886 RESEARCH AND SCIENCE

Nadine D. Feil
Andreas Filippi Frequency of fissured tongue
1 Department of Oral Surgery,
Oral Radiology and Oral Medi-
(lingua plicata) as a function of age
cine and Center of Dental
Traumatology, University
Center for Dental Medicine
Basel, University of Basel,
Switzerland

CORRESPONDENCE
Prof. Dr. med. dent. 
Andreas ­Filippi
Klinik für Zahnärztliche Chirur- KEYWORDS
gie, -Radiologie, Mund- und lingua plicata,
Kieferheilkunde und Zahn­ age dependence,
unfallzentrum, Universitäres fissured tongue,
Zentrum für Zahnmedizin Basel tongue diagnostics
Hebelstrasse 3
CH-4056 Basel
Tel. +41 61 267 26 11
Fax +41 61 267 26 07
E-mail: andreas.filippi@
SUMMARY
unibas.ch
Fissured tongue (lingua plicata; LP) is a mostly tures, and potential mouth burning. Subsequent-
SWISS DENTAL JOURNAL SSO 126: asymptomatic condition characterized by grooves ly, photographs of the protruded tongue were
886–891 (2016) and fissures of varying depth on the dorsal sur- taken and examined by two investigators regard-
Accepted for publication: face of the tongue. Most reports in the literature ing the presence of LP. Four degrees of severity of
8 March 2016
indicate a prevalence of 10–20%, although there the condition were distinguished. Degrees of se-
is marked variation. On the basis of 1,000 pa- verity of LP as well as numbers of affected indi-
tients (n = 465 males, n = 535 females), this study viduals increased as a function of age (p < 0.001).
examined the association between LP and age as LP occurred more frequently in males than fe-
well as further influencing factors. Participants males (p = 0.0029). In addition, smoking exerted
completed a questionnaire comprising informa- a positive influence on the prevalence (p < 0.05),
tion regarding gender, age, alcohol and tobacco and a positive correlation appeared between
consumption, possibly existing removable den- mouth burning and LP (p < 0.01).

Introduction whereas the endodermal base (radix) of the tongue located

Fissured tongue (lingua plicata; LP) is a common normal vari- ­behind the sulcus terminalis is spared (Cesko et al. 2006).
ant or sign of age of the tongue surface, which does not require Diagnosis is made on the basis of a clinical examination, bi-
treatment (Cesko et al. 2006). Clinically, fissures of varying opsies are rarely taken. For the examination the tongue is pro-
depth up to 6 mm sometimes extending to the margin are ap- truded in such a way that the fissures unfold and become visible
parent on the dorsal surface of the tongue (Du Toit 2006, Silver- (Silverman et al. 2001). The prevalence of LP in the general pop-
man et al. 2001). Mostly, a central longitudinal furrow (median ulation is reported to be 10 to 20 per cent (Darwazeh & Almelaih
sulcus) initially develops in the middle of the dorsum of the 2011, Gönül et al. 2011, Jahanbani et al. 2009, Patil et al. 2013).
tongue (Eisen 1998). The deeper this median sulcus, the more Children under 4 years of age exhibit fissured tongue only as
numerous transversal furrows radiate from it (Cesko et al. an exception, and in less than 10-year-olds the prevalence
2006). Extensive furrows can be connected with each other (Du amounts to less than 2 per cent (Järvinen et al. 2014, Shulman
Toit 2006), making the tongue look like composed of separate 2005). In general, LP occurs more frequently in males than fe-
lobes (Kelsch et al. 2014). The condition is confined to the an- males (Darwazeh & Almelaih 2011, Patil et al. 2013) and increas-
terior two-thirds of the tongue which are of ectodermal origin, es strikingly with increasing age in both genders (Järvinen et al.

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2014, Jahanbani et al. 2009, Reichart 2000). Sometimes LP occurs Despite a number of publications on LP, it has never been
in combination with a geographic tongue (Cesko et al. 2006, Jo- ­ xplicitly examined, from what age on this variant of the
e
seph & Savage 2000). tongue occurs with increased frequency. The primary target
Typically, LP is clinically asymptomatic (Du Toit 2006, Rogers ­parameter of the present study was the age from which LP
& Bruce 2004). Also secretion and composition of saliva are nor- ­occurs more ­often. As secondary parameters, the associations
mal (Kullaa-Mikkonen et al. 1985). If fissures are deep enough of LP with smoking, alcohol consumption, mouth burning, and
that food residues are entrapped in them and persist, an inflam- wearing of a denture were investigated.
mation can ensue (Darwazeh & Almelaih 2011). In this case, the
patient should be informed about the harmlessness of the con- Materials and Methods
dition (Kelsch et al. 2014) and instructed about correct tongue In the course of the present study, 1,000 patients from a dental
cleansing (Du Toit 2006, Silverman et al. 2001). practice in St. Gall (Switzerland) were examined within a period
The etiology of LP is not completely known yet (Silverman et of 8 months. At the start of sampling, consecutive patients
al. 2001). A polygenic or autosomal dominant hereditary com- without preselection were asked upon reception, whether they
ponent is presumed, because LP clusters in families with other would participate in the study. Thereafter, only those individu-
affected individuals. However, the difference in prevalence ob- als were invited who fitted the study design with respect to age
served in various age groups suggests that LP primarily is not of (Tab. I). Voluntary participation in the study was integrated at
genetic origin (Järvinen et al. 2014). the dentist’s visit. All participants completed a written declara-
Smoking constitutes a risk factor for many oral mucosal lesions tion of consent. For individuals of less than 18 years of age, par-
and in particular also for LP (Al-Attas et al. 2014). Benign tobac- ents’ consent was obtained as well. The observational study was
co-associated alterations of the oral mucosa most notably are approved by the ethical committee of St. Gall (EKSG Nr: 13/132).
smoker’s melanosis (brownish hyperpigmentation of the kerati- The clinical examination, taking of photographs, and the com-
nized gingiva) and smoker’s leukokeratosis (smoker’s palate). pletion of the questionnaire were always carried out by the
Oral leukoplakia is considered the most important precancerosis. same investigator (the first author).
When affecting the squamous epithelium, it constitutes a poten- The study participants from 0 to 99 years of age were classi-
tially life-threatening alteration of the oral mucosa (Bornstein et fied into 10 age groups. A group comprised all patients of a par-
al. 2006). Besides, the risk of mouth carcinomas is increased as a ticular decade of life. Numbers of patients per age group were
result of chronic alcohol consumption (Singer & Teyssen 1999). set according to the percentage of the respective age group in
The best known cause of LP is age. An additional factor influ- the Swiss resident population. These data were obtained from
encing the development of LP is hyposalivation which in turn is the Swiss Federal Statistical Office in 2011 (Tab. I).
also associated with age (Patil et al. 2013). In humans with tri- Together with the investigator, patients completed a ques-
somy 21, LP is frequently observed in childhood (Al-Maweri et tionnaire containing information regarding age and gender.
al. 2015, Bilgili et al. 2011). In addition, LP particularly often ­Because of the negative effects of bad habits on the oral cavity,
occurs in individuals wearing a removable denture (Gönül et al. patients were asked whether alcohol was consumed (daily or
2011) as well as in cases of psoriasis or following an oncological occasionally) and whether they smoked. The presence of a re-
therapy (Nisa & Giger 2012, Zargari 2006). Also, individuals suf- movable denture was ascertained clinically, because prosthesis
fering from granulomatous inflammatory diseases frequently carriers in comparison to patients without prostheses exhibit
exhibit LP. In particular, fissured tongue is invariably present as a significantly elevated prevalence of oral mucosal lesions
part of the Melkersson-Rosenthal syndrome which constitutes (­Jainkittivong et al. 2002, Lin et al. 2001). Finally, patients were
a form of orofacial granulomatosis and is characterized by the asked about possible tongue burning (Tab. II). Excluded from
triad of recurrent orofacial swelling, recurrent facial palsy, and the study were patients following radiotherapy or chemothera-
LP (Cesko et al. 2006, Rogers 1996). However, an orofacial gran- py as well as individuals suffering from Melkersson-Rosenthal
ulomatosis can also be an oral manifestation of a systemic dis-
ease, in particular of sarcoidosis or Crohn’s disease (Blank et al.
2014, Grave et al. 2009).
Tab. I  Composition of the study sample corresponding to the
In the anterior two-thirds the dorsum of the human tongue
Swiss population in the year 2011
is covered by specialized keratinized mucosa (Joseph & Savage
2000). Healthy tongues exhibit filiform and fungiform papillae. Age Age cat- Total Percent- Number
The histological appearance of LP differs from that of a healthy egory 7,954,662 age in study
tongue (Järvinen et al. 2014). Investigations have shown that 0–10 0 861,608 11 110
not only the epithelium, but also the lamina propria and mus-
11–20 1 877,785 11 110
culature are involved in the formation of fissures (Cesko et al.
2006, Rogers & Bruce 2004). In cases of LP, the number of in- 21–30 2 1,032,732 13 130
flammatory cells is markedly elevated in the entire mucosa of 31–40 3 1,110,174 14 140
the dorsum of the tongue (Kullaa-Mikkonen et al. 1985, Kul-
laa-Mikkonen & Sorvari 1986). Filiform papillae at the surface of 41–50 4 1,291,094 16 160
the tongue persist, those in deeper fissures can be missing as a 51–60 5 1,049,864 13 130
result of the bacterial inflammation (Kelsch et al. 2014, Rogers
61–70 6 847,371 10 100
& Bruce 2004). In cases of LP, the lamina propria is also thick-
ened (Du Toit 2006, Kelsch et al. 2014). In addition, the upper 71–80 7 546,549 7 70
muscle cells are slender and separated (Järvinen et al. 1991). The 81–90 8 291,599 4 40
smooth surface on the inside of the fissures exhibits scattered
91–100 9 45,093 1 10
abortive papillae (Cesko et al. 2006, Rogers & Bruce 2004).

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Tab. II  Summary of possible findings and statements

Gender Female Male

Smoking Non-smoker Smoker

Alcohol Never Occasionally Daily

Removable denture No Yes

Mouth burning No Yes

Lingua plicata Grade 0 = no LP Grade 1 = tongue visible Grade 2 = partly smooth Grade 3 = smooth squa-
in the fissures squamous epithelium mous epithelium in the
(without visible tongue fissures at all locations
papillae) in the fissures (middle, side, margin)

Location middle, side No LP Middle Side Margin

or margin

Fig. 1  Grade 0 = no fissured tongue Fig. 2  Grade 1 = tongue papillae visible in the fissures

Fig. 3  Grade 2 = partly smooth squamous epithelum (without visible tongue Fig. 4  Grade 3 = smooth squamous epithelium in the fissures along the
papillae) in the fissures along the middle, on the side, or on the margin of the middle, on the side, and on the margin of the tongue
tongue (at the maximum in two locations)

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Fig. 5  Graphical representation of only smooth squamous epithelium could be recognized. As

the locations of fissures along the soon as this occurred in the middle, on the side, and on the
middle (green), on the side (blue),
and on the margin (red) of the margin, the tongue was assigned to grade 3. In addition, the
tongue. This served as the basis ­location of the fissure was recorded (Fig. 5).
for the classification into grades. After all the findings and statements of the investigation had
been collected (Tab. II), data was statistically evaluated using
ordinal logistic regression. The degree of severity of the tongue
fissures constituted the dependent variable. Independent vari-
ables were age, gender, smoking, alcohol consumption, and
mouth burning (R Core Team 2014).

Results
Among the total of 1,000 patients examined, 465 were males
and 535 females. The age of the individuals ranged from 0 to
96 years (the average age was 41.3 years). 206 patients smoked,
syndrome, which constitute the most frequent causes of non-­ 598 consumed alcohol occasionally, and another 83 daily.
age-associated LP. Further possible exclusion criteria such as 68 patients were wearing a dental prosthesis and 17 confirmed
trisomy 21 or acromegaly did not occur in the patient sample to sometimes suffer from mouth burning. 732 participants
examined. (361 males and 371 females) revealed LP. Grade 1 was observed
A color photograph of the protruded tongue was taken in 488 patients, grade 2 in 173, and grade 3 in 71 individuals. In
(­Canon EOS 40D with EF-S 18–135 mm 3.5–5.6 IS lens). The 646 patients there was at least a fissure along the midline. 62 of
faces of the participants could not be recognized on the pic- the 68 denture wearers revealed LP. 16 patients (16 after radio-
tures. Diagnosis of LP was made on the basis of the photographs therapy/chemotherapy and 0 because of Melkersson-Rosenthal
which were viewed full-screen always on the same computer syndrome) were excluded from the study prior to the clinical
monitor (iMac 27 inches) and evaluated by two dentists inde- examination. The average age of individuals revealing grade 1
pendently. Calibration of the investigators in the course of a and grade 3 LP was 24.5 years and 66.4 years, respectively.
preliminary test was accomplished based on photographs from The four degrees of severity were associated with the age cat-
the University of Basel. In cases of divergent ratings by the egories (Fig. 6). In 0- to 20-year-olds the proportion of grade 0
­investigators (n = 76), photographs were once more viewed exceeded 50%. Starting from 20 years of age the proportion of
­together and assigned to a degree of severity. The main target grade 1 increased markedly. From the age category 7 to cate­
parameter was the age from which LP occurs with significantly gory 9, the frequency of grade 3 rose from 15% to 36%, and
increased frequency. Secondary parameters were the associa- grade 0 was observed only in exceptional cases. Hence from the
tions of LP with smoking, alcohol consumption, mouth burn- 80th year of life, LP of grades 2 or 3 was present in more than
ing, and wearing of prostheses. Fissures were classified into four 70% of individuals. Overall, age correlated markedly with the
degrees (Figs. 1–4). If fissures were visible with the naked eye, occurrence of LP (p < 0.001).
the tongue was assigned to a grade from 1 to 3. Starting with Also, the localization of LP as a function of age was examined.
grade 2 no papillae were visible anymore in deeper fissures and In younger individuals, fissured tongue was found rather isolat-

Fig. 6  Graphical representation of

the four degrees of severity of LP in
the age categories specified in Table I

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Fig. 7  Graphical representation

of the four degrees of severity of LP
as against gender

ed in the middle of the tongue. The older the individuals the of severity of LP (grade 0 to grade 3) also rose with increasing
more frequently LP was observed on the entire dorsal tongue age. Almost 40% of the more than 90-year-olds revealed LP of
surface, i.e. in the middle, on the side, and on the margin grade 3.
(Fig. 5). Several oral lesions tend to develop more rapidly and more
In comparison to females, males more often exhibited LP ­frequently in elderly individuals. Reasons for this tendency are a
(p = 0.0029; Fig. 7). In addition, smoking and mouth burning ­reduced immune response, a diminished repair capacity of the
positively affected the presence of LP in the sample investigated DNA, and the age-associated atrophy of oral tissues, in particular
(p = 0.02 related to smoking, p = 0.0028 related to mouth burn- of epithelia and the salivary glands (Reichart 2000). The preva-
ing). As far as alcohol consumption and wearing of a removable lence of LP increases significantly at ages over 59 years (Darwazeh
denture were concerned, no differences between patients with & Almelaih 2011). In over 70-year-olds, authors even reported a
and without LP could be detected. frequency of more than 37% (Jainkittivong et al. 2002).
Various previous studies showed a gender difference in the
Discussion prevalence of LP. Some investigators observed an only slightly
Since the clinical appearance of LP and the pattern of fissures more frequent occurrence in males (Kelsch et al. 2014, Patil et
vary markedly, it is difficult to classify LP into degrees of severi- al. 2013), whereas others found a strikingly increased frequen-
ty and to define a threshold above which a tongue fissure should cy of LP in males (Darwazeh & Almelaih 2011). In other studies,
be considered LP. In the present sample, LP was observed in 73% however, females were affected more often (Vieira-Andrade et
of individuals (grade 1 in 49%, grade 2 in 17%, grade 3 in 7%). al. 2011, Bànòczy et al. 1993). The present data record confirms
The prevalence considerably exceeded that found in previous the proposition that males exhibit LP significantly more fre-
studies. For the classification in this investigation, deliberately quently (p = 0.0029). Grade 0 occurred in only 10% of males,
no minimum in depth or length of fissures was used. As soon as but in 16% of females.
a fissure could be recognized with the naked eye, it was classi- In the present study, 80% of smokers showed LP. In other in-
fied into grades 1 to 3. If our classification, similar to that in vestigations the proportion amounted to about 27% (Al-Attas
­other studies, had started with a fissure depth at which only et al. 2014). Tobacco consumption probably does not lead di-
smooth squamous epithelium was visible (grade 2), a prevalence rectly to LP. The correlation could also be attributed to gender,
of 24% would have emerged. In previous investigations, varying because more males than females smoke. On the other hand,
definitions were used. Some authors only considered tongue fis- the effect could also be due to age. The majority of smoking par-
sures of at least 2 mm in depth and extending over more than a ticipants in the present sample was aged over 30 years.
third of the dorsal tongue surface (Darwazeh & Almelaih 2011). Also regarding mouth burning, the correlation with LP could
Other investigators in turn also took into account smaller variet- be indirect. Reasons could be systemic diseases or the fact that
ies such as fissures along the midline, which resulted in a preva- mouth burning also occurs more often at old age. In this study,
lence of over 20% (Kovac-Kavcic & Skaleric 2000). 17 patients complained of mouth burning. This resulted in a sig-
Evidence that LP constitutes a sign of age, on the one hand, nificant association with LP (p = 0.0028).
is the average age of participants with LP of grade 3, which The present data record did not reveal an association of LP
strikingly exceeded that of participants without LP or with LP and alcohol consumption. Alcohol consumption is assumed to
of grade 1. On the other hand, the frequency of LP increased lead to pathologic alterations of the oral mucosa, but not to be
with age, and a tendency could be recognized that the degree responsible for the occurrence of LP. In addition, alcohol-in-

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duced alterations largely concern the floor of the mouth and the ries was representative for the Swiss population. In order to
retromolar area. preclude regional peculiarities, additional studies in other re-
Wearing of dental prostheses is associated with an elevated gions of Switzerland possibly are necessary.
prevalence of oral mucosal lesions. Among these, LP is the most
frequent alteration (Kovac-Kavcic & Skaleric 2000, Lin et al. Résumé
2001). The same conclusion was also reached by other authors La langue plicaturée (LP) se caractérise par des sillons et fissures
who, however, acknowledged that prosthesis carriers are gen- de profondeurs variables sur la face dorsale de la langue. Cette
erally older and, hence, this association in fact could be due to altération est habituellement asymptomatique. La prévalence
the correlation with age (Jainkittivong et al. 2002). Although in déclarée est généralement de 10 à 20% mais il y a là de grandes
the present sample, 62 out of the 68 prosthesis carriers exhibit- différences.
ed LP, this did not entail a significant correlation of LP with La présente étude examine sur un groupe de 1000 patients
wearing of a denture. The statistical regression analysis suggest- (n = 465 hommes, n = 535 femmes) la relation entre une LP et
ed that other features such as age were responsible for the con- l’âge des patients ainsi que d’autres facteurs. Les participants
nection. Thus, the correlation with LP was indirect. Wearing of ont rempli un questionnaire donnant des informations sur leur
a dental prosthesis was not discriminating with respect to the sexe, âge, consommation d’alcool et de tabac, le port éventuel
occurrence of LP. It could be worthwhile to conduct specific de prothèses dentaires et les brûlements de bouche. Puis une
­investigations in prosthesis carriers using controlled groups of photo de la langue a été faite. Les photos ont été examinées et
similar age classes. classées en quatre niveaux différents d’altération.
Of relevance for the general dentist is the fact that LP is ob- La manifestation d’une LP ainsi que le nombre de personnes
served frequently and requires no specific therapy, unless it is concernées augmentent avec l’âge (p < 0,001). Chez les hommes,
part of an orofacial granulomatosis. If symptoms arise as a result une LP est plus fréquente que chez les femmes (p = 0,0029).
of a plaque-related inflammation, oral hygiene measures should Fumer a également une influence positive sur la prévalence
be instructed (tongue cleansing). (p < 0,05) et on constate une corrélation positive entre les brûle-
The present study was carried out using randomly selected ments de bouche et une LP (p < 0,01).
patients from a dental practice. The distribution of age catego-

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