What investigations and management are recommended for a patient presenting with glossitis and mouth ulcers?

Investigations for Glossitis and Mouth Ulcers

Initial Laboratory Workup

For any patient presenting with glossitis and mouth ulcers, obtain a full blood count, fasting blood glucose, HIV antibody, and syphilis serology as your first-line investigations. 1, 2

Essential First-Line Tests

• Full blood count: Screens for anemia, leukemia, and other hematologic disorders that commonly present with oral ulceration 1, 2
• Fasting blood glucose: Identifies diabetes, which predisposes to invasive fungal infections 1, 2
• HIV antibody testing: Rules out HIV-associated ulceration 1, 2
• Syphilis serology: Excludes syphilitic ulcers 1, 2

Second-Line Nutritional Screening

• Vitamin B12, folate, and iron levels: Check these if first-line tests are unrevealing, as vitamin B12 deficiency commonly causes glossitis and oral ulceration even without anemia or macrocytosis 2, 3
• Glossitis with linear lesions is an early clinical sign of vitamin B12 deficiency and may occur before neurologic symptoms or anemia develop 4

Pre-Biopsy Coagulation Studies

• Blood coagulation studies: Obtain before any biopsy to rule out surgical contraindications 1

When to Proceed to Biopsy

Any oral ulcer persisting beyond 2 weeks despite treatment requires biopsy to exclude malignancy and establish a definitive diagnosis. 5, 2, 6

Biopsy Technique Considerations

• Multiple biopsies: Perform if ulcers involve multiple sites with different morphological characteristics 1, 2
• Direct immunofluorescence (DIF): Add this if bullous diseases are suspected based on clinical presentation 2
• Excisional biopsy: Preferred for small lesions (≤3mm) to allow complete histopathologic assessment 6

Critical Pitfalls to Avoid

• Do not delay biopsy for persistent ulcers (>2 weeks), as squamous cell carcinoma can present as small lesions, and even a 2-3% annual malignant transformation rate for potentially malignant disorders warrants prompt tissue diagnosis 6
• Do not overlook systemic causes: Recurrent oral ulcers may be the presenting sign of Crohn's disease, blood disorders, or other systemic conditions requiring broader evaluation 1, 2
• Do not rely solely on clinical appearance: Pathology reports showing only "inflammatory ulcer" or "chronic inflammation" require consultation with superior pathologists or further systemic workup 1

Specialist Referral Indications

• Refer to oral medicine specialist if ulcers persist beyond 2 weeks or fail to respond to initial treatment 2
• Coordinate multidisciplinary care when systemic diseases are identified (gastroenterology for inflammatory bowel disease, hematology for blood disorders) 2
• Bone marrow biopsy: Consider if full blood count suggests leukemia or other hematologic malignancy 1, 2