Transient lingual papillitis: A retrospective study of 11 cases and review of the literature

Abstract

Background
Transient lingual papillitis (TLP) is a common, under-diagnosed, inflammatory hyperplasia of one or multiple fungiform lingual that has an acute onset, and is painful and transient in nature.

Material and Methods
Eleven cases of TLP were diagnosed based on their clinical features. Information on demographics, clinical characteristics, symptoms, individual or family history of similar lesions, medical history, management and follow-up were extracted from the patients’ records. The English literature was reviewed on TLP differential diagnosis, pathogenesis and management.

Results
The study group included 8 females and 3 males (age: 10-53 years, mean age 31.7±12.88 years). Seven cases were classified as generalized form of TLP and 4 as localized form. Nine cases were symptomatic. Time to onset ranged from 1 to 14 days. A specific causative factor was not identified in any case and management was symptomatic.

Conclusions
Although TLP is not considered as a rare entity, available information is limited. Diagnosis is rendered clinically, while biopsy is required in cases with a differential diagnostic dilemma. TLP should be included in the differential diagnosis of acute, painful tongue nodules.
Key words:Transient lingual papillitis, fungiform papillary glossitis, tongue, nodules.

Full text

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
E1
Journal section: Oral Medicine and Pathology
Publication Types: Case Report
Transient lingual papillitis: A retrospective
study of 11 cases and review of the literature
Eleni-Marina Kalogirou 1, Konstantinos I. Tosios 2, Nikolaos G. Nikitakis 3, Georgios Kamperos 1, Alexandra
Sklavounou 4
1 DDS MSc, Department of Oral Medicine and Pathology, National and Kapodistrian University of Athens, Athens, Greece
2 DDS, PhD, Assistant Professor, Department of Oral Medicine and Pathology, National and Kapodistrian University of Athens,
Athens, Greece
3 DDS, MD, PhD, Associate Professor, Department of Oral Medicine and Pathology, National and Kapodistrian University of
Athens, Athens, Greece
4 DDS, MSc, PhD, Professor, Department of Oral Medicine and Pathology, National and Kapodistrian University of Athens,
Athens, Greece
Correspondence:
Department of Oral Medicine and Pathology
Faculty of Dentistry
National and Kapodistrian University of Athens
2 Thivon Street, 11527 Athens, Greece
eleni_kalogirou@hotmail.com
Received : 01/06/2016
Accepte d: 02/08/2016
Abstract
Background: Transient lingual papillitis (TLP) is a common, under-diagnosed, inammatory hyperplasia of one or
multiple fungiform lingual that has an acute onset, and is painful and transient in nature.
Material and Methods: Eleven cases of TLP were diagnosed based on their clinical features. Information on de-
mographics, clinical characteristics, symptoms, individual or family history of similar lesions, medical history,
management and follow-up were extracted from the patients’ records. The English literature was reviewed on TLP
differential diagnosis, pathogenesis and management.
Results: The study group included 8 females and 3 males (age: 10-53 years, mean age 31.7±12.88 years). Seven
cases were classied as generalized form of TLP and 4 as localized form. Nine cases were symptomatic. Time to
onset ranged from 1 to 14 days. A specic causative factor was not identied in any case and management was
symptomatic.
Conclusions: Although TLP is not considered as a rare entity, available information is limited. Diagnosis is rende-
red clinically, while biopsy is required in cases with a differential diagnostic dilemma. TLP should be included in
the differential diagnosis of acute, painful tongue nodules.
Key words: Transient lingual papillitis, fungiform papillary glossitis, tongue, nodules.
doi:10.4317/jced.53283
htt p://dx.d oi.or g/10.4317/jced .53283
Please cite this article in press as: Kalogirou EM, Tosios KI, Nikitakis
NG, Kamperos G, Sklavounou A. Transient lingual papillitis: A retro-Transient lingual papillitis: A retro-
spective study of 11 cases and review of the literature. J Clin Exp Dent.
(2016), doi:10.4317/jced.53283

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
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Introduction
The term “transient lingual papillitis” (TLP) was in-
troduced by Whitaker et al. (1) in 1996 to describe the
inammatory hyperplasia of one to several fungiform
lingual papillae that has an acute onset, is painful and
transient in nature (1). Similar lesions were, also, re-
ported as “lingual fungiform papillae hypertrophy” (2)
and “fungiform papillary glossitis” (3-5), “lie bumps
or liar’s bumps” (1,6,7) and “photocopier’s papillitis”
(8). “Eruptive lingual papillitis”, (9) “eruptive familial
lingual papillitis” and “eruptive lingual papillitis with
household transmission” (6,9,10) may be included in the
spectrum of TLP.
TLP is considered as a common but under-diagnosed
disease (11). It was self-reported by 92 (56%) of 163
workers at the Dental School of the Medical College of
Georgia, in a study conducted through questionnaires
(1). Three variants of TLP have been described, based
on their clinical features (1,6,10,12). The localized va-
riant presents with swelling of a single to several fungi-
form papillae of a solitary lingual area, especially of the
tip, the lateral borders and the dorsal surface and may
occur in patients of every age with a female predilec-
tion (1,11). In the generalized variant a large proportion
of the fungiform papillae is involved. During its usual
course, a child of a median age of 3.5 years is initially
affected and progressively the disease presents in other
family members. This form is more consistent with the
descriptive terms eruptive familial lingual papillitis or
eruptive lingual papillitis with household transmission
(6,10). Both the localized and generalized forms have an
acute onset (1,7,11) and the enlarged papillae may vary
in color from normal, erythematous or whitish to yellow,
while they rarely appear brown or black, due to staining
from food or smoking (13). Moreover, these two clinical
patterns may be accompanied by disproportionate symp-
toms, including pain, burning, tingling or itchy sensation,
difculty in feeding, sensitivity to hot foods (1,6,10,11)
and, in cases with familial transmission, hypersalivation
and occasionally fever and lymphadenopathy (6,10).
Symptoms typically resolve after a few hours or 1 to 4
days (1,7,11), while they may last for 1 to 3 weeks, when
diffuse lingual inammation coexist (11). Biopsy is not
required for the nal diagnosis (10,11), but in cases whe-
re it was performed microscopic examination showed an
inamed fungiform papillae with minimal spongiosis
and neutrophils inltration of the epithelium (1,10,12).
Taste buds that are normally present in fungiform pa-
pillae were not detected (1,10,12). The papulokeratotic
variant of TLP is characterized by chronic, generalized
tongue involvement with painless, whitish or white-ye-
llow in color enlarged fungiform papillae, histologically
corresponding to parakeratosis (12).
TLP is not considered a rare disease, but only few case
reports or case studies are found in the literature (1,2,6,8-
18). The aim of the present study is to report 11 new
cases of TLP and to review the English literature on its
differential diagnosis, pathogenesis and the appropriate
management.
Material and Methods
This is a retrospective study on 11 cases of TLP diagno-
sed and managed between the years 2009-2014 by three
members (K.I.T, N.G.N and G.K) of the Department of
Oral Medicine and Pathology, Faculty of Dentistry, Na-
tional and Kapodistrian University of Athens. Data ex-
tracted from patients’ records included sex and age of
the patients; time to presentation; symptoms; individual
or family history of similar lesions; history of recurrent
aphthous ulcerations, herpetic stomatitis, allergic reac-
tion or recent oropharyngeal infection; medical history,
in particular concerning systemic diseases and medica-
tion, smoking habit, recent blood examination; clinical
presentation; management and follow-up. All patients at
the time of their initial examination gave written con-
sent for the future use of their data for study. This study
was approved by the Research Ethics Committee of the
School of Dentistry, National and Kapodistrian Univer-
sity of Athens (NKUOA code number 289).
Results
Table 1 summarizes the main clinical features of our
cases. There were 8 female and 3 male patients and
the mean age was 31.7 years (range 10 to 53 years,
SD=12.88). Seven cases were classied as generalized
variant (Fig. 1) and mostly involved the anterior lingual
dorsum and the tip of tongue. In 4 cases few enlarged
fungiform papillae were recognized in one or two lin-
gual sites (Fig. 2 A,B). One of those cases was consi-
dered as a papulokeratotic variant (case no #8), but as
biopsy was not performed, it was classied as localized
TLP. Symptoms were present in most cases (81.8%) and
included pain, difculty in eating, especially spicy or
acidic food, burning and tingling sensation, xerostomia
and dysgeusia. Time to onset ranged from 1 to 5 days,
with the exception of case #5 where it was reported to
be 2 weeks. Two patients (cases #7 and #10) had used
anti-inammatory agents, antiseptic mouthwashes or an
antifungal gel for a few days, without self-reported im-
provement.
None of the patients could remember the occurrence of
similar lingual lesions in the past or in other members
of their family, except for a high-school student (case
#3), who reported that similar lesions had reappeared
twice during last year, both times in conjunction with
school examinations. Two patients (cases #7 and #11)
gave a history of recurrent aphthous ulcerations, while
patient in case #2 reported suppurative tonsillitis a mon-
th before the appearance of the tongue lesions. None of
the patients had a history of herpetic stomatitis or oral

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
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Case Gender/
age*
Clinical presentation Symptoms Management Outcome**
1F/10 localized pat ter n; 3 enla rged fungifor m
papillae, either side of the tip of tongue
pain, difculty
in feedi ng
dexamethasone oral solution
(3 times/day), avoidance of
lingual ir ritation
FOD 4 days later; NR
16 months later
2M/38 localized pattern; 4-5 enlarged
fungiform papillae on the anter ior
tongue dorsum
pain, difculty
in feedi ng
dexamethasone oral solution
(3 times/day), avoidance of
lingual ir ritation
FOD 7 days later; NR
10 months later
3F/17 localized pattern; 2 enlarged whitish
fungiform papillae on tongue dorsum
none avoidance of lingual
irritation
FOD 3 days later; NR
17 months later
4F/28 generalized pattern; multiple nor mal
colored enlarged fungiform papillae
pain, tingling
sensation
avoidance of lingual
irr itation, spicy and acidic
food
FOD 10 days later, 5
recur rences in the next
2 years
5M/26 generalized pattern; multiple
erythematous enlarged fungifor m
papillae
pain avoidance of lingual
irr itation, spicy and acidic
food
lost to follow-up
6F/47 generalized pat ter n; multiple
erythematous enlarged fungifor m
papillae on the anterior tong ue dorsum
erythema,
xerostomia
avoidance of lingual
irr itation, oral moisturizing
product
(4 times/day)
FOD 7 days later, NR 2
years later
7F/41 generalized pattern; multiple
erythematous enlarged fungifor m
papillae on the tongue dorsu m
burn ing
mouth,
xerostomia,
dysgeusia
avoidance of lingual
irr itation, oral moisturizing
products
(4 times/day)
FOD 10 days later, NR
5 years later
8M/53 localized pattern; several enlarged
fungiform papillae on the left and r ight
anterior tongue dorsum
dysgeusia avoidance of lingual
irritation
lost to follow-up
9F/36 generalized pattern; multiple
erythematous enlarged fungifor m
papillae on the tongue dorsu m
none avoidance of lingual
irritation
FOD 4 days later; NR 6
years later
10 F/31 generalized patter n; multiple
erythematous enlarged fungifor m
papillae of tip of tongue
burn ing
mouth,
tingling
sensation,
dysgeusia
avoidance of lingual
irr itation, antiinammatory
analgesic agent (3 times/
day),
oral moist uri zing products
(4 times/day)
lost to follow-up
11 F/22 generalized pattern; multiple
erythematous enlarged fungifor m
papillae of tip of tongue
mild pain avoidance of ling ual
irr itation, chamomile rinses
(3-4 times/day)
FOD 7 days later, NR 3
years later
Table 1. Demographics, clinical presentation, management and outcome of the 11 TLP cases.
*age in years; F, female; M, male; **FOD, free of disease; NR, no recurrence.

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
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Fig. 1. Mult iple erythematous enlarged fungifor m papillae on the
anterior tongue dorsum (#7).
Fig. 2. Localized for m of TLP affecting A) both sides of the tip of tongue (#1) and B) the anterior tongue
dorsum (#2).
allergic reaction, while all denied regular use of antisep-
tic mouthwashes. Three patients (cases #2, #4 and #8)
reported “geographic tongue” that was present at the
time of examination in one of them (case #2). Habitual
lingual trauma was reported by 2 patients (cases #7 and
#10), although in 3 more patients (cases #1, #3 and #11)
a diffuse erythematous area on the tip of tongue was
indicative of tongue thrusting. In case #1 tongue thrus-
ting on an upper xed orthodontic appliance was con-
Fig. 3. Generali zed form of TLP on the tongue dorsum A) at init ial exam ination and B) partially ame-
liorated 7 days later (#4).
sidered plausible. Medical history was not contributory
in none of the cases. Patients reported systemic disea-
ses, including familial hypercholesterolemia (case #1),
thyroid diseases (cases #4-#6), hypertension (case #8)
and β-thalassemia trait (cases #4 and #10). Two patients
were smokers (cases #7 and #8) and 1 patient (case #8)
reported low blood zinc levels.
Management of TLP was symptomatic therefore in as-
ymptomatic patients no treatment was prescribed. Pa-
tients reporting symptoms were advised to avoid tongue
friction and irritating foods that could exacerbate their
symptoms. In cases #1 and #2 where persistent pain
caused difculty in feeding oral rinses with a dexame-
thasone solution were prescribed, while in patients #6
and #7 that complained for coexisting xerostomia, oral
moisturizing products were, additionally, suggested.
Fungiform papillae’s enlargement resoluted in 3 to 10
days, while among the 8 cases with available follow up,
recurrences were reported only in one patient (case #4),
who had initially presented with a diffuse variant of TLP
(Fig. 3A,B). In this patient, 5 relapses were seen in 2
years of follow-up.
Discussion
The cases presented herein were consistent with TLP.
Although there are no clear diagnostic criteria for TLP,

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
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biopsy is not required for the nal diagnosis (10,11). A
system proposed for the diagnosis and classication of
TLP (3) that is based on color, size and location of the
fungiform papillae, is not easily applicable to clinical
practice and does not take into account factors such as
the symptoms and resolution of the lesions, and normal
diversity of fungiform papillae (4).
In our study there was a female preponderance (72.7%),
6 out of 11 patients were older than 30 years, and only
two juveniles aged 10 and 17 years, respectively, were
found. In previous studies no marked gender preference
(6,10-12,16) and a female preponderance (1) are repor-
ted, while most patients are in the 1st to 4th decades of
life (1,6,10-12,16).
The differential diagnosis of the localized variant of TLP
includes reactive oral lesions, such as brous hyperpla-
sia, giant cell broma and pyogenic granuloma, but in
contrast to those lesions, TLP regresses, as was evident in
our cases. The generalized enlargement of the fungiform
papillae seen in the generalized variant of TLP repre-
sents a characteristic nding of scarlet fever that usually
manifests in children and is caused by group A (beta-he-
molytic) Streptococcus (7). Tongue dorsum in scarlet fe-
ver initially demonstrates a white coating dispersed with
hyperemic enlarged fungiform papillae causing the cha-
racteristic “strawberry tongue” (7). “Strawberry tongue”
is also seen in strep mouth that unlike scarlet fever is not
accompanied by skin rash, as well as Kawasaki disease
or mucocutaneous lymph node syndrome, an idiopathic,
acute, febrile, multisystem disorder of children, which
shares common clinical manifestations with scarlet fe-
ver (7). Furthermore, enlarged fungiform papillae were
a feature of psoriasiform fungiform hypertrophy in 3 pa-
tients with a history of psoriasis that developed guttate
psoriasis following streptococcal pharyngitis (16). They
were also seen in kidney transplant patients receiving
cyclosporine A, where they were associated with ei-
ther change in the microbial ora or poor oral hygiene
(2,17) and with increased risk of graft rejection (2). It
is not clear whether the lingual enlargement regresses
with discontinuation of cyclosporine (2). In psoriasis
and cyclosporine A uptake, it is hypothesized that the
fungiform papillae do not in fact enlarge, but as the li-
form papillae are lost, they protrude and become more
apparent (7). A similar phenomenon may be also seen
in iron deciency anemia, erythematous candidiasis and
patients receiving chemotherapy (7). Seven of the cases
presented herein were consistent with the generalized
variant of TLP, but in contrast to previous reports (6,10)
no family transmission was reported, while none of the
above stated diseases were diagnosed.
Chronic lingual papulosis is considered as the lingual
counterpart of the inammatory papillary hyperplasia of
the palate (7). It affects adults and presents as multiple,
painless, localized or diffuse, normal colored, enlarged,
mainly liform papillae on the tip or dorsal surface of
the tongue (7). Histologically, brous hyperplasia is ob-
served, while, in one case, taste buds were also noticed,
indicating that the lesion originated from the fungiform
papillae. Finally, TLP should be differentiated from di-
seases manifesting with multiple nodules on the dorsal
tongue, including the epidermal nevus syndrome, Bowen
papillomatosis, acanthosis nigricans, exophytic form of
median rhomboid glossitis, neurobromatosis, tuberous
sclerosis, amyloidosis, lipoid proteinosis, lepromatous
leprosy and Cowden syndrome (7). Those nodules are
asymptomatic and do not resolve spontaneously, there-
fore in equivocal cases a biopsy may be indicated. One
of our cases was clinically consistent with this variant,
but as no biopsy was indicated we chose to classify it as
a localized variant.
The etiology of TLP is unknown and probably multi-
factorial, as it can be hypothesized by the variable and
non-specic histological ndings (12). It is related to
acute or chronic mechanical trauma, compulsive lingual
movements because of local irritating factors, such as
sharp-edged teeth or restorations, orthodontic applian-
ces or increased calculus on the anterior teeth (1,7,11).
Other possible factors include stress, lack of sleep, poor
nutrition, geographic tongue (1,11), thermal injury (7),
excessive smoking and alcohol uptake (12), consump-
tion of spicy or acidic foods (1), allergy to foods, oral
hygiene products or photocopier’s toner (1,8,11), as well
as gastrointestinal disorders and hormonal changes du-
ring menstruation or menopause (1,11). As TLP is more
common in patients with history of atopy, it may also
represent a local atopic reaction to heat or irritating fo-
ods (3). Often, though, TLP is considered idiopathic (1),
while it is also regarded as a relapse in adults of erup-
tive familial lingual papillitis or eruptive lingual papi-
llitis with household transmission that occurred during
childhood (6, 10). In the present cases, possible trigge-
ring factors included the chronic lingual irritation on the
orthodontic appliance, the habitual lingual trauma, stress
or the coexistence with geographic tongue. In one case,
although the patient reported recent suppurative tonsilli-
tis, neither history nor clinical examination were consis-
tent with strep mouth infection.
Infectious agents, particularly viruses, is implicated in
the pathogenesis of both TLP and eruptive familial lin-
gual papillitis or eruptive lingual papillitis with house-
hold transmission, but is not documented (6, 10). Immu-
nohistochemical investigation for human papillomavirus
types 6 and 11 and herpes simplex virus (HSV) type 1
and 2 (1), as well as the histochemical investigation for
fungi and parasites in biopsy specimens were all nega-
tive in TLP (1,10,12). In a recent publication, though,
Krakowski et al. (18) described a case of TLP, where the
presence of HSV type 1, was conrmed by direct lesio-
nal viral culture, in a patient with Kawasaki disease.

J Clin Exp Dent-AHEAD OF PRINT Transient l ingual papil litis
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Management of TLP is symptomatic and aims to relieve
symptoms (1,11). In painful cases local anesthetics, to-
pical corticosteroids, coating agents, saline mouthwas-
hes and combination of antihistamines with aluminum
hydroxide or magnesium hydroxide suspension for topi-
cal use have been administrated, and eating of cold fo-
ods has been recommended. The use of analgesics such
as paracetamol or ibuprofen does not affect the duration
and intensity of symptoms (6), while there is no con-
sensus on the usefulness of topical antiseptics (1,6). Pa-
tients are also recommended to avoid irritating chewing
gums, candies or oral hygiene agents (13). In our ca-
ses, divergent therapeutic approaches were decided, all
of them conforming to the various treatment modalities
proposed in the literature. Most approaches achieved a
symptomatic relief.
TLP may relapse (10,11), most commonly its papuloke-
ratotic variant (12). In recurrences the investigation of
the possible trigger factors, especially trauma or aller-
gens, is mandatory (11). The available follow-up pe-
riod in our cases was not adequate for conclusions to be
drawn regarding relapses.
TLP is a multifactorial, underdiagnosed disease, occa-
sionally painful. Its recognition and differential diagno-
sis from other diseases manifesting with lingual nodules
helps in avoiding unnecessary diagnostic workup and
treatments, while the investigation and identication of
possible triggers contributes to relapses’ prevention. Des-
cription of more cases will improve our understanding of
the disease’s pathogenesis and appropriate management.
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Conict of Interest
All authors declare no conict of interest.