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Sore Mouth and Tongue

Last updated 1 Jun 2026 · General Practice / Dental

📋 Key Information Summary

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  • Most mouth ulcers are benign: Minor aphthous ulcers (miRAS) account for ~80% of recurrent oral ulceration and are self-limiting within 7–14 days; a systematic diagnostic approach is essential to exclude sinister causes.
  • Red-flag ulcers require urgent referral: Any non-healing oral ulcer persisting >3 weeks, a painless indurated ulcer, or an ulcer in a patient with risk factors for malignancy (smoking, alcohol, betel nut) warrants same-week oral medicine or ENT review.
  • Traumatic ulceration is the most common cause of acute solitary oral ulceration — always assess for sharp dental edges, ill-fitting prostheses, or chemical injury before attributing to aphthous disease.
  • Topical corticosteroids are first-line for aphthous ulcers: triamcinolone acetonide in orabase (Kenalog in Orabase®), betamethasone soluble tablet as a mouth rinse, or clobetasol gel for major aphthae. PBS-listed options should be prioritised.
  • Oral candidiasis presents as white plaques that scrape off (pseudomembranous) or erythematous mucosa; risk factors include inhaled corticosteroid use, denture wearing, diabetes, and immunosuppression. Nystatin suspension or miconazole oral gel are first-line; fluconazole for refractory cases.
  • Oral lichen planus affects ~1–2% of the population; the reticular (Wickham striae) form is usually asymptomatic, but erosive forms cause significant pain and carry a small (~1%) malignant transformation risk requiring long-term surveillance.
  • Angular cheilitis most commonly reflects Candida albicans infection in the setting of denture-related stomatitis, diabetes, or iron/B12/folate deficiency — treat the underlying cause plus topical miconazole or a combination antifungal-corticosteroid cream.
  • Herpes simplex gingivostomatitis is the most common cause of acute diffuse oral ulceration in children; oral aciclovir within 72 hours of onset shortens duration. Valaciclovir is an alternative with improved bioavailability and simpler dosing.
  • Burning mouth syndrome (glossodynia) is a diagnosis of exclusion — normal-appearing oral mucosa with persistent burning pain for ≥2 hours/day for ≥3 months; investigate for candidiasis, nutritional deficiency, and medication side effects before diagnosis.
  • Investigate recurrent or severe aphthous ulcers for underlying causes: coeliac disease, inflammatory bowel disease, Behçet disease, haematinic deficiency (iron, folate, B12), and HIV infection.
  • Oral lichenoid reactions may be drug-induced (NSAIDs, ACE inhibitors, beta-blockers, sulfonylureas) or represent a contact reaction to dental materials (amalgam); medication review is essential.
  • ATSI populations have higher rates of oral health disease, limited access to dental and specialist services, and higher prevalence of betel nut use in some Torres Strait Islander communities — consider these factors in assessment and referral.
  • Chlorhexidine 0.12–0.2% mouthwash (Savacol®) reduces secondary infection and aids healing in most oral ulceration; avoid prolonged use (>2 weeks) due to taste disturbance and tooth staining.

Introduction & Australian Epidemiology

Oral complaints including sore mouth, tongue discomfort, and mucosal ulceration are among the most common presentations in Australian general practice. The oral mucosa is a readily visible and accessible tissue that reflects both local pathology and systemic disease. A structured clinical approach — combining history, examination, and targeted investigation — enables accurate diagnosis and timely management of conditions ranging from benign self-limiting aphthous ulcers to oral malignancy.

In Australia, oral health conditions affect a significant proportion of the population across all age groups:

  • Recurrent aphthous stomatitis (RAS) affects approximately 20–25% of the general population, with onset typically in childhood or adolescence and peak prevalence in the second and third decades of life.
  • Oral candidiasis is reported in 35–60% of denture wearers and is a frequent complication of inhaled corticosteroid use in the estimated 2.7 million Australians with asthma.
  • Oral lichen planus has a prevalence of approximately 1–2%, with a female-to-male ratio of approximately 1.4:1 and peak incidence between ages 30 and 60.
  • Oral cancer accounts for approximately 4,000 new cases annually in Australia, with a 5-year survival rate of ~68% — late presentation remains a significant concern, particularly in regional and remote areas.
  • The Australian Institute of Health and Welfare (AIHW) reports that Aboriginal and Torres Strait Islander peoples experience oral disease at 1.5–2 times the rate of non-Indigenous Australians, with significantly higher rates of tooth loss and untreated decay.

This guideline provides a practical, evidence-based framework for the diagnosis and management of the most common oral mucosal and tongue conditions presenting in Australian primary care, with attention to PBS-listed therapies, appropriate referral pathways, and health equity considerations.

Mouth Ulcers Diagnostic Model

A systematic diagnostic approach is essential when evaluating patients with oral ulceration. The majority of mouth ulcers encountered in general practice are benign, but the differential diagnosis is broad and includes infectious, autoimmune, traumatic, and malignant aetiologies. The following model organises the clinical assessment into key diagnostic domains.

History — Key Diagnostic Questions

Domain Questions to Ask Diagnostic Significance
Duration How long has the ulcer been present? Has it changed in size? >3 weeks non-healing → suspect malignancy; recurrent episodes → RAS
Number Single vs. multiple? Clustered or scattered? Single → traumatic, malignancy; multiple/scattered → aphthous, herpetic, Behçet
Location Lip, buccal mucosa, tongue, palate, gingivae? Non-keratinised mucosa (buccal, soft palate) → aphthae; attached gingiva/palate → herpetic
Pain Severity? Interfering with eating/drinking/sleeping? Painless indurated ulcer → malignancy (urgent referral)
Recurrence Previous episodes? Frequency? Family history? Recurrent pattern with healing between episodes → RAS; family history in 30–40% of RAS
Triggers Stress, trauma, foods, menstrual cycle, medications? Food triggers (citrus, cinnamon, chocolate) → aphthae; new medication → lichenoid reaction
Systemic symptoms Fevers, rash, genital ulcers, eye symptoms, diarrhoea, weight loss? Behçet, IBD, coeliac disease, SLE, HIV
Risk factors Smoking, alcohol, betel nut, immunosuppression, dentures? Malignancy risk, candidiasis risk

Clinical Examination Approach

1
Inspect systematically
Examine all oral mucosal surfaces including buccal mucosa, palate (hard and soft), floor of mouth, ventral and dorsal tongue, oropharynx, and lips. Use a good light source and tongue depressor.
2
Characterise the ulcer
Note size (mm), shape (round/irregular), edges (raised/rolled/everted → suspect malignancy), base (clean/fibrinous/necrotic), surrounding mucosa (erythema, white striae), and induration on palpation.
3
Assess for dental/traumatic causes
Run a gloved finger along dental edges to identify sharp cusps or broken restorations. Examine denture fit. Check for chemical burns (aspirin held against mucosa).
4
Extra-oral examination
Inspect skin (petechiae, rash), eyes (conjunctivitis, uveitis), genitalia (if indicated), and cervical lymphadenopathy (hard, fixed nodes → malignancy).
5
Categorise by morphology
Apply the diagnostic model below to classify ulcers as minor aphthous, major aphthous, herpetiform, traumatic, infectious, immune-mediated, or suspicious for malignancy.

Diagnostic Classification of Oral Ulcers

Category Key Features Typical Duration Action
Minor aphthous Round/oval, <10 mm, yellow-grey base, erythematous halo; non-keratinised mucosa 7–14 days, heals without scarring Topical treatment; investigate if frequent/severe
Major aphthous (Sutton's) >10 mm, deep, punched-out; may scar; lips, soft palate, fauces Weeks to months Systemic steroids; oral medicine referral
Herpetiform 1–3 mm, multiple (10–100), may coalesce; recurrent pattern 7–14 days Topical steroids; consider aciclovir if herpetic
Herpetic (HSV) Vesicles → shallow ulcers; attached gingiva, palate; children: acute gingivostomatitis with fever 10–14 days (primary) Antivirals within 72 hours of onset
Traumatic Corresponds to mechanical/chemical injury site; irregular shape; heals when cause removed 7–14 days after cause removal Remove cause; chlorhexidine rinse
Immune-mediated Lichen planus (Wickham striae), pemphigoid (desquamative gingivitis), pemphigus (flaccid blisters) Chronic/recurrent Oral medicine / dermatology referral
Malignant Painless, indurated, rolled/everted edges, non-healing (>3 weeks); floor of mouth, lateral tongue, soft palate complex Persistent, progressive Urgent oral medicine / ENT / head & neck referral
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Red flags requiring urgent referral (within 2 weeks): Any oral ulcer persisting >3 weeks; a painless, indurated, or fixed ulcer; unilateral cervical lymphadenopathy; unexplained oral bleeding; non-healing extraction socket; white or red patch that cannot be wiped off (leukoplakia/erythroplakia); progressive dysphagia or voice change. Refer to oral medicine specialist, oral & maxillofacial surgeon, or ENT head & neck surgeon.

Recurrent Aphthous Ulceration & Traumatic Ulceration

Recurrent Aphthous Stomatitis (RAS)

RAS is the most common oral mucosal disease, characterised by recurrent episodes of discrete, painful ulcers on non-keratinised oral mucosa with intervening ulcer-free periods. The pathogenesis is multifactorial, involving T-cell-mediated immune dysregulation against oral epithelial antigens, with genetic predisposition (positive family history in 30–40% of cases).

Predisposing and Exacerbating Factors

  • Nutritional deficiency: Iron, vitamin B12, folate, zinc — check FBC, serum ferritin, serum B12, red cell folate, zinc
  • Haematological: Anaemia (iron deficiency, B12/folate deficiency), cyclic neutropenia
  • Gastrointestinal: Coeliac disease (prevalence of RAS up to 25% in coeliac patients), inflammatory bowel disease
  • Immunological: Behçet disease, HIV, cyclic neutropenia, MAGIC syndrome
  • Medications: NSAIDs, nicorandil, methotrexate, immune checkpoint inhibitors
  • Lifestyle: Psychological stress, local trauma, smoking cessation (paradoxical increase), sodium lauryl sulphate in toothpaste

Treatment of Aphthous Ulceration

Mild (Minor Aphthae) — Symptomatic & Barrier Measures

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Chlorhexidine 0.12–0.2% Mouthwash
Savacol® · Chlorhex-R® · Antiseptic mouthwash
Adult dose 10–15 mL rinse for 30–60 seconds, spit out, TDS–QID
Paediatric dose 5–10 mL (age >6 years who can reliably spit out)
Duration Until ulcer healed (typically 7–14 days); avoid >2 weeks continuous use
Key notes Reduces secondary infection, may aid healing. Causes taste disturbance and extrinsic tooth staining with prolonged use. Do not use simultaneously with toothpaste (SLS inactivates chlorhexidine).
PBS status ✔ PBS General Benefit
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Benzydamine Hydrochloride 0.15% Mouthwash / Spray
Difflam® · Difflam Forte® · Analgesic/anti-inflammatory
Adult dose 15 mL rinse for 30–60 seconds, TDS–QID; or 4–8 sprays to affected area, TDS–QID
Paediatric dose Spray: 1 spray per 4 kg body weight (max 4 sprays), TDS–QID
Duration Up to 7 days; review if no improvement
Key notes Topical NSAID with local analgesic and anti-inflammatory properties. Useful for pain relief in oral ulceration. May cause local numbness. Avoid in aspirin-sensitive asthma.
PBS status ⚠ Not PBS (OTC)

Moderate — Topical Corticosteroid Therapy

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Triamcinolone Acetonide 0.1% in Orabase
Kenalog in Orabase® · Topical corticosteroid paste
Adult dose Apply a thin layer to dried ulcer surface after meals and at bedtime (QID)
Paediatric dose Same application technique; ensure child does not ingest paste
Duration Until ulcer healed (typically 5–10 days)
Renal adjustment Not required (topical with minimal systemic absorption)
Key notes First-line topical corticosteroid for aphthous ulcers. Dry the ulcer with gauze before application to improve adhesion. Avoid use if active oral candidiasis (treat candidiasis first).
PBS status ✔ PBS General Benefit
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Betamethasone Sodium Phosphate 0.5 mg Tablets (as Mouth Rinse)
Betnesol® soluble tablets · High-potency topical corticosteroid
Adult dose Dissolve 1 tablet (0.5 mg) in 10–20 mL water; rinse for 2–3 minutes, spit out, TDS
Paediatric dose Half tablet (0.25 mg) in 10 mL water, rinse and spit, BD–TDS (supervised use only)
Duration 7–14 days; taper if used >1 week
Key notes Useful for widespread aphthous ulceration affecting multiple sites. Also effective for erosive lichen planus. Ensure patient spits out — do not swallow. Monitor for oral candidiasis with prolonged use.
PBS status ✔ PBS General Benefit
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Clobetasol Propionate 0.05% Gel
Dermol® · Eumovate® 0.05% · Ultra-high potency topical corticosteroid
Adult dose Apply sparingly to dried ulcer BD; typically used with an adhesive base
Duration 7–14 days; specialist-guided for longer courses
Key notes Reserved for major aphthae and erosive lichen planus not responding to weaker topical corticosteroids. Usually initiated by or in consultation with an oral medicine specialist. High risk of mucosal atrophy and candidiasis with prolonged use.
PBS status ✔ PBS General Benefit

Severe / Refractory — Systemic Therapy

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Prednisolone
Panafcortelone® · Solone® · Systemic corticosteroid
Adult dose 0.5–1 mg/kg/day (typically 25–50 mg/day) PO for 5–7 days, then taper over 1–2 weeks
Paediatric dose 1–2 mg/kg/day PO, taper over 5–7 days (specialist-directed)
Duration Short course (1–3 weeks total including taper); long-term use requires specialist supervision
Renal adjustment Not required
Key notes Indicated for major aphthous ulceration, herpetiform ulceration unresponsive to topical therapy, and acute Behçet flares. Exclude active infection (especially HSV, VZV) before initiating. Screen for diabetes. Concurrent PPI for GI protection if risk factors.
PBS status ✔ PBS General Benefit
⚠️
Investigation of recurrent or severe RAS: Consider the following workup for patients with frequent (≥3 episodes/year), large (>10 mm), or persistent aphthous ulcers: FBC with film, serum ferritin, vitamin B12, red cell folate, zinc, ESR/CRP, coeliac serology (anti-tTG IgA, total IgA), and HIV testing (with consent). If Behçet disease is suspected: HLA-B51, pathergy test, ophthalmology review.

Traumatic Ulceration

Traumatic ulceration is the most common cause of solitary oral ulceration in general practice. Causes include mechanical trauma (sharp dental cusps, broken restorations, ill-fitting dentures, cheek biting), thermal burns (hot food/drink), and chemical injury (aspirin held against mucosa, caustic substances).

Management Principles

  • Identify and remove the cause: Sharp dental edges → dental referral for smoothing/polishing; ill-fitting denture → denture adjustment or relining; cheek biting → occlusal splint if bruxism-related.
  • Topical analgesia: Benzydamine 0.15% mouthwash (Difflam®) QID for pain relief.
  • Antiseptic mouthwash: Chlorhexidine 0.12–0.2% (Savacol®) to prevent secondary infection.
  • If no healing within 2–3 weeks after cause removal: Biopsy to exclude malignancy, especially in patients with risk factors.
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Traumatic eosinophilic granuloma (Riga-Fede disease): A chronic traumatic ulcer on the ventral tongue of infants, typically caused by natal/neonatal teeth or the lower primary incisors. Usually self-limiting once the causative tooth is managed. Refer to paediatric dentistry.

Oral Candidiasis, Lichen Planus & Angular Cheilitis

Oral Candidiasis

Oral candidiasis (oral thrush) is a fungal infection of the oral mucosa caused predominantly by Candida albicans. It is the most common oral fungal infection in Australia and affects immunocompromised and immunocompetent individuals alike.

Risk Factors

  • Inhaled corticosteroid use (especially without mouth rinsing after use) — the most common iatrogenic cause
  • Denture wearing (especially overnight) — denture-related stomatitis
  • Diabetes mellitus (poorly controlled)
  • Immunosuppression: HIV/AIDS (oral candidiasis is an AIDS-defining illness), chemotherapy, organ transplant, corticosteroid use
  • Xerostomia (medication-induced, Sjögren syndrome, post-radiotherapy)
  • Antibiotic use (broad-spectrum disrupting oral flora)
  • Iron deficiency, vitamin B12 / folate deficiency
  • Smoking
  • Neonates and elderly

Clinical Forms

Form Appearance Key Features
Pseudomembranous Creamy white plaques that wipe off leaving erythematous base Classic "thrush"; most common form; any mucosal surface
Erythematous (atrophic) Red, smooth, raw-looking patches; often on palate (denture-related) or tongue dorsum May be asymptomatic or burning; common with inhaled corticosteroids
Chronic hyperplastic White, non-wipeable plaques, typically on buccal mucosa commissure Does NOT scrape off; requires biopsy to differentiate from leukoplakia; may be premalignant
Denture stomatitis Erythema and petechiae under upper denture fitting surface Often asymptomatic; associated with Candida colonisation; may cause angular cheilitis

Treatment of Oral Candidiasis

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Nystatin Oral Suspension 100,000 IU/mL
Nilstat® · Nystat® · Topical antifungal
Adult dose 5 mL (500,000 IU) rinse around mouth for as long as possible then swallow, QID
Paediatric dose 1 mL (100,000 IU) to each cheek QID (infants); 2–5 mL QID (older children)
Duration 7 days after clinical resolution (minimum 7–14 days); continue 48 hours after symptoms resolve
Key notes First-line for mild-moderate oral candidiasis. Not absorbed systemically. Preservative-free formulation available for neonates. Retain in contact with mucosa as long as possible before swallowing.
PBS status ✔ PBS General Benefit
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Miconazole Oral Gel 20 mg/g
Daktarin Oral Gel® · Topical azole antifungal
Adult dose Apply 2.5 mL to affected area QID; hold in mouth as long as possible before swallowing
Paediatric dose Infants <6 months: 1.25 mL to each cheek QID; 6 months–2 years: 2.5 mL QID (apply with finger to avoid choking)
Duration 7 days after clinical resolution (minimum 7–14 days)
Key notes More effective than nystatin for moderate infection. Also treats denture stomatitis and angular cheilitis. Apply to denture fitting surface for denture stomatitis. Drug interactions: inhibits CYP3A4 — caution with warfarin, simvastatin, tacrolimus, ciclosporin. Avoid in infants <4 months (risk of choking with gel formulation).
PBS status ✔ PBS General Benefit
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Fluconazole 50 mg / 150 mg Capsules
Diflucan® · Azocan® · Systemic azole antifungal
Adult dose 50 mg PO daily for 7–14 days (mild); 100–200 mg PO daily (moderate-severe / immunocompromised)
Paediatric dose 3–6 mg/kg/day PO (max 200 mg/day)
Duration 7–14 days; longer courses (weeks–months) for immunocompromised patients under specialist direction
Renal adjustment eGFR <50 mL/min: reduce dose by 50%
Hepatic adjustment Use with caution; monitor LFTs in prolonged courses
Key notes Indicated for: refractory oral candidiasis failing topical therapy, immunocompromised patients, moderate-severe pseudomembranous candidiasis, chronic mucocutaneous candidiasis. Significant drug interactions (CYP2C9/3A4 inhibitor): warfarin, phenytoin, statins, tacrolimus.
PBS status ✔ PBS General Benefit (50 mg, 150 mg)

Oral Lichen Planus

Oral lichen planus (OLP) is a chronic T-cell-mediated inflammatory disease affecting the oral mucosa, with an estimated prevalence of 1–2% in Australia. It predominantly affects middle-aged adults, with a female-to-male ratio of approximately 1.4:1. OLP is classified as a potentially malignant disorder by the WHO, with malignant transformation rates reported at approximately 1–2% over long-term follow-up.

Clinical Forms

Form Appearance Symptoms
Reticular White, lace-like (Wickham) striae; bilateral buccal mucosa, gingivae, tongue Usually asymptomatic; patient may notice white patches
Erosive Erythematous, ulcerated areas surrounded by white striae Painful; burning; difficulty eating spicy/acidic foods
Atrophic Thin, erythematous mucosa with minimal striae Burning, sensitivity
Plaque-like Homogeneous white plaques (resembles leukoplakia) Usually asymptomatic; requires biopsy
Bullous Fluid-filled bullae that rupture to form erosions Painful; rare form
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Biopsy is essential to confirm the diagnosis of oral lichen planus and exclude lichenoid dysplasia or malignancy, especially in the erosive or plaque-like forms. Lichenoid reactions mimicking OLP can be caused by medications (NSAIDs, ACE inhibitors, beta-blockers, sulfonylureas, thiazides) and dental materials (amalgam). Always review the medication chart.

Treatment of Oral Lichen Planus

Treatment is indicated for symptomatic (erosive/atrophic) forms. Asymptomatic reticular OLP does not require treatment but warrants long-term monitoring.

Mild
Reticular / Mild Erosive
Minimal symptoms, white striae ± small erosions. Manage triggers, oral hygiene, avoid spicy/acidic foods.
Setting: GP management with dental monitoring
Moderate
Erosive / Painful
Significant pain affecting eating. Topical corticosteroids (triamcinolone paste, betamethasone rinse, clobetasol gel). 6-monthly review.
Setting: GP with oral medicine referral consideration
Severe
Widespread / Refractory
Extensive erosions, significant functional impairment. Topical tacrolimus, systemic immunosuppression (azathioprine, mycophenolate). Oral medicine specialist-led.
Setting: Oral medicine / dermatology specialist
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Tacrolimus 0.1% Ointment (Topical)
Protopic® · Calcineurin inhibitor (topical)
Adult dose Apply thin layer to affected oral mucosal areas BD
Duration Initial course 6–8 weeks; maintenance as directed by specialist
Key notes Second-line for erosive OLP refractory to topical corticosteroids. Off-label use in the oral cavity (used under specialist supervision). Black box warning re: theoretical malignancy risk — generally considered low risk for short courses in oral mucosa. Avoid in active infection.
PBS status ✘ Authority Required (Specialist initiation)

Angular Cheilitis

Angular cheilitis (angular stomatitis, perlèche) presents as erythema, fissuring, and maceration at the oral commissures. It is most commonly caused by Candida albicans, often in the context of denture-related stomatitis, but may also involve Staphylococcus aureus or Streptococcus species, or be multifactorial.

Underlying Causes to Investigate

  • Denture-related stomatitis (most common association) — loss of vertical dimension creating moisture/fold at commissures
  • Iron deficiency anaemia
  • Vitamin B12 or folate deficiency
  • Diabetes mellitus
  • Immunosuppression (HIV, corticosteroids)
  • Drooling in children with atopic dermatitis or in elderly with sagging facial skin

Treatment

💊
Miconazole 2% Cream
Daktarin® cream · Topical antifungal
Adult dose Apply to affected commissures BD–TDS
Duration 7–14 days (continue 48 hours after resolution)
Key notes First-line for candidal angular cheilitis. If secondary bacterial infection suspected (crusting, weeping), consider adding mupirocin 2% ointment (Bactroban®) or using a combination product. Treat concurrent denture stomatitis with miconazole oral gel applied to denture fitting surface.
PBS status ✔ PBS General Benefit
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Hydrocortisone 1% + Miconazole 2% Cream
Daktacort® · Antifungal + mild corticosteroid combination
Adult dose Apply to affected commissures BD
Duration 7 days; review — avoid prolonged corticosteroid use at commissures
Key notes Useful when there is significant inflammation/eczema around commissures in addition to candidal infection. Not for prolonged use due to steroid component. Ideal for atopic dermatitis-related angular cheilitis in children.
PBS status ✔ PBS General Benefit
💡
Denture hygiene advice: Patients with denture-related stomatitis and angular cheilitis should remove dentures at night, clean dentures daily with a denture brush and effervescent tablet (e.g., Polident®), and soak overnight in chlorhexidine 0.2% or water. A 2-week course of miconazole oral gel applied to the fitting surface of the denture is recommended.

The Painful Tongue & Oral Dermatoses

Burning Mouth Syndrome (Glossodynia)

Burning mouth syndrome (BMS) is characterised by a persistent burning sensation of the oral mucosa (most commonly the tongue) in the absence of clinically identifiable mucosal lesions. It is a neuropathic pain disorder affecting an estimated 1–5% of the general population, with a strong female predominance (especially postmenopausal women, F:M ratio ~7:1).

Diagnostic Criteria (International Headache Society)

  • Oral pain recurring daily for ≥2 hours per day for >3 months
  • Burning quality, with or without dysgeusia (altered taste) or xerostomia (dry mouth)
  • Clinically normal oral mucosa on examination
  • Not better explained by another oral or systemic condition

Differential Diagnosis — Conditions to Exclude Before Diagnosing BMS

Category Condition Investigation
Local Oral candidiasis (erythematous), lichen planus (atrophic), geographic tongue, contact allergy (dental materials, toothpaste) Examination ± swab ± patch testing
Nutritional Iron deficiency, B12 deficiency, folate deficiency, zinc deficiency FBC, serum ferritin, B12, red cell folate, zinc
Endocrine Diabetes mellitus, hypothyroidism, menopause Fasting glucose / HbA1c, TFTs
Medication-related ACE inhibitors, SSRIs, antihypertensives, antiretrovirals (dysgeusia) Medication review
Neurological Glossopharyngeal neuralgia, trigeminal neuropathy, multiple sclerosis Neurological examination ± MRI
Psychological Anxiety, depression (common comorbidity, may be cause or consequence) PHQ-9, GAD-7 screening

Management of Burning Mouth Syndrome

  • Reassurance and education: Explain that BMS is a real neuropathic condition, not imagined. Identify and address comorbid anxiety/depression.
  • Address treatable causes: Correct nutritional deficiencies, manage candidiasis, adjust medications where possible.
  • Topical therapies: Benzydamine 0.15% mouthwash (Difflam®) for symptomatic relief; capsaicin rinse (0.025% capsaicin in 5 mL water, TDS) — evidence limited but may reduce pain perception.
  • Systemic therapy (for refractory cases):
💊
Low-dose Clonazepam
Rivotril® · Benzodiazepine (neuropathic pain)
Adult dose 0.25–0.5 mg PO nocte; titrate to 0.5 mg BD if needed
Duration Minimum 3–6 months; gradual taper to avoid withdrawal
Key notes Most studied agent for BMS with moderate evidence. Dissolve tablet in mouth and hold on tongue for 2–3 minutes before swallowing for enhanced effect. Monitor for sedation, dependency risk. Avoid in elderly at risk of falls.
PBS status ✔ PBS General Benefit
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Alpha-lipoic Acid
Thiogamma® · Neuroprotective antioxidant (supplementary)
Adult dose 600 mg PO daily
Duration Minimum 2–3 months to assess efficacy
Key notes Some evidence of benefit in RCTs for BMS. Available as complementary medicine. Generally well tolerated; may cause GI upset. Not available on PBS.
PBS status ✘ Not PBS

Geographic Tongue (Benign Migratory Glossitis)

Geographic tongue affects approximately 1–3% of the Australian population and is characterised by irregular, erythematous patches with elevated yellow-white borders on the dorsum and lateral aspects of the tongue. The pattern migrates over days to weeks (the "wandering rash" of the tongue). Most cases are asymptomatic; a minority report burning or irritation, especially with spicy or acidic foods.

  • No treatment is usually required. Reassurance is the primary intervention.
  • If symptomatic: benzydamine 0.15% mouthwash (Difflam®) PRN for pain; avoid known triggers (spicy, acidic foods).
  • Associated with psoriasis (up to 10% of patients with geographic tongue have psoriasis) — screen for skin and nail changes.
  • Topical corticosteroids are rarely indicated but may be used for severe symptomatic flares.

Oral Herpes Simplex Virus (HSV)

Primary herpetic gingivostomatitis is the most common cause of acute diffuse oral ulceration in children, caused by HSV-1 (or HSV-2). It presents with fever, irritability, submandibular lymphadenopathy, and widespread painful vesicles and ulcers affecting the oral mucosa, gingivae, tongue, and palate. Recurrent herpes labialis (cold sores) affects the vermillion border of the lips.

Treatment

💊
Aciclovir (Oral)
Zovirax® · Antiviral (nucleoside analogue)
Adult dose Primary: 200 mg PO 5 times daily for 5–10 days; Recurrent: 400 mg PO TDS for 5 days (start at prodrome)
Paediatric dose Primary gingivostomatitis (>2 years): 200 mg PO 5 times daily for 5 days; (<2 years): 100 mg PO 5 times daily for 5 days
Duration 5–10 days (primary); 5 days (recurrent)
Renal adjustment eGFR 10–25 mL/min: standard dose q12h; eGFR <10: half dose q12h
Key notes Must be initiated within 72 hours of symptom onset for maximal benefit. IV aciclovir reserved for immunocompromised or severe disseminated disease. Encourage adequate fluid intake (risk of crystalluria with dehydration).
PBS status ✔ PBS General Benefit
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Valaciclovir
Valtrex® · Antiviral (prodrug of aciclovir)
Adult dose Recurrent HSV: 500 mg PO BD for 3–5 days; Suppressant: 500 mg PO daily
Paediatric dose Not routinely used in children <12 years (aciclovir suspension preferred)
Duration 3–5 days (recurrent); 6–12 months (suppression, then trial cessation)
Renal adjustment eGFR 30–50: 1 g q12h (treatment), 500 mg q24h (suppressant); eGFR <30: 500 mg q24h
Key notes Improved oral bioavailability (~55% vs. ~20% for aciclovir) allowing simpler BD dosing. Preferred for suppressive therapy. Available as 500 mg and 1 g tablets.
PBS status ⚠ Authority Required (suppressant for recurrent herpes)

Other Oral Dermatoses

Oral Manifestations of Lichenoid Drug Reactions

Lichenoid drug reactions mimic oral lichen planus clinically and histologically, but are caused by systemically administered medications or contact with dental materials. Common causative medications include:

  • NSAIDs (ibuprofen, naproxen, diclofenac)
  • ACE inhibitors (enalapril, ramipril, perindopril)
  • Beta-blockers (atenolol, metoprolol, propranolol)
  • Sulfonylureas (glibenclamide, gliclazide)
  • Thiazide diuretics
  • TNF-alpha inhibitors (infliximab, adalimumab)
  • Dental amalgam (contact lichenoid reaction — unilateral, adjacent to amalgam restoration)

Management: Medication review and switch to an alternative agent if possible. Contact reactions to amalgam may resolve with replacement of amalgam restorations with composite or porcelain (refer to dentist). Topical corticosteroids for symptomatic relief while the causative agent is being addressed.

Oral Pemphigoid and Pemphigus

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Blistering oral conditions — specialist referral required. Mucous membrane pemphigoid presents with desquamative gingivitis (erythematous, peeling gingivae) ± conjunctival involvement (risk of blindness). Pemphigus vulgaris presents with flaccid blisters and erosions (positive Nikolsky sign). Both require biopsy with direct immunofluorescence and urgent oral medicine / dermatology referral for systemic immunosuppressive therapy.

Investigations & Referral Indications

Investigations for Recurrent / Severe Oral Ulceration

Essential Full blood count (FBC) with film Assess for anaemia, neutropenia, macrocytosis. MBS item 66500.
Essential Serum ferritin, iron studies Iron deficiency is a common reversible cause of RAS. MBS item 66551.
Essential Serum vitamin B12, red cell folate B12/folate deficiency associated with RAS and burning mouth syndrome. MBS item 66551.
Available Serum zinc Zinc deficiency associated with RAS; particularly consider in malabsorption, elderly, vegan diet. MBS item 66551.
Available ESR, CRP Screen for systemic inflammatory conditions (Behçet, IBD). MBS item 65070 / 66545.
Available Coeliac serology (anti-tTG IgA + total IgA) RAS may be the presenting feature of coeliac disease. MBS item 66837.
Available Fasting glucose / HbA1c Screen for diabetes mellitus (candidiasis risk, BMS association). MBS item 66551 / 66555.
Available Thyroid function tests (TSH) Hypothyroidism associated with BMS. MBS item 66720.
Available Oral swab for microscopy, culture, and sensitivity If candidiasis suspected — confirm Candida species; culture if refractory to standard therapy (identify non-albicans species or resistance).
Referral Incisional biopsy Indicated for: any ulcer >3 weeks duration, non-healing extraction socket, suspicious lesion (indurated/rolled edges), oral lichen planus confirmation, blistering conditions. Refer to oral medicine or oral & maxillofacial surgery.
Specialist HIV serology (with informed consent) Consider in recurrent/severe oral ulceration, chronic oral candidiasis, or unexplained oral disease. MBS item 69308.

When to Refer

Referral Indication Timeframe
Oral medicine specialist Refractory aphthous ulcers, erosive lichen planus, blistering conditions, BMS, diagnostic uncertainty, biopsy Routine to semi-urgent (2–4 weeks)
Oral & maxillofacial surgery / ENT head & neck Suspected oral malignancy (ulcer >3 weeks, induration, rolled edges, cervical lymphadenopathy) Urgent — within 2 weeks
Dermatology Oral lichen planus with skin involvement, pemphigus, mucous membrane pemphigoid Semi-urgent (2–4 weeks)
Gastroenterology Positive coeliac serology, suspected IBD, Behçet disease Routine (4–6 weeks)
Dentist / Prosthodontist Denture-related stomatitis, traumatic ulcers from dental causes, replacement of amalgam restorations Routine (2–4 weeks)
Ophthalmology Suspected Behçet disease (anterior uveitis), mucous membrane pemphigoid (conjunctival involvement) Semi-urgent (within 1–2 weeks)

Special Populations

🤰

Pregnancy

Oral candidiasis: Nystatin oral suspension is preferred (minimal systemic absorption). Miconazole oral gel is also considered safe in pregnancy.
Aphthous ulcers: Chlorhexidine mouthwash and benzydamine rinse are safe. Avoid systemic corticosteroids unless essential (risk of preterm birth, gestational diabetes). Topical triamcinolone in orabase has minimal systemic absorption and may be used for short courses.
HSV: Aciclovir has an established safety record in pregnancy (Register data). Valaciclovir is acceptable if indicated. Avoid prolonged high-dose aciclovir in the first trimester unless essential.
Fluconazole: Single-dose 150 mg is likely safe, but prolonged courses are contraindicated (teratogenic at high doses). Avoid in first trimester if possible.
Pregnancy gingivitis and pyogenic granuloma (pregnancy tumour) are common — refer to dental care. Hyperemesis can cause erosive gastritis-related oral changes from repeated vomiting.
👶

Paediatrics

Primary herpetic gingivostomatitis: Most common cause of acute oral ulceration in children aged 1–5 years. Aciclovir suspension 200 mg/5 mL (100 mg QID for <2 years; 200 mg 5 times daily for >2 years). Supportive care: paracetamol, adequate hydration, soft diet.
Oral candidiasis (neonates): Nystatin suspension 100,000 IU (1 mL applied to each cheek QID). Treat concurrently if mother has nipple candidiasis.
Hand, foot, and mouth disease: Common cause of oral vesicles/ulcers in children <5 years (Coxsackievirus A16, enterovirus 71). Self-limiting; supportive care (paracetamol/ibuprofen, fluids, soft diet). No specific antiviral.
Miconazole oral gel: Use with caution in infants <4 months (risk of choking/aspiration). Apply to the inner cheek using a clean finger rather than directly from the tube.
Riga-Fede disease (traumatic ulcer from natal/neonatal teeth) — refer to paediatric dentistry. Recurrent aphthous ulcers in children with failure to thrive or GI symptoms → consider coeliac disease workup.
👴

Elderly

Denture-related oral candidiasis: Very common. Miconazole oral gel applied to denture fitting surface + nystatin rinse. Emphasise overnight denture removal and cleaning.
Xerostomia: Medication-induced dry mouth (polypharmacy) increases risk of candidiasis, dental caries, and burning mouth. Review medications (anticholinergics, opioids, diuretics). Saliva substitutes (Biotene®) and sugar-free gum may help.
Oral malignancy: Peak incidence in 60–70 year age group. Low threshold for biopsy of any non-healing oral ulcer or red/white patch, especially with smoking or alcohol history.
Clonazepam for BMS: Use with extreme caution — increased risk of falls, cognitive impairment, sedation. Start at lowest dose (0.25 mg nocte). Consider gabapentin as alternative if benzodiazepines contraindicated.
Polypharmacy increases risk of drug-induced oral lichenoid reactions. Regular oral health assessment is recommended as part of the over-75 health assessment (MBS item 707).
🫘

Renal Impairment

Aciclovir / Valaciclovir: Dose reduction required (risk of neurotoxicity and crystalline nephropathy with renal impairment). Aciclovir: eGFR 10–25 → q12h; eGFR <10 → half dose q12h. Ensure adequate hydration.
Fluconazole: Reduce dose by 50% if eGFR <50 mL/min.
Topical agents: Triamcinolone orabase, nystatin, chlorhexidine, benzydamine — no dose adjustment required.
CKD patients may have uraemic stomatitis (ammonia-related mucosal irritation); management involves optimising dialysis and oral hygiene. Iron and B12 deficiency are common in CKD — investigate.
🫁

Hepatic Impairment

Fluconazole: Use with caution; hepatotoxicity risk with prolonged courses. Monitor LFTs if courses >2 weeks. Avoid in severe hepatic impairment unless benefits outweigh risks.
Valaciclovir: No specific dose adjustment in hepatic impairment, but use with caution in severe liver disease.
Systemic corticosteroids: Can precipitate hepatic decompensation; use cautiously and for the shortest duration possible in patients with cirrhosis.
Oral manifestations of chronic liver disease include jaundice, glossitis (smooth tongue from folate/B12 deficiency), and increased susceptibility to candidiasis. Lichen planus has been associated with hepatitis C infection — consider hepatitis C serology.
🛡️

Immunocompromised

Oral candidiasis: More severe, frequently recurrent, may involve non-albicans species. First-line: fluconazole 100–200 mg/day for 14–21 days. Refractory cases: culture and sensitivity; consider itraconazole, voriconazole, or caspofungin under infectious disease guidance.
HSV reactivation: May be severe and prolonged. Aciclovir 400–800 mg PO TDS–5 times daily (or IV if severe). Valaciclovir 500–1000 mg BD for suppression. Consider lifelong suppression if ≥3 episodes/year.
HIV/AIDS: Oral candidiasis is an AIDS-defining illness. Oral hairy leukoplakia (EBV-associated, white corrugated lesions on lateral tongue) is diagnostic of immunosuppression. Kaposi sarcoma (purple plaques, palate). Aphthous-like ulcers may be large and persistent — trial of thalidomide under specialist care.
Post-transplant / chemotherapy: Oral mucositis management with benzydamine rinse, cryotherapy (ice chips during chemotherapy infusions). Neutropenic patients: urgent antifungal/antiviral therapy for any oral ulceration.
All immunocompromised patients with oral ulceration should be assessed promptly. Low threshold for empiric antifungal/antiviral therapy and early specialist referral.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Oral health inequity
Aboriginal and Torres Strait Islander peoples experience significantly higher rates of oral disease compared to non-Indigenous Australians. The AIHW reports that Indigenous adults are 1.6 times more likely to have tooth loss and 2.3 times more likely to have untreated decay. Children in remote communities have approximately 3 times the rate of dental caries compared to non-Indigenous urban children.
Access to dental care
There is a critical shortage of dental services in remote and very remote areas. Many communities rely on visiting dental teams (funded through state/territory programs and the Commonwealth Oral Health Program). Wait times for public dental care can exceed 12 months in some jurisdictions. Aboriginal Community Controlled Health Organisations (ACCHOs) play a vital role but often lack dedicated oral health practitioners.
Access to specialist care
Oral medicine, oral surgery, and ENT specialist services are concentrated in metropolitan and major regional centres. Patients from remote communities may need to travel hundreds of kilometres, requiring assistance with Patient Assisted Travel Schemes (PATS) or the Medical Specialist Outreach Assistance Program (MSOAP). Telehealth oral medicine consultations are increasingly available through some ACCHOs and regional hospitals.
Risk factors — smoking and chronic disease
Tobacco smoking rates among Indigenous Australians are approximately 3 times the non-Indigenous rate (~40% vs. ~12%). This significantly increases the risk of oral premalignant and malignant lesions. Higher prevalence of diabetes mellitus (3–4 times higher) predisposes to oral candidiasis and periodontal disease. Addressing smoking through culturally appropriate cessation programs (Tackling Indigenous Smoking program) is essential.
Betel nut (buai) use
Betel nut (areca nut) chewing is practiced in some Torres Strait Islander and Papua New Guinean communities in the Torres Strait region and northern Australia. It is classified as a Group 1 carcinogen by IARC and is strongly associated with oral submucous fibrosis (premalignant condition) and oral squamous cell carcinoma. Clinicians should ask sensitively about betel nut use and counsel regarding cessation. Refer to the Australasian Society of Oral Medicine or the Torres and Cape Hospital and Health Service for culturally appropriate guidance.
Health literacy and communication
Use plain language and visual aids when explaining oral conditions and treatment. Many patients in remote communities speak English as a second, third, or fourth language — arrange interpreter services through the Aboriginal Interpreter Service (NT), Aboriginal and Torres Strait Islander Language Services (QLD), or equivalent state/territory services. Health promotion materials should be co-designed with community health workers and use local language where appropriate.
Pharmaceutical access
Patients in very remote communities may have limited access to pharmacies. The Section 100 Close the Gap PBS Co-payment Program provides PBS medicines at reduced or no cost for eligible Indigenous Australians through ACCHOs. Ensure prescriptions are dispensed through ACCHOs or Remote Area Aboriginal Health Services (RAAHS) where possible. Where pharmacies are unavailable, Remote Area Aboriginal Health Services can hold and supply medicines under Section 100 arrangements.
Culturally safe care
Understand that some patients may be embarrassed to discuss oral symptoms or may attribute oral disease to cultural factors. Build trust through continuity of care and respectful communication. Recognise the importance of family and community in health decision-making. Avoid making assumptions about health behaviours. Engage Aboriginal Health Workers and Aboriginal Health Practitioners as key intermediaries in oral health education, assessment, and follow-up.

📚 References

  1. 1. Australian Institute of Health and Welfare. Oral health and dental care in Australia. Canberra: AIHW; 2024. Available from: https://www.aihw.gov.au/reports/dental-oral-health
  2. 2. Scully C, Felix DH. Oral medicine — update for the dental practitioner: oral white patches. British Dental Journal. 2005;199(9):565–572.
  3. 3. Ship JA, Chavez EM, Doerr PA, Henson BS, Sarmadi M. Recurrent aphthous stomatitis. Quintessence International. 2000;31(2):95–112.
  4. 4. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thongprasom K. Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005;100(2):164
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).