Geographic Tongue: Is There a Systemic Link?

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Geographic tongue is an inflammatory but harmless condition affecting the surface of the tongue. With geographic tongue, patches on the surface of the tongue are missing papillae and appear as smooth, red “islands,” often with slightly raised borders. Geographic tongue is said to be idiopathic in nature. With so much research connecting systemic disease with oral manifestations, is it possible that geographic tongue is an oral manifestation of a systemic disease?

Geographic Tongue Causes

Several studies in recent years have concluded that some oral lesions, such as geographic tongue and fissured tongue, are strongly associated with psoriasis.1 A higher prevalence of geographic tongue and fissured tongue in patients with psoriasis compared to the general population has prompted some clinicians to consider these oral findings ‘oral psoriasis.’2

According to the American Academy of Dermatology, in the United States, about 7.5 million people have psoriasis. About 80% of those with psoriasis have plaque psoriasis. Seventy five percent of those who will get psoriasis will show symptoms by age 40. Another common age for psoriasis to begin is between 50 and 60 years of age.3

Although geographic tongue is commonly observed in conjunction with psoriasis, its coexistence with other conditions is also apparent. Some of these conditions include diabetes mellitus, hormonal disorders, reactive bronchitis, asthma, eczema, hay fever, atopy, elevated serum IgE, other chronic inflammatory conditions, bacterial infections, anemia, dietary deficiencies, such as vitamin B complex and iron deficiency, Reiter syndrome, and Down syndrome. Nevertheless, a plethora of epidemiological studies showed geographic tongue is most common in psoriatic patients.4

Geographic Tongue and Psoriasis

Geographic tongue is shown to be associated with an array of clinical characteristics of psoriasis, especially its severity. Aside from being a marker of psoriasis severity, geographic tongue seems to also be a predictor of this condition. In some published case reports, the presence of geographic tongue preceded the development of skin psoriasis. Interestingly, histological studies demonstrated even in non-psoriatic patients with geographic tongue, the same histopathological features of psoriasis are present in most cases.4  

Although many studies show a statistical correlation between skin psoriasis and geographic tongue, geographic tongue is often seen in otherwise healthy people in the general population, leading to an underestimation of the value of these findings in psoriatic patients.5 It has been theorized the presence of geographic tongue in the absence of cutaneous lesions may be a failed form of psoriasis.6

In relation to the age of psoriasis onset, data showed a statistically significant occurrence of geographic tongue in early-onset psoriasis, whereas fissured tongue was associated with late-onset psoriasis. Geographic tongue is a psoriatic expression of transitory character, whereas fissured tongue may be a later, more permanent expression of psoriasis.6 Usually, oral manifestations coexist with the involvement of skin, but there are cases in which ‘oral psoriasis’ preceded the development of dermal lesions as well.4

Geographic Tongue Symptoms

Generally, geographic tongue is asymptomatic. However, typical symptoms, when present, may include oral pain, burning, or changes in taste perception. Patients may also express concerns about the malignant potential of lesions or the unaesthetic appearance of the affected area. Although many of the therapeutic modalities for cutaneous psoriasis are not appropriate for use in the oral cavity, a variety of approaches have been documented.4

For mild cases, the recommendation of lukewarm saline rinses, oral moisturizers, alkaline mouth rinses, anesthetic rinses such as viscous xylocaine or diphenhydramine, and mucosal coating agents can afford some relief. Improved control of cutaneous disease can also improve oral manifestations.2

There is evidence from individual case reports that suggests psoriatic patients with concomitant geographic tongue and or fissured tongue may respond well to systemic treatment with retinoids and cyclosporine.4

Considering the findings in many studies that conclude that geographic tongue and fissured tongue can be clearly suggested as oral manifestations of psoriasis, dental professionals should inform patients with these conditions about the correlation. Although the reason for this association is not clear, to strongly validate the relationship between these entities further, additional studies should be conducted.5,7

Dental professionals are encouraged to check for skin lesions in patients with geographic tongue. In addition, dental professionals are advised to recommend patients with geographic tongue for routine skin examinations with a dermatologist.7 Better care for our patients can help them live the healthiest lives possible. Dental professionals are an intricate piece to that puzzle.

SEE ALSO: Why Dental Hygienists Should NEVER Treat Patients with Active Oral Herpes

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  1. Romero, U., Richetta, A., Rocchetti, F., et al. Oral Features in Patients with Psoriasis: An Observational Study. Minerva Stomatol. 2018; 67(1): 12-19.
  2. Fatahzadeh, M., Schwartz, R. Oral Psoriasis: An Overlooked Enigma. Dermatology. 2016; 232(3): 319-325.
  3. Psoriasis Resource Center. (n.d.). American Academy of Dermatology Association.
  4. Pietrzak, D., Pietrzak, A., Krasowska, D., et al. Digestive System in Psoriasis: An Update. Arch Dermatol Res. 2017; 309(9): 679-693.
  5. Germi, L., De Giorgi, V., Bergamo, F., et al. Psoriasis and Oral Lesions: Multicentric Study of Oral Mucosa Diseases Italian Group (GIPMO). Dermatology Online Journal. 2012; 18(1): 11.
  6. Picciani, B.L., Souza, T.T., Santos, V.deC., et al. Geographic Tongue and Fissured Tongue in 348 Patients with Psoriasis: Correlation with Disease Severity. The Scientific World Journal. 2015: 564326.
  7. Tarakji, B., Umair, A., Babaker, Z., et al. Relation Between Psoriasis and Geographic Tongue. J Clin Diagn Res. 2014; 8(11): ZE06-ZE7.