Ulcerated and inflammatory lesions of the oral mucosa are not rare. A detailed patient medical and social history including habits and abuses, as well as the duration, location, focality and presence, or lack of local and/or systemic symptoms is critical in establishing a proper diagnosis. This article discusses the clinical presentation, management, and histopathologic characteristics of a variety of ulcerative and inflammatory lesions seen in the oral cavity.
Key points
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The causes of ulcerations and inflammatory lesions of the oral mucosa are variable and include mechanical, chemical, thermal, and ischemic injuries, as well as foreign body reactions.
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A detailed and careful review of the patient’s history and symptoms is crucial in rendering an accurate clinical diagnosis or differential diagnoses.
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Biopsy is indicated for oral ulcerations or inflammation that fails to resolve and/or to confirm the clinical diagnosis.
Content
Traumatic Ulcers
Traumatic ulcers (TUs) are a relatively common in the oral cavity. TUs can be either acute or chronic. Acute TUs are characteristically painful and have a yellow-tan base and an erythematous halo. Acute ulcers will resolve in 7 to 10 days if the cause is eliminated. Chronic oral ulcers, however, persist greater than 2 weeks, elicit little to no pain, have a yellow-tan center, and demonstrate white, elevated and/or keratotic margins ( Fig. 1 ). On palpation, chronic TUs can feel indurated. This firmness is the result of chronic inflammatory infiltration and subsequent fibrosis.
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a specific type of chronic ulcer in which the inflammation extends into the underlying muscle. Clinically it most often occurs on the lateral tongue and presents as a long-standing, indurated ulcer with raised or rolled borders ( Fig. 2 ). Microscopically, it demonstrates a lymphocytic and eosinophilic inflammatory infiltrate that extends into the underlying skeletal muscle.
The clinical presentation of chronic TUs, particularly TUGSE, can mimic other conditions including squamous cell carcinoma, syphilitic chancre, and deep fungal infection. It is for this reason that biopsy is recommended for all oral ulcers that persist more than 2 weeks despite the removal of any identifiable inciting factor (ie, a sharp tooth cusp). In some cases, a cause for the traumatic ulcer cannot be identified and in rare cases may be factitial. TUs often have sharp(geometric) borders.
Most TUs will resolve on their own and should remain under observation until they heal. Topical corticosteroids such as lidex or clobetasol 0.05% gels can help hasten healing and reduce pain. Intralesional corticosteroid injections might be beneficial for TUGSE.
Foreign Body Reactions
Foreign body reactions occur when exogenous material becomes embedded within oral mucosal tissues. There is an associated inflammatory response, during which the body attempts to wall off the foreign material. This results in a pattern of granulomatous inflammation when the lesion is examined microscopically. Foreign body reactions may have varied clinical presentations. If particulate foreign matter is deposited in the gingiva, the gingiva will become inflamed, erythematous, and hyperplastic. This may occur infrequently following the use of certain brands of dental ultrasonic scalers and is termed granulomatous gingivitis ( Fig. 3 ). Foreign body reactions may also present as poor or nonhealing ulcerations or raised nodular masses resembling more frequently encountered benign, reactive pathologic conditions. This latter presentation is often how oral lesions associated with dermal fillers will present. A foreign body reaction may be considered in the clinical differential diagnosis based on provided patient history; however, a biopsy of the lesion is required to confirm the diagnosis. Microscopic examination will demonstrate granulomatous inflammation and polarizable foreign material. The absence of identifiable foreign material does not necessarily preclude this diagnosis; however, other causes of granulomatous inflammation such as tuberculosis, sarcoidosis, Crohn disease, and systemic fungal infections need to be excluded.
Necrotizing Sialometaplasia
Necrotizing sialometaplasia is a benign but clinically worrisome tumor-like lesion most frequently affecting the minor salivary glands of the palate. Reactive and inflammatory in nature, the lesion initially presents as a localized soft tissue swelling in which the mucosa then sloughs resulting in a crater-like ulcer ( Fig. 4 ). Necrotizing sialometaplasia is thought to be the result of localized ischemic necrosis. Causes for the ischemia include but are not limited to trauma, local anesthetic injection, smoking, and bulimia. Lesions are typically a few centimeters in diameter. Most are unilateral although bilateral lesions have been reported. , Surprisingly most patients do not complain of pain despite their clinical appearance. The clinical presentation can mimic squamous cell carcinoma or a salivary gland tumor. Biopsy is indicated to confirm the diagnosis.
Microscopically, as the name implies, necrotizing sialometaplasia demonstrates necrosis of the minor salivary acinar structures and squamous metaplasia of the ducts in a background of chronic inflammation and fibrosis. It can also show psuedoepitheliomatous hyperplasia of the surface epithelium. These surface and ductal epithelial changes can be misinterpreted by the pathologist as squamous cell or mucoepidermoid carcinoma.
Necrotizing sialometaplasia heals on its own during the course of several weeks.
Geographic Tongue
Geographic tongue, also referred to as benign migratory glossitis or erythema migrans, is a commonly encountered variation of normal anatomy. It can be detected in approximately 1% to 3% of the population, with no strong race, gender, or age predilection. It most commonly involves the tongue and presents as one or multiple flat, erythematous, depapillated areas surrounded by yellow-white serpiginous borders ( Fig. 5 ). The anterior and dorsal aspects of the tongue are most often affected; however, the lesions may also involve the lateral and ventral tongue surfaces. Geographic tongue is seen more frequently in patients who have fissured tongue. These lesions may also occasionally be seen on other oral mucosal sites, such as the labial mucosa, buccal mucosa, and palatal mucosa ( Fig. 6 ). In these instances, the terms benign migratory stomatitis or ectopic geographic tongue may be used. Areas of geographic tongue will characteristically disappear and subsequently reappear, and their clinical appearance with regard to affected site and number of lesions may vary from day to day. Geographic tongue can be diagnosed based on the clinical appearance of the lesions but if a biopsy is performed, it will demonstrate features similar to those of psoriasis (psoriasiform mucositis) and show collections of neutrophils within the spinous layers of the epithelium (Munro microabscesses). No treatment of asymptomatic geographic tongue is indicated because it represents a benign variation of normal anatomy. A small percentage of patients with geographic tongue will experience discomfort such as a burning, stinging, or itching sensation exacerbated by spicy, acidic, and/or citrus-based foods and beverages. This is most appropriately managed with topical steroid therapy as needed for symptomatic flare-ups. Symptomatic geographic tongue should be ruled out in patients being evaluated for burning mouth syndrome.
Thermal and Chemical Injuries
Minor thermal and chemical injuries to the oral mucosa are not infrequent. Fortunately, serious thermal and chemical injuries are rare.
Thermal injuries are often the result of consuming too hot food and beverages. Microwave heated food is the most common offender. High temperatures produce a scalding of the mucosal tissue, which can develop into vesicles and ulcers ( Fig. 7 ). Besides food and beverages, oral thermal burns from the explosion of e-cigarettes, reverse smoking, and smoking of crack cocaine have been reported. Iatrogenic thermal burns can also occur in the dental office. Overheated electric handpieces, lasers and heated border molding material are some possible offenders.
