What are the symptoms and management options for tongue ulcers?

Tongue Ulcer Symptoms and Management

Tongue ulcers should be treated with topical corticosteroids (0.1% triamcinolone acetonide in orabase) as first-line therapy, applied 2-4 times daily until healing occurs, typically within 7-14 days. 1

Symptoms and Characteristics of Tongue Ulcers

Tongue ulcers present with several characteristic symptoms:

• Pain, which may interfere with eating, speaking, and swallowing 2
• Visible ulceration on the tongue surface
• Redness surrounding the ulcer
• Possible swelling
• Discomfort that worsens with spicy, acidic, or rough foods 1

Tongue ulcers can be classified into three main types:

• Minor aphthous ulcers: Small (less than 1 cm), shallow, round or oval ulcers that heal within 7-14 days 3
• Major aphthous ulcers: Larger (over 1 cm), deeper, with irregular borders that may take weeks to months to heal 4
• Herpetiform aphthous ulcers: Multiple small clustered ulcers that may coalesce 3

Diagnostic Approach

When evaluating tongue ulcers, assess:

• Duration: Ulcers persisting beyond 2 weeks despite treatment require biopsy to rule out malignancy 1
• Shape, location, number, and appearance of ulcers 1
• Presence of cervical lymphadenopathy 1
• Red flags for malignancy: induration, fixation, unexplained bleeding, growth despite treatment, numbness/paresthesia 1

Management Algorithm

First-Line Treatment:

1. Topical corticosteroids: 0.1% triamcinolone acetonide in orabase, applied 2-4 times daily until healing 1

   • Alternative options: clobetasol 0.05% ointment, betamethasone sodium phosphate, fluticasone propionate 1

2. Pain management:

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

3. Supportive care:

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

For Resistant Cases:

1. Alternative topical treatments:

   • Tacrolimus 0.1% ointment 1
   • Intralesional triamcinolone acetonide injections 1
   • Sucralfate suspension 1, 3

2. Systemic treatments (for severe or recurrent cases):

   • Colchicine (particularly effective for erythema nodosum lesions) 1, 3
   • Pentoxifylline 1
   • Short courses of systemic corticosteroids 1
   • Thalidomide (reserved for severe cases due to toxicity concerns) 2

Important Monitoring and Cautions

• Stop treatment and consult a healthcare provider if:

  • Symptoms do not improve within 7 days
  • Pain, irritation, or redness persists or worsens
  • Swelling, rash, or fever develops 5

• Biopsy is necessary if:

  • Ulcer persists beyond 2 weeks despite treatment 1
  • Any solitary chronic ulcer to rule out squamous cell carcinoma 3

• Consider underlying conditions when ulcers are recurrent or severe:

  • Systemic diseases (inflammatory bowel disease, celiac disease)
  • Nutritional deficiencies (iron, folates)
  • Immune disorders (HIV infection, neutropenia)
  • Behçet's disease (recurrent bipolar aphthosis) 3, 6
  • PFAPA syndrome in children (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 7

Prevention Strategies

• Avoid known triggers:
  • Hard, acidic, spicy, or salty foods
  • Toothpastes containing sodium lauryl sulfate
  • Alcohol and carbonated drinks 1
• Regular dental check-ups
• Stress management (as stress can be a precipitating factor) 2

Regular monitoring is essential, with follow-up every 3-6 months for persistent symptomatic cases 1. Remember that recurrent aphthous stomatitis affects up to 25% of the population with three-month recurrence rates as high as 50% 2, making proper management crucial for patient quality of life.