Traumatic Oral Ulcer

A traumatic oral ulcer is a loss of the oral epithelium caused by mechanical, thermal, chemical or electrical injury to the mucosa. It is the commonest oral ulcer, usually heals within 7 to 14 days after the cause is removed, and must be distinguished from malignancy when it persists.

• Mechanical: cheek, lip and tongue biting (accidental, during sleep, seizures, or habitual), sharp tooth or broken filling, ill fitting dentures, orthodontic brackets and wires, hard food (chips, bones), vigorous brushing, dental treatment, and self-inflicted injury (Riga-Fede disease in infants from natal teeth).
• Thermal: hot food or drinks (pizza burn on the palate), hot instruments.
• Chemical: aspirin or paracetamol tablets held against the gum, hydrogen peroxide, caustic mouthwash, eucalyptus, and sodium hypochlorite.
• Others: radiation, electrical injury (children biting cords), and ulcers over unwashed denture stomatitis.
• Risk is higher in children, people with learning disabilities, epilepsy, neurological disorders, dentures, and altered sensation (after local anaesthetic).

• Painful ulcer with an irregular outline, a yellow white fibrinous base and a red margin, in a site that matches the cause (cheek line at the occlusion, lateral tongue next to a sharp cusp, denture flange).
• Onset acute, often after an obvious injury; may be a white keratotic area or haematoma first, then the ulcer.
• Chronic traumatic ulcer: indurated, may persist for weeks while the irritant remains (traumatic ulcerative granuloma with eosinophilia on the tongue).
• Pain with eating and speaking, drooling in children, and sometimes secondary infection with pus or lymph node swelling.
• Red flags for malignancy or systemic disease: ulcer persisting more than 3 weeks after cause removal, firm or rolled edges, base induration, fixation to deeper tissue, red or white patch around it, location on lateral tongue, floor of mouth or retromolar area, painless ulcer, lymphadenopathy, unexplained tooth mobility, age over 40, tobacco, alcohol and betel nut use.

• Clinical: history of injury, matching site, and examination of teeth, restorations and dentures for sharp edges; check the whole oral cavity and neck lymph nodes.
• If no cause or no healing in 2 to 3 weeks: biopsy (incisional, from the edge including normal tissue) and urgent referral to oral and maxillofacial or head and neck services.
• Investigations for recurrent or unexplained ulcers: FBC, ferritin, B12, folate, coeliac serology, HbA1c, and swab or PCR for herpes simplex virus and other organisms.
• Differentials: recurrent aphthous ulcer, herpes simplex ulcer, squamous cell carcinoma, syphilitic chancre, tuberculous ulcer, drug induced ulcer, lichen planus, pemphigus, pemphigoid, and Crohn disease.

Remove the cause

• Smooth or adjust sharp teeth and restorations, repair or replace ill fitting dentures and appliances (leave dentures out at night until corrected), cover orthodontic wires with wax, change habits of biting, and manage seizures; avoid contact with the offending chemical.

Local care

• Rinse with warm salt water (half a teaspoon in a glass) after meals and 4 to 6 times daily.
• Benzydamine hydrochloride 0.15 percent mouthwash or spray 15 mL every 1.5 to 3 hours for up to 7 days; chlorhexidine gluconate 0.2 percent mouthwash 10 mL twice daily to prevent secondary infection (up to 2 weeks).
• Topical anaesthetic: lidocaine 2 percent gel or viscous solution, small amounts up to four times daily (not for young children).
• Protective paste or gel (carmellose or triamcinolone 0.1 percent oral paste applied thinly 2 to 3 times daily) for painful ulcers on the gum or palate; hydrocortisone 2.5 mg buccal tablet four times daily for persistent ulcers.
• Soft, cool, bland diet; avoid hot, spicy, acidic and rough foods; drink through a straw if necessary; maintain fluid intake.

Analgesia

• Paracetamol 1 g orally every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food (children: paracetamol 15 mg/kg, ibuprofen 10 mg/kg).

Infection and burns

• Antibiotics only for a secondarily infected ulcer with cellulitis: amoxicillin 500 mg orally three times daily for 5 days.
• Large burns, chemical burns, or electrical burns of the lip (especially in children) need urgent assessment for airway, scarring and later bleeding from the labial artery.

Follow up

• Review in 10 to 14 days: ulcers from a removed cause should be healing or healed.
• Refer urgently (within 2 weeks) to oral and maxillofacial or head and neck services for any ulcer persisting beyond 3 weeks after the cause has been removed, or earlier if suspicious features are present. Do not treat with repeated steroid courses without a biopsy.