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QUESTION: My husband has suffered from geographic tongue for a few years now. It normally only affects the left lateral and dorsal part on his tounge and the tip of his tongue. Recently I noticed he had a red area with a white border on the right side of tongue kind of underneith his tongue and the border. It comes and goes, the red will go away and the border will disappear then come back a few days later. Can gt occur in this area of the tongue? At first I thought it may be irritation from good but it keeps coming and going. Does this look like geographic tongue to you?

Red spot with white border

http://i1209.photobucket.com/albums/cc393/kkingery83/28BA955D-6AC2-4841-9742-18A

Few days later and it's gone

http://i1209.photobucket.com/albums/cc393/kkingery83/D368A10D-F9AC-4FF9-B09B-FC6

ANSWER: Hi Kim and thanks for your question.

While I hesitate to give you a definitive diagnosis without the privilege of being able to examine your husband personally, the clinical course, symptoms and appearance do fit that of GT. The transient nature, migratory pattern and physical characteristics do resemble those found in GT, together with the lack of noticeable pathological change. The only entity which seems to be absent, is the presence of fissuring on the dorsum of the tongue, which is where GT usually presents itself. GT is also usually associated with symptoms of a burning sensation on the tongue, especially with spicy and sharp foods such as tomato, pineapple and alcohol - things with a high acidic value, which should be reduced in the diet to improve the quality of life. Sadly, the specific cause and cure is yet to be pin pointed but it seems as if emotional and/or physical  stress may play a role in its onset. For most patients, this condition seems to burn out spontaneously at some point, but there is no guarantee that it wont recur later in life. If this is GT, I have had several patients who have found relief from their symptoms by switching to sensodyne toothpaste. The precise mechanism of action here is not clear and I have written to the company to inform them of this finding, but without response as of yet. It may be the active ingredient, triclosan in sensodyne, or the fact that it has a lower sugar content or lower menthol content which reduces irritation of the tissues. But either way, its worth giving it a try and monitoring the changes. Please let me know what your findings are on this matter if you decide to try it. Another condition should also be considered, given the nature and clinical picture which is aphthous ulcers. These present much like GT but have more of a migratory pattern and affect smaller surface areas of the tongue in a more defined pattern.  Again the cause and treatment elude us greatly but the immune system may play a vital role in its existence and progression. Dietary supplements such as Vit B, folic acid, vit C and E could be useful here by boosting the immune system a bit. Additionally, agents such as Modu-care, Swedish Bitters or any other immune enhancer could improve this condition and reduce the severity of attacks. I noticed from the image you so kindly sent, that there seems to be what looks like a cold sore lesion with signs of chronic scarring on your husbands lower lip on the left side. Not that this influences the other pathology, but it does tend to indicate that your husband has been exposed to herpes simplex virus type I at some stage, not to be confused with type II, like 90 percent of adults, including myself. If this is so, then please let him know that the best way of managing this condition, is to put 90 percent alcohol on the lesion as soon as he suspects its recurrence. This will dry the lesion out in no time and its very cheap - most pharmacies stock this readily. This can be applied frequently throughout the day until the lesion dries out. I am not a fan of topical creams available commercially to treat this because the response to treatment is very lengthy and never results in complete erradication of the viral particles, which remain dormant in the nerve ganglia located further away. Just thought I would mention it.

I hope this helps and wish both you and your husband all the best further. I would suggest that for complete peace of mind and to eliminate other possible causes, such as allergic reactions or other auto-immune diseases, that you make an appointment with your dentist to get this diagnosed definitively, because many auto-immune diseases also present intra-orally and can be a useful signs of pathology elsewhere in the body. But given the nature of his symptoms, I wouldn't loose sleep over this, but please get it checked out just to be sure.

Take care and kind regards
Dr Craig Peck

---------- FOLLOW-UP ----------

QUESTION: Thank you for your reply. Here is another pic so you can see how it has changed which makes me think geographic tongue.

http://i1209.photobucket.com/albums/cc393/kkingery83/836C4755-2264-4E6A-85B7-138

Normally the outbreak affects the left border and dorsal tongue and the tip so this is new for him. He does go to his dentist every 6 months and his next appointment is in two months. Can he wait until then to go? Also he had a biopsy done over a year ago on the left lateral border of his tongue which diagnosed chronic glossitis consistent with geographic tongue.

Here is a pic of where it normally breaks out.

http://i1209.photobucket.com/albums/cc393/kkingery83/5E229FB5-FFBE-4986-A843-318

Also he hasn't had much problems with cold sites but with chronic dry happens lips which bleed then leave scars. He has seen a dermatologist for this also. At any rate do you think the redness on his tongue could be associated with anything serious like cancer?

ANSWER: Hi Kim and thanks for your follow-up.

The pic you sent now is a clearer image of what you suspect, geographic tongue and it is certainly consistent with the clinical diagnosis thereof, but it would be unethical and dangerous for me to confirm this diagnosis without further testing.  Either was, the image, symptoms and nature of the lesion is not consistent with that of oral cancer, which usually affect the lateral border of the tongue with a persistent, painful and non-healing ulcer with associated lymph node swelling in the neck and a tender mass which gradually develops at the site. I can give you a 95% reassurance that this is not oral cancer, given its migratory pattern, clinical appearance, location and associated symptoms - or lack thereof. If he had a biopsy a year ago and diagnosis was confirmed as chronic glossitis which in fact the same histological appearance as GT, aka benign migratory glossitis, why is there still confusion over what this condition is?  As the name suggests, this condition will constantly change its position, shape and form in a random and unpredictable fashion.  This has nothing to do with the severity of the condition, but is merely one of its characteristics which allow us to make a diagnosis.  I see no reason why your husband shouldnt wait 2 months until his next dental appointment, unless the symptoms worsen, making function more difficult.  During those 2 months, the condition may modulate itself anyway and be present or absent on the day of this appointment, but either way, it is worth mentioning to his dentist to update his clinical notes.

Take care and best wishes further
Dr Craig Peck

---------- FOLLOW-UP ----------

QUESTION: I was just confused because he has never had an outbreak in that area if his tonge kind of underneith. It does come and go which makes me also beleive that it has to be geographic tongue. Can geograpgic infuse affect any part of the tongue and is it common on this part of the tongue? My main reason for second guessing is because the biopsy was taken in an different area on the tongue. Also as for his lips. Here is a pic of his lips when there really chapped and bleeding. Does this still look like cold sores  to you?

http://i1209.photobucket.com/albums/cc393/kkingery83/D741846B-C879-4DAE-A6A1-79C

Answer
Hi Kim and thanks for your follow up. Apologies for my rather late response to your last follow up.

There is absolutely nothing wrong with being over cautious and for making sure that you have the correct facts about everything that happens in ones body.  If more people did that, diseases would be identified much earlier on in their course, decreasing the need for advanced and often more costly treatment, and inherently the prognosis and outcome to treatment would be greatly increased.  

Benign migratory glossitis, aka GT as it is known colloquially, is so named because one of its main characteristic is the migratory pattern that it presents with on the tongue. The pattern of the lesions and location thereof do not follow a set, pre-determined formula, but the overall appearance and other distinguishing traits, especially when confirmed by biopsy of the area, lead to the making a positive diagnosis of the otherwise very benign and insidious condition.

But rest assured, GT has no association of any other more threatening pathology and the presence of GT does not predispose anyone who suffers with this condition, to developing oral later later in life - mainly because most patients who are affected by GT at some point during their lifetime, report sporadic remission of all signs and symptoms.  As I have said, this time period varies greatly between patients, but it seems that the integrity of ones immune system, emotional and/or physical stress, nutrition and the presence of other systemic illnesses may modulate this time period and influence the severity of symptoms.  but this link has yet to be proved and remains educated speculated and probability.

As far as your husbands lips are concerned, from the pic which you sent now I cannot say for sure if he has been exposed to the HSV-I, without there being an active lesion or very clear signs of post-healing scarring in the area of the lesion. Majority of the causes of chapped lips are situation-specific, such as due to wind, sunburn, dry air, air-cons and heater, and easily treatable using commercial lip balm with a very high SPF. Reason why the lips display symptoms before other parts of the skin, is because they are very sensitive due to the absence of keratin in the epithelium - which is why the lips are softer and a lighter pink in colour, and bleed easier due to the lack of this 'toughness' factor. Other common causes include dehydration, electrolyte disturbances, mouth breathers and snorers, people who habitually lick their lips constantly, allergies (to cosmetic products, toothpaste ingredients, etc). Once the precise cause of the chapping has been discovered and effectively managed and/or treated, most patients recover from this affliction.  In any event, it would not be a bad idea to start with ensuring that ones body is fully hydrated throughout the day (min 2 liters water) and by using a lip balm with a high SPF, which should be applied several times throughout the day to ensure that all the layers of the skin are receiving adequate moisture (superficial and deep). This prevents any cracking, which then reduces the risk of bleeding and associated discomfort. When it comes to the lips, one must be proactive, because acting when the lips are already cracked, is like trying to extinguish a forest fire with a bucket of water

I hope this helps you and thank you most sincerely for your generous rating of my advice. I was my absolute pleasure to have been able to assist you and your husband with this matter.  Take care.

Kind regards
Craig

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Dr Craig W Peck ( B.Med.Sc., B.Ch.D., Clin. Botox, Cosmet. Derm.)

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I am a General Dental Practitioner, with special interests in Cosmetic Dentistry & facial aesthetics and Periodontology, placing a strong emphasis on the establishment and maintenance of a healthy periodontium (the support structure of the tooth) before cosmetic options are considered. I uphold all principles of prevention above interventional treatment and try as far as possible, to remain conservative in my approach. I believe in detailed, open and honest patient discussion, establishing what the patients expectations are and what the reality is of achieving this and involving the patient at every level of the treatment. I have strong principles on ethical treatment and appropriate patient management. I have chosen to treat and rehabilitate many nervous and phobic patients, who, for whatever reason, find it impossible to take part in the very important task of even a routine check-up. I will accept questions relating to general and cosmetic dentistry (in conjunction with the use of facial cosmetic procedures) and dental fears/phobias. I will be more than willing to answer any academic questions in dentistry, biology, physiology, psychology and health sciences in general. As most dentists will tell you, there is often not only one way of dealing with a dental issue - so very often, there is no precise right and wrong way of approaching the problem. All clinicians vary when it comes to treatments and what works best in their hands is often the treatment that is advised. Be understanding of this and bear in mind that nothing lasts forever! Patients are happy to accept only a one-years warrantee when buying a new car, but seem to expect that dental work is going to last them their lifetime.

Experience

I have worked for many years in the UK and RSA as a general dental practitioner - within the NHS, private practice and the government dental health services. I am certificated for the administration of Botox and Dermal Fillers for facial lines and wrinkles as I have attended further courses in minimally invasive facial cosmetic procedures. I started seeing an increasing number of patients who presented with severe to moderate dental fears, even with full-blown phobias, so I started with the slow and patient task of tackling this problem and have successfully rehabilitated many patients. The key is good, effective, concise and understandable communication, shifting control from the dentist to the patient in order to slowly, but confidently, regain their trust back in dentistry, thereby giving them the feeling of achievement and this self-empowerment which drives them to the next level of treatment.

Organizations
Academy of General Dentistry. American Dental Education Association. IAPAM (International Association for Physicians in Aesthetic Medicine). Professional Speakers, Writers and Managements Consultants in Dentistry. The British Dental Association. UK Aesthetics Group. ARC - Aesthetic Professionals. Botox. Aesthetics & Beauty. American Association for Dental Research. FDI - World Dental Federation. SOURCE1uk. World Dental Hygiene Forum. ProDentalCPD. Public Health Dentistry. Dentist Network. LinkedIn. Who's Who of South Africa.

Education/Credentials
B.Med.Sc. Degree (Medical Physiology and Medical Virology; Physiology Cum Laude; Stell 1994). B.Ch.D. Degree (Bachelor of Dental Surgery; Clinical Dentistry Cum Laude; Stell 1997). CPR and CPR-Advanced Courses (2000/2001; UK). Clinical Botox (UK, 2001). Cosmetic Dermatology (Botox and Dermal Fillers; RSA 2011).

Awards and Honors
Placed on the Dean's List at University for academic achievement (1994). Highest achievement in the subject Dental Materials. Medal from 3M and the Radiology Association of South Africa for highest achievement in the subject Dental Radiology and Imaging. Medal from The Periodontal Association of South Africa for highest achievement in the subject Periodontology. Highest achievement for Oral Medicine. Highest achievement in Oral Pathology. Received the DASA (Dental Ass. of South Africa) Gold Medal for highest achieving dental student across the 5 1/2 years of the Degree. Passed the subject, Clinical Dentistry with distinction in final year.

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