Peer Reviewed

Photoclinic

Fissured Tongue

Alexander K.C. Leung, MD, MBBS, FRCPC, FRCP
Benjamin Barankin, MD, FRCPC
Volume 57 - Issue 6 - June 2017

Authors:
Alexander K. C. Leung, MD
Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada

Benjamin Barankin, MD
Toronto Dermatology Centre, Toronto, Ontario, Canada

Citation:
Leung AKC, Barankin B. Fissured tongue. Consultant. 2017;57(6):378-379.

 

A 68-year-old woman presented after having been told by her family physician during a routine medical examination that her tongue looked abnormal. She was asymptomatic and had no problems with eating or drinking. Her past health was unremarkable. In particular, she had no history of diabetes, hypertension, or psoriasis. She was not on any medication.

Physical examination revealed a deep, central, anteroposteriorly oriented groove on the dorsum of the tongue. Smaller radiating grooves extended laterally from the central groove. No abnormalities were noted on the face, skin, and nails. The rest of the examination findings were unremarkable.

The patient received a diagnosis of fissured tongue.

Fissured tongue

Discussion. Fissured tongue, also known as grooved tongue, furrowed tongue, scrotum tongue, lingua fissurata, and plicated tongue, is a benign condition characterized by a fissure/groove oriented anteroposteriorly, often with multiple branch fissures/grooves extending laterally on the dorsum of the tongue.1,2

Epidemiology. Fissured tongue occurs in approximately 0.5% to 6% of the general population.3-5 The condition is very rare in children younger than 10 years.4 The prevalence increases significantly with age, especially after the age of 40.6 There is a slight male predominance.7

Etiology. The exact etiology is not known. Most cases are idiopathic and sporadic. At times, it can be familial.8 A polygenic mode of inheritance has been suggested, because the condition is seen with increased frequency in families with an affected proband.7,9 An autosomal mode of inheritance with incomplete penetrance has also been described.5,8

In one study of 69 individuals with fissured tongue who were typed for HLA-DRB1*, the authors found that patients with HLA-DRB1*08, DRB1*11, DRB1*14, and DRB1*16 were at increased risk, whereas those with DRB1*03 and DRB1*08 were at decreased risk for fissured tongue.5 Further studies are necessary to confirm or refute these findings.

Geographic tongue is a common accompaniment, and some authors believe that these 2 conditions are related.10,11 Fissured tongue is a common oral lesion in patients with psoriasis.12 Furthermore, it forms 1 of the 3 triads of Melkersson-Rosenthal syndrome, namely, a fissured tongue, relapsing orofacial edema, and facial nerve palsy.4,13 Other conditions associated with a fissured tongue have been reported, including diabetes mellitus, hypertension, Down syndrome, acromegaly, vitamin A deficiency, vitamin B deficiency, pernicious anemia, xerostomia, Sjögren syndrome, Coffin-Lowry syndrome, Cowden syndrome, Fraser syndrome, Pierre Robin sequence, Mohr syndrome, Maroteaux-Lamy syndrome, oral-facial-digital syndrome, and orofacial granulomatosis.4,5,7,13-15

Histopathology. Histologic findings include intraepithelial and subepithelial infiltrates of polymorphonuclear leucocytes and lymphocytes, increased thickness of subepithelial connective tissue, hyperplasia of the rete pegs, and enlargement of the lingual papillae.4,5

Clinical manifestations. Based on the pattern of the fissures, 5 clinical variants are recognized: central longitudinal pattern with a vertical fissure running along the midline of the dorsal surface of the tongue, central transverse pattern with horizontal fissure(s) crossing the midline, lateral longitudinal pattern with vertical fissure(s) running laterally to the midline, branching pattern with transverse fissures extending from the central longitudinal fissure (as is illustrated in the present case), and diffuse pattern with fissures diffusely distributed across the surface of the tongue.7 The size and depth of the fissures vary. When the fissures are particularly large and deep, they may be interconnected, separating the dorsum of the tongue into what may look like several lobules.

The majority of patients are asymptomatic, and the condition is often discovered during a routine oral examination.3,9 Occasionally, affected individuals experience discomfort, pain, stinging, or a burning sensation, especially with the consumption of spicy or acidic foods.7

Diagnosis and differential diagnosis. The diagnosis is based on the characteristic clinical appearance. No laboratory test or biopsy is necessary unless the history or physical findings suggests otherwise. Referral to a dermatologist can be considered if there is diagnostic doubt.

The differential diagnosis includes geographic tongue, atrophic glossitis, oral lichenoid drug reaction, lichen planus, oral candidiasis, leukoplakia, and hairy tongue; each of the aforementioned has a unique clinical presentation.13,16

Complications and prognosis. Accumulation of food debris and microorganisms (bacteria, viruses, and fungi) in the fissures can lead to infection and halitosis, as well as an increased potential for dental caries.11,14,17

The condition is benign but usually permanent. It has no malignant potential.

Management. The underlying cause, if present, should be treated. Treatment of the underlying condition, for example psoriasis, may lead to improvement of the appearance of the fissured tongue.1 Otherwise, no medical intervention is required apart from reassurance. Gentle brushing and/or scraping of the dorsum of the tongue after meals and before bedtime is advisable to eliminate food debris in the fissures that may serve as an irritant or reservoir for microorganisms.9,13,15 

REFERENCES:

  1. D’Erme AM, Agnoletti AF, Prignano F. Fissured tongue responding to biologics during the treatment of psoriasis: the importance of detecting oral involvement of psoriasis. Dermatol Ther. 2013;26(4):364-366.
  2. Zargari O. The prevalence and significance of fissured tongue and geographical tongue in psoriatic patients. Clin Exp Dermatol. 2006;31(2):192-195.
  3. Fisher BK, Linzon CD. Scrotal glans penis (glans penis plicatum) associated with scrotal tongue (lingua plicata). Int J Dermatol. 1997;36(10):762-763.
  4. Järvinen J, Mikkonen JJW, Kullaa AM. Fissured tongue: a sign of tongue edema? Med Hypotheses. 2014;82(6):709-712.
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  11. Dudko A, Kurnatowska AJ, Kurnatowski P. Prevalence of fungi of geographical and fissured tongue. Ann Parasitol. 2013;59(3):113-117.
  12. Picciani BLS, Souza TT, Santos Vde C, et al. Geographic tongue and fissured tongue in 348 patients with psoriasis: correlation with disease severity. ScientificWorldJournal. 2015;2015:564326. doi:10.1155/2015/564326
  13. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627-634.
  14. Gonzaga HFS, Marcos EVC, Santana FCS, Jorge MA, Tomimori J. HLA alleles in Brazilian patients with fissured tongue. J Eur Acad Dermatol Venereol. 2013;27(2):e166-e170.
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  17. Leung AKC, Robson WLM, Fung GW, et al. Halitosis. Ann R Coll Physicians Surg Can. 1995;28:213-216.