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)

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 squamous cell carcinoma).
• Associated cervical lymphadenopathy.

Management

1. Topical: Corticosteroids (triamcinolone 0.1% in Orabase), sucralfate, hyaluronic acid, amide anesthetics.
2. Systemic (severe): Colchicine, dapsone, thalidomide, biologics (anti-TNF).
3. Deficiency correction: Iron, B12, folate, zinc if low.
4. SLS-free toothpaste (e.g., Sensodyne, Rembrandt).
5. Trigger avoidance diary.

Most aphthae are self-limited. Persistent or atypical ulcers mandate exclusion of malignancy and systemic disease.