Median rhomboid glossitis as a sign of undiagnosed diabetes mellitus - a case report

Background : Median Rhomboid Glossitis (MRG) is included in the group of nodular-plaque-like candidiasis, a subtype of chronic hyperplastic candidiasis. A lot of literature suggests that MRG is a manifestation of Diabetes Mellitus (DM), but the association between DM and MRG is unclear until now. This article reports an MRG found in an undiagnosed diabetes mellitus patient . Case : In October 2019, A 71-year-old man came to RSGM Universitas Jember to fix his loose denture. In the oral examination, we found a well-bordering, atrophic oval area surrounded by thick-soft white plaque. In his leg, we found itchy papule, ulcer, and crust multiple lesions. The microscopic examination of the white plaque swab showed that the spore and hyphae were found to fill all fields of view. The direct sugar blood level test showed that the sugar blood level was 390 mg/dL. We diagnosed the patient as having an MRG associated with suspected DM. The patient was given miconazole oral gel and recommended to use it after cleaning the tongue three times a day. For diabetes management, the patient was referred to the Unit Medical Center University of Jember. The patient was diagnosed with diabetes mellitus and given oral-antidiabetics. After two weeks, the atrophic area had improved, and the white plaque had disappeared. Conclusion : General practitioners must be aware if they find the MRG in their patients caused a probability of underlying undiagnosed systemic disease, particularly diabetes mellitus on them .


INTRODUCTION
Median rhomboid glossitis (MRG) is a type of chronic oral candidiasis. In the last classification of oral candidiasis, MRG was included in the chronic hyperplastic nodular-plaque-like subtype.
MRG clinically presents as an erythematous atrophic lesion on the posterior middle line of the tongue. The lesion is formed by atrophic filiform papillae that are oval and sometimes lobulated. 1 Only recently, the pathogenesis of MRG is still not known with certainty. At first, MRG was considered a growth disorder. 2 Furthermore, because of histopathology examination, the lesions showed the presence of hyphae, MRG was considered a type of oral candidiasis lesion. The predisposing factors of the diseases were smoking, using dentures, and inhaling steroids. 3 Subsequent studies have shown the relationship between MRG and immune deficiency, HIV infection, and diabetes mellitus 3 .
Because of the increasing prevalence of diabetes mellitus and this disease's significant influence on dental treatment, the dentist must recognize lesions that are manifestations of diabetes mellitus, especially in undiagnosed patients.
In this article, we present a case report of MRG in a patient that had not been /undiagnosed with DM. The patient came to fix a loose denture.
We hope this article can be used as additional information for dentists that MRG may be a sign of DM in a patient.

CASE REPORT
In   was given oral antidiabetics to control their blood sugar levels. The routine blood test resulted in the monocyte differential counting, which increased by 10.8% (N: 3-7%). The leucocyte count was 6,500 /µL. The absolute monocyte count was 702/µL= 0,7x10 9 /L. The normal absolute monocyte count ranges from 0.2-0.8 × 10 9 /L in adults. Even the differential counting of monocyte was increased, but the absolute monocyte count was in the normal range. The absolute monocyte in man tend to be higher than in women. 4 Figure 2. The patient's tongue at the next visit (a) At the 2nd visit, the MRG lesion was still visible, but the colour was almost like the surrounding. The plaque around the MRG lesion began to thin, and the atrophic tip of the tongue was no longer visible (b) At the 3rd visit, a week later, the atrophic MRG lesion was still in place, but the surface and colour were almost the same as the surrounding, the white plaque was no longer visible.
On the 2nd visit, the MRG lesions were still visible, but the colour was almost similar to the surrounding. The plaque around the MRG lesion began to thin out, and the atrophic on the tip of the week later, the atrophic MRG lesion was still present, but the surface and colour were almost the same as the surrounding, and the white plaque was no longer visible. (Fig. 2b)  countries with highest number of diabetes patients.

DISCUSSION
More than 10.8 million people were suffering from diabetes in 2020. 21 The authors suspect this does not represent the true prevalence considering that many patients are undiagnosed and unrecorded.
Factors causing the diabetes mellitus undiagnosed include the patient does not feel symptoms, low socioeconomic status, and educational level.

CONCLUSION
Given the high prevalence of diabetes mellitus in Indonesia and the possibility of many undiagnosed patients from middle to lower economic groups, a dentist must always be aware of the probability of diabetes mellitus in their patient.
Through both history taking or signs of diabetes intra-oral and general and extra-oral conditions of the patient, a dentist can detect and manage their patient appropriately and avoid the complication that are common in diabetic patients.