What are the possible causes of tongue, teeth, and gum pain with several ulcers on the tongue in a patient with trouble eating due to pain for the past three days?

Differential Diagnosis of Tongue, Teeth, and Gum Pain with Multiple Ulcers

The most likely causes in a patient with multiple oral ulcers and severe pain for three days include traumatic injury (from sharp foods or dental appliances), viral infection (herpes simplex), recurrent aphthous stomatitis, or less commonly, bacterial infection or early manifestation of systemic disease. 1, 2

Immediate Clinical Assessment Required

Examine for these specific features to narrow the differential:

• Constitutional symptoms: Fever suggests infection (viral, bacterial abscess) or systemic disease rather than simple trauma 3, 4
• Ulcer location: Herpes simplex typically affects keratinized mucosa (gingiva, hard palate), while aphthous ulcers favor non-keratinized areas (tongue, buccal mucosa, soft palate) 1
• Ulcer characteristics: Single large ulcer suggests trauma or malignancy; multiple small ulcers suggest viral or aphthous etiology 1, 2
• Duration and recurrence: New acute onset versus recurrent episodes changes the differential significantly 1, 5

Most Common Causes by Category

Traumatic Causes

• Sharp food items causing mucosal injury 6
• Dental appliances creating friction or acute trauma 6
• Ill-fitting prostheses or sharp tooth edges 7

Infectious Causes

• Herpes simplex virus ("cold sores") - most common viral cause, presents with multiple small vesicles that rupture into ulcers 1
• Tongue abscess - rare but presents with severe throbbing pain, swelling, fever, and difficulty swallowing 4
• Acute necrotizing ulcerative gingivitis - rapid onset with gingival involvement 1

Inflammatory/Immune Causes

• Recurrent aphthous stomatitis ("canker sores") - most common cause of recurrent oral ulcers, affecting 2-10% of population 5
• Erosive lichen planus - chronic condition requiring immunofluorescence for diagnosis 1

Serious Causes Requiring Urgent Evaluation

• Oral squamous cell carcinoma - commonly presents as non-healing solitary ulcer, frequently misdiagnosed as trauma 8
• Systemic diseases - Behçet's disease, inflammatory bowel disease, blood disorders 9, 1

Red Flags Requiring Urgent Biopsy

Any ulcer persisting beyond 2 weeks without healing mandates biopsy to exclude malignancy, regardless of apparent trauma. 8, 9 Oral squamous cell carcinoma is frequently misdiagnosed as traumatic ulceration, leading to dangerous treatment delays 8.

Initial Management Approach

Symptomatic Relief (Start Immediately)

• Topical anesthetics: Viscous lidocaine 2%, 15 mL per application before eating 7
• Anti-inflammatory rinse: Benzydamine hydrochloride every 3 hours, particularly before meals 7
• Antiseptic mouthwash: 0.2% chlorhexidine (diluted 50% to reduce soreness) or 1.5% hydrogen peroxide twice daily 7
• Mucoprotectant: Apply three times daily to protect ulcerated surfaces 7
• Emollients: White soft paraffin ointment to lips every 2 hours 7

If Symptoms Don't Improve in 7 Days

Stop topical treatments and seek medical evaluation - this timeline is critical per FDA guidance 10. Persistent symptoms beyond one week require diagnostic workup 10.

Diagnostic Workup for Non-Resolving Cases

Order these tests before or concurrent with biopsy:

• Complete blood count - screens for leukemia, anemia, neutropenia 9
• Coagulation studies - ensures safe biopsy 9
• Fasting blood glucose - identifies diabetes predisposing to fungal infection 9
• HIV antibody and syphilis serology - excludes infectious causes 9

Common Pitfalls to Avoid

• Never assume oral ulcers are "just trauma" without confirming complete healing within 2 weeks 8
• Never allow continued use of suspected traumatic source (dentures, sharp teeth) while "monitoring" the ulcer 8
• Don't forget to examine the entire oral cavity, including floor of mouth palpation and tongue mobility 8
• Avoid hard, acidic, salty foods; toothpastes with sodium lauryl sulfate; alcohol; and carbonated drinks during acute phase 5

Escalation for Severe or Persistent Cases

If topical measures fail after 7 days or pain is severe:

• Topical high-potency corticosteroids: Dexamethasone 0.1 mg/mL mouth rinse or clobetasol 0.05% gel for accessible ulcers 7
• Systemic corticosteroids: For highly symptomatic cases, prednisone 30-60 mg (or 1 mg/kg) for 1 week with tapering 7
• Systemic analgesics: Follow WHO pain ladder; consider fast-acting fentanyl preparations for severe pain before meals 7