Mouth Ulcers / Sore Tongue
Mouth ulcers are painful breaks in the oral mucosa, and a sore tongue (glossitis or glossodynia) refers to inflammation or pain of the tongue, both arising from causes such as trauma, nutritional deficiencies, infections, autoimmune conditions, or systemic diseases.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Recurrent aphthous stomatitis (RAS) | Small, painful, shallow, self-limiting (< 2 wk), recurrent; no systemic features | 「痱滋係咪每次自己好返，通常兩個禮拜內？」 | ~35% |
| Traumatic ulcer | History of biting, sharp tooth, ill-fitting denture; single ulcer at trauma site | 「有冇咬到自己？假牙有冇刮到？」 | ~20% | |
| Serious Not To Miss | Oral squamous cell carcinoma | Non-healing ulcer > 3 wk, indurated/raised edges, painless → late pain, ± leukoplakia/erythroplakia, cervical LN [1][2] | 「個痱滋超過三個禮拜都未好？摸落去硬唔硬？」 | ~2% |
| Acute leukaemia | Gum hypertrophy, bleeding, pallor, fever, bruising [8] | 「牙肉有冇腫脹？容易流血瘀青？」 | < 1% | |
| Behçet's disease | Recurrent oral + genital ulcers, uveitis, skin lesions, pathergy [5] | 「下面有冇生過痱滋？眼有冇紅痛？」 | < 1% | |
| SLE | Oral ulcers (often painless), malar rash, joint pain, photosensitivity, alopecia [9] | 「面有冇出紅疹？曬太陽有冇差啲？有冇甩頭髮？」 | < 1% | |
| Pitfalls | Iron / B12 / folate deficiency | Glossitis: smooth red tongue, loss of papillae; angular stomatitis [3][4] | 「脷有冇變得光滑紅腫？嘴角有冇爆裂？」 | ~5% |
| HSV gingivostomatitis | Vesicles → painful ulcers on lips/gums/anterior tongue; primary infection in young; fever [10] | 「痱滋開頭有冇好似水泡？嘴唇邊有冇？」 | ~5% | |
| HFMD / Herpangina | Vesicles on hands, feet, mouth (HFMD) or soft palate only (herpangina); fever; children [11] | 「手腳有冇出水泡？有冇發燒？」 | ~3% | |
| Coeliac disease / IBD | Chronic diarrhoea, weight loss, anaemia; aphthous ulcers are extraintestinal manifestation of IBD [7] | 「有冇長期肚瀉或者肚痛？」 | ~2% | |
| Masquerades | Depression/stress | Poor sleep, low mood, stress; triggers aphthous recurrence | 「心情點呀？壓力大唔大？」 | ~15% |
| Anaemia (Fe/B12/folate) | Pallor, fatigue, glossitis, koilonychia (IDA), neuropathy (B12) [3][4] | 「有冇覺得好攰？面色蒼白？」 | ~5% | |
| Drug-induced ulcers | Temporal link to MTX, NSAIDs, nicorandil, alendronate | 「最近有冇開始食新藥？」 | ~3% | |
| Trying to Tell Me Something? | Work/exam stress | Stress-triggered aphthous ulcers | 「最近工作或者讀書壓力大唔大？」 | ~15% |
| Cancer worry / Health anxiety | Came today because friend/relative diagnosed with oral cancer | 「你最擔心嘅係咩？有冇身邊人有類似問題？」 | ~10% | |
| Relationship / psychosexual concern | Genital ulcers → embarrassment → presents with mouth ulcers only | 「仲有冇其他地方唔舒服想講？」 | ~3% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好！我係今日嘅醫生，請問點稱呼你？」「今日有咩唔舒服想睇吓？」 | Friendly opening, patient-centred start; scores interpersonal marks |
| 0:30–2:00 | HPI – symptom analysis | 「口瘡/脷痛幾耐㗎？」「有幾多粒？喺邊度？」「痛唔痛？食嘢有冇影響？」「之前有冇試過？幾密發作？」「有冇嘢令到好啲或者差啲？」 | Covers onset, site, number, severity, recurrence, aggravating/relieving factors |
| 2:00–3:00 | Red flags & systems review | 「有冇體重輕咗？」「有冇持續發燒？」「有冇流血唔止或者瘀青？」「有冇皮膚出疹？」「有冇眼痛或者紅眼？」「有冇肚瀉或者肚痛？」「下面有冇痱滋？」 | Screens for malignancy, Behçet's, IBD, haematological disease, SLE |
| 3:00–3:45 | PMH, Drug Hx, Allergy, FHx, Social Hx | 「以前有冇乜嘢病？食緊咩藥？有冇藥物敏感？屋企人有冇類似問題？你食煙飲酒嗎？工作壓力大唔大？瞓得好唔好？」 | Drug causes (MTX, steroids); smoking/alcohol (oral CA risk); stress (aphthous trigger) |
| 3:45–4:30 | ICE – uncover hidden agenda | 「你自己覺得會唔會係咩嚟㗎？」(Idea) 「你最擔心嘅係咩？」(Concern) 「你嚟睇醫生最希望我幫到你咩？」(Expectation) | ICE marks are high-weight; hidden agenda often = cancer worry or persistent pain affecting eating |
| 4:30–5:15 | Signpost → focused physical exam offer | 「我想幫你睇吓口腔裏面，可以張開口俾我睇吓嗎？」「我仲想睇吓你頸有冇淋巴腫脹」 | Shows you know what exam to do; scores physical exam marks |
| 5:15–6:00 | Summarise, safety-net, close | 「咁總結返，你口瘡反覆發作咗X個月，最擔心係…我嘅初步印象係…如果兩個禮拜都未好，或者有流血/體重輕，一定要返嚟覆診。你有冇嘢想問？」 | Summarising & safety-netting score high marks; empathic close |
Uncovering the hidden agenda: Ask 「其實今日點解特別嚟睇呢個問題？」— the patient may have been living with ulcers for a while but came today because of a specific worry (e.g. "Is it cancer?", "My friend had tongue cancer", stress at work making it worse, or a new symptom like weight loss).
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the ulcers start? How long does each episode last? | 「幾時開始㗎？每次通常幾耐先好？」 | Aphthous heals in 1–3 wk; non-healing > 3 wk = red flag for malignancy [1] | Oral SCC if > 3 wk non-healing |
| Number/Site | How many ulcers? Where exactly? | 「有幾多粒？喺脷邊、脷底、牙肉定係面頰裏面？」 | Lateral/ventral tongue → higher malignancy risk [2]; soft palate → herpangina | Oral SCC; herpangina; HFMD |
| Recurrence | Have you had mouth ulcers before? How often? | 「以前有冇試過生痱滋？幾密發作？」 | Recurrent = aphthous or Behçet's; single non-healing = malignancy | Recurrent aphthous stomatitis; Behçet's |
| Pain/Function | Is it painful? Does it affect eating or drinking? | 「痛唔痛？食嘢飲水有冇影響？」 | Functional impact = biopsychosocial; painless indurated ulcer = CA | Oral CA (painless → painful late); nutritional impact |
| Sore tongue | Is the tongue painful/burning? Is it smooth? | 「脷有冇痛或者灼熱感？脷面有冇變得光滑咗？」 | Glossitis → Fe/B12/folate deficiency [3][4] | IDA, B12/folate deficiency |
| Weight loss | Have you lost weight recently? | 「最近有冇瘦咗？」 | Red flag for malignancy, IBD, coeliac | Oral SCC, IBD, coeliac |
| Fever | Any fever? | 「有冇發燒？」 | Viral infection (HFMD, HSV), leukaemia | HSV gingivostomatitis; leukaemia |
| Skin rash | Any skin rash or nodules? | 「身上有冇出疹或者紅色腫塊？」 | Behçet's (EN, pathergy); SLE (malar rash); HFMD (hand/foot vesicles) | Behçet's, SLE, HFMD |
| Genital ulcers | Any ulcers in the genital area? | 「下面私密位置有冇生過痱滋？」 | Genital ulcers = most specific lesion for Behçet's [5] | Behçet's disease |
| Eye symptoms | Any eye pain, redness, or blurred vision? | 「眼有冇痛、紅或者矇？」 | Uveitis in Behçet's, IBD, SLE [6] | Behçet's, IBD |
| GI symptoms | Any diarrhoea, blood in stool, or abdominal pain? | 「有冇肚瀉、大便有血、或者肚痛？」 | Aphthous ulcers are extraintestinal manifestation of IBD [7] | Crohn's disease, coeliac |
| Joint pain | Any joint pain or swelling? | 「有冇關節痛或者腫？」 | SLE, Behçet's, IBD, reactive arthritis | SLE, Behçet's |
| Bleeding/bruising | Any easy bruising or bleeding gums? | 「有冇容易瘀青或者牙肉流血？」 | Leukaemia, aplastic anaemia | Acute leukaemia [8] |
| Drug history | Are you taking any medications? (MTX, steroids, phenytoin, NSAIDs) | 「有冇食緊咩藥？例如風濕藥、止痛藥、薄血丸？」 | MTX → folate def → ulcers; NSAIDs → direct mucosal injury; immunosuppressants | Drug-induced ulcers |
| Smoking/Alcohol | Do you smoke or drink? | 「你有冇食煙飲酒？」 | Smoking + alcohol = major risk factors for oral SCC; leukoplakia causes: "5S" — Sore teeth, Smoking, Spirits, Sepsis, Syphilis [3] | Oral SCC, leukoplakia |
| Diet | What is your usual diet? Are you vegetarian? | 「你平時食啲咩？有冇偏食或者食素？」 | Vegan/poor diet → B12/folate/iron deficiency | Nutritional glossitis |
| Stress/Sleep | Have you been under stress? How is your sleep? | 「最近壓力大唔大？瞓得好唔好？」 | Stress triggers aphthous ulcers; may be the hidden agenda | Recurrent aphthous stomatitis |
| Sexual/STI | Any new sexual contacts? Any genital symptoms? | 「有冇新嘅性伴侶？有冇其他症狀？」 | Syphilis (painless chancre); HIV (oral ulcers, candidiasis) | Syphilitic chancre, HIV |
Case Report Form Answer Builder
- CC: Mouth ulcers / sore tongue × [duration]
- HPI high-yield points to capture:
- Onset, duration of each episode, number of ulcers, site (lateral tongue vs buccal vs palate)
- Pain severity, effect on eating/drinking/speech
- Recurrence pattern (first episode vs recurrent)
- Associated features: fever, rash, genital ulcers, eye symptoms, GI symptoms, joint pain, weight loss, bleeding tendency
- Aggravating factors: stress, spicy food, trauma
- PMH (autoimmune disease, IBD), Drug Hx (MTX, NSAIDs), smoking/alcohol
- Previous treatment tried
- Examples: "Painful mouth ulcers not healing, affecting eating" / "Worried the mouth ulcer might be cancer" / "Recurrent mouth ulcers with increasing frequency"
- Choose the reason that best captures why today — often the concern rather than the symptom itself.
| Likely Examples | Exact Wording for CRF | |
|---|---|---|
| Idea | "I think it's just 'yeet hay' (熱氣)" / "I read online it could be cancer" | Patient thinks ulcers are due to heat/stress; OR patient worries about oral cancer |
| Concern | "Worried it's something serious / cancer" / "Worried it won't heal" | Patient is concerned the non-healing ulcer could be malignant / affect nutrition |
| Expectation | "I want medication to make it heal faster" / "I want a blood test" / "I want a referral" | Patient expects symptomatic treatment; OR expects investigation to rule out cancer |
- Recurrent aphthous stomatitis — if: recurrent, small, painful, shallow ulcers on non-keratinised mucosa, self-limiting within 2 weeks, no systemic features, no induration, no cervical lymphadenopathy.
- Minimum supporting evidence: recurrent painful shallow ulcers, heals spontaneously, no red flags.
If the ulcer is non-healing > 3 weeks
Always consider oral SCC as the most likely diagnosis instead. Key features: indurated edges, painless initially, leukoplakia/erythroplakia, smoking/alcohol history, cervical lymphadenopathy. This is the "must not miss" diagnosis.
| DDx | One Key Discriminator |
|---|---|
| 1. Iron / B12 / folate deficiency (glossitis/angular stomatitis) | Smooth red tongue (loss of papillae), pallor, fatigue, ± macrocytosis or microcytosis on CBC [3][4] |
| 2. Oral SCC | Non-healing ulcer > 3 wk, indurated edges, ± leukoplakia, cervical LN, smoker/drinker [1][2] |
| 3. Behçet's disease | Recurrent oral + genital ulcers, uveitis, pathergy, young adult along Silk Road populations [5] |
Alternative DDx depending on stem: HSV gingivostomatitis (if acute, vesicular), drug-induced, SLE (if systemic features), IBD-related.
| Domain | Problem |
|---|---|
| Biological | Painful mouth ulcers → difficulty eating → risk of nutritional deficiency / weight loss |
| Psychological | Anxiety about possible malignancy / cancer worry; or stress triggering recurrences |
| Social | Functional impact on work/study (difficulty speaking/eating); social embarrassment; if smoker/drinker → lifestyle counselling needed |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Recurrent aphthous stomatitis (most likely) | Small (< 1 cm), round/oval, shallow ulcer with yellow-grey base and erythematous halo on non-keratinised mucosa (buccal, labial, floor of mouth) — no induration | Inspect oral cavity with torch and spatula; palpate ulcer edge — should be soft and non-indurated | Aphthous ulcers are shallow, soft-edged, well-demarcated; induration would suggest malignancy [3] |
| Oral SCC | Indurated, non-healing ulcer with raised/rolled edges ± surrounding leukoplakia/erythroplakia [1][2] | Inspect lateral/ventral tongue; bimanual palpation of ulcer for extent of induration; palpate cervical LN | Induration + non-healing > 3 wk + leukoplakia = high suspicion for oral SCC |
| Iron deficiency anaemia | Atrophic glossitis: smooth, red tongue with loss of papillae ± angular cheilitis [3][4] | Inspect dorsum and edges of tongue; look at corners of mouth | Epithelial cells turn over rapidly → sensitive to iron/B12 deficiency; koilonychia in hands supports IDA |
| B12/folate deficiency | Beefy-red glossitis + angular stomatitis ± conjunctival pallor [4] | Inspect tongue (smooth, beefy-red); pull down lower eyelid for conjunctival pallor | B12 def causes glossitis + neurological signs (peripheral neuropathy, loss of proprioception) |
| Behçet's disease | Genital ulcers on examination; or +ve pathergy test | Inspect genital area (with consent); pathergy test: skin prick → pustule at 48h [5] | Genital ulcers are the most specific lesion for Behçet's |
| SLE | Painless oral ulcers (often on hard palate) + malar rash [9] | Inspect hard palate; look for butterfly rash on face | Oral ulcers are a criterion for SLE; typically painless unlike aphthous |
| HSV gingivostomatitis | Vesicles/ulcers on keratinised mucosa (gingiva, hard palate, lips) + fever | Inspect gingiva and lips for grouped vesicles on erythematous base [10] | HSV affects keratinised mucosa (vs aphthous on non-keratinised) |
Top Traps That Lose Marks
- Forgetting to ask about duration — a non-healing ulcer > 3 weeks is oral SCC until proven otherwise. This is the #1 red flag.
- Not asking about genital ulcers — Behçet's is missed if you don't ask. Students feel awkward but examiners expect it.
- Ignoring glossitis as a separate entity — "sore tongue" ≠ "mouth ulcer." A smooth painful tongue without discrete ulcers points to nutritional deficiency (Fe, B12, folate), not aphthous ulceration.
- Not asking about smoking and alcohol — these are the major risk factors for oral SCC and leukoplakia. The "5S" mnemonic for leukoplakia: Sore teeth, Smoking, Spirits, Sepsis, Syphilis [3].
- Forgetting ICE — the patient often comes because of cancer worry, not because of pain. If you don't elicit this, you lose marks on ICE and hidden agenda.
- Not palpating the ulcer — induration is the key physical finding that separates malignancy from benign. State you would bimanually palpate.
- Missing systemic associations — mouth ulcers can be the presenting feature of IBD, coeliac disease, SLE, or Behçet's. Always screen with a brief systems review.
Must-Not-Miss Red Flags → Urgent Referral:
- Non-healing oral ulcer > 3 weeks → urgent ENT/OMFS referral (2-week wait pathway for suspected oral cancer)
- Indurated ulcer with cervical lymphadenopathy
- Unexplained weight loss + oral ulcer
- Gum hypertrophy + bleeding + pallor → suspect acute leukaemia → urgent CBC + blood film
Shortest Safe Management / Safety-Net Line:
「如果兩個禮拜都未好，或者個痱滋越嚟越大、流血、體重輕咗，一定要即刻返嚟覆診，我會安排轉介專科跟進。」 ("If it hasn't healed in 2 weeks, or if the ulcer gets bigger, bleeds, or you lose weight, you must come back immediately — I will arrange a specialist referral.")
High Yield Summary
What to ASK: Duration (> 3 wk?), site (lateral tongue?), recurrence, induration, smoking/alcohol, genital ulcers, GI symptoms, systemic features (fever, weight loss, rash, joint pain, eye symptoms), drug history, dietary history, stress. Always ask ICE — hidden agenda is often cancer worry.
What to WRITE: Chief complaint with duration; one clear RFC (e.g. "worried about cancer" or "recurrent ulcers affecting eating"); ICE verbatim; most likely Dx = recurrent aphthous stomatitis (if typical) with supporting sign = shallow soft-edged ulcer on non-keratinised mucosa, no induration; DDx = oral SCC, nutritional deficiency (glossitis), Behçet's; biopsychosocial = pain/nutrition, anxiety/cancer worry, work/social impact.
What NOT to MISS: Non-healing ulcer > 3 weeks (oral SCC); indurated edges; cervical lymphadenopathy; genital ulcers (Behçet's); smooth tongue = glossitis (Fe/B12/folate); gum hypertrophy + pallor (leukaemia); painless oral ulcers + malar rash (SLE).
Active Recall - Family Medicine Clinical Test
[1] GC 219. Infections and tumours in pharynx and oral cavity.pdf (slide: Clinical features of oral cavity cancer — non-healing ulcer, leukoplakia/erythroplakia, induration, elective neck dissection) [2] MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.244 — Cancer of tongue: lateral/ventral surface, erythroplakia, leukoplakia, risk factors, clinical manifestation) [3] Ryan Ho Fundamentals.pdf (p.62 — Oral cavity: leukoplakia "5S" causes, glossitis = Fe/B9/B12 deficiency, aphthous ulcers, angular stomatitis, causes of oral ulcers) [4] Block A - Pallor_ diagnosis of anaemia; nutritional anaemia; anaemia of systemic diseases.pdf (p.18 — Pernicious anaemia: glossitis, angular stomatitis, oral ulcers) [5] Ryan Ho Rheumatology.pdf (p.98 — Behçet disease: oral ulcers, genital ulcers most specific, pathergy, HLA-B51) [6] Ryan Ho Ophthalmology.pdf (p.31 — Uveitis systemic associations: Behçet's orogenital ulcers, IBD, AS) [7] Block A - Chronic diarrhoea_ irritable bowel syndrome and inflammatory bowel disease.pdf (p.34 — IBD extraintestinal: aphthous ulcers of mouth) [8] Block A - High white cell count_ acute and chronic leukaemia.pdf (p.3 — Acute leukaemia: gum hypertrophy in acute monoblastic leukaemia) [9] GC 046. Facial rash and painful fingers_SLE.pdf (slide: Mouth ulcers in SLE) [10] Adrian Lui Pediatrics Notes.pdf (p.477 — HSV gingivostomatitis: vesicular lesions on lip, gum, anterior tongue, hard palate) [11] MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p.60 — HFMD and herpangina: oral ulcers, vesicles on hands/feet)
Lymphadenopathy
Lymphadenopathy is the abnormal enlargement of one or more lymph nodes, often indicating infection, inflammation, or malignancy.
Nail Abnormalities
Nail abnormalities are changes in the color, shape, texture, or growth of the fingernails or toenails that may indicate local disease, systemic conditions, or nutritional deficiencies.