tongue deviation differential diagnosis

While the exact etiology of geographic tongue is unclear, multiple causes have been proposed. National Library of Medicine However, if there are associated symptoms such as difficulty with talking or swallowing, then a pathology should be ruled out. Oral Surg Oral Med Oral Pathol. A few studies have implicated bismuth, tetracycline, erythromycin, linezolid and olanzapine as contributing to the development of keratin on the tongues filiform papillae.15 General debilitation and history of radiation therapy can predispose individuals to hairy tongue.5. Melanocytic macule. Merck Manual. Course of oral lichen planus: a retrospective study of 808 northern Italian patients. paralysis, fasciculations, atrophy of the tongue muscles. Get useful, helpful and relevant health + wellness information. Glossitis, by causing swelling of the tongue, may also cause the tongue to appear smooth. Alioglu Z, Caylan R, Adanir M, Ozmenoglu M. Melkersson-Rosenthal syndrome: report of three cases. Tongue deviation in unilateral stroke most likely results from asymmetrical supranuclear control of the 12th cranial nerve in many individuals. Carbone M, Arduino PG, Carrozzo M, et al. The nerve arises from the hypoglossal nucleus of the brainstem, which is located near the midline of the medulla oblongata, and then travels between the carotid artery and jugular vein to end up on the underside of the tongue. Pancreatitis. Dermatology. *V"^@mvvfvvwg'#4h!Pre[g/B{r\rYSu|_*~aoMt*tTf_uvuWt>5Z0M0&{|7Zf^1;F X>2kr =kB5258,A4F$Ps6juJU q1ivgg[w~/>F}|>;K?/'=3wwO)` @~`p`x]Ad1h :`4N Jean Paul Ortonne, MD Chair, Department of Dermatology, Professor, Hospital L'Archet, Nice University, France Focal epithelial hyperplasia of mouth or tongue. She served as an assistant professor at the University of Colorado School of Dental Medicine in Aurora, Colorado, for more than seven years. The patient will often present with a painful mass in the tongue or a non-healing ulcer. The finding that it occurs relatively commonly in large (non-lacunar) infarcts and its association with dysphagia may have clinical utility. Oral manifestations and differential diagnosis of isolated - PubMed Epub 2022 Dec 8. Behav Brain Res. Even though geographic tongue is usually diagnosed by its characteristic history and clinical features, in cases of atypical lesions the differential diagnosis includes erythroplakia, lichen planus, candidiasis, contact stomatitis, leukoplakia, trauma, aphthous ulcer, squamous cell cancer, and plaque psoriasis. 2022 Apr 7;12(5):505-510. doi: 10.1016/j.jtcme.2022.04.001. Median rhomboid glossitis: a clinical and microbiological study. https://www.physio-pedia.com/index.php?title=Hypoglossal_Nerve&oldid=267232, Infranuclear and nuclear lesions cause weakness of the tongue but additionally cause ipsilateral atrophy. Cranial nerve XII: the hypoglossal nerve. Discussion. A single non-healing, erythematous, painful ulcer suggests lingual or oral cancer, particularly if the patient uses tobacco and/or alcohol. available from: I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Parashar specializes in clinical and microscopic diagnosis of oral lesions, and her research interests include oral cancer and identifying the role of human papillomavirus in oral lesions. Damage to the hypoglossal nerve causes paralysis of the tongue. [QxMD MEDLINE Link]. One of the first signs of tongue cancer is a lump or sore on the side of your tongue that doesn't go away. This presents with a small, stiff tongue. A proper workup, which may include fine needle aspiration of the mass, is necessary for diagnosis. 00001). 2005 Jul. 2000 Aug. 29(7):331-5. Disclaimer. Lower facial weakness can produce the appearance of tongue deviation when none is present because of distortion of the normal facial appearance. Major aphthous ulcers are >1cm in size and may scar when they heal. Lateral medullary syndrome | Radiology Reference Article - Radiopaedia These may present with dysarthria or dysphagia. Bethesda, MD 20894, Web Policies Objective: A unique case in which an isolated lower motor neuron finding - tongue fasciculations presents as the initial clinical manifestation of B12 deficiency. After you receive a list of possible conditions, your healthcare provider will continue their diagnostic process by ordering tests to eliminate potential conditions on your differential diagnosis list. 2010 Mar;81(3):267. doi: 10.1016/j.resuscitation.2009.12.013. We do not endorse non-Cleveland Clinic products or services. A contribution to the differential diagnosis of ulcerative mucosal changes in HIV-infected patients]. Young Patient With Isolated Tongue Deviation | Stroke Most patients with hairy tongue remain asymptomatic,5,13 although complaints of oral malodor, nausea or altered taste have been reported. Avcu N, Kanli A. The ventral surface may have some visible vasculature. It appears in one of several patterns: minor, major, or herpetiform. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. Lawoyin D, Brown RS. All may result in odynophagia when they occur toward the posterior surface of the oropharynx. A relationship between etiopathogenesis and systemic conditions, such as hepatitis C, is controversial.18,19 Individuals with diabetes may have a slightly elevated risk of developing the condition.19. Gross anatomy and development of the peripheral nervous system. Differential Diagnoses | Iron Deficiency Anemia - U.OSU Unilateral Tongue Atrophy Due to Hypoglossal Nerve Mechanical Case Responses: Tongue Deviation in a Man with Alcoholism official website and that any information you provide is encrypted 2023 - Decisions in Dentistry All Rights Reserved. Decisions in Dentistry - A peer-reviewed journal that offers evidence-based clinical information and continuing education for dentists. Next is its size. These tests will lead to your diagnosis. On rare occasions, a biopsy is required to confirm a histologic diagnosis.6 Because the majority of patients are asymptomatic and because geographic tongue is chronic or intermittent no treatment is generally indicated. . MeSH Patient history and risk factors are important to note. Physical exam may reveal a tender lump in the tongue on palpation, however physical examination may not reveal anything if the mass is toward the posterior end of the tongue. Another clinical variant is plaque-like oral lichen planus, which presents with white elevated patches (Figure 7). Tongue deviation Treatment includes any of a number of antifungals, including a nystatin gargle. Accessed 9/16/2021. A differential diagnosis of elevated alkaline phosphatase includes but is not limited to: Symptoms of fatigue include feeling tired, lack of energy, not getting enough sleep and feeling weak throughout your entire body. Fujii H, Ohtsuki T, Takeda I, et al. FOIA Dysphagia and dysarthria occurred in 43 and 90% of patients with tongue deviation. Other terminology has been ascribed to this condition, such as lingua villosa nigra, hyperkeratosis of the tongue, nigrities linguae, keratomyositis linguae and melanotrichia linguae but none of these is commonly used today.12, Hairy tongue affects the filiform papillae, which undergo hypertrophy and therefore elongate. A differential diagnosis of asthma includes: Symptoms of back pain include aching, burning or sharp, stabbing pain that increases when standing, walking, lifting objects or twisting. As severe tonsillitis causes a bent uvula or uvular deviation, it is beneficial to know the symptoms of tonsillitis, and these include: throat pain or tenderness in the throat, redness appearing at the back of the throat, painful blisters on the throat, and difficulty in swallowing or breathing through the mouth. [Full Text]. Deviating tongue - Neurology - MedHelp Oral candidiasis, or thrush, is the result of infection of the oropharynx byCandida albicans. Your physician or dentist can usually make a diagnosis of geographic tongue based on an examination of your tongue and your signs and symptoms. [QxMD MEDLINE Link]. Tongue deviation caused by a tonic contraction is the most common condition, almost always associated with other, generally ipsilateral, FMDs. A differential diagnosis of hypertension includes: Symptoms of knee pain include swelling around the knee, instability when standing, stiffness and popping noises when you move your knee. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Stanford ENT Free Oral Screening November 2nd. You are being redirected to Huang YS, Wu HK, Chang HH, Lee TC, Huang SY, Chiang JY, Hsu PC, Lo LC. Higher Order Thinking About Differential Diagnosis. J Cutan Pathol. Before Clipboard, Search History, and several other advanced features are temporarily unavailable. Were conduct, Last chance! Reamy BV, Derby R, Bunt CW. A, Fissured tongue. 8600 Rockville Pike Would you like email updates of new search results? They'll then make a final diagnosis and recommended treatment. Oral Hairy Leukoplakia, in an HIV-positive individual. Clinical signs in neurology: a compendium. A differential diagnosis of back pain includes: Symptoms of chest pain include aching, sharp pain, burning sensations, tightness or squeezing pressure localized in your chest area. Multiple pages reviewed for this article. Some asymmetry in the tongue with mild deviation can occur and can be a normal finding. ASA syndrome; Watershed area of hypoperfusion in T4-T8; Bilateral pain/temp loss in trunk and extremities (spinothalamic) Bilateral weakness in trunk and extremities (corticospinal) Preservation of dorsal columns; Differential Diagnosis Stroke-like Symptoms. Patient has this new skin finding, what should you worry about? Stroke; Seizures/postictal paralysis . Carotid dissection may also present as an isolated hypoglossal nerve palsy. What Is The Specific Cause of This Patients Clubbing? Cranial nerve XII: the hypoglossal nerve. Sublingual glands should not be displaced. 1173185. physiotutors.Cranial Nerve 12 | Hypoglossal Nerve Assessment for Physiotherapists. This site needs JavaScript to work properly. and transmitted securely. Since there are a lot of different conditions that often share similar symptoms, your provider will create a differential diagnosis, which is a list of possible conditions that could cause your symptoms. At this stage in the diagnostic process, your healthcare provider will offer tests as a process of elimination to narrow down your specific diagnosis. Due to the close association of geographic tongue in psoriatic patients, dentists are advised to inquire about skin problems in patients with geographic tongue, and refer these individuals for a skin evaluation if needed.11, Hairy tongue, also referred to as black hairy tongue or coated tongue, affects just 0.5% of the adult population.5 Amato Lusitano, a Portuguese physician, first described this condition in 1557.12 In a study conducted on 5150 Turkish dental patients, 11.3% presented with hairy tongue that included filiform papillae elongated more than 3 mm, and 23.2% exhibited hairy tongue in which the filiform papillae were less than 3 mm.3 In a study of 3611 Minnesota schoolchildren, however, prevalence of this condition was very low (0.05%).7 There is no gender predilection. Deviation was always to the side of the limb weakness. [QxMD MEDLINE Link]. Citation, DOI, disclosures and article data. Philadelphia: Wolters Kluwer Epub 2010 Jan 13. The malignant transformation of oral lichen planus and oral lichenoid lesions: a systematic review. Tongue diagnosis - Wikipedia ADA CERP does not approve or endorse individual activities or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tongue-tie (ankyloglossia) is a problem with the tongue that is present from birth. Ching V, Grushka M, Darling M, Su N. Increased prevalence of geographic tongue in burning mouth complaints: a retrospective study. (1,2) Whether this is toward or away from the side of the lesion depends on the specifics of the lesion. Oral Melanoacanthoma. Your symptoms increase in severity or go away. A person, particularly if it's a new patient, walk into the clinic treatment . Cranial nerve XII innervates the left and right genioglossus muscles. Geographic tongue is sometimes referred to as migratory because its location and pattern of presentation tend to change. Video describes about the tongue deviation in upper motor neurone vs lower motor neurone hypoglossal palsy. A differential diagnosis is part of the diagnostic process that eliminates error. To alleviate anxiety, patients often need to be assured that it is a benign process.6 Treating geographic tongue with topical corticosteroids, topical anesthetic agents and antihistamines may help alleviate symptoms, but no specific therapy has demonstrated consistent success.5,6, The differential diagnosis for geographic tongue includes erythroplakia or candidiasis. This diagnosis must account for the most unusual feature of this case, the deviation of the tongue to the left. Neurol Sci. official website and that any information you provide is encrypted In addition to weakness, nuclear and infranuclear lesions cause atrophy of the involved side. Differential Diagnosis of Oral Lesions and Developmental Anomalies Following an evaluation, your healthcare provider might order laboratory or imaging tests to confirm diagnostic theories that will pinpoint which condition is most accurate. Hypoglossal Nerve in Neurologic Disorders: Progressive bulbar palsy and advanced MND can cause severe tongue atrophy and an inability for the tongue to be protruded leading to the inertia of the tongue. Although the tongue is primarily composed of muscle tissue, most pathologic lesions arise from the cells of the surface epithelium, which covers the tongue, and blood vessels.2 This article describes a few of the most common benign conditions that affect the tongue. Tongue deviation towards lesion; Inferior ASA. KT (United Kingdom) Response 55. It supplies into the tongue, There are two hypoglossal nerves in the body: one on the left, and one on the right.[1]. Prevalence of geographic tongue, fissured tongue, median rhomboid glossitis, and hairy tongue among 3611 Minnesota schoolchildren. Cranial functional (psychogenic) movement disorders Antkiewicz HJ, Sadlak-Nowicka JM, Szumska-Tyrzyk B. Jrgensen O, Altermatt HJ, von Overbeck J, Berthold H. Schweiz Monatsschr Zahnmed. Fissured tongue. (Credit), A black, hairy tongue consistent withaspergillusovergrowth (Credit). The tongue is first observed for position and appearance while it is at rest. The tongue protrudes toward the weak side, which is also the side of the lesion. Careers. New-onset macroglossia in an adult is pathognomonic for amyloidosis and should be treated as such until proven otherwise. The prognosis is good. The process begins during an exam when they'll ask questions related to your condition including: Next, your healthcare provider will review your medical history to see if the symptoms connect to any previous health concerns or already diagnosed conditions. 1. A . This theory has been discarded, however, and median rhomboid glossitis is now considered a form of erythematous candidiasis.5,16 Central papillary atrophy and posterior midline atrophic candidiasis are other names for this condition.16. Accessibility Forensic Sci Med Pathol. https://thegeneralinfo.com/hypoglossal-nerve/, https://www.statpearls.com/articlelibrary/viewarticle/23265/, https://www.youtube.com/watch?v=e6X8vMYTSHs. Clear Cell Carcinoma of the Base of the Tongue: MR Imaging Findings 2013 Sep;9 (3):462-4. doi: 10.1007/s12024-012-9378-2. Have you noticed anything that might trigger your symptoms or make them worse or better? [QxMD MEDLINE Link]. Tongue Diagnosis - VUIM DYSARTHRIAS: DIFFERENTIAL DIAGNOSIS | Julie A.G. Stierwalt, Ph.D. Mayo Clinic The Dysarthrias "A collective name for a group of neurologic speech disorders resulting from abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for control . It's important to stay in contact with your healthcare provider during your diagnostic process especially if you have any changes to your symptoms or medical history, which could affect the results of your diagnosis. The plaque-like form of oral lichen planus is easily confused with leukoplakia.18 For symptomatic patients, administering topical or systemic steroids remains the most common therapy. Usually, one side of the tongue is affected, and when the person sticks out his or her tongue, it deviates or points toward the side that is damaged. 2008 Jun;49(6):962-7 tongue deviation to the right, with no ophthalmoplegia. eCollection 2022 Sep. Smaoui S, Peladeau-Pigeon M, Mancopes R, Sutton D, Richardson D, Steele CM. 2015 Jul;53(1):95-6. doi: 10.1016/j.pediatrneurol.2015.03.009. Clinical presentation of hairy tongue is classic, and, as such, biopsies are generally unnecessary.5 As a benign condition, treatment is usually not required, although gentle debridement of the tongue with a soft toothbrush or commercial tongue scraper can expedite the removal of the keratin. Deviation to the left - suggests a lesion of the left hypoglossal (XII) nerve or higher Deviation to the right - suggests a lesion of the right hypoglossal (XII) nerve or higher Causes of Tongue Deviation Contralateral upper motor neuron lesion - trauma, tumour, ischaemia, demyelination Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/cerp. In Traditional Chinese Medicine, by looking, listening, questioning & feeling the pulse with 8 differential diagnosis, a TCM practitioner can identify the conditions of a patient. This is seen in 1-3% of the population. 12 Furthermore, it forms 1 of the 3 triads of Melkersson-Rosenthal syndrome, namely, a fissured tongue, relapsing orofacial edema, and facial nerve palsy. The https:// ensures that you are connecting to the 2,3 Considering the safety of thrombolysis in stroke mimics (complication rate: 1.5%) 3 and its potential benefit in acute . The tongue is a complex organ composed of muscles, minor salivary glands, papillae, sensory and motor nerve fibers, blood vessels, adipose tissues, etc., This wide variety of tissues poses. Before your provider makes a diagnosis, they will evaluate your symptoms by asking questions that go over your overall health and your medical history. J Speech Lang Hear Res. Indeed, a spectrum of disorders can give rise to oral mucosal ulcers ranging from minor local trauma to significant local disease such as malignancy or systemic illness. When one of the two nerves is damaged, then the tongue, when protruded will deviate towards the damaged nerve because of the overaction of the strong genioglossus muscles. Get unlimited access to our CE, Adopting a multidisciplinary approach can improve, This case series presents a clinical solution to r, The February issue of Decisions in Dentistry is no, In this episode of The Art of Dental Finance and M. Identify the most common benign lesions found on the tongue. Tongue diagnosis is one of those ways. Oral lichen planus is a relatively common disorder affecting the epithelium and oral mucosa.18 It affects 1% to 2% of the general adult population.19 It is more common among women than men. Nutritional deficiencies include iron, folate and vitamin B12 deficiency. It is one step that your healthcare provider will take before making a final diagnosis. . Available at http://library.med.utah.edu/neurologicexam/html/gait_abnormal.html#13. 2014 Jul;52(6):572-4. doi: 10.1016/j.bjoms.2014.04.005. With gloved hands, hold the tongue with gauze in one hand while palpating the tongue between the thumb and index finger of the other, noting masses and areas of tenderness. Centers for Disease Control and Prevention. Neville BW, Damm DD, Allen CM and Bouquot JE. Clinical Presentation and Differential Diagnosis of Oral Cancer Diagnostic Considerations. 2014;23:e405-e406. Courtesy of Kozlovsk (own work), via Wikimedia Commons. Over 90% of oral cancers are squamous cell carcinomas (OSCCs) which are of epithelial origin. This is a normal tongue pattern observed in early chewing. Please check your email and click the confirmation button so we can send you your free blood pressure table! This is most typically in patients with some form of immunocompromise, particularly HIV, diabetes, or chronic antibiotic use, which leads to fungal overgrowth. Gerressen M, Ghassemi A, Stockbrink G, Riediger D, Zadeh MD. It causes speech and eating problems in some children. Have you experienced any major changes in your life? The vertebrobasilar arterial system perfuses the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Pink-red on dorsal and ventral surfaces. D, Lingual thyroid of the midline base of the tongue. Lower. In a large series of patients with acute unilateral ischemic strokes above the lower brainstem, tongue deviation occurred in 29%, always toward the side of limb weakness. Herpetiform ulcers are pin-point size, often multiple, and may coalesce to form a larger ulcer. -, Forensic Sci Med Pathol. The other differential diagnosis is subarachoid haemorrhage. An official website of the United States government. Ocular Torticollis - EyeWiki Policy. (https://doi.org/10.1016/j.bjpt.2019.01.010), Symptom to Diagnosis: An Evidence-Based Guide, (https://accessmedicine-mhmedical-com.ccmain.ohionet.org/content.aspx?bookid=2715§ionid=228237277), (https://medlineplus.gov/lab-tests/differential-diagnosis/), Visitation, mask requirements and COVID-19 information, Chronic obstructive pulmonary disease (COPD). Background: Vitamin B12 (cobalamin) is a water-soluble vitamin found in nutrition. However, bilateral lesions can cause profound difficulty with speech and swallowing as the patient cannot protrude the tongue for these necessary functions. In most cases Physiopedia articles are a secondary source and so should not be used as references. In hemiparesis due to a carotid dissection, the tongue may deviate to the side opposite the hemiparesis because the dissection injures the hypoglossal nerve as it curves around the carotid sheath. Questions about your medical history include: Last, your healthcare provider will perform a physical examination by checking your blood pressure, heart rate and listening to your lungs. Sayan A, Abeysinghe AH, Brennan PA, Ilankovan V. Br J Oral Maxillofac Surg. Last reviewed by a Cleveland Clinic medical professional on 01/27/2022. Then the patient is asked to protrude the tongue, move it in and out, side to side, and up and down. New-onset fasciculations are concerning for amyotrophic lateral sclerosis. A supranuclear palsy will cause motor dysfunction contralateral to the side of the lesion without atrophy or fasciculations. Stanford Medicine 25 Skills Symposium 2015, Approach to Spinal Disease by Dr. Rick Hodes. It is necessary in many functions, including the synthesis of both DNA, RNA and myelin production, particularly in the spinal cord. It may be pinkish-red in color. loss of vibration and proprioception in the left upper and lower limbs. Functional symptoms and signs in neurology: assessment and diagnosis Abraham-Vergheses-TED-Talk:-Over-one-million-views! Dermatologic Aspects of Addison Disease. Normal variations of oral anatomy and common oral soft tissue lesions: evaluation and management. Copyright 2000 S. Karger AG, Basel MeSH terms Age Distribution (4) Keane reported four cases of wrong way tongue deviation toward the normal side rather than the hemiparetic side in functional hemiparesis. Other causes of RAU include drug reactions, Marshall Syndrome, and MAGIC (Mouth and Genital ulcers with Inflamed Cartilage) syndrome. You should contact your healthcare provider if: Several conditions share similar symptoms. A differential diagnosis is a list of possible conditions that share the same symptoms that you described to your healthcare provider. Eye deviation; Head and neck jerky movements; No tonic contraction of the muscles between the spasms; Dyskinesia of the tongue and lips; Dyskinesia of the limbs; Dyskinesia of the neck; It is a clinical diagnosis depending on Shulman JD, Carpenter WM. Special attention is given when the tongue is weak, atrophied, moving abnormally, or impaired. [1] Normal tongue [ edit] The prevalence of tongue lesions in 5150 Turkish dental outpatients. A differential diagnosis of depression includes: Symptoms of elevated alkaline phosphatase include stomach or abdominal pain, nausea and vomiting and a yellow color to the skin (jaundice). During a differential diagnosis, it might be daunting to see a list of possible conditions that could cause your symptoms. Tests vary based on your symptoms and could include: After your healthcare provider reviews your symptoms, asks questions about your medical history and examines the results of any additional tests, they are able to pinpoint exactly what is causing your symptoms. Even though many reports claim no gender predilection, others suggest that the disorder is more common among women.4,6,7 In a study of 188 Thai subjects, Jainkittivong and Langlais found that women were slightly more likely to be affected than men.8. There may be a history of leukoplakia, dysphagia, or dysarthria. National Library of Medicine The formal continuing education programs of this program provider are accepted by the AGD for Fellowship/Mastership and membership maintenance credit. If you log out, you will be required to enter your username and password the next time you visit. 2004. To protrude the tongue in the midline, a balanced action of both genioglossus muscles is required. MeSH What will bedside manner look like for new data-driven physicians? Support Lucile Packard Children's Hospital Stanford and child and maternal health. Therefore it should be considered in differential diagnosis. The tongue is first observed for position and appearance while it is at rest. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. The prevalence of median rhomboid glossitis is slightly higher among individuals who have diabetes, patients who are immunosuppressed, and those who have recently taken a broad-spectrum antibiotic. 29% of stroke patients and 5% of controls had tongue deviation (p < 0. Jean Paul Ortonne, MD is a member of the following medical societies: American Academy of DermatologyDisclosure: Nothing to disclose. The prevalence of oral mucosal lesions in a population in Ljubljana, Slovenia. Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical AssociationDisclosure: Nothing to disclose. J Tradit Complement Med. Lingual cancer is the second most-common head and neck cancer, after that of the labia. A biopsy or culture may also aid the diagnosis. Sometimes the sore will bleed if you touch or bite it.. 2010 Mar 1. Tongue conditions - Knowledge @ AMBOSS Video used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Tongue Diagnosis for Quick Self-Diagnosis - Acupuncture Points

How To Colour Buttercream Icing, Articles T