Editor's note: Originally published in 2011 and updated regularly
Integrative medicine practitioners often link the tongue to other areas of the body. The most common tongue condition in the literature is geographic tongue followed by fissured tongue (see Figure 1). The fissured tongue is also the most common oral finding in patients with psoriasis. Other names applied to the fissured tongue are scrotal or plicated tongue.
Erythema migrans (geographic tongue) is often associated with fissured tongue as well.Additionally, certain medical disorders are associated with fissuring of the tongue such as Melkersson-Rosenthal syndrome (MRS) (consisting of a triad of components: fissuring, orofacial edema, and facial nerve palsy), Down syndrome, acromegaly, and Sjögren's syndrome. Electrolyte imbalances in saliva and mild hemolytic abnormalities have been noted as well (Eisen and Lynch, 1998). All of the above disease states can usually be eliminated as possibilities because of the strong clinical characteristics of each.
Intraoral findings: A chief complaint is that of malodor and discoloration associated with deep fissuring of the tongue due to the bacteria and food particles that become embedded in the grooves and cracks. The trapped particles may lead to inflammation and often cause discomfort/burning in the patient.
When fissuring is found in conjunction with geographic tongue, the various balding, concentric rings and unusual patterns can cause alarm in patients who often seek answers from dental professionals.
The more subtle patterns usually are noticed during dental exams, and the health-care provider can offer reassurance to the patient that the condition is benign. In most cases, the tongue exhibits a central groove with smaller grooves radiating from the center line. Some practitioners view the fissuring of the tongue more as a sign of other underlying issues with the total body.
What do we know about the fissured tongue?
Literature suggests that the fissured tongue is relatively common. In fact, it's so common that it is not noted in many clinical exams. Both aging and local environmental factors may also contribute to the small and deep grooves that become noticeable. As we age, other factors may come into play, such as the way that we process foods, vitamins, and minerals, and our T-cell functions decrease or may become faulty.
The grooves may be from 2 to 6 mm in depth. Although the condition is usually seen in adults, it has been reported in children as well. Neville et al. reports that geographic tongue and fissuring have been reported as occurring together or as a separate entity. It is also noted that there may be a familial history.
An integrative approach: In Chinese medicine, the tongue is considered to be the window to total body health. A Chinese medicine practitioner will take a thorough lifestyle history and a medical history, and then the first element of the body that is examined is the tongue. Integrative medicine practitioners do link the tongue to other areas of the body such as the liver, heart, bladder, spleen, and intestines. Many organs are associated with key areas of the tongue.
A naturopathic practitioner, Alyse Shockey, RDH, advises patients regarding the status of the color, shape, thickness, and coating of the tongue with regard to their total health. As with Chinese medicine and integrative approaches, the naturopathic practitioner views the tongue as exhibiting possible health issues that may need monitoring with regard to the total body.
I asked Alyse what her recommendation would be when she examined a patient with a fissured tongue such as the example depicted in Figure 1. She explained that the tongue appearance indicated that there has been a long-term period of deficiency in the body similar to a period of drought over a mass of land. The ground will become extremely dry and start to crack. The tongue topography will look the same way. The deeper the crack, the more chronic the condition of the tongue. The body is experiencing dehydration and long-term adrenal stress. Typically, the tongue is swollen in this state and the pressure causes cracking. Once the underlying issues have been addressed, the fissuring should begin to diminish. So she believes that this condition would not be genetic in nature, but more environmental in most cases.
Alyse also states that the color of the tongue is a useful tool for monitoring the improvements or possibly decline in a patient's condition. The tongue's body color helps determine chronic conditions, and the coating helps determine acute conditions. She correlates this with the patient who has flaming red gingiva vs. pale, pink tissue.
Her advice to the patient would be to address lifestyle factors that may be preventing the body's natural ability to heal itself. The pH is an important aspect in rebuilding and detoxifying the body. Since the condition has been chronic and has taken a long time to reach the current level found clinically, the patient must realize that the process of healing will take some time as well. She usually will suggest a "live food supplement" to make the content readily available to the body.
The most common items missing in the body are minerals, proper fats such as essential fatty acids (EFAs) and greens. The diet is extremely important, and the patient needs to increase fresh foods and water. Once the factors associated with lifestyle are addressed, the body will begin to heal on its own, and the fissuring will start to diminish.
Conclusions: Even though the fissured tongue is considered a benign condition with no treatment needed, the body is perhaps telling us something that needs to be addressed. Assisting patients in trying to determine some lifestyle changes that may be beneficial for total health is certainly something that we need to consider.
In addition to letting the patient know about a tongue cleaner, brushing the tongue with a soft brush to get into the crevices is beneficial. As with any chronic medical or dental problem, keeping a diary of foods and environmental agents that may cause problems or act as trigger mechanisms is the optimal recommendation. Often, a patient may be hearing these suggestions for the very first time since we tend to overlook changes that are considered to be just "benign" in nature. The phrase "learn to live with it" is heard more often than we can imagine.
As many readers, I am a firm advocate of decreasing your toxic world by cleaning up your environment and air quality. Many allergy sufferers will tell you that their world changed when they removed carpeting, covered beds with "dust mite" proof covers, discarded old mattresses, and began to use a neti pot when needed to clear nasal passages. These factors often allow a patient to stop or reduce taking their daily allergy medications and begin to breathe clean air again. Dust and dirt need to be removed from our world, especially in areas where we sleep.
As Alyse has indicated, fresh food sources instead of the processed foods that are commonly eaten can make a huge difference in our health. I have mentioned in a previous column that I like to attend Dr. Andrew Weil's integrative medicine seminars yearly and that I continue to learn new material. There is always a common theme that runs throughout the information presented by Dr. Weil and his associates:
- If you would not place an ingredient in your mouth, don't use it on your skin!
- If the label lists more than five ingredients, you do not need it!
- If your great grandmother would not recognize what you are about to eat, don't eat it!
- Do not buy your meals in the same place that you feed your car!
As always, keep listening to your patients and always ask good questions.
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;109:5: 659-663.
Burkhart N. Geographic tongue. RDH, 2008; Oct 28:10: 54-58.
Eisen D, Lynch D. The Mouth: Diagnosis and Treatment. Mosby St. Louis, 1998.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. Philadelphia: Saunders-Elsevier; 2008.
Reamy BV, Derby R, Bunt CW. Common Tongue Conditions in Primary Care. Am Fam Physician 2010; Mar 1;81(5):627-34.
Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Dent Assoc. 2004; 135(9):1279-1286.
Nancy W. Burkhart, EdD, MEd, BS, RDH, AAFAAOM, is an adjunct professor in the department of periodontics-stomatology at Texas A&M University College of Dentistry. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (dentistry.tamhsc.edu/olp) and coauthor of General and Oral Pathology for the Dental Hygienist, in its third edition. She was awarded an affiliate fellow status in the American Academy of Oral Medicine in 2016. She received the Dental Professional of the Year award in 2017 through the International Pemphigus and Pemphigoid Foundation and is a 2017 Sunstar/Award of Distinction recipient. She can be contacted at [email protected].