What is the treatment for tongue ulcers?

Treatment of Tongue Ulcers

For tongue ulcers, start with topical corticosteroids (betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution four times daily) combined with benzydamine hydrochloride oral rinse every 3 hours for pain control. 1, 2

First-Line Topical Therapy

Corticosteroid Options

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water: Use as a 3-minute rinse-and-spit preparation four times daily 1, 2
• For localized tongue ulcers: Apply clobetasol propionate 0.05% mixed in equal amounts with Orabase directly to the dried ulcer twice daily 1, 2
• Fluticasone propionate nasules diluted in 10 mL water twice daily can serve as an alternative corticosteroid option 2

Mucoprotectant Barrier

• Apply Gelclair mucoprotectant gel three times daily to form a protective coating over ulcerated surfaces, reducing pain and promoting healing 1
• Gengigel mouth rinse/gel can be used as an alternative barrier preparation for pain control 2

Pain Management

• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, provides anti-inflammatory pain relief 1, 3, 2
• For severe pain unresponsive to benzydamine, use viscous lidocaine 2% applied 3-4 times daily 1, 3, 2
• Avoid eating or drinking for 30 minutes after using topical anesthetics for maximum effectiveness 3

Essential Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1, 2
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as an antiseptic rinse 1, 3, 2
• Alternatively, use 1.5% hydrogen peroxide mouthwash twice daily 1
• If toothbrushing is too painful, chlorhexidine rinses can substitute temporarily 3

Treatment of Secondary Candidal Infection

Tongue ulcers are susceptible to secondary fungal infection, which should be treated promptly:

• Nystatin oral suspension 100,000 units four times daily for 1 week 1, 3, 2
• Miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week as an alternative 1, 3, 2

Second-Line Treatments for Refractory Ulcers

If first-line topical therapy fails after 2 weeks:

• Tacrolimus 0.1% ointment applied twice daily for 4 weeks for recalcitrant ulcers 1, 2
• Intralesional triamcinolone injections combined with topical clobetasol for persistent localized ulcers 1, 2
• Liquid dexamethasone 0.5 mg/5 mL elixir or fluocinonide 0.05% gel for moderate inflammation 3

Systemic Therapy for Severe or Recurrent Cases

Reserve systemic treatment for highly symptomatic or frequently recurrent tongue ulcers:

• Prednisone/prednisolone 30-60 mg (or 1 mg/kg) for 1 week with tapering over the second week 2, 4
• Colchicine is particularly effective for recurrent aphthous stomatitis, especially when associated with erythema nodosum or genital ulcers 2, 4
• For resistant cases, consider azathioprine, interferon-alpha, or TNF-alpha antagonists 2
• Thalidomide is the most effective treatment for recurrent aphthous stomatitis but should be reserved as an alternative to oral corticosteroids due to toxicity and cost 5, 4

Dietary and Lifestyle Modifications

• Avoid hard, acidic, salty, spicy foods and hot beverages 3, 4
• Avoid alcohol and carbonated drinks 4
• Avoid toothpastes containing sodium lauryl sulfate 4
• Use a soft toothbrush or swab if regular brushing is too painful 3

Common Pitfalls to Avoid

• Do not prematurely taper corticosteroids before disease control is established 2
• Ensure proper diagnosis before treatment—solitary chronic tongue ulcers lasting more than 2-3 weeks require biopsy to rule out squamous cell carcinoma 6, 7
• For recurrent tongue ulcers (≥4 episodes per year), investigate underlying systemic conditions including celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folate, B12), HIV infection, or Behçet's disease 7, 5, 4
• Perform regular oral examinations to monitor treatment effectiveness and detect secondary infections 3

When to Escalate Care

• Refer to dermatology or oral medicine if ulcers persist despite 4 weeks of appropriate topical therapy 3
• Refer to dentistry for persistent symptoms or if dental trauma is contributing 3
• Any solitary tongue ulcer persisting beyond 2-3 weeks requires biopsy to exclude malignancy 6, 7