What is the best course of action for managing a canker on the right side of the tongue?

Management of Tongue Canker Sore

For a canker sore (aphthous ulcer) on the right side of the tongue, initiate topical corticosteroids as first-line treatment while ruling out secondary causes through targeted history and examination. 1

Immediate Assessment Priorities

Rule Out Malignancy First

Before treating as a benign canker sore, you must exclude malignancy, particularly if:

• Patient age >40 years 2
• Tobacco or alcohol use history 2
• Ulcer persists >2-3 weeks 3
• Limited tongue mobility (suggests muscle/nerve invasion) 2
• Associated symptoms: otalgia, dysphagia, odynophagia, weight loss, or hemoptysis 2

Physical examination technique: Use gauze to grasp the tongue and inspect lateral aspects thoroughly, palpate the lesion for induration or fixation, and examine for cervical lymphadenopathy 2. A nontender neck mass is more suspicious for malignancy than a tender one 2.

Exclude Secondary Causes

Before diagnosing primary aphthous stomatitis, systematically rule out:

Infectious causes:

• Oral candidiasis: Perform scraping with KOH preparation 4
• Herpes simplex: Consider if vesicular or clustered presentation 5

Traumatic causes:

• Sharp dental edges, thermal burns, chemical injury 4
• Examine for denture trauma (remove dentures for complete inspection) 2

Systemic conditions requiring laboratory workup:

• Complete blood count: Rule out anemia 4
• Vitamin B12, iron studies (ferritin, serum iron, TIBC): Deficiencies commonly cause oral burning/ulceration 4, 6
• Thyroid function: Hyperthyroidism can cause tongue symptoms 4

Autoimmune diseases:

• Sjögren's syndrome, pemphigus, pemphigoid 4, 3

First-Line Treatment

Topical corticosteroids are the established first-line therapy for aphthous ulcers due to minimal side effects. 1

Topical Management

• Apply high-potency topical corticosteroid (e.g., triamcinolone acetonide 0.1% or clobetasol 0.05%) directly to the ulcer 2-4 times daily 1
• Topical anesthetics (benzocaine-containing products) provide symptomatic relief for pain but do not accelerate healing 7
• Continue treatment until ulcer heals, typically 7-14 days for minor aphthous ulcers 1

When Topical Therapy Fails

Systemic medications become necessary if disease progresses or topical treatment is inadequate: 1

• Consider systemic corticosteroids for severe or major aphthous ulcers
• Evaluate for underlying systemic disease if ulcers are recurrent or refractory 1

Red Flags Requiring Urgent Referral

Refer immediately to oral and maxillofacial surgery or head and neck surgery if: 6

• Ulcer persists beyond 2-3 weeks despite treatment 3
• Induration, fixation, or rolled borders suggesting malignancy 2
• Tonsil asymmetry or mass on oropharyngeal examination 2
• Inability to complete examination due to anatomic constraints 2
• Suspected deep tissue involvement requiring biopsy 6

Common Pitfalls to Avoid

• Do not assume all tongue ulcers are benign canker sores in patients >40 years with risk factors—squamous cell carcinoma can present as a non-healing ulcer 2, 3
• Do not overlook nutritional deficiencies (B12, iron, folate) as reversible causes of oral ulceration 4, 6
• Do not delay biopsy if the lesion has atypical features or fails to heal within 2-3 weeks 6
• Do not examine the oropharynx with tongue protruded—this obscures visualization; ask patient to open mouth without tongue protrusion 2