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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 5  |  Page : 323-328

Glossitis mimicking median rhomboid glossitis induced by throat lozenges and refreshment candies

Department of Oral Medicine, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Date of Web Publication24-Sep-2019

Correspondence Address:
Prof. Diah Savitri Ernawati
Department of Oral Medicine, Faculty of Dental Medicine, Universitas Airlangga, Jl. Mayjend Prof. Dr. Moestopo 48, Surabaya 60132.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_76_19

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Acute sore throat is a condition of inflammation, characterized by pain, swelling, and burning sensation, which result from inflammation of the upper respiratory tract. Throat lozenges and refreshment candy containing the antiseptics and local anesthetics are commonly used to relieve the symptoms of sore throat. Side effects of using throat lozenges and refreshment candy have not been reported. This case report presents the case of glossitis mimicking median rhomboid glossitis induced by throat lozenges and refreshment candy, which is used to relieve the symptoms of sore throat. Management includes anamnesis, clinical examination, and instructions for stopping throat lozenges and refreshment candy consumption.

Keywords: Glossitis, refreshment candy, sore throat, throat, lozenges

How to cite this article:
Surboyo MD, Ernawati DS, Parmadiati AE. Glossitis mimicking median rhomboid glossitis induced by throat lozenges and refreshment candies. J Int Oral Health 2019;11:323-8

How to cite this URL:
Surboyo MD, Ernawati DS, Parmadiati AE. Glossitis mimicking median rhomboid glossitis induced by throat lozenges and refreshment candies. J Int Oral Health [serial online] 2019 [cited 2023 Nov 30];11:323-8. Available from:

  Introduction Top

Acute sore throat is an inflammatory condition, characterized by swelling, pain, and burning sensation, which result from the inflammation of the upper respiratory tract. The sore throats have a negative effect on normal daily activities and functioning, including swallowing, talking, eating, and sleeping.[1] Throat lozenges containing the antiseptics and local anesthetics that are commonly used to relieve the symptoms of sore throat.[2] They can be purchased from pharmacy or over the counter without prescription from doctor and they have pleasant taste. It easy to use, do not require water intake for administration, can last in a certain time to to elicit an effect in the oral cavity.[3] The side effects of using throat lozenges have not been reported.

Tongue surface is made up of four types of papillae, namely filiform, fungiform, foliate, and circumvallate papillae. They assist in the mastication of food by increasing friction during chewing.[4] The papillae can undergo changes due to various etiologies. There are four kinds of changes as erythematous, depapillation, atrophy, and rhomboid. These four conditions can be referred to as glossitis and classified based on the degree of loss of the papillae.[5] Depapillation is a condition of loss of papillae and the papillae can regrow, such as geographic tongue.[6] The atrophy is absence of filiform or fungiform papillae, often called as smooth tongue or atrophic glossitis.[7],[8] The rhomboid is the condition of papillae that cannot be formed because of growth disturbance, such as median rhomboid glossitis.[9] The papilla able to lost because trauma.[10],[11] The trauma to the tongue could be physical, chemical, and thermal. The chemical trauma to the tongue can be noted due to accidental contact of caustic, dangerous chemicals, or drugs. The pain that is caused by this kind of injury can be reduced by stopping intake of caustic chemicals or drugs.[12]

Median rhomboid glossitis affects 0.01%–1.0% of the population. These lesions are more common in men than that in women with a ratio of 3:1.[10] Initially, it was believed to be developmental in origin, but during the recent years, it has been considered and associated with Candida infection.[13] The diagnosis of median rhomboid glossitis can be established through isolating Candida from the lesion.[9] According to many reports, topical antifungal therapy promotes the resolution of median rhomboid glossitis in most cases.[14]

  Case Presentation Top

A 28-year-old man presented to the dental clinic of Dr. Surboyo, with a chief complaint of thickened, discomfort, and burning sensation on the tongue for the last 2 days. Extreme burning sensation increased when consuming hot and spicy food. Five days ago, the patient had influenza and was diagnosed as upper respiratory tract infection by a doctor in general hospital in Surabaya. The medication was given by doctor including ciprofloxacin, tablet containing phenylpropanolamine HCl, chlorpheniramine, and paracetamol. The other symptoms of the patient during that condition were sore throat, dizziness, and fatigue. The patient and also his family did not have a history of allergies. To reduce the discomfort due to sore throat, he consumed throat lozenges up to five grains (tablet) a day for 7 days. The oral examination revealed a deep fissure surrounded by brownish macular area, regular edge, and clear border on the dorsum of the tongue [Figure 1]A. The diagnosis of this condition was glossitis and the treatment given was povidone–iodine 1% mouthwash, three times daily.
Figure 1: The clinical appearance of dorsum of the tongue. (A) First visit: brownish macular area, regular edge, and clear border on the dorsum of the tongue. (B) Second visit: reddish macular area with irregular edges, surrounded by brownish areas. (C) third visit: widened reddish macular area, smooth surface, regular edges, which was surrounded by yellowish area. (D) fourth visit: widened reddish area, yellowish area almost disappeared and normal palatal mucosa(E). (F) fifth visit: reddish area almost completely disappeared

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On the second visit (3 days after first visit), the oral examination revealed reddish macular area with irregular edges, surrounded by brownish areas [Figure 1]B. He complained of thickened, moderate pain, and burning on the tongue (Wong–Baker Faces Pain Rating Scale was 6), even though he did not consume hot and spicy foods. The patient had stopped taking the medication given by doctor 2 days ago and the symptoms of influenza disappeared. The diagnosis was glossitis with a differential diagnosis of median rhomboid glossitis, and the treatment given was triamcinolone acetonide 0.1% paste, applied twice daily, with the instruction to stop consuming the throat lozenges.

On the third visit (2 days after second visit), the oral examination revealed reddish macular area widened, smooth surface, regular edges, which was surrounded by yellowish area [Figure 1]C, and the patient still complained of mild pain and burning sensation of tongue (Wong–Baker Faces Pain Rating Scale was 4). The result of complete blood count obtained was low Mean corpuscular volume (MCV) (79.5 fL; normal range, 80–99 fL). The other parameters were in the normal range. The diagnosis was glossitis and the treatment continued as per the second visit.

On the fourth visit (2 days after third visit), the reddish area widened, yellowish area almost disappeared [Figure 1]D. The palatal mucosa also was examined and no abnormality was found [Figure 1]E. Pain and burning sensation disappeared. The general condition of the patient was good. The treatment given was povidone–iodine 1% mouthwash, twice daily.

On the fifth visit (2 days after fourth visit), the reddish area in the tongue almost completely disappeared [Figure 1]F and no complaint was reported. On the basis of anamnesis, clinical appearance from 1st until 5th visit, and laboratory examination, the condition can be identified as tongue depapillation and diagnosed as glossitis. The differential diagnosis was acute erythematous candidiasis and median rhomboid glossitis.

Seven months later, he complained of a mild pain (Wong–Baker Faces Pain Rating Scale was 4) on the tongue for the last 2 days, when consuming hot and spicy food. The location and symptoms were similar to previous condition. The patient felt flu-like symptoms and sore throat, but had not taken drugs nor visited doctor. To reduce the symptoms, he consumed another throat reliever (refreshment candy) (seven strips a day for 5 days). The intraoral examination found a reddish macula with regular edges with a size 2.5 × 2.5cm on the dorsum of the tongue [Figure 2]A. Direct swab on macular area and fungal direct examination using potassium hydroxide (KOH) revealed no yeast. The possible diagnosis for this condition was glossitis and the treatment given was triamcinolone acetonide 0.1% paste, to be applied twice daily, with the instructions to stop consuming refreshment candy.
Figure 2: The clinical appearance of dorsum of the tongue after 7 months. (A) first visit: reddish macula with regular edges on the dorsum of the tongue. (B-C) second and third visit: the macular area on the dorsum of tongue was widened and normal palatal mucosa (E). (D) Macula area was disappeared

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On the second visit (2 days after first visit) and the third visit (2 days after second visit), the complaint about pain reduced (Wong–Baker Faces Pain Rating Scale was 2). The macular area on the dorsum of tongue was widened compared to the first visit [Figure 2]B and [Figure 2]C. The palatal area was also examined. No abnormality was found in mucosa of the palatal area [Figure 2]E. The symptoms of flu were reduced. The diagnosis made in this condition was glossitis because of refreshment candy. The treatment given was povidone–iodine 1% mouthwash, twice daily, and triamcinolone acetonide 0.1% paste, applied twice daily. On the fourth visit (2 days after third visit), the macula on the tongue disappeared, looked normal, with no other complaint [Figure 2D].

On the basis of history, clinical, and laboratory examination in the first period and second period, the final diagnosis was glossitis induced by throat lozenges and refreshment candy.

  Discussion Top

The abnormality of the tongue in this case was the depapillated areas in the dorsum of the tongue, with clinical appearance of asymptomatic reddish macular area. Depapillation is a condition of loss of papillae, where the papillae can regrow.[6] Depapillation of tongue could be found in other cases, such as geographic tongue. Geographic tongue or benign migratory glossitis is well-defined red depapillated areas surrounded by serpiginous yellow white lines.[12] The diagnosis was based on its migratory characteristic, the tendency of the lesions to change and move throughout the day. In this case, the diagnosis of geographic tongue could not be established because the macular area did not change and was still in the same area after 12–24h, after first observation.[8]

The other possibility was rhomboid condition. Rhomboid or rhombus, appears as loss of tissue because of developmental disturbance,[9] such that papillae cannot be formed.[6] This condition can be found in median rhomboid glossitis.[11] It presents as a well-demarcated, depapillated area, and appears as papilla atrophy on the posterior dorsal tongue from the anterior to the circumvallate papillae.[15] High levels of Candida can also be found in this lesion.[16] Median rhomboid glossitis believed as developmental disorder of tongue formation. The depapillated area is a persistent tuberculum impar that cannot fuse completely with lateral lingual swelling in the development of tongue, resulting a smooth, erythematous and lacking papillae. Today, it is considered as a variant of candidiasis.[13] On the basis of study report, in mycological examination, Candida species were diagnosed in 90.0% of the patients with median rhomboid glossitis. Candida albicans, Candida kefyr, Candida tropicalis, Candida krusei, and Candida glabrata found in the most cases of median rhomboid glossitis.[17] The suspicion of median rhomboid glossitis–related candida can be excluded because the direct examination is negative and no “kissing lesion” is found in palatal area. Another consideration in the condition in this case is reddish macular area that can disappear after treatment and the discontinuation of throat lozenges and refreshment candy. Median rhomboid glossitis, with or without Candida involvement, the reddish macular area remain persistent due to the persistence of the tuberculum impar, which affected papilla cannot grow in that area.[13] This condition also confirmed, by the visit 7 months later, that presence of Candida was not found on direct examination.

Acute erythematous candidiasis is also determined as differential diagnosis. This condition is also known as antibiotic sore mouth, which frequently occurs after the consumption of broad-spectrum antibiotic,[16] even though the patient has a history of taking antibiotics. In the third visit, fungal examination to confirm acute erythematous candidiasis was not carried out for two reasons. First, no macular area was found, which presented redness on other area such as the palatal, only in small area in the dorsum of the tongue it was found.[6],[18] Second, the antibiotics consumed by patients were stopped a day after the first visit and the macular or erythematous area appeared on the third visit, but the complaints of pain were reduced compared to the second visit. This condition was confirmed later, in the next visit 7 months later, the patient had not consumed antibiotic, and mycological examination carried out then gave the result as negative.

The final diagnosis of this case was glossitis with appearance as depapillated area, which was caused by the consumption of throat lozenges and refreshment candy. Throat lozenges are available as candy, which provides relief for pain because of inflammation in the throat. Throat lozenges, containing many chemical ingredients, such as menthol, eucalyptus, amylmetacresol, and dybenal. Amylmetacresol and dybenal are the main active ingredients with the role as antiseptic, local anesthetics, and viricidal. Viricidal effect is related with a pH-induced rearrangement of the tertiary structure of attachment proteins, or some selective effect on viral lipid membrane interaction to be responsible for the morphological change.[2] Amylmetacresol and dybenal did not show antifungal properties but showed antibacterial effect against Streptococcus pyogenes, S. aureus, S. dysgalactiae, Arcanobacterium haemolyticum, and Haemophilus influenza.[19] This explains why the fungal examination showed negative result not because the amylmetacresol and dybenal inhibit the oral fungal. The refreshment candy also contains menthol, peppermint oil, eucalyptol, methylsalicylic acid, and thymol. Some of the contents such as menthol and eucalyptol showed antibacterial activity.[20],[21] The side effects of the ingredient of throat lozenges may include tingling, numbness, stinging, burning sensations, and altered sense of taste.[22] The side effect of the amylmetacresol and dybenal, which is related to the depapillation of tongue occurs when the throat lozenges come in contact with the dorsum of tongue. Amylmetacresol and dybenal are contained in throat lozenges that has pH 2.2-5.8.[2] During the consumption of throat lozenges and refreshment candy, they will come in contact with the area where macular area was found. The low pH may irritate the oral mucosa, resulting in depapillation.[2] Depapillation may be the nonallergic reaction due to the local use of chemicals.[23] To confirm this condition, a patch test was required but the patient refused. In this case, the confirmation of the diagnosis lies in stopping the use of irritant followed by the disappearance of the lesion.[24]

The glossitis with loss of papillae or depapillation may occur because of systemic or local conditions. On the basis of clinical appearance, a complete blood examination was carried out on the third visit in the first period. A complete blood test was performed to rule out suspected anemia. The oral manifestation of anemia can be atrophy or depapillation on the tongue.[25] The results show low MCV (79.5 fL; normal range, 80–99 fL). MCV below the reference value is usually an indication of iron deficiency.[26] Iron, vitamin B12, and folic acid deficiency can contribute in depapillated and atrophy glossitis.[27] But other indicators such as hemoglobin (Hb) (15.7g/dL; normal range, 12–16g/dL), MCHC (35.9g/dL; normal range, 32–36g/dL), and RBC (5.6 × 106/μL; normal range, 4–5.5 × 106/μL) are normal. In this patient, we could not suspect anemia because the Hb was in normal range. The blood Hb concentration is the most reliable indicator of anemia.[28] The other reason that explains the low value of MCV is due to the general condition of patients experiencing flu. When experiencing flu, the body’s condition will decrease due to the infection. The infection will cause increased body temperature, lymphocyte, and platelet numbers, and decreased MCV value.[29]

The loss of tongue papillae can be symptomatic. Complaints such as mild to severe burning sensation,[30] itching, or pain due to the inflammation by loss of papillae were observed.[8] The treatment similar to this condition can be supportive and symptomatic. Triamcinolone acetonide 0.1% paste was given as an anti-inflammatory to reduce patient complaint, and povidone–iodine 1% mouthwash as an antiseptic to prevent infection. Triamcinolone acetonide is in a corticosteroid group, which has a medium to high potency. Triamcinolone acetonide is commonly used as a temporary relief of symptoms that are associated with oral inflammation such as aphthous stomatitis.[31] Other case, as presented by Najafi et al.[32] (2016), showed that the pain, burning sensation, and lesion extension can be reduced by treatment with triamcinolone acetonide in the case of depapillation such as geographic tongue. Triamcinolone acetonide has an anti-inflammatory property by preventing the initiation of inflammatory cascade and inhibiting the enzyme released.[32] The povidone–iodine 1% mouthwash was prescribed to maintain the patient’s oral hygiene and to prevent oral infection. Povidone–iodine is a broad-spectrum antimicrobial, which releases the iodine toward bacterial cell membrane. It is commonly used as an infection therapy that is caused by bacteria, virus, fungi, and protozoa.[33]

Finally, the term of glossitis is used in this case because it’ is characteristic by depapillated condition. On the basis of a study by Nakamura et al.,[5] in 2017, glossitis can be defined with several classification based on degree of depapilation as grade 1, 2, 3, and 4. Grade 1 (mild glossitis), the loss papillae in the affected area were smaller. Grade 2 (moderate glossitis), partial loss of papillae less than 50%. Grade 3 (severe glossitis), partial loss of papillae more than 50% and grade 4 (profound loss), all the papillae were lost.[5] Grade 4 has the appearance of a smooth glossy tongue. This condition is also known as bald tongue and atrophic glossitis.[34] Grade 2 is represented in this case and it mimics median rhomboid glossitis. The condition was strengthened by stopping the consumption of throat lozenges and refreshment candy, which could reduce symptoms and improve the clinical conditions.

  Conclusion Top

Glossitis can be induced by throat lozenges and refreshment candy although it contains antiseptic. Throat lozenges and refreshment candy must be consumed with care because there are ingredients that can trigger depapillation and even inflammation.

Declaration of patient consent

The author certify that the patient has signed an informed consent. An explanation of the possibility of clinical images and other clinical information will be reported in journals. The identity as names and initials will not be mentioned to maintain aspects of confidentiality.

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Conflicts of interest

There are no conflicts of interest.

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