Ulcerations in the oral cavity are relatively common in general practice, with estimates suggesting that up to 4% of the population in the United States suffer from some form of ulcerative lesion, and the tongue is one of the sites where they may develop [1] [2]. The reason for this rather high prevalence rate is the diverse etiology [1] [3] [4] [5] [6] [7]:

• Trauma - Mechanical trauma (for example tongue biting) or chemical/thermal irritation [1] [4].
• Infectious agents - Herpes simplex virus type 1 (HSV-1, responsible for both primary herpetic and recurrent herpes stomatitis) and Varicella zoster virus (VZV) are rather common causes of ulcerative lesions in the oral cavity, and the clinical presentation involves the initial appearance of vesicular lesions followed by their ulceration [1]. Actinomyces, Mycobacterium tuberculosis, Treponema pallidum (responsible for syphilis), and human immunodeficiency virus (HIV) are less frequent but still important pathogens responsible for ulcerative lesions [1] [4] [7].
• Autoimmune conditions - Aphthous stomatitis is described as a separate entity of tongue and oral lesions due to their rather frequent occurrence, and studies estimate that up to 25% of the world's population may develop this type of lesion [1] [6]. They have a recurring pattern in many patients, and the term recurrent aphthous stomatitis (RAS) is used to denote the appearance of multiple, small, ovoid or round ulcers in the first few decades of life that spontaneously resolve within a few weeks [1] [6] [7]. They possess a gray to yellowish floor and are encircled by a red halo [6]. The pathogenesis remains unknown, but systemic lupus erythematosus (SLE), Crohn disease, and Behçet syndrome have been associated with their appearance [7]. In all of the mentioned conditions, oral ulcers are one of the key presenting signs [1] [3] [4]. In SLE, the "discoid lesions", hallmarks of this autoimmune disorder, are observed as painful erythematous erosions and ulcers, which is also the case in Pemphigus and Pemphigoid (bullous dermatoses that also cause ulcerations of the tongue and oral cavity), but also Crohn's disease [1] [4]. In addition, Lichen planus is also an important autoimmune etiology or tongue ulcers, having a similar clinical picture to SLE, but a diffuse pattern of ulceration is seen in this disorder [1] [4] [7].
• Malignant diseases - The lateral border of the tongue is the predominant location of the squamous carcinoma of the oral cavity, the single most important malignant etiology of tongue ulcers [1] [8]. The presence of risk factors such as cigarette smoking, alcohol abuse, increased age, male gender, and the absence of other conditions to which ulcers can be attributed, significantly increases suspicion toward a neoplasia [1] [3]. A painless, non-healing ulcer that persists for several weeks is highly suggestive of a tumor [1] [4] [7].
• Drug-induced - Aspirin, chemotherapeutic drugs, bisphosphonates and nicorandil (a vasodilatory drug) are known to cause ulcers in the oral cavity and tongue [1] [7].

In most cases, tongue ulcers have a benign and self-limiting course with spontaneous resolution within several days or a few weeks [1], but in the setting of persistent, more severe damage to the tongue and oral mucosa, the cause of ulceration may require specific treatment.

The diagnostic workup of tongue ulcers must be detailed and comprehensive. The physician must obtain a thorough patient history, which will encompass the onset, course, and progression of ulcers [1] [5] [6] [7]. Furthermore, patients should be asked about their sexual habits (to exclude syphilis and HIV), recent dental or medical procedures in the oral cavity (to exclude trauma), and the use of drugs such as aspirin and cytotoxic agents [1] [7]. Conversely, a full inspection of the oral cavity, and not only the tongue, will warrant visualization of oral ulcers that might be missed without appropriate illumination and clinical suspicion. The size, shape, location, and the appearance (color, induration, and other associated features) should be assessed [1] [7]. The initial diagnosis is made based on clinical criteria, but laboratory studies might be employed to assist in determining the underlying pathology, including a complete blood count (CBC), serum inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, or CRP and ESR, respectively), anti-nuclear antibodies (ANA), and a basic biochemical panel. Vitamin deficiencies (primarily B12 and folate, but also iron) are well-established risk factors for ulcers of the tongue and oral cavity [1], and their levels should be evaluated as well. Biopsy of the tongue ulcer, however, and subsequent histopathological examination is quite useful, and is recommended whenever possible [1] [5] [6].

Treatment for tongue ulcers depends on the underlying cause. For minor ulcers, over-the-counter topical treatments and mouth rinses can provide relief. Maintaining good oral hygiene and avoiding irritants like spicy foods can also help. If an infection or systemic condition is identified, specific medications or therapies may be required. Persistent or recurrent ulcers should be evaluated by a healthcare professional for further management.

The prognosis for tongue ulcers is generally good, especially when they are caused by minor injuries or irritations. Most ulcers heal within one to two weeks with appropriate care. However, if an ulcer persists beyond this period or is associated with other concerning symptoms, further investigation is warranted to rule out more serious conditions.

Tongue ulcers can result from various causes, including mechanical trauma (such as biting the tongue), infections (like viral or bacterial infections), nutritional deficiencies (such as vitamin B12 or iron deficiency), and systemic diseases (like autoimmune disorders). Stress and hormonal changes can also contribute to the development of ulcers.

Tongue ulcers are a common condition affecting people of all ages. They are more prevalent in individuals with a history of recurrent aphthous stomatitis, a condition characterized by recurring mouth ulcers. Certain populations, such as those with compromised immune systems or nutritional deficiencies, may be more susceptible to developing tongue ulcers.

The pathophysiology of tongue ulcers involves the breakdown of the mucosal lining of the tongue, leading to the formation of a sore. This breakdown can be triggered by physical trauma, infections, or immune-mediated processes. Inflammatory responses play a significant role in the development and persistence of ulcers, contributing to pain and discomfort.

Preventing tongue ulcers involves maintaining good oral hygiene, avoiding known irritants, and managing underlying health conditions. Regular dental check-ups can help identify potential issues early. A balanced diet rich in essential vitamins and minerals can also reduce the risk of nutritional deficiencies that may contribute to ulcer formation.

Tongue ulcers are common lesions that can cause significant discomfort. While they are often benign and self-limiting, persistent or recurrent ulcers may indicate underlying health issues. A comprehensive approach to diagnosis and management, including identifying and addressing potential causes, is essential for effective treatment and prevention.

For patients experiencing tongue ulcers, it is important to maintain good oral hygiene and avoid foods or habits that may irritate the tongue. Over-the-counter treatments can provide relief, but if ulcers persist or recur frequently, seeking medical advice is recommended to rule out more serious conditions. Understanding the potential causes and maintaining a healthy lifestyle can help prevent future occurrences.

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