Erythema migrans (EM) is a benign, red-and-white condition that commonly affects the tongue. When the lesions of EM appear on the dorsal surface or lateral borders of the tongue, the condition is referred to as geographic tongue (GT).1 As a red and white lesion, geographic tongue may produce cancer anxiety in patients. However, it also can be difficult to arrive at a diagnosis and may result in an overreaction and misdiagnosis as erythroplakia, a condition that is malignant or premalignant. This article is intended to provide a review of GT that will help with diagnosis of this condition, which is benign. Four case studies will be presented. The cases will illustrate the variable clinical manifestations of GT and illustrate that the symptoms the patient reports may not be linked to the clinical presentation.2-4
THE PRESENTATION OF GEOGRAPHIC TONGUE
GT often appears as groups of smooth, reddish-pink, atrophic, or depapillated patches on the dorsum or lateral borders of the tongue. These patches frequently have a slightly elevated, thin, yellow border. The borders are frequently irregular, such that the appearance is reminiscent of an aerial view of land masses, hence the term “geographic.” The smooth, red areas represent loss of filiform papillae, and the yellow, serpiginous borders represent intense aggregates of neutrophils within the epithelium. The locations and patterns change with time, even over just a few days. This changeable nature of the lesions and the redness account for the alternative, more technical name for GT, namely benign migratory glossitis. Several other less common names are, in fact, used for this disorder, such as geographic stomatitis, marginal exfoliative glossitis, transitory benign plaques of the tongue, and more technically, areata stomatitis migrans and exfoliatio areata linguae.
THE ETIOLOGY AND PREVALENCE OF GEOGRAPHIC TONGUE
The cause of GT is unknown. However, situations and conditions producing stress, including allergies, hormonal disturbances, nutritional deficiencies, psychological disturbances, Reiter’s Syndrome,5 and even spicy foods, are related to GT. There are also strong associations with certain other diseases such as psoriasis6 and juvenile diabetes.7 The association of GT with fissured tongue, which has a strong hereditary component, suggests a genetic predisposition for GT. The microscopic characteristics of GT are similar to those of psoriasis, and this leads some to consider GT a form of psoriasis.8
The prevalence of GT in the general population is approximately 1% with no gender specificity, although the prevalence in a population of psoriasis patients is approximately 5%.4,8
SYMPTOMS ASSOCIATED WITH GEOGRAPHIC TONGUE
The majority of patients presenting to the dental office with GT will be asymptomatic. This, however, will not preclude the patient from experiencing cancer anxiety. If symptoms are present, they may include burning mouth,9,10 general oral discomfort, a sensation of something foreign in the mouth, episodes of pain in the ears, or swollen submandibular lymph nodes. This article will review 4 cases, illustrating a lack of correlation between symptoms and clinical appearance of GT.
Case Report No. 1: Geographic Tongue With Fissured Tongue and Mild Burning Mouth
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| Figure 1. Case No. 1 showing a mild presentation of geographic tongue. This patient had mild burning mouth symptoms. |
A 44-year-old female presented with a chief complaint of “tongue discomfort” and clinically evident lesions typical of GT on the right anterior one third of the dorsal surface of the tongue (Figure 1). This condition was first noted at the age of 30. The patient’s physicians had not been able to determine a cause for her condition. Different foods were noted to affect the patient’s tongue. Specifically, this condition was sensitive to spearmint, toast (because of texture), apples, pepper, vinegar, orange juice, spicy foods, and acidic beverages. The patient noted GT during her second pregnancy and had several photographs that documented a florid appearance. She had tried a steroid rinse (dexamethasone elixir), but the condition did not significantly improve.
Diagnosis: fissured tongue and geographic tongue with burning mouth related to intake of food and drink (eg, spicy foods and acidic beverages).
Fissured tongue is a variation of normal and is sometimes called cat’s tongue or scrotal tongue. The tongue has many pronounced grooves, and patients with this condition tend to be more sensitive to acidic beverages and spicy foods. The prevalence is approximately 1% to 2% of the population. GT occurs in approximately 1% of the population, and it occurs in association with fissured tongue in 50% of those patients.4 It is rare that treatment is necessary for either condition, although some patients have utilized a steroid rinse for relatively short periods of time and experienced relief. Note that cinnamon, whitening agents, and products containing triclosan (for tartar control) may be problematic. Therefore, it is advised not to use products with these ingredients for a period of time; on reintroduction, a determination should be made whether they exacerbate the problem.
Case Report No. 2: Geographic Tongue and Severe Burning Mouth
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| Figure 2. Case No. 2 showing a mild presentation of geographic tongue. This patient had severe burning mouth symptoms that waxed and waned independently of the presence of GT. |
A 64-year-old female presented with a chief complaint of “painful erosions on the tongue.” The appearance was typical of GT (Figure 2). The patient described her pain as extending to the teeth but mainly noticed on the tip of the tongue. The condition began approximately 3 months earlier. The patient believed that the current burning symptoms might have been due to a drug side effect. She was previously on the antihypertensive drug Benicar (olmesartan medoxomil, Sankyo Pharma) for ap-proximately 6 to 9 months, and she associated it with a red, burning tongue. At the time of presentation the patient was taking Dyrenium (triamterine, GlaxoSmithKline), a potassium sparing diuretic, and believed that this drug caused her symptoms to exacerbate. She was on Bactrim DS (sulfanilamide, Roche Laboratories) for years and believed that this sulfa antibiotic caused tongue lesions. A week after she discontinued the Bactrim DS, her oral condition improved. However, she then took the fluoroquinoline antibiotic Tequin (Bristol-Myers Squibb), and the mouth condition regressed. She then discontinued this drug, and the condition improved. Subsequently she was using a beta-blocker drug, and the condition became worse.
The medical history was significant for poorly controlled hypertension and elevated serum cholesterol along with an extensive history of allergic reactions or side effects to medications including several antibiotics, antihypertensives, and drugs to inhibit gastric acid production. The patient had prepared a 2-page list of reactions to various medications. The reactions included burning mouth, chest pain, nausea, shortness of breath, dizziness, heart palpitations, and chills. The patient at the time of presentation still suffered from moderate to severe hypertension and high serum cholesterol. She was in the process of discontinuing her prescription for Dyrenium and had previously discontinued taking cholesterol-lowering agents. The patient’s medical history was positive for atrial fibrillation treated with AV node ablation surgery and implantation of a pacemaker. She noted stenosis of the renal artery, reported relatively severe glaucoma, and recent night sweats associated with anxiety. The patient had no history of using tobacco or alcohol. She claimed she was allergic to penicillin and other antibiotics. However, the reported reactions to antibiotics, including gastrointestinal distress, were consistent with drug side effects, not allergies.
Diagnosis: unrelated conditions of geographic tongue and essential burning mouth syndrome (ie, burning mouth syndrome with no apparent relationship to external irritants).
Case Report No. 3: Extensive Geographic Tongue
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| Figure 3. Case No. 3 showing a striking, florid presentation of erythema migrans on the dorsal surface of the tongue (geographic tongue) and on the soft palate. This patient had no symptoms. | Figure 4. Case No. 3 showing the same patient as in Figure 3 with a concomitant presentation of erythema migrans on the tongue’s ventral surface. |
A 72-year-old female patient in the process of having new dentures made presented with a florid array of lesions on the dorsum of the tongue, ventral tongue, and soft palate (Figures 3 and 4). There were no oral symptoms, and the current and past medical histories were noncontributory. There were many oral lesions, and all these lesions were similar in appearance: a central erythematous area surrounded by a well-defined white border. The ongoing fabrication of full dentures was completed uneventfully.
Diagnosis: The diagnosis of the lesions of the dorsal tongue was GT, and the diagnosis of the lesions of the ventral tongue and soft palate was EM.
Case Report No. 4: EM on the Labial Mucosa, No Symptoms
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| Figure 5. Case No. 4 showing a mild, asymptomatic presentation of erythema migrans with lesions on the labial mucosa. The lesions are similar to those of geographic tongue. |
A 36-year-old male patient with no significant medical problems or symptoms presented with lesions on the anterior labial mucosa (Figure 5). No tongue lesions were present. The 2 lesions on the anterior mandibular facial gingiva, below the level of the attached gingiva, were asymptomatic. These lesions were present bilaterally and were approximately 1 and 2 cm in diameter. The lesions had a smooth, slightly erythematous appearance with defined margins. According to the patient, the lesions changed in area, position, and size, and disappeared and reappeared over time.
Diagnosis: The appearance and history were clinically consistent with a diagnosis of EM.
DISCUSSION: THE MANY FACES OF GEOGRAPHIC TONGUE
Case No. 1 is GT with minor sensitivity to acidic beverages and spicy foods. This case demonstrates that some patients with GT will present with mild symptoms of burning mouth. Elimi-nating potential sources of irritation is often sufficient to relieve these symptoms.
Case No. 2 is interesting in that although the patient was experiencing severe burning mouth syndrome, her condition was consistent with GT. While the patient believed that the clinically evident GT was the source of her discomfort, the GT would come and go, but the symptoms of burning mouth were chronic.
Burning mouth syndrome or glossodynia is a relatively common neuropathic pain condition of unknown etiology. This condition mainly affects women over 40 years of age. Approxi-mately 30% of patients with burning mouth syndrome also experience taste abnormalities (dysgeusia). Similar symptoms may occur in patients with candidiasis infections and neuropathies secondary either to nutritional deficiencies or to diabetes. Also, some patients taking ACE-inhibitors for hypertension experience a similar condition. Initial therapy is often predicated upon evaluating the patient for these conditions. Burning mouth syndrome often does not have any clinical oral signs.9,10
Case No. 2 demonstrates that a patient can present with more than one condition at the same time. Further-more, patients may believe that the cause of the painful condition is something that they can see rather than being a nonvisible neuropathic condition. It is important to emphasize that patients are the best source of information about their conditions, and the clinician must listen carefully to the information being conveyed. However, as illustrated here, cases exist where a long and convoluted history of different illnesses produces confusing impressions.
Case No. 3 demonstrates an extreme clinical presentation of GT without symptoms. This case shows that there is not necessarily a correlation between the clinical appearance and symptoms. Furthermore, this case presented with both GT (dorsal tongue) and EM of the soft palate and ventral tongue. The appearance of essentially the same lesion in different anatomical sites is important, as this demonstrates that this condition can affect tissues other than the dorsum of the tongue.
Case No. 4 (EM) demonstrates an asymptomatic lesion of the labial mucosa similar to the asymptomatic lesion of the soft palate seen in the third patient. Note that a biopsy may be needed for a definitive diagnosis.
TELLING THE DIFFERENCE BETWEEN GT AND ORAL CANCER
Squamous cell carcinoma (SCC) is the most common form of oral cancer. It presents as a persistent, frequently painless (since the nerve endings are de-stroyed), ulcerated, solitary, crater-like lesion with a velvety red base (erythroplakia) and a rolled, indurated (hard) border.11,12 GT may present as a solitary lesion, though not usually, but there is no ulcer, no erythroplakia, no indurated border (its borders are serpiginous, soft, and elevated only relative to the depapillated surface of the tongue), and the pattern is transitory, with change noted even over a few days. In addition to the striking differences in clinical appearance between SCC and GT, risk factors that are associated with oral cancer (such as older age, alcohol consumption, and tobacco use) are not associated with GT.
If the clinician does see a solitary ulcer on the oral mu-cosa, the first consideration should be conditions associated with ulcers of short duration (less than 3 weeks), including trauma, recurrent aphthous ulcer, an odontogenic infection, and vesiculobullous disease. If the ulcer persists beyond 3 weeks after removing any local irritants, consideration should be given to chronic trauma, chronic odontogenic infection, major aph-thous ulcer, gumma (from syphilis), and, of course, SCC.
CONCLUSION
EM can appear on the dorsal surface of the tongue and is commonly called geographic tongue. EM can also appear on the ventral surface of the tongue, on the soft palate, and on other intraoral mucosa. GT, while having a wide spectrum of appearances and variable symptomology, has a decidedly different appearance and behavior than a precancerous or malignant lesion. GT should be readily identifiable without causing the patient undue anxi-ety. A biopsy may be performed to aid in a definitive diagnosis.
References
1. Erythema migrans (geographic tongue). In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia, Pa: WB Saunders; 2002:677-679.
2. Jainkittivong A, Langlais RP. Geographic tongue: clinical characteristics of 188 cases. J Contemp Dent Pract. 2005;6:123-135.
3. Menni S, Boccardi D, Crosti C. Painful geographic tongue (benign migratory glossitis) in a child. J Eur Acad Dermatol Venereol. 2004;18:737-738.
4. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113:751-755.
5. O’Keefe E, Braverman IM, Cohen I. Annulus migrans. Identical lesions in pustular psoriasis, Reiter’s syndrome, and geographic tongue. Arch Dermatol. 1973;107:240-244.
6. Femiano F. Geographic tongue (migrant glossitis) and psoriasis. Minerva Stomatol. 2001;50:213-217.
7. Wysocki GP, Daley TD. Benign migratory glossitis in patients with juvenile diabetes. Oral Surg Oral Med Oral Pathol. 1987;63:68-70.
8. van der Wal N, van der Kwast WA, van Dijk E, van der Waal I. Geographic stomatitis and psoriasis. Int J Oral Maxillofac Surg. 1988;17:106-109.
9. Grushka M, Epstein JB, Gorsky M. Burning mouth syndrome. Am Fam Physician. 2002;65:615-260.
10. Grushka M, Kawalec J, Epstein JB. Burning mouth syndrome: evolving concepts. Oral Maxillofac Surg Clin N Am. 2000;12:287-295.
11. Squamous Cell Carcinoma. In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia: WB Saunders; 2002:356-369.
12. Wood NK, Goaz PW. Solitary Oral Ulcers and Fissures. In: Wood NK, Goaz PW, eds. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th ed. St Louis, Mo: Mosby; 1997:162-181.
Dr. Pass is associate professor, department of oral diagnostic services, Howard University College of Dentistry. He can be reached at bpass@howard.edu.
Dr. Brown is professor, department of oral diagnostic services, Howard University College of Dentistry, and clinical associate professor, department of otolaryngology, Georgetown University Medical Center. He can be reached at rbrown@howard.edu.
Dr. Childers is professor and interim chair, department of oral diagnostic services, Howard University College of Dentistry. She can be reached at echilders@howard.edu.
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Continuing Education Test No. 68.2
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After reading this article, the individual will learn:
• the clinical signs of geographic tongue and erythema migrans, and be familiar with the variability of these appearances, and
• how to distinguish clinically between geographic tongue (and erythema migrans) and intraoral squamous cell carcinoma.
1. What is the approximate incidence of geographic tongue in the general population?
a. 1%
b. 5%
c. 10%
d. 20%
2. Geographic tongue is best described as a ______ :
a. premalignant lesion.
b. malignant lesion.
c. benign lesion.
d. infection.
3. In the majority of patients geographic tongue is ______ :
a. symptomatic with burning pain.
b. symptomatic with aching pain.
c. symptomatic with regard to general sensitivity.
d. asymptomatic.
4. The red central area of a geographic tongue lesion is due to ______ :
a. excess filiform papillae.
b. lack of filiform papillae.
c. increased vascularity.
d. increased neutrophils.
5. Such medical conditions as ______ and ______ are associated with geographic tongue.
a. arthritis, syphilis
b. herpes zoster, juvenile diabetes
c. psoriasis, syphilis
d. psoriasis, juvenile diabetes
6. When erythema migrans occurs on the dorsal tongue, it is usually called ______ :
a. areata stomatitis migrans.
b. transitory benign plaques of the tongue.
c. exfoliation areata linguae.
d. geographic tongue.
7. An ulcer on the tongue due to squamous cell carcinoma (SCC) would differ clinically from a patch of erythema migrans (geographic tongue) in that:
a. an ulcer from SCC is painful.
b. an ulcer from SCC has a white border.
c. an ulcer from SCC has a hard, rolled border.
d. both b and c.
8. Burning mouth syndrome is:
a. usually associated with geographic tongue.
b. an autoimmune disorder.
c. frequently associated with oral lesions.
d. frequently associated with taste abnormalities.
To submit Continuing Education answers, download the answer sheet in PDF format (click Download Now button below). Print the answer sheet, identify the article (this one is Test 68.2), place an X in the box corresponding to the answer you believe is correct, and mail to Dentistry Today Department of Continuing Education (complete address is on the answer sheet).
