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Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 94-98  

Traumatic oral lesions: Pictorial essay

Private Practice, Departments of Oral Medicine and Radiology and Prosthodontics, Private Practice, Jind, Haryana, India

Date of Web Publication18-May-2018

Correspondence Address:
Swati Phore
Department of Oral Medicine and Radiology, Private Practice, Jind, Haryana
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Oral mucosal lesions are a common occurrence and very often dentists are called on to see such patients. Among many causes, trauma is one of the leading for oral mucosal diseases. Oral traumatic lesions are diverse in which some present as acute lesions while the majority are chronic lesions. Clinical presentation of traumatic lesions varies significantly and most of the occasions, the cause and the effect can be established with thorough history and clinical examination. Although biopsy of such lesions is not required in most of the occasions, some may warrant histological investigations to exclude conditions which clinically mimic traumatic lesions. This paper provides an overview of common and some rare traumatic conditions of the oral mucosa.

Keywords: Chemical burn, morsicatio buccarum, traumatic

How to cite this article:
Phore S, Panchal RS. Traumatic oral lesions: Pictorial essay. Med J DY Patil Vidyapeeth 2018;11:94-8

How to cite this URL:
Phore S, Panchal RS. Traumatic oral lesions: Pictorial essay. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Jan 17];11:94-8. Available from: https://www.mjdrdypv.org/text.asp?2018/11/2/94/232653

  Introduction Top

Oral lesions associated with trauma are a relatively common finding in dental practice. A diverse array of oral mucosal disorders caused by acute and chronic trauma exists. They manifest in the oral mucosa as acute or chronic ulcers, white or red lesions, mucositis, and reactive hyperplasia or even as bone exposures with sequestration. Such lesions may also impair oral functions to a significant extent and also pose some difficulties in arriving at a diagnosis, especially the chronic lesions. However, prompt diagnosis and elimination of the causative factor ensure cure. Injury of the oral mucosa could result from physical, chemical, or thermal trauma. They could be originated from accidental dental biting, sharp or pointing food stuff, sharp edges of teeth, hot food, or overzealous tooth brushing. Some injuries also could result from iatrogenic damage during dental treatment or other procedures involving oral cavity such as intubation during general anesthesia. Similarly, chemical or physical injury could result from undue or careless handling of chemicals and dental instruments during dental treatment procedures. This paper reviews some common causes of traumatic injuries, their diagnosis, and management.

[Figure 1] and Cheek Biting [Figure 2]">  Lip [Figure 1] and Cheek Biting [Figure 2] Top
Figure 1: Traumatic lip bite on lower labial mucosa

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Figure 2: Morsicatio buccarum

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Bite or chewing trauma, usually of the nonkeratinized mucosa, takes two clinical forms. Acute bite trauma is caused by a sudden usually unintentional injury to the oral mucosa with a strong masticatory force such as occurs during eating and results in a localized painful traumatic ulcer [Figure 1]. However, primary chronic chewing injuries are white lesions that result from repetitive, chronic frictional trauma, usually from raking of the teeth over the mucosa or “nibbling” of the mucosa, depending on the severity of the habit. These lesions have been referred to as “pathominia mucosae oris,” “morsicatio mucosae oris,” “morsicatio [Figure 2] buccarum,” or “morsicatio labiarum,” depending on the location.[1]

  Linea Alba Top

White line, seen bilaterally, streak on buccal mucosa at the level of occlusal plane extending horizontally from commissure to most posterior teeth.[2]

[Figure 3]">  Traumatic Ulcer [Figure 3] Top
Figure 3: Traumatic ulcer on lateral border of tongue

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Traumatic ulcer is usually a single lesion with erythematous, noneverted margins and with a clean base covered with a pseudomembrane [Figure 3]. They are usually painful and occur due to bite or trauma from sharp teeth or ill-fitting dentures. They disappear in 7–10 days following elimination of the cause. If there is any clinical suspicion, a biopsy is indicated. Traumatic ulcerative granuloma with stromal eosinophilia is known by a number of other names, including traumatic granuloma, eosinophilic ulcer, and eosinophilic granuloma of the tongue. This is a reactive, self-limiting condition of the oral cavity. It occurs most commonly by far on the dorsal and lateral tongue, followed by the lips and buccal mucosa. Acute trauma in the form of a sharp puncture to the muscle is the main cause, but occasionally a history of trauma is absent, and the etiology is unknown. The source of trauma can be a sharp tooth, a sharp filling, an ill-fitting partial denture, or a physical sharp bite (which may or not be due to a neurological disorder). Dorsal tongue traumatic ulcerative granuloma with stromal eosinophilia is usually due to trauma from the maxillary incisors or sharp cusps of the posterior teeth.[3]

[Figure 4]">  Traumatic or Irritational Fibroma/fibrous Hyperplasia [Figure 4] Top
Figure 4: Irritational fibroma/hyperplasia

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Inflammatory hyperplastic lesion may be defined as an increase in the size of an organ or tissue due to an increase in the number of constituent cells, as a local response of tissue to injury. The local irritants include calculi, overhanging margins, restorations, foreign bodies, chronic biting, margins of caries and sharp spicules of the bone, and overextended borders of appliances. Traumatic fibroma is healed end product of inflammatory hyperplastic lesion.[4]

Clinically, they appear either as pedunculated or sessile growth on any surface of the mucous membrane. The majorities are small lesions and those measuring >1 cm are rare. They do not have malignant potential and recurrences are mostly as a result of failure to eliminate the chronic irritation involved [Figure 4].[5]

It is self-limiting process unlike neoplasia and hyperplastic cells sometimes show regression after removal of the stimulus.[6]

[Figure 5] and [Figure 6]">  Traumatic Keratosis [Figure 5] and [Figure 6] Top
Figure 5: Traumatic keratosis on maxillary alveolar ridge due to occluding opposite mandibular teeth

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Figure 6: Traumatic keratosis on lateral border of tongue with marked tooth indentations

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It is a common chronic mucosal frictional keratosis characterized by poorly demarcated, rough, shaggy, peeling, white papules, and plaques on the buccal mucosa, lateral border of the tongue [Figure 6], or the lower labial mucosa, areas that are easily accessible to and readily traumatized by the teeth. It is often factitial or self-induced although the patient may not be conscious of the habit or it may be secondary to a nocturnal parafunctional habit. Chronic frictional injury of the gingiva or alveolar ridge mucosa [Figure 5], especially of the retromolar pad, presents as benign alveolar ridge keratosis with different histologic features, namely, hyperorthokeratosis and acanthosis with slight papillomatosis, features identical to friction-induced skin lesions of lichen simplex chronicus.[7]

It usually lacks distinct margin or demarcation of the white area from the surrounding normal mucosa. A history of a chronic chewing habit may or may not be elicited.[8],[9]

 Riga-Fede disease More Details [Figure 7]">  Riga-Fede Disease [Figure 7] Top
Figure 7: Riga-Fede disease on ventral surface of tongue

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Riga-Fede disease is a chronic, benign, ulcerative granulomatous process that occurs as a result of continuous trauma on the ventral surface of the tongue most commonly caused by neonatal or natal teeth in newborns [Figure 7].[10],[11]

It may also be associated with repetitive tongue thrusting habits in older infants after the eruption of primary lower incisors.[12]

The lesion was first described by Antonio Riga, an Italian physician in 1881. In 1890, Fede published the first histological studies. Subsequently, it was called “Riga-Fede disease.”[13]

This condition may interfere with proper feeding which, in turn, may pose potential risks to infants due to nutritional deficiency. Consequently, proper dental management for these patients must be considered. Treatment of the disease should begin conservatively and should focus on eliminating the source of trauma. Failure to diagnose and late treatment can result in dehydration and malnutrition. For traumatic lesions which have a clear irritating factor, the factor should be removed first. If healing does not occur after 2 weeks, biopsy is indicated.[14]

[Figure 8] and Chemical Burn [Figure 9]">  Thermal [Figure 8] and Chemical Burn [Figure 9] Top
Figure 8: Thermal burn on palate

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Figure 9: Aspirin-induced chemical burn on lower labial mucosa

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Chemical burn results from applying analgesics such as aspirin or acetaminophen, to the mucosa adjacent to an aching tooth, mild white filmy desquamation seen in oral mucosa. Areas of necrosis typically heal without scarring in 7–10 days after discontinuation of the drug [Figure 9].

Simultaneously, palliative and symptomatic treatment such as topical anesthetics (benzocaine gel) and topical corticosteroids (triamcinolone ointment) may be helpful.[15]

Thermal burn is characterized by erosive lesion with erythematous borders surrounding whitish damaged mucosa. It usually involves palatal area and patient gives a positive history of eating or drinking something hot [Figure 8].[16]

[Figure 10] and [Figure 11]">  Denture-Associated Trauma [Figure 10] and [Figure 11] Top
Figure 10: Denture-induced stomatitis

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Figure 11: Denture induced hyperplasia/epulis fissuratum

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Lesions of the oral mucosa associated with wearing of removable dentures may represent acute or chronic reactions to microbial denture plaque, a reaction to constituents of the denture base material, or a mechanical denture injury. The lesions constitute a heterogeneous group with regard to pathogenesis. They include denture stomatitis [Figure 10], angular cheilitis, traumatic ulcers, denture irritation hyperplasia or epulis fissuratum [Figure 11], flabby ridges, and oral carcinomas. Denture stomatitis is the most common condition which affects the palatal mucosa in about 50% of wearers of complete or partial removable dentures. Most of the lesions caused by chronic infection (Candida albicans) or mechanical injury, whereas allergic reactions to the denture base materials are uncommon. Angular cheilitis (lesions of the angles of the mouth) is characterized by maceration, erythema, and crust formation. The prevalence is about 15% among wearers of complete dentures. The lesions have an infectious origin but several local, including prosthetic or systemic predisposing conditions, is usually present. Traumatic ulcers caused by dentures with overextended or unbalanced occlusion are seen in about 5% of denture wearers. Denture irritation hyperplasia (epulis fissuratum), which is caused by chronic injury of the tissue in contact with the denture border, is present in about 12% of denture wearers. Flabby ridge, which is replacement of alveolar bone by fibrous tissue, is present in 10%–20%. Finally, there is evidence that chronic injury of the oral mucosa by dentures in rare instances may predispose to development of carcinomas. Most types of lesions are benign and quite symptomless. However, diagnosis may be difficult, and the more severe and dramatic tissue reactions to dentures may indicate underlying systemic diseases. To prevent or minimize the extent of the lesions, denture wearers should be recalled regularly for an examination of the oral cavity and the dentures. It is important that the examination is carried out by a person who has adequate medical knowledge.[17]

[Figure 12]">  Mucocele [Figure 12] Top
Figure 12: Mucocele on ventral surface of the tongue

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The mucocele is a term that describes swelling caused by accumulation of saliva as a result of trauma or obstruction of minor salivary glands. They are classified as extravasation type and retention type of which the extravasation type is more common. Laceration of ducts leads to pooling of saliva in submucosal tissue, and although termed as a cyst, the extravasation type does not have an epithelial lining or distinct borders [Figure 12].[18]

Trauma to minor salivary glands has been cited as the reason for the formation of an extravasation mucocele. The lower lip is the most common area for occurrence of this lesion where the most common history of trauma has been reported. They present as discrete painless swelling measuring from a few millimeters to a few centimeters. Appearance of a bluish lesion after trauma is highly suggestive of a mucocele. Sometimes a superficial nodule is traumatized allowing it to deflate, but recurrence is common under these circumstances.[19]

  Conclusion Top

This paper gives an overview of traumatic lesions of the oral mucosa. The paper summarizes the common to rare disorders causing traumatic lesions. Diverse array of causative factors can be identified. Commonly, encountered lesions are generally straightforward to diagnose and hence easy to manage by elimination of the causative factor and enhancing the healing of the lesion. If chronic ulcer persists after the elimination of the suspected causative factor within a reasonable time limit (2–3 weeks), a biopsy should be considered to confirm the diagnosis. Thorough clinical examination and attention to all possible aspects of causative factors are mandatory for complete resolution of the lesion.

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  References Top

Hjorting-Hansen E, Holst E. Morsicatio mucosae oris and suctio mucosae oris. An analysis of oral mucosal changes due to biting and sucking habits. Scand J Dent Res 1970;78:492-9.  Back to cited text no. 1
Bhasin M, Saini RS, Laller S, Malik M. Keratotic white lesions of oral mucosa: An oral stomatologist perspective. J Periodontal Med Clin Pract 2016;3:33-40.  Back to cited text no. 2
Ishaquddin S, Maya D, Ghadage M. Traumatic ulcer or squamous cell carcinoma of the tongue?: Case report. Int J Healthc Biomed Res 2013;2:57-60.  Back to cited text no. 3
Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th ed. Missouri: Mosby; 2006. p. 136-8.  Back to cited text no. 4
Greenberg MS, Glick M, Ship JA. Burket's Oral Medicine. 11th ed. Ontario: BC Decker Inc.; 2008. p. 131-2.  Back to cited text no. 5
Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 6th ed. Philadelphia: W.B. Saunders; 2009. p. 126-7.  Back to cited text no. 6
Natarajan E, Woo SB. Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity. J Am Acad Dermatol 2008;58:151-7.  Back to cited text no. 7
Silverman S Jr., Gorsky M. Proliferative verrucous leukoplakia: A follow-up study of 54 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:154-7.  Back to cited text no. 8
Zakrzewska JM, Lopes V, Speight P, Hopper C. Proliferative verrucous leukoplakia: A report of ten cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:396-401.  Back to cited text no. 9
Goho C. Neonatal sublingual traumatic ulceration (Riga-Fede disease): Reports of cases. ASDC J Dent Child 1996;63:362-4.  Back to cited text no. 10
Zaenglein AL, Chang MW, Meehan SA, Axelrod FB, Orlow SJ. Extensive Riga-Fede disease of the lip and tongue. J Am Acad Dermatol 2002;47:445-7.  Back to cited text no. 11
Slayton RL. Treatment alternatives for sublingual traumatic ulceration (Riga-Fede disease). Pediatr Dent 2000;22:413-4.  Back to cited text no. 12
Abramson M, Dowrie JO. Sublingual granuloma in infancy (Riga-Fede disease): Reports of two cases. J Pediatr 1944;24:195-8.  Back to cited text no. 13
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. St. Louis: W.B. Saunders; 2002.  Back to cited text no. 14
Neville BW, Damm DD, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 3rd ed. Westline industrail Drive. St Louis, Missouri, USA: Elsevier; 2009. p. 291-4.  Back to cited text no. 15
Kafas P, Stavrianos C. Thermal burn of palate caused by microwave heated cheese-pie: A case report. Cases J 2008;1:191.  Back to cited text no. 16
Budtz-Jørgensen E. Oral mucosal lesions associated with the wearing of removable dentures. J Oral Pathol 1981;10:65-80.  Back to cited text no. 17
Greenberg MS, Glick M, Ship JA. Burket's Oral Medicine. 11th ed. Ontario: BC Decker Inc.; 2008. p. 202-3.  Back to cited text no. 18
Rangeeth BN, Moses J, Reddy VK. A rare presentation of mucocele and irritation fibroma of the lower lip. Contemp Clin Dent 2010;1:111-4.  Back to cited text no. 19
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   Lip [Figure 1] a...
  Linea Alba
   Traumatic Ulcer ...
   Traumatic or Irr...
   Traumatic Kerato...
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   Thermal [Figure ...
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