Case report

Thermal burn of palate in an elderly diabetic patient

Sathya Kannan1*, Balamanikandasrinivasan Chandrasekaran1*, Senthilkumar Muthusamy2,

Preena Sidhu2 and Nanditha Suresh2
1
Academic Unit of Craniofacial Clinical Care, Faculty of Dentistry, AIMST University, Kedah, Malaysia; 2Academic Unit of Adult Dental
Health, Faculty of Dentistry, AIMST University, Kedah, Malaysia

doi: 10.1111/ger.12010
Thermal burn of palate in an elderly diabetic patient
Background: Burns of the oral mucosa may be caused by thermal, mechanical, chemical, electrical or
radiation injury. Clinically, these burns can produce localised or diffuse areas of tissue damage depend-
ing on the severity and extent of the insult. Most oral thermal burns produce erosions or ulcers on the
palate or tongue.
Materials and methods: A case of palatal burn in a 66-year-old diabetic patient caused by drinking
hot cereal is presented. The role of diabetes in causing oral mucosal dysesthesia that predisposed the
occurrence of this burn is also discussed.
Conclusion: Insensate palatal burn as a rare complication of diabetes mellitus is reported here. With
the disease being more widespread now, its potential oral complications will be seen with increasing
frequency.

Keywords: burning mouth syndrome, diabetes, oral health

Accepted 2 September 2012

had predisposed him to the occurrence of a ther-

Introduction
Thermal burns in the oral cavity arise from
accidental ingestion of hot foods or beverages. It
results in inadvertent injury to the oral mucosa
that clinically appears as areas of erythema,
erosion or ulceration with or without superficial
necrosis. Mild burns from hot food are relatively
common in the mouth and are of little clinical
consequence. These are often inconspicuous or
involve small areas, and usually resolve quickly
without treatment1–4.
Most thermal burns reported occurred after eat-
ing hot pizza or microwaved food. The reason in
these situations being the hot heat-holding cheese
in pizzas and food that is cool on the outside and
extremely hot in the inside when heated in a
microwave3–7.
We report a case of thermal palatal burn in a
66-year-old man with diabetes. A plethora of oral
complications associated with diabetes have been
reported previously8,9. In this patient, his diabetes
*These author contributed equally.
mal burn.
Case presentation
A 66-year-old partially edentulous man was
referred to the Oral Surgery department for com-
plete extraction of his remaining teeth (21, 22,
43, 44 and 45) which were affected with chronic
periodontitis. Medically the patient had a 10-year
history of Type II diabetes and was taking oral
hypoglycemics regularly. His remaining history
was non-contributory. His preoperative blood
sugar levels were within normal limits and he
underwent extraction of the upper anterior teeth.
Post-extraction instructions were given and he
was prescribed a painkiller and an antibiotic.
When the patient reported 2 weeks later for
extraction of his lower teeth, he presented with a
single ulcer measuring approximately 2.5 9 1 cm
at the centre of the hard palate posteriorly and
extending into the soft palate (Figs 1 and 2). The
ulcer was surrounded by erythema and there was
no evidence of cervical lymphadenopathy. The

© 2014 The Gerodontology Society and John Wiley & Sons A/S,
Gerodontology 2014; 31: 149–152 149
150 S. Kannan et al.
Figure 1 Ulcer on posterior palate.
Figure 2 Ulcer showing surrounding erythema.
patient had no pain and was not aware of the
lesion. On enquiry he described drinking hot cer-
eal from a mug during meal times for the past
1 week. As he had only three remaining teeth, he
had opted for semisolid and liquid food, usually
cereal. Although the cereal had always been
served ‘scalding hot’, he had never felt the heat
in his mouth. This decreased sensation to hot food
had been present for approximately 3 months and
had become more obvious recently. Of late he
had also noticed reduced ability to taste spicy and
salty food. From the history and clinical appear-
ance of the lesion, it was provisionally diagnosed
as a thermal palatal burn. Other considerations
included malignancies, midline lethal granuloma,
Wegener’s granulomatosis, necrotising sialometa-
plasia and bacterial or fungal infection. The
patient was informed of the lesion and was asked
Figure 3 Palate after healing of ulcer.
to avoid hot food; an antiseptic mouth rinse
(0.12% chlorhexidine) was prescribed to prevent
secondary infection. He was then referred to his
physician to assess his blood sugar profile. Blood
sugar tests (fasting blood sugar – 6.9 mM, post-
prandial – 9.8 mM, random blood sugar –
8.8 mM, HBA1C – 7.9%) and a routine check
was carried out, during which he showed signs of
peripheral neuropathy in his lower limbs. After
2 weeks of follow-up, the palatal ulcer had healed
satisfactorily (Fig. 3). The patient was educated
regarding the importance of diabetes control and
advised to follow his physician’s instructions
regarding this.
Discussion
Thermal burns in the mouth manifesting as ulcers
often go unnoticed unless symptomatic. Specific
anatomic sites such as the anterior part of the
tongue and palate become common victims to
these burns3–5. The degree of damage that could
result from such burns varies in size, depth
and severity, depending on factors such as the
temperature of food, its ability to hold heat, its
duration of contact, rate of heat transfer and tis-
sue conductivity10.
A burn injury immediately destroys cells or dis-
rupts their metabolic functions completely so that
cellular death ensues. The underlying pathophysi-
ology was explained by Bledsoe et al.11 According
to their theory thermal burns increased the rate
at which tissue molecules moved and collided
with each other; then as temperatures increased,
the molecular speed also increased causing
© 2014 The Gerodontology Society and John Wiley & Sons A/S,
Gerodontology 2014; 31: 149–152

damage to cell components. The resultant mem-
brane breakdown and protein denaturing lead to
progressive injury and cell death.
Three concentric zones of tissue injury cha-
racterise a full-thickness burn: zones of coagula-
tion, stasis and hyperemia. The central zone of
coagulation has the most intimate contact with
the heat source and usually appears white
clinically. It consists of dead or dying cells as a
result of coagulation necrosis and absent blood
flow. The intermediate zone of stasis surrounds
the critically injured area and consists of poten-
tially viable tissue despite serious thermal injury.
The outer zone of hyperemia is a red zone that
has increased blood flow because of normal
inflammatory response. These zones were
described with reference to burns on the skin by
Jackson12. Although the zones may not be evi-
dent in the oral mucosa as distinctly as in skin,
the pathophysiology is similar.
Our patient had a lesion on his palate that was
whitish in the centre surrounded by erythema.
Correlation of the clinical appearance and history
justifies the diagnosis as a thermal burn. In this
situation, the patient was a known diabetic under
medication for 10 years. Diabetes mellitus is a
common disease with diverse oral manifestations
and systemic complications. The profound effect
of diabetes on every system of the human body
has been well documented. Likewise, its associa-
tion with increased incidence of periodontitis, oral
infections, oral mucosal diseases, neurosensory
disorders, taste disturbances, salivary dysfunction
and dental caries has been studied previously.
Development of these occurrences in the oral cav-
ity has been linked to poor glycemic control and
hyperglycemia13.
Among the above mentioned, a major complica-
tion in longstanding diabetes is peripheral neurop-
athy. Although this nerve dysfunction typically
affects the lower limbs, it can involve any part of
the nervous system where patients generally expe-
rience pain, dysesthesia or loss of sensation in the
affected area. However, about 50% of diabetic
neuropathies (DN) may be asymptomatic but a
diagnosis can be made on examination, which usu-
ally reveals sensory loss to vibration, pressure, pain
and temperature perception and absence of
reflexes. These patients are at a risk of insensate
injury, commonly to their feet8,14. Our patient was
diagnosed with DN by his physician as he had
diminished reflexes and reduced sensory percep-
tion in his lower limbs.
Moore et al.9 studied the association of periph-
eral neuropathy and burning mouth syndrome.
© 2014 The Gerodontology Society and John Wiley & Sons A/S,
Gerodontology 2014; 31: 149–152
Thermal burn of palate 151
They noted dysesthesia and numbness in the oral
cavity of subjects with DN. Other oral findings in
diabetic neuropathy noted by Collin et al.8 were
increased tooth loss and temporomandibular joint
dysfunction. According to the authors, the com-
bined effects of peripheral neuropathy and oral
dysesthesias impaired the maintenance of daily
oral hygiene that indirectly resulted in increased
tooth loss8,9. This could also be a reason for the
tooth loss in our patient. Besides that the pres-
ence of an insensate palatal ulcer arising from the
intake of scalding hot cereal confirmed the pres-
ence of numbness in the oral cavity. Further, the
patient also had taste disturbances. Altogether,
this could show an association between oral
dysesthesia and DN.
Healing of thermal burns in the oral cavity is
generally uneventful and most lesions heal within
2 weeks. But in the presence of poor oral hygiene
and systemic states that complicate healing addi-
tional treatment measures such as use of antibiot-
ics or antimicrobial mouth rinses may be
required. As diabetes delays wound healing and
increases the risk of infection, this patient was
given an antimicrobial mouth rinse.
Conclusion
A case of thermal burn in the palate that arose as
a consequence of oral numbness has been
described. Such lesions often go unnoticed by the
clinician because they are usually small and
remain painless. Therefore, emphasis is made on
thorough examination of all areas of the oral
cavity. Diabetes may have a role in causing
numbness of the oral cavity as in this scenario.
Correlation of clinical findings with a patient’s
history, habits and systemic diseases is therefore
necessary for appropriate diagnosis. With the
increasing prevalence of diabetes, dental practitio-
ners will be treating more patients with this disor-
der and may encounter similar oral lesions in the
future.
Acknowledgement
The authors would like to thank Professor M.B.
Comfort, Faculty of Dentistry, AIMST University,
for her editorial advice.
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Correspondence to:
Dr Sathya Kannan, Faculty of Dentistry, AIMST
University, Bedong 08100. Kedah. Malaysia.
Tel.: +60164703646
Fax: +604298449
E-mail: drsathyas@yahoo.com
© 2014 The Gerodontology Society and John Wiley & Sons A/S,
Gerodontology 2014; 31: 149–152