What is the appropriate workup and management for a patient presenting with a fissured (scrotal) tongue?

Workup and Management of Fissured Tongue

Fissured tongue is a benign anatomical variant that requires no laboratory testing, imaging, or treatment in the vast majority of cases. 1

Initial Clinical Assessment

Confirm the Diagnosis

• Examine the tongue for characteristic deep grooves along the dorsal and/or dorsolateral surfaces, which may vary in depth and pattern (central longitudinal, branching, or multiple fissures). 2, 3
• Fissured tongue is a clinical diagnosis made by visual inspection alone—no biopsy, imaging, or laboratory studies are indicated for typical presentations. 1, 4

Rule Out Atypical Features Requiring Further Evaluation

• If the patient has associated symptoms (pain, burning, bleeding from fissures, or difficulty eating), evaluate for secondary infection (candidiasis), nutritional deficiencies, or inflammatory conditions rather than attributing symptoms to the fissures themselves. 1, 4
• Check for coexisting geographic tongue (migratory erythematous patches with white borders), which occurs in association with fissured tongue in many patients and shares a common inflammatory pathophysiology. 5, 3
• If atrophic glossitis is present (smooth, red tongue with loss of papillae), order serum vitamin B12, folate, ferritin, and complete blood count to evaluate for nutritional deficiencies or anemia. 5, 1

Laboratory Testing: When and What to Order

No Routine Testing for Uncomplicated Fissured Tongue

• Do not order laboratory studies in asymptomatic patients with typical fissured tongue, as this is a benign variant that does not indicate systemic disease in most cases. 1, 4

Selective Testing for Symptomatic or Atypical Cases

• If the patient has symptomatic fissured tongue with pain, burning, or associated atrophic glossitis, order:
  • Complete blood count (to assess for anemia, thrombocytopenia, or leukopenia) 5
  • Serum vitamin B12 5, 1
  • Serum folate 5, 1
  • Serum ferritin 5, 1
• Note that one older study found slightly lower mean levels of vitamin B12, folate, and ferritin in fissured tongue patients compared to controls, along with decreased thrombocyte and leukocyte counts, though these findings have not been consistently replicated and their clinical significance remains unclear. 5

Imaging Studies

• No imaging is indicated for fissured tongue—this is not a condition that requires ultrasound, CT, or MRI. 1, 4

Management and Patient Counseling

Reassurance and Education

• Reassure the patient that fissured tongue is a benign anatomical variant present in approximately 15.5% of the US population and does not require treatment. 1, 2
• Explain that fissured tongue is not congenital but develops over time, as it is rare in children under 10 years old and increases in prevalence with age. 3

Hygiene Recommendations

• Advise gentle tongue brushing to remove debris that can accumulate in the fissures, which may reduce the risk of secondary candidal infection or halitosis. 1
• If secondary candidal infection is suspected (white coating in fissures, burning, or pain), treat with topical antifungals (nystatin suspension or clotrimazole troches). 1

Address Associated Conditions

• If geographic tongue is present, reassure the patient that this is also benign and typically requires no treatment unless symptomatic. 1, 3
• If nutritional deficiencies are identified on laboratory testing, replace the deficient nutrient (vitamin B12, folate, or iron) and reassess tongue symptoms after repletion. 5, 1

When to Refer or Pursue Further Evaluation

Red Flags Requiring Biopsy or Specialist Referral

• If there is a focal mass, ulceration, or indurated lesion on the tongue (not simply fissures), refer to oral and maxillofacial surgery, otolaryngology, or a dentist experienced in oral pathology for biopsy to rule out leukoplakia or squamous cell carcinoma. 1
• If the patient has persistent burning mouth syndrome involving the tongue that does not resolve spontaneously, consider trial of gabapentin, topical clonazepam, or capsaicin, or refer for cognitive behavioral therapy. 1

No Routine Follow-Up Required

• Fissured tongue does not require scheduled follow-up visits, as it is a stable benign condition that does not progress to malignancy. 1, 4

Common Pitfalls to Avoid

• Do not order extensive laboratory panels or imaging studies for asymptomatic fissured tongue—this leads to unnecessary cost and patient anxiety without clinical benefit. 1, 4
• Do not confuse fissured tongue with other tongue pathology such as oral lichen planus, leukoplakia, or squamous cell carcinoma, which require biopsy and specific treatment. 1
• Do not attribute all tongue symptoms to the fissures themselves—if the patient has pain or burning, actively search for secondary infection, nutritional deficiencies, or other inflammatory conditions. 5, 1