|Year : 2015 | Volume
| Issue : 2 | Page : 78-81
Map on tongue: An enigmatic oral lesion - rare case report of 2 pediatric patients
Swati Phore1, Rahul Singh Panchal2
1 Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan, India
2 Department of Prosthodontics, Jaipur Dental College, Jaipur, Rajasthan, India
|Date of Web Publication||20-Jul-2015|
Department of Oral Medicine and Radiology, Jaipur Dental College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
It is truly said that the tongue is a mirror of the body. Very often, the manifestations of diseases or systemic conditions of body are reflected on the tongue. There are a variety of different lesions present on the tongue out of which geographic tongue (GT) is the second most common, but its frequency of occurrence in the pediatric population is very rare. This condition is most commonly asymptomatic and is usually discovered on routine clinical examination. This case report describes symptomatic GT, an uncommon occurrence reported in the pediatric literature.
Keywords: Geographic, glossitis, migratory, tongue
|How to cite this article:|
Phore S, Panchal RS. Map on tongue: An enigmatic oral lesion - rare case report of 2 pediatric patients. J Dent Res Rev 2015;2:78-81
|How to cite this URL:|
Phore S, Panchal RS. Map on tongue: An enigmatic oral lesion - rare case report of 2 pediatric patients. J Dent Res Rev [serial online] 2015 [cited 2020 Jun 6];2:78-81. Available from: http://www.jdrr.org/text.asp?2015/2/2/78/161207
| Introduction|| |
Benign migratory glossitis was first reported as a wandering rash of the tongue, in 1831, by Rayer.  This constantly changing pattern of serpiginous white lines surrounding areas of depapillated mucosa resembles land masses and oceans on a map. A number of synonyms are used in literature may refer to this condition such as geographic tongue (GT), erythema migrans, annulus migrans, wandering rash. Sapiro and Shklar also called it as "stomatisis areta migrans."  The term "migratory" is used to denote apparent migration due to simultaneous epithelial desquamation at one site and proliferation at another. 
It is characterized by circinate, erythematous, ulcer-like lesion on the dorsum and lateral border of the tongue due to loss of filiform papillae of tongue epithelium.  GT is not able to change the perception of taste for salty, sweet, sour, or bitter. 
The exact prevalence is not known. However, the prevalence of GT with other tongue lesions is 18.5%.  Percentage of reported cases among children in India is 0.89%, and overall prevalence is 1-2.5% in general population.  Khozeimeh and Rasti reported its prevalence as 4.8%.  Redman observed 1% prevalence in school children with equal distribution among males and females.  Similar prevalence was reported in an investigation by Meskin et al.  Very high prevalence rates were reported in Japanese children (8%) and Israel (14%) with a peak age of 2-3 years. ,
Here, the author presents two rare cases of GT in pediatric patients.
| Case Reports|| |
A 5-year-old [Figure 1] male patient presented to the dental outpatient department with the chief complaint of burning sensation on the tongue on eating citrus and spicy foods. Medical history was noncontributory, and general physical examination was normal. On clinical examination, there was an irregularly erythematous lesion present with loss of filiform papillae on the tip of the tongue [Figure 2]. According to patient's mother, it was present from last 1-month and his father also have similar kind of lesion on the tongue occasionally which resolves on its own and reappears again without a definitive cause in both. After obtaining informed consent from the patient's parent, routine blood investigations were advised. Hemoglobin was found to be 14.2 g%, and total RBC was also within normal limits. A smear was also done to rule out candidal superimposition. No allergen was reported by the parent. On the basis of clinical examination, waxing and waning pattern of the lesion, diagnosis of GT made. Parents were reassured for the tongue lesion and were advised for proper tongue cleaning, avoid spicy and citrus food, and supplementation with Vitamin B12. After 15 days follow-up visit, the lesion showed drastic healing [Figure 3].
A 4-year-old [Figure 4] female patient reported to the outpatient department with a chief complaint of pain in right lower back teeth. On intraoral examination, 74 and 85 were decayed. Irregular erythematous patch with the loss of filiform papillae was reported on lateral border of the tongue [Figure 5]. According to the patient's mother, it was present since 3-4 months, without any discomfort and resolves own its own and then reappears again at a different site on the tongue. After parents, informed consent investigations were advised. Blood investigations and smear reports were within normal limits, and no allergen was reported. A provisional diagnosis of GT and caries with respect to 74, 85 were made based on clinical appearance and remission of the tongue lesion. The patient was advised for the restoration of the decayed teeth, and since no etiological factor was evident, only proper oral hygiene instructions were recommended for the tongue lesion with regular follow-ups.
|Figure 5: Multiple atrophic patches with raised white circinate borders at periphery|
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| Discussion|| |
GT can present as solitary/multiple, intermittent/continuous, usually characterized by periods of remission and exacerbation of varying duration, also called as "waxing and waning pattern."  During remission, the condition resolves without any residual scar formation.  Clinically, it comprises irregular erythematous circinate patches surrounded by a white hyperkeratotic border. It is an asymptomatic inflammatory condition of the dorsum of the tongue sometimes extending toward the lateral borders.  If present anywhere on the oral cavity then it is called as ectopic erythema migrans or annulus migrans.
The exact etiology is unclear. Heredity plays a role in etiology of GT; Redman postulated polygenic mode of inheritance for GT. Redman et al. determined that the prevalence of GT in parents and siblings combination was significantly higher than that observed in the general population as reported in one of the above case.  There have been many reports regarding association between GT and psoriasis. ,
Ray et al. conducted a study in Ohio pediatric population to investigate the possibility of erythema migrans. He concluded that more medications patients were taking, greater the likelihood of erythema migrans. Similarly, there was increased incidence of erythema migrans with the increase number of medical diagnosis. Gender, oral hygiene, and behavioral status were not found to be statistically significant in erythema migrans incidence. 
Other causes like Vitamin B deficiency, a trigger from certain foods such as cheese, congenital anomaly, asthma, rhinitis, systemic diseases such as anemia, gastrointestinal disturbances, candidiasis, lichen planus, hormonal imbalance, spicy food, emotional stress, psychological disturbances, etc., have been suggested in the literature. ,
The diagnosis of GT usually is based on history and clinical presentation which would include characteristic migratory pattern and chronic nature. 
Blood and smear investigations should be done to rule out neutropenia/anemia and fungal infection, respectively. If the definitive diagnosis still not made, then biopsy of the representative lesion would be warranted.
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. 
In 75% of the cases it's asymptomatic. 
Since GT is usually asymptomatic and only rarely does significant pain develop and persist, so patients do not usually require any treatment. , In most of the cases, reassurance about the benign nature of the disorder with proper maintenance of oral hygiene is the only treatment advised like in above cases. 
If symptomatic, patient should be instructed to avoid any known irritants such as hot, spicy, or acidic foods. If treatment is required, then it should be palliative using topical anesthetic rinses or gels, steroids.  Topical and systemic antihistamines have also shown better results.  A psychological component may contribute to the development of GT, so tranquilizers may also be considered as a treatment option.  About 0.1% tacrolimus ointment was also used for treating painful and persistent GT.  Clarithromycin and amoxicillin are equally effective and safe in the treatment of children with solitary erythema migrans, but side effects are also reported in some patients. 
| Conclusion|| |
As the etiology of the GT is still unclear so the result of therapy on symptomatic patients are difficult to interpret because of the possibility that the observed response may merely reflect the natural course of disease rather than effect of the medication. Careful examination and investigations are recommended to rule out probable cause. Reassurance and follow-up of both the young and adult patients are mandatory.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]