In this seminar we will learn about the development or tongue and oropharynx starting with Pharynx, its Boundaries and Parts, Structure, layers, muscles of pharynx. Then cover the Blood supply, nerve supply and Lymphatic drainage pharynx. We will also read about Oropharynx and its Relations, Waldeyer’s lymphatic ring and Physiology of deglutition Tongue, its Parts, External features and Papillae of the tongue Muscles of the tongue, Blood supply of the tongue , Arterial and nerve supply, Venous and lymphatic drainage. Development of the tongue and Physiology of taste sensation Developmental disturbances of the tongue and Periodontal implications are other parts of this seminar

1. OROPHARYNX AND TONGUE
PRESENTED BY:
DR. NEHA YADAV
FIRST YEAR PG
DEPARTMENT OF PERIODONTOLOGY
AND ORAL IMPLANTOLOGY
GUIDED BY:
DR. VIVEK CHATURVEDY
DR. H. L. GUPTA
DR. PRADEEP CHAUDHARY
DR. SHRADHA SETHI

2. OROPHARYNX AND TONGUE
GOOD MORNING

3. OROPHARYNX AND TONGUE
 Introduction
 Pharynx:
 Boundaries
 Parts
 Oropharynx:
 Relations
 Waldeyer’s lymphatic ring
 Structure of pharynx:
 Layers of pharynx
 Muscles of pharynx
 Blood supply:
 Arterial supply
 Venous supply

4. Lymphatic drainage
Nerve supply of pharynx
Physiology of deglutition
Tongue:
Parts
External features
Papillae of the tongue
Muscles of the tongue
Blood supply of the tongue
Arterial supply
Venous drainage
Lymphatic drainage
Nerve supply of the tongue

5. Development of the tongue
Physiology of taste sensation
Developmental disturbances of the tongue
Periodontal implications
References

6. Oropharynx and Tongue
INTRODUCTION
•Pharynx is a wide muscular tube situated behind the nose, mouth
and the larynx.
•It is a common passage for both food and air
•It is about 12 cm in length
•Width:
Upper part – Widest – 3.5 cm
Middle part – narrow
Lower part – narrowest
•Tongue is a muscular organ situated in the floor of the mouth with
functions of taste, speech, mastication, deglutition.
•The tongue and oropharynx together form the gateway organs of the
alimentary canal.

7. PHARYNX
Boundaries:
Superiorly – Base of the skull including the posterior part of the body of
sphenoid bone and the basillar part of the occipital bone in front of the
pharyngeal tubercle.
Inferiorly - It is continuous with oesophagus at the level of 6th cervical
vertebra at the lower level of cricoid cartilage.
Posteriorly – It glides freely on the prevertebral fascia which separates
it from the cervical spine.
Anteriorly – It communicates with the nasal cavity, oral cavity and the
larynx. Thus the anterior wall is incomplete.

8. On either sides:
A) It is attached to:
• Medial pterygoid plate
• Pterygo mandibular raphe.
• Mandible
• Tongue
• Hyoid bone
• Thyroid and cricoid cartilages.
B) It communicates on each side with the middle ear cavity through
the auditory tube.
C) It is related on either side to:
• The styloid process and the muscles attached to it.
• The CCA, ICA and ECA.
• Cranial nerves related to them.

10. PARTS OF THE PHARYNX
It is divided into:
a) Nasopharynx
b) Oropharynx
c) Laryngopharynx

11. OROPHARYNX
It is the middle part of the pharynx situated behind the oral cavity where the
pathways of air and food cross each other.
Above : It communicates with the nasopharynx via the pharyngeal isthmus.
Below : It communicates with the laryngopharynx at the level of upper border
of epiglottis.
Behind : It is supported by the body of axis vertebra and the upper part of the
body of 3rd cervical vertebra.
Lateral Wall: Presents the palatine tonsil which lies in the tonsillar fossa. This
fossa is bounded anteriorly by palatoglossal and posteriorly by
palatopharyngeal arches.
The wall of the oropharynx is formed posteriorly by inferior, middle and
superior constrictor muscles of pharynx.

13. WALDEYER’S LYMPHATIC RING:
It is an aggregation of lymphoid tissue
in relation to the oropharyngeal
isthmus.
The Waldeyer’s ring constitutes:
Pharyngeal tonsil: Posteriorly and above
Tubal tonsils: Laterally and above
Palatine tonsils: Laterally
Lingual tonsil: Inferiorly over the
posterior part of the dorsum of the
tongue.

14. Structure of the pharynx
The wall of the pharynx is composed of the following 5 layers:
1. Mucosa – lined by squamous epithelium.
2. Sub mucosa.
3. Pharyngobasilar fascia/pharyngeal aponeurosis:
It is a fibrous sheet deep to the pharyngeal muscles. It thick in the
upper part where it fills the gap between the upper border of the
superior constrictor and the base of the skull. Posteriorly, it forms
the pharyngeal raphe .
Superiorly, it is attached to:
• Basiocciput
• Petrous temporal bone medial to carotid canal.
• Posterior border of medial pterygoid plate.
• Bridges under the auditory tube.
• Pterygo mandibular raphe.

18. Inferiorly, it is gradually lost deep to muscles, and hardly extends beyond the
superior constrictor muscle.
4. Muscle coat – consists of:
Outer circular layer - made up of 3 constrictors.
Inner longitudinallayer – made up of Stylopharyngeus, Salpingopharyngeus,
Palatopharyngeus.
5. Buccopharyngeal fascia – Covers the outer surface of the constrictors
and extends forwards across the pterygomandibular raphe to cover the
buccinator.
The pharyngobasilar and the buccopharyngeal fascia are confined to the
upper part of the pharynx, otherwise they would impede swallowing.
Beneath the buccopharyngeal fascia, on the muscular coat, there lies the
pharyngeal plexus of veins and nerves.

21. BLOOD SUPPLY OF THE PHARYNX
Arterial supply:
•Ascending pharyngeal branch of ECA.
•Ascending palatine and tonsillar branches of facial artery.
•Dorsal lingual branches of lingual artery.
•Greater palatine, pharyngeal and pterygoid branches of the maxillary artery.
Venous supply:
•Veins form a plexus on the posterolateral aspect of the pharynx.
•It receives blood from, pharynx, soft palate and prevertebral region.
• It communicates with the plexus above and drains into the IJV and facial
vein.
Lymphatic drainage:
Drain into retropharyngeal and deep cervical lymph nodes.

22. NERVE SUPPLY
Supplied by pharyngeal plexus of nerves which lies on the middle
constrictor. The plexus is formed by:
•Pharyngeal branch of vagus.n.
•Pharyngeal branch of glossopharyngeal.n.
•Pharyngeal branches of superior cervical sympathetic ganglion.
Vagal fibers – motor.
Glossopharyngeal fibers – sensory.
Sympathetic fibers – vasomotor.
Motor fibers: are derived from cranial accessory nerve through the
branches of vagus nerve. They supply all the muscles of pharynx except
stylopharyngeus which is supplied by glossopharyngeal nerve.
The inferior constrictor is additionally supplied by external laryngeal nerve
and recurrent laryngeal nerve.
The pharyngeal plexus also supplies all muscles of soft palate except
tensor palati which is supplied by mandibular nerve.

23. •Sensory fibers are derived mostly from glosspharyngeal
nerve and partly from vagus nerve. However soft palate and
tonsil are supplied by lesser palatine nerve and
glossopharyngeal nerves.
•Taste sensations from the vallecula and epiglottis area pass
through internal laryngeal branch of vagus nerve.
•Parasympathetic secreto motor fibres to the pharynx are
derived from greater petrosal nerve through the lesser
palatine branches of pterygopalatine ganglion.

24. PHYSIOLOGY OF DEGLUTITION
It occurs in 3 stages:
A. First stage:
Voluntary
1.Anterior part of the tongue is raised and pressed against the hard
palate by the intrinsic muscles of the tongue especially superior
longitudinal and transverse muscles. This pushes the food bolus into
the posterior part of the oral cavity.
2. The soft palate closes down onto the tongue to form a food bolus.
3. Hyoid bone is moved upwards and forwards by the suprahyoid
muscles + elevation of posterior part of the tongue upwards and
backwards by styloglossus muscle + palatoglossal arches are
approximated by palatoglossal muscles. This pushes the bolus into
the oropharynx.

26. B. Second stage:
Involuntary stage.
1. Food is pushed from the oropharynx to the lower part of laryngopharynx.
2. The nasopharyngeal isthmus is closed by the elevation of soft palate and
approximation of posterior pharyngeal wall. This prevents food entering
the nose.
3. The inlet of larynx is closed by the approximation of aryepiglottic folds.
This prevents the food bolus from entering the larynx.
4. The larynx and pharynx are elevated behind the hyoid bond and the bolus
is pushed down over the posterior surface of epiglottis, the closed inlet of
larynx and the posterior surface of the arytenoid cartilages, by gravity and
by contraction of the superior and middle constrictors and of the
palatopharyngeus.

27. C. Third stage:
Involuntary.
1. Food passes from the lower part of the pharynx to the oesophagus.
2. This is brought about by the inferior constrictors of the pharynx.

29. TONGUE
It is a muscular organ situated in the floor of the mouth.
Functions: taste, speech, mastication, deglutition.
Parts:
1. Oral part
2. Pharyngeal part
External features :
The tongue has 1. Body
2. Root
3. Tip/Apex
Body: It has
a) curved upper surface called dorsum and
b) Inferior surface.
Root:
Attached to the mandible and soft palate above and hyoid bone below.
These 2 attachments prevent the tongue from being swallowed.
Tip:
Forms the anterior free end which at rest lies behind the upper incisor teeth.
Separated by a V-shaped sulcus terminalis

31. Dorsum of the tongue
Convex in all directions
Divided into:
1) Oral part or anterior 2/3rds.
2) Pharyngeal or posterior post 1/3rd
The division is by a faint V-shaped groove called “sulcus
terminalis” which contains a median pit called foramen
caecum – represents the site from which the thyroid
diverticulum grows down in the embryo.

32. The oral/papillary part of the tongue:
•Placed on the floor of the mouth.
•Its margins are free and in contact with the gums and teeth.
•The margin in front of the palatoglossal arch shows 4-5 vertical
folds named foliate papillae.
•The superior surface shows a median furrow and is covered with
papillae which make it rough.
•The inferior surface shows a median fold called the lingual
frenum/frenulum linguae.
•On either side of the frenulum, there is a prominence produced by
the deep lingual veins.
•More laterally, there is a fold called plica fimbriata that is directed
forwards and medially towards the tip of the tongue.

33. The pharyngeal/lymphoid part of the tongue:
• It lies behind the palatoglossal arches and the sulcus terminalis.
• Its posterior surface i.e. the base of the tongue forms the anterior
wall of oropharynx.
• The mucous membrane here is devoid of papillae and contains
many lymphoid follicles that are collectively called as the lingual
tonsil.
• This part is connected to the epiglottis by 3 folds of mucous
membrane:
1. Median glosso epitglottic fold.
2. Right and left lateral glosso epiglottic folds.
3. On either side of the median fold, there is a depression called
as vallecula.
• The lateral folds separate the vallecula from the piriform fossa.

35. PAPILLAE OF THE TONGUE
These are projections of mucous membrane or corium which give the
anterior 2/3rds of the tongue, its characteristic roughness. They are:
1. Circumvallate papillae/vallate papillae:
• Larger in size
• 8-12 in number and 1-2 mm in diameter.
• Situated in front of the sulcus terminalis.
• Each papilla is a cylindrical projection surrounded by a circular
sulcus and the walls of the papilla are raised above the surface.
2. Fungiform papillae:
• Present near the tip and margins.
• Smaller than vallate papillae but larger than filiform papillae.
• They are bright red in color and have a narrow pedicle with a large
round head.

37. 3. Filiform papillae/conical papillae:
•Covers the presulcal area of the dorsum of the tongue.
•They give the tongue surface, a velvety appearance.
•They are the smallest and most numerous of the lingual papillae.
•Each papilla is pointed and covered with keratin.
•The apex is often split into filamentous processes.
•They are non-gustatory.
4. Foliate papillae:
•Present on the posterolateral border of the tongue.
•Each papilla is a pocket shaped invagination lined with the taste buds.
•These invaginations protect the taste buds from direct physical
damage.

38. Muscles of the tongue
The tongue is divided into 2 halves by a middle fibrous septum.
Each half contains:
4 intrinsic muscles –
1.Superior longitudinal
2.Inferior longitudinal
3.Transverse
4. Vertical
4 extrinsic muscles –
1.Genioglossus
2.Hyoglossus
3.Styloglossus
4.Palatoglossus

39. Intrinsic muscles
•Occupy the upper part of the tongue.
•Attached to the submucous fibrous layer and to the median fibrous septum.
•They alter the tongue shape.
•Superior longitudinal muscle lies beneath the mucous membrane. It shortens
the tongue and makes its surface concave.
•The inferior longitudinal muscles lies at the inferior surface of the tongue
between the genioglossus and hyoglossus. It shortens and makes the dorsum
of the tongue, convex.
•Transverse muscle extends from the median fibrous septum to the margins. It
makes the tongue narrow and elongated.
•Vertical muscle is found at the borders of the anterior part of the tongue. It
makes the tongue broad and flattened.

40. Extrinsic muscles
Genioglossus:
•It is a fan shaped muscle which forms the main bulk of the tongue.
•Arises from the upper genial tubercle of the mandible.
•From the tubercles, the fibers are divided as 3 groups –
The upper fibers –inserted into the tip (they retract the tip)
The middle fibers – into the dorsum (depress the tongue)
The lower fibers – into the hyoid bone (pull the posterior part of
the tongue forwards and hence protrude it out of the mouth).
•If this muscle is paralyzed, it will fall back on the oropharynx and
block the air passage.
•During anaesthesia, the tongue is pulled forwards to clear the air
passage.

42. Hyoglossus
•Forms an important land mark of the submandibular region.
•Arises from the whole length of greater cornua and lateral part of body of hyoid
bone.
•Fibers run upwards and forwards and inserted into the side of the tongue
between the styloglossus and inferior longitudinal muscle of the tongue.
•It depresses and makes the dorsum convex. It retracts the protruded tongue.
Styloglossus
•Arises from the tip and adjacent part of the anterior surface of the styloid
process as well as from the upper end of the stylohyoid ligament.
•The fibers pass downwards and forwards and are inserted into the side of the
tongue, intermingling with the fibers of the hyoglossus.
•During swallowing it pulls the tongue upwards and backwards.

43. Palatoglossus
•Arises at the oral surface of palatine aponeurosis.
•The fibers descend in the palatoglossal arch, and inserted to the
side of the tongue at the junction of its oral and pharyngeal parts.
•It pulls up the root of the tongue, approximates the palatoglossal
arches and thus closes the oropharyngeal isthmus.

44. Blood supply of the tongue
Arterial supply:
•Chiefly derived from the lingual artery, a branch of the ECA.
•The root of the tongue is also supplied by the tonsillar and ascending
pharyngeal arteries.
Venous drainage:
•Veins of the tongue are also called as venae comitantes.
•2 venae comitantes accompany the lingual artery.
•1 vena comitantes accompany the hypoglossal nerve.
•The largest and principal vein of the tongue is the deep lingual vein which
is visible on the inferior surface of the tongue. It runs backwards and
crosses the genioglossus and the hyoglossus below the hypoglossal nerve.
•These veins unite at the posterior border of the hyoglossus to form the
lingual vein which ends either in the common facial vein or IJV.

46. Lymphatic drainage
•The tip of the tongue drains bilaterally to the sub
mental lymph nodes.
•The right and left halves of anterior 2/3rds drain into
the submandibular lymph nodes of the respective
side.
•The posterior 1/3rd drain into the jugulo-omohyoid
lymph nodes. These are called lymph nodes of the
tongue.

48. Nerve supply of the tongue
Motor nerve:
 Hypoglossal nerve: supplies all the intrinsic and extrinsic muscles of
the tongue except palatoglossus.
 Cranial root of the accessory nerve through the pharyngeal plexus:
supplies palatoglossus muscle.
Sensory nerves:
1.Lingual nerve – anterior 2/3 rds of the tongue (general sensation).
2.Chordatympani nerve – anterior 2/3rds of the tongue except
circumvallate papillae (Taste sensation).
3.Glossopharyngeal nerve – posterior 1/3rd of the tongue and
circumvallate papillae (both general sensation and taste).
4.Vagus nerve though internal laryngeal branch – posterior most part of
the tongue.

50. Development of the tongue
1.Epithelium :
 Anterior 2/3rds – From 2 lingual swellings and 1 tuberculum impar,
which arise from the 1st branchial arch. The impar soon disappears.
Therefore it is supplied by lingual nerve (post trematic) and
chordatympani (pre trematic).
 Posterior 1/3rd – From cranial large part of hypobranchial
eminence i.e. from the 3rd arch. Therefore it is supplied by
glossopharyngeal nerve.
 Posterior most part - From 4th arch. Therefore it is supplied by the
vagus nerve.
2.Muscles:
They develop from the occipital myotomes which are supplied by the
hypoglossal nerve.
3.Connective tissue – Develops from the local mesenchyme

53. Taste sensation
 The sensation of taste is perceived by end organs called ‘taste buds’.
 Taste receptors in the young infant are about 10,000 in number but they
begin to diminish as age advances.
 Most of the taste receptors are situated in the dorsum of the tongue. A
few receptors are also seen on the mucous membrane of the cheek and
epiglottis.
 Taste buds are scattered over the papillae present on the dorsum of the
tongue.
 Taste buds are commonly found along the sides of the vallate papillae,
areas in between the papillae but are totally absent on the filiform
papillae.
 A single papilla may contain several taste buds. Thus a fungiform papilla
may contain 8-10 taste buds and vallate papilla may contain 6-12 taste
buds.

54. Taste bud
•Each taste bud is an oval shaped structure which is packed with cells
and in its tip, there is a pore, called the taste pore.
•The cells that fill the taste buds are 2 types:
1. Supporting/Sustentacular cells
2. Taste/Receptor cells.
•In an individual taste bud, the taste and supporting cells together
constitute about 40-50 cells in number.
•Amongst them about 12 cells are of ‘taste cell’ type and the remaining,
‘supporting cells’.
•Both the taste cells and the supporting cells are now believed to belong
to the same class of cells and represent merely different stages of
development.

56. • From the taste cells, hair like processes, the ‘microvilli’, project out of the
pore.
• It is believed that the molecular receptors are present on these microvilli.
Thus the taste sensation is received by the ‘taste cells’.
• Fine nerve fibers are found within each taste bud.
• These nerve fibers carry taste sensation and constitute either the
chordatympani (anterior 2/3rds) or the glossopharyngeal nerve (posterior
1/3rd).
• Taste cells constantly degenerate and are replaced by new cells from the
surrounding supporting cells throughout the life of an individual.
• Although the taste cells degenerate regularly the nerve terminals do not.
But if the nerve fibers degenerate due to disease, the taste cells also die.

57. Mechanism of the taste sensation:
•The substance that causes taste sensation must be in solution and
must attach itself with the molecular receptors of the microvilli.
•This combination leads to some electro physiological changes to cause
stimulation of the ‘taste cell’ and then the nerve fibers emerging from the
taste bud are stimulated.
•The impulse thus created then reaches the appropriate part of the brain.
Taste pathway:
•Taste sensation from the anterior 2/3 rd of the tongue, is carried by
chordatympani nerve and then proceeds in the secondary division of the
7th cranial nerve and terminate on the nuclei of ‘tractus solitarius’ (NTS).
•2nd order neurons arise from the NTS – relay to the opposite thalamus
– further order neurons arise from the thalamus and terminate on the
post central gyrus at its lower lateral part which is buried within the
lateral sulcus.
•This area is called as the highest cortical center for taste.

59. Features of taste sensation:
There are basically 4 fundamental taste sensations:
1. Salt
2. Sweet
3. Sour
4. Bitter
Admixture of these fundamental sensations in different
proportions, produce different kinds of taste sensations.

60. •Salty taste is produced by:
Inorganic and ionizable substances. NaCl is a classic example of the
ions, the cation is the chief determinant for a salty taste.
•Sour taste is produced by substances which are acidic in nature, that is
those substances which on ionization produces H+
ions. H+
ions produce
the sour taste.
•Sweet tastes are produced by a large number of compounds, most of
which are organic substances. E.g. : Various sugars like glucose,
fructose, sucrose etc;
•Bitter tastes are produced by mostly organic compounds such as
alkaloids. E.g.: Quinine, morphine, strychnine etc. Some inorganic
compounds are also bitter in taste.
•Bile salt is an organic, non alkaloid substance with a bitter taste.

61. Specificity of taste buds:
• An individual taste bud can respond to more than one fundamental taste
sensation, although the bud remain much more sensitive to one type of taste
sensation than others.
• Individual taste cells in a given bud may also have varied sensitivity. For eg.
in a given taste bud, some taste cells may be more sensitive to salt but much
less sensitive to sweet or bitter tastes, other taste cells in the same bud
might be less sensitive to salt but more sensitive to other tastes and so on.
Distribution of specific taste sensitivity:
1. Tip of the tongue – sweet taste
2. The back (near the ‘V’) – bitter taste
3. Sides – sour and salty tastes.
4. Mid dorsum – insensitive to taste.

63. Biologic importance of taste:
•Sweet tastes provoke attraction and bitter tastes provoke rejection
of food. This may be important for herbivorous animals where bitter
plants often contain poisonous alkaloids.
•If there is a need for a specific nutrient in the body, the animal often
develops a crave for it. Thus sodium deficient rats enjoy drinking of
very salty solutions which normal rats would not touch.
Applied physiology:
•In radiotherapy, taste buds are destroyed and taste sensation is
lost.
•The inability of few persons to sense the bitter taste of
phenylthiocarbamide (PTC) unless given in a very high
concentration is called as ‘selective taste blindness’. It is a genetic
disorder.

64. Examination of the tongueExamination of the tongue
Developmental disturbances of the tongueDevelopmental disturbances of the tongue
Other deformitiesOther deformities
Periodontal implicationsPeriodontal implications
ReferencesReferences
OROPHARYNX AND TONGUE

65. Examination of the tongue
A routine periodontal examination should also include the examination of
the tongue on the dorsal surface, lateral borders, and the base for:
Shape
Color
Size
Texture
Consistency
Fissures
Papillae
Coatings
Lesions
Indurations and
Muscular actions.

66. DEVELOPMENTAL
DISTURBANCES OF THE
TONGUE

67. DEVELOPMENTAL DISTURBANCES OF THE
TONGUE
MICROGLOSSIA
Presence of a small or rudimentary tongue. Patients with microglossia
have
difficulties in eating and talking.
MACROGLOSSIA
An enlarged tongue, a somewhat more common condition
thanmicroglossia, may be either congenital or secondary in type.
 Congenital macroglossia is due to an over development of the
musculature as in:
Down’s syndrome
Beckwith's hypoglycemic syndrome
In cretinism or congenital hypothyroidism.
 Secondary macroglossia may occur as a result of:
A tumor of the tongue
Acromegaly due to hyperpituitarism

68. •Macroglossia of either type may produce displacement of
teeth and malocclusion because of the strength of the muscles
involved and the pressure exerted by the tongue on the teeth.
•It is common to see crenation or scalloping of the lateral
borders of the tongue in this condition, the tips of the scallops
fitting into lie interproximal spaces between the teeth.
•There is no particular treatment for macroglossia except
removal of the primary cause, although in some instances
surgical trimming has been used to reduce the bulk of tissue
present.

70. ANKYLOGLOSSIA
•Complete ankyloglossia occurs as a result of fusion between the tongue
and the floor of the mouth.
•Partial ankyloglossia, or the common "tongue-tie," is usually a result of a
short lingual frenum or one which is attached too near the tip of the
tongue. Because of the restricted movement of the tongue, patients with
this defect exhibit speech difficulties, chiefly in the pronunciation of
certain consonants and diphthongs.
•Although some cases of partial ankyloglossia are self-corrective, the
majority are treated surgically by clipping the frenum.
CLEFT TONGUE
•A completely cleft or bifid tongue is a rare condition that is apparently
due to lack of merging of the lateral lingual swellings of this organ.
•A partially cleft tongue is considerably more common and is manifested
simply as a deep groove in the midline of the dorsal surface.

72. •FISSURED TONGUE ("Scrotal" Tongue)
•The fissured tongue is a malformation manifested clinically by
numerous small furrows or grooves on the dorsal surface, often radiating
out from a central groove along the midline of the tongue.
•It has been reported to develop simultaneously with, or as a sequel to,
geographic tongue or benign migratory glossitis.
•Fissured tongue is usually painless except in occasional cases in which
food debris tends to collect in the grooves and produce irritation.
•Here the material may be removed by stretching and flattening the
fissures and using a toothbrush or gauze sponge to cleanse the surface.

74. MEDIAN RHOMBOID GLOSSITIS (Central Papillary Atrophy of
the Tongue)
Median rhomboid glossitis appears as an ovoid-, diamond-, or rhomboid-
shaped reddish patch or plaque on the dorsal surface of the tongue
immediately anterior to the circumvallate papillae.
Current evidence strongly suggests an etiologic relationship between
median rhomboid glossitis and a localized chronic fungal infection,
specifically Candida albicans.
Treatment:
•There is no specific treatment for this lesion. Farman and his associates
treated a group of patients with antifungal agents, either nystatin or
amphotericin B, and found that the lesions regressed in some instances
but not in others.
•Sometimes these lesions will regress spontaneously without treatment.

76. BENIGN MIGRATORY GLOSSITIS (Geographic Tongue; Wandering
Rash of the Tongue; Glossitis Areata Exfoliativa; Erythema
Migrans)
•The condition consists usually of multiple areas of desquamation of the
filiform papillae of the tongue in an irregular circinate pattern.
• The central portion of the lesion sometimes appears inflamed, while the
border may be outlined by a thin, yellowish-white line or band.
•The fungiform papillae persist in the desquamated areas as small, elevated
red dots.
•The areas of desquamation remain for a short time in one location and then
heal and appear in another location, thus giving rise to the idea of migration.
Treatment and Prognosis:
Since the etiology is unknown, the treatment is empirical. Because the
condition is a benign one, there should be no need for concern other than to
reassure the patient.

78. HAIRY TONGUE
•This condition is characterized by hypertrophy of the filiform papillae of the
tongue, with lack of normal desquamation which may be extensive and form
a thick matted layer on the dorsal surface.
•The color of the papillae may vary from yellowish white to brown or even
black, depending upon their staining by such extrinsic factors as tobacco,
certain foods, medicines, or chromogenic organisms of the oral cavity.
•The papillae, which may be of considerable length, occasionally will brush
the palate of the patient and produce gagging.
Etiology:
•Microorganisms, particularly fungi, including Candida albicans.
•Systemic disturbances (e.g., anemia, gastric upsets)

79. •Oral use of certain drugs (e.g., sodium perborate, sodium peroxide, and
antibiotics such as penicillin and Aureomycin) may incite this condition. In
the case of antibiotics, it is reasoned, there is suppression of growth of the
normal oral bacterial population and a concomitant unrestrained growth of
fungi.
•Heavy smoking
•In patients who have had exten­sive x-ray radiation about the head and
neck for the treatment of a tumor.
Treatment:
•This is a benign condition. Treatment is empirical because the etiology is
still unknown.
•Food debris often collects deep between the papillae and produces
irritation of the tongue. In such cases the tongue may be brushed with a
toothbrush to promote desquamation and remove the debris.

81. ATROPHIC GLOSSITIS (Burning Tongue)
•In this situation the tongue appears smooth, shiny, and bald,
with atrophied papillae.
•The condition is related to anemia that results from a
deficiency of iron or combinations of deficiencies.

83. LINGUAL VARICES (Lingual or Sublingual Varicosities)
•A varix is a dilated, tortuous vein, most commonly a vein which is
subjected to increased hydrostatic pressure but poorly supported by
surrounding tissue.
•Varices involving the lingual ranine veins are relatively common,
appearing as red or purple shotlike clusters of vessels on the ventral
surface and lateral borders of the tongue as well as in the floor of the
mouth.
•These varicosities represent an aging process and that, when they
occur prior to 50 years of age, they may indicate premature aging.

85. LINGUAL THYROID NODULE
•The lingual thyroid is an anomalous condition in which follicles of thyroid
tissue are found in the substance of the tongue, possibly arising from a thyroid
anlage that failed to migrate to its predestined position or from anlage
remnants that became detached and were left behind.
•The lingual thyroid may be manifested clinically as a nodular mass in or near
the base of the tongue in the general vicinity of the foramen caecum
Etiology:
•The benign enlargement of lingual thyroid tissue is thought to be due to
functional insufficiency of the chief thyroid gland in the neck, since some
patients with such a lingual lesion are without a demonstrable main thyroid
gland.
•Other cases of lingual thyroid nodules occur in patients residing in goitrous
areas.
•The failure of the primitive thyroid anlage to descend is the cause of the
majority of cases of nongoitrous sporadic cretinism.

87. OTHER DEFORMITIES

88. OTHER DEFORMITIES
GLOSSODYNIA
•It is the pain and the burning sensation in the lingual and oral mucosa. It may also be
experienced as a sandy feeling, tickling or itching sensation in the tongue.
•It occurs particularly in postmenopausal women with accompanying complaints of
changes in the taste sensation and a dry mouth.
Etiology:
•Geographic tongue, fissured tongue, and median rhomboid glossitis may produce
glossodynia.
•Lichen planus may also cause glossodynia which some authors refer it to as ‘lichen
rubber glossodynicus’.
•Habits such as sucking, constantly moving the tooth along the teeth or dentures may
also cause pain especially in the presence of sharp edges of broken down teeth and
restorations.

89. • Pernicious anemia.
• Plummer Vinson syndrome
• Hormonal changes during menopause
• Psychiatric diseases such as depression, cancerophobia,
neurosis, schizophrenia etc.
• As a side effect to certain drugs used to modify psychological
functions or mental states.
Treatment:
• Stop spicy foods or beverages
• Psychotherapy
• Anti depressant drugs with little anticholinergic effects for
depression induced glossodynia.

90. STOMATITIS AREATA MIGRANS
•Circular or arcuate lesions of ventral tongue, floor of the mouth and
buccal vestibule are seen similar to benign migratory glossitis.
•Clinical behaviour- similar to that of benign migratory glossitis but no
associated traumatic factors.
Treatment:
•Removal of local irritational causes and empirical treatment
•Patient to stop brushing the tongue as it intensifies and prolongs the
condition.

92. CHRONIC ULCERS
•They differ from ulcers of other parts of the oral cavity of the mouth as they
tend to remain relatively unchanged for long periods.
•They are commonly found on the middle and posterior thirds of the lateral
borders of the tongue.
•Appear as a shallow ulceration surrounded by a raised rolled border of
fibrous tissue and an outer wide zone of induration.
Etiology:
•Injury as a result of lack of tongue coordination during mastication caused by
prescribed medication or a systemic condition such as a Parkinson’s disease
or a stroke that involves the cranial nerves.
•Enlarged tongue also causes injury.
•In denture wearers, malpositioned posterior teeth on the denture base may
be a contributing factor.

94. TONGUE WITH PERIODONTAL
IMPLICATIONS

95. TONGUE THRUST HABIT
Tongue thrust is defined as:
The infantile pattern of suckle-swallow movement in which the tongue is
placed between the incisor teeth or alveolar ridges which may result in an
anterior open bite, deformation of jaws, and abnormal function.
Etiology of tongue thrust
•Genetic factors: Hypertonic orbicularis oris activity.
•Learned behavior (habit):
a. Improper bottle feeding
b. Prolonged thumb sucking
c. Prolonged tonsillar and upper respiratory tract infections
d.Prolonged duration of tenderness of gum or teeth can result in a
change in swallowing pattern to avoid pressure on the tender zone

96. •Maturational: Sometimes the maturation is delayed and thus infantile
swallow persists for a longer duration of time.
•Mechanical restrictions: The presence of certain conditions such as
macroglossia, constricted dental arches and enlarged adenoids predispose to
tongue thrust habit.
•Neurological disturbance: Such as hyposensitive palate and moderate
motor disability can cause tongue thrust habit.

97. Clinical features
The tongue thrust habit can be associated with the following features:
a. Proclination of anterior teeth.
b. Anterior open bite.
c. Bimaxillary protrusion.
d. Posterior open bite in case of lateral tongue thrust.
e. Posterior crossbite
Management of tongue thrust
The management of tongue thrust involves interception of the habit followed
by treatment to correct the malocclusion.

98. ORAL MALODOR
• Oral malodor in healthy patients arises from the oral cavity and generally
originates on the dorsum of the tongue.
• The volatile sulfur compounds (VSCs) producing anaerobic bacteria
appear to be the primary source of these odors.
• The bacteria hydrolyze the proteins to amino acids, three of which
contain sulfur groups and are the precursors to VSCs.
• These gaseous substances consist primarily of:
1. Hydrogen sulfide (H2S)
2. Dimethyl sulfide ([CH3]2S)
3. Methylmercaptan (CH3SH) and
4. Sulfur dioxide (SO2).

99. The tongue plaque coating
•The tongue is an excellent site for the growth of microorganisms since the
papillary nature of the tongue dorsum creates a unique ecological site that
provides an extremely large surface area, favoring the accumulation of oral
bacteria.
•The proteolytic, anaerobic bacteria that reside on the tongue play an
essential part in the development of OM.
•The presence of tongue coating has been shown to have a correlation with
the density or total number of bacteria in the tongue-plaque coating.
•Higher mouth odor organoleptic scores are associated with heavy tongue
coating and correlate with the bacterial density on the tongue and with the
BANA-hydrolyzing bacteria: T.denticola, P.gingivalis, and B.forsythus.
•Approximately 80% to 90% of the oral malodor originates from the dorsum of
the tongue. Therefore, treatments targeted toward reduction of the oral
malodor will require antimicrobial agents directed against the tongue
microflora.

100. TONGUE CLEANING
Total mouth cleanliness includes tongue care.
A. Microorganisms of the Tongue
1. Main foci for oral microorganisms are:
a. Dorsum of tongue.
b. Gingival sulci and pockets.
c. Bacterial plaque on all teeth.
2. Microorganisms in saliva are principally from the tongue.
3. The microflora of the tongue is not constant, but changes frequently. (Van der
Weijden &Van der Velden in 1991)
B. Effects of Cleaning the Tongue
1. Retards bacterial plaque formation and total plaque accumulation.
2. Reduces number of microorganisms.
3. Reduces potential for halitosis.
4. Contributes to overall cleanliness.

101. C. Anatomic Features of Tongue Conducive to Debris Retention
1. Surface Papillae: Numerous filiform papillae extend as minute
projections, whereas fungiform papillae are not as high and create
elevations and depressions that entrap debris and microorganisms.
2. Fissured Tongue: Fissures may be several millimeters deep and retain
debris.
D. Brushing Procedure
1. Hold the brush handle at a right angle to the midline of the tongue and
direct the brush tips toward the throat.
2. With the tongue extruded, the sides of the filaments are placed on the
posterior part of the tongue surface.
3. With light pressure, draw the brush forward and over the tip of the
tongue. Repeat three or four times. Do not scrub the papillae.

102. E. Tongue Scraper
• Tongue cleaners or scrapers may be made of plastic, stainless steel, or other
flexible metal.
• They are curved and wide enough to fit over the tongue surface without
hitting the teeth.
• Some are made with a single handle, whereas others have two ends to hold.
1. Purpose: By removing debris and microorganisms, the patient can expect
tongue scraping to contribute to overall mouth cleanliness, reduce the
numbers of bacteria available for plaque formation, and lessen mouth odors.
The procedure can be especially helpful for the patient who has xerostomia,
a coated tongue, deep fissures, or who smokes.
2. Procedure: Place the arch toward the posterior of the dorsal surface. Press
with a light but firm stroke, and pull forward. Repeat several times, covering
the entire surface of the tongue. Wash the tongue scraper under running
water.

104. REFERENCES
1. A Colour Atlas Of Human Anatomy – Mc Minn & Hutchings.
2. Human Anatomy – Regional and Applied - B.D.Chaurasia – 4th Edition.
3. Atlas of Human Anatomy – Frank H. Netter – 3rd Edition.
4. Gray’s Anatomy – 38th Edition.
5. Text Book of Medical Physiology – Guyton & Hall – 10th Edition.
6. Concise Medical Physiology – Chaudhuri – 3rd Edition.
7. Physiology – Berne, Levy, Koeppen, Stanton – 5th Edition.
8. Clinical Oral Physiology – Timothy S Miles, Bergitte Nauntofte, Peter
Svenson.
9. Illustrated Physiology – Mackenna & Callander – 6th Edition
10. An Introduction to Human Embryology – Inderbir Singh – 6th Edition.
11. Langman’s Medical Embryology - 9th Edition.
12. Orthodontics: The Art & Science – S.I.Bhalajhi.
13. A Textbook of Oral Pathology – Shafer, Hine, Levy – 4th Edition.
14. Clinical practice of the Dental Hygienist – Wilkins – 8th Edition.
15. Antibiotic & antimicrobial use in Dental Practice – 2nd
Edition.
16. Color Atlas of Clinical Oral Pathology – Neville, Damm & White – 2nd Edition.
17. JCP 2001;28(10):970-978.
18. JP 1972;43(7):418-422.