Correlation of geographic tongue with early childhood caries in pediatric patient: A review of literature and case series :Sucheta Mahant, Sanjay Kumar Thakur, Indian Journal of Dental Sciences

ORIGINAL ARTICLE
Year : 2023 | Volume : 15 | Issue : 1 | Page : 28--32

Correlation of geographic tongue with early childhood caries in pediatric patient: A review of literature and case series

Sucheta Mahant¹, Sanjay Kumar Thakur²,
¹ Department of Dentistry, Dr. Radhakrishnan Government Medical College, Hamirpur, Himachal Pradesh, India
² Department of Orthopaedic Surgery, Dr. Radhakrishnan Government Medical College, Hamirpur, Himachal Pradesh, India

Correspondence Address:
Sanjay Kumar Thakur
Department of Orthopaedic Surgery, Dr. Radhakrishnan Government Medical College, Hamirpur, Himachal Pradesh
India

Abstract

Background: Benign migratory glossitis(GT) is a recurrent asymptomatic lesion found on the tongue) shows multiple, circinate, and irregular erythematous patches surrounded by slightly elevated white-colored keratotic band.Early childhood caries (ECC) is one of the most common oral disease in children in developing countries. Aim: To find correlation of geographic tongue,anaemia with Early Childhood Caries in children. Result: Early childhood caries (ECC) was found to be high in children with Geographic tongue. In this case series, anemia was also found to be contributory factor for both GT and ECC. Conclusion: GT, a benign recurrent condition on tongue found in children, has ECC can be associated with fissured tongue and anemia.

How to cite this article:
Mahant S, Thakur SK. Correlation of geographic tongue with early childhood caries in pediatric patient: A review of literature and case series.Indian J Dent Sci 2023;15:28-32

How to cite this URL:
Mahant S, Thakur SK. Correlation of geographic tongue with early childhood caries in pediatric patient: A review of literature and case series. Indian J Dent Sci [serial online] 2023 [cited 2023 Mar 26 ];15:28-32
Available from: http://www.ijds.in/text.asp?2023/15/1/28/369897

Full Text

Introduction

Tongue is a sense organ of the oral cavity used for many vital functions such as taste, swallowing, speech, mastication, speaking, breathing, and cleaning of teeth. Geographic tongue (GT) is also known as benign migratory glossitis (BMG) due to the lesion's ability to migrate over time from one location to another. It is a recurrent condition of unknown etiology in which lesion activity may wax and wane with time. It is a benign condition commonly seen on the tip, lateral borders, and dorsum of the tongue. The American Academy of Pediatric Dentistry defines early childhood caries (ECC) as the presence of one or more decayed (noncavitated or cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. For children younger than 3 years of age, any sign of smooth-surface caries indicates severe ECC (S-ECC).[1] ECC has direct impact on oral health such as chewing, eating, disturbed sleep pattern, low self-esteem, and indirect impact on general health by nutritional deficiency. Iron-deficiency anemia is the worldwide form of nutritional deficiency affecting one-third of the world population.[2] Nandini et al. noticed GT with dental caries in 3-year-old child during dental screening camp had found an association of GT with ECC and stress.[3] Fissured tongue is a benign condition characterized by deep grooves on the dorsum of tongue and sometimes associated with GT.[4] Yarom N et al. found a strong correlation between fissured tongue and GT.[5] Hence, parent awareness is a crucial concern to reassure, maintain oral hygiene, and provide well-balanced, healthy nutrition to the children. The objective in this case series and review of literature is to discuss the clinical presentation, associated causative factors, and management strategies of GT.

Epidemiology

GT has a prevalence rate of 3% in the United States.[6] In India, GT reported in children is 0.89% and overall prevalence is 1%–2.5% in the general population.[7] A higher female preponderance is also reported with a ratio of females to males (1.5:1) aged between 9 and 79 years in a population of Thailand.[7] Its prevalence was observed to be 1% by Redman in children.[8] Meskin et al. calculated a similar prevalence in investigation by university students.[9] In Japan, the prevalence of GT in children was found to be 8% and in Israel was found to be 14% with peak age of 2–3 years.[10] The prevalence of GT in pediatric population ranges from 0.37% to 14.3% with unknown etiology.[11] The children with psychosomatic factors such as emotional, more conscious, restless, anxious, and untidy have been found with GT.[8] In children, it can be associated with environmental allergies.[9] The genetic factors have also been considered in etiology as positive family history in some reports, suggesting a polygenic inheritance.[3],[10] A significantly higher prevalence of geographical tongue has been seen in parents and siblings of affected individuals.[11] Nutritional deficiency such as iron-deficiency anemia, Vitamin D, B6, B12, folic acid, and zinc also contribute in ECC and GT due to disturbance in the production of erythrocyte.[3],[12],[13] Health survey (NFHS) 2005–2006 revealed in study that 80% of Indian rural children aged between 12 and 23 months were anemic.[14]

Clinical feature

Geographical tongue is also known by many names such as BMG, annulus migrans, lingual erythema migrans, exfoliation linguae areata, areata stomatitis migrans,[7] and wandering rash of the tongue.[15] Rayer first reported this condition in 1831.[4] The lesions similar to GT occurring in other areas of oral mucosa are called “ectopic GT.”[7] This was first described by Cooke under the name “erythema migrans.”[16] The location and pattern of lesion change over time, thereby called for the name “migratory.” This apparent migration is due to concurrent epithelial desquamation of one location and proliferation at another site.[7] During remission, the condition resolves without any residual scar formation.[7] These periods of remission may last for days, months, or years.

The clinical features include multifocal, circinate, irregular erythematous patches bounded by slightly elevated and white-colored keratotic bands. It is characterized GT by a central erythematous zone having atrophy of the filiform papillae, whereas the white zone shows regenerating filiform papillae along with keratin. The lesions are nontender and nonscrapable. The term “geographic” refers to the resemblance of the dorsum of tongue to an aerial view of areas of landmasses and oceans on a map.[17] Site most commonly involved is the dorsum of the tongue, labial mucosa, gingiva, ventral surface of tongue, and palate.[15]

Usually, it is present as a different pattern such as wavy one dimension, oblate, and in spiral pattern. It is usually asymptomatic but occasionally presents with burning sensation and sensitivity to hot and spicy food.[18] Exfoliation linguae areata is a possible manifestation of atopy as study was done on atopic patients where 35.7% of patients had GT.[19] GT and psoriasis have strong association with HLA-Cw6 and weak link with HLA-B13 is controversial.[3] GT is usually diagnosed by history and clinical features.

Histological feature

Histologically there is epithelial degeneration in the erythematous zone and elongated rete pegs with hyperkeratosis in the white zone. The connective tissue shows infiltration of polymorphonuclear leukocytes and lymphocytes.[20] Most of the cases of GT are self-healing. As the condition is benign in nature, usually histological confirmation is not needed.

Diagnosis

Diagnosis is based upon detail history and clinical examination. Routine laboratory tests are usually normal. Biopsy and histological examination of the lesion is usually not required considering the benign nature of the disease, but may assist in reassuring patients, more so with cancer phobia, of the benign nature of the disease.[21] Exfoliative cytology usually shows Candida association of the lesion as Candida albicans is a normal inhabitant of the oral cavity. Electron microscopy reveals complete loss of filiform papillae in erythematous area and necrotic flaking cells in white borders.[22]

Differential diagnosis

The differential diagnosis of GT in children includes leukoplakia, aphthous ulcer, contact stomatitis, lichen planus, and candidiasis.[3] Leukoplakia is a frictional lesion caused by chronic irritation from rough teeth, mechanical irritation from toothbrush, improper fillings, tobacco habits, smoking, or Epstein–Barr virus-associated oral hairy leukoplakia in immunocompromised persons.[23] Removal of the etiologic factor results in regression of the leukoplakia in a few weeks to a month. Lesion biopsy is taken along with uninvolved mucosa to rule out cancer. GT may have variable appearances and symptoms that need to be differentiated from other lesions of the tongue. Other differential diagnosis includes psoriasis, Reiter's syndrome, systemic lupus erythematosus, herpes simplex, and drug reaction. In children, local trauma, chemical burn, and severe neutropenia should be excluded.[21]

Treatment

Patient usually does not require treatment apart from reassurance. The conditions that exacerbate patient's symptoms such as very hot, spicy, acidic food, and dried salty nuts should be avoided. Various symptomatic treatments have been tried that include hydration, acetaminophen, mouth rinsing with topical anesthetic agents, antihistamines, anxiolytics, and analytics steroids.[7] The other treatment option includes topical tretinoin, Vitamin A therapy, sodium bicarbonate in water, tacrolimus, and combination of retinoic acid and triamcinolone acetonide in symptomatic patients. These drugs actually modulate inflammatory, macrophages activity, and immunological responses.[24] Retinoic acid is a synthetic Vitamin A with anti-inflammatory, antikeratotic, and immunoregulator interfere with arachidonic acid cascade resulting in wound healing and angiogenesis stimulation.[25] Helfman reported satisfactory results after treating three patients with topical tretinoin.[26] Abe et al. reported marked improvement in a female suffering from persistent and painful BMG by systemic administration of cyclosporin. The systemic treatment of cyclosporine microemulsion 3 mg/kg/day resulted in a satisfactory improvement. Two months later, patient was started on maintenance therapy with cyclosporine microemulsion preconcentrate at a dose of 1.5 mg/kg/day.[27] For caries control in children, parents were assured for diet counseling, oral hygiene maintenance, and restorative work of all the carious teeth followed by regular checkup of oral cavity.

Ethical statement

Ethical clearance was taken from the institutional ethical committee before conducting a study of case series.

Informed consent

Informed consent written and verbal assent was obtained from the concerned parent before conducting the clinical examination and taking photographs of children.

Case Series

Case 1

A 3-year-old boy visited along his mother to Department Of Dentistry, Dr. Radhakrishnan Government Medical College Hamirpur, Himachal Pradesh, India, with complaint of red and white patches on tongue, difficulty in eating food for 15 days [Figure 1]a.{Figure 1}

Family history revealed a similar pattern of patches on her elder sister who was 9-year-old showing positive sibilant history. The lesions usually appear off and on with varying sizes and areas of tongue. Fissures in midline of the dorsum of tongue were seen. The child had neither bottle-feeding nor frequent sugar consumption habits. The child was fearful and nervous. His home oral hygiene practice was with toothbrush once in a day in morning only. General medical and physical examination was noncontributory. Allergen to spicy, salty, and hot food was reported by the parents. Clinical examination revealed 51, 52, 54, 61, 62, 64, 71, 81, and 84 teeth were carious [Figure 1]b. There were multiple irregularly erythematosus, asymptomatic lesions extending in the dorsum of tongue to lateral border of tongue surrounded by an elevated thick white border. Filiform papillae were absent [Figure 1]a. After obtaining an informed consent from the patient's parent, a smear was made which came out to be negative for Candida infection. Blood investigation for Hb was 10.5%, and total red blood cell (RBC) count was 2.7 ml/mm3. A provisional diagnosis of GT, fissured tongue along Type III ECC-severe with anemia was made. Parent counseling for oral hygiene maintenance followed by diet counseling and restoration of all carious teeth was done, and strip crown was placed in upper anterior teeth. Parents were reassured for the present condition and instructed for regular follow-up checkups, and at a 20-day follow-up visit, the remission of lesion started [Figure 1]c and [Figure 1]d.

Case 2

A 3-year-old [Figure 2] female patient with chief complaint of decayed upper front teeth, reported to the Department Of Dentistry, Dr. Radhakrishnan Government Medical College Distt. Hamirpur, Himachal Pradesh. Medical history, family history, and general physical examination were noncontributory. According to the patient's mother, lesion was present from last 1 month but not associated with any discomfort. Dietary history revealed that the child always refused to eat hot and spices even salty food. The child was foodie about sweet food only. Personal history revealed prolonged bottle-feeding along with night bottle-feeding. On clinical examination, 51, 52, 61, 62, 71, 74, 75, 81, 82, 84, and 85 teeth were carious [Figure 2]b. 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]a. On routine investigation, hemoglobin was found to be 10.5 g % and total RBC was 2.9 ml/mm3. Diagnosis of Type III ECC-S with GT with anemia was made.{Figure 2}

Counseling of parents for proper oral hygiene maintenance followed by diet counseling was done. The child behavior was found to be definitely negative according to Frankel's Behavior Rating Scale as the child was emotionally immature.[28] Parents were instructed for the further follow-up visits.

Case 3

A 2.5-year-old girl child parent reported to OPD with a chief complaint of dirty-looking teeth after the eruption of milk teeth. Personal history revealed no prolonged bottle and breastfeeding. No history of burning sensation was depicted by child. The child behavior was apprehensive and highly anxious. On intraoral examination, dorsum, lateral, and tip of tongue showed multiple varying sizes denuded areas representing atrophy of papillae with white circinate slight elevated borders surrounding the lesion [Figure 3]a. Fissured were seen on the dorsum of tongue. Intraoral examination showed fair oral hygiene. On clinical examination, 51, 52, 54, 61, and 62 teeth were carious [Figure 3]b. In routine investigation, hemoglobin was found to be 9.5 g % and total RBC was 2.1 ml/mm3. PAS smear was negative for fungal infection of C. albicans.{Figure 3}

Diagnosis of Type II ECC with GT, fissured tongue, and anemia was made. In this case, only oral hygiene instructions for proper oral hygiene maintenance along with tongue cleaning by stroking with soft toothbrush. Parent was reassured, followed by diet counseling and advised for restoration of carious teeth with strip crowns. At 15-day follow-up visit, the lesion was healed.

Case 4

A 3-year-old male child came with his mother in OPD with a chief complaint of broken front teeth with red patches in tongue. His mother complained of discomfort during eating salty and spicy food. The child was highly apprehensive and fearful. Personal history revealed no prolonged breastfeeding and no bottle-feeding. No history of allergy, drug, disease, and family history of GT was present. During intraoral examination, tongue had the presence of local denuded erythematous zones surrounded by a slightly elevated, yellowish-white border in both lateral surfaces of tongue. On clinical examination, 51, 52, 61, and 62 teeth were carious [Figure 4]a and [Figure 4]b. Personal oral hygiene history was with one-time brushing only. On routine investigation, hemoglobin was found to be 8.5 g % and total RBC was 2.5 ml/mm3.{Figure 4}

Diagnosis of Type I ECC with GT along anemia was made [Figure 4]a and [Figure 4]b. Counseling and education of parents for proper oral hygiene maintenance along with tongue cleaning by stroking with soft toothbrush was educated. Parents were advised to take plenty of fluid intakes and recalled for restoration of carious teeth. None of the above-presented cases had any relevant positive history of any drug intake or allergy. In all the subjects had ECC associated with geographic lesions on tongue with no acceptance of spicy and hot food.

Discussion

BMG or GT is commonly asymptomatic of unknown etiology, but sometimes it causes burning sensation to topical factors such as hot and spicy food. Hence, such children are usually fond of sweet food. Kumar et al.[29] also found ECC in children of GT. Hamissi et al.[30] also reported case of GT along with fissured tongue. The lesions site the most common occur on the dorsum of tongue. Due to the presence of irregularly erythematous patches oral hygiene, maintenance of tongue in children is difficult as of their immature age and manual skills, teeth may be insufficiently cleaned leading to more dental caries. Specific cause of GT remains unknown. Cameron et al. found that 90% of children who are diagnosed with GT do not develop psoriasis-like none of the cases had a history of psoriasis.[31] The most common affected site is tongue; however, other oral mucosal soft-tissue sites can be affected. GT and ECC in children are usually related to nutritional deficiency.[12] Anemic children experience more ECC compared to healthy children as experienced by Schroth et al., Gurunathan et al.[3],[32],[33]

Rajkumaar and Mathew found salivary ferritin level high in children with S-ECC which is the expression of iron-deficiency anemia.[34] High ferritin level with diminished cytochrome oxidase depicts oral epithelial changes so have favorable conditions for GT.[35] A systemic review by Hashemi et al. stated that ECC is risk factor for iron-deficiency anemia.[36] Reassurance of the concern parents is must to understand the benign condition of tongue to avoid with cancer phobia.

Conclusion

This case series frame a relation among GT, ECC, and iron-deficiency anemia in pediatric patients. GT usually associated with fissured tongue. Child stress can be contributory factor for GT and ECC. Awareness of parent for oral hygiene is necessary as being association of high caries rate in GT of children. The condition should be considered in the differential diagnosis of red and white lesions even in the early age group. Diet counseling followed by supplementary food with added iron salt can contribute effective role in controlling ECC and GT.

Limitations

The limitation of the case series was small sample size of the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1 American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Unique challenges and treatment options. Pediatr Dent 2002;24 7 Suppl: 24-5.

2 Gurunathan D, Swathi A, Kumar MS. Prevalence of iron deficiency anaemia in children with severe early childhood caries. Biomed Pharmacol J 2019;12:1.

3 Nandini DB, Bhavana SB, Deepak BS, Ashwini R. Paediatric geographic tongue: A case report, review and recent updates. J Clin Diagn Res 2016;10:ZE05-9.

4 Goswami M, Verma A, Verma M. Benign migatory glossitis with fissured tongue. J Indian Soc Pedod Prev Dent 2012;30:173-5.

5 Yarom N, Cantony U, Gorsky M. Prevalence of fissured tongue, geographic tongue and median rhomboid glossitis among Israeli adults of different ethnic origins. Dermatology 2004;209:88-94.

6 Greenburg M, Glick M. Burket's Oral Medicine. 9^th ed. Hamilton: BC Decker Inc.; 2014. p. 103-4.

7 Jainkittivong A, Langlais RP. Geographic tongue: Clinical characteristics of 188 cases. J Contemp Dent Pract 2005;6:123-35.

8 Redman RS. Prevalence of geographic tongue, fissured tongue, median rhomboid glossitis, and hairy tongue among 3,611 Minnesota schoolchildren. Oral Surg Oral Med Oral Pathol 1970;30:390-5.

9 Meskin LH, Redman RS, Gorlin RJ. Incidence of geographic tongue among 3,668 students at the University of Minnesota. J Dent Res 1963;42:895.

10 Eidelman E, Chosack A, Cohen T. Scrotal tongue and geographic tongue: Polygenic and associated traits. Oral Surg Oral Med Oral Pathol 1976;42:591-6.

11 Shekhar MG. Geographic tongue in monozygotic twins. J Clin Diagn Res 2014;8:ZD01-2.

12 Sigal MJ, Mock D. Symptomatic benign migratory glossitis: Report of two cases and literature review. Pediatr Dent 1992;14:392-6.

13 Bansal K, Goyal M, Dhingra R. Association of severe early childhood caries with iron deficiency anemia. J Indian Soc Pedod Prev Dent 2016;34:36-42.

14 WHO. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia. Geneva: World Health Organization; 2008.

15 Pass B, Brown RS, Childers EL. Geographic tongue: Literature review and case reports. Dent Today 2005;24:54, 56-7.

16 Cooke BE. Erythema migrans affecting the oral mucosa. Oral Surg Oral Med Oral Pathol 1955;8:164-7.

17 Bajaj P, Kapoor C, Garg D, Mohammed PK, Sabharwal R, Vaidya S. Geographical tongue in a 6 year old child: A case report with review of literature. Dent J 2013;1:112-7.

18 Togo T. Clinical study on geographic tongue. Kurume Med J 1961;24:1156-72.

19 Ullmann W. Correlation between exfoliatio linguae areata and atopy. Hautarzt 1981;32:629-31.

20 Dayal S, Sahu P, Jain VK. Painful geographical tongue in two siblings. Indian J Pediatr Dermatol 2016;17:75-6.

21 Binmadi NO, Jham BC, Meiller TF, Scheper MA. A case of a deeply fissured tongue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:659-63.

22 Picciani BL, Domingos TA, Teixeira-Souza T, Santos Vde C, Gonzaga HF, Cardoso-Oliveira J, et al. Geographic tongue and psoriasis: Clinical, histopathological, immunohistochemical and genetic correlation – A literature review. An Bras Dermatol 2016;91:410-21.

23 Van der Waal I. Oral leukoplakia, the on going discussion on definition and terminology. Med Oral Patol Oral Cir Buccal 2015;20:e685-92.

24 Boorghani M, Gholizadeh N, Taghavi Zenouz A, Vatankhah M, Mehdipour M. Oral lichen planus: Clinical features, etiology, treatment and management; a review of literature. J Dent Res Dent Clin Dent Prospects 2010;4:3-9.

25 Samuelsson B. An elucidation of the arachidonic acid cascade. Discovery of prostaglandins, thromboxane and leukotrienes. Drugs 1987;33 Suppl 1:2-9.

26 Helfman RJ. The treatment of geographic tongue with topical Retin-A solution. Cutis 1979;24:179-80.

27 Abe M, Sogabe Y, Syuto T, Ishibuchi H, Yokoyama Y, Ishikawa O. Successful treatment with cyclosporin administration for persistent benign migratory glossitis. J Dermatol 2007;34:340-3.

28 Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in dental operatory? J Dent Child 1962;29:150-63.

29 Kumar T, Puri G, Aravinda K, Arora N. Benign migratory glossitis: A rare presentation of a common disorder. J Indian Acad Oral Med Radiol 2015;27:112-4.

30 Hamissi JH, Esfehani M, Hamissi Z. Case report treatment of geographic tongue superimposing fissured tongue: A literature review with case report. Sch J Dent Sci 2015;2:409-13.

31 Cameron P, Jelinek G, Everett I. Textbook of Paediatric Emergency Medicine. Madrid: Elsevier; 2006. p. 365.

32 Schroth RJ, Levi J, Kliewer E, Friel J, Moffatt ME. Association between iron status, iron deficiency anaemia, and severe early childhood caries: A case-control study. BMC Pediatr 2013;13:22.

33 World Health Organization, Benoist B, McLean E, Egli I, editors. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia. Geneva, Switzerland: World Health Organization; 2008.

34 Rajkumaar J, Mathew MG. Association of severe early childhood caries with salivary ferritin. J Family Med Prim Care 2020;9:3991-3.

35 Jagannathan N, Thiruvengadam C, Ramani P, Premkumar P, Natesan A, Sherlin HJ. Salivary ferritin as a predictive marker of iron deficiency anemia in children. J Clin Pediatr Dent 2012;37:25-30.

36 Hashemi A, Bahrololoomi Z, Salarian S. Relationship between early childhood caries and anaemia: A systemic review. Iran J Pediatr Hematol Oncol 2018;8:126-38.