CASE REPORT

Post extraction lingual mucosal ulceration

with bone necrosis
 Juma Alkhabulia, , ,
 Vladimir Kokovicb,
 Abdullah Emadc

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http://dx.doi.org/10.1016/j.sjdr.2015.04.002
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Open Access funded by King Saud University
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Abstract
This report describes a case of a 49 year old male patient presenting with lingual mucosa
ulceration with cortical bone necrosis, above mylohyoid ridge in the right side of mandible. The
patient had extraction a few days before development of the ulcer. The patient’s medical history
was clear and not on any drugs. Clinically, he presented with moderate pain and discomfort.
Intraoral examination revealed a discrete ulcer of about 1 cm in diameter and exposure of the
underlying bone, which was necrotic. Extra-oral examination showed no abnormalities.
Radiographs revealed no pathology, apart from extraction socket. The case was treated in two
phases; initial control of acute signs and symptoms by antibiotic cover and analgesic for 5 days,
and smoothening of the exposed bone. This was followed by surgical removal of the necrotic
bone and dressing of the vital bone with iodoform gauze. The lesion healed completely in
3 weeks.

Although the cause of this lesion is not clear, minor trauma from suture may be initiated the
process. These ulcers are basically uncommon; however, general dental practitioners are invited
to understand the potential systemic and local etiological factors and the management to avoid
any unwanted complications.

Keywords
 Cortical necrosis;
 Post-extraction;
 Oral ulceration;
 Mucositis;
 Bone diseases
1. Introduction
Mucosa covering the lingual cortex of mandible is thin and vulnerable to trauma, particularly the
posterior supra mylohyoid region. Injury to this region may lead to full thickness ulceration and
subsequent exposure of the cortical bone. Furthermore, prominent mylohyoid ridge or
mandibular tori place this area at a high risk of traumatic ulceration.1 and 2 The exposed lingual
bone invariably endures ischemic necrosis and possibly sequestration. In addition, poor
vascularization of this anatomical site prolongs the healing process from a week to several
months.3 and 4

Oral ulceration with potential osteitis or sequestration has been associated with numerous
factors, such as aphthous stomatitis, systemic diseases, oral bisphosphonate, syphilis and
radiotherapy.5, 6, 7 and 8 Onset of bone necrosis can be provoked by a number of conditions related
to poor host immune response, including immunosuppression, diabetes mellitus, malnutrition
and extreme age.9

Although lingual mucosal ulceration (LMU) with osteonecrosis following extraction of lower
molars is uncommon, it remains a known condition among oral and maxillofacial surgeons.
Jackson and Malden10 reported three cases of LMU, two involving a history of recent extraction.
In one of the cases, ulceration developed a week after extraction with no associated trauma. In
the second case ulceration developed a month after extraction and the exposed necrotic bone
further caused traumatic ulceration to the lateral surface of the tongue. Several cases of
spontaneous LMU with osteonecrosis “Idiopathic benign sequestration of the mandible” have
been reported in various forms and sizes and were neither associated with history of trauma nor
extraction. Interestingly, one of the reported cases had simultaneous bilateral lingual ulceration
with bone exposure.11, 12 and 13

Obviously, trauma is the most common cause of oral ulceration. There is an array of diverse
etiological factors including iatrogenic damage during dental treatment that may clinically
manifest as ulcers or bone necrosis with sequestration.14 Nevertheless, in the majority of these
cases the cause is identifiable and a differential diagnosis can be made.

Oral and maxillofacial surgeons are aware of these conditions; nevertheless, general dental
practitioners are less familiar with these lesions. The affected patients usually presented with
mild to moderate pain and discomfort. The clinical presentation reveals an avascular yellowish
necrotic bone at the base of the ulcer. There might be necrotic bone spicules projecting out,
which may cause trauma to the adjacent soft tissues. The ulcer margins may show redness and
irregularities. Usually, there are no or subtle bone changes, therefore radiographic examination
has little or no value to add in the examination.

2. Case report
A 49-year-old male patient attended the oral diagnosis department, College of Dentistry, Medical
and Health Sciences University, Ras Al-Khaimah, UAE complaining of moderate pain on the
lower right lingual mucosa of 3 days duration. Pain developed a few days after the extraction of
his lower right third molar. The extraction was performed by a senior dental surgeon in the
college dental clinic. Review of the patient’s medical and dental history, revealed neither he was
suffering from systemic illnesses nor taking any medicine. He reported pain in relation to a badly
decayed 48 tooth, which was removed without any difficulty or complication. However, one
interrupted suture was placed on the mesial aspect of the socket to approximate the soft tissues,
which were elevated to take a deep grip of the broken crown.

Intraoral examination revealed a round ulcer with an erythematous halo of 1cm in diameter
associated with exposure of the underlying bone. The ulcer was located on the right lingual
aspect of the extraction socket, just above the mylohyoid ridge line (Fig. 1). The socket was
filled with clot and appeared to be healing normally. Ulcer margins and tissues in the vicinity
were edematous, sensitive and erythematous. The yellowish exposed bone (osteonecrotic bone)
was insensitive with no sign of vascularity; however, not separated from the lingual plate (no
sequestrum formation). Extra-oral examination revealed no swelling, tenderness or regional
lymphadenopathy. A radiograph was taken but showed no evidence of any pathology (Fig. 2).
No other findings of significance were noticed. A diagnosis of idiopathic lingual ulcer with
ostietis was made.
The treatment was initiated by filing the exposed bone under inferior alveolar nerve block to
avoid any injury to the tongue. Oral antibiotics in the form of Amoxicillin 500 mg three times
daily for 5 days and Brufen 400 mg tablets twice daily were prescribed to control the acute phase
of the condition. In the second visit (4 days later), clinically, most of the acute signs and
symptoms had been resolved. Under mandibular nerve block anesthesia, the margins of the ulcer
were slightly elevated by periosteal elevator and the lingual necrotic bone at the base of the ulcer
was removed by surgical bur down to the vascularized bone layer (Fig. 3). The freshly exposed
bone was covered by iodoform gauze and sutured in place to promote healing (Fig. 4). Post-
surgical instructions including maintenance of good oral health with the aid of antiseptic mouth
rinse were given to the patient. The patient was reviewed 48 h after surgery and good initial
epithelialization of the ulcer was evident (Fig. 5). The condition was healed completely within 3
weeks (Fig. 6).
3. Discussion
LMU with osteonecrosis is not commonly seen in daily dental practices, thus understating of the
potential causes, differential diagnosis and clinical presentations is paramount, particularly to
general dental practitioners.

Normally, the lower posterior teeth are lingually inclined and this provides protection to the
underlying soft tissues. Extraction of lower molars, particularly the second and third molars
allows the posterior lingual mucosa to be vulnerable to masticatory forces or occlusal trauma,
which may lead to ulceration and bone denudation.

Wounds associated with the surgical removal of third molars are invariably closed with multiple
sutures. Theoretically, tongue and associated tissues may exert a muscular pull against the
sutured lingual mucosa causing lingual ulceration; however, clinically such ulcers are
uncommon.

Generally, mandibular cortical bone is covered by thin mucosa and less vascular in comparison
with the maxillary bone reflecting the prolonged healing time. Furthermore, the lingual cortex is
distant from the main vascular bed of the mandible and largely depends on the periosteum
vascularity, which contains a small amount of connective tissue.15

In the present case, although the extraction was atraumatic, minor trauma maybe was the
initiating factor. It has been reported that minor trauma, such as those arising from scaling or
even thermoplastic impression materials may initiate ulceration with subsequent bone
necrosis.5 and 16 Trauma is a well-known precipitating factor in minor aphthous stomatitis,
however, the clinical picture of the present case, particularly the lingual cortical bone necrosis is
far from the diagnosis of minor aphthous ulcer.

Patients are usually unaware of bone exostosis or enlarged mylohyoid ridge until trauma causes
ulceration. A careful examination of our case confirmed that none of such abnormalities are
present.
Apparently, an interrupted suture was given to the socket; but we cannot confirm that it initiated
ulceration. Furthermore, the presence of any contributing system factors has been excluded, as
the patient’s medical history was clear.

Sequestrum formation is invariably associated with lingual ulceration.4 In the current case,
neither clinically nor radiographically could see evidence of sequestrum formation. This is
probably due to the early diagnosis and management of the case.

A variety of treatment modalities including prescription of antibacterial mouth rinses and anti-
inflammatory creams as non-invasive and supportive treatment to aid the healing process have
been advocated.2 Potential injury to tongue from the exposed necrotic bone has been reported.10
Therefore, controlling of the acute symptoms and prevention of potential complication, as
described earlier are mandatory and prior to any surgical intervention. However, some authors
are reluctant to active surgical intervention asserting compromised cortical bone vascularity.2 In
the absence of clear sequestration, removal of the necrotic surface layer provides better and
quicker healing environment. The presented case showed complete healing in approximately
3 weeks after surgery. A radiographic examination 6 weeks post-surgical intervention revealed
no adverse bone changes.

4. Conclusion
Lingual mucosal ulceration and associated osteonecrosis are presented clinically with mild to
moderate symptoms. There might be an iatrogenic cause, nevertheless, in many cases there is no
obvious attributable factor making the diagnosis quite challenging. Although oral and
maxillofacial surgeons are encountering such cases in their practices, it is imperative for general
dental practitioners to be familiar with the potential etiological factors and clinical presentation
to exclude any sinister pathology and properly treat the patients.

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Peer review under responsibility of King Saud University.

Corresponding author at: RAK College of Dental Sciences, P.O. Box: 12973, RAK,
United Arab Emirates. Tel.: +971 72222593.

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