Sore Mouth & Tongue — Assessment & Management

Safety

Red Flags — Oral Malignancy, Epiglottitis & Systemic Disease

Done

Any unexplained oral ulceration lasting more than 3 weeks, or an unexplained oral mass Possible oral squamous cell carcinoma — induration, rolled edges or painlessness are not required (SCC can be painful, non-indurated or subtle). → ulcer: NICE NG12 says consider a suspected cancer pathway referral; this site's local safety policy is to refer by default. Lip or oral lump: consider an urgent referral for dental/oral surgery assessment (within 2 weeks). Do not use topical steroids to postpone referral — biopsy is arranged by the specialist. Most common sites: floor of mouth, lateral/ventral tongue, retromolar trigone.

Rapidly progressive dysphagia + drooling + severe throat pain + fever + "hot potato" voice in an adult Suspected epiglottitis/supraglottitis: keep the patient calm and upright, avoid a tongue depressor or uncomfortable throat examination, do not leave the patient unattended, and arrange emergency airway-capable transfer — call 999 for stridor, respiratory distress, rapidly progressive symptoms or inability to maintain the airway. Suspected quinsy: same-day ENT/hospital assessment; 999 if stridor, respiratory distress or impending airway compromise.

Widespread painless white oral plaques that cannot be wiped off + immunosuppression or unexplained weight loss + oral candidiasis Possible hairy leukoplakia (EBV-associated; an HIV-associated marker but not diagnostic — also occurs in other immunosuppression) or candidiasis in undiagnosed HIV. → Offer an HIV test and arrange oral medicine/sexual-health assessment. CD4 testing and HIV specialist referral follow the test result and clinical context. Do not label an unexplained white plaque as hairy leukoplakia without specialist assessment.

Painful mucosal erosions + blistering or epidermal detachment + targetoid lesions ± fever/systemic illness ± ocular or genital involvement Stevens-Johnson syndrome / toxic epidermal necrolysis (SJS/TEN) or severe mucocutaneous disease — not only after a recent medication change. → Emergency hospital transfer (999 if extensive or systemically unwell). Stop the suspected causative medicine now (discuss with the specialist before stopping an essential medicine). Urgent dermatology; ophthalmology if ocular symptoms or signs. No topical oral steroids as GP treatment; avoid re-challenge unless advised by a specialist.

Rapidly spreading floor of mouth swelling + trismus + neck swelling + difficulty breathing + "woody" firmness of submandibular space Ludwig's angina (dental space infection — airway emergency). → 999 with respiratory or airway symptoms. IV antibiotics. Surgical airway if needed. See surgical emergencies algorithm.

Floor-of-mouth swelling, dysphagia, rapidly progressive oral infection, dehydration or inability to maintain oral intake Suspected deep infection, severe primary herpetic gingivostomatitis with dehydration, or rapidly progressive oral disease in an immunocompromised patient. → Same-day hospital/oral surgery/OMFS.

Oral ulcers in a patient receiving chemotherapy, radiotherapy or systemic anticancer treatment Assess for neutropenia and treatment-related mucositis. → Follow the acute oncology pathway (UKONS).

Recurrent oral and genital ulceration, ocular inflammation, skin lesions or vascular/neurological features Possible Behçet's disease (systemic vasculitis). → Urgent specialist assessment. HLA-B51 is neither diagnostic nor required for referral; do not perform pathergy testing in primary care. Absence of the classic triad does not exclude Behçet's.

Oral SCC is the most important diagnosis not to miss in mouth ulcer presentations, and survival is strongly stage-dependent. The GP should apply a strict 3-week rule: any oral ulcer that has not healed within 3 weeks should be referred on the head and neck suspected cancer pathway (NICE NG12 says consider; this site's local safety policy is to refer by default), regardless of whether it appears clinically benign. Tobacco and alcohol increase oral SCC risk, but referral is based on the lesion and symptoms, not only smoking or alcohol exposure. Human papillomavirus (HPV, especially HPV-16) is an increasingly important risk factor for oropharyngeal SCC (tonsil, base of tongue), and HPV-associated disease can occur in people without these risk factors. GPs who reassure a patient with a floor-of-mouth ulcer with 'it's probably aphthous' and prescribe a topical steroid without arranging follow-up are at risk of a delayed diagnosis medicolegal claim.

Diagnose

Classification of Sore Mouth Conditions

Done

Ulcerative conditions

Aphthous ulcers (most common): painful, well-defined, shallow, grey-white base with red halo, typically <10 mm. Minor aphthae (most common): 1-5 mm, heal in 1-2 weeks without scarring. Major aphthae: >10 mm, persist for weeks-months, may scar. Herpetiform aphthae: multiple small ulcers (1-3 mm) clustering. Aetiology: idiopathic, stress, iron/B12/folate deficiency, coeliac disease, IBD (Crohn), SLE, Behçet's. Herpes labialis (cold sore — HSV-1): vesicles then crusting at vermilion border, prodromal tingling. Primary herpetic gingivostomatitis (HSV-1, first infection — children): high fever, diffuse vesicles/ulcers on gingiva and oral mucosa, lymphadenopathy, extremely painful.

White lesions

Oral candidiasis (thrush): creamy white plaques that can be wiped off leaving red base; antibiotics, corticosteroids, dry mouth, immunosuppression, diabetes, dentures. Leukoplakia (white patch that cannot be wiped off, not attributable to another condition): potentially malignant; a clinical diagnosis of exclusion requiring specialist dental/oral medicine assessment (biopsy arranged by the specialist). Lichen planus (oral): white lacy Wickham's striae + possible erosive component + bilateral buccal mucosa. Hairy leukoplakia (EBV): white corrugated plaque on lateral tongue — HIV-associated marker, not diagnostic; also seen in other immunosuppression.

Other causes

Geographic tongue (benign migratory glossitis): smooth red patches with pale borders on dorsal tongue, migrating pattern — benign, no treatment. Median rhomboid glossitis: smooth red diamond-shaped central tongue — chronic candidiasis. Burning mouth syndrome (BMS): burning sensation in oral mucosa without mucosal changes, more common in peri- and postmenopausal women — a chronic pain condition and diagnosis of exclusion. Erythema multiforme (EM): targetoid skin lesions + oral erosions — post-infectious (HSV most common trigger) or drug-induced.

Medication-related oral ulceration

NSAIDs, nicorandil, methotrexate, bisphosphonates/denosumab, cytotoxic and immunosuppressive therapy. Review the medication history in any persistent or unexplained ulcer.

Patients on anticancer treatment

Oral ulcers during chemotherapy, radiotherapy or systemic anticancer treatment require assessment for neutropenia and treatment-related mucositis according to the acute oncology pathway.

Leukoplakia is the most important oral white lesion to recognise and refer — it is defined as a white patch or plaque on the oral mucosa that cannot be wiped off and cannot be attributed to any other condition. It is a clinical diagnosis of exclusion: all other causes of oral white lesions must be excluded first (candidiasis, trauma, frictional keratosis, lichen planus, hairy leukoplakia). Malignant transformation risk varies with the histological grade of dysplasia, the clinical pattern (homogeneous, speckled, or verrucous), and the anatomical site (floor of mouth and lateral tongue have highest risk). Leukoplakia requires specialist dental/oral medicine assessment; biopsy is arranged by the appropriate specialist. For a lip/oral lump or red/red-white patch, arrange urgent assessment by a dentist/oral surgery service — if the dentist considers oral cancer possible, referral proceeds via the suspected cancer pathway. Every red or red-white patch needs urgent assessment (within 2 weeks, NICE NG12) — do not wait for pain, swelling or bleeding. Speckled leukoplakia (erythroleukoplakia — red and white areas mixed) has the highest malignant transformation risk and requires particularly urgent referral. GPs should not treat leukoplakia empirically with topical antifungals without first confirming it is not fixed white — doing so delays diagnosis.

Diagnose

Assessment — History, Examination & Investigations

Done

History

Onset and duration (acute = infective/traumatic; a solitary unexplained ulcer persisting beyond 3 weeks requires urgent assessment; recurrent, stereotyped aphthous ulcers that heal completely between episodes can usually be assessed separately if there are no red flags). Character: painful (aphthous, herpes, candida, lichen planus erosive) vs painless (oral SCC in early stages, leukoplakia). Location: tongue (geographic, SCC, median rhomboid), floor of mouth (SCC — highest risk), gingiva (herpetic, periodontal), buccal mucosa (lichen planus, aphthous). Systemic: fever (primary herpetic, viral, systemic disease), weight loss (malignancy, HIV), dysphagia (malignancy), lymphadenopathy (malignancy, EBV, HIV). Smoking + alcohol (SCC risk). Medications: NSAIDs, nicorandil, methotrexate, cytotoxic/immunosuppressive therapy (ulceration), bisphosphonates/denosumab/antiangiogenic therapy (MRONJ), antibiotics (candida), ACE inhibitors (angioedema), immunosuppressants (viral reactivation). Dental work (trauma). Nutritional: iron/B12/folate deficiency → aphthous. GI symptoms (Crohn, coeliac — oral manifestations).

Examination

Systematic oral examination (good light + wooden spatula + gloves): lips (inner surface), labial mucosa, buccal mucosa, gingiva, hard and soft palate, oropharynx, floor of mouth, all tongue surfaces (lateral and ventral — retract with gauze). Characterise lesions: colour, size, surface (smooth, rough, verrucous), borders (distinct vs irregular/indurated), base (hard = malignancy), mobility. Cervical lymphadenopathy (lymph node metastases from oral SCC). Bimanual palpation of floor of mouth (submandibular gland, SCC of floor of mouth).

Investigations

No blood tests for a typical single minor aphthous ulcer healing within 1–2 weeks with no red flags. Targeted tests only: FBC + ferritin + B12 + folate (recurrent/severe aphthosis, glossitis, angular cheilitis) · Coeliac serology (recurrent aphthosis with GI symptoms, iron deficiency or other suspicion) · HbA1c (recurrent candidiasis or diabetes symptoms/risk) · HIV test (recurrent/severe candidiasis, hairy leukoplakia, recurrent severe aphthae or relevant exposure) · HSV PCR (only when the result will alter management) · Fungal culture (treatment failure, unexplained recurrence or suspected resistant/non-albicans infection — not for uncomplicated first episodes). Do not routinely order ANA, anti-dsDNA, immunoglobulins or broad autoimmune panels in primary care. Consider IBD, Behçet's, medication-related ulceration and nutritional deficiency with relevant systemic symptoms.

The bimanual palpation of the floor of the mouth is a clinical examination technique that GPs should be competent in for detecting submandibular masses, salivary gland pathology, and floor of mouth SCC — the technique: with one finger of the examining hand inside the patient's mouth on the floor of the mouth (between the tongue and the lower front teeth), the other hand is placed externally under the chin in the submandibular region. The two hands gently compress toward each other, allowing palpation of: the submandibular gland (to detect stones or masses), the floor of mouth tissue (for induration suggesting SCC), and the tongue base. The floor of the mouth is the second most common site for oral SCC (after the lateral and ventral tongue) and is an area that is easily missed on inspection alone due to tongue obstruction — bimanual palpation identifies submucosal masses that are not visible on surface examination. Any induration (firmness beyond normal tissue) in the floor of mouth should prompt immediate suspected cancer pathway referral.

Diagnose

Oral Lichen Planus, Candida & Burning Mouth

Done

Oral lichen planus (OLP)

Patterns: reticular (most common — white lacy Wickham's striae on buccal mucosa, asymptomatic or mild); erosive (erosions with white striae at margins — painful, on buccal mucosa, tongue, gingiva); plaque-like. Small risk of malignant transformation (varies between studies and lesion types). Associations: hepatitis C (test only with epidemiological risk or unexplained liver disease — not routinely), other autoimmune conditions (thyroid, diabetes), drugs (NSAIDs, beta-blockers, ACE inhibitors, antimalarials — lichenoid reaction mimics OLP). Management: reticular, asymptomatic OLP usually requires dental/oral medicine assessment and ongoing surveillance. Painful erosive disease may require a topical corticosteroid after diagnosis. Check for secondary candidiasis. Persistent, indurated, ulcerated, red or changing areas require repeat specialist assessment and possible biopsy.

Oral candidiasis

Risk factors: antibiotics (most common GP-relevant cause), inhaled corticosteroids (ICS — must rinse mouth after use), dentures (dental plaque reservoir), dry mouth (xerostomia), diabetes, immunosuppression. Types: pseudomembranous (white plaques — wipe off leaving red base), erythematous (red, smooth — often atrophic, may be missed), denture stomatitis (erythema under denture surface — most common form). Treatment (follow the local antimicrobial pathway and product information): mild/localised disease is usually treated topically — miconazole oral gel is commonly first-line in adults where suitable, with nystatin suspension as an alternative (use nystatin if the patient takes warfarin — miconazole raises the INR; MHRA). Fluconazole is generally reserved for extensive, severe, refractory or oesophageal disease. Persistent or recurrent candidiasis: review the diagnosis, inhaled corticosteroids, dentures, diabetes, recent antibiotics, immunosuppression and HIV risk. Oral swabs are not needed for uncomplicated first episodes.

Burning mouth syndrome (BMS)

Diagnosis of exclusion — burning sensation in absence of mucosal changes. Typically bilateral, affects tip of tongue and lower lip most commonly, constant or worsening through the day, relieved by eating/drinking. More common in peri- and postmenopausal women. Assessment: oral examination and dental review; medication and xerostomia review; candidiasis assessment; targeted FBC, ferritin, B12, folate, glucose/HbA1c and thyroid testing where clinically indicated; assess for anxiety, depression, sleep disturbance and chronic pain. Exclude: dry mouth (Sjogren's, medications), nutritional deficiency, diabetes, oral candida, denture problems, contact allergy (dental materials). Management: psychological therapy, pain-focused CBT, and management of xerostomia or nutritional deficiencies. Discuss with oral medicine or a specialist pain service before considering topical or systemic clonazepam (off-label).

Topical clonazepam for burning mouth syndrome is off-label and not a routine primary-care treatment. It can still produce systemic absorption, sedation and dependence — spitting it out does not eliminate these risks. Discuss with oral medicine or a specialist pain service before considering topical or systemic clonazepam, and avoid routine long-term benzodiazepine prescribing. Alpha-lipoic acid has inconsistent evidence and is not standard NHS treatment. Tricyclic antidepressants are not absolutely contraindicated but may worsen dry mouth, and should be considered cautiously only after specialist assessment. Psychological therapy and pain-focused CBT, with management of xerostomia or nutritional deficiencies, are the core primary-care measures.

Refer

Referral Pathways

Done

999

Airway compromise, stridor or respiratory distress · Suspected epiglottitis with airway concern · Ludwig's angina with respiratory or airway symptoms · SJS/TEN with extensive mucocutaneous involvement or systemic illness

Same-day hospital / oral surgery / OMFS

Floor-of-mouth swelling, dysphagia or rapidly progressive oral infection · Suspected quinsy or deep infection · Severe dehydration or inability to maintain oral intake · Severe primary herpetic gingivostomatitis with dehydration · Immunocompromised patient with rapidly progressive oral disease

Suspected cancer: head and neck

NICE NG12 (updated April 2026): unexplained ulceration in the oral cavity lasting more than 3 weeks, or a persistent unexplained lump in the neck → consider a suspected cancer pathway referral (local safety policy: refer by default) · a lump on the lip or in the oral cavity, or a red or red-and-white patch consistent with erythroplakia or erythroleukoplakia → consider an urgent referral for assessment by a dentist or oral surgery team (within 2 weeks; do not wait for pain, swelling or bleeding) · Do not delay referral while trying topical treatment

Urgent dental / oral surgery assessment

Oral/lip lump · Red or red-white patch · Suspected leukoplakia (biopsy arranged by the specialist) · Persistent ulcer where a benign diagnosis cannot be made · Persistent or changing lesion in oral lichen planus · Suspected MRONJ · Unexplained loose teeth

Oral medicine / secondary care dentistry

Oral lichen planus (diagnosis, surveillance + management) · Recurrent severe major aphthosis not responding to topical treatment · Suspected Behçet's disease · Burning mouth syndrome needing drug treatment

GUM / HIV clinic

Suspected hairy leukoplakia — offer HIV test; oral medicine/sexual-health assessment; CD4 and HIV specialist referral according to the result · Oral candidiasis in risk groups without clear benign cause

GP management

Recurrent minor aphthous ulcers: topical corticosteroid (hydrocortisone 2.5 mg buccal tablets, or betamethasone soluble tablet mouthwash off-label) once confirmed aphthous; chlorhexidine 0.2% mouthwash is not a substitute. Oral candidiasis: topical antifungal (miconazole oral gel, or nystatin if on warfarin); fluconazole for extensive, severe or refractory disease. Herpes labialis: topical aciclovir started very early; systemic aciclovir only selectively. Primary HSV gingivostomatitis (children): oral aciclovir may be considered if started early, especially in severe disease (age/weight-specific dosing — BNFC). ICS-induced candida: rinse and spit after ICS use, spacer where appropriate, check technique and dose.

The head and neck suspected cancer referral threshold for oral lesions is one of the most frequently missed in UK primary care — NICE NG12 (updated April 2026) says consider a suspected cancer pathway referral (this site's local safety policy is to refer by default) for unexplained ulceration in the oral cavity lasting more than 3 weeks, or a persistent unexplained neck lump, at any age — there is no age threshold — and urgent dental assessment for a lump on the lip or in the mouth, or a red or red-and-white patch consistent with erythroplakia or erythroleukoplakia. The most important single factor driving missed oral SCC diagnoses in primary care: GP unfamiliarity with the presentation of early oral SCC (which is often painless, non-bleeding, and overlooked by both patient and clinician) combined with inadequate systematic oral examination. A GP who does not lift the tongue and inspect the lateral and ventral tongue surfaces, and the floor of the mouth, at a consultation for 'sore mouth' has not performed an adequate oral examination. A systematic mouth examination with a good light and tongue depressor is quick and is the most important part of any oral symptoms consultation.

Treat

Aphthous Ulcers, Herpes & Oral Candida Treatment

Done

Aphthous ulcers — stepwise treatment

Confirm the lesion is aphthous and not herpetic, candidal or malignant first. Topical corticosteroid: hydrocortisone 2.5 mg mucoadhesive buccal tablets (licensed for aphthous ulceration) — place against the ulcer and let it dissolve, four times a day for up to 5 days; or betamethasone 500 microgram soluble tablet as a mouthwash (off-label; rinse and spit out, do not swallow); doses: NICE/SPC, BNF, local formulary; avoid application to suspected infection and warn that topical corticosteroids can precipitate/worsen candidiasis. Benzydamine 0.15% mouthwash (Difflam) — analgesic, not disease-modifying. Chlorhexidine 0.2% mouthwash may reduce secondary infection but is not a substitute for topical corticosteroid treatment. Hyaluronic acid gel (Gengigel) — barrier and comfort. Recurrent, frequent or severe aphthae — targeted investigation (FBC, ferritin, B12, folate; coeliac/HIV if indicated). Systemic prednisolone and colchicine (narrow therapeutic index; renal, hepatic and interaction assessment needed) are specialist-led, not routine GP treatment.

Oral herpes

Herpes labialis (cold sore): topical aciclovir has modest benefit and should be started very early (prodromal tingling). Systemic aciclovir is not routinely required for ordinary cold sores — use selectively for severe or extensive disease, immunocompromised patients, severe primary infection, frequent or disabling recurrences, or complications such as ocular herpes (check SPC/BNF dose and renal function). Primary herpetic gingivostomatitis (children): oral aciclovir may be considered when started early, especially in severe disease — use age/weight-specific BNFC dosing with renal cautions. Analgesia + fluid intake. Hospital assessment if dehydration, inability to swallow, severe pain preventing oral intake, encephalitis or neurological symptoms, immunocompromise or ocular involvement.

Oral candidiasis

ICS-induced: after using an inhaled corticosteroid, rinse the mouth and spit out the water. Use a spacer where appropriate (metered-dose inhalers), check inhaler technique and consider whether the corticosteroid dose remains necessary. Mild/localised (symptomatic): topical treatment per local antimicrobial pathway — miconazole oral gel where suitable, or nystatin suspension (use nystatin if on warfarin — miconazole, including oral gel, can raise the INR and cause serious bleeding; MHRA). Fluconazole: reserve for extensive, severe, refractory or oesophageal disease; before prescribing check pregnancy, liver disease, renal function, QT-prolonging medicines, warfarin and other interactions (statins, ciclosporin/tacrolimus, some antiepileptics) — see current SPC. Denture stomatitis: treat dentures with dilute sodium hypochlorite solution + antifungal; leave dentures out at night. Recurrent: review diagnosis and predisposing causes (ICS, dentures, diabetes, antibiotics, immunosuppression, HIV risk); swab if treatment fails or non-albicans Candida suspected.

Burning mouth syndrome

Exclude organic causes first. Psychological therapy and pain-focused CBT; manage xerostomia and nutritional deficiencies. Topical or systemic clonazepam is off-label — discuss with oral medicine or a specialist pain service first (systemic absorption, sedation and dependence still occur). Alpha-lipoic acid: inconsistent evidence, not standard NHS treatment. Tricyclic antidepressants are not absolutely contraindicated but may worsen dry mouth — consider cautiously only after specialist assessment. Avoid routine long-term benzodiazepine prescribing.

The ICS (inhaled corticosteroid) candida prevention strategy of mouth-rinsing after every dose is one of the most impactful, simple, and frequently not-communicated medication counselling points in respiratory medicine — inhaled corticosteroid particles deposit in the oropharynx and cause local immunosuppression of the mucosal immune response, allowing commensal Candida albicans to overgrow. The solution is mechanical removal of the ICS particles: rinsing the mouth with water and spitting it out after each ICS dose. Using a spacer with metered-dose inhalers reduces oropharyngeal deposition (not applicable to every device); also check inhaler technique and whether the corticosteroid dose remains necessary. GPs prescribing ICS for the first time should make ICS mouth-rinsing advice part of the standard counselling at first prescription — it takes 30 seconds to demonstrate and significantly reduces candida-related morbidity.

Treat

Oral Lichen Planus & Specific Oral Conditions

Done

Oral lichen planus management

Reticular, asymptomatic OLP usually requires dental/oral medicine assessment and ongoing surveillance arranged by those services. Painful erosive disease may require a topical corticosteroid after diagnosis (product as advised by oral medicine). Topical steroids can cause candidiasis — check for secondary candidiasis and advise patients to report worsening soreness or new white plaques. Tacrolimus (off-label) and systemic prednisolone are specialist-led and should not be initiated in primary care for ordinary OLP. Persistent, indurated, ulcerated, red or changing areas → repeat specialist assessment and possible biopsy.

Medication-related osteonecrosis of the jaw (MRONJ)

Osteonecrosis of the jaw in patients exposed to bisphosphonates (IV most common — zoledronate for bone metastases; oral less risk — alendronate), denosumab, antiangiogenic therapies or some oncology regimens. Presentation: persistent exposed bone, fistula, non-healing extraction socket, pain, swelling or infection → urgent dental/oral surgery or OMFS assessment. Risk: dental extraction, poor oral hygiene, steroid use. Do not advise routine cessation of bisphosphonate or denosumab — any decision rests with the prescribing specialist and dental/oral surgery team. Patients starting high-dose IV antiresorptive treatment for malignancy need coordinated dental assessment per their oncology pathway. Do NOT attempt curettage, debridement or extraction in primary care.

Sjögren's syndrome oral manifestations

Dry mouth (xerostomia) is the primary oral manifestation: increased caries risk, difficulty chewing and swallowing, altered taste, oral candida (recurrent). Management: saliva substitutes and sugar-free gum (safer initial measures; artificial saliva products are not routinely NHS-prescribable in England outside relevant ACBS indications), regular sips of water, high-fluoride toothpaste (for example Duraphat 5000 ppm) and fluoride varnish from the dental practitioner, regular dental review. Pilocarpine is not a simple GP option: confirm clinically significant xerostomia, review causative medicines, check for asthma/COPD, cardiac disease, narrow-angle glaucoma and urinary outflow problems, and involve dental/oral medicine or rheumatology. Ophthalmology (dry eyes).

Next steps: see Aphthous ulcer · Genital herpes · Coeliac disease · Vulvar disorders

MRONJ (medication-related osteonecrosis of the jaw) is an increasingly important iatrogenic condition in primary care given the widespread use of bisphosphonates for osteoporosis and bone metastases — GPs who prescribe alendronate (oral bisphosphonate) or refer for zoledronate (IV bisphosphonate) infusions should be aware that dental extraction and other dental procedures are major risk factors for MRONJ. The risk is much lower for oral than IV antiresorptives. Advise good oral hygiene and regular dental review; patients commencing high-dose IV antiresorptive treatment for malignancy require coordinated dental assessment according to their oncology pathway. Do not advise routine cessation of bisphosphonates or denosumab — there is no reliable evidence that stopping before dental procedures reduces risk, and the decision belongs to the prescribing specialist and dental/oral surgery team. Use the term MRONJ (not BRONJ).

Lifestyle

Oral Hygiene, Nutrition & Tobacco Cessation

Done

Oral cancer prevention — tobacco and alcohol Advise smoking cessation and moderation of alcohol. NHS Stop Smoking services (referral at any oral symptoms consultation). AUDIT-C for alcohol. Reducing risk: stop smoking (most important), reduce alcohol to no more than 14 units a week (UK CMO). HPV vaccination (Gardasil 9 — school-age programme + MSM catch-up programme): protects against HPV-16/18-related oropharyngeal cancer. Persistent or changing oral lesions should be assessed professionally rather than managed through prolonged self-monitoring.

Oral hygiene for disease prevention Twice-daily brushing with fluoride toothpaste (1,350–1,500 ppm for adults). Interdental cleaning daily (floss or interdental brushes). Mouthwash: chlorhexidine 0.2% short-term (e.g. post-oral surgery) — not a substitute for brushing or for topical corticosteroid treatment of aphthae. Encourage regular dental review at intervals advised by the dentist. Urgent dental care: the patient's own dentist, or NHS 111 if they have none or out of hours.

Nutrition and oral mucosal health Iron, B12, folate deficiency → recurrent aphthous ulcers, angular cheilitis, glossitis. Targeted FBC + ferritin + B12 + folate for recurrent/severe aphthosis, glossitis or angular cheilitis (not annual testing for all oral complaints). Zinc deficiency: impaired wound healing, altered taste. Vitamin C deficiency (scurvy): rare in UK but bleeding gums + poor wound healing in food-insecure patients or alcoholics.

Dry mouth management (general) Xerostomia from medications is extremely common (anticholinergics, antihypertensives, antidepressants, antihistamines — all reduce salivary flow). Review medications: is the xerostomia-inducing drug essential? Can it be switched? Saliva substitutes and sugar-free gum are safer initial measures (artificial saliva not routinely NHS-prescribable in England outside ACBS indications). Pilocarpine: only after confirming clinically significant xerostomia and reviewing causative medicines — cautions include asthma/COPD, cardiac disease, narrow-angle glaucoma and urinary outflow problems; involve dental/oral medicine or rheumatology. Avoid: alcohol-containing mouthwashes (further dry the mucosa). Frequent sips of water.

Aphthous ulcer triggers and avoidance Food triggers: identify and avoid (common triggers — tomatoes, citrus fruits, strawberries, chocolate, coffee, nuts, toothpaste with sodium lauryl sulphate — SLS). Stress: significant aphthous trigger in many patients — stress management, sleep. Sodium lauryl sulphate (SLS) in toothpaste: a foaming agent that triggers aphthous in susceptible individuals — switch to SLS-free toothpaste (Sensodyne Pronamel, Biotene, Kingfisher toothpaste).

Denture hygiene and candida prevention Denture stomatitis (candidal infection under denture) is common in complete denture wearers. Prevention: remove dentures at night (allows mucosal recovery), clean dentures daily (remove, brush with denture brush + soap, soak in denture cleaner tablet), do not sleep in dentures. Treatment: topical antifungal + denture hygiene; systemic fluconazole only for extensive, severe or refractory disease. Annual denture review with dentist (ill-fitting dentures cause mucosal trauma + stomatitis).

Oral health in vulnerable groups Elderly care home residents: poor oral health is common (oral candida, periodontitis, missing teeth, dry mouth). GP responsibility: annual oral examination at care home visit, promote oral hygiene care in care home staff training, dental referral for pain or suspected pathology. Patients with learning disability: dental anxiety, difficulty cooperating with dental examination — specialist dental services available via community dental services. Post-radiotherapy to head/neck: severe dry mouth (xerostomia from salivary gland damage), mucositis, increased caries and MRONJ risk — specialist dental care essential.

Oral health in pregnancy Pregnancy gingivitis: exaggerated gum response to dental plaque from progesterone effects — common from trimester 2. Regular dental check recommended in pregnancy (NHS dental treatment free in pregnancy). Pregnancy epulis (pyogenic granuloma of gum): common benign vascular lesion on gingiva — regresses post-delivery. Vomiting in pregnancy: acid erosion of teeth — do not brush immediately after vomiting (wait 30 min), rinse with fluoride mouthwash, avoid acidic foods.

The SLS-free toothpaste advice for recurrent aphthous ulcers is a simple, evidence-based intervention that is rarely communicated in primary care consultations — sodium lauryl sulphate (SLS) is a synthetic surfactant used in most commercially available toothpastes as a foaming agent. SLS disrupts the oral mucosal protective barrier by denaturing mucosal proteins, increasing mucosal permeability and sensitising the epithelium to irritants. Some studies suggest SLS-free toothpaste may reduce aphthous ulcer frequency in recurrent aphthous stomatitis. Given that SLS-free toothpastes are widely available and inexpensive, this is a low-risk, low-cost intervention that should be recommended to any patient with recurrent aphthous ulcers before or alongside a topical corticosteroid.

Safety

Follow-Up & Surveillance

Done

Oral lichen planus monitoring

Surveillance is arranged through dental/oral medicine services, not assumed to be GP-led. Persistent, indurated, ulcerated, red or changing areas → urgent dental/oral medicine reassessment and possible biopsy. Advise patients using topical steroids to report worsening soreness or new white plaques.

Leukoplakia surveillance

Surveillance, biopsy and treatment of leukoplakia (including excision or laser ablation for dysplasia) are specialist-led; the specialist sets the follow-up interval. GP role: ensure the patient is under review and re-refer urgently if the lesion changes.

After suspected cancer pathway referral for oral lesion

Ensure referral accepted and appointment received. If lesion worsens (bleeds, enlarges rapidly, lymphadenopathy develops) while awaiting appointment: urgent same-day contact with the receiving team. Document referral outcome in GP notes when received.

Recurrent aphthous ulcers — investigation completeness

Targeted tests completed? FBC + ferritin + B12 + folate; coeliac serology if GI symptoms, iron deficiency or other suspicion; HIV test by risk or recurrent severe disease. If all normal: manage symptomatically + SLS-free toothpaste + topical corticosteroid; specialist referral if severe or refractory. If deficiency identified: treat and recheck at 3 months.

999

Airway compromise/stridor/respiratory distress (suspected epiglottitis — keep upright, do not examine the throat) · Ludwig's angina with airway symptoms · SJS/TEN (extensive oral + skin blistering or systemic illness). Same-day: suspected quinsy, floor-of-mouth swelling, dehydration, rapidly progressive infection

Suspected cancer

Unexplained oral ulcer >3 weeks or persistent unexplained neck lump → consider a suspected cancer pathway referral (NICE NG12, updated April 2026; local safety policy: refer by default) · Red or red-and-white patch, or lump on the lip or in the mouth → consider an urgent referral for dental/oral surgery assessment within 2 weeks (NG12) · Unexplained loose teeth → urgent dental assessment · Any oral lesion with unexplained cervical lymphadenopathy · Do not delay referral while trying topical treatment

Safety-net

Tell the patient: call 999 for difficulty breathing or noisy breathing, drooling or being unable to swallow saliva, or fast-spreading swelling under the tongue or in the neck. Same day: blistering or peeling skin or sore eyes with mouth sores, being unable to eat or drink enough, or a fast-spreading mouth infection. Come back if any ulcer, lump or patch has not healed within 3 weeks — give the date.

The medicolegal documentation standard for oral ulcer management requires a written record of the clinical findings, the decision-making rationale, and the safety-netting plan — a GP who sees a patient with a floor-of-mouth ulcer and documents only 'oral ulcer — prescribed a topical steroid' without documenting the size, duration, character, whether it was indurated, the patient's smoking and alcohol history, and whether a suspected cancer referral was considered, has an inadequate clinical record. The appropriate documentation: 'Oral ulcer lateral tongue, 8 mm, duration 10 days, non-indurated, regular borders, no associated lymphadenopathy. Patient is a non-smoker with minimal alcohol use. Clinical appearance consistent with aphthous ulcer. Topical corticosteroid prescribed. Safety-net: if not healed within 3 weeks, urgent review for suspected cancer pathway referral. Patient advised to re-attend if not healed by [date].' This documents the clinical reasoning and the planned safety-net, providing a defensible record if the lesion later proves to be malignant.