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Median Rhomboid Glossitis

Median rhomboid glossitis (MRG) refers to a well-demarcated, largely symmetric lesion of the dorsum of the tongue. This lesion corresponds to an area of papillary atrophy, although most patients remain asymptomatic. The etiology of this rather common condition remains essentially unknown. In general, treatment is not required. In determined cases, patients may benefit from an antifungal therapy.


Presentation

MRG is a common condition and it has been estimated that up 1% of the population show some degree of central papillary atrophy [1]. Men are affected about three times as often as women.

MRG appears as a well-demarcated, roughly rhomboid, erythematous and thus bright red lesion directly anterior to the vallate papillae [2]. Commonly, it seems patchy as the rhomboid area still includes papilla-carrying spots that bear an off-white color. Its surface is smooth or lobulated, and rarely bears erosions [1]. It may be slightly elevated above the surrounding tongue surface. While an MRG lesion is most commonly located in the midline of the dorsum of the tongue, paramedian occurrences have also been described [3]. Usually, patients don't claim any other symptoms. In few cases only, they describe pruritus or pain in the affected area.

There may be a similar lesion in the opposing area of the palate. Such an anomaly is sometimes referred to as "kissing lesion". It may imply an infectious pathogenesis of MRG in an immunodeficient patient. Accordingly, diagnostic measures should be taken to assess their immune system. Diabetes mellitus should be considered in this context, but this variant of MRG is more commonly associated with an HIV infection and an acquired immunodeficiency syndrome [4].

Disability
  • Successful targeted therapies are currently lacking for this oftentimes disabling disorder.[ncbi.nlm.nih.gov]
Lesion of the Tongue
  • Infection by Candida Albicans was found in all biopsies taken from ten patients presenting with midline lesions of the tongue which clinically presented as median rhomboid glossitis.[ncbi.nlm.nih.gov]
  • Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis. We document a case of median rhomboid glossitis with heavy colonisation by Actinomyces in a 60-year-old male.[ncbi.nlm.nih.gov]
  • The main sign of median rhomboid glossitis is a lesion on your tongue. This lesion is erythematous (red) and is located either in the middle of your tongue or at the back of your tongue.[aupairargentina.com]
  • J Postgrad Med 1991 Oct;37(4):238-40 Abstract quote Median rhomboid glossitis is an inflammatory lesion of the tongue, now believed to be secondary to candidiasis.[thedoctorsdoctor.com]
  • Farman AG: Atrophic lesions of the tongue: A prevalence study among 175 diabetic patients. J Oral Pathol 1976;5:255–264. Whitaker SB, Singh BB: Cause of median rhomboid glossitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:379–380.[karger.com]
Malocclusion
  • – Jaw joints, chewing muscles and bite abnormalities Bruxism Condylar resorption Mandibular dislocation Malocclusion Crossbite Open bite Overbite Overeruption Overjet Prognathia Retrognathia Scissor bite Maxillary hypoplasia Temporomandibular joint dysfunction[en.wikipedia.org]
Macrostomia
  • Sialectasis Sialocele Sialodochitis Sialosis Sialolithiasis Sjögren's syndrome Orofacial soft tissues – Soft tissues around the mouth Actinomycosis Angioedema Basal cell carcinoma Cutaneous sinus of dental origin Cystic hygroma Gnathophyma Ludwig's angina Macrostomia[en.wikipedia.org]
Ankylosis
  • Plasmoacanthoma Stomatitis Aphthous Denture-related Herpetic Smokeless tobacco keratosis Submucous fibrosis Ulceration Riga–Fede disease Verruca vulgaris Verruciform xanthoma White sponge nevus Teeth ( pulp , dentin , enamel ) Amelogenesis imperfecta Ankylosis[en.wikipedia.org]

Workup

MRG is usually diagnosed clinically. However, it may not always be feasible to distinguish an uncomplicated MRG from aphthous stomatitis, granuloma, precancerous erythroplakia or neoplasms like hemangioma, squamous cell carcinoma or granular cell tumor [3]. In order to do so, a biopsy and subsequent analysis of the tissue sample is required. During a microscopic examination, the absence of papillae can be confirmed. Also, epithelial anomalies ranging from atrophic to hyperplastic changes are most commonly revealed [5]. Atypical nuclei and numerous mitotic figures are not characteristic of MRG and may indicate a neoplasm, though. In underlying layers of tissue, infiltrating inflammatory cells may be visible. Immunohistochemical stains may be applied to further evaluate the cells' characteristics if deemed necessary.

Additionally, characteristic spores and yeast buds forming pseudohyphae can be recognized microscopically and reveal the presence of Candida spp. If doubts remain as to the presence of yeasts, samples can be subjected to fungal stains. Fungal cultures are rarely required, but may provide interesting epidemiological data. In general, MRG has been associated with chronic Candida infections: A recent microbiological study found Candida albicans to account for the majority of cases, while Candida kefyr, tropicalis, krusei and glabrata have also been isolated [2]. However, one out of ten MRG patients tested negative for Candida spp. Non-Candida pathogens have occasionally been implicated in the development of MRG and may serve as an explanation in this regards [6].

As has been implied in the previous paragraph, if a kissing lesion is present or additional symptoms hint at a dysfunction of the immune system, this suspicion should be followed up.

Polyps
  • Wisdom tooth impaction Macrodontia Meth mouth Microdontia Odontogenic tumors Keratocystic odontogenic tumour Odontoma Dens in dente Open contact Premature eruption Neonatal teeth Pulp calcification Pulp stone Pulp canal obliteration Pulp necrosis Pulp polyp[en.wikipedia.org]

Treatment

  • Treatment: Mycological tests are required, followed by antifungal treatment – median rhomboid glossitis being assimilated with chronic candidiasis. Most of the times the lesion is reversable with proper treatment.[citydent.ro]
  • Dentures and other mouth appliances are also treated with the antifungal treatments to stop the candida from spreading. Although these treatments can help clear the candida, they are not always effective at clearing the lesions.[wisegeekhealth.com]
  • Although conservative or surgical treatment may provide relief, management should also include attention to possible predisposing local factors.[ncbi.nlm.nih.gov]
  • The rete ridges are elongated and hyperplastic (pseudoepitheliomatous hyperplasia, which may be mistaken for carcinoma ). [2] Treatment and prognosis [ edit ] Treatment may involve smoking cessation and prescription of topical or systemic antifungal medication[en.wikipedia.org]
  • Q: What is the treatment for median rhomboid glossitis? A: In general, no treatment is necessary for median rhomboid glossitis.[aaom.com]

Prognosis

  • The rete ridges are elongated and hyperplastic (pseudoepitheliomatous hyperplasia, which may be mistaken for carcinoma ). [2] Treatment and prognosis [ edit ] Treatment may involve smoking cessation and prescription of topical or systemic antifungal medication[en.wikipedia.org]
  • […] branching septated hyphae -invasion of blood vessels -inflammatory response -allergic/non-invasive surgical debridgement,antifungal, steroids -localized/invasive Voriconazole, Itraconazole -Disseminated form Amphotericin B w/ or w/o debridgement -good prognosis[quizlet.com]
  • In most cases, the prognosis for recovery is very good. Defining Oral Candidiasis Oral candidiasis is a fungus and was first isolated in the sputum of a tuberculous patient in 1844.[naturalremedies.org]
  • Glossitis Prognosis This condition generally shows a positive response to treatment if the cause of inflammation is addressed and cured.[hxbenefit.com]
  • Prognosis Erythroplasia has areas of dysplasia, carcinoma in situ , or invasive carcinoma in most cases.[nature.com]

Etiology

  • The findings in 18 patients with median rhomboid glossitis only support partly the hypothesis of Candida albicans being an important etiologic factor.[ncbi.nlm.nih.gov]
  • Although extrapolation of findings from postmortem material to normal subjects is somewhat hazardous, the results seem to question the importance of Candida in the etiology of median rhomboid glossitis.[ncbi.nlm.nih.gov]
  • Maria Angela Naval Machado) Despite the relative frequency of MRG, little is known about its etiology. MRG once was thought to be developmental in origin, although it is seen almost exclusively in adults (Baughman 1971 ; Cooke 1975 ).[pocketdentistry.com]
  • The etiology of this rather common condition remains essentially unknown. In general, treatment is not required. In determined cases, patients may benefit from an antifungal therapy.[symptoma.com]
  • The etiology of this lesion is unknown.[ghorayeb.com]

Epidemiology

  • The anomalies are organized by anatomical system and presented in a consistent manner, including details of the clinical presentation, epidemiology, embryology, treatment and prevention for each anomaly.[books.google.com]
  • Fungal cultures are rarely required, but may provide interesting epidemiological data.[symptoma.com]
  • Seite 124 - High incidence of multinodular toxic goitre in the elderly population in a low iodine intake area vs. high incidence of Graves' disease in the young in a high iodine intake area: comparative surveys of thyrotoxicosis epidemiology in East-Jutland[books.google.com]
  • Usually the mucosal changes resolve with antifungal therapy, but sometimes the lesion is resistant to complete resolution. [2] [4] Epidemiology [ edit ] It is an uncommon condition, occurring with equal prevalence in males and females and at any age.[en.wikipedia.org]
  • […] general Inflammation or beefy red tongue associated with deficiency states Due to atrophy of tongue papillae, thinning of mucosa and exposure of underlying vasculature Terminology Also called central papillary atrophy, posterior lingual papillary atrophy Epidemiology[pathologyoutlines.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology, etiologic factors, and clinical management of oral lichen planus, part I: facts and controversies. Clin Dermatol . 2010;28:100‒108. From Dimensions of Dental Hygiene . August 2013; 11(8): 21–25.[dimensionsofdentalhygiene.com]

Prevention

  • The anomalies are organized by anatomical system and presented in a consistent manner, including details of the clinical presentation, epidemiology, embryology, treatment and prevention for each anomaly.[books.google.com]
  • Candida tends to create an environment that generally results in poor oral health as it prevents harmful bacteria from being washed away. Another possible cause might be excess force exerted from the tongue during speaking or swallowing .[wisegeekhealth.com]
  • Once the infection is gone, you'll need to prevent it from coming back. Your dentist can recommend ways to do this, such as maintaining a good oral hygiene routine.[aupairargentina.com]
  • It can also be prevented by drinking lots of water so as to produce sufficient amounts of saliva which shall prevent the growth of bacteria in the mouth.[primehealthchannel.com]
  • Treatment and Prevention of Glossitis In the vast majority of cases, glossitis is not a dangerous condition to a person’s health and usually does not require any special treatment.[healthpedian.org]

References

Article

  1. Joseph BK, Savage NW. Tongue pathology. Clin Dermatol. 2000; 18(5):613-618.
  2. Goregen M, Miloglu O, Buyukkurt MC, Caglayan F, Aktas AE. Median rhomboid glossitis: a clinical and microbiological study. Eur J Dent. 2011; 5(4):367-372.
  3. Lago-Mendez L, Blanco-Carrion A, Diniz-Freitas M, Gandara-Vila P, Garcia-Garcia A, Gandara-Rey JM. Rhomboid glossitis in atypical location: case report and differential diagnosis. Med Oral Patol Oral Cir Bucal. 2005; 10(2):123-127.
  4. Fine DH, Tofsky N, Nelson EM, Schoen D, Barasch A. Clinical implications of the oral manifestations of HIV infection in children. Dent Clin North Am. 2003; 47(1):159-174, xi-xii.
  5. Fowler JC, White P. A classic case of median rhomboid glossitis. Jaapa. 2009; 22(6):70.
  6. Deshpande RB, Bharucha MA. Median rhomboid glossitis: secondary to colonisation of the tongue by Actinomyces (a case report). J Postgrad Med. 1991; 37(4):238-240.

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Last updated: 2018-06-21 21:30