Traumatic Ulcer
Complete loss of surface epithelium exposing the underlying connective tissue, caused by mechanical, thermal, or chemical trauma to the oral mucosa. A reactive lesion that resolves once the causative trauma is removed.
Etiology and Pathophysiology
- An ulcer is the loss of surface epithelium with exposure of the underlying connective tissues.
- Reactive ulceration results from trauma to the mucosal lining; a large group of conditions of differing origin, including self-inflicted lesions, iatrogenic disorders, and drug-related adverse effects.
- The oral mucosa responds to trauma with complete loss of epithelium, leaving exposed connective tissue (the yellow appearance is the exposed connective tissue once the pink epithelium is gone).
- Traumatic ulcers are almost always of acute onset, immediately following the traumatic event.
Contributory factors :
- Mechanical trauma (often chronic): sharp tooth margins, fractured/sharp cusps, prostheses, incongruous denture flanges, self-biting, and factitious (self-inflicted) injuries.
- Biting trauma may produce two small adjacent ulcers matching the cusps of opposing upper and lower teeth.
- A large ulcer can follow biting of anaesthetised mucosa after a dental local anaesthetic.
- Thermal trauma: contact with hot foods/drinks (e.g. “pizza burn”), microwaved food; electrical burns of lips/commissures in children chewing electrical cords.
- Chemical trauma (usually accidental self-inflicted or iatrogenic): caustic dental agents such as etchant (phosphoric acid), sodium hypochlorite, hydrogen peroxide/whitening gels, and silver nitrate; aspirin held against the alveolus for toothache (epithelial necrosis → ulceration); other medications (bisphosphonates, antipsychotics), recreational drugs, and non-pharmaceutical substances.
- Riga-Fede disease: traumatic ulceration of the anterior ventral tongue in infants (1 week–12 months) from natal/erupting lower incisor teeth during feeding; also associated with neurologic conditions (cerebral palsy, Tourette syndrome).
- Anaesthetic necrosis: an unusual traumatic ulceration after greater palatine foramen injection, attributed to epinephrine-induced ischaemia and localised necrosis.
Prevalence
- Ulcers are one of the most common injuries to the human body; reactive/traumatic ulcers represent a large and common group of oral ulcerations (sources do not give a numeric prevalence).
Histological Features
- Discontinuity of the surface epithelium covered by a layer of fibrinous (fibrinopurulent) exudate.
- Underlying connective tissue shows a heavy acute inflammatory infiltrate (predominantly neutrophils) and granulation tissue (proliferating new blood vessels and fibroblasts) at the base.
- Hypertrophic squamous epithelium immediately adjacent to the ulcer with an abrupt (“traumatic”) epithelial edge; inflammatory infiltrate may extend into underlying muscle.
- Features are those of non-specific inflammation and repair only, so biopsy is not diagnostically helpful except to exclude other disease.
- Eosinophilic ulcer / TUGSE: a mixed inflammatory infiltrate of eosinophils, pale macrophages, and endothelial cells extending deeply and disrupting underlying tissues, with possible suspicion of cytological atypia and mitotic activity (can mimic lymphoma histologically).
Clinical Features
Location
- Trauma-prone sites: lateral border of the tongue and labial mucosa are most common; also lip, buccal mucosa, and mucosa adjacent to a denture flange.
- Can affect any mucosal surface.
- Riga-Fede: anterior ventral surface of the tongue (infants).
Appearance
- Round to ovoid depression with a yellow/yellow-grey necrotic (fibrinous) centre and erythematous, irregular (“mechanical”) borders.
- Tender/painful; pain slowly subsides as the lesion heals.
- May develop a rolled white border of hyperkeratosis adjacent to the ulcer.
- No induration unless the site is scarred from repeated episodes of trauma.
- Inflammation, swelling, and erythema vary depending on the cause and time since trauma.
Differential Diagnoses
- Oral squamous cell carcinoma — the key concern: a single indurated ulcer; a chronic traumatic ulcer of the tongue can share features (long-lasting, pauci-symptomatic, indurated, single) with SCC of the same site.
- Aphthous stomatitis (recurrent aphthous stomatitis).
- Necrotizing sialometaplasia.
- Eosinophilic ulcer / traumatic ulcerative granuloma (TUGSE) — chronic, may resemble carcinoma or lymphoma.
- Other ulcer causes per the oral ulcer differential: immune-mediated (lichen planus, pemphigus, mucous membrane pemphigoid, lupus, Behçet’s), infective (herpes, syphilis, tuberculosis), and drug reactions.
Relevant Clinical Investigations
- Diagnosis is based on history and clinical presentation, with identification of the source of trauma.
- A reactive (traumatic) lesion should resolve or significantly improve once the stimulus is removed — this clinical response is itself diagnostic.
- Biopsy is indicated if the ulcer persists beyond ~10–14 days without reduction in size/symptoms, or if there is any other cause for suspicion (e.g. induration, failure to heal), to exclude malignancy and other diseases.
- Biopsy is otherwise unhelpful (non-specific inflammation/repair).
Patient Management
- Identify and remove the source of trauma (e.g. adjust a sharp tooth, relieve a denture flange).
- Expect spontaneous resolution, generally within 7–14 days (7–10 days; 10–14 days) once the causative factor is removed.
- Supportive / palliative care: chlorhexidine gel or mouthrinse (antiseptic), lignocaine gel (pain relief), anti-inflammatory mouthrinse (e.g. Difflam/benzydamine).
- Review after treatment: if the lesion heals it was reactive; if it persists, biopsy is required to rule out malignancy (SCC).
- TUGSE / eosinophilic ulcer: a deep, pseudoinvasive chronic inflammatory reaction that is slow to resolve and may not heal even after addressing trauma; diagnosis confirmed on biopsy. Lesions usually heal spontaneously within 3–10 weeks, and biopsy itself often triggers more rapid resolution.