What are the causes of fissured tongue?

Causes of Fissured Tongue

Fissured tongue is associated with multiple conditions including autoimmune disorders, nutritional deficiencies, and certain systemic diseases, though in many cases it may be a benign developmental variation.

Definition and Clinical Presentation

Fissured tongue (FT) is characterized by grooves or fissures on the dorsal and/or dorsolateral aspects of the tongue that vary in depth. The condition presents with:

• Central longitudinal fissuring (most common pattern)
• Multiple fissures branching from a central groove
• Enlarged, smooth filiform papillae
• Subepithelial inflammatory infiltration

Primary Causes and Associations

Developmental/Genetic Factors

• Not truly congenital as previously thought, as it's rare in children under 10 years 1
• Increases in prevalence with age
• May have genetic predisposition (family history often present)

Associated Conditions

1. Geographic Tongue

   • Strong association with geographic tongue 2
   • May represent different stages of the same condition
   • Geographic tongue may be a precursor to fissured tongue

2. Autoimmune Disorders

   • Lichen sclerosus 3
   • Autoimmune thyroid disease
   • Alopecia areata
   • Vitiligo

3. Systemic Diseases

   • Hypertension (significant association) 4
   • Diabetes mellitus
   • Gastrointestinal disorders including chronic gastritis 5

4. Nutritional and Hematological Factors

   • Slightly lower levels of vitamin B12, ferritin, and folate 6
   • Decreased thrombocyte and leukocyte counts
   • Lower lymphocyte count and serum IgG levels

5. Other Associations

   • Use of anti-hypertensive medications 4
   • Tobacco products, particularly Swedish snus 4
   • Possible association with tongue edema 2

Pathophysiological Mechanisms

The exact etiology remains unclear, but several mechanisms have been proposed:

• Inflammatory Process: Subepithelial infiltrates of polymorphonuclear leukocytes and lymphocytes causing edema 2
• Immune Dysregulation: Decreased immunological defense mechanisms 6
• Possible Edematous Origin: The fissures may result from subepithelial edema rather than being a true anatomical anomaly 2

Diagnostic Considerations

When evaluating fissured tongue, consider:

• Pattern of fissuring (central longitudinal vs. multiple fissures)
• Presence of associated tongue anomalies (geographic tongue)
• Age of onset (more common in adults than children)
• Presence of symptoms (often asymptomatic)
• Associated systemic conditions

Clinical Implications

• Most cases of fissured tongue are benign and require no treatment
• When associated with systemic conditions, treating the underlying disorder may help
• For symptomatic cases associated with gastritis, adjunctive treatment with Lactobacillus has shown promise 5
• Atypical presentations or sudden onset should prompt investigation for underlying conditions

Key Points to Remember

• Fissured tongue is not always congenital and often develops with age
• The condition may represent tongue edema rather than a true anatomical anomaly
• When fissures occur off the midline, evaluation for underlying conditions is warranted
• Geographic tongue and fissured tongue may represent different stages of the same condition
• Consider systemic associations, particularly autoimmune disorders and hypertension