What is the management and treatment for a patient with a tongue ulcer?

Management and Treatment of Tongue Ulcers

The management of tongue ulcers should begin with accurate assessment of the ulcer characteristics, followed by appropriate treatment based on etiology, with specialist referral indicated for persistent ulcers (>2 weeks) or those not responding to 1-2 weeks of treatment. 1

Assessment and Classification

• Document ulcer characteristics using standardized terminology noting their well-demarcated appearance, size, number, location, and depth 2
• Classify ulcers based on clinical presentation:
  • Minor aphthous ulcers: small, shallow lesions that heal within 1-2 weeks 3
  • Major aphthous ulcers: larger, deeper ulcers that may take weeks to months to heal 3
  • Herpetiform aphthous ulcers: multiple, small clustered ulcers 3
• Assess for potential underlying causes including trauma, infections, systemic diseases, or malignancy 1, 3

Initial Management

• First-line treatment: Topical therapies 3
  • Topical anesthetics (e.g., benzocaine) for pain relief - apply to affected area up to 4 times daily 4
  • Topical corticosteroids to reduce inflammation 3, 5
  • Sucralfate as a protective barrier 3
• Preventive measures:
  • Eliminate sources of trauma (e.g., sharp edges, ill-fitting dental prostheses) 6
  • Avoid painful stimuli such as hot foods/drinks and hard, sharp, or spicy foods 6
  • Maintain effective oral hygiene 6
• Pain management:
  • Topical 2.5% lidocaine ointment for pain control 6
  • Oral acetaminophen for systemic pain relief 6
  • Barrier preparations such as mouth rinses/gels 1

Treatment Algorithm Based on Etiology

Traumatic Ulcers

• Remove source of trauma (dental appliances, sharp teeth edges) 1, 7
• Apply topical anesthetics for pain relief 4
• Monitor for healing - should resolve within 1-2 weeks after trauma removal 7

Infectious Ulcers

• Bacterial infections: Consider appropriate antibiotics based on culture 6
• Fungal infections: Antifungal medications 6, 1
• Viral infections: Antiviral medications if indicated 3

Aphthous Ulcers

• Topical corticosteroids as first-line treatment 5
• Topical anesthetics for pain relief 4, 3
• Consider systemic therapy for severe recurrent cases 3, 5

When to Refer to a Specialist

• Ulcers persisting for more than 2 weeks 1, 2
• Ulcers not responding to 1-2 weeks of treatment 1, 4
• Ulcers associated with systemic symptoms 1, 2
• Any solitary chronic ulcer requires biopsy to rule out malignancy 3
• Recurrent aphthous stomatitis (RAS) with 4+ episodes per year 3

Special Considerations

• Monitoring: If using topical benzocaine, discontinue and consult a doctor if symptoms do not improve within 7 days or if irritation, pain, redness persists or worsens 4
• Biopsy: Every oral solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 3
• Systemic disease evaluation: Consider screening for underlying conditions in recurrent cases (celiac disease, inflammatory bowel disease, nutritional deficiencies, immune disorders) 3, 5

Common Pitfalls to Avoid

• Relying solely on topical treatments without establishing a definitive diagnosis for persistent ulcers 1
• Overlooking systemic causes of oral ulcers leading to delayed diagnosis 1
• Inadequate biopsy sampling that may miss important diagnostic features 1
• Failing to refer persistent cases (>2 weeks) to specialists 1, 2