Publication: Ear, Nose & Throat Journal

Author: Thompson, Lester D R

Date published: November 1, 2011

A traumatic ulcer is a chronic traumatic ulceration of the oral mucosa that shows unique
histopathologic features. Also known as traumatic granuloma, eosinophilic granuloma, and Riga-
Fede disease, this lesion is usually caused by some sort of mechanical injury. The most common
causes include accidental trauma from biting, malposed teeth, and even sharp foodstuffs.
However, self inflicted wounds caused by nocturnal clenching or tongue and lip biting, electrical
and thermal injuries, hot foods or beverages, and even factitial injuries yield a similar finding.
Ulceration of the ventral tongue as a result of tongue thrusting in infants with natal or neonatal
teeth is referred to as Riga-Fede disease.

Oral traumatic ulcer is probably under-reported, but it is considered less common than aphthous
stomatitis. The age at presentation is usually related to the specific cause, with a male
predominance. Patients present most commonly with a painful ulcer covered by a fibrinopurulent
membrane on the lateral border of the tongue, although anywhere in the oral cavity can be
affected. The rim of hyperkeratosis and induration may mimic squamous cell carcinoma.

Ulcers that do not spontaneously resolve may need excision, although a biopsy may instigate
resolution. Steroid injections into the lesion have been advocated by some authors. It is important
to note that the source of the trauma should be removed, if possible; otherwise there is a high rate
of recurrence.

Microscopically, an abrupt ulcer is covered by a very thick fibrinopurulent exudate or membrane

(figure 1). The immediately adjacent epithelium will frequently show pseudoepitheliomatous
hyperplasia, while the ulcer bed contains granulation tissue (figure 2). The granulation tissue
shows an endothelial proliferation with a rich investment by inflammatory cells, including
lymphocytes, histiocytes, neutrophils, eosinophils, and even plasma cells (figure 3). The
inflammation may extend into the subjacent muscle bundles (figure 1). The muscle bundles may
appear atrophic, with withered cytoplasm. Atypical histiocytes may also be seen in a few cases.
Mitotic figures are usually easily identified, while necrosis tends to be limited to thermal or
electrical injury cases. A number of cells may be CD30-positive, and monoclonal rearrangements
have been reported, although their significance is unknown.

The most common differential diagnostic consideration is with recurrent aphthous stomatitis,
which tends to have superficial ulcers without the inflammatory infiltrate extending into the
muscle. CD30-positive Tcell lymphoma is very uncommon, but generally has a heavier
inflammatory infiltrate and more atypia.

Suggested reading

Baroni A. Capristo C. Rossiello L, et al. Lingual traumatic ulceration (Riga-Fede disease). Int J
Dermatol 2006;45(9): 1096-7.
el-Mofty SK. Swanson PE, Wick MR. MillerAS. Eosinophilic ulcerof the oral mucosa. Report of
38 new cases with immunohistochemical observations. Oral Surg Oral Med Oral Pathol
1993;75(6):716-22.

Hirshberg A. Armariglio N. Akrish S. et al. Traumatic ulcerative granuloma with stromal

eosinophilia: A reactive lesion of the oral mucosa. Am J Clin Pathol 2006;126(4):522-9.

Segura S. Romero D. Mascaró JM Jr., el al. Eosinophilic ulcer of the oral mucosa: Another
histological simulator of CD30+ lymphoproliferative disorders. BrJ Dermatol 2006:155(2):460-
3.

Author affiliation:

Lester D.R. Thompson, MD

Author affiliation:

From the Department of Pathology, Southern California Permanente Medical Group, Woodland
Hills Medical Center, Woodland Hills, Calif.

Read more: http://www.readperiodicals.com/201111/2557063671.html#ixzz2GVuM3Vim

http://www.readperiodicals.com/201111/2557063671.html
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 self- mutilation 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 ill-
fitting 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.