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Chronic lingual papulosis: new, independent entity or “mature” form of transient lingual papillitis?

      Objective

      Several acute, usually pediatric variants of edematous, symptomatic fungiform lingual papillitis have been reported since the 1990s, most notably transient lingual papillitis (TLP); but no chronic forms have been mentioned. Is there a chronic counterpart, akin to the older palatal examples of inflammatory papillary hyperplasia? The objective of this study was to clinicopathologically characterize a previously unreported entity with clustered, chronic fibrous papules (nonsyndromic) of the tongue.

      Methods

      Cases were collected from clinics in 2 dental schools.

      Results

      Five women and 4 men were identified with multiple, moderately firm, slightly pedunculated, normally colored masses clustered at the tip of the tongue (n = 4), covering the dorsal surface (n = 4) or on the lateral border (n = 1); 2 showed several erythematous or edematous papules (similar to TLP) admixed with fibrous papules. Patient ages ranged from 31 to 62 years (average 49) and all lesions had been present for many years. All lesions were asymptomatic except for the lateral border lesion, which presented with a burning sensation and mild tenderness (disappeared with antifungal medication). Five cases were associated with mouth breathing or a tongue-thrust habit; 4 were associated with geographic tongue or fissured tongue. Four papules were biopsied. All were composed of dense, avascular fibrous tissue with no or very few inflammatory cells; one showed focal mild neovascularity and edema. The lesion appeared to represent altered filiform papillae, more so than fungiform papillae.

      Conclusions

      Chronic lingual papulosis (CLP) is an innocuous entity represented by focal or diffuse enlargement of numerous lingual papillae, primarily the filiform papillae. It appears to usually have an adult onset and most likely represents papillary reaction to very low-grade, chronic irritation or desiccation. Some cases with childhood onset, however, seem to be variations of normal anatomy. No treatment or biopsy is required, but a number of systemic disorders and syndromes must be ruled out before applying the CLP diagnosis.
      Transient lingual papillitis (TLP), initially reported by Whitaker et al. in 1996, is a common acute inflammatory enlargement of fungiform papillae.
      • Whitaker S.B.
      • Krupa 3rd, J.J.
      • Singh B.B.
      Transient lingual papillitis.
      • Neville B.
      • Damm D.
      • Allen C.
      • Bouquot J.
      It has an abrupt onset, with 1 or more edematous, erythematous 2- to 3-mm masses developing over 1- to 3-hours, sometimes “instantly.” Affected papillae may become pustular, but even without pus, TLP is accompanied by moderate-to-severe pain and tenderness, often with considerable thermal sensitivity as well. The pain spontaneously resolves after 1 to 4 days and the papillae return to normal with minimal risk of recurrence.
      • Whitaker S.B.
      • Krupa 3rd, J.J.
      • Singh B.B.
      Transient lingual papillitis.
      • Lacour J.P.
      • Perrin C.
      Eruptive familial lingual papillitis: a new entity?.
      • Flaitz C.M.
      • Chavarria C.
      Painful tongue lesions associated with a food allergy.
      • Brannon R.B.
      • Flaitz C.M.
      Transient lingual papillitis: a papulokeratotic variant.
      • Galun E.
      • Rubinow A.
      Photocopier's papillitis.
      • Roux O.
      • Lacour J.P.
      Paediatricians of the Region var-Côte d'azur Eruptive lingual papillitis with household transmission: a prospective clinical study.
      • Marks R.
      • Scarff C.E.
      • Yap L.M.
      • Verlinden V.
      • Jolley D.
      • Campbell J.
      Fungiform papillary glossitis: atopic disease in the mouth?.
      • Chaudhry S.I.
      • Buchanan J.A.
      • Boulter A.
      • Hodgson T.A.
      • Porter S.R.
      • Campbell J.
      Fungiform papillary glossitis: a ‘new’ diagnosis or a ‘misdiagnosis’?.
      • Noonan V.
      • Kemp S.
      • Gallagher G.
      • Kabani S.
      Transient lingual papillitis.
      • Giunta J.L.
      Transient lingual papillitis: case reports.
      The etiology of TLP is unclear but appears to be multifactorial. Suggested causes include acute thermal injury (i.e., coffee, tea, soup, tobacco smoke), acute mechanical trauma, chronic mechanical trauma (tongue-thrust habit), hypersensitivity to food or candy or oral hygiene products, contact or airborne toxins (photocopier's papillitis), unidentified infections (local), atopic disease, and hormonal changes (in women).
      • Whitaker S.B.
      • Krupa 3rd, J.J.
      • Singh B.B.
      Transient lingual papillitis.
      • Neville B.
      • Damm D.
      • Allen C.
      • Bouquot J.
      • Lacour J.P.
      • Perrin C.
      Eruptive familial lingual papillitis: a new entity?.
      • Flaitz C.M.
      • Chavarria C.
      Painful tongue lesions associated with a food allergy.
      • Brannon R.B.
      • Flaitz C.M.
      Transient lingual papillitis: a papulokeratotic variant.
      • Galun E.
      • Rubinow A.
      Photocopier's papillitis.
      • Roux O.
      • Lacour J.P.
      Paediatricians of the Region var-Côte d'azur Eruptive lingual papillitis with household transmission: a prospective clinical study.
      • Marks R.
      • Scarff C.E.
      • Yap L.M.
      • Verlinden V.
      • Jolley D.
      • Campbell J.
      Fungiform papillary glossitis: atopic disease in the mouth?.
      Association with benign migratory glossitis has been reported.
      • Whitaker S.B.
      • Krupa 3rd, J.J.
      • Singh B.B.
      Transient lingual papillitis.
      The infective variant seems to follow a viral or “strep-mouth” pattern, may involve filiform papillae as well, is typically pediatric in presentation, is apparently contagious, and is associated with fever and other signs of upper respiratory infection or strep throat.
      • Lacour J.P.
      • Perrin C.
      Eruptive familial lingual papillitis: a new entity?.
      • Roux O.
      • Lacour J.P.
      Paediatricians of the Region var-Côte d'azur Eruptive lingual papillitis with household transmission: a prospective clinical study.
      A common myth represents TLP, especially the single, exquisitely painful papilla, as resulting from the telling of a lie. This potential etiology has not been thoroughly researched but “lie bumps” or “liar's bumps” are often so painful, albeit transient, that affected persons clip them off with a nail clipper to obtain relief. No long-term (years) variant of TLP has been reported, but we herein present a series of cases of multiple, sometimes generalized, asymptomatic enlargement of lingual papillae with a chronic duration.

      Cases

      Nine cases were derived from the authors' patient panels (Table I). Of these, 5 (56%) were in women. Patient ages at diagnosis ranged from 31.0 to 62.0 years, with an average of 49.2 years. No common underlying systemic disease or medication was identified, although 2 patients were on thyroid replacement therapy and 2 were taking hypertensive medication. Lingual changes predated medications in all cases. All lesions (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6) had been present for many years, often decades, with at least 3 being present since childhood. No patient could remember precisely when the tongue changes began, however, and none had noticed change over time. All but one of the tongues were asymptomatic and no patient could remember ever experiencing the exquisite pain of TLP. The single symptomatic case in our series was a lateral border lesion with a burning sensation and mild tenderness, both of which disappeared with topical antifungal medication (Figure 6). No patient presented with dysgeusia, hypogeusia, xerostomia, or halitosis.
      Table ISummary of 9 affected patients
      GenderAge at diagnosis, yClinical presentation and biopsy results, if biopsy was performedTongue/Oral abnormalities and habits
      M
      Childhood onset.
      31Figure 1. Diffuse involvement of dorsum, bilaterally: papules of uniform size.None
      M
      Childhood onset.
      62Figure 2, Figure 7. Diffuse involvement of dorsum, bilaterally: considerable variation in size of papules; some papules look pale. Biopsy: dense fibrous tissue and mild hyperkeratosis.Fissured tongue
      Geographic or fissured tongue was in the area of chronic lingual papulosis.
      F54Figure 3. Tip of tongue: uniform papules surrounded by geographic tongue.Geographic tongue
      Geographic or fissured tongue was in the area of chronic lingual papulosis.
      ; fissured tongue
      M53Figure 4. Tip of tongue: papules uniform in size and extending onto dorsum; some are slightly “edematous”; lateral tongue crenations.Mouth breather; nasal obstruction; tongue-thrust habit; macroglossia
      F38Figure 5. Tip of tongue: multiple, asymptomatic, moderately firm, slightly pedunculated uniform papules. Biopsy: avascular fibrous tissue with a few subepithelial lymphocytes; small surface projection of granulation tissue.Mouth breather; anterior open bite; white-coated tongue
      F53Figure 6, Figure 8. Lateral border and left dorsum of tongue: some papules with mild erythema or translucency; mild burning sensation (disappeared with antifungal prescription); crenations on lingual borders and with an irritation fibromalike mass. Biopsy: dense fibrosis, mild chronic subepithelial inflammation; taste buds in epithelium.Tongue rubbing against sharp premolars; fissured tongue
      Geographic or fissured tongue was in the area of chronic lingual papulosis.
      ; candidiasis
      F46Tip of tongue: moderate involvement with extension onto dorsum; papules are somewhat irregular in size.None
      M47Diffuse involvement of dorsum: uniform sized papules of normal color. Biopsy: dense fibrous tissue with a small number of dilated subepithelial capillaries.Tongue-thrust habit; mouth breather; geographic tongue
      F
      Childhood onset.
      59Diffuse involvement of dorsum, bilaterally; associated with fissured tongue; papules of uniform size.Mouth breathing; anterior open bite; fissured tongue
      Geographic or fissured tongue was in the area of chronic lingual papulosis.
      All tongue changes had been present for many years in each patient. No systemic or syndromic diseases were associated.
      M, male; F, female.
      low asterisk Childhood onset.
      Geographic or fissured tongue was in the area of chronic lingual papulosis.
      Figure thumbnail gr1
      Figure 1Diffuse, bilateral involvement of most lingual papillae. Some papules have a mild semitranslucent appearance.
      Figure thumbnail gr2
      Figure 2Diffuse, bilateral involvement of much of the dorsal surface, with considerable variation in size of papules and with some papules showing mild pallor from hyperkeratosis (inset). Fissured tongue is admixed with the papulosis. Arrow points to biopsied mass (see ).
      Figure thumbnail gr3
      Figure 3Tip of tongue shows diffuse enlargement of most papillae, with some showing a somewhat transparent appearance. Papules are located primarily within an area of geographic tongue, with white streaking at borders of the papulosis.
      Figure thumbnail gr4
      Figure 4Most papillae of the tip of the tongue are enlarged and some seem slightly edematous. Papules extend onto the anterior dorsum and crenations are seen on the lateral borders.
      Figure thumbnail gr5
      Figure 5Mild involvement of the tip of the tongue in a mouth breather. The dorsum shows mild white-coated tongue, which is not evident in the papulosis. The patient has mild geographic and fissured tongue (not shown).
      (Courtesy of Dr. Edward Halusic, Greensburg, PA; with permission.)
      Figure thumbnail gr6
      Figure 6Unilateral involvement of dorsum and border of tongue. Clinically classic irritation fibroma look-alike lesion (arrow) is seen in otherwise generalized enlargement of lingual papillae. Biopsy of the “fibroma” is shown in .
      The papules showed 2 patterns: focal and diffuse (generalized). Focal aggregates of papules were usually found at the tip of the tongue (n = 4), but one was along the lateral border (Figure 6). Diffuse lesions (n = 4) presented as generalized, scattered papules covering most of the dorsal surface (Figure 1); one of these was unilateral. Individual papules were pedunculated, slightly more firm than normal, varying in size from 2 to 5 mm, and were of normal color or were slightly erythematous. Occasional cases showed much larger individual papules among the smaller, more uniform ones (Figure 6); it is not clear whether these represent a variant of chronic lingual papulosis (CLP) or a simple combination of several entities (e.g., CLP and irritation fibroma). Some appeared somewhat translucent, presumably from a thin excess of surface keratin, possibly from mild subepithelial edema. Filiform papillae seemed to be primarily affected, but occasional fungiform papillae were involved.
      Four papules were biopsied. All were composed of dense, avascular fibrous tissue with no or very few inflammatory cells (Figure 7) , essentially indistinguishable from an irritation fibroma. One papule had a small secondary surface projection with dilated capillaries, fibroplasias, and focal edem (i.e., granulation tissue), whereas another was hyperkeratotic. The largest papule (see arrow in Figure 6) looked histopathologically like an inflamed irritation fibroma, but it was an obvious fungiform papilla, because taste buds could be seen in the epithelium (Figure 8) .
      Figure thumbnail gr7
      Figure 7Biopsy from . The papule is composed of dense, rather avascular fibrous tissue with a few chronic inflammatory cells beneath the epithelium. Surface epithelium is not atrophic and shows a thickened surface layer of parakeratin. (Magnification ×100; H&E stain.)
      Figure thumbnail gr8
      Figure 8Biopsy of large papule from shows the greatest number of chronic inflammatory cells of all biopsied papules; there is also mild angiogenesis. This papule appears to represent an enlarged fungiform papilla with taste buds (arrows, inset). (Magnification ×200; H&E stain.)
      Etiologies could not be definitively established, but additional tongue changes were seen in all but 2 cases, and 4 (44%) cases were associated with mouth breathing, tongue-thrust habit, or both. Two of these showed only tongue tip involvement, whereas 2 had diffuse papulosis of the entire dorsum. Four patients had fissured tongue, all with fissures intimately admixed with the CLP. Two cases of CLP also had geographic tongue. One of these was physically associated with CLP (Figure 3), but the “moveable” nature of geographic tongue is such that close contacts at other points in time may or may not have occurred.
      None of the patients demonstrated a smooth tongue or hairy tongue, but one had a mild coated tongue with loss of coating in the area of CLP (Figure 5). Two cases had no lingual abnormalities except the CLP.

      Discussion

      We suggest the name “chronic lingual papulosis” for this previously unreported entity. CLP appears typically to be a fibrous hyperplastic response of filiform and sometimes fungiform papillae to mild mechanical irritation, low-grade, long-term inflammation or chronic desiccation. Although TLP has a papulokeratotic variant, which may persist for several weeks or months, CLP does not appear to represent this or any other form of chronic TLP.
      • Flaitz C.M.
      • Chavarria C.
      Painful tongue lesions associated with a food allergy.
      CLP duration is far too long, is not associated with change over time, and, moreover, none of our patients had ever painful TLP.
      To clarify the CLP diagnosis: it is characterized by multiple (dozens, at least) asymptomatic, normal-colored, enlarged lingual papillae, composed microscopically of dense fibrous tissue with few, if any, inflammatory cells. The abnormality may have an adult or childhood onset, perhaps with different etiologic factors at work, and the papules may be clustered or generalized.
      Although all but 2 of our cases exhibited other lingual pathoses, these did not seem necessary for CLP development, as no secondary condition was constantly associated and many were not physically close to the area of CLP involvement. The most-often associated condition, fissured tongue, at first seems a likely candidate for CLP etiology, but we have no means by which to determine which came first in our patients and, more significantly, not all cases demonstrated fissuring.
      Adult-onset CLP is, perhaps, most similar to inflammatory papillary hyperplasia beneath a denture (i.e., a disease that starts with edematous, usually asymptomatic or mildly symptomatic hard papules that become more and more fibrotic and less edematous or acutely inflamed over time). We can only speculate on this pathophysiology, of course, as none of our patients could remember an early phase with edematous or erythematous papules. Confirmation might be found in the presence of sporadic erythematous papules (Figure 3, Figure 5) and the occasional mild chronic inflammatory changes seen microscopically (Figure 8), although this is far from conclusive evidence.
      Childhood-onset CLP (Figure 1) is possibly developmental rather than inflammatory and it might, therefore, be logical to refer to the childhood-onset cases as “congenital CLP” or “developmental CLP.” Unfortunately, none of our patients could shed light on the exact time or manner of onset, and potential etiologic associations, such as mouth breathing and fissured tongue, are also seen in children. Until an investigation of childhood cases clarifies this point, we prefer the CLP diagnosis to be based entirely on the clinical presentation, not the age of onset or possible etiologies. In this regard, the reader is reminded that CLP is, by definition, not associated with any of the numerous systemic diseases or syndromes presenting with multiple lingual papules or nodules (Table II).
      • Simpson H.E.
      Lymphoid hyperplasia in foliate papillitis.
      • Stankler L.
      • Kerr N.W.
      Prominent fungiform papillae in guttate psoriasis.
      • Gorlin R.J.
      • Cohen M.M.
      • Levin L.S.
      Syndromes of the head and neck.
      • Menni S.
      • Beretta D.
      • Piccinno R.
      • Ghio L.
      Cutaneous and oral lesions in 32 children after renal transplantation.
      • Shapiro S.D.
      • Abramovitch K.
      • Van Dis M.L.
      • Skoczylas L.J.
      • Langlais R.P.
      • Jorgenson R.J.
      • et al.
      Neurofibromatosis: oral and radiographic manifestations.
      • Di Felice R.
      • Lombardi T.
      Foliate papillitis occurring in a child: a case report.
      • Silverberg N.B.
      • Singh A.
      • Echt A.F.
      • Laude T.A.
      Lingual fungiform papillae with cyclosporin A.
      • Kato N.M.D.
      • Tomita Y.
      • Yoshida K.
      • Hisai H.
      Involvement of the tongue by lymphomatoid papulosis.
      • Sciubba J.
      • Said-Al-Naief N.
      • Fantasia J.
      Critical review of lymphomatoid papulosis of the oral cavity with case report.
      • Essick G.K.
      • Chopra A.
      • Guest S.
      • McGlone F.
      Lingual tactile acuity, taste perception, and the density and diameter of fungiform papillae in female subjects.
      • Purohit-Sheth T.S.
      • Carr W.W.
      Oral allergy syndrome (pollen–food allergy syndrome).
      • Chimenos Küstner E.
      • Pascual Cruz M.
      • Pinol Dansis C.
      • Vinals Iglesias H.
      • Rodríguez de Rivera Campillo M.E.
      • López López J.
      Lepromatous leprosy: a review and case report.
      • Martins M.D.
      • Russo M.P.
      • Lemos J.B.
      • Fernandes K.P.
      • Bussadori S.K.
      • Corrêa C.T.
      • et al.
      Orofacial lesions in treated southeast Brazilian leprosy patients: a cross-sectional study.
      • Sparling J.D.
      • Hong C.H.
      • Brahim J.S.
      • Moss J.
      • Darling T.N.
      Oral findings in 58 adults with tuberous sclerosis complex.
      • Lier G.C.
      • Mrowietz U.
      • Wolfart M.
      • Warnke P.H.
      • Wiltfang J.
      • Springer I.N.
      Psoriasis of the tongue.
      • Cengiz M.I.
      • Wang H.L.
      • Yıldız L.
      Oral involvement in a case of AA amyloidosis: a case report.
      • Maltos A.L.
      • da Silva L.L.
      • Bernardes Junior A.G.
      • Portari G.V.
      • da Cunha D.F.
      Scurvy in a patient with AIDS: case report.
      • Haberland-Carrodeguas C.
      • Allen C.M.
      • Lovas J.G.
      • Hicks J.
      • Flaitz C.M.
      • Carlos R.
      • et al.
      Review of linear epidermal nevus with oral mucosal involvement—series of five new cases.
      Table IIDisorders associated with multiple nodules or papules of the tongue
      • Simpson H.E.
      Lymphoid hyperplasia in foliate papillitis.
      • Stankler L.
      • Kerr N.W.
      Prominent fungiform papillae in guttate psoriasis.
      • Gorlin R.J.
      • Cohen M.M.
      • Levin L.S.
      Syndromes of the head and neck.
      • Menni S.
      • Beretta D.
      • Piccinno R.
      • Ghio L.
      Cutaneous and oral lesions in 32 children after renal transplantation.
      • Shapiro S.D.
      • Abramovitch K.
      • Van Dis M.L.
      • Skoczylas L.J.
      • Langlais R.P.
      • Jorgenson R.J.
      • et al.
      Neurofibromatosis: oral and radiographic manifestations.
      • Di Felice R.
      • Lombardi T.
      Foliate papillitis occurring in a child: a case report.
      • Silverberg N.B.
      • Singh A.
      • Echt A.F.
      • Laude T.A.
      Lingual fungiform papillae with cyclosporin A.
      • Kato N.M.D.
      • Tomita Y.
      • Yoshida K.
      • Hisai H.
      Involvement of the tongue by lymphomatoid papulosis.
      • Sciubba J.
      • Said-Al-Naief N.
      • Fantasia J.
      Critical review of lymphomatoid papulosis of the oral cavity with case report.
      • Essick G.K.
      • Chopra A.
      • Guest S.
      • McGlone F.
      Lingual tactile acuity, taste perception, and the density and diameter of fungiform papillae in female subjects.
      • Purohit-Sheth T.S.
      • Carr W.W.
      Oral allergy syndrome (pollen–food allergy syndrome).
      • Chimenos Küstner E.
      • Pascual Cruz M.
      • Pinol Dansis C.
      • Vinals Iglesias H.
      • Rodríguez de Rivera Campillo M.E.
      • López López J.
      Lepromatous leprosy: a review and case report.
      • Martins M.D.
      • Russo M.P.
      • Lemos J.B.
      • Fernandes K.P.
      • Bussadori S.K.
      • Corrêa C.T.
      • et al.
      Orofacial lesions in treated southeast Brazilian leprosy patients: a cross-sectional study.
      • Sparling J.D.
      • Hong C.H.
      • Brahim J.S.
      • Moss J.
      • Darling T.N.
      Oral findings in 58 adults with tuberous sclerosis complex.
      • Lier G.C.
      • Mrowietz U.
      • Wolfart M.
      • Warnke P.H.
      • Wiltfang J.
      • Springer I.N.
      Psoriasis of the tongue.
      • Cengiz M.I.
      • Wang H.L.
      • Yıldız L.
      Oral involvement in a case of AA amyloidosis: a case report.
      • Maltos A.L.
      • da Silva L.L.
      • Bernardes Junior A.G.
      • Portari G.V.
      • da Cunha D.F.
      Scurvy in a patient with AIDS: case report.
      • Haberland-Carrodeguas C.
      • Allen C.M.
      • Lovas J.G.
      • Hicks J.
      • Flaitz C.M.
      • Carlos R.
      • et al.
      Review of linear epidermal nevus with oral mucosal involvement—series of five new cases.
      Observed papillary changeSpecific/suspected etiologyComment
      Fungiform hyperplasia, with filiform depapillationCyclosporin therapy (e.g., transplantation)Called “lingual fungiform papillary hypertrophy”; may be associated with gingival hyperplasia
      Strep mouth
      No actual enlargement of papillae, but fungiform papillae are not lost and so appear to be more prominent because they are no longer admixed with filiform papillae.
      Acute infection by hemolytic streptococci, usually with strep throat; like scarlet fever tongue (strawberry tongue, raspberry tongue), but with no skin rash; acute onset, oral and pharyngeal pain, 1-wk duration
      Scurvy (hypovitaminosis C)Eventually entire tongue enlarges; also with gingival hyperplasia and palatal edema
      Familial dysautonomiaAlso called Riley-Day syndrome; an inherited autonomic neuropathy with widespread autonomic and sensory nerve dysfunction, including insensitivity to pain and misinterpretation of taste and heat-input signals
      Guttate psoriasis
      No actual enlargement of papillae, but fungiform papillae are not lost and so appear to be more prominent because they are no longer admixed with filiform papillae.
      Prominent fungiform papillae in a smooth lingual dorsum; tear-drop–shaped erythematous and keratotic psoriasiform skin lesions; usually in persons <30 years of age
      Fungiform hyperplasia, without filiform depapillationCyclosporin therapyUsually the filiform papillae are atrophied
      Normal-sized fungiform papillae, with filiform depapillationAnemia, candidiasis, chemotherapy, AIDSAtrophic glossitis; fibrous fungiform hyperplasia with otherwise smooth dorsal surface; may also show angular cheilosis (anemia, candidiasis)
      Guttate psoriasisCalled psoriasiform fungiform hypertrophy
      Kawasaki diseaseStrawberry tongue
      PapillomatosisEpidermal nevus syndromePigmented verruciform plaques of the skin, central nervous system abnormalities, mental deficiencies, seizures; oral mucosa papules may be numerous and clustered
      Bowenoid papulosisSmall granular surface change in erythroplakia; microscopically, severe dysplasia or carcinoma in situ
      Acanthosis nigricansBrown hyperkeratotic skin papules; gastrointestinal and gastrointestinal adenomas and adenocarcinomas; tongue appears “shaggy” from papillary hypertrophy, as do the lips
      Ichthyosis hystrixHyperkeratosis of skin (defective keratinocyte sloughing); pebbled oral mucosal surfaces, usually unilateral; skin nevi, called nevus unius lateris, may be seen without the ichthyosis disorder (see epidermal nevus syndrome)
      Supernumerary fungiform papillaeSupertastersNormal fungiform size; increased risk of burning tongue, orofacial pain
      Lymphoid/foliate papilla hyperplasiaHyperplastic lingual tonsilChronic enlargement of lingual tonsils (posterior lateral border) from responding to repeat infections; not seen on the dorsum; also called foliate papillitis
      Lymphoid papillitisUlcerated nodules, with malignant-appearing lymphoid stroma; skin nodules also
      Nodules and papules of tongue (not papillae)Nodular median rhomboid glossitisSessile fibrous nodules on depapillated region of the glossitis; posterior dorsum, midline
      NeurofibromatosisBenign nerve tumors or fibrous nodules of any oral surface, but especially the tongue
      Tuberous sclerosisInherited disorder with seizures, mental deficiency, angiofibromas; irregular fibrous growths of gingiva, lips, and tongue
      AmyloidosisIrregular-sized nodules and papules represent infiltration of amyloid beneath the epithelium; slow onset (months or weeks)
      Lipoid proteinosisInherited lysosomal storage disease with numerous nodular infiltrates of skin and mucous membranes; tongue becomes less mobile over time; lingual dorsum becomes depapillated, with papillae replaced by disease nodules and papules
      LeprosyEspecially in lepromatous type (masses called lepromas); multiple granulomatous masses of the tongue and face, with eventual ulceration
      Cowden syndromeMultiple hamartomas of skin and mucous membranes; numerous oral fibromas, especially of the tongue, lips, and gingiva
      Enlarged circumvallated papillaeHypertrophied circumvallated papillaeVariation of normal anatomy; papillae are uniformly enlarged, perhaps as much as twice normal size
      low asterisk No actual enlargement of papillae, but fungiform papillae are not lost and so appear to be more prominent because they are no longer admixed with filiform papillae.
      How problematic is CLP to good oral or physical health? It appears to be innocuous in its biological behavior and requires no treatment, unless secondarily infected by Candida in the furrows surrounding the papules. Our understanding of this is not, of course, based on long-term follow-up, but rather on the uneventful presence of CLP in our patients for many years, usually decades, before diagnosis.
      We consider this entity to require clinical diagnosis only; biopsy should not be required unless the enlarged papillae appear atypical (Figure 6), possibly representing a separate or superimposed lesion. In addition, we believe CLP to be relatively common, even though we present only 9 cases. Throughout the many years of our collective practice experience, we have seen similarly affected tongues with relative frequency. Our cases, however, represent only a convenience sample selected because of good documentation and representation of the entire spectrum of CLP; a valid prevalence rate is not available.
      Along a similar line, oral pathology biopsy services receive tissue samples of “hyperplastic lingual papilla” with some frequency. This does not provide a CLP diagnosis because the surgeon typically does not provide information relative to additional similar lingual masses in the patient.
      Mucosal changes without names are extremely rare in oral pathology, especially for such an obvious surface alteration. We have no explanation for the fact that this supposedly common entity has not been previously reported. Perhaps the present report will stimulate more significant pathoetiologic investigation, because, after all, such investigations are done only on named entities.

      Conclusions

      CLP is an innocuous lesion represented by focal or diffuse fibrous enlargement of numerous lingual papillae, primarily the filiform papillae. It appears to usually have an adult onset and most likely represents papillary reaction to very low-grade, chronic irritation or desiccation. Some cases with childhood onset, however, may be developmental in nature. No treatment or biopsy is required, but a number of systemic disorders and syndromes must be ruled out before applying the CLP diagnosis.

      References

        • Whitaker S.B.
        • Krupa 3rd, J.J.
        • Singh B.B.
        Transient lingual papillitis.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996; 82: 441-445
        • Neville B.
        • Damm D.
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