Lactobacillus treatment as adjuvant for geographic tongue and fissured tongue with gastritis: case report

Introduction

Geographic tongue and fissured tongue are common oral mucosal diseases (1). Geographic tongue is a noninfectious tongue disease, which often manifests as smooth red lesions with filamentous papillary atrophy and filamentous papillary hyperplasia around the lesions, which appear similar to a map (2). Because of the boundary, size, and position of the disease can change at any time, so it is also called migratory glossitis. The fissured tongue shows a long or short central groove and a number of irregular secondary grooves (3). The shape and direction of the fissure can be different. Both diseases have the features of a difficult-to-determine cause, a long course of disease, and the characteristics of repeated attacks (4). Early disease shows no obvious symptoms, but later, pain when eating irritant food, dry mouth, a burning feeling, and sometimes even taste disorders can emerge (5). Generally speaking, these 2 diseases co-occur, and patients may have a family history, which means the diseases may be determined by the same gene (6). Because the cause is difficult to establish, symptomatic treatment is often used to treat geographic tongue and fissured tongue, which may include regular sleep and rest, a healthy diet, or the use of local treatment drugs to relieve symptoms of pain, allergy, or taste disorders (7). The prognosis of geographic tongue and fissured tongue is generally good, but the course may be too lengthy, and it often occurs intermittently, putting patients in a long-term state of anxiety.

In addition to genetic factors (8), the occurrence of geographic tongue and fissured tongue is also associated with psychiatric, systemic, and immune factors, such as psoriasis and diabetes mellitus (9). It has been reported that the occurrence of geographic tongue may also be associated with gastrointestinal diseases (10). This may be because the occurrence of geographic tongue is related to the bacterial microenvironment of the stomach, and patients with gastritis also often have accompanying Helicobacter pylori (H. pylori) infection, which may cause the occurrence of fissured tongue and geographic tongue (11). This means that attention should be paid to the treatment of gastritis when treating gastritis-related geographic tongue and fissured tongue so as to better help treat the glossitis.

There are many treatments for chronic gastritis (12), with inhibition of H. pylori growth being particularly prominent (13). In addition to medication, treatment includes the use of probiotics to control the growth of H. pylori. As a kind of probiotic, Lactobacillus has been confirmed by a large number of experiments to be effective in fighting H. pylori and treating gastritis, and other research suggests progress in treating oral diseases in this manner (14). At present, it is also used as one of the adjuvants of anti-H. pylori triple antibiotic therapy (15). However, there are seldom studies about Lactobacillus used in the treatment of oral mucous membrane diseases， especially geographic tongue and fissured tongue.

Therefore, this case we used typically causative therapy with Lactobacillus as adjuvant to treat patient with a geographic tongue and fissured tongue with gastrointestinal disease and explore the effectiveness for further application. In this case report we used Lactobacillus in fresh yogurt as adjuvant, combined with typically causative therapy. The course of the diseases was shortened with no recurrence, and gastrointestinal symptoms were improved after addition of Lactobacillus as an adjuvant. We present the following article in accordance with the CARE reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-23-203/rc).

Case presentation

A 33-year-old female patient visited the Chinese PLA General Hospital on July 14^th, 2022 with a geographic tongue and fissured tongue with taste disturbance for 2 months. Two months prior, the patient reported an irregular smooth red lesion on the back of her tongue and 2–3 shallow cracks in the center of her tongue. She did not experience pain or a burning sensation when brushing her teeth or eating, and no treatment was given. Three days prior, the patient found that the shape of the red lesions on the back of the tongue had changed, and red lesions on the side of the tongue had also appeared. The cracks in the center of the tongue deepened to about 0.8 cm, and the number of cracks increased to 4–5 and were accompanied by symptoms of taste disorders. The examination showed irregular red lesions on the back and ventral tongue accompanied by filamentous papilla atrophy. The surface of the lesions was smooth, and the boundary between the lesions and the surrounding areas was obvious. The mucosa was congested and red-colored, and the filamentous papilla around the lesions was thickened without tenderness. A deep fissure was seen in the center of the dorsal tongue about 2.5 cm in length and 0.8 cm in depth. Additionally, 5–6 small superficial cracks were seen in the tip of the tongue, and the mucosa at the bottom of the cracks was intact without tenderness (Figure 1). The patient reported no family history of the disease, no history of systemic diseases, a 1-year history of chronic gastritis, frequent occurrence of soft stool and stomach acid reflux, and discomfort. The C14 test was positive.

Figure 1 The first visit of the patient.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

In this case, the patient was treated with medications, including sodium bicarbonate tablets (1 tablet, once a day), Kangfuxin solution (gargling for 15 min, 3 times a day), chlorhexidine solution (smear, 3 times a day), and stomatitis spray (external application, 3 times a day). As usual, we suggested that the patient use a yogurt machine to mix yogurt and pure milk (1:4) daily to make 500 mL of sour milk and ingest this daily. In addition, we recommended that the patient maintain a daily regimen of a light diet without stimulating food, regular work, and sufficient rest.

Three days after the first visit, the patient’s symptoms began to be alleviated. Five days after the first visit, the area of the geographic tongue on the dorsum and abdomen of the tongue had shrunk, the central fissure had become shallow with a length increased, and the number of superficial cracks on the dorsum of the tongue had decreased to 2–3 (Figure 2). Ten days after the first visit, the lingual area of the dorsal and left lingual hinterland map had been significantly reduced, and the filiform papillae had grown again (Figure 3). The crack in the middle of the back of the tongue had become shallower, the coating of the tongue had thickened around the crack, the length had decreased, the superficial crack on the tip of the tongue had disappeared, and the symptoms of taste disorders had begun to be alleviated. Twenty days after the initial diagnosis, the geographic tongue lesions had disappeared and the cracks had basically healed (Figure 4). The patient reported that the gastric symptoms had improved, and there was no soft stool or stomach discomfort. The whole timeline is shown in Table 1.

Figure 2 The fifth day after the first visit.

Figure 3 Ten days after the first visit.

Figure 4 Recovery after 20 days.

Discussion

Geographic tongue and fissured tongue are common mucosal diseases (16). The former often manifests as smooth, red lesions and is caused by atrophy of the filamentous papilla of the tongue, while the latter manifests as the appearance of different shades and numbers of lines on the tongue. The incidence of the two is significantly correlated, and they often occur together. Many discussions on the etiology of geographic tongue have been published (17). In addition to genetic factors, mental factors, and immune factors, the occurrence of geographic tongue may also be linked to other diseases. For example, a study has shown that weakened gastrointestinal function and the change of the bacterial microenvironment may cause geographic tongue (18). Therefore, in this study, Lactobacillus, which can inhibit H. pylori (the most common infection bacterium of chronic gastritis), was selected as an adjuvant to treat gastritis, and then the course and conditions of the patients were observed and reported.

Because geographic tongue and fissured tongue are often treated according to symptoms in clinical practice, Kangfuxin solution and some stomatitis spray were also prescribed in this case. Both of these drugs have the effect of anti-inflammation, improvement of blood circulation, and promotion of wound repair. Besides this, chlorhexidine is also a kind of common drug used in the treatment of geographic tongue and fissured tongue. The mechanism behind chlorhexidine’s effect is that, as a cationic surfactant disinfectant, it can destroy the osmotic barrier on the plasma membrane of bacterial cells, thus exerting a bacteriostatic role. In addition, we chose sodium bicarbonate as one of the drugs in this study. Typically, in the treatment of glossitis, sodium bicarbonate is often used in the form of a 2% concentration mouthwash, but in this case, we chose an oral route. The patient in this case did not have fungal infection as determined by her history and signs. It was not necessary to gargle with sodium bicarbonate solution to create an alkaline environment in the mouth. However, because sodium bicarbonate can react with stomach acid, it can suppress stomach acid and treat gastritis. In addition, considering the relationship between gastritis and gastric flora, Lactobacillus, which has an inhibitory effect on H. pylori, was selected as an adjuvant in this treatment, so as to regulate the gastric bacterial environment. The method of self-made lactic acid bacteria was used, as, compared with medicinal lactic acid bacteria tablets, the activity of freshly made lactic acid bacteria would be higher. After treating the gastric diseases and glossitis at the same time, we found that the course of the patient was shorter than that of the patients with gastric diseases and glossitis in general, and there has been no recurrence thus far. This suggests that we should ask about the history of gastrointestinal diseases in the treatment of geographic tongue and fissured tongue, and consider the treatment of gastrointestinal diseases in conjunction with those of the tongue, so as to accelerate the treatment of geographic tongue and fissured tongue.

There are also some limitations in this study. First, we only report an encounter of a single case, which is likely not representative. Secondly, Lactobacillus was used to inhibit H. pylori in this case, but some cases of chronic gastritis are not accompanied or caused by H. pylori infection, and these should be treated with other gastritis methods. In addition, in this case, we recommended for the patient to make yogurt by herself using a yogurt machine, which can ensure the activity of Lactobacillus. However, the preparation procedure is relatively complicated, which may lead to patient’s poor compliance. In the future, more cases will be collected by using and evaluating this treatment in the clinic. In addition, when deciding whether a patient needs adjuvant Lactobacillus therapy, a C14 test, the gold standard method for detecting H. pylori, is recommended. When the patient is diagnosed with gastritis complicated with H. pylori infection, Lactobacillus could be used to improve the gastrointestinal flora and environment. Finally, we can improve the procedure of producing the Lactobacillus to reduce the impact of poor compliance of the patient. Finally, we can also compare the differences between fresh Lactobacillus and Lactobacillus tablets. If there is little difference between them, we can also try to use Lactobacillus tablets for treatment.

Conclusions

In this case report, Lactobacillus was used as an adjuvant in the treatment of geographic tongue and fissured tongue with gastritis. It was found that the course in this case was shorter than that in other patients on average, and the symptoms of gastritis were also relieved.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-23-203/rc

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-23-203/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-203/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Gray)