Evaluation of the factors associated with sublingual varices: a descriptive clinical study

Cross-sectional study of sublingual varicosities: systemic exposures

PURPOSE

Sublingual varicose veins are a common vascular lesion with different names, such as caviar tongue or vascular malformations. This study aimed to investigate whether there is an association between sublingual varicose veins and cardiovascular diseases by observing arterial hypertension, diabetes, thrombosis, and infarction. In addition, to evaluate a series of thrombi that affected the oral cavity and to analyze their clinical aspects and relate them to possible systemic alterations.

METHODS

This is a cross-sectional study consisting of a sample of 134 varicosities, 23 vascular malformations, and 4 thrombosis.

RESULTS

Lingual varicosities are more frequently observed in women aged 57.4 ± 16.4 years. Hypertension was present in lingual varicosities (n = 73), as well as diabetes (n = 107), reports of thrombosis (n = 41), and infarction (n = 45). Arterial hypertension was decompensated (n = 12). The most frequent underlying diseases were diabetes (p < 0.001), infarction (p = 0.012), and thrombosis (p = 0.004), and the most commonly used drug was losartan.

CONCLUSION

It can be inferred from the present study that lingual varicosities are related to cardiovascular diseases and can serve as a parameter to measure their decompensation.

Association of Sublingual Varices With Heart- and Cerebrovascular Disease

OBJECTIVE

The aim of this research was to investigate whether sublingual varices (SV) are associated with new events of ischaemic heart disease (IHD) and new events of cerebrovascular disease.

METHODS

A prospective observational study was conducted amongst 1139 dental patients aged between 48 and 84 years across 2 cohorts (201 enrolled from 2010-2013 and 938 from 2018-2020). Participants provided baseline data on demographics, risk factors, and medical diagnoses, followed by an assessment of their tongue's ventral surface to classify veins as either having no sublingual varices (nSV) or having sublingual varices (SV). Information regarding medical diagnoses was gathered during the follow-up period from both participants and their medical records. The primary outcome variables were the onset of new IHD and new cerebrovascular disease events. Comparisons were made between participants with SV and nSV.

RESULTS

The study population comprised 54% women with an average age of 66 years. SV were present in 33% of participants. Those with SV predominantly were male, older, and smokers; had a higher body mass index, and exhibited more instances of hypertension, diabetes, and dyslipidaemia than those with nSV. New occurrences of IHD (4.5% vs 1.8%, P = .009) and cerebrovascular disease (4.2% vs 2.0%, P = .026) were more prevalent in the SV group compared with the nSV group. The link between SV and new IHD events persisted even after adjustments for sex, age, and smoking habits (OR, 2.26; 95% CI, 1.074.76), but not for new cerebrovascular disease events (OR, 1.77; 95% CI, 0.843.71).

CONCLUSIONS

Our study identifies a correlation between SV and new events of IHD, but not new events of cerebrovascular disease. The detection of SV occurred prior to the IHD events, suggesting a temporal relationship. This novel finding proposes a potential shared pathophysiology between IHD and SV.

Relationship between sublingual varices and hypertension: a systematic review and meta-analysis

BACKGROUND

Previous research has investigated the connection between sublingual varices (SV) and cardiovascular disease, aging, and smoking. However, it is still unclear whether arterial hypertension affects the presence of SV. This meta-analysis aimed to investigate the relationship between hypertension and the presence of SV.

METHODS

The literature search was performed using PubMed, Web of Science, Scopus, Google Scholar, and Embase for cross-sectional studies until July 2023. PRISMA guidelines were used for article selection. A meta-analysis using standardized mean differences by a random effects model was conducted to pool studies.

RESULTS

A total of 568 articles were retrieved, of which twelve were included in the meta-analysis. Cumulatively, 2543 samples in the case group (1185 with hypertension) and 3897 samples (821 with hypertension) were studied in the control group. Using the random effects model, the pooled odds ratio (OR) revealed a significant association between hypertension and sublingual varices (OR = 2.66; 95% CI: 1.69-4.18).

CONCLUSION

The meta-analysis showed a significant and positive association between sublingual varices and hypertension. SV's presence could be used by dentists as a non-invasive indicator of hypertension screening.

Core characteristics of sublingual veins analysis and its relationship with hypertension

BACKGROUND

The sublingual vein (SV) is a specialized diagnostic method used in Traditional Chinese Medicine (TCM). Despite its ability to objectively reflect blood flow, SV is often overlooked in clinical practice.

OBJECTIVE

This study aims to analyze the core characteristics of SV and investigate the in-depth relationship between its digital characteristics and hypertension. The goal is to find a link between SV and hypertension and break out of the current situation.

METHODS

Modern digital analysis techniques were applied to the traditional SV diagnostic theory. In a controlled study with 204 participants, the digital characteristics of SV were documented using TFDA-1, and its color value was analyzed using TDAS. Morphological characteristics of SV, such as trunklength, width, and tortuosity, were examined by combining computer vision with expert interpretation. This involved the application of automatic ranging methods and a rectangular approximation algorithm, which are novel approaches in the field of TCM. The t-test and Mann-Whitney U test were used to analyze the digital characteristics of SV in hypertension. Binary logistic regression and neural network models were established using machine learning to explore the deep relationship between SV characteristics and hypertension.

RESULTS

There was a significant difference of the tortuosity of SV between the two groups (Z=-2.629, p= 0.009). The results revealed thick width of SV (OR = 2.64, 95% CI: 1.02-6.79) was the risk factor for hypertension. Addition of SV characteristics improved overall percent correct for hypertension prediction to 80%.

CONCLUSION

TCM method of diagnosis of SV has been greatly expanded in terms of technical means, and the close relationship between SV and hypertension has been found in clinical data.

Is there any difference based on sublingual varices frequency between hypertensive patients and healthy persons?

BACKGROUND

Sublingual varices (SV) are benign vascular lesions that have questionable associations with aging, smoking, and hypertension. This study purposed to evaluate whether SV frequency differs between hypertensive patients and healthy persons.

METHODS AND MATERIAL

This cross-sectional study was conducted on 120 dental patients referred to Yazd Oral Medicine Department. At first sublingual surface of the tongue were examined before the routine oral survey, and blood pressure (BP) was measured in a sitting position. SV were classified into Grade 1 (no/mild), Grade 2 (medium to severe), and Grade 3 (multi-focal). Blood pressure was measured in all participants. Participants based on the obtained BP, divided into normal, prehypertension, stage 1, and 2 groups. Frequency of SV was compared in regarding age, gender, and stage of hypertension. All of the analyses were conducted at a p < 0.05 level of significance by the SPSS22 statistical package using chi-square test.

RESULTS

Out of 120 patients, 84 (70%) had SV. The frequency of SV in patients with hypertension (HT) (86.8%) was significantly higher than in others (48.1%); (p < 0.001). Data analysis showed there was a significant difference between the age groups. There was no significant difference based on SV between two genders. There was no significant difference in the frequency of sublingual varices between males and females. Aging could impact the frequency of SV.

CONCLUSION

This study revealed that patients with hypertension had more SV. A simple valuable method for dental clinicians to be active in preventive health care is evaluating sublingual surface of tongue.

The relative area score for sublingual varices reliability measurement: a diagnostic study

BACKGROUND

Sublingual varices (SV) and their predictive potential for other clinical parameters is a much studied topic in oral medicine. SVs have been well studied as predictive markers for many common diseases such as arterial hypertension, cardiovascular disease, smoking, type 2 diabetes mellitus and age. Despite many prevalence studies, it is still unclear how the reliability of SV inspection affects its predictive power. The aim of this study was to quantify the inspection reliability of SV.

METHODS

In a diagnostic study, the clinical inspection of 78 patients by 23 clinicians was examined for the diagnosis of SV. Digital images of the underside of the tongue were taken from each patient. The physicians were then asked to rate them for the presence of sublingual varices (0/1) in an online inspection experiment. Statistical analysis for inter-item and inter-rater reliability was performed in a τ-equivalent measurement model with Cronbach's [Formula: see text] and Fleiss κ.

RESULTS

The interrater reliability for sublingual varices was relatively low with κ = 0.397. The internal consistency of image findings for SV was relatively high with α≈ 0.937. This shows that although SV inspection is possible in principle, it has a low reliability R. This means that the inspection finding (0/1) of individual images often cannot be reproduced stably. Therefore, SV inspection is a difficult task of clinical investigation. The reliability R of SV inspection also limits the maximum linear correlation [Formula: see text] of SV with an arbitrary other parameter Y. The reliability of SV inspection R = 0.847 limits the maximum correlation to [Formula: see text] (SV, Y) = 0,920-a 100% correlation was a priori not achievable in our sample. To overcome the problem of low reliability in SV inspection, we propose the RA (relative area) score as a continuous classification system for SV, which normalises the area of visible sublingual veins to the square of the length of the tongue, providing a dimensionless measure of SV.

CONCLUSIONS

The reliability of the SV inspection is relatively low. This limits the maximum possible correlation of SV with other (clinical) parameters. SV inspection reliability is an important indicator for the quality of SV as a predictive marker. This should be taken into account when interpreting previous studies on SV and has implications for future studies. The RA score could help to objectify the SV examination and thus increase its reliability.

Machine Learning-Based Technique for the Severity Classification of Sublingual Varices according to Traditional Chinese Medicine

Tongue diagnosis, a noninvasive examination, is an essential step for syndrome differentiation and treatment in traditional Chinese medicine (TCM). Sublingual vein (SV) is examined to determine the presence of blood stasis and blood stasis syndrome. Many studies have shown that the degree of SV stasis positively correlates with disease severity. However, the diagnoses of SV examination are often subjective because they are influenced by factors such as physicians’ experience and color perception, resulting in different interpretations. Therefore, objective and scientific diagnostic approaches are required to determine the severity of sublingual varices. This study aims at developing a computer-assisted system based on machine learning (ML) techniques for diagnosing the severity of sublingual varicose veins. We conducted a comparative study of the performance of several supervised ML models, including the support vendor machine, K-neighbor, decision tree, linear regression, and Ridge classifier and their variants. The main task was to differentiate sublingual varices into mild and severe by using images of patients’ SVs. To improve diagnostic accuracy and to accelerate the training process, we proposed using two model reduction techniques, namely, the principal component analysis in conjunction with the slice inverse regression and the convolution neural network (CNN), to extract valuable features during the preprocessing of data. Our results showed that these two extraction methods can reduce the training time for the ML methods, and the Ridge-CNN method can achieve an accuracy rate as high as 87.5%, which is similar to that of experienced TCM physicians. This computer-aided tool can be used for reference clinical diagnosis. Furthermore, it can be employed by junior physicians to learn and to use in clinical settings.

Persistence and stability of sublingual varices over time and their connection to underlying factors: an 8 year follow up study

Objective

To investigate whether sublingual varices are constant or inconstant over time and whether this is connected to background variables, cardiovascular risk factors or disease.

Design

This longitudinal observational study was performed between 2010 and 2020 at the Public Dental Services Västra Vall, Varberg, Sweden. The study was based on 431 patients included in a previous study in which the relationship between sublingual varices and hypertension was examined. In connection to the annual dental examination, 281 patients were included in the follow-up study. They completed a questionnaire about background and health factors and diseases. Length and weight were measured. Two intraoral photos were taken with a digital camera. Two dentists independent of each other graded all photographs as none/few visible sublingual varices (nSV) or medium/severe sublingual varices (SV).

Results

The prevalence of SV was 25.6% at baseline and 30.6% at follow-up. At the follow up, a total of 76.5% had maintained their sublingual vascular status. Of those with nSV at baseline (n209), 80.9% still had nSV, and 19.1% had developed SV during the 8-year follow-up period. Of those 72 participants who had SV at baseline, 46 (63.9%) were unchanged at follow-up, and 26 (36.1%) were classified as nSV. Those who had developed SV at follow-up had a higher mean age (p = 0.003) and a higher prevalence of cardiovascular disease (CVD), 13.2% versus 3.0% (p = 0.021). This association with CVD did not persist after an adjustment for sex and age (OR 3.2, 95% CI 0.81–12.46). They exhibited more hypertension (35.0% vs. 22.5%) and diabetes type 2 (7.5% vs. 3.0%), but with no significant difference.

Conclusions

This study revealed that 76.5% of the participants had an unchanged status regarding sublingual varices during an 8-year period and that the development from nSV to SV was associated with advanced age.

The Association Between Sublingual Varices and Cardiovascular Risk Factors

Objective

To study the association between sublingual varices (SV) and cardiovascular (CVD) risk factors.

Methods

A total of 989 consecutive dental patients aged 55-84 years participated in the study, which applied a survey about risk factors, diseases and medications. Digital photos of the lateral borders of the tongue, height, weight, waist, hip and blood pressure were registered, and blood samples were analyzed. Those with SV were compared with those without SV (nSV).

Results

Those with SV had more hypertension 41.8% vs 27.0% (p<0.0001), a higher systolic blood pressure (BP) 139.5 (SD 18.6) mmHg vs 134.3 (SD 18.8) mmHg (95% CI -7.73 ─ -2.72), more diabetes type 2 (DM-2) 7.4% vs 3.8% (p=0.014), a higher fasting plasma glucose 5.9 (SD 1.5) mmol/L vs 5.7 (SD 1.0) mmol/L (95% CI -0.42 ─ -0.05), more dyslipidemia 24.1% vs 17.7% (p=0.018), lower HDL 1.6 vs 1.7 (p=0.003), a greater waist circumference 97.0 cm vs 93.9 cm (95% CI -4.66 ─ -1.46), a greater waist/hip ratio 0.92 cm/cm vs 0.90 cm/cm (95% CI -0.03 ─ -0.01), and a higher BMI 26.6 kg/m² vs 26.0 kg/m² (95% CI -1.11 ─ -0.03). The following associations with SV were found in multivariate analysis: hypertension OR=1.6 (95% CI 1.19 ─2.13), a high systolic BP OR =1.5 (95% CI 1.11 ─2.13), a high fP-glucose OR= 1.8 (95% CI 1.03 ─3.21), a low HDL OR= 1.8 (95% CI 1.15 ─2.92), a greater waist circumference OR= 1.68 (95% CI 1.10 ─2.58), a greater waist/hip ratio OR=2.21 (95% CI 1.36 ─3.58), and a higher BMI OR=1.05 (95% CI 1.02 ─1.09).

Conclusion

This study shows an association between SV and a high BP, a high fP-glucose, hypertension, diabetes mellitus type 2, dyslipidemia, abdominal obesity, older age and smoking.

The Relationship between Smoking and Sublingual Varices in the Elderly

Objectives

We investigated the existence of any connection between smoking and sublingual varices (SLV) in the older population.

Methods

This case-control study was conducted in 2019 on adults > 65 years old at Kahrizak Charity Nursing Home, Alborz, Iran. We conducted clinical examination and inspection of 222 elderly patients. Both the case group and control group contained the same number of patients (n = 111). SLV were classified as grade 0 (few or none visible) and grade 1 (moderate or severe). The case group included patients with SLV and the control group consisted of those older adults without SLV and who were matched with the case group based on age, gender, blood pressure, denture wearing, and varicose veins in their legs. Cigarette smoking habits were investigated in both groups. Smokers were considered those who smoked at least one cigarette per day for more than six months. Chi-square and odds ratio (OR) were used to statistically analyze the exposure of participants to smoking in both groups.

Results

Among 222 participants, 21.6% and 5.4% were smokers in the case and control groups, respectively. The results of our data analysis revealed that SLV were significantly associated with smoking (p < 0.001, OR = 4).

Conclusions

Elderly patients with SLV are more likely to be cigarette smokers. Therefore, cigarette smoking cessation programs are recommended for older adults in society.

Influence of hypertension and other risk factors on the onset of sublingual varices

Background

Sublingual varices (SV) are dilatations of tortuous veins that increased with age. Previous studies showed that this pathology could be correlated to some risk factors such as hypertension, age, gender and diabetes mellitus. In this study we evaluated, on a large number of subjects, the relationship between SV and different grades of hypertension as well as some risk factors extending the analysis to new risk factors such as dyslipidemia, obesity and antihypertensive therapy, modelling a possible dependence of SV on all these factors.

Methods

In the study 1008 subjects, 284 with and 724 without SV, were examined. The blood pressure was measured in office condition and, to exclude subjects with white coat syndrome or masked hypertension, also using a 24 h Holter pressure monitor. Hypertensive subjects were divided in resistant, drugs controlled (compensated) and patients with prior unknown hypertension (new diagnosed) groups. The presence or absence of SV as well as of the risk factors was assessed clinically. We tested the influence of age on the presence of SV by using the chi-square test and the relation between each risk factor and SV by the Cochran–Mantel–Haenszel test. Finally, we carried out a multivariate regression tree analysis in order to predict the presence of SV.

Results

We confirmed the influence of age on SV and found a significant relationship between SV and both the compensated and resistant hypertension grades. We highlighted a relationship between SV and dyslipidemia in subjects with new diagnosed hypertension, and between SV and smoking in subjects with compensated hypertension grade. The regression tree showed a classification accuracy of about 75% using as variables hypertension grades, age and antihypertensive treatment.

Conclusions

We confirmed the SV dependence on age, resistant hypertension and smoking, highlighting a new association with dyslipidemia in new diagnosed hypertensive subjects and new relations depending on the hypertension grades. Thus, the SV inspection could be used to suggest a lipidologist as well as a hypertension specialist visit for a pharmacological and pressure check particularly in subjects presenting SV and dyslipidemia. However, further parameters are to be considered to improve the sensitivity of the prognostic tree model.

Pigmented Fungiform Papillae of the Tongue and Lingual Fimbriae as Single Presentation in Adult: A Case Report and Literature Review

The normal variant in the oral mucosa is a nonpathological condition. Clinical examination must be carefully performed to avoid misdiagnosis as pathological condition. We reported two rare cases of pigmented fungiform papillae and lingual fimbria. Case 1 presented a 22-year-old Javanese man, with no systemic disease and several dark patches over the tongue for2 years. Case 2 presented a 21-year-old Javanese woman with dark patches over the dorsal and lateral of the tongue which had been known for over 4 to 5 months. Both patients had no systemic issues and there were no complaints about the patches. The dark patches, which appeared in both cases, were found together with linear small bumps on the ventral surface of the tongue and near the lingual frenulum. Further examination and specific treatment were not carried out, in accordance with the condition on the tongue.