Case Study

A 24-year-old male visited a dentist's office for routine dental treatment. Oral examination revealed an ulceration on the ventral tongue.

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A 24-year-old male visited a dentist's office for routine dental treatment. Oral examination revealed an ulceration on the ventral tongue.

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History
The patient stated that the ulcer on his tongue had started three days earlier. He described the area as painful and claimed that both eating and drinking intensified the pain. When questioned about trauma to the area, the patient recalled hitting the area with his toothbrush. The patient denied any history of recurrent, similar lesions.

The patient's medical history was reviewed. No significant findings were noted. At the time of the examination, the patient was not taking any medications.

Examinations
Examination of the head and neck regions revealed one enlarged and tender submandibular lymph node. Oral examination revealed one ulceration on the ventral tongue. The lesion measured approximately one centimeter in diameter (see photo). The lesion appeared to have a yellowish, necrotic center surrounded by an erythematous halo. Further oral examination revealed no other oral lesions.

Differential diagnosis
Based on the clinical information provided, which one of the following is the most likely diagnosis?

  • Aphthous ulcer
  • Traumatic ulcer
  • Squamous cell carcinoma
  • Chemical injury
  • Primary syphilis

Diagnosis
Traumatic ulcer

Discussion
The ulcer is the most common oral lesion. A variety of ulcers may occur in the oral cavity, and some have similar clinical appearances. Although oral ulcers look alike, their causes will vary. An oral ulcer may be reactive, infectious, autoimmune, or neoplastic in origin. Of all of the oral ulcers, the traumatic ulcer is the most common. As the name traumatic suggests, this ulcer is the result of trauma.

Clinical features
The traumatic ulcer is caused by some form of simple mechanical trauma. Sources of trauma may include accidental biting, a toothbrush injury, a denture irritation, injury caused by orthodontic brackets and wires, or an injury caused by some sort of external irritant. Trauma may also take the form of iatrogenic injuries that occur during dental treatment. Trauma resulting from contact with a saliva ejector or excessive drying from placement of cotton rolls may injure the oral soft tissues and result in a traumatic ulcer.

The traumatic ulcer resembles other solitary ulcers that occur in the oral cavity. This lesion exhibits a yellowish, necrotic center surrounded by a red or erythematous halo. The borders may be smooth or irregular. The traumatic ulcer usually occurs as a single lesion. Multiple lesions may be seen with traumatic ulcers associated with ill-fitting dentures or orthodontic brackets and wires.

The traumatic ulcer has a propensity to occur in the areas that are easily trapped between the teeth, such as the tongue, lower lip, and buccal mucosa. Occasionally, a traumatic ulcer may be seen in the mucobuccal fold or on the tissues of the hard palate or gingiva. The traumatic ulcer is typically painful following the incident of an injury. Within four to five days after the injury, the lesion is typically described as painless. The traumatic ulcer is expected to heal within 10 to 14 days.

Diagnosis
The diagnosis of a traumatic ulcer is made on a clinical basis. The diagnosis is established based on the history of trauma to the affected area. The traumatic ulcer should not be confused with a recurrent aphthous ulcer (RAU). If trauma is the cause, the diagnosis is a traumatic ulcer. The RAU is autoimmune in origin and does not have trauma associated with it. In addition, the RAU has a history of recurrence.

Treatment
To alleviate pain and discomfort, the traumatic ulcer maybe treated palliatively. Over-the-counter products such as Zilactin® or Zilactin-B® (with 10 percent benzocaine) gel can be used to protect this lesion. When applied to the ulcer, the Zilactin products form a tenacious adhesive film over the lesion that lasts for four to six hours and serves to protect the ulcer from oral irritants.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.

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