Systemic Causes of Tongue Ulcers
Tongue ulcers can be manifestations of various systemic conditions including autoimmune disorders, hematologic diseases, nutritional deficiencies, infections, and inflammatory bowel disease, requiring comprehensive evaluation for proper diagnosis and management. 1, 2
Common Systemic Causes of Tongue Ulcers
Hematologic Disorders
- Blood system diseases such as anemia and leukemia can present with oral ulcers, requiring full blood count, bone marrow biopsy, and immunotyping for diagnosis 1
- Neutropenia may present with widespread necrotic ulcers with yellowish-white pseudomembrane, as seen in cases of acute monocytic leukemia 1
Nutritional Deficiencies
- Vitamin B12 deficiency has a clear relationship with recurrent aphthous ulcers and should be considered in all patients with recurrent oral ulceration 3
- Iron and folate deficiencies can also contribute to oral ulceration 1, 4
Infectious Causes
- HIV infection can manifest with oral ulcers, requiring HIV antibody testing in persistent cases 1
- Syphilis infection can present with oral ulceration, necessitating syphilis serology examination 1
- Tuberculosis can cause stellate ulcers with undermined edges and clear boundary, potentially indicating pulmonary tuberculosis 1, 5
- Deep fungal infections, particularly in patients with hyperglycemia, can cause persistent oral ulcers 1, 4
Autoimmune and Inflammatory Conditions
- Bullous diseases (pemphigus, pemphigoid) require evaluation for serum specific antibodies such as Dsg1, Dsg3, BP180, and BP230 1
- Behçet's disease presents with recurrent bipolar aphthosis (oral and genital ulcers) 4
- Inflammatory bowel diseases (Crohn's disease, ulcerative colitis) can manifest with oral ulcers 6, 4
Other Systemic Conditions
- Systemic amyloidosis can present with tongue manifestations 7
- Erythema multiforme, often triggered by medications or infections, can cause acute multiple oral ulcers 8
Diagnostic Approach for Persistent Tongue Ulcers
Initial Evaluation
- For ulcers persisting over 2 weeks or not responding to 1-2 weeks of treatment, specialist referral and comprehensive testing are indicated 1, 2
- Blood tests should include full blood count, coagulation, fasting blood glucose level, HIV antibody, and syphilis serology examination 1, 9
Advanced Diagnostics
- Biopsy is essential for persistent ulcers, with consideration for multiple biopsies if ulcers involve different sites with varying morphological characteristics 1, 2
- Special tests including direct immunofluorescence, serum antibody tests, and microbiological cultures may be necessary for definitive diagnosis 2
Management Considerations
Treatment Approach
- Treatment should target the underlying systemic cause while providing symptomatic relief 9
- For autoimmune conditions, topical or systemic corticosteroids may be indicated 9
- For Behçet's syndrome, colchicine is often used as first-line systemic therapy 9
Common Pitfalls to Avoid
- Inadequate biopsy (small or superficial) may miss important diagnostic features 2
- Overlooking systemic causes can lead to delayed diagnosis and inappropriate management 2
- Relying solely on topical treatments without establishing a definitive diagnosis for persistent ulcers can delay proper treatment 2