What is the plan of care for an adult or elderly patient with a persistent sore on the tongue that won't heal, possibly with a history of smoking or underlying conditions such as diabetes?

Management of a Non-Healing Tongue Sore

Any oral lesion persisting beyond 2 weeks requires biopsy to exclude malignancy, particularly squamous cell carcinoma, which can present as small white ulcerative lesions. 1

Immediate Assessment and Workup

Before proceeding to biopsy, obtain mandatory laboratory studies: 1

• Complete blood count to exclude anemia, leukemia, and neutropenia 1
• Blood coagulation studies to rule out surgical contraindications 1
• Fasting blood glucose to identify diabetes (a major risk factor for invasive fungal infection and poor wound healing) 1
• HIV antibody and syphilis serology to exclude infectious causes 1

Perform complete oral cavity examination including all mucosal surfaces, floor of mouth, and oropharynx to identify synchronous lesions 1. Document the lesion's size, location, borders, color, and presence of induration or lymphadenopathy 2.

Biopsy Indications and Technique

The American Academy of Oral Medicine mandates biopsy for any oral lesion persisting beyond 2 weeks, especially without response to 1-2 weeks of symptomatic treatment. 1

Biopsy technique depends on lesion size: 1

• Excisional biopsy for small lesions (≤3mm) to allow full histopathologic assessment 1
• Incisional biopsy from the ulcer edge (including adjacent normal tissue) for larger lesions 1
• Multiple biopsies when ulcers involve multiple sites with different morphological characteristics 1

Symptomatic Management While Awaiting Biopsy Results

Topical pain control: 3

• Benzydamine hydrochloride oral rinse every 3 hours, particularly before eating 2, 3
• Viscous lidocaine 2% (15 mL per application) up to 3-4 times daily for severe pain 2, 3
• Gelclair mucoprotectant gel three times daily to form a protective barrier over the ulcer 2, 3

Oral hygiene and infection prevention: 2, 3

• Clean mouth daily with warm saline mouthwashes 2, 3
• Use 0.2% chlorhexidine digluconate mouthwash twice daily as antiseptic rinse (may dilute by 50% to reduce soreness) 2, 3
• Apply white soft paraffin ointment to lips every 2 hours if lips are affected 2

Dietary modifications: 2, 3

• Avoid crunchy, spicy, acidic foods, hot beverages, alcohol, and tobacco 2, 3

Treatment Based on Biopsy Results

For squamous cell carcinoma: 2

• Immediate referral to head and neck surgeon or oral maxillofacial surgeon 2
• Contrast-enhanced CT or MRI to assess tumor extent and lymph node involvement 2
• Chest imaging to assess for metastases or second primary lung cancer in smokers 2

For oral tuberculosis: 1

• Four-drug anti-tuberculous therapy: isoniazid, rifampicin, pyrazinamide, and ethambutol 1

For NK/T-cell lymphoma: 1

• Requires hematology-oncology referral for systemic chemotherapy 1

For candidal infection (median rhomboid glossitis): 3, 4

• Nystatin oral suspension 100,000 units four times daily for 1 week 3
• Or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 3

For aphthous ulcers (if biopsy confirms benign etiology): 3

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as rinse-and-spit four times daily 3
• Or clobetasol 0.05% ointment mixed in 50% Orabase twice weekly applied directly to dried mucosa 3
• For refractory cases: tacrolimus 0.1% ointment twice daily for 4 weeks 3

For nutritional deficiency-related atrophic glossitis: 4

• Correct underlying deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin 4

Critical Pitfalls to Avoid

Never assume a small or benign-appearing lesion is non-malignant—squamous cell carcinoma can present deceptively as small white ulcerative lesions 1. Do not delay biopsy beyond 2 weeks for any persistent ulcer, as this represents excessive delay in diagnosing potentially life-threatening conditions 1.

Do not overlook systemic disease associations—oral ulcers may be the first manifestation of Crohn's disease, Behçet's disease, hematologic malignancies, or immunosuppression 1, 3. Always inquire about constitutional symptoms (fever, weight loss, malaise), gastrointestinal symptoms, and immunosuppression history 1.

Hyperglycemia is a critical predisposing factor for invasive fungal infections presenting as oral ulcers 3. In patients with diabetes or smoking history, maintain high suspicion for both malignancy and opportunistic infections 2, 1.