Migratory Glossitis
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White snaky lines (arrow) with parallel grooves are characteristic. |
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Quick Review for Patients
| Migratory glossitis is a psoriasis-like or psoriasis-related condition of the tongue resulting in the production of snaky white lines on the tops and sides, often with small parallel grooves adjacent to them. As in psoriasis, these lines "roam" around the tongue, changing locations or appearances on a weekly, sometimes daily, basis. Many times these lines slowly radiate from a central area of smooth red mucosa, i.e. the normal tongue papillae or "bumps" disappear temporarily. The latter appearance often imparts an appearance similar to that of a globe of the Earth, with irregular white lines representing outlines of continents, hence, the common name for this disease: geographic tongue. Occasional patients have no white lines but have instead smooth red patches, sometimes with small grooves at their edges. Migratory glossitis is usually without symptoms, but some may complain of a burning or tingling sensation, often from secondary fungus or bacterial infection, possibly from a developing anemia (unrelated to the geographic tongue). No treatment is normally needed, but antifungal and antibacterial medications may be used for symptomatic cases; topical or systemic cortisone or prednisone may also be effective. There is no malignant potential. |
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Benign migratory glossitis is a psoriasiform mucositis of the dorsum of the tongue. Its dominant characteristic is a constantly changing pattern of serpiginous white lines surrounding areas of smooth, depapillated mucosa. The changing appearance has led some to call this the wandering rash of the tongue, with the depapillated areas have reminded others of continental outlines on a globe, hence the use of the popular term geographic tongue. As with psoriasis, the etiology of benign migratory glossitis is unknown, but it does seem to become more prominent during conditions of psychological stress and it is found with increased frequency (10%) in persons with psoriasis of the skin. The great majority of those with oral involvement, however, lack psoriatic skin involvement. Approximately 1-2% of the population are affected, although most cases are so mild that they are never formally diagnosed (Table 1).
Clinical Features
All of the microscopic features of psoriasis are present in benign migratory glossitis and migratory stomatitis, but these will not be obvious unless the biopsy is taken from a prominent serpiginous line at the periphery of a depapillated patch. A thickened layer of keratin is infiltrated with neutrophils, as are lower portions of the epithelium to a lesser extent (Figure 6). These inflammatory cells often produce small microabscesses, called Monro's abscesses, in the keratin and spinous layers. Rete ridges are typically thin and considerably elongated, with only a thin layer of epithelium overlying connective tissue papillae (Figures 7 & 8). When rete ridges are not elongated, the pathologist should consider Reiter's syndrome as a diagnostic possibility. Chronic inflammatory cells can be seen in variable numbers within the stroma and silver or PAS staining will often demonstrate candida hyphae or spores in the superficial layers of the epithelium. There is no liquefactive degeneration of basal cells, as seen in lichenoid lesions, and there is no ulceration except in cases of Reiter's syndrome.
Few other pustular diseases affect the oral mucosa. True psoriasis of the oral mucosa would present, of course, an identical appearance under the microscope. Other pustular diseases include pyostomatitis vegetans, stomatitis herpetiformis and the hyperplastic inflammatory response (parulis) at the orifice of a fistula extending to the surface from a dental or periodontal abscess. These lesions all present with microabscess or neutrophilic infiltration of the lower portions of the epithelium or of the underlying connective tissue papillae. None present with abscesses of the keratin or superficial layers. Also, occasional examples of subcorneal pustular dermatitis are encountered in the mouth as subcorneal pustular mucositis, but the separation of the keratin layer from the spinous layer makes it rather easy to differentiate from migratory stomatitis.
Pathology and Differential Diagnosis
All of the microscopic features of psoriasis are present in benign migratory glossitis and migratory stomatitis, but these will not be obvious unless the biopsy is taken from a prominent serpiginous line at the periphery of a depapillated patch. A thickened layer of keratin is infiltrated with neutrophils, as are lower portions of the epithelium to a lesser extent (Figure 6). These inflammatory cells often produce small microabscesses, called Monro's abscesses, in the keratin and spinous layers. Rete ridges are typically thin and considerably elongated, with only a thin layer of epithelium overlying connective tissue papillae (Figures 7 & 8). When rete ridges are not elongated, the pathologist should consider Reiter's syndrome as a diagnostic possibility. Chronic inflammatory cells can be seen in variable numbers within the stroma and silver or PAS staining will often demonstrate candida hyphae or spores in the superficial layers of the epithelium. There is no liquefactive degeneration of basal cells, as seen in lichenoid lesions, and there is no ulceration except in cases of Reiter's syndrome.
Few other pustular diseases affect the oral
mucosa. True psoriasis of the oral mucosa would present, of course, an identical
appearance under the microscope. Other pustular diseases include pyostomatitis vegetans,
stomatitis herpetiformis and the
hyperplastic inflammatory response (parulis) at the orifice of a
fistula extending to the surface from a dental or periodontal abscess. These
lesions all present with microabscess or neutrophilic infiltration of the
lower portions of the epithelium or of the underlying connective tissue papillae.
None present with abscesses of the keratin or superficial layers. Also,
occasional examples of subcorneal pustular dermatitis are encountered
in the mouth as subcorneal pustular mucositis, but the separation
of the keratin layer from the spinous layer makes it rather easy to differentiate
from migratory stomatitis.
Treatment and Prognosis
No treatment is usually necessary for benign migratory glossitis and stomatitis. Symptomatic lesions can be treated with topical prednisolone and a topical or systemic antifungal medication can be tried if a secondary candidiasis is suspected. Occasional symptomatic cases respond well to topical tetracycline or systemic, broad-spectrum antibiotics, but this should not be expected.
References (Chronologic Order)
Note: Click on underlined author's names for additional detail.
General references:
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Philadelphia, W. B. Saunders; 1995.
Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Lever's Histopathology of the skin, 8th edition. Philadelphia; Lippincott-Raven, 1997.
Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. Mosby; St. Louis, 1997.
Odell EW, Morgan PR. Biopsy pathology of the oral tissues. London; Chapman & hall Medical, 1998.
Specific references:
Marks R, Radden BG. Geographic tongue: a clinico-pathological review. Australas J Dermatol 1981; 22:75-79.
Littner M, Dayan D, Gorsky M, et al. Migratory stomatitis. Oral Surg Oral Med Oral Pathol 1987; 63:555-559.
Zunt SL, Tomich CE. Erythema migrans - a psoriasiform lesion of the oral mucosa. J Dermatol Surg Oncol 1989; 15:1067-1070.
Gibson J, et al. Geographic tongue: the clinical response to zinc supplementation. J Trace Elem Exp Med 1990; 3:203-208.
Sklavounou A, Laskaris G. Oral psoriasis: report of a case and review of the literature. Dermatologica 1990; 180:157-159.
Espelid M, et al. Geographic stomatitis: report of 6 cases. J Oral Pathol Ned 1991; 20:425-428.
Morris LF, et al. Oral lesions in patients with psoriasis: a controlled study. Cutis 1992; 49:339-344.
Siegal MJ, Mock D. Symptomatic benign migratory glossitis: report of two cases and literature review. Pediatr Dent 1992; 14:392-396.
Table 1: Gender-specific prevalence rates per 1,000 population for selected oral masses and surface alterations in U.S. adults, ranked by total frequency. Modified from Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc 1986; 112:50-57, and Bouquot JE, Gundlach KKH. Oral exophytic lesions in 23,616 white Americans over 35 years of age. Oral Surg Oral Med Oral Pathol 1986; 62:284-291.
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Diagnosis |
Number of lesions per 1,000 population* |
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Males |
Females |
Total |
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Leukoplakia |
43.2 |
20.9 |
28.9 |
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Torus palatinus |
13/2 |
21.7 |
18.7 |
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Irritation fibroma |
13.0 |
11.4 |
12.0 |
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Fordyce granules |
17.7 |
5.2 |
9.7 |
| Torus mandibularis | 9.6 | 7.9 | 8.5 |
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Hemangioma |
8.4 |
4.1 |
5.5 |
| Erythema, inflammatory | 4.5 | 4.8 | 4.7 |
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Papilloma |
5.3 |
4.2 |
4.6 |
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Epulis fissuratum |
3.5 |
4.4 |
4.1 |
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Varicosities, lingual |
3.5 |
3.4 |
3.5 |
| Fissured tongue | 3.5 | 3.1 | 3.2 |
| Benign migratory glossitis | 3.4 | 3.0 | 3.1 |
| Aphthous ulcer | 3.3 | 3.0 | 3.1 |
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Papillary hyperplasia |
1.7 |
3.8 |
3.0 |
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Mucocele |
1.9 |
2.6 |
2.5 |
| Herpes labialis (herpes simplex) | 2.4 | 2.6 | 2.5 |
| Traumatic ulcer | 2.1 | 2.1 | 2.1 |
| Angular cheilitis | 1.8 | 1.9 | 1.9 |
| Smokeless tobacco keratosis | 4.3 | 0.2 | 1.7 |
| Hematoma or ecchymosis | 2.0 | 1.4 | 1.6 |
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Enlarged lingual tonsil |
2.4 |
1.2 |
1.6 |
| Chronic cheek bite | 0.7 | 1.4 | 1.2 |
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Lichen planus |
1.2 |
1.1 |
1.1 |
| Squamous cell carcinoma | 2.5 | 0.1 | 0.9 |
| Amalgam tattoo | 0.6 | 1.0 | 0.9 |
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Buccal exostosis |
0.9 |
0.9 |
0.9 |
| Leaf-shaped fibroma | 0.4 | 1.2 | 0.9 |
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Median rhomboid glossitis |
0.8 |
0.5 |
0.6 |
| Hairy tongue | 1.2 | 0.3 | 0.6 |
| Nicotine palatinus | 1.2 | 0.2 | 0.6 |
| Atrophic glossitis (smooth tongue) | 0.6 | 0.5 | 0.6 |
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Epidermoid cyst |
0.7 |
0.4 |
0.5 |
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Oral melanotic macule |
0.5 |
0.3 |
0.4 |
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Oral tonsils (except lingual) |
0.5 |
0.3 |
0.4 |
| Leukoedema | 0.4 | 0.3 | 0.3 |
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Lipoma |
0.2 |
0.1 |
0.2 |
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Non-lingual oral tonsils |
0.2 |
0.1 |
0.2 |
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Ranula |
0.2 |
0.1 |
0.2 |
| Gingival hyperplasia | 0.1 | 0.1 | 0.1 |
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Buccinator node, hyperplastic |
0.1 |
0.1 |
0.1 |
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Pyogenic granuloma |
0.0 |
0.07 |
0.04 |
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Nasoalveolar cyst |
0.0 |
0.07 |
0.04 |
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Neurofibroma |
0.0 |
0.07 |
0.04 |
* total examined population = 23,616 adults over 35 years of age
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Figure 1: White snaky lines (arrow) with parallel grooves are characteristic. Notice the small grooves parallel to some lines. [return to text] |
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Figure 2: Serpiginous white lines may be quite pronounced and often surround erythematous areas of papillae loss or edematous papillae. From: Bouquot JE, Gundlach KKH. Quintessence Internat 1986; ; used with permission. [return to text] |
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Figure 3: Many cases have irregular red macules without obvious white peripheral lines. Here the patient also has a mild white coated tongue, a common comorbid feature of geographic tongue. [return to text] |
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Figure 4: The erythematous macules are much more obvious when combined with white coated tongue or, as here, with a mild white hairy tongue. Occasional macules are outlines with irregular white lines, a pathognomonic feature. [return to text] |
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Figure 5: Geographic tongue occurs even in children and infants. [return to text] | |
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Figure 6: Biopsy is usually not necessary, but if done the tissue sample should include a white serpiginous line or the edge of a re macule. The surface will show degenerated epithelium with excess keratin and embedded neutrophils. Chronic inflammatory cells are in the underlying stroma, and rete ridges may be elongated. [return to text] | |
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Figure 7: Small pustules or Monro abscesses in the upper part of the epithelium are characteristic. [return to text] | |
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Figure 8: Higher power view of the neutrophils in the superficial region of the epithelium. [return to text] |
