Chapter 72: Sore mouth and tongue

Evaluating the sore mouth and tongue is basically an understanding of disorders of the oral mucosa. Disorders of the oral mucosa are a common problem in general practice, with recurrent aphthous ulceration being the most common oral mucosal disease in humans.

There are three types of stratified squamous epithelium in the oral mucosa:¹

1. masticatory—surface layer, cornified (orthokeratinised), attached to underlying periosteum (e.g. hard palate and gingivae)

2. lining—(e.g. lip and buccal mucosa, alveolar mucosa, floor of mouth, soft palate and tongue—lateral and undersurface)

3. specialised—with taste buds and papillae, e.g. on dorsum of tongue

The histology of oral ulceration is usually non-specific, with fibrin slough covering granulation tissue, and the aetiology is varied. The ulceration is a breach in the epithelial compartment with inflammatory cell infiltrate in the submucosa. The most common form is recurrent aphthous ulceration. Always inquire about a history of skin problems, medication, bowel function and psychological stress.

A list of causes is presented in the diagnostic strategy model (see TABLE 72.1). Depending on the clinical picture, investigations may include FBE, swabs, autoantibody screen, syphilis serology, blood sugar, vitamin B12 and folate levels, and biopsy.

Recurrent aphthous ulceration

Aphthous ulcers are round/oval ulcers usually 3–5 mm in diameter with an erythematous margin and sloughing base.

Aphthous ulcers occur in all ages on un(para)-keratinised mucosa such as the buccal and labial mucosa and the floor of the mouth (not on orthokeratinised mucosa) (see FIG. 72.1). The frequency of aphthous ulcers in the population varies from 5% to 25% (average 20%). The cause is unknown, although human herpes virus 6 has been implicated, as have nutritional and autoimmune factors.³ People with recurrent aphthous ulcers have a genetic predisposition.

Precipitating factors

• Trauma (e.g. cheek and tongue biting, toothbrush, dental pressure)

• Drug reaction (e.g. new medication)

• Stress

• Allergy

• Systemic factors (e.g. iron, folate, vitamin B12 deficiency, hormonal)

Note: Exclude blood dyscrasias, Crohn disease, Behçet syndrome, coeliac disease, drug therapy (e.g. phenytoin, cytotoxics, corticosteroids, immunosuppressants).

Rules

• Minor ulcer <5 mm in diameter: lasts 5–10 days and heals without scarring

• Major ulcer >8 mm: can persist for up to 6 weeks³

• Major ulcers usually occur on lips, soft palate and fauces and sometimes on the tongue

• Minor ulcers are usually found on the buccal and labial mucosa and the floor of the mouth

• Non-healing ulcers: consider SCC (biopsy required)

• Recurrent ulcers: consider Behçet syndrome. Check serum iron and folate

Treatment

There are multiple methods but none are specific.

• topical lignocaine (e.g. 2% jelly or 5% ointment) with cotton bud: after 2 minutes apply lignocaine gel or paint (e.g. SM-33 adult paint formula or SM-33 gel children) every 3 hours

• or

• eutectic EMLA cream 5%—apply on a cotton bud or gauze for 5 minutes

• Triamcinolone 0.1% (Kenalog in Orabase) paste, apply three times daily after meals and nocte (preferred method but be careful of herpes simplex ulcers).

• Other topical steroids (e.g. betamethasone 0.05% ointment, hydrocortisone 1%).

• Hydrocortisone lozenges (if available)—dissolve in contact with ulcer, qid.

• 10% chloramphenicol in propylene glycol—apply with cotton bud for 1 minute (after drying the ulcer) 6 hourly for 3–4 days.

• Beclomethasone dipropionate 50 mcg spray onto ulcer tds.

• Sucralfate 1 g in 20–30 mL of warm water—use this as a mouthwash.

• Diclofenac 3% in hyaluronan 2.5%.

All of the above treatments have been shown to be effective in controlled trials.

Major ulceration

Consider:

• injection of steroids into the base of the ulcer

• and/or

• oral prednisolone 25 mg daily, 5–7 days⁴

• Referral: Patients with a non-healing ulcer within 3 weeks of presentation.

Complementary measures

1. Teabag method. Consider applying a wet, squeezed-out, black teabag directly to the ulcer regularly (the tannic acid promotes healing). Must be used when ulcer is worse.

2. Melaleuca (tea-tree) oil. 1% tea-tree oil used as a mouth rinse for 1 minute has been shown to prevent secondary infection.⁵

3. Acupuncture. This is advocated by its protagonists. It has been proven to improve salivary flow.

Traumatic ulceration

• This is commonly caused by sporting injuries, biting of the cheek and lip, and hot food.

• Factitious causes include scratching of an ‘itchy’ mouth or over-brushing of the teeth.

• Other relevant causes include dentures, sharp tooth surface, orthodontic bands and sharp objects, such as pencils and hard food.

• Aspirin ‘burns’ are caused by people leaving salicylate-based tablets to dissolve against oral mucosa.

• Iatrogenic causes include surgical procedures, such as intubation and endoscopy, and dental treatment, such as retractors and removing dry cotton rolls.

Management¹

• Explanation, including removal of the cause.

• Warm salt-water mouthwashes, and/or local anaesthetic mouthwashes:

  • benzocaine compound (Cepacaine), swirl in mouth 10–15 mL for 10–15 seconds and expel, every 3 hours prn

  • or

  • benzydamine hydrochloride (Difflam), swirl in mouth 15 mL for 30 seconds and expel

These ulcers can take up to 10 days to resolve.

Lichenoid drug reaction

Several drugs can induce a lichenoid drug reaction of the oral mucosa, that is, cause shallow mucosal erosions similar to lichen planus. The drugs include gold, the NSAIDs, carbimazole, selected antihypertensives and cytotoxics.

Herpes infection

• It is important to beware of herpes simplex virus lesions.

• Primary herpetic gingivostomatitis is usually obvious but herpes infection has an extraordinary ability to present in many ways. It can spread from the hands to the mouth.

• Application of a topical corticosteroid, such as Kenalog in Orabase, can aggravate and spread the herpetic lesion.

• Treatment: aciclovir or similar antiviral if seen early, e.g. 48 hours from onset; fluids + + + ; analgesic mouth rinses, e.g. Difflam; consider admission for IV aciclovir and hydration.

• Lesions of herpes zoster virus affecting the maxillary division of the trigeminal nerve, for example, can involve the buccal mucosa in a unilateral pattern.

A reduction in the surface epithelial layer causes erythematous patches. Causes include trauma (e.g. cheek biting), infection (e.g. Candida albicans), geographic tongue, haematologic disorders, the dermatoses and neoplasia.

Neoplasia that can look red includes squamous cell carcinoma, Kaposi sarcoma and erythroplakia. Erythroplakia is similar in significance to leucoplakia except for the erythematous feature. It is an important condition to recognise since about 90% of cases are either dysplastic or cancer.⁶

White patches occur where the epithelial compartment thickens. Causes include inflammation due to trauma or infection, especially Candida, dermatoses and neoplasia.

An interesting condition is hyperkeratotic burns on the dependent floor of the mouth, which appear white. Causes include tea-tree oil mouthwash and the sucking of aspirin.

Leucoplakia is any white lesion that cannot be removed by rubbing the mucosal surface (unlike oral candidiasis). About 5% of cases represent either dysplasia or early SCC.⁶ Any persistent white patch should be biopsied (see FIG 72.2).

Specific conditions causing red and/or white patches follow.

Oral candidiasis (thrush)

This is usually tender and looks like white or yellowish curd-like patches overlying erythematous mucosa. Unlike lichen planus or leucoplakia, they are usually readily rubbed off and hence only the underlying red patch may be seen.

Patients may also complain of a bad metallic taste or halitosis and dysphagia. They often complain of sensitivity to toothpaste or acidic substances in general.

Consider predisposing factors:

• immunodeficiency and cytotoxic therapy

• medication, especially broad-spectrum antibiotics and corticosteroids, including inhalers

• debility and anaemia (iron, folic acid, vitamin B6 deficiency)

• diabetes mellitus and HIV infection

The carriage rate of Candida albicans in the oral cavity is 60–75%. The diagnosis is made clinically but a wet preparation using potassium hydroxide will reveal spores and perhaps mycelia.

Treatment

Attend to underlying cause. Consider dental hygiene multivitamin preparations. Antifungal agents should not be used until the fungal infection is confirmed.⁵

• nystatin suspension, rinse and swallow qid: place 1 mL under the tongue then swallow

• or

• miconazole oral gel (as directed by manufacturer)

• or

• amphotericin 10 mg or nystatin 100 000 U lozenges dissolved slowly in oral cavity, 6-hourly, for 7–14 days. Avoid with a severe dry mouth.

Use if unresponsive to topical therapy and the immunocompromised:⁵

• fluconazole 50 mg (o) daily for 7–14 days

Dentures need to be decontaminated, especially if acrylic. Use:

• chlorhexidine denture scrub (care with bleaching), or

• dilute Milton’s denture scrub (e.g. ¼ teaspoon White King in a cup of water)

Keep dentures in a dry place at night when not being worn.

If oral thrush, brush the dentures each night with a thin coat of nystatin cream or oral miconazole.

Angular cheilitis

Feature is redness, soreness and maceration of the corners of the mouth. Usually associated with oral candidiasis. Consider poor-fitting dentures, diet—vitamin B deficiency, iron deficiency and atopic or seborrhoeic dermatitis. Treat with topical nystatin or miconazole. ‘Golden’ crusting indicates S. aureus.

Erythematous bleeding gums are a common worldwide problem, which is almost always a localised inflammation associated with poor dental hygiene.⁷ Systemic problems usually as part of a bleeding diathesis need to be considered.

The causes are summarised in the diagnostic strategy model (see TABLE 72.2).

Acute necrotising ulcerative gingivitis (Vincent infection or trench mouth) caused by anaerobic organisms is rarely seen but is more common in undernourished or ill young adults under stress.

Gingivitis

Caused by plaque (bacterial biofilm) with calculus (tartar secondary to poor oral hygiene).

Features

• Red, swollen gingivae adjacent to teeth (see FIG. 72.3)

• Bleeds with gentle probing

• Halitosis

• Usually no pain

Treatment^4,7

• Dental care—remove plaque and clean

• Cease smoking

• Mouthwash: chlorhexidine 0.2 or 0.12% aqueous solution 10 ml for 1 minute 8–12 hourly for 10 days or until pain abates (beware of superficial discolouration of teeth with prolonged use)

Acute ulcerative gingivitis

This is a very painful form of gingivitis. Treatment is as for gingivitis but add antibiotics, e.g. metronidozole 400 mg (o) 12 hourly or tinidazole 2 g (o) single dose and drain pus from abscess.⁴

Periodontitis

This is inflammation of the periodontal space. It is a sequel to gingivitis and shows periodontal ligament breakdown with recession or periodontal pocketing and alveolar bone loss. There is possible loosening of teeth and periodontal abscess formation (see FIG. 72.4). An underlying medical condition must be suspected.

Risk factors are smoking and diabetes.

Treatment is meticulous dental treatment and mouthwashes. Antibiotics are rarely required.⁴

Prevention of gingival disease

• Use a fluoride, abrasive type of toothpaste.

• Brush with a medium-to-soft, nylon-tufted, small-headed toothbrush.

• Direct at gingival margin with a small horizontal motion.

• Keep interdental spaces clean with dental flossing in a vertical direction or tooth picking.

• Regular dental review—eliminate plaque.

Oral dermatoses

The dermatoses include lichen planus, pemphigus vulgaris (uncommon), mucous membrane pemphigoid (uncommon) and lupus erythematosus. The clinical appearance of these conditions in the mouth is quite different to the skin condition because of the environment, especially due to the presence of saliva.

Diagnosis

Histopathological examination (after appropriate biopsy) with immunofluorescence is recommended, especially because of the similarity of the lesions of lupus erythematosus and lichen planus, which are both considered to be potentially premalignant in the mouth.⁸

Clinical features

Lichen planus:

• affects 2% of the population, usually over 45 years

• can vary from asymptomatic to severely painful

• usually white lace-like patterns on mucosa, cheeks and tongue

• may form superficial erosions

Lupus erythematosus:

• oral lesions may be first sign of SLE

• usually on lateral aspects of the hard palate

• can resemble lichen planus

Treatment

Consider specialist referral.

• Oral hygiene and pain control:

• chlorhexidine mouthwash

• or

• tetracycline/nystatin mouthwash

• or

• topical analgesics (e.g. lignocaine preparation)

• Corticosteroids:

  • topical (e.g. Kenalog in Orabase; betamethasone dipropionate 0.05%)

  • intralesional (e.g. triamcinolone 10 mg/mL, especially for lichen planus)

  • systemic—may be necessary in severe cases

The painful tongue⁹

Pain in the tongue is a reasonably common symptom in general practice. The cause is usually obvious upon examination, but there are some obscure causes. As for many other oral mucosal problems, shared care with a dental or oral medical specialist is important. The causes of a sore or painful tongue are similar to that of the sore throat or mouth. Xerostomia is common in the elderly.

Investigations may include an FBE, serum vitamin B12, folate and ferritin levels, a swab or a biopsy of a suspicious lesion.

A diagnostic strategy with lists of causes is presented in TABLE 72.3.

Tongue tips

• Look for evidence of trauma, especially from a sharp tooth.

• A miserable child with a painful mouth and tongue is likely to have acute primary herpetic gingivostomatitis or hand, foot and mouth disease.

• When taking the history, take note of self-medications, especially sucking aspirin, a history of skin lesions (e.g. lichen planus) and consider underlying diabetes or immunosuppression.

• A long history of soreness with spicy or other foods indicates benign migratory glossitis (geographic tongue) or median rhomboid glossitis (see FIG. 72.5).

• Any non-healing or chronic ulcer requires urgent referral.

• Macroglossia (large tongue): consider acromegaly, myxoedema, amyloidosis, lymphangioma.

• Strawberry tongue: consider scarlet fever, Kawasaki disease.

• Glossodynia (painful tongue): characteristically presents as a burning pain on the tip of the tongue.⁹ It can be a real ‘heartsink’ presentation. Consider depressive illness as an underlying cause.

Erythema migrans (geographic tongue)

Also known as benign migratory glossitis, this benign condition shows changing patterns of desquamatous areas and erythema on the dorsum and edges of the tongue. With the smooth red patches and raised whitish grey edges, the pattern resembles a relief map with mountain ridges. The border changes shape within weeks. It is irregular and slightly reddened.

It is considered to be a hypersensitivity reaction but the offending allergen has not been identified. Stress, tobacco, alcohol, marijuana and spicy foods can aggravate the condition in some individuals.

Management

• The condition is self-limiting and there is no specific therapy.

• Explanation and reassurance is important.

• No treatment is recommended if asymptomatic.

• If tender, benzocaine compound (Cepacaine) gargle 10 mL tds.

• If persistent and troublesome, low-dose inhaled glucocorticoid (e.g. beclomethasone 50 mcg tds—don’t rinse after use).

Black or hairy tongue

This is due to overgrowth of papillae or reduced wear of papillae, e.g. debility and lack of fibrous foods.

• Appearance: dark, elongated filiform papillae giving brownish appearance to dorsum (posterior) of tongue.

• Symptoms: bad tastes and malodorous oral cavity.

Causes

• Unknown

• Poor oral hygiene/debility

• Iatrogenic (e.g. antibiotics, major tranquillisers, corticosteroids)

Treatment

Brush or scrape tongue to remove stained papillae. Use a topical keratolytic agent such as salicylate, with pineapple being the most practical (95% cases are helped).

• Cut a thin slice of pineapple into eight segments. Slowly suck a segment on the back of the tongue for 40 seconds and then slowly chew it. Repeat until all segments are completed. Do this bd for 7–10 days.¹ Repeat if recurs.

Note: The salicylate in pineapple can aggravate irritable bowel syndrome.

Consider sodium bicarbonate mouthwash.

Oral dysaesthesia (‘burning mouth’ syndrome)

The classic chronic burning sensation of the oral cavity appears to have a neuropathic and/or psychological basis.¹ Symptoms include:

• altered sensitivity—burning pain or ‘raw’ sensation, mainly of the tongue and mucosa of lips

• altered taste—sweet, salty, bitter or metallic

• altered saliva (subjective)—quality and quantity

• altered tooth sensation (e.g. ‘phantom tooth pain’)

• dry mouth (xerostomia)

Consider the underlying cause:

• medications

• haematinic deficiency—iron, folate, vitamin B12

• autoimmune disorder (e.g. Sjögren syndrome)

• endocrine disorder (e.g. diabetes)

• psychological disorder

Management

• Detailed history with exclusion of organic causes

• Provision of education and understanding

Consider clonazepam 0.5–1 mg bd.

Oral cancer

Cancer of the lip and oral cavity accounts for 2–3% of all newly diagnosed cancers in Australia.¹⁰

SCC is the most common malignancy of the oral cavity, accounting for 90% of cases. It has a 5-year survival rate of 65% without lymph node involvement and 50% with local node metastases.¹¹ Cancer of the lip is usually treated successfully by excisional biopsy but intraoral cancer has significant morbidity and mortality.¹⁰

Other malignancies include mucoepidermoid carcinoma, lymphoma, Kaposi sarcoma and malignant melanoma, which is usually found on the palate.

Predisposing or associated factors for SCC include tobacco and marijuana abuse, alcohol abuse, excessive sunlight and immune suppressive disorders such as HIV, lymphoma and various medications.

SCC is usually found as a chronic indurated ulcer on the ventral and lateral surfaces of the tongue followed by the floor of the mouth and buccal mucosa. It may present as a white patch or, more commonly, as a speckled white and red nodular patch or a red velvety patch.

The red patches of erythroplakia (in particular) and the white patches of leucoplakia may be premalignant or early invasive cancer and necessitate further investigation, particularly incisional biopsy.

Treatment for oral cancer is surgery ± radiotherapy and chemotherapy.

Epulis

An epulis is a benign, localised gingival swelling. It is a very ancient term with no pathological significance, meaning a ‘tumour situated on the gum’. There are two distinct types—a fibrous epulis and giant cell epulis. An epulis emerges between two teeth from the periodontal membrane where there is usually dental decay or a site of irritation, such as a partial denture. It appears to be more common during pregnancy where the epulis has a more vascular appearance.

Treatment is usually by excision, with histological examination, curettage of the origin and extracting associated teeth. The ‘pregnancy’ epulis should be left for several weeks after childbirth before treatment.

Typical locations of intraoral tumours are shown in FIGURE 72.6.

Pyogenic granuloma

These may occur on the gums or oral mucosa of the lips and look like pyogenic granulomas of the skin, which also are associated with minor trauma. It is best treated by excision.

Retention cysts (mucous cysts)

The oral mucosa contains numerous mucous cysts and accessory mucous and serous salivary glands.

Small retention cysts are probably caused by minor trauma to the duct. They may rupture spontaneously. They commonly occur on the mucosa of the lower lip. Treatment is by incision and enucleation under local anaesthesia. Larger ones require marsupialisation. Others occur on the tonsils where they usually appear as sessile yellow swellings. A special type of retention cyst is the ranula.

Ranula

A ranula is a large transparent mucocele occurring in the floor of the mouth. A blue colour and small tortuous veins stretched across the surface is typical.

It is usually unilateral and simple but may extend into the tissues of the floor of the mouth and neck (plunging ranula). Patients may give a history of a cyst that bursts and then returns.

Treatment is usually by marsupialisation.

Fibrous (fibroepithelial) hyperplasia

Hyperplasia of the oral mucosa, a very common condition, is usually seen on the floor of the mouth and is due to chronic irritation from ill-fitting dentures. Removal of the offending irritation is necessary. The hyperplasia may resolve, but if it doesn’t, surgical removal of the residual mass is necessary.

Haemangioma

These appear as a dark blue/purple sessile or modular swelling anywhere in and around the mouth, especially on the vermilion border of the lips, floor of the mouth and tongue. They blanch on pressure. No treatment is needed except for pressing cosmetic reasons. Copious bleeding can occur with attempted removal.

Other soft tissue swellings

Swelling that may be encountered includes squamous papillomas (like viral warts), fibroepithelial polyps (inner side cheek), mixed salivary tumours, vascular haematomas and giant cell granulomas.

The most common benign intraoral salivary neoplasm is the pleomorphic adenoma usually presenting as an asymptomatic swelling of the hard palate or cheeks.² Excision is recommended.

Bony exostoses

Bony outgrowths of the maxilla and mandible are reasonably common and the hard intraoral lump may cause concern. The most common is known as torus palatinus (see FIG 72.7), which is situated in the centre of the hard palate. A similar exostosis is torus mandibularis, which occurs inside the mandible, opposite the premolar teeth and is usually bilateral. These lesions are hamartomas and do not require removal except if there is impending dental obstruction.

Xerostomia (dry mouth)

This is a symptom rather than a disease entity. It occurs in about 10% of the population and approximately 70% of patients have a systemic cause.¹²

The most common cause is a side effect of drug therapy and it is relative rather than absolute. Some patients who have a dry mouth on clinical examination do not complain of it while others who do complain of it may be found to have a normal salivary flow rate (a feature of depressive illness).

Other obvious causes are dehydration, mouth breathing and psychogenic.

Primary xerostomia

Causes

• Salivary gland atrophy due to ageing

• Salivary gland infections

• Autoimmune salivary gland disease (e.g. Sjögren syndrome)

Secondary xerostomia

Causes

• Mouth breathing

• Drugs: antidepressants (especially tricyclic agents), diuretics, anticholinergics, tranquillisers, antihistamines, anti-emetics, antihypertensives (some), antimigraine (some), antiparkinson, lithium and opioids

• Depression and anxiety (e.g. public speaking)

• Thirst/hunger

• Dehydration (e.g. diabetes, diarrhoea, kidney failure)

• Anaemias: iron, folate, vitamin B12 deficiency

Consequences¹²

Xerostomia interferes with speech, mastication and swallowing and causes difficulty in managing oral hygiene, especially dentures.

Symptoms include a burning sensation, a decrease in taste or a bad taste and fetid breath.

There is an increase in dental decay and perhaps a tendency to Candida albicans infection.

Treatment

This involves education, especially the need for meticulous oral hygiene, including topical fluoride preparations to the teeth and regular dental checks.

The cause must be diagnosed and treated if possible, especially a review of (and replacement of if necessary) drug therapy.

Avoid decongestants and antihistamines.

• Suck ice or lozenges, sip sugarless fluids frequently and chew sugarless gum (avoid mouthwashes containing sugars and alcohol).

• Use a saliva substitute (e.g. Aquae, Saliva Orthana) or frequent mouthwashes (e.g. lemon and glycerin, 5–10 mL in 100 mL water as required—can be used in a plastic squeeze bottle).

• Use sodium fluoride 0.5% mouthwash for 5 minutes each day.

• Topical applications of glycerin or paraffin oil to the lips.

Halitosis⁴

Causes

The diagnostic strategy model for chronic halitosis (bad breath) is presented in CHAPTER 17. The commonest causes are orodental disorders secondary to poor oral hygiene and inappropriate diet. Bacterial putrefaction of dental and food debris, together with inflammation of the gums, is largely responsible for the oral malodour. Smoking, alcohol and a dry mouth will aggravate the problem. (A 1999 survey showed that 87% of patients with halitosis had an oral cause, 8% an ear, nose and throat cause with 5% having other or unidentified causes.)

Management

• First exclude dental disease, malignancy (esp. nasopharyngeal cancer), pulmonary TB, hairy tongue, nasal and sinus infection.

• Refer for a dental check. Treat gingivitis.

• Consider drugs such as isosorbide dinitrate and various antidepressants as a cause.

• Cease smoking if this is a factor.

• Avoid or limit onions, garlic, peppers, curries, spicy salami and similar meats.

• Avoid or limit strong cheeses.

• Avoid smoking and excessive nips of alcohol.

• Brush teeth regularly during the day—immediately after meals.

• Gently brush the dorsum of the tongue with special, available soft brushes.

• Rinse mouth out with water after meals.

• Avoid fasting for long periods during the day.

• Drink copious amounts of water during the day.

• Chew sugarless gum to help moisten the mouth.

• Gargle with mouthwash regularly (e.g. Listerine; Cepacol Mint mouthwash; 0.2% aqueous chlorhexidine).

• Use dental floss regularly to clean the teeth.

Tip: use an oil/water wash (e.g. equal volumes of cetylpyridinium chloride (Cepacol) and olive oil), gargle a well-shaken mixture and spit out, qid.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Aphthous ulcers

• Halitosis

• Hand, foot and mouth disease

• Tongue soreness