Investigation and treatment of oral ulcers, by consultant oral medicine.
A proper work-up for a persistent mouth ulcer - history, examination, targeted bloods, swabs, biopsy under local anaesthetic if needed, and a plan you can actually act on. NICE NG12 2-week-wait pathway for anything suspicious.
Indicative pricing
What a private oral-ulcer work-up costs in London.
Indicative ranges across UK private providers.
In short
£500–£950, diagnosis within two weeks.
| Item | Indicative range | Typical duration | Turnaround |
|---|---|---|---|
| Oral medicine consultation | £150–£350 | 30–45 min | Same visit |
| OMFS 2-week-wait review (suspected cancer) | NHS 2WW / £250–£400 private | 30 min | Same week |
| Incisional biopsy under LA | £350–£600 | 20–30 min | Histology 7–14 days |
| Blood panel (FBC, iron, B12, folate, coeliac, HIV) | £180–£320 | 15 min draw | 24–72 hours |
| HSV / Candida swab | £60–£140 | 5 min | 2–5 days |
| Topical treatment course (steroid, antimicrobial) | £20–£90 script | n/a | From pharmacy |
| MRI head & neck (staging, if indicated) | £450–£900 | 30–45 min | 48–72 hours |
Prices vary by clinic, by whether a biopsy is needed, and by which blood tests are chosen. Anything meeting NICE NG12 2-week-wait criteria is arranged on the NHS pathway at no cost - we still hold your hand through it.
The problem
A persistent mouth ulcer deserves more than another mouthwash.
Most mouth ulcers are harmless and heal in a fortnight. The ones that don’t need a proper look - not another course of chlorhexidine and a "come back if it isn’t better".
-
Recurrent and not sure why?
A blood panel - iron, B12, folate, coeliac serology - often finds the driver. Then we treat the cause, not just the ulcer.
-
Painful and not settling?
Topical steroid, SLS-free toothpaste and - for severe cases - systemic therapy under a specialist. There is more than one lever to pull.
-
Been there over three weeks?
That triggers NICE NG12 - a 2-week-wait head-and-neck review to rule out oral squamous cell carcinoma. No ambiguity.
When it helps
The eight patterns of oral ulceration we see.
Ulcers we investigate every week - plus the one red flag that means a 2-week-wait referral rather than an appointment.
-
Recurrent aphthous stomatitis (RAS)
The classic recurrent mouth ulcer - minor, major or herpetiform. Usually idiopathic, often lifelong, sometimes iron or B12 driven.
-
Traumatic ulcer
A sharp tooth, a rubbing denture, an aspirin burn, a scald from hot food or drink - heals within days once the cause is removed.
-
Infection (HSV, HFMD, Candida)
Primary herpes gingivostomatitis, cold sores, hand-foot-and-mouth, angular cheilitis or denture stomatitis - treated by the underlying bug.
-
Systemic disease - Behçet’s, IBD, coeliac
Behçet’s (oral + genital + uveitis), Crohn’s or ulcerative colitis, coeliac disease, PFAPA and cyclical neutropenia can all present in the mouth.
-
Autoimmune - pemphigus, MMP, lichen planus
Pemphigus vulgaris, mucous membrane pemphigoid and erosive oral lichen planus - the latter carries a 1–2% malignancy risk.
-
Drug-induced - nicorandil, methotrexate
Nicorandil is a well-recognised cause of chronic mouth (and anal) ulceration. Methotrexate, chemotherapy and biologics also feature.
-
Nutritional deficiency
Iron, B12 and folate deficiency can drive recurrent ulcers - worth a blood test, worth correcting.
-
Red flag: ulcer over 3 weeks
Any oral ulcer lasting more than three weeks - especially in an adult over 45, a smoker or a drinker - is a NICE NG12 2-week-wait referral for suspected oral cancer.
Investigation options
The tests that actually give an answer.
What each investigation on the table actually shows - and which fits which pattern.
-
Clinical examination
Oral mucosa, dentition, palpation of submandibular and cervical nodes, plus a targeted skin, eye and joint screen if a systemic cause is on the table.
-
Blood panel
FBC (neutropenia, anaemia), iron studies, B12 and folate, coeliac serology (IgA tTG), HIV, syphilis, ANA and ESR/CRP where indicated.
-
Microbiology swab
HSV PCR, bacterial swab (streptococci), Candida - targeted at the lesion, not fired off at random.
-
Incisional biopsy under LA
The definitive test for any persistent, atypical, red or white lesion. Histology, immunohistochemistry and direct immunofluorescence as needed.
-
MRI head and neck
Cross-sectional imaging for staging where oral squamous cell carcinoma is suspected or confirmed.
-
PET-CT
Whole-body staging for suspected oral or oropharyngeal malignancy - arranged through an MDT.
-
Dental review
A parallel appointment to smooth a sharp tooth, adjust a denture or address a chronic mucosal trauma.
-
Photographic follow-up
Documented photos at baseline and review - the quickest way to see whether an ulcer is genuinely healing.
Safety and red flags
What matters, and what warrants a 2-week-wait.
Investigating an oral ulcer is low-risk. The thing worth being sharp about is timing - three weeks is the number, and NICE NG12 is the rulebook.
-
Three weeks is the number to remember
An adult ulcer that has not healed in three weeks needs a proper look, not another mouthwash. NICE NG12 is explicit about this.
-
Red or white patches matter
Erythroplakia and leukoplakia carry a real risk of dysplasia or early cancer - they warrant biopsy, not reassurance.
-
A biopsy is quick and safe
Done under local anaesthetic in clinic. A few dissolvable stitches, a sore spot for a couple of days, and a proper diagnosis at the end of it.
-
SLS-free toothpaste reduces recurrence
For recurrent aphthous stomatitis, Cochrane evidence supports switching away from sodium lauryl sulphate toothpastes.
-
Topical steroids work - used properly
Hydrocortisone mucoadhesive tablets, triamcinolone in Orabase or betamethasone mouthwash (spit-out) settle most recurrent aphthous ulcers.
-
Some ulcers are the tip of a systemic iceberg
Recurrent ulcers with genital ulcers, eye inflammation, gut symptoms or skin rash need a systemic work-up, not just a local treatment.
-
Nicorandil is a known culprit
If you take nicorandil for angina and have chronic mouth ulceration, it is very likely the drug. Never stop it without cardiology input.
-
HPV changes the picture
HPV-related oropharyngeal cancer is rising and often presents as a persistent lump or ulcer at the tonsil or tongue base - worth a proper look.
-
Red flags
An ulcer over three weeks, unexplained neck lump, persistent hoarseness over three weeks, red or white patches, unexplained loose teeth - all warrant 2-week-wait referral.
Reading your clinic letter
Your clinic letter in four parts. Read the last one first.
Whichever investigations were done, the letter the consultant sends you keeps to the same shape.
A quiet reminder
Histology language is precise and can read coldly - we translate it for you.
If you would like us to talk you through the letter and biopsy report before your review, just ask.
- 01 Header
Diagnosis and differential
What the ulcer is - RAS, traumatic, HSV, autoimmune, malignant - and what the differential is if the picture is not yet clear.
- 02 Findings
Clinical exam and investigation results
Where the ulcer sits, its size, edges and induration, plus blood, swab and biopsy results in plain language.
- 03 Technique
What was done
Whether a biopsy was taken, which site, which histology was requested, and any imaging or MDT referral arranged.
- 04 Impression
Treatment plan and follow-up
Read this first: what to use, how long for, when to review, and the exact red flags that mean coming back sooner.
Recognised by major UK insurers
Cover for oral medicine consultations and biopsy varies by insurer - usually funded when there is a clinical indication.
Frequently asked
Everything we get asked about mouth ulcers.
Quick answers on healing time, biopsy, the 2-week-wait pathway, and what actually treats recurrent ulcers.
-
How long should a mouth ulcer take to heal?
A run-of-the-mill aphthous ulcer heals in seven to fourteen days. Anything that has not healed in three weeks - especially in an adult over 45, or a smoker or drinker - is a NICE NG12 2-week-wait referral for suspected oral cancer.
-
What causes recurrent mouth ulcers?
Most are recurrent aphthous stomatitis, which is idiopathic but often familial. Iron, B12 or folate deficiency, coeliac disease, Crohn’s or ulcerative colitis, Behçet’s, HIV and drugs such as nicorandil can all drive them. A blood panel is a sensible first step.
-
When does a mouth ulcer need a biopsy?
Any ulcer lasting more than three weeks, any red or white patch, any lump, and any ulcer with raised, indurated or irregular edges. Biopsy is done under local anaesthetic in clinic and reported by a head-and-neck pathologist.
-
What is the NICE 2-week-wait for suspected oral cancer?
NICE guideline NG12 says an adult with unexplained oral ulceration lasting more than three weeks, an unexplained lump in the mouth or neck, red or white patches, or unexplained tooth mobility should be referred within two weeks to a head-and-neck team.
-
Can toothpaste cause mouth ulcers?
It can contribute. Sodium lauryl sulphate - the foaming agent in most toothpastes - is linked to recurrent aphthous ulcers, and switching to an SLS-free brand reduces recurrence in Cochrane reviews.
-
What treatments actually work for aphthous ulcers?
Chlorhexidine and benzydamine (Difflam) mouthwashes for symptom control; hydrocortisone mucoadhesive tablets (Corlan), triamcinolone in Orabase or betamethasone mouthwash for potent topical steroid; short-course prednisolone, colchicine or thalidomide for severe disease under specialist supervision.
-
Are mouth ulcers a sign of cancer?
Most are not - but a persistent, painless, indurated ulcer, especially at the tongue edge or floor of mouth in a smoker or drinker, can be an oral squamous cell carcinoma. Three weeks is the threshold at which it must be taken seriously.
-
How much does private investigation of mouth ulcers cost in London?
A consultation is roughly £150–£350, a biopsy £350–£600, a blood panel £180–£320 and topical treatment £20–£90 on private prescription.