What are the causes and treatment options for fissures in the tongue?

Fissured Tongue: Causes and Treatment

Direct Answer

Fissured tongue is a benign condition that requires no treatment in the vast majority of cases, as it does not cause morbidity or affect quality of life. 1

What is Fissured Tongue?

Fissured tongue is characterized by deep grooves along the dorsal and/or dorsolateral aspects of the tongue, often with enlarged, smooth filiform papillae. 2 It occurs in approximately 15.5% of the US population and is one of the most common tongue conditions encountered in primary care. 1

Causes and Etiology

Not a Congenital Condition

• Fissured tongue is not a congenital anomaly, despite historical beliefs. 2
• The condition is very rare or absent in children younger than 10 years old and appears more commonly in adults, indicating an acquired rather than congenital nature. 2

Proposed Mechanisms

• Subepithelial edema and inflammation may be the underlying cause, with infiltrates of polymorphonuclear leukocytes and lymphocytes causing swelling beneath the epithelium. 2
• The visible grooves and enlarged papillae may result from chronic inflammation and edema underneath the epithelium. 2

Associated Conditions

• Geographic tongue (benign migratory glossitis) is frequently associated with fissured tongue, with evidence suggesting fissured tongue may be a consequence or later stage of geographic tongue. 2, 3
• Some studies suggest associations with hypertension and diabetes, though causation is not established. 4
• Immunological findings include decreased thrombocyte and leukocyte counts, lower lymphocyte counts, and reduced serum IgG in patients with fissured tongue. 5

Treatment Approach

Primary Recommendation: No Treatment Required

Fissured tongue does not require treatment in asymptomatic cases, which represent the vast majority. 1 This is the most important clinical point—reassurance is the primary intervention.

When Symptoms Are Present

For Pain or Discomfort:

• Maintain excellent oral hygiene to prevent food debris accumulation in the fissures, which can cause secondary irritation. 1
• Gentle brushing of the tongue surface to keep fissures clean. 1

If Secondary Candidal Infection Develops:

• Antifungal therapy may be indicated if candidal overgrowth occurs in the fissures, presenting with white patches or burning sensation. 1
• Consider nystatin oral suspension or miconazole oral gel if candidal infection is suspected. 6

For Associated Geographic Tongue with Symptoms:

• Topical corticosteroids (betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit) may reduce inflammation if geographic tongue causes significant discomfort. 6
• Topical anesthetics like benzydamine hydrochloride or viscous lidocaine 2% can provide symptomatic relief. 6

Critical Clinical Pitfalls to Avoid

Do Not Confuse with Other Conditions

• Atypical presentations (severe pain, bleeding, unilateral fissuring, or rapid progression) require evaluation for underlying systemic disease, nutritional deficiencies, or malignancy. 1
• Rule out nutritional deficiencies (vitamin B12, folate, iron) if atrophic glossitis is present alongside fissuring. 1, 5

Do Not Over-Treat

• Avoid unnecessary interventions for this benign condition that does not affect morbidity or mortality. 1
• Patient education and reassurance are the cornerstones of management. 1

When to Refer

• Refer to oral medicine specialist or dentist if there is diagnostic uncertainty, concern for malignancy, or persistent symptoms despite conservative management. 1
• Consider referral if associated with severe geographic tongue requiring specialized management. 3