What is the appropriate treatment for an adult with a tongue ulcer of unknown cause?

Treatment of Tongue Ulcers in Adults

For tongue ulcers of unknown cause, begin with topical barrier protection using white soft paraffin ointment applied every 2 hours, combined with warm saline mouth rinses and benzydamine hydrochloride oral spray every 3 hours for pain control, while simultaneously investigating the underlying cause through biopsy if the ulcer persists beyond 2 weeks. 1, 2

Immediate Symptomatic Management

Barrier Protection and Hygiene

• Apply white soft paraffin ointment to affected areas every 2 hours to protect and moisturize the ulcerated surface 2, 3
• Clean the mouth daily with warm saline mouthwashes to reduce bacterial load and promote healing 2
• Use mucoprotectant mouthwash (such as Gelclair) three times daily to protect ulcerated mucosal surfaces 2

Pain Control

• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, for anti-inflammatory effect and pain relief 2, 3
• If pain control is inadequate, escalate to viscous lidocaine 2% (15 mL per application) as a topical anesthetic 2
• Avoid alcohol-containing mouthwashes as they cause additional pain and irritation 1, 3

Infection Prevention

• Apply antiseptic oral rinse such as 0.2% chlorhexidine digluconate mouthwash (10 mL) twice daily to reduce bacterial colonization 2
• Alternatively, use 1.5% hydrogen peroxide mouthwash (10 mL) twice daily 2

Diagnostic Workup for Persistent Ulcers

Any tongue ulcer lasting more than 2 weeks requires biopsy to rule out malignancy, preceded by blood tests to exclude contraindications and identify systemic causes. 1

Pre-Biopsy Blood Work

• Full blood count to detect blood system diseases 1
• Coagulation studies to exclude bleeding disorders 1
• Fasting blood glucose level 1
• HIV antibody and syphilis serology 1

When to Biopsy

• Ulcers persisting beyond 2 weeks 1
• Ulcers not responding to 1-2 weeks of symptomatic treatment 1
• Any solitary chronic ulcer to rule out squamous cell carcinoma 4, 5

Cause-Specific Treatment

For Inflammatory/Aphthous Ulcers

• Apply topical corticosteroid four times daily, such as betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation 2
• For localized lesions, consider clobetasol propionate 0.05% cream/ointment applied directly to affected areas 2
• For recurrent aphthous stomatitis (≥4 episodes per year), colchicine combined with topical treatments is appropriate 4

For Fungal Infections

• Nystatin oral suspension 100,000 units four times daily for 1 week 2
• Alternative: miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 2

For Suspected Bacterial Infection

• Obtain bacterial cultures before initiating antibiotics 6
• Administer appropriate antibiotics for at least 14 days based on culture results 6

Critical Pitfalls to Avoid

• Never delay biopsy for solitary ulcers persisting beyond 2 weeks, as squamous cell carcinoma commonly presents as a solitary tongue ulcer 4, 5
• Do not use white soft paraffin chronically on lips, as it promotes mucosal cell dehydration and increases risk of secondary infection 1
• Avoid starting interdental cleaners during active ulceration if the patient is not already using them regularly, as this can break the epithelial barrier 1
• Do not overlook medication-induced ulcers in patients on NSAIDs, ACE inhibitors, methotrexate, or other commonly implicated drugs 7

Reassessment Timeline

• Evaluate treatment response within 2 weeks 2
• If no improvement after 2 weeks of appropriate treatment, reevaluate diagnosis and consider alternative treatments or underlying systemic conditions 2, 3
• Perform daily oral review during acute phase for severe cases 2

Special Populations

• Immunocompromised patients may require more aggressive and prolonged therapy 6
• Patients with recurrent ulcers should be screened for celiac disease, inflammatory bowel disease, nutritional deficiencies (iron, folates), and immune disorders 4
• Drug-induced ulcers typically appear after several weeks of treatment and resist conventional therapy but heal rapidly after drug discontinuation 7