Geographic tongue in a two-year-old child with Down syndrome: A case report

INTRODUCTION

Down syndrome is one of the most common chromosomal disorders worldwide, occurring in approximately 1 in 600–1000 live births. In nearly 95% of cases, it results from trisomy of chromosome 21, while translocation and mosaicism account for a smaller proportion of cases.^[1] Individuals with Down syndrome commonly present with mild to moderate intellectual disability, expressive language delay, and characteristic craniofacial and oral features.

Oral manifestations frequently reported in children with Down syndrome include cheilitis, fissured tongue, geographic tongue, macroglossia, periodontal disease, and increased susceptibility to candidiasis.^[2–4] These manifestations are attributed to altered immune responses, muscular hypotonia, mouth breathing, and associated systemic conditions. Because of communication limitations and increased parental concern, benign oral lesions in these children may generate significant anxiety and may be misinterpreted as infectious or premalignant conditions.

Geographic tongue, first described in 1831, is a benign inflammatory disorder characterized by well-demarcated erythematous depapillated areas caused by atrophy of filiform papillae, bordered by slightly elevated white margins.^[5] The lesions exhibit a migratory pattern, changing in size, shape, and location over time without scarring. The prevalence in the general population ranges from 1% to 3%.^[6] Although geographic tongue has been reported in individuals with Down syndrome, its occurrence in very young children, particularly below 3 years of age, is rarely documented in the literature, thereby adding clinical relevance to the present case. Reports suggest that geographic tongue may be more prevalent in individuals with certain systemic or genetic conditions, including Down syndrome.^[7]

Studies among Indian parents of children with Down syndrome have highlighted the psychosocial impact of oral health problems and the challenges faced in maintaining adequate oral care. This case report details geographic tongue in a two-year-old child with Down syndrome and highlights the importance of recognizing and conservatively managing this condition in such patients. Written informed consent was obtained from the caregiver for the publication of clinical findings and images.

CASE REPORT

A two-year-old male child diagnosed with Down syndrome was brought for a routine dental evaluation. The child had a confirmed history of trisomy 21 and exhibited typical phenotypic features, including mild macroglossia and an open-mouth posture. Medical history did not reveal any systemic complications such as congenital heart disease or diabetes. No history of allergies or atopy was reported.

The caregivers did not report pain, burning sensations, feeding difficulty, or behavioral changes in their child. The absence of symptoms was evaluated based on caregiver observations, including normal feeding behavior, no irritability, and no aversion to spicy or hot foods. The child exhibited moderate intellectual disability and communicated mainly through gestures and limited verbal responses. Oral hygiene routines were performed with caregiver assistance. Tongue lesions were noticed incidentally during the clinical examination, which revealed multiple (approximately 3–4), irregular, well-demarcated erythematous depapillated areas measuring approximately 0.5–1.5 cm in diameter, surrounded by slightly elevated whitish borders on the dorsal surface of the tongue [Figure 1]. The lesions were predominantly located on the anterior two-thirds of the dorsal tongue. The lesions exhibited a configuration different from that in previous photographs taken at home by caregivers three weeks earlier, indicating a migratory pattern [Figure 2]. No ulceration, bleeding, or removable plaques were present. The lateral borders of the tongue and other oral mucosal surfaces appeared normal. Based on the characteristic clinical appearance and migratory behavior of the lesions, a diagnosis of geographic tongue was established. Differential diagnoses considered included erythematous candidiasis, traumatic glossitis, and oral candidiasis. Candidiasis was excluded based on the absence of removable plaques and a lack of response to wiping, with no additional diagnostic tests required, given the classical presentation. In view of the asymptomatic nature and typical features, no biopsy or laboratory investigations were performed.

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Figure 1: Clinical image showing multiple erythematous depapillated areas with surrounding white borders on the dorsal surface of the tongue, characteristic of geographic tongue in a 2-year-old child with Down syndrome.

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Figure 2: Three week earlier photograph of the tongue, demonstrating a migratory pattern with altered lesion configuration. Image captured at home by caregivers.

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Counseling and reassurance were provided to the caregivers, explaining the benign, self-limiting nature of the condition. Instructions were given to maintain optimal oral hygiene and avoid irritating foods if symptoms developed. Periodic follow-up was advised, considering the child’s Down syndrome and limited ability to express discomfort verbally.

At the three-month telephonic follow-up, the mother of the child reported that lesions persisted, with altered configuration, but remained asymptomatic. No new oral findings were detected. Caregivers reported reduced anxiety after receiving an explanation regarding the benign nature of the lesion. The child continues to be monitored at regular intervals.

DISCUSSION

Down syndrome is frequently associated with various oral and dermatological manifestations due to genetic and immunological alterations.^[8] Fissured tongue and cheilitis are among the most commonly reported oral findings, while geographic tongue has also been described more frequently than in the general population.^[7,9]

The prevalence of geographic tongue in healthy individuals ranges between 1% and 3%.^[6] Some studies indicate increased occurrence among individuals with Down syndrome, possibly related to immune dysregulation, altered epithelial turnover, or genetic susceptibility.^[9]

The pathogenesis of geographic tongue remains uncertain. Proposed causes include genetic predisposition, stress, hormonal influences, atopy, psoriasis, nutritional deficiencies, and immunological factors.^[10] Children with Down syndrome often present with various oral health issues influenced by genetic, immunological, and behavioral factors. Along with commonly reported conditions such as periodontal disease, fissured tongue, and delayed tooth eruption, parental awareness and access to oral healthcare significantly impact disease recognition and management. A recent study by Gupta et al.^[11] highlighted that caregivers of children with Down syndrome often face difficulties in maintaining oral hygiene and obtaining appropriate dental care, which may contribute to delayed detection of oral mucosal conditions.

In this context, the present case is clinically important, as geographic tongue, although benign and self-limiting, may cause concern among caregivers, especially when observed in very young children. Limited awareness regarding such conditions can lead to anxiety and unnecessary interventions. Therefore, early recognition, appropriate counseling, and reinforcement of oral hygiene practices are essential components of management. The findings of this case further emphasize the need for increased parental education and routine oral examinations in children with Down syndrome to ensure timely diagnosis and reassurance.

Although geographic tongue has been reported in individuals with Down syndrome, it has been documented only in a limited number of studies, and its occurrence in very young children, particularly those below 3 years of age, remains rarely reported in the literature.^[12] In individuals with Down syndrome, altered immune response, impaired epithelial integrity, and increased inflammatory mediators may contribute to its occurrence.^[13]

Clinically, the migratory pattern and absence of scarring are features of geographic tongue. The main differential diagnoses include candidiasis, psoriasis-related oral lesions, and lichen planus. However, in very young children, erythematous candidiasis and traumatic glossitis are more relevant differentials.^[14] Recognition of the characteristic appearance is essential to prevent unnecessary investigations.

Management tends to be conservative. Asymptomatic cases do not require active treatment beyond reassurance and maintaining oral hygiene. In symptomatic cases, topical anesthetics, antihistamines, or mild corticosteroids may be considered.^[5] In the present case, the absence of symptoms justified a non-interventional approach.

CONCLUSION

Geographic tongue in children with Down syndrome is a benign variation of the oral mucosa that requires precise clinical recognition. This case illustrates its rare early occurrence in a 2-year-old child and underscores the need for clinician awareness. Recognizing its distinctive migratory pattern helps prevent unnecessary investigations and overtreatment. Conservative management with reassurance and regular monitoring remains the preferred approach.