Mucous Patches of Secondary Syphilis 
The lesions of secondary syphilis on the tongue are known as mucous patches (Fig. 21.7); (see discussion of syphilis in Chapter 28: Sexually Transmitted Diseases).
Geographic Tongue
Geographic tongue, or benign migratory glossitis, is a common idiopathic finding (Fig. 21.8).
Clinical Manifestations
Lesions consist of shiny, red, patches that are devoid of papillae that resemble mucous patches. Such lesions seem to move about on the surface of the tongue and change configurations from one day to the next, thus accounting for the bizarre, shifting patterns.
Reports have suggested an association of geographic tongue with psoriasis; however, its 2% incidence in patients with psoriasis is no greater than that would be expected in the otherwise healthy population.
Black Hairy Tongue
Black hairy tongue is more than just a pigmentary change. Actually, it represents benign, asymptomatic hyperplasia (an accumulation of keratin) or hypertrophy of the filiform papillae of the tongue. The pigmentation results from the normal pigment-producing bacterial flora that colonize the keratin.
It has been debatably associated with smoking, excessive coffee or tea drinking, and the prolonged use of oral antibiotics.
Management Clinical Manifestations
A black discoloration of the tongue should be distinguished from black hairy tongue. In these cases, there is no hyperkeratosis or hypertrophy of papillae.
Oral mucous membrane pigmentation has been noted to result from the following agents:
Antimalarials (Fig. 21.10), bismuth (Fig. 21.11), chlorhexidine mouth rinses, doxorubicin, fluoxetine, inhalation of heroin smoke, ketoconazole, propranolol, risperidone, sulfonamides, terbinafine, tobacco, zidovudine, and tetracycline.
Artifactual pigmentation has also been noted to result from iatrogenic amalgam tattoos and dental fillings caused by traumatic implantation of dental amalgam into soft tissue. Lesions are gray, blue or black macules on the oral mucous membranes (Fig. 21.12).
Oral Leukoplakia
White macular or plaque-like lesions are considered precursors to squamous cell carcinoma of the mucous membranes.
Smoking, chewing tobacco, and ethanol abuse are all contributing factors.
Clinical Manifestations
Lesions occur on the tongue (Fig. 21.13), buccal mucosa, hard palate, and gums.
Oral leukoplakia may resemble oral lichen planus, oral hairy leukoplakia, or white plaques caused by trauma.
Less than 5% of lesions have been reported to develop into squamous cell carcinoma.
Oral hairy leukoplakia is associated with the Epstein-Barr virus.
Seen in patients with HIV infection (see Chapter 24: Pruritus: The “Itchy” Patient) and in transplant recipients.
Clinical Manifestations
Filiform papules that resemble white hairs are seen on the sides of the tongue (Fig. 21.14).
Oral Candidiasis (“Thrush”)
Most oral fungal infections are caused by Candida albicans, a harmless commensal organism inhabiting the mouths of almost 50% of the world's population. Under suitable circumstances, it can become an opportunistic pathogen.
In infants, acute pseudomembranous candidiasis (thrush) may be observed in healthy neonates or in people in whom antibiotics, corticosteroids, or xerostomia (dry mouth) disturb the oral microflora.
Oral candidiasis is most prevalent in people with immunosuppressive conditions (HIV-associated oral candidiasis) and diabetes as well as those on long-term broad-spectrum antibiotics as well as systemic and aerosolized corticosteroids. Xerostomia (as in Sjögren syndrome) and radiotherapy to the head and neck also predisposes individuals to oral yeast infections.
Clinical Manifestations
White patches/plaques are present on the surface of the buccal mucosa, palate, or tongue.
Lesions develop into confluent plaques that resemble milk curds (multiple white-fleck appearance) and can be wiped off to reveal an erythematous base (Fig. 21.15).
Erythematous areas found generally on the dorsum of the tongue, palate, or buccal mucosa.
Lesions may involve the tongue, the oropharynx, buccal mucosa, and the angles of mouth (angular cheilitis [see below]).
Lesions on the dorsum of the tongue present as depapillated areas.
Diagnosis
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