Physical injuries of soft tissues

Linea Alba
➡ Linea alba is a white line observed on the buccal mucosa.

➡ It extends from the commissures posteriorly at the level of the occlusal plane.

➡ It is typically caused by the physical irritation and pressure exerted by the

posterior teeth.

➡ Linea alba is usually bilateral and more pronounced in individuals with

clenching habits or bruxism.

➡ Histologically, it is characterized by hyperkeratosis and intracellular edema

of the epithelium.

Toothbrush Trauma:
➡ Gingival injury caused by toothbrush use.
➡ Presents as white, reddish, or ulcerative lesions or linear superficial erosions.
➡ Typically affects the marginal and attached gingiva of the maxillary canine
and premolar region.
➡ Severe cases may lead to clefting of the gingival margin, gingival recession,
notching of teeth, and alveolar bone loss.
➡ Symptoms include pain and burning sensation.
➡ Often due to faulty brushing technique or excessive cleanliness practices.

Toothpick Injury:
➡ Another form of self-inflicted oral injury.
➡ Involves the interdental gingiva.
➡ Occurs due to overzealous oral hygiene practices.

Histologic Features of Toothbrush Trauma:

➡ Focal ulceration.
➡ Formation of granulation tissue.
➡ Diffuse, chronic inflammatory cell infiltration.
➡ Hyperkeratosis and acanthosis of the adjacent epithelium.

Treatment:
➡ Medications to relieve symptoms.
➡ Instruction in proper brushing technique.

Traumatic Ulcer (Decubitus

Ulcer)
A traumatic ulcer of the oral mucosa is a lesion caused by various forms of
trauma. This trauma can result from factors such as biting the mucosa,
dentures, orthodontic appliances, toothbrush injuries, exposure to sharp teeth
or carious lesions, or irritation from other external sources.

Common causes of traumatic ulcers include:

➡ Injury from severe tongue biting.

➡ "Cotton roll injury," often occurring when a dry cotton roll is roughly
removed by a dentist, tearing the mucosa it was adhering to.

➡ Occurrence on the buccal mucosa, lips, and sometimes the palate.

While most traumatic ulcers in the oral mucosa heal rapidly and without
complications, some may persist for an extended period without healing.
Traumatic ulcers on the tongue, in particular, can resemble carcinoma and may
be biopsied multiple times in an attempt to diagnose neoplasms.

Interestingly, some long-lasting traumatic ulcers tend to heal promptly

after a minor surgical procedure, such as an incisional biopsy.

Treatment:
The primary management of traumatic ulcers involves alleviating symptoms.
However, these ulcers typically heal quickly once the source of irritation is
removed.

Traumatic Ulcerative Granuloma

with Stromal Eosinophilia (TUGSE)
Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE), also known
as eosinophilic ulceration or traumatic granuloma, is a reactive, benign, and
usually asymptomatic lesion found in the oral mucosa. It tends to be
self-limiting and is characterized by the presence of eosinophils in the stroma.

Clinical Features and Etiology:

➡ TUGSE can sometimes resemble squamous cell carcinoma in its clinical
presentation.
➡ The exact cause of TUGSE is not well understood, but it may be associated
with trauma. Trauma can be caused by factors such as malposed teeth or
partial dentures.
➡ In infants, a related condition called Riga-Fede disease may occur. This
typically affects infants between 1 week and 1 year of age and presents with
lesions on the anteroventral surface of the tongue. These lesions result from
contact with erupting mandibular incisors, which are often natal or neonatal
teeth.
Pathogenesis:
➡ While trauma may play a role in the development of TUGSE, its pathogenesis
is likely mediated by T-cells.

Atypical Eosinophilic Ulcer:

➡ An atypical eosinophilic ulcer, also known as atypical histiocytic granuloma, is
a rare lesion that follows a sequence of ulceration, necrosis, and self-regression.

➡ Unlike TUGSE, it is not associated with trauma and is believed to represent an

oral counterpart of a T-cell cutaneous lymphoproliferative disorder.

Clinical Features of Eosinophilic Ulcerations:

➡ Eosinophilic ulcerations can develop in individuals of any age, but they show
a notable preference for males.

➡ These ulcers are often found on the anteroventral and dorsal surfaces of the
tongue. However, they can also occur in other locations within the oral cavity,
including the gingiva, palate, and mucobuccal fold.

➡ Eosinophilic ulcerations tend to be persistent, lasting from weeks to months.

➡ Clinically, they resemble traumatic ulcers.

➡ The center of the ulcer is typically covered by a removable yellow

fibropurulent membrane, while the borders appear erythematous (red).

Histologic Features of Eosinophilic Ulcerations:

➡ Eosinophilic ulcerations exhibit a histological pattern similar to simple
traumatic ulcerations.

They are characterized by:

 ➡ A dense and deeply infiltrative lymphoproliferation.
➡ Epitheliotropism, indicating that the lymphocytes and histiocytes
infiltrate the epithelium.
➡ Massive eosinophilia.
➡ Sheets of lymphocytes and histiocytes.
➡ Hyperplasia of the vascular connective tissue, leading to elevation of
the surface ulceration.

Treatment and Prognosis:

➡ Treatment for eosinophilic ulcerations is similar to that for simple traumatic
ulcerations.

➡ Even large eosinophilic ulcerations heal rapidly after a biopsy.

➡ In cases of Riga–Fede disease (infants with ulcers caused by erupting

mandibular incisors), extracting the involved teeth can resolve the problem.
However, teeth should be retained if they are stable.

Angina bullosa
hemorrhagica
(traumatic oral hemophlyctenosis, benign
hemorrhagic bullous stomatitis)
Angina bullosa hemorrhagica (ABH) is an uncommon condition characterized by
the sudden appearance of one or more blood blisters within the oral mucous
membrane. It is considered a benign and self-limiting disorder. The name
"angina bullosa" may be misleading, as it does not refer to the heart condition
angina but rather to a blister or swelling in the oral cavity.
Pathogenesis:
The exact cause of ABH is not fully understood, but it is often associated with
minor trauma or mechanical injury to the oral mucosa. These injuries can
include:

1. Hot Foods: Consuming hot foods or beverages that can cause thermal injury
to the oral tissues.

2. Dental Procedures: Restorative dental procedures that involve manipulation

of the oral tissues.

3. Periodontal Therapy: Dental cleanings or procedures involving the gums.

4. Intraoral Anesthetic Injections: Trauma caused by injections of local

anesthetics during dental treatments.

5. Steroid Inhalers: Long-term use of steroid inhalers for respiratory conditions,

which may lead to mucosal fragility.

6. Chlorhexidine Gluconate Mouthwash: The use of certain mouthwashes

containing chlorhexidine gluconate, which can potentially irritate the oral
tissues.

Clinical Features:
➡ ABH typically presents with the sudden appearance of one or more
blood-filled blisters or bullae within the oral cavity.

➡ The blisters may vary in size and can be solitary or multiple.

➡ The most commonly affected site is the soft palate, but lesions can occur in
other areas, such as the buccal mucosa, tongue, or fauces.

➡ Lesions may be dark red to purple in color.

➡ Importantly, ABH is usually painless, and patients often become aware of it
when they notice the presence of the blood-filled blisters.

Differential Diagnosis:
ABH should be differentiated from other oral conditions that may present with
similar features, such as:

➡ Epidermolysis bullosa
➡ Bullous lichen planus
➡ Pemphigus vulgaris
➡ Linear IgA disease
➡ Stomatitis herpetiformis
➡ Thrombocytopenic purpura

Prognosis and Treatment:

ABH is generally considered a benign and self-limiting condition. The blood
blisters may rupture spontaneously or during eating, resulting in the release of
blood into the mouth. After the blister ruptures, the underlying epithelium may
appear eroded or ulcerated.

Treatment of ABH is typically not required, as the condition tends to resolve on

its own. Management may include providing reassurance to the patient,
advising them to avoid any known irritants or traumas, and recommending
gentle oral hygiene practices. In most cases, the lesions heal without scarring or
complications.

It's important for healthcare providers to be aware of ABH to avoid

unnecessary diagnostic tests or treatments, as the clinical presentation and
history of minor trauma are usually indicative of the condition.

Factitial injuries:
➡ Factitial injuries are self-induced injuries to the oral cavity.
➡ They can be habitual, accidental, or have a psychological basis.

➡ These injuries may overlap with other types of physical and chemical injuries
to the oral tissues.

➡ Factitial injuries can take various forms and can result from intentional
actions or behaviors.

➡ Management may require addressing the underlying psychological or

behavioral factors contributing to these injuries.

➡ Dentists should recognize and understand factitial injuries to provide

appropriate care and support to affected individuals.

Lip biting, cheek biting, and gingival injury due to

factitial causes:

➡ Lip biting, also known as morsicatio labiorum, involves the habitual or

psychogenic action of holding, biting, and tearing the epithelium of the lips.

➡ Cheek biting, referred to as morsicatio buccarum, is a similar habit or

psychogenic behavior where the individual chews on the buccal mucosa (inner
cheek).

➡ Tongue biting and stripping of the epithelium using fingers or creating

negative pressure by sucking the lips and cheeks can also be part of these
factitial injuries.

➡ These behaviors are often seen in individuals who are experiencing

psychological stress or have underlying emotional issues.

➡ In some cases, gingiva may also be involved in factitial injuries. Habitual

gingival injury may occur when a patient uses their fingernails to press on the
attached gingiva or force the free gingival margin apically.
Clinical Features:
➡ These injuries are typically bilateral and are commonly found along the
occlusal line (where the upper and lower teeth meet) and on the vestibular
surface of the lips (the inner surface of the lips facing the oral cavity).

➡ The affected mucosa often appears white and shredded, with areas of
redness. Ulceration can also be a common feature.

➡ Factitial gingival injury, when it occurs, is characterized by vertical clefting in

the free gingiva (the part of the gums not attached to the teeth), exposure of
the tooth root, and the presence of gingival ulcers.

➡ It's worth noting that this condition is more prevalent in females.

Histologic Features:
➡ Histologically, extensive areas of hyperkeratosis (thickening of the outer
layer of skin or mucosa) can be observed, with keratin projections representing
the ragged areas.

➡ Chronic inflammatory cell infiltration is seen in the areas of ulceration.

Treatment:
➡ Counseling and psychotherapy are the preferred treatment options for
individuals with factitial injuries, as these behaviors often have underlying
psychological or emotional causes.

➡ In some cases, an acrylic shield can be used to prevent the teeth from
coming into contact with the lips and cheeks, reducing the opportunity for
further injury.
Denture injuries
The oral mucosa is subject to a variety of injuries as a result of the wearing of
artificial dentures. These may be manifested specifically as follows:
1. Traumatic ulcer
2. Generalized inflammation
3. Inflammatory hyperplasia
4. Papillary hyperplasia of palate
5. Denture base (acrylic) intolerance or allergy

Traumatic Ulcer (Sore Spots) Caused by Denture Irritation

Traumatic ulcers caused by denture irritation are similar to ulcers resulting from
various other forms of physical injuries.

Clinical Features:
➡ Denture ulcers typically develop within 1 or 2 days after the insertion of a new
denture. The ulceration may occur due to several factors, such as overextension
of the denture flanges, the presence of bone spicules trapped under the
denture, or the presence of rough, sharp, or high spots on the fitting surface of
the denture.

➡ These ulcers are usually small and painful, with irregular shapes. They are
often covered by a delicate gray necrotic membrane and are surrounded by an
inflammatory halo.

➡ Without proper treatment, there may be signs of tissue proliferation around

the periphery of the lesion due to an inflammatory response.

Histologic Features of Traumatic Ulcer (Sore Spots) Caused by Denture

Irritation
The histologic features of a traumatic ulcer caused by
denture irritation are as follows:
➡ The traumatic ulcer is a nonspecific ulcer microscopically, characterized by
the loss of continuity of the surface epithelium.

➡ The ulcerated area typically has a fibrinous exudate covering the exposed
connective tissue.

➡ The epithelium bordering the ulcer often exhibits proliferative activity,

indicating an attempt at tissue repair.

➡ In the connective tissue beneath the ulceration, there is infiltration of

polymorphonuclear leukocytes. In chronic lesions, these inflammatory cells may
be replaced by lymphocytes and plasma cells.

➡ Capillary dilatation and proliferation may also be evident in the affected

area.

➡ Fibroblastic activity can be prominent, suggesting a reparative response to

the injury.

➡ Macrophages may be present in moderate numbers, reflecting the presence

of an inflammatory process.

Generalized Inflammation (Denture Sore Mouth, Denture

Stomatitis)
Generalized inflammation of the oral mucosa, often referred to as "denture sore
mouth" or "denture stomatitis," is a condition that can affect patients who wear
dentures, whether they have new dentures or not.

This condition is not due to a true allergic reaction to denture materials, as

patch testing with denture materials typically yields negative results.
-Instead, it is associated with various factors, including Candida albicans
infection, denture trauma, prolonged denture wear, poor oral hygiene,
and potentially dietary and systemic factors.
Clinical Features:
➡ The mucosa beneath the denture becomes inflamed, leading to various
clinical features:
➡ Extreme redness of the mucosa
➡ Swelling of the affected area
➡ Smooth or granular appearance of the mucosa
➡ Pain and discomfort, often described as a severe burning sensation
➡ Multiple pinpoint areas of hyperemia (increased blood flow), typically
observed in the maxilla (upper jaw)
➡ The redness of the mucosa is sharply outlined and primarily occurs in areas
that are in direct contact with the denture.

Etiology:
➡ Candida albicans: In some cases, denture stomatitis may be associated with
a Candida albicans infection, although it does not always present with the
typical white patches seen in oral thrush. Cultures from patients with denture
stomatitis have shown the presence of yeast-like fungi of the C. albicans type.

➡ Denture trauma: Continuous pressure and irritation from ill-fitting or poorly

adjusted dentures can contribute to mucosal inflammation.

➡ Prolonged denture wear: Wearing dentures for extended periods without

adequate breaks can increase the risk of denture stomatitis.

➡ Poor oral hygiene habits: Inadequate cleaning of dentures and the oral cavity
can promote inflammation.

➡ Dietary and systemic factors: Dietary habits and certain systemic conditions
may also play a role in denture stomatitis.
Treatment:
The treatment of denture stomatitis typically involves addressing the
contributing factors:

➡ Antifungal therapy may be prescribed if a Candida albicans infection is

present.

➡ Adjustments to dentures to alleviate pressure points and trauma.

➡ Good denture hygiene practices, including regular cleaning and removal of

dentures at night.

➡ Improvement of overall oral hygiene.

➡ Dietary and systemic considerations may also be addressed.

Inflammatory (fibrous) hyperplasia (denture injury tumor, epulis

fissuratum)
Inflammatory fibrous hyperplasia, also known as denture injury tumor or epulis
fissuratum, is a common tissue reaction that occurs in response to chronic
irritation caused by ill-fitting dentures.

This condition can develop not only along the denture borders but also in other
areas of the oral mucosa where chronic irritation is present, such as the gingiva,
buccal mucosa, and angle of the mouth.

Clinical Features:
➡ Inflammatory fibrous hyperplasia typically manifests as the development of
elongated rolls or folds of tissue in the mucolabial or mucobuccal fold areas of
the mouth. These folds conveniently accommodate the ill-fitting denture flange.
➡ The proliferation of this tissue is usually a slow process and may result from
both the resorption of the alveolar ridge (bone) and the trauma caused by the
loose dentures.

➡ While this excess tissue fold is not highly inflamed in most cases, there may
be some irritation or even ulceration at the base of the fold where it
accommodates the denture flange.

➡ Clinically, the lesion feels firm to palpation.

Histologic Features:
The histological characteristics of inflammatory fibrous hyperplasia typically
include:

➡ An excessive mass of fibrous connective tissue, which makes up the bulk of

the lesion.

➡ The connective tissue is covered by a layer of stratified squamous epithelium.

This epithelial layer can be of normal thickness or may show acanthosis, which
is an abnormal thickening of the epithelium.

➡ Pseudoepitheliomatous hyperplasia, a condition where the epithelium

appears to proliferate excessively, is often found in these lesions.

➡ Hyperkeratosis, which is the thickening of the outer layer of the skin (stratum
corneum), is frequently present.

➡ The connective tissue consists mainly of coarse bundles of collagen fibers

and contains few fibroblasts (cells responsible for collagen production) or blood
vessels. However, an active inflammatory reaction may be seen in the base of
the fissure near the denture flange, especially if the tissue is superficially
ulcerated.
Treatment and Prognosis:
Inflammatory fibrous hyperplasia should be treated by surgical excision, which
involves removing the excess tissue. Additionally, it's essential to address the
cause of the condition, which is often ill-fitting dentures. Therefore, new
dentures should be constructed, or existing dentures should be rebased to
ensure proper fit and retention.

With appropriate treatment, the lesion is unlikely to recur, and the prognosis is
generally favorable. Properly fitting dentures and good oral hygiene practices
are essential to prevent the recurrence of this condition.

Inflammatory Papillary Hyperplasia (Palatal Papillomatosis):

Inflammatory papillary hyperplasia, also known as palatal papillomatosis, is an
unusual condition that affects the mucosa of the palate (roof of the mouth).
While the exact cause of this condition is unknown, it is often associated with
certain factors:

1. Ill-Fitting Dentures: One of the primary risk factors for inflammatory

papillary hyperplasia is the use of ill-fitting dentures. Dentures that do not fit
properly can cause frictional irritation to the palate's mucosa.

2. Poor Oral Hygiene: A lack of proper oral hygiene practices can contribute to
the development of this condition. Poor oral hygiene allows for the buildup of
debris, microorganisms, and irritants in the oral cavity.

3. Chronic Hyperplastic Candidiasis: In many cases, there is an association

between inflammatory papillary hyperplasia and chronic hyperplastic
candidiasis, which is a condition characterized by the chronic overgrowth of the
Candida yeast in the oral mucosa.

➡ Inflammatory papillary hyperplasia, or palatal papillomatosis, affects the

palate.

➡ Associated with ill-fitting dentures, poor oral hygiene, and sometimes chronic
candidiasis.
➡ Presents as small raised lesions on the palate.

➡ Microscopic features include small projections of stratified squamous

epithelium and connective tissue.

➡ Pseudoepitheliomatous hyperplasia may be present but is not indicative of

malignancy.

➡ Inflammatory cell infiltration and salivary gland inflammation can occur.

➡ Treatment involves improving denture fit, maintaining good oral hygiene, and
addressing candidiasis.

➡ Surgical excision of the lesion may be necessary before new dentures are
constructed.

➡ Proper management can prevent recurrence.

Denture Base Intolerance or Allergy:

➡ Denture base intolerance or allergy is a rare condition related to the
materials used in denture fabrication.

➡ It is extremely uncommon for individuals to develop a true allergy to denture

base materials.

➡ Soft liners in dentures contain plasticizers that have been found to be

cytotoxic and can impact cellular metabolic reactions in laboratory settings.

➡ In some rare instances, individuals may exhibit sensitivity or allergic

reactions to the monomer used in denture base materials, including both
regular and self-curing types.

➡ While cases of denture base intolerance or allergy have been reported, they
remain infrequent, and true allergies to these materials are rare.
➡ It's important for individuals experiencing any adverse reactions to their
dentures to consult with a dental professional for a proper evaluation and
potential solutions.

Sialolithiasis
➡ Definition: Sialolithiasis is the presence of a stone or calculus within salivary
ducts or glands, formed by calcium salt deposition around a central nidus,
potentially causing salivary gland obstruction.

Epidemiology: Most common in middle-aged adults, with submandibular gland

and duct (64%) involvement being more prevalent than parotid (20%) and
sublingual (16%).

Clinical Features:
➡ Pain: Patients often experience moderate to severe pain, especially before,
during, and after meals, due to stimulated salivary flow and gland swelling.

➡ Swelling: Obstruction by the stone prevents normal saliva flow, leading to

gland swelling.

➡ Diffuse Swelling: Swelling may appear diffuse, resembling cellulitis.

➡ Palpable Stones: Larger stones, if sufficiently sized, can sometimes be

palpated.

➡ Imaging: Techniques like dental radiography and sialography are used to

visualize stones; not all are visible on X-rays.

Involvement of Minor Salivary Glands:

➡ Sites: Sialolithiasis can affect minor salivary gland ducts, with the upper lip
(90%) and buccal mucosa being common locations.
 ➡ Presentation: Typically presents as solitary, firm, movable masses,
sometimes asymptomatic.

Etiology: The exact cause of sialolithiasis is unclear, with calcium salt deposition
around various central nidus types, including salivary mucins, cells, bacteria,
foreign bodies, or bacterial products.

Recurrence: Sialolithiasis can recur, and it may lead to both complete and
partial gland or duct blockage.

➡ Chemical and Physical Features:

➡ Shape: Sialoliths can vary in shape, including round, ovoid, or elongated
forms.

➡ Size: They may range from a few millimeters to over 2 cm in diameter.

➡ Number: Ducts can contain single or multiple stones.

➡ Surface: Sialoliths typically have a rough surface, potentially leading to duct

lining changes like squamous metaplasia.

➡ Color: They are usually yellow but may occasionally appear white or
yellowish-brown.

➡ Composition: Sialoliths consist mainly of calcium phosphates, with smaller

amounts of calcium carbonates, organic materials, and water. Submandibular
stones are typically larger than those in the parotid or minor glands.

➡ Histologic Features:
➡ Microscopic Appearance: Sialoliths exhibit concentric laminations around a
central nidus of amorphous debris.
 ➡ Lamellated Structure: The layered structure of the calculi results from
successive deposition of inorganic and organic materials.

➡ Inflammation: Periductal inflammation is often present. Ductal obstruction

can lead to acute or chronic sialadenitis in the affected gland.

➡ Treatment and Prognosis:

➡ Small Stones: Some small calculi may be removed through manipulation or
by stimulating salivation (e.g., sucking a lemon).

➡ Infection Management: Antibiotics may be necessary to treat bacterial

infections resulting from persistent duct obstruction.

➡ Large Stones: Larger stones usually require surgical removal, potentially

involving extirpation of the gland if they are deeply embedded.

➡ Alternative Treatment: Piezoelectric shock wave lithotripsy may be

considered as an alternative to surgical removal.

➡ Recurrence: Solitary sialoliths typically do not recur once removed.

Maxillary Antrolithiasis
(Antral Rhinolith):
Maxillary antrolithiasis is a relatively rare condition characterized by the
complete or partial calcific encrustation of a foreign body within the maxillary
sinus. This foreign body, known as a nidus, can be of endogenous (originating
from within the body) or exogenous (originating from outside the body) nature.

➡ Nidus Types: An endogenous nidus may be derived from dental structures

like a root tip or soft tissue, bone, blood, or mucus fragments. Exogenous nidi
are less common and may consist of materials like snuff paper.
➡ Clinical Features:
➡ Age and Gender: Maxillary antroliths can occur at any age and affect both
sexes.

➡ Symptoms: While some individuals with antroliths remain asymptomatic,

others may experience symptoms such as pain, sinusitis (sinus inflammation),
nasal obstruction, foul-smelling discharge, and even epistaxis (nosebleeds).

➡ Radiographic Discovery: In some cases, antroliths are incidentally

discovered during radiographic examinations, where an opaque mass is visible
within the maxillary sinus.

➡ Fungal Involvement: In certain instances, Aspergillus species may act as a

central fungal nidus, typically associated with chronic sinusitis and poor sinus
drainage, leading to the formation of a sinus stone.

➡ Treatment:
➡ Surgical Removal: The primary treatment for maxillary antrolithiasis is
surgical removal of the antrolith. This procedure is necessary to alleviate
symptoms and prevent potential complications.

Rhinolithiasis:
Rhinolithiasis refers to the presence of rhinoliths, which are calcareous
concretions that develop within the nasal cavity. These concretions are relatively
uncommon and are formed as a result of the calcification of either endogenous
(originating from within the body) or exogenous (originating from outside the
body) foreign materials within the nasal cavity.

➡ Age Distribution: While nasal foreign bodies are more commonly observed
in children, rhinoliths can develop in individuals of all age groups.
Clinical Features:
➡ Chronic Presence: Rhinoliths can persist within the nasal cavity for an
extended period, often years.

➡ Symptoms: They can lead to various symptoms, including:

➡ Odorous Discharge: Rhinoliths may cause foul-smelling nasal
discharge.
➡ Nasal Obstruction: Patients may experience symptoms of nasal
obstruction.
➡ Sinusitis: Rhinoliths can contribute to sinusitis, which is
inflammation of the sinuses.
➡ Epiphora: This term refers to excessive tearing or watery eyes.
➡ Pain: Some individuals with rhinoliths may experience pain.
➡ Epistaxis: Nosebleeds (epistaxis) can also occur as a result of
rhinoliths.