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TRAUMATIC ULCERS Author : Glen Houston, DDS, MSD Chair, Professor, Department of Oral and Maxillofacial Pathology, University

of Oklahoma Health Sciences Center http://emedicine.medscape.com/article/1079501-overview#showall Background Traumatic injuries involving the oral cavity may typically lead to the formation of surface ulcerations. The injuries may result from events such as accidentally biting oneself while talking, sleeping, or secondary to mastication. Other forms of mechanical trauma, as well as chemical, electrical, or thermal insults, may also be involved. In addition, fractured, carious, malposed, or malformed teeth, as well as the premature eruption of teeth, can contribute to the formation of surface ulcerations. Poorly maintained and ill-fitting dental prosthetic appliances may also cause trauma.

Pathophysiology Nocturnal parafunctional habits, such as bruxism (ie, grinding of the teeth) and thumb sucking, may be associated with the development of traumatic ulcers of the buccal mucosa, the labial mucosa, the lateral borders of the tongue, and the palate. In addition, local irritants such as fractured or malposed teeth and ill-fitting dentures may cause mucosal ulcers of the buccal mucosa, the lateral and ventral surfaces of the tongue, and the alveolar mucosa overlying the osseous structures. Healing of the ulcerated mucosa is usually delayed when the lesions overlie the maxillary or mandibular alveolar process. Ulcerations may be the result of voluntary, self-induced, and deliberate acts by patients with physical or psychological symptoms who are seeking medical attention. Butler et al report a patient with a congenital insensitivity to pain. The patient presented with selfmutilation bite injuries to the oral tissues and to his hands.[1]

Epidemiology Frequency United States Although the exact incidence is unknown, traumatic ulcerations are considered the most common oral ulcerations.[2]

Mortality/Morbidity Rarely, infection is a consequence of a traumatic event.

Chronic ulcerations as a result of trauma (from fractured, carious, malformed teeth, as well as illfitting dentures) have not been associated with premalignant/malignant transformation in the oral mucosa. Age Newborns and infants: Sublingual ulcerations (as in Riga-Fede disease) may occur as a result of chronic mucosal trauma due to adjacent anterior primary (baby) teeth. The trauma is often associated with breastfeeding.[3, 4] Children: The major traumatic injuries in this group include electrical and/or thermal burns of the lips and commissure areas. Extensive ulcerations with necrosis may develop. Children tend to be curious about electrical cords and other items unknown to them, and as they explore these items, they tend to put them in their mouth. Adults: Ulcers are typically the result of traumatic injuries related to carious, fractured, or abnormal teeth; involuntary movements of the tongue and mandible; ill-fitting maxillary and/or mandibular dentures; overheated foods; and xerostomia (ie, dry mouth). History Patients may report a history of ulceration after a traumatic event such as the following: Biting oneself while talking, sleeping, or secondary to mastication Mechanical trauma Chemical, electrical, or thermal insults In most cases, the source of the injury is identified. The patient's usual complaint is pain or a painful ulceration. Traumatic ulcers are usually sensitive to hot, spicy, or salty foods. Physical Surface ulcerations usually heal within 10-14 days, but occasionally, they may persist for a significantly longer time due to systemic factors. Ulcerations can occur throughout the oral cavity. Individual lesions usually appear as areas of erythema that surround a removable, central, yellow, fibrinopurulent membrane. In some patients, a rolled border is apparent adjacent to the area of ulceration. Ulcers may have varying features depending on their cause. Mechanical trauma: Ulcers associated with mechanical trauma are often found on the buccal mucosa, the labial mucosa of the upper and lower lips, and the lateral border of the tongue. The mucobuccal folds, gingiva, and palatal mucosa may also be involved.

Electrical insults: Most lesions associated with electrical burns occur in the pediatric population and involve the lips and commissure areas. Thermal insults: Injuries related to hot foods typically occur on the posterior buccal mucosa and the palate. Chemical insults: Chemicals can damage any area of the oral mucous membrane. Examples include aspirin, hydrogen peroxide, silver nitrate, and phenol.[5, 6, 7] Factitial injuries: Self-inflicted ulcerations may arise on any oral mucosal surface and are most frequently observed on the lips, tongue, and buccal mucosa. On the contrary, ulcerations caused by foreign objects most commonly involve the palate and gingiva. Causes The clinical presentation of an ulcer often suggests its etiology.[8]

Traumatic ulcers may result from events such as accidentally biting oneself while talking, sleeping, or during mastication. Fractured, carious, malposed, or malformed teeth or the premature eruption of teeth may lead to surface ulcerations. Poorly maintained and ill-fitting dental prosthetic appliances may also cause trauma. Iatrogenic trauma also can occur.[9] Other forms of mechanical trauma (eg, irritation with sharp or hard foodstuffs), as well as chemical, electrical, or thermal insults, may result in ulceration.

Procedures Ulcerations without an etiology or those that persist despite therapy may need to be examined microscopically to exclude malignancy and other causes. Some ulcers caused by trauma may resemble squamous cell carcinoma or granulomatous ulcers (eg, those resulting from deep fungal infections or tuberculosis). If the cause of the ulceration is not obvious at clinical examination or if no response to local therapy is noted, biopsy may be indicated to exclude these conditions

Histologic Findings Microscopic features include an area of surface ulceration covered by a fibrinopurulent membrane consisting of acute inflammatory cells intermixed with fibrin. The stratified squamous epithelium from the adjacent surface may be hyperplastic and exhibit areas of reactive squamous atypia. The

ulcer bed is composed of a proliferation of granulation tissue with areas of edema and an infiltrate of acute and chronic inflammatory cells.

Medical Care The treatment of ulcerated lesions varies depending upon size, duration, and location.

With ulcerations induced by mechanical trauma or thermal burns from food, remove the obvious cause. These lesions typically resolve within 10-14 days. Ulcerations associated with chemical injuries will resolve. The best treatment for chemical injuries is preventing exposure to the caustic materials. With electrical burns, verify status and administer the vaccine if necessary. Patients with oral electrical burns are usually treated at burn centers.[12] Antibiotics, usually penicillin, may be administered to prevent secondary infection, especially if the lesions are severe and deeply seated. Most traumatic ulcers resolve without the need for antibiotic treatment. Treatment modalities for minor ulcerations include the following: Removal of the irritants or cause Use of a soft mouth guard Use of sedative mouth rinses Consumption of a soft, bland diet Use of warm sodium chloride rinses Application of topical corticosteroids Application of topical anesthetics

Deterrence/Prevention The best treatment for chemical injuries is preventing the exposure to caustic materials. Traumatic ulcers can be prevented by correction of the etiology, for example, by restoring carious, fractured, or malpositioned teeth. Traumatic ulcers can also be prevented by replacing ill-fitting maxillary and mandibular dentures to minimize irritation of the oral mucosa.

Parents can prevent their children from having access to electrical cords and wires and thereby minimize the potential for electrical and thermal injuries

In severe ulcers, secondary infection, scarring, contracture, and disfigurement are potential problems.[13] Severe ulcers may remain for longer than 10-14 days.

Patient Education Instruct parents about how to childproof their homes to prevent electrical burns. Remind patients to be careful when eating hot foods. Inform patients that many over-the-counter medications for mouth pain can compound the traumatic injury. Mucosal damage from many topical medications sold as treatments for mouth sores or toothaches has been reported. Products containing eugenol, phenol, or hydrogen peroxide have produced adverse reactions. In addition, aspirin can cause mucosal necrosis if it is held in the mouth. Silver nitrate remains a popular treatment for aphthous ulcerations (canker sores), but its use should be discouraged because of the extent of mucosal damage that may result. For excellent patient education resources, visit eMedicine's Teeth and Mouth Center and Burns Center. Also, see eMedicine's patient education articles Canker Sores and Thermal (Heat or Fire) Burns.