What is the workup and treatment for a patient presenting with an ulcer on the tongue?

Workup and Treatment for Tongue Ulcers

Any persistent ulcer on the tongue that lasts beyond 2 weeks requires prompt biopsy to rule out squamous cell carcinoma and other serious conditions. 1

Initial Diagnostic Workup

Clinical Evaluation

• Thoroughly examine the entire oral cavity, noting:
  • Ulcer characteristics: size, shape, borders, base, duration, pain
  • Presence of induration or fixation (red flag for malignancy)
  • Unexplained bleeding (red flag)
  • Cervical lymphadenopathy (red flag)
  • Growth despite treatment (red flag)
  • Numbness or paresthesia (red flag) 1

Risk Factor Assessment

• Tobacco use and alcohol consumption (account for 75-85% of head and neck cancers)
• HPV infection history
• Chronic irritation (ill-fitting dentures, sharp teeth edges)
• Immunosuppression status 1

Laboratory Tests

• Complete blood count
• Liver enzymes
• Serum creatinine
• Albumin
• Coagulation parameters
• TSH 1

Imaging (if malignancy suspected)

• Contrast-enhanced CT scan and/or MRI to assess primary tumor and regional lymph nodes
• Chest imaging in high-risk cases to assess for distant metastases 1

Biopsy

• Essential for any ulcer persisting beyond 2 weeks
• Provides definitive diagnosis and rules out malignancy 1

Differential Diagnosis

Consider these potential causes of tongue ulcers:

• Squamous cell carcinoma
• Recurrent aphthous stomatitis
• Traumatic ulcers
• Infectious causes (tuberculosis, fungal infections)
• Autoimmune conditions (pemphigus vulgaris, bullous pemphigoid)
• Medication-related ulcers
• Systemic diseases (Crohn's disease)
• Eosinophilic ulcer (rare, benign, self-limiting) 1, 2, 3

Treatment Approach

For Non-Malignant Ulcers

1. First-Line Treatment:

   • Topical corticosteroids (0.1% triamcinolone acetonide in orabase, applied 2-4 times daily until healing) 1

2. Alternative Topical Treatments:

   • Clobetasol 0.05% ointment
   • Betamethasone sodium phosphate
   • Fluticasone propionate
   • Tacrolimus 0.1% ointment
   • Intralesional triamcinolone acetonide injections 1

3. Pain Management:

   • Topical anesthetics (lidocaine viscous 2% solution)
   • Barrier preparations (Gengigel, Gelclair)
   • Oral analgesics as needed 1

4. Supportive Care:

   • Good oral hygiene with soft toothbrush and mild non-foaming toothpaste
   • Saline solution rinses 4-6 times daily
   • Alcohol-free mouthwash
   • Dietary modifications: avoid spicy, acidic, and rough foods
   • Stay hydrated 1

For Specific Conditions

• Tuberculosis: If TB is suspected (based on histopathology showing granulomatous inflammation), chest radiographs and sputum cultures should be obtained. Anti-tubercular therapy will be required if confirmed. 4, 5

• Eosinophilic Ulcer: Often self-limiting and may heal after biopsy. Characterized histologically by mixed inflammatory infiltrate with numerous eosinophils. 2, 3

Follow-up and Monitoring

• Regular monitoring is essential, especially for persistent cases
• Monitor for signs of systemic disease
• Assess pain daily
• Regular follow-up every 3-6 months for persistent symptomatic cases 1

Important Pitfalls to Avoid

1. Delayed Diagnosis: Neoplastic ulcerated lesions can mimic benign conditions. Never delay biopsy for persistent ulcers. 6

2. Overlooking Systemic Disease: Oral ulcers may be the first manifestation of systemic conditions like tuberculosis. 4, 5

3. Misdiagnosis: Some rare conditions like eosinophilic ulcer can mimic malignancy clinically but are benign. Histopathological examination is crucial. 2, 3

4. Inadequate Follow-up: Even after initial treatment, regular monitoring is necessary to ensure complete resolution and detect any recurrence or transformation. 1