Macroglossia And Dental Problems

Introduction

Tongue, the only organ of our body which doesn’t have bone. Tongue is part of our oral cavity which helps in chewing food, swallowing, phonation ( speaking). tongue also contains taste buds on the surface of it through which one can perceive different tastes.

Let us know about the tongue disorder and its association with dental problems.

What is macroglossia?

Macroglossia¹ is a condition characterized by an abnormal, unusually large tongue. It is also known as giant tongue or enlarged tongue and this enlargement of the tongue is painless in nature. The cause of macroglossia² is multifactorial and This disorder is genetically associated with autosomal dominant traits.

What are the causes and types of macroglossia?

The condition can be split into two types: true macroglossia and relative macroglossia.

True and relative macroglossia can be further divided into congenital and acquired types:

• True macroglossia – A condition in which the enlargement of the tongue is due to a disease or condition.
• Relative macroglossia -  In this type the tongue appears larger than the surrounding structures like teeth.
• Congenital macroglossia – This inherited condition is present from birth and may include disorders like Beckwith Wiedemann syndrome³ ( a condition in which excessive growth of other structures is also noted), Down syndrome, acromegaly⁴ (excessive secretion of growth hormone), Hunter syndrome and Hurler syndrome.
• Acquired macroglossia – The enlargement of tongue is due to chronic infections or inflammatory diseases such as amyloidosis⁵ (accumulation of abnormal proteins), malignancies, hypothyroidism⁶ (accumulation of subcutaneous mucopolysaccharides due to decreased degradation), cretinism, allergic reactions, lymphomas, lymphangiomas, head and neck infection and trauma or surgery.

Symptoms of macroglossia

Macroglossia is usually an uncommon condition andt is seen more in children.

The main feature in macroglossia is a severe enlargement of the tongue which  can cause facial and cosmetic disturbances.⁷

The symptoms are: 

• Difficulty in breathing, airway obstruction and noisy breathing
• Difficulty in eating and swallowing
• Speech difficulties
• Drooling of saliva
• Mouth breathing
• Orthodontic problems like a space between teeth (diastema)
• Malocclusion and crowding of teeth
• Difficulty in feeding
• Necrosis of tip of tongue due to injury from other oral structures
• Enlarged tongue may be prone to infections, drying of tongue due to prolongation outside the mouth

Diagnosis of macroglossia

• Clinical evaluation – the size of the tongue can be evaluated clinically by comparing it with other structures in the oral cavity.
• Other tests – Pregnant women are advised to have a few tests done to see if the condition is present in the baby. Tests such as detailed ultrasound and foetal echocardiogram are used to detect macroglossia in the womb. After the delivery of the baby, tests like CT scans and MRI are suggested.

Dental problems associated with macroglossia

Irregular teeth (malocclusion)

Occlusion in simple words means, the proper alignment of upper and lower teeth when the jaw is closed. Malocclusion, however, is a misalignment or incorrect relation between teeth of upper and lower dental arches when they approach each other as the jaw closes.

Angle’s classification is based on one anatomical point which is maxillary (upper) first molar, and classified malocclusion into three major types:

• Angle’s class I – Malocclusion characterized by presence of normal interarch molar relation. The mesio-buccal cusp¹⁰ of maxillary first molar occludes in the buccal groove of the mandibular first molar.¹¹      
• Angle's class II – Characterized by disto-buccal cusp of upper first molar, occludes in the buccal groove of the lower first molar.
• Angle's class III – The mesiobuccal cusp of the maxillary first molar occludes in the interdental space between the mandibular first and the second molar.

Gum tissue health

Due to enlarged tongue, it almost always comes outside of the mouth. This results in dryness of the gum tissue.

Dry mouth can lead to gingivitis,¹² decaying of teeth, bad breath, difficulty in swallowing and chewing, and oral infections.

Speech disorder 

Children with enlarged tongue cannot pronounce some letters such as P, M and B as the tongue sticks to the top of the lip making it difficult to speak.

Saliva plays an important role in speech and as we have seen above, dry mouth is a key problem caused by macroglossia. If adequate saliva is not present, the lips get stuck to each other resulting in speech disorder.

Maintaining oral health hygiene

Due to abnormally large tongues, it is difficult to maintain oral hygiene. The tongue becomes a hindrance during teeth brushing. If one cannot maintain proper oral hygiene, it causes plaque accumulation, initiation of cavities, gingivitis and other dental problems

How to identify dental problems associated with macroglossia?

• Clinical examination of patients – It is easily diagnosed, as the unusual, abnormal, enlarged tongue is clearly visible in the mouth.¹³
• The problems associated with macroglossia such as, protrusion of the mandible, diastema, lacerations caused due to tongue bite and teeth crowding can also be detected clinically.
• Radiological evaluation – Ultrasound is done in utero to diagnose macroglossia. X-rays can also be taken to detect the size of the tongue.

Treatment and multidisciplinary management

Treatment and management of macroglossia includes a multi-disciplinary team which includes dentists, orthodontists, periodontists, surgeons, speech language pathologists and psychologists for mental care of the patient and the caretaker. Key treatments include: 

• Surgery¹⁴ of the enlarged tongue to reduce the size of the tongue
• Treating malocclusion with brackets and orthodontic appliances
• Treatment of underlying causes like amyloidosis and hypothyroidism
• Gingival health – Once the tongue size is reduced and the underlying cause is treated, the decayed tooth should be restored. Gingivitis is treated with antibiotics, proper tooth brushing techniques and flossing is suggested to maintain healthy gingival tissue
• Speech disorders¹⁵ are treated with speech language therapy for children and adults
• Oral hygiene is maintained by advising mouthwashes and flossing

Summary

Macroglossia is a rare condition seen most commonly in children and few cases in adults. The condition is characterized by abnormal enlargement of the tongue compared to the normal size of the tongue.

The cause is multifactorial and it may be due to an underlying disease such as hypothyroidism, amyloidosis or genetic conditions like Beckwith Wiedemann syndrome, acromegaly and Turner’s syndrome.

Due to this condition, patients often encounter many dental problems such as teeth crowding, malocclusion, gingivitis, decayed tooth, oral infections, xerostomia, speech impairment and difficulty in swallowing and mastication.

The management and treatment is multidisciplinary in action involving an expert team.

FAQs

What is macroglossia?

Macroglossia is an unusual enlargement of the tongue. The tongue size is abnormally larger than normal size.

What are the causes of macroglossia?

Macroglossia can be acquired or congenital. It is seen in conditions like Beckwith Wiedemann syndrome, acromegaly, hypothyroidism, Turner’s syndrome and amyloidosis.

What are the symptoms of macroglossia?

Symptoms may include difficulty in breathing, difficulty in swallowing, speech disorder, xerostomia, tongue protrusion, hoarse voice and mouth breathing.

What are the dental problems associated with macroglossia?

Dental problems like teeth crowding, malocclusion, gingival problems, dry mouth, oral infections, spacing between teeth, mandible protrusion and poor oral hygiene.

How is macroglossia treated?

Treatment of macroglossia is done by a team of experts. It involves surgical reduction of tongue size, treatment of underlying disease, orthodontic treatment for malocclusion and antibiotics for gingival treatment.