Traumatic Ulcers

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.

United States statistics

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.