Fissured Tongue

Fissured tongue (scrotal tongue, lingua plicata) is a common benign anatomical variation characterised by grooves or furrows on the dorsal tongue, varying in depth from 2 to 6 mm and extending from a central groove to side fissures. Prevalence is 5 to 20 percent in adults and rises with age, reaching about 30 to 40 percent in the elderly. It is also seen in children with Down syndrome (in up to 80 percent).

Aetiology is mainly hereditary (polygenic), with age as a modifier, and an association with geographic tongue (up to 30 percent of fissured tongues co-exist), psoriasis, Sjogren syndrome, acromegaly (macroglossia), Down syndrome, orofacial granulomatosis, and Melkersson-Rosenthal syndrome (a triad of fissured tongue, recurrent orofacial swelling, and facial palsy). Fissures trap debris and bacteria and can cause halitosis, irritation, and Candida overgrowth. The condition is not premalignant.

• Multiple longitudinal or transverse grooves on the dorsum of the tongue, with a central deep groove and branching fissures; surface papillae present.
• Usually asymptomatic.
• When symptomatic: burning, soreness with acidic or spicy foods, halitosis, and food impaction.
• Associated: geographic tongue, macroglossia, oral candidiasis, angular cheilitis.
• Melkersson-Rosenthal syndrome: recurrent lip or facial swelling lasting days to weeks, relapsing peripheral facial palsy.
• Red flags: ulceration within a fissure that does not heal in 3 weeks, white or red patches, induration, lymphadenopathy, rapid macroglossia, and signs of acromegaly.

• Clinical diagnosis by inspection of the tongue; document depth, extent, and the presence of debris or inflammation.
• Swab or smear for Candida species when the tongue is sore or fissures are inflamed.
• Blood tests when symptomatic: full blood count, ferritin, vitamin B12, folate, glucose or HbA1c, and zinc.
• Further investigations if the history suggests a related disease: serum IGF-1 and growth hormone for suspected acromegaly, anti-Ro and anti-La with Schirmer test for Sjogren syndrome, thyroid function tests, and skin examination for psoriasis.
• Biopsy only for non-healing ulceration, induration, or suspicious white or red patches.
• Exclude oral candidiasis, glossitis (nutritional), syphilitic glossitis (tertiary), leukoplakia, lichen planus, malignancy, and granulomatous diseases (Crohn disease, sarcoidosis).

• Asymptomatic: no treatment; reassurance that this is a normal variant.
• Oral hygiene: gently brush the dorsum of the tongue with a soft toothbrush or tongue scraper once or twice daily to remove debris; rinse after meals; brush teeth twice daily with fluoride toothpaste.
• Antiseptic rinse for halitosis and inflamed fissures: chlorhexidine gluconate 0.12 to 0.2 percent mouthwash 10 mL for 1 minute twice daily for 7 to 14 days (avoid prolonged use because of staining), or cetylpyridinium chloride rinse.
• Candida infection: nystatin oral suspension 100 000 units/mL, 5 mL four times daily for 7 to 14 days, or miconazole oral gel 20 mg/g, 2.5 mL four times daily for 14 days; fluconazole 50 to 100 mg orally once daily for 7 to 14 days for resistant cases (check interactions).
• Symptomatic soreness: benzydamine 0.15 percent rinse 15 mL every 3 hours as needed; avoid irritants (spicy, acidic, hot foods; alcohol; tobacco).
• Nutritional deficiency: iron (ferrous sulfate 200 mg three times daily), vitamin B12 (1 mg intramuscularly alternate days for 2 weeks, then every 3 months), folate (5 mg daily for 4 months), zinc sulfate 220 mg daily for 8 weeks.
• Treat associated disease: psoriasis, Sjogren syndrome (artificial saliva, pilocarpine 5 mg three times daily), acromegaly, diabetes.
• Melkersson-Rosenthal syndrome: prednisolone 30 to 40 mg orally daily for 2 to 4 weeks with taper for facial swelling or palsy; intralesional triamcinolone 10 mg/mL, 0.1 mL per site; specialist referral.
• Follow up: routine dental review every 6 to 12 months; earlier if non-healing lesion.
• Counselling: the condition is harmless and not infectious; meticulous tongue cleaning prevents symptoms.