Tongue Ulcer

• Clinical Definition: When there is a focal area where there has been disruption of the protective tongue epithelial lining allowing exposure of the inflamed sub-epithelial tissue. 

• Urgent Signs Include: Ulcers larger than 2 cm in diameter that have lasted longer than 14 days, growth of the tissue within the ulcer, painless firm lumps in the affected area, hardening around the edges of the ulcer, fever greater than 101°F (38.5°C), unexplained significant weight loss, or difficulty swallowing. 

• Primary Causes: Primary causes for development of a tongue ulcer include accidental bites during eating or chewing food, fractured teeth, poorly fitting dentures, local irritants such as spicy or acidic foods & drinks, chemical injuries (such as burns), malnutrition (including B12 deficiency, folate deficiency, iron deficiency), and systemic autoimmune diseases. 

• Treatment Options: It include topical anesthetic gels, antiseptic mouthwashes (e.g., Chlorhexidine / povidone-iodine), laser photobiomodulation therapy, cauterization, and removal of contributing dental trauma or systemic causes.

• Tactile Sensations: Sharp, burning, or stinging pain at a specific location on the tongue's margin, tip or underside that is exacerbated when eating salty foods, spicy food, or extremely warm foods/drinks.

• Visual Presentation: An isolated rounded/oval shaped crater with a yellowish-white fibrin clot centrally located within it; this area will be bordered by an elevated, reddened (erythematous) area.

• Physical Changes: Swelling at the site of injury (edema); restriction of tongue function/mobility; altered sense of smell/taste (dysgeusia); excessive production of saliva (sialorrhea).

• Functional Impact: Painful chewing (mastication) and speaking (articulation) that can result in compensatory movements of the jaw/mouth.

• Non-healing Ulcers: Any ulcer that has persisted for longer than two weeks which has continued to grow larger is concerning for the possibility of Oral Squamous Cell Carcinoma.

• Induration: The ulcer base/borders are hardened into an indurated mass similar to a large knot through the skin and muscle beneath the ulcer.

• Systemic Involvement: Fever greater than 101°F (38.5°C), unexplained significant weight loss, or difficulty swallowing. 

• Functional Impairment: Inability to drink liquids resulting in possible dehydration and difficulty in speaking as a result of severe inflammation.

• Mechanical/Dental Injury: A variety of direct injuries to the tongue are caused by accidentally biting into the tongue while eating, sharp cusps on a fractured tooth, or an irregular edge created by either an orthodontic appliance or a worn-out acrylic denture.

• Dietary Injuries/Disorders: Consume excessive amounts of very spicy foods such as extremely spiced Indian curry, raw tamarind or hot chili oil that will create a localized chemical dissolution of the protective layer over the mucosa of your mouth.

• Nutritional Disorders: Systemically low levels of vitamins B12, iron, zinc, or folate will prevent mucous membrane cell growth and weaken the protection of the epithelium of your mouth.

• Immune/Stress Induced Injuries: Emotional stress, hormonal changes or immune system disorders can cause T-lymphocytes to destroy local tissue in your mouth including mucous membranes.

• Regional Eating Habits: Consuming large quantities of fried snack foods with sharp points, high concentrations of spice (hot sauce, etc.), and/or consuming large quantities of acidic juice or citrus items commonly found in the diet of people who live in coastal regions of South India (Malabar) and Southern coastal areas.

• Other Systemic Diseases: People with celiac disease, Crohn's disease, Behcet's Syndrome, or those who have compromised immune systems due to poor control of their blood sugar level through their diabetes treatment may be at higher risk for developing recurrent aphthous tongue ulcers. 

• Oral Appliances: Poor fitting removable partial dentures or unadjusted orthodontic bands used for many years could develop small abrasions along the sides of your tongue due to constant friction from these appliances rubbing against the side of your tongue when you eat or talk.

• Chemicals Used in Cleaning Your Mouth: If you frequently brush your teeth using products that contain sodium lauryl sulfate (SLS), chew areca nut/betel leaf/paan/tobacco products, etc., it may contribute to developing conditions that make it easy for you to damage the inside of your mouth.

• Visual Evaluation: Position yourself in front of a well-lighted mirror. Stretch your tongue completely; look at the very back side of your tongue (the dorsum), the lateral margins (sides) and the end tip of your tongue.

• Evaluation of Ventral Side: Pull your tongue up and have it touch the roof of your mouth to see the ventral (bottom) side of your tongue and the bottom of your mouth.

• Light Touch (Palpation): Thoroughly wash your hands. Place a clean index finger lightly on the lesion to determine whether it has a soft and pliable consistency or an unusual hardness.

• Precautions: Never use fingernail tips, or unclean/unsterilized tools found around home to try and "pop" or scratch a tongue ulcer. This can cause secondarily infected bacteria to enter the deeper layers of muscles within your tongue.

• Physical Evaluation of Lesion: Clinical evaluation of a tongue lesion by means of visual inspection (using a combination of a light source, mouth mirror, and high-intensity LED magnification to evaluate size, shape, border characteristics, color, etc.) and palpation (feeling) of the lesion.

• Dental/Vital Assessment: Assessing the vitality and condition of adjacent teeth by checking for sharp enamel edges, fractured enamel, or failing dental restorative materials by feeling the teeth with dental explorers and assessing through palpation.

• Diagnostic Biopsy: A small incisional or excisional biopsy may be required for a long-standing or suspicious tongue lesion that persists beyond two weeks. The biopsy is done after administering local anesthesia, which allows for a sample of tissue from the lesion to be evaluated via histopathology.

• Laboratory Blood Panels: Complete Blood Counts (CBC); serum ferritin; vitamin B12; and serum folate levels are ordered to rule-out systemic deficiencies, or hematologic disorders.

• Grade 1 (minor aphthae): Small (less than 10 mm), shallow ulcerations with minor discomfort that resolve on their own in 7-10 days with no residual scarring.

• Grade 2 (major aphthae): Larger (greater than 10 mm) and deeper, crater-like ulcerations with irregular borders that last for many weeks and result in significant discomfort and possible scarring.

• Grade 3 (herpetiform ulcers): Clusters of very small (1-2 mm) pinpoint-sized aphthous ulcerations that merge together into a large area of ulcerative pain, which are non-viral in nature and may be associated with general body fatigue.

• Grade 4 (malignancy/deep traumatic ulcers): Deeply penetrating, hardened, nonhealing ulcerations with rolled edges that represent extensive tissue necrosis or dysplasia.

• Prescription Topical Treatments: Triamcinolone Acetonide 0.1% Gel; Benzocaine & Lidocaine Pastes; Hyaluronic Acid Protective Barrier Gels.

• Laser Therapy: Low Level Laser Therapy (LLLT); Diode Laser Photobiomodulation directly on the ulcer to immediately kill off nerve endings that transmit pain and promote accelerated epithelium repair.

• Cautery Treatments: Professional chemical cauterization of silver nitrate or debacterol directly to the bottom of the ulcer to provide instant pain relief.

• Corrective Dental Work: Smoothing of sharp tooth enamel edges; replacement of broken dental restorations; correction of poorly fitting acrylic denture linings to eliminate physical irritation.

• Private Clinic Consultations: ₹300 – ₹800 in the major cities of Kochi, Thiruvananthapuram, and Kozhikode.

• Prescription Topical Applications/ Rinse: ₹150 - ₹600 for the high-end corticosteroids & special antiseptics.

• Laser Photobiomodulation: ₹1,500 – ₹4,000 depending on the type of laser technology being used by the clinic & urban localization.

• Polish Enamel/Major Tooth Adjustments: ₹500 – ₹1,500 for smoothing sharp teeth surfaces or acrylic adjustment.

• Primary Care Provider/GDP: Initial evaluation & basic management of aphthae, as well as minor adjustments such as smoothing of tooth edges, can be performed by a Primary Care Provider or General Dental Practitioner (GDP).

• Oral Medicine/Radiology Specialist: Necessary for recurrent ulcers with atypical appearance or size that may require systemic therapy, advanced diagnostics, or biopsy procedures.

• OMFS (Oral and Maxillofacial Surgeon): When surgical excision of lesions, complex tissue biopsy procedures, or laser resection of indurated/suspicious mucosal lesions is required.

• Periodontist/Prosthodontist: If an ulcer is caused by complex gum-line inflammation or poorly fitting removable/fixed dental prosthetic appliances.

• Urgent Care (24 hours): Ulcers larger than 2 cm in diameter lasting longer than 14 days, tissue growth within the ulcer, firm indurated lumps, submandibular or facial swelling, fever greater than 101°F (38.5°C), or difficulty swallowing. 

• Priority Scheduling (2-4 days): Failure of ulcers to improve within 7 days, continued pain which interferes with consuming soft foods, or recurrent groups of ulcers occurring more than once monthly.

• Routine Dental Evaluation: Minor smoothing of small pointed cusp tips on teeth; evaluation of occasional transient ulcers.

1. Can consuming hot and spicy dishes such as spicy fish curry or pickled mango produce long lasting tongue ulcers?

Hot and spicy food is not capable of creating permanent tongue ulcers, however it will create chemical irritation. In some cases it may also be able to break down mucous membranes in very sensitive people, causing them to have an acute ulcerative reaction.

2. How many rupees would you expect to pay for each laser session of tongue ulcer pain relief at dental clinics located in Kochi?

The costs of laser treatments using Photobiomodulation for tongue ulcers in large cities like Kochi or Kozhikode can range anywhere from ₹1500 - ₹3500 per session and immediately provide relief by significantly reducing pain and shortening the recovery time of your tongue.

3. What types of home remedies are safe to use for immediate relief before going to see a physician?

Using warm saltwater (one half teaspoon of salt dissolved into one cup of warm water), or doing coconut oil pullings can both help relax the tissues and reduce bacteria. Do NOT place any raw spices, acidic lime juice, or untested chemical substances on the exposed surface of the ulcer.

• Oral candidiasis (thrush), which is an overgrowth of fungus in the mouth resulting in white, wipeable plaques that may result in raw, ulcerated mucosal surfaces beneath these areas.

• Geographic tongue (erythema migrans) is an inflammatory process creating smooth, red bands edged in white on the tongue surface, rendering this area extremely susceptible to ulceration. 

• Oral lichen planus is a chronic autoimmune process producing lacy white patches (Wickham's striae) and painful erosions on the margin of the tongue. 

• Gastroesophageal reflux disease (GERD), is a chronic nighttime acid reflux into the oral cavity leading to erosion of the thin lingual mucosa over time.

• Coronoplasty & Restorative Smoothing: Coronoplasty involves gently smoothing down the sharp edge of the tooth cusp to prevent further physical injury to the tongue mucosa, while restorative smoothing places a smooth composite material over a fractured enamel surface. 

• Full Oral Prophylaxis: This is a professional oral cleaning treatment that removes all plaque bacteria from the teeth and gums reducing the total amount of microbes in the oral cavity and reduces the potential for secondary infections of any ulcers present. 

• Custom Night Guards: This treatment creates a custom-made soft acrylic occlusal guard for individuals who have been identified as having involuntary bruxism at night (the habit of grinding the teeth). The purpose of this appliance is to protect the tongue from injury when biting during sleep. 

• Prosthetic Relining & Re-adaptation: This treatment relines or adjusts the underside of removable partial or full dentures to remove any chronic friction point(s) that could cause continued irritation to the tongue.

Many times, tongue ulcers are viewed as minor irritants but can actually indicate localized trauma or systemic imbalance. With most cases of aphthous or traumatic ulcers healing themselves within 10 days under protective topical treatments, non-healing ulcers cannot be taken lightly. As such, it is essential to make an accurate differential diagnosis in early stages of clinical care to determine if there is any indication of premalignancy or chronic autoimmune disease. Therefore, patients experiencing continuous pain in their tongues should seek medical attention promptly as opposed to continuing self-treatment. To maintain optimal oral health and prevent future occurrence of ulcers, patients need to continue practicing good oral hygiene practices, address dental structure issues and take action to improve their nutritional status.