Tongue Ulcers (Canker Sores): Etiology, Differential, and Management
Aphthous ulcers (canker sores) are the most common cause of tongue ulcers. They are not herpes (which affects keratinized mucosa: lips, attached gingiva).
Etiology (Multifactorial)
| Category | Triggers |
|---|
| Trauma | Biting, sharp teeth/restorations, braces, aggressive brushing |
| Immune | T-cell mediated; associated with Behçet's, HIV, cyclic neutropenia |
| Nutritional | Iron, folate, B12, zinc deficiency |
| Hormonal | Menstrual cycle (premenstrual), pregnancy |
| Stress | Psychological, oxidative stress |
| Chemical | SLS (sodium lauryl sulfate) in toothpaste, nicotine withdrawal |
| Genetic | Positive family history in ~40% |
Clinical Classification
- Minor (80%): <1 cm, heal 7–10 days, no scar.
- Major (10%): >1 cm, heal weeks-months, may scar.
- Herpetiform (10%): Clusters of 1–3 mm ulcers, coalesce, heal ~10 days.
Red Flags — Refer for Biopsy
- Ulcer >2 weeks without healing.
- Indurated, rolled borders, fixation.
- Single, persistent, painless (early SCC).
- Associated cervical lymphadenopathy.
Management
- Topical: Corticosteroids (triamcinolone 0.1% in Orabase), sucralfate, hyaluronic acid, amide anesthetics.
- Systemic (severe): Colchicine, dapsone, thalidomide, biologics (anti-TNF).
- Deficiency correction: Iron, B12, folate, zinc if low.
- SLS-free toothpaste (e.g., Sensodyne, Rembrandt).
- Trigger avoidance diary.
Most aphthae are self-limited. Persistent or atypical ulcers mandate exclusion of malignancy and systemic disease.
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