To whom should a patient with a tongue ulcer be referred for evaluation and management?

Referral for Tongue Ulcer Evaluation

Patients with tongue ulcers should be referred to an oral medicine specialist or oral and maxillofacial surgeon as the first line of specialist consultation, as they are specifically trained in the diagnosis and management of oral ulcerations. 1

Indications for Immediate Specialist Referral

• Any tongue ulcer persisting beyond 2 weeks
• Ulcers that don't respond to 1-2 weeks of initial treatment
• Ulcers with suspicious features (irregular borders, induration, fixation)
• Painful ulcers affecting quality of life

Risk Assessment for Malignancy

Certain factors increase suspicion for malignancy and should prompt urgent referral:

• Patient age >40 years
• History of tobacco use or alcohol abuse
• Immunocompromised status
• Increased number of sexual partners (risk for HPV-related cancers)
• Associated symptoms like hoarseness, otalgia, or intraoral numbness 2

Diagnostic Approach Prior to Referral

1. Thorough examination of the tongue:

   • Use gauze to grasp the tongue to facilitate inspection of lateral aspects
   • Check for limited tongue mobility (may indicate muscle/nerve invasion)
   • Palpate for induration or fixation 2

2. Examination of the neck:

   • Palpate for lymphadenopathy (nontender nodes raise suspicion for malignancy)
   • Evaluate for associated neck masses 2

Common Pitfalls to Avoid

• Delayed diagnosis: Tongue ulcers are frequently misdiagnosed as benign conditions like aphthous ulcers or candidiasis, delaying proper treatment of malignancies 3
• Inadequate examination: The base of tongue cannot be examined without flexible laryngoscopy or indirect laryngoscopy; incomplete examination should prompt specialist referral 2
• Failure to biopsy: Any ulcer persisting beyond 2 weeks requires biopsy to rule out malignancy 1

Differential Diagnosis of Tongue Ulcers

Tongue ulcers may be caused by:

• Squamous cell carcinoma (most concerning)
• Infectious causes (tuberculosis, herpes, candidiasis)
• Autoimmune conditions
• Traumatic injuries
• Eosinophilic ulcer (benign but can recur) 4, 5, 6

Referral Algorithm

1. For ulcers <2 weeks duration without suspicious features:

   • Consider symptomatic treatment with topical benzocaine 20%
   • Schedule follow-up in 1-2 weeks
   • If no improvement, refer to oral medicine specialist or oral maxillofacial surgeon

2. For ulcers >2 weeks duration OR with any suspicious features:

   • Immediate referral to oral medicine specialist or oral maxillofacial surgeon
   • Do not delay referral for treatment trials 1

3. For ulcers with highly suspicious features for malignancy:

   • Refer to oral medicine specialist or oral maxillofacial surgeon
   • Consider concurrent referral to otolaryngology (ENT) if features strongly suggest malignancy or if neck masses are present 2

Remember that early diagnosis of oral malignancies significantly improves survival rates, making prompt and appropriate referral essential for optimal patient outcomes.