Which specialist should a patient with a chronic tongue ulcer be referred to?

Specialist Referral for Chronic Tongue Ulcers

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

Rationale for Specialist Selection

Oral medicine specialists and oral and maxillofacial surgeons are the most appropriate specialists for initial evaluation because:

• They have specialized training in diagnosing and managing oral ulcerations
• They can perform thorough oral examinations and biopsies when needed
• They can differentiate between benign and potentially malignant lesions
• They are recommended by both the American Dental Association and American College of Surgeons for oral ulcerative lesions 1

When to Refer

Immediate specialist referral is indicated for:

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

Clinical Evaluation by Specialist

The specialist will conduct:

• Detailed clinical history focusing on duration, pain characteristics, and associated symptoms
• Thorough examination of the oral cavity, including tongue mobility assessment
• Evaluation for potential underlying systemic conditions 1, 2

Diagnostic Approach

The specialist may perform:

1. Biopsy: Essential for ulcers persisting beyond 2 weeks to rule out malignancy 1, 2
2. Laboratory investigations:
   • Complete blood count
   • Coagulation studies
   • Fasting blood glucose
   • HIV testing
   • Syphilis serology 1
3. Microbiological testing when infection is suspected 1

Important Considerations

Potential Etiologies

Chronic tongue ulcers may result from:

• Malignancy (squamous cell carcinoma)
• Infections (tuberculosis, histoplasmosis)
• Autoimmune conditions
• Trauma from dental malocclusion
• Systemic diseases 3, 4, 2, 5, 6

Warning Signs

Particular concern should be given to:

• Ulcers in patients >40 years (higher risk of malignancy)
• Limited tongue mobility (may indicate muscle or nerve invasion from tumor)
• Unilateral symptoms
• Associated weight loss or systemic symptoms 7, 2

Common Pitfalls to Avoid

1. Delayed referral: Assuming all oral ulcers are benign without proper evaluation can lead to missed serious diagnoses, including malignancy 1

2. Incomplete examination: The tongue base cannot be examined without flexible laryngoscopy or indirect laryngoscopy. Incomplete examination warrants specialist referral 7

3. Failure to biopsy: Neglecting biopsy for persistent ulcers can delay diagnosis of malignancy, which can mimic benign conditions 1, 2

4. Overlooking systemic causes: Chronic oral ulcers may indicate underlying systemic conditions that require comprehensive evaluation 1, 2

In cases where malignancy is suspected or confirmed, subsequent referral to an otolaryngologist (ENT specialist) or head and neck oncologist may be necessary for definitive management 7.