1 2 3Roopavathi KM , Suhas S , Sanjay Venugopal

1 2Senior Lecturer, Department of Periodontics, Professor & Head, Department of Oral Medicine & Radiology,

3Professor & Head, Department of PeriodonticsSri Siddhartha Dental College & Hospital, Tumakuru,

Sri Siddhartha Academy of Higher Education, Tumakuru.

Drug induced allergic glossitis – Report of a rare case

Address for Correspondence:Dr. Roopavathi KM, Senior Lecturer, Dept of Periodontics, Sri Siddhartha Dental College & Hospital, Tumkur-572107, Karnataka, India.Email: roopavathikm@gmail.com

Abstract

Allergic glossitis is a rare disorder, which may pose a challenge to dentists in diagnosis. Allergic reactions occurring

in the oral cavity can be attributed to the use of various materials such as chrome cobalt dentures, gold crowns,

denture soft lining material, chewing gum, dental amalgam, acrylic dentures, toothpaste, benzocaine, impression

material, medications etc. In this article we are presenting a unique case of allergic glossitis in an adult female

patient aged 35 years who presented with depapillation and erythematous areas with pseudomembrane on the

dorsum of tongue, associated with burning sensation on intake of food. On the basis of patients history and clinical

observations, it was inferred to be a case of allergic glossitis. Since these lesions produce symptoms acutely, its

severity ranging from moderate to severe, early identification and initiation of treatment with the help of topical

steroid rinses will alleviate symptoms of this self-limiting condition.

Key words: Allergic glossitis, Depapillation, Burning sensation, Steroid rinses.

IntroductionMany contributing factors like systemic conditions or

consumption of medications are attributed to cause oral

diseases or conditions. According to World Health

Organization an adverse drug reaction is defined as a

response to a drug which is noxious and unintended, and

which occurs at doses normally used in man for the

prophylaxis, diagnosis, therapy of diseases or for the [1]

modification of physiological function.

When an allergen (defined as an antigen that reacts

specifically with a specific type of Ig E reagin antibody)

enters the body, an allergen-reagin reaction takes place

and a subsequent allergic reaction occurs resulting in [2]

clinical symptoms (allergy).

Allergy can occur when allergen locally contacts the

sensitive area or when the allergen is introduced

systemically. The present case reports a systemically

induced antigenic response manifested as a local lesion

on the dorsum of tongue.

23

Case reportA 35 year old female, reported with a chief complaint of

burning sensation accompanied by pain and discomfort

on tongue while eating, followed by the peeling of

tongue surface, with appearance of red lesion which was

gradually worsening on the dorsal surface since five

days. She gave history of intake of an antibiotic with the

contents of Norfloxacin 400 mg + Tinidazole 600 mg + 6

Lactic acid bacillus 120 x 10 spores for the treatment of

stomach upset seven days ago. Gastrointestinal

disturbances included muscle cramps followed by loose

motions. The patient was on antibiotics twice daily for

three days, lesions on the tongue started to appear a day

after the consumption of the drug.

Past dental history revealed appearance of similar lesion

Case Report

DOI-10.46319/RJMAHS.2020.v03i02.006

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two years ago, when she had consumed the same

antibiotic. The severity of the lesion was less when

compared to the present lesion and it had subsided with

use of benzocaine mouth rinse. Systemic review of the

patient was done and no significant medical history was

revealed by the patient.

On intraoral examination, dorsum of tongue revealed

irregular, raised, multiple bright red patches with areas

of depapillation surrounded by erythematous zones

(Figure 1).

Figure 1: Before treatment (Day- 0)

Figure 2: Day two

Figure 3: Day three

Figure 4: Day four

Figure 5: Day five

During treatment (0-5 days) (Figure 2 to 5)

Patient was advised to continue the medications for

three more days, following which lesions healed

completely (Figure 6). At the end of the treatment patient

was also counseled and advised not to use the same

antibiotics again.

DiscussionGlossitis is an inflammatory condition associated with

depapillation of the dorsal surface, leaving a smooth and

Figure 6: Post treatment (Day-08)

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erythematous surface. Various causes for allergic

reaction include use of toothpaste, mouthwashes and

v a r i o u s m e d i c a t i o n s l i k e A C E i n h i b i t o r s ,

bronchodilators and antibiotics. The incidence of 23%

geographic tongue due to allergy to drugs, food and [3]others was reported. Drug allergy is described as an

i m m u n o l o g i c a l l y m e d i a t e d r e s p o n s e t o a

pharmaceutical and / or for formulation agent (allergen) [4]in a sensitized person. It is reported that the flavouring

agent rather than the antibiotic itself is the cause of such [5]reaction.

One of the manifestations of allergic reaction caused by

systemic medication is Fixed drug eruption also called

stomatitis medicamentosa. These appear clinically as

localized hypersensitivity reactions which reappear at

the same site each time the patient takes the medication.

Common areas where these lesions occur in oral cavity

are buccal mucosa, lips and tongue, but occasionally it is

seen on the palate and gingiva also. It occurs on oral

mucosa in the form of localized, sharply demarcated

erosion, with thick pseudomembranes. These fixed drug

eruptions are commonly seen within 24 hours after

consumption of the medication and the lesions

spontaneously resolves once the medication is stopped.

(Table 1)

Ampicillin

Barbiturates

Chlorhexidine

Dapsone

Gold

Ibuprofen

Indomethacin

Lignocaine

NSAIDs

Penicillamine

Salicylates

Sulphonamides

Tetracyclines

Table 1. Medications commonly associated to cause [6]Fixed Drug Eruptions.

Mechanism of action of allergic lesions on the

dorsum of the tongue

Glossitis is an allergic reaction that affects individuals

who have been previously sensitized to allergen. It is a

type IV hypersensitivity reaction. It becomes evident

several hours or even days after exposure to antigen. It is

a delayed hypersensitivity reaction and involves a

cascade of cellular events. The process has two phases,

an induction phase sensitizes the immune system to the

allergen, and an effector phase during which the immune [7]

response is triggered. Allergens bind to epithelial

proteins and infiltrate mucosal epithelium. The

epi the l ia l pro te in a l le rgen complexes have [8]

immunogenic properties. These complexes are

phagocytocized by macrophages and migrate towards

regional ganglia in induction phase and recognized by

helper T cells. During stimulation and division phase,

two other types of T lymphocytes, memory and

cytotoxic T lymphocytes are produced. On subsequent

contact with antigen, memory T lymphocytes are

stimulated leading to beginning of the entire previous

cycle. Since memory T lymphocytes remain in the body

for life, more aggressive and rapid immune response is [8]triggered.

Some local conditions like eosinophilic granuloma, auto

mutilation, facial hemiatrophy cranial arteritis, and

chronic candidiasis can cause depapillation of the

tongue. Systemic causes for tongue depapillation

include iron deficiency anemia, plummer Vinson

syndrome, pernicious anemia, Niacin deficiency,

systemic lupus erythematosis, dermatomyositis,

diabetes, syphilis, zoster infection, tuberculosis.

Chronic atrophic candidiasis is commonly seen on the

dorsum of tongue and because of similarity with median

rhomboid glossitis it is challenging to clinically

differentiate but by scrapping and cytological

examination it can be diagnosed. Many systemic causes

like iron deficiency anemia, Plummer Vinson syndrome,

pernicious anemia are also attributed to cause this which

can be confirmed by checking blood parameters. We can

also observe depapillation of the tongue in zoster

infections which occurs due to herpes zoster virus but in

these conditions multiple vesicles are seen on the ventral [9]surface of the tongue.

Allergic glossitis is difficult to differentiate from

traumatic glossitis, erythema, edema and ulceration in

severe cases at the site of contact are the characteristic [10]features of the allergic glossitis. In 68.6% of patients,

location of glossitis is on lateral border of the tongue [3]which is similar to our case. Cathy Nikdel, et al

reported a case similar to present case with

erythematous lesion and absence of filiform papilla on

the body & lateral borders of the tongue due to pea nut [11]

allergy.

Elimination of the causative allergic agent is the primary

Roopavathi KM, et al.: Drug induced allergic glossitiswww.rjmahs.org

DOI -10.46319/RJMAHS.2020.v03i02.006

management of allergic glossitis. The allergic properties

may be confirmed by the reappearance of inflammatory

lesions on re-introduction of the agent. Patients who

experience more severe symptoms may in addition need

to be prescribed a topical corticosteroid either in form of [12]ointment, gel or mouthwash to promote faster healing.

The primary objective of glossitis management is to

minimize inflammation which can be achieved by

maintaining good and clean oral hygiene by meticulous [13]

brushing of teeth twice a day without fail. Complete

resolution of the lesion can sometimes take upto two

weeks. Along with these measures additional use of

antihistamine suspension in a swish and swallow

method is shown to provide advantage of both local and [14]systemic actions.

ConclusionAllergic glossitis sometimes can be confused with

benign migratory glossitis. Careful history taking and a

high degree of suspicion is essential to establish a cause

and effect relationship. Medical management will

include the use of antihistamines and glucocorticoids.

Early and accurate diagnosis relieves the patient from

symptoms and discomfort.

Financial support and sponsorship: Nil

Conflict of interest: Nil

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