MECHANICAL, CHEMICAL and

THERMAL INJURIES
MUCOSITIS
 MECHANICAL, CHEMICAL and THERMAL
INJURIES - MUCOSITIS
Mechanical Injuries
• Traumatic ulcer
• Traumatic hematoma
• Chronic biting
• Facticia
• Denture stomatitis
• Papillary palatal hyperplasia
• Mucosal necrosis due to
injection
• Eosinophilic ulceration
Chemical burns
• Aspirin
• Alcohol and Iodine
• Agricultural chemical agents
• Epithelial peeling
Thermal Lesions
• Nicotine stomatitis
• Thermal burn
Amalgam tattoo and other
exogenous pigmentations
Mechanical
Injuries
 Traumatic ulcer
• It is the most common ulcer of the mouth.
• Acute or chronic injury to the oral mucosa may lead to an ulcer. The
most common are: a sharp or broken tooth, rough fillings, sharp full
or atrial dentures, sharp food stuffs and other foreign bodies, biting
of the mucosa
• Self-limiting process that heals within 5-8 days following removal of
etiologic factor. Topical corticosteroid ointments improve the
symptoms and help healing. Systemic oral corticosteroids may be
administered in low dose for a short time, (e.g. prednisolone 10-20
mg/day for 4-6 days) for chronic and painful traumatic ulcers.
Oxygen releasing mouthwashes are helpful.
• Clinically, may mimic oral squamous cell carcinoma.
• Frequently, occurs on the tongue, buccal mucosa, lips and gingiva.
Traumatic ulcer

Riga-Fede ulceration in infants

 Traumatic Hematoma

• It appears suddenly, after a mechanical injury that provokes

vessel breakage, hemorrhage and entrapment of blood within
the oral tissues.
• Patients under anticoagulant therapy may be at risk of
developing hematomas.
• The diagnosis is based on the history and the clinical features
• The overlying oral mucosa is usually intact.
• The color of the lesion is deep red.
• The lesion disappears usually in 8-10 days without treatment.
• No treatment is required as the lesion resolves spontaneously
 Clinical features
• Traumatic ulcers appear as single painful lesions with a
smooth red or white-yellow surface and thin erythematous or
whitish halo and soft to palpation.
• When the cause is sustained and intense, the ulcer’s surface
may become irregular with vegetations, the border raised and
the base indurated, due to scar formation and chronic
inflammation.
 Chronic Biting
• A relatively common habit particularly with
anxiety and other psychological problems.
• The buccal mucosa at the level of occlusal
plane, the lateral border of the tongue and the
labial mucosa are most frequently involved.
• The lesions are innocent without risk of
malignancy.
• No treatment is required. Patients should be
aware about the habit and suggestions to stop
it
• Chronic biting appears as a localized or diffuse
irregular whitish of small furrows, with
desquamation of the affected epithelium.
• Usually, the lesions are bilateral although
unilateral lesions may be seen.
 Factitious Trauma
• It occurs usually in patients with serious emotional problems or
mental impairment.
• The trauma is usually inflicted by biting, fingernails or by use of a
sharp object.
• The most common clinical feature is small to large ulceration.
• The diagnosis is based on the clinical criteria.
• Local measures, such as corticosteroid paste in Orabase,
antibacterial mouthwashes and psychiatric support are the suggested
measures.
 Denture Stomatitis
• Denture stomatitis is a common disorder
in people who wear dentures for long
periods of time
• Etiologic factors are irritation from ill-
fitting dentures, food debris, Candida
albicans and bacterial accumulation
under the denture surface or poor
denture hygiene.
• The mucosa beneath the denture is Treatment
edematous and erythematous with or Improvement of denture fit,
without whitish spots that represent oral hygiene and antifungal
hyphae of Candida albicans drugs systematically e.g.
• Most patients are asymptomatic but fluconazole 50mg/day or
some complain of a burning sensation, itraconazole caps 100 mg/day
irritation or mild pain. for 6 to 7 days are the first line
therapy
 Papillary Palatal Hyperplasia
• Papillary palatal hyperplasia is a
variety of denture stomatitis.
Appears as asymptomatic, multiple
coalescing, small edematous and
reddish papillary projections, at the
midline of the anterior part of the
palate
• Mechanical irritation by foods or
mouth breathing with a high palatal
vault are the causative factors in
edentulous people, or mouth
breathing and secondary Candida
albicans
• Excision of the severe lesion by
electrosurgery or CO2 laser are the
treatment of choice.
 Mucosal necrosis due to injection

• Local anesthetic injection may

occasionally be followed by
mucosal necrosis.
• Rapid injection of the solution
results in local ischemia, which
may be followed by tissue necrosis
• The hard palate is the site of
predilection.
• Clinically, palatal necrosis appears
as a well-circumscribed deep ulcer,
exactly at the site of injection.
• The ulcer develops 3 to 6 days
after the procedure and frequently
heals spontaneously within
2 weeks
 Eosinophilic Ulceration
• A self-limiting benign inflammatory
lesion (unrelated to eosinophilic
granuloma of Langerhans cell
histiocytosis).
• Trauma is considered to be the
causative factor.
• The tongue is the site of predilection.
• Appears as sudden onset painful ulcer
with an irregular surface, covered
with a whitish-yellow membrane, and
raised inflammatory and indurated
border.
• The diagnosis is based on the
histopathologic examination.
• Heals over several weeks or months.
Spontaneous healing after a biopsy
may also occur. The healing time can
be shortened by systemic treatment
with corticosteroids. Prednisone
20-30 mg/day or betamethasone
2-3 mg/day for one week
Chemical Burns
 Chemical burns
• Careless or inappropriate use of many caustic chemical
agents and drugs in dental practice may cause oral
lesions(i.e Trichloroacetic Acid ,Eugenol, Hydrogen
peroxide). The wide use of the rubber dam has
reduced the frequency of such lesions.
• In addition, accidental ingestion of household
chemicals, such as kitchen, toilet and metal cleansers
or even agricultural drugs may cause mild or severe
damage of the oral mucosa.
• The severity of the lesion depends on the type of
chemical utilized, its concentration and the time of
contact with the oral tissues
 Agricultural Chemical Agents Burn
• Clinically, oral lesions present with edema,
redness to painful extensive erosions or
ulcerations covered with whitish or brownish
necrotic epithelial debris
• The duration of oral lesions varies from 1 to 2
weeks time. Systemic complication may occur in
severe cases.
• Treatment
It depends on the severity of the lesion and the
nature of the agent. Severe cases with systemic
symptoms must send to the Hospital as
soon as possible. In less severe cases without
systemic complications the oral lesions, should
be managed by local anesthetics and antiseptic
mouthwashes in association with systemic
corticosteroids, e.g. prednisone 10-20 mg/day,
4-6 d
 Aspirin Burn

• One of the most common chemical

injuries of the oral mucosa.
• It is usually caused when patients
with toothache apply an aspirin
tablet topically on the oral mucosa.
Clinically, aspirin burn initially
presents as an irregular whitish and
wrinkled mucosal area. Later, the
necrotic epithelium desquamates
exposing an underlying painful
erosion
• No treatment is necessary as the
lesion heals spontaneously within 4
to 6 days
 Alcohol and Iodine Burn
• Repeated application of
concentrated alcohol or iodine
solution by patients as a local
anesthetic for mouth pain or as
antiseptic may result to mucosal
damage.
• Lesions may be painful or not
depending on the severity of
damage.
• Clinically, the affected mucosa is
whitish or red, wrinkled and tender
• Superficial erosions in more severe
cases may occur.
• The diagnosis is based on the
history and the clinical features.
• The lesion usually heals
spontaneously within 2 to 4 days
 Epithelial Peeling

• A superficial desquamation of the oral

mucosa that is usually caused by the direct
irritating effect of toothpastes that contain
high amounts of pyrophosphate or sodium
lauryl sulfate.
• Epithelial peeling presents as a superficial,
asymptomatic white membrane that can be
easily lifted from the oral mucosa. The lesion
may be localized or generalized. The buccal
mucosa and the muccobuccal folds are more
commonly affected
• The lesions are asymptomatic and harmless.
• The diagnosis is based on the clinical
features.
• No treatment is needed. Avoid the causative
agent
Thermal
Injuries
 Nicotinic Stomatitis

• This develops in response to heat rather

than the chemicals in tobacco smoke.
• The palatal lesions are primarily due to
pipe and less commonly to cigar or
cigarette smoking.
• The palatal mucosa assumes a grayish-
white color associated with multiple
nodules.
• A characteristic finding is the multiple
red dots, 1-5 mm in diameter, in the
center of the nodules, which represent
the inflamed orifices of the secretory
ducts of the minor salivary glands.
• The lesion is not premalignant.
Treatment
Cessation of smoking. The palate returns to
normal, usually within 2-4 weeks after
smoking ceases.
 Thermal Burn
• This is a relatively common lesion on the
oral mucosa.
• Very hot foods such as pizzas, melted
cheese, beverages or metal objects are
the most common causes.
• The severity and extent of the lesion
depends on the temperature of the
responsible food or material.
• Clinically, the oral mucosa is red, and Thermal pizza burn
may undergo epithelial desquamation
leaving small or extensive painful
erosions. Vesicles may also develop.
• The palate, lips, tongue and the floor of
the mouth are most frequently affected
• Mild lesions usually resolve within a
week without treatment

coffee thermal burn

Metal and
Other
Deposits
 Amalgam Tattoo
• Amalgam tattoo is the most common form
of pigmented exogenous materials that may
be implanted within the oral mucosa. Other
materials could be silver, lead, bismuth,
foreign bodies.
• Clinically amalgam tattoo appears as an
asymptomatic, well defined bluish or black,
usually flat, irregular discoloration of varying
size. The lesions may be solitary or multiple
• The gingiva, alveolar mucosa, floor of the
mouth and buccal mucosa are the sites most
involved.
• The diagnosis is based on the clinical
features, radiographic findings and
histopathology.
• Conservative surgical excision is the
treatment of choice along with the
histologic examination, to rule out any
other benign or malignant melanocytic
lesion.
Bismuth line Graphite deposition

Silver cone Soil granule

 Materia Alba

• Materia alba is the result of bacteria, dead

epithelial cells and food debris
accumulation. It is commonly found at
the dentogingival margins of persons with
poor oral hygiene and the basic factor for
periodontal disease.
• Clinically, material alba of the oral
mucosa appears as a whitish or white-
grey soft plaque which characteristically
is easily detached after slight pressure by
a wood spatula leaving a redish surface
• No treatment is required, other than to
improve oral hygiene
Mucositis
 Mucositis

•12-100% of the immunosuppressed patients experience

mucositis lesions. These are mainly caused by DNA or RNA
alterations of the epithelial cells.
• Epithelial cells have a high rate of proliferation therefore
are more sensitive to radio/chemotherapy
• Predisposing factors:
• Genetic predisposition, Female> Male
• Therapy protocol
• Underlying disease
• Age
• Oral hygiene
• Alcohol/Smoking
 Mucositis
Mucositis, usually starts at the end of the first
week of therapy.
Clinically presents as diffuse erythema and
edema associated with a burning sensation
and pain. During the second week the
erythema becomes more severe and
painful erosions or ulceration may develop,
which are covered by a whitish-yellow
necrotic membrane.
Oral infections, dental decay, jawbone
necrosis, gingivitis and periodontitis,
atrophy and fibrosis of the oral mucosa,
inability to eat or even speak, xerostomia,
loss of taste are common complications
that can lead to cessation of treatment, Pathogenesis model of Mucositis
phsycological problems and bad quality of Sonis ST. J Support Oncol 2004

life.
The lesions usually last 6 to 10 weeks
 Mucosal lesions of mucositis
White, thick mucosa, then gets thin and erythematous.
Formation of ulcers and erosions, pain, carries.
 Mucosal lesions due to chemotherapy

Ulceration due to methotrexate Ulceration due to azathioprene

 Treatment
palliative care

• Soft toothbrush, toothpaste with fluoride

(5000 ΙU)
• Dental floss
• Oral mouthwash
• Cryotherapy
(30’ before chemo and continue for 6 hrs)
 Pharmaceutical treatment

• Palifermin * (Kepivance, KGF) 60mcg/Kgr/d, IV

• Amifostine *200mg/m3/d 15-30’ before radiation
• Chlorhexidine 3-4 t/d
• Magic mouthwash (Lidocaine, Diphenhydramine, Maalox 3-4t/d)
• Antimicrobial agents (polymyxin, tobramyxin, amphotericin B)
• Anti- bacterials, antifungals, anti-virals

* these agents are at an experimental stage

 Magic Mouthwash
• In 120 ml NaCL 0,9%
•
• Xylocain Gel Tube I
•
• Vibramicin Syr FL I
•
• Daktarin gel Tube I
•
• Peptonorm Susp 40ml
•
• Soldesanil Or sol D 2MG/ML Fl x 10ml
•
➢ Keep it in the mouth for 2 min and spit it
➢ Use it 4 times a day
 Pharmaceutical treatment

• Local anesthetics
• Anti-inflammatory agents
• Vitamin Ε, Vitamin Β
• Local/systemic corticosteroids
• LLLT(Low Level Laser Therapy)
 References/Further reading
1. da Silveira Teixeira D, de Figueiredo MAZ, Cherubini K, de Oliveira SD, Salum FG. The topical effect of
chlorhexidine and povidone-iodine in the repair of oral wounds. A review. Stomatologija.
2019;21(2):35-41.
2. Wright KT, Pozdnyakova O. Say hello to TUGSE! Blood. 2019 Oct 17;134(16):1360.
3. Gual-Vaqués P, Jané-Salas E, Egido-Moreno S, Ayuso-Montero R, Marí-Roig A, López-López J.
Inflammatory papillary hyperplasia: A systematic review. Med Oral Patol Oral Cir Bucal. 2017 Jan
01;22(1):e36-e42.
4. Kanumuri PK. Riga Fede Disease. J Neonatal Surg. 2017 Jan-Mar;6(1):20. 12.
5. Benitez B, Mülli J, Tzankov A, Kunz C. Traumatic ulcerative granuloma with stromal eosinophilia -
clinical case report, literature review, and differential diagnosis. World J Surg Oncol. 2019 Nov
09;17(1):184.
6. Sharma B, Koshy G, Kapoor S. Traumatic Ulcerative Granuloma with Stromal Eosinophila: A Case
Report and Review of Pathogenesis. J Clin Diagn Res. 2016 Oct;10(10):ZD07-ZD09
7. Kannan S, Chandrasekaran B, Muthusamy S, Sidhu P, Suresh N. Thermal burn of palate in an elderly
diabetic patient. Gerodontology. 2014 Jun;31(2):149-52
8. Dellinger TM, Livingston HM. Aspirin burn of the oral cavity. Ann Pharmacother. 1998
Oct;32(10):1107
9. Kang S, Kufta K, Sollecito TP, Panchal N. A treatment algorithm for the management of intraoral
burns: A narrative review. Burns. 2018 Aug;44(5):1065-1076.
• Jolly M. White lesions of the mouth. Int J Dermatol. 1977 Nov;16(9):713-25.
• Babu B, Hallikeri K. Reactive lesions of oral cavity: A retrospective study of 659
cases. J Indian Soc Periodontol. 2017 Jul-Aug;21(4):258-263.
• Holmes RG, Chan DC, Singh BB. Chemical burn of the buccal mucosa. Am J Dent
2004; 17:219-220.
• Brown FH, Houston GD. Smoker’s melanosis: A case report. J Periodontol
62:524,1991
• Taybos G. Oral changes associated with tobacco use. Am J Med Sci 2003; 326:179-
182.
• Tran HT, Anandasabapathy N, Soldano AC. Amalgam tattoo. Dermatol Online J
2008; 14:19.
• Elad S, Yarom N, Zadik Y, Kuten-Shorrer M, Sonis ST. The broadening scope of oral
mucositis and oral ulcerative mucosal toxicities of anticancer therapies. CA Cancer
J Clin. 2022 Jan;72(1):57-77.