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.[1]
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 self-mutilation bite injuries to the oral tissues and to his hands.[2]
Ulcerations are the most common oral lesions associated with COVID-19. A review by Wu et al found that most of these lesions presented as aphthous-like ulcers, but some occurred as herpetiform ulcerations. In older, immunosuppressed patients and in those with severe COVID-19, widespread ulcerations accompanied by necrosis were observed.[3]
Etiology
The clinical presentation of an ulcer often suggests its etiology, as follows[4] :
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.[5]
Other forms of mechanical trauma (eg, irritation with sharp or hard foodstuffs), as well as chemical, electrical, or thermal insults, may result in ulceration.
Although the exact incidence is unknown, traumatic ulcerations are considered the most common oral ulcerations.[6]
Age-related demographics
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.[7, 8, 9]
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).
Ulcers that are caused by acute trauma typically resolve without complication within 14 days; however, chronic ulcers may not have an obvious source of trauma and may require biopsy to exclude malignancy and other conditions.[1]
Morbidity/mortality
Rarely, infection is a consequence of a traumatic event.
Chronic ulcerations as a result of trauma (from fractured, carious, malformed teeth, as well as ill-fitting dentures) have not been associated with premalignant/malignant transformation in the oral mucosa.
Complications
In severe ulcers, secondary infection, scarring, contracture, and disfigurement are potential problems.[10]
Severe ulcers may remain for longer than 10-14 days.
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, as follows:
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.
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 the following causes:
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.[12, 13, 14]
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.
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[15] 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. Also see Oral Manifestations of Systemic Diseases.
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.
The treatment of ulcerated lesions varies depending upon size, duration, and location, as follows:
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.[16]
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
A study by Jivanescu et al evaluated the effectiveness of a hydrogel patch to treat wounds of the oral mucosa caused by dentures in edentulous persons and found that the patch was an effective treatment for accelerating healing of traumatic ulcers and reducing the pain associated with them. In 23 adult patients with newly fabricated, complete sets of dentures, from baseline to day 1, the lesions treated with the hydrogel patch decreased in size by 25%; by day 7, they decreased by 75%. Lesions receiving usual care decreased in size by 10% (day 1) and 50% (day 7). Significant reductions in pain were reported as 65% for lesions treated with the hydrogel patch, versus 30% with usual care.[17]
Consultations
Patients with repeated factitial ulcerations may be considered for referral to a psychiatrist or psychologist.
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.
Glen Houston, DDS, MSD, Heartland Pathology Consultants, PC
Disclosure: Nothing to disclose.
Specialty Editors
Michael J Wells, MD, FAAD, Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology
Disclosure: Nothing to disclose.
Drore Eisen, MD, DDS, Consulting Staff, Dermatology of Southwest Ohio
Disclosure: Nothing to disclose.
Chief Editor
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates
Disclosure: Nothing to disclose.
Additional Contributors
Daniel Mark Siegel, MD, MS, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate Medical Center
