriasis and fissured tongue are at greater risk. Cigarette smoking is inversely related.
Geographic tongue is not thought to be associated with human immunodeficiency virus (HIV) infection; however, an increased prevalence has been reported in very specific HIV-positive populations: pregnant women in rural Malawi and children in northern Thailand.
What is the Cause of the Disease?
Geographic tongue is an inflammatory condition of unknown etiology. It occurs spontaneously and typically remits spontaneously, but relapses are common.
Systemic Implications and Complications
There are no known systemic implications or complications.
For asymptomatic patients, reassurance that geographic tongue is not infectious or contagious, and is not associated with oral cancer, is often sufficient.
For symptomatic patients, management can be challenging. The first interventions should be aimed at avoiding oral irritants, including oral care products (mouthwashes and toothpastes containing tartar control, whitening [bleaching] products, or baking soda) ) and certain foods (spicy, acidic, and cinnamon- or mint-flavored foods).
Symptom modulation can sometimes be achieved with topical viscous lidocaine solution. Occasionally, medications used in an attempt to alter the disease process are successful. Such topical medications include mid- to high-potency corticosteroid gels or solutions, tretinoin gels or solutions, and antihistamine solutions. Oral medications are used much less frequently but include prednisone and cyclosporin.
Lidocaine 2% viscous solution, 15ml swish and spit, every 3 hours as necessary, not to exceed eight doses in 24 hours
Fluocinonide or clobetasol gel, applied two to three times a day
Dexamethasone solution 0.5mg/5ml, 5ml swish and spit, two to three times a day
Tretinoin 0.01 or 0.025% gel, applied two to three times a day
Tretinoin 0.05% solution, 5ml swish and spit, two times a day (may need to be compounded)
Diphenhydramine 12.5mg/5ml solution, 5 to 10ml swish and spit, two to three times a day
Prednisone (for severe refractory cases only)
Cyclosporin (for severe refractory cases only)
Optimal Therapeutic Approach for this Disease
Because of the limited literature and the natural course of spontaneous remission, it is impossible to present an evidence-based therapeutic ladder for geographic tongue. Topical therapies mentioned above and oral antihistamines present low-risk treatment options. The risks associated with more aggressive oral therapies that are not curative need to be weighed against the need for chronic treatment until spontaneous remission occurs.
Because of the benign nature of geographic tongue, no specific follow-up is required. If medications are prescribed for palliation or treatment, appropriate monitoring should be performed.
Unusual Clinical Scenarios to Consider in Patient Management
Some patients report a decrease in lingual tactile sensitivity.
What is the Evidence?
Abe, M, Sagobe, Y, Syuto, T, Ishibuchi, H, Yokoyama, Y, Ishikawa, O. “Successful treatment with cyclosporin administration for persistent benign migratory glossitis”. J Dermatol. vol. 34. 2007. pp. 340-3. (Case report of an unusually aggressive, but successful, treatment of a patient with isolated geographic tongue)
Khongkunthian, P, Grote, M, Isaratanan, W, Piyaworawong, S, Reichart, PA. “Oral manifestations in 45 HIV-positive children from Northern Thailand”. J Oral Pathol Med. vol. 30. 2001. pp. 549-52. (Unexpected finding of slightly increased prevalence of geographic tongue in this pediatric population)
Muzyka, BC, Kamwendo, L, Mbweza, E. “Prevalence of HIV-1 and oral lesions in pregnant women in rural Malawi”. Oral Surg Oral Med Oral Pathol Oral Radiol Edod. vol. 92. 2001. pp. 56-61. (Unexpected finding of slightly increased prevalence of geographic tongue in this population)
Shullman, JD, Carpenter, WM. “Prevalence and risk factors associated with geographic tongue among US adults”. Oral Dis. vol. 12. 2006. pp. 381-6. (Population-based case-control study, providing epidemiologic data on geographic tongue)
Sigal, MJ, Mock, D. “Symptomatic benign migratory glossitis: report of two cases and literature review”. Pediatr Dent. vol. 14. 1992. pp. 392-6. (Two cases of symptomatic pediatric geographic tongue successfully treated with topical diphenhydramine)
Zellickson, BD, Muller, SA. “Generalized pustular psoriasis”. Arch Dermatol. vol. 127. 1991. pp. 1339-45. (Case series establishing the increased prevalence of geographic tongue in patients with pustular psoriasis)
Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.
No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.