PHYSICAL AND CHEMICAL INJURIES OF THE ORAL CAVITY BDS III ORAL MEDICINE 29/02/2024 DR TSHEPHO KGOKOLO tshephok@hotmail.com 1 LEARNING OBJECTIVES Describe the clinical features of the different physical injuries Discuss clinical features chemical injuries Discuss osteoradionecrosis Discuss bisphosphonates-associated osteonecrosis 2 INTRODUCTION Lesions caused by physical and/or chemical agents are often found during routine examinations Common finding as oral cavity is exposed to trauma and chemical agents These agents range from traumatic occlusion, sharp occlusal anatomy, drugs, alkaline and acidic products and varying temperatures of food and drinks. 3 PHYSICAL INJURIES Linea Alba Morsicatio mucosae oris Traumatic ulcerations Electrical and thermal injuries 4 LINEA ALBA Common alteration of the buccal mucosa (normal aberration) Associated with pressure, frictional trauma or sucking pressure from buccal surfaces of teeth Clinical features: White line, usually bilateral May be scalloped Found on the buccal mucosa, at the level of the occlusal plane Restricted to dentate areas More pronounced posteriorly Female predominance 5 LINEA ALBA Olmo, 2022 6 MORSICATIO MUCOSAE ORIS Chronic mucosal nibbling,chewing or biting Classified according to location: Morsicatio buccarum (buccal mucosa) Morsicatio labiorum (labial mucosa) Morsicatio linguarum (lateral border of the tongue) Found in people who have psychologic conditions or stress Patient may be in denial or unaware of habit and injury 7 MORSICATIO MUCOSAE ORIS cont. Clinical features: Women older than 35 years Mostly bilateral on the anterior buccal mucosa, may be unilateral Other sites, lips and tongue Thick, shredded, white areas, may have erythematous areas, erosions and focal ulcerations Surface irregular and ragged Border blends into surrounding mucosa Histologic resemblance: oral hairy leukoplakia, uremic stomatitis, betel quid chewer’s mucosa 8 B C MORSICATIO MUCOSAE ORIS (C) Morsicatio linguarum (B) Morsicatio buccarum 9 (A) Morsicatio laborium TRAUMATIC ULCERATIONS Surface ulcerations can have different causes: systemic, malignancies, local causes, aphthous and drugs One of the local causes is trauma Ulcerations may be acute and chronic injuries Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) Mucosal and submucosal benign reactive inflammatory process, usually involving the tongue May be asymptomatic or associated with pain Self-limiting Slow-healing Differential diagnoses: OSCC,TB ulcer, syphilis and EBV ulcer In children: Riga-Fede disease Often associated with nursing of the newborn Sublingual ulcerations from adjacent anterior primary teeth 10 TRAUMATIC ULCERATIVE GRANULOMA WITH STROMAL EOSINOPHILIA (TUGSE) Clinical features: Patients older than 40 years (male predilection) Simple chronic ulcers may occur on the tongue (most common site), lips and buccal mucosa (from dentition) Ulcers on palate, gingiva and mucobuccal fold may be from other causes Erythematous areas surrounding a yellow, fibrinopurulent membrane Lesion may develop a rolled, white border of hyperkeratosis adjacent to the ulceration May mimic oral squamous carcinoma, biopsy is mandatory Treatment: Remove cause, pain management (topical anaesthetic or protective film like Orabase) 11 TRAUMATIC ULCERATIVE GRANULOMA WITH STROMAL EOSINOPHILIA (TUGSE) Ulcer on ventral surface of tongue (hyperkeratotic border) Riga-Fede disease: traumatic ulceration caused by natal tooth Source: Neville et al, 2016 12 SUBMUCOSAL HAEMORRHAGE Haemorrhage and subsequent entrapment of blood in the tissues Aetiology: Trauma, increased intra-thoracic pressure, thrombocytopenia, viral infections and implant placement Clinical features: Red, or purple to blue or bluish-black, non-blanching flat or elevated area Common site: labial and buccal mucosa When intra-thoracic pressure involved: skin of face and neck, and soft palate 13 DIFFERENT TERMS FOR SUBMUCOSAL HAEMORRHAGE (SIZE) Petechiae: minute haemorrhages into the skin, mucosa and serosa Purpura: slightly larger area than petechiae is covered Ecchymosis: accumulation greater than 2cm Haematoma: when the accumulation of blood within the tissue produces a mass 14 SUBMUCOSAL HAEMORRHAGE Blood trapped in palatal mucosa (dentalcare.com) Sublingual haematoma after implant placement (researchgate.com) 15 Traumatic haematoma with central ulceration (dentalaka.blogspot.com) Traumatic ulceration on posterior buccal mucosa (Neville et al, 2016) 16 ELECTRICAL INJURIES Constitutes 5% of burn injuries in admissions Types: contact (electric current through the body) and arc (saliva is a conductor) Clinical features: Most common sites affected: lips and commissures Initially: painless, charred, yellow appearance with little to no bleeding ~4th day: area becomes necrotic and begins to slough Occasionally: adjacent teeth become non vital, facial nerve paralysis (usually resolves) and malformation of teeth 17 ELECTRICAL INJURIES Neville et al, 2016 18 THERMAL INJURIES From ingestion of hot food and beverages Clinical features: Lesions usually seen on the palate and posterior buccal mucosa Zones of erythema and ulceration Often has remnants of necrotic epithelium at the periphery Swelling may affect upper airway if hot beverage is swallowed Treatment: most resolve with no treatment, if severe, antibiotics and corticosteroids are given 19 THERMAL INJURIES Thermal burn on palate (Neville et al, 2016) 20 CHEMICAL INJURIES Chemicals and drugs are caustic and can cause damage to the mucosa Chemicals and drugs placed in the oral cavity to resolve various problems Examples: aspirin, sodium perborate, hydrogen peroxide, gasoline and battery acid Tooth whitening products containing hydrogen peroxide and carbamide peroxidase Clinical features: Aspirin burn is common Extensive area of white epithelial necrosis of the buccal mucosa Prolonged exposure to aspirin placed to treat pain Treatment :Removal of cause 21 Aspirin burn on buccal mucosa (Neville et al, 2016) Aspirin burn on buccal mucosa extending into the vestibule and gingiva (capedental.com) 22 MUCOSITIS Complication of high dose chemotherapy and radiation therapy Aetiology: Chemotherapy-associated mucositis typically involves nonkeratinized surfaces Radiation-associated mucositis typically involves mucosal surfaces within direct portals of radiation Agents strongly associated: methotrexate, 5-fluorouracil, etoposide Clinical features: First sign: whitish discolouration due to insufficient desquamation of keratin Subsequently: replacement by atrophic mucosa (erythematous, oedematous and friable) Ulcerations develop with the formation of a removable yellowish, fibrinopurulent surface membrane 23 MUCOSITIS Radiation induced mucositis (dentistrytoday.com) Chemotherapy associated mucositis (Neville et al, 2016) 24 ANAESTHETIC NECROSIS Aetiology: Administration of local anaesthetic may cause injury and necrosis at site of injection (rare) Necrosis probably results from local ischaemia from faulty technique, excess solution into firmly bound tissues and epinephrine containing local anaesthetic. Clinical features: Found several days after procedure Common site: hard palate Ulceration erythematous and deep Slow healing 25 ANAESTHETIC NECROSIS juniordentist.com 26 MYOSPHERULOSIS Aetiology: Topical antibiotic in petrolatum base placed in a surgical site Foreign body reaction Most common site: extraction site to prevent alveolar osteitis Clinical features: Can occur at any site where antibiotic is placed Site may be swollen, painless and discovered on radiographs Well-circumscribed radiolucency on a previous extraction site May be painful, with purulent drainage and black tar-like material 27 28 Alveolar dressing used in the treatment of alveolar osteitis (Bowe et al, 2011) SMOKER’S MELANOSIS Oral pigmentations are significantly increased in heavy smokers Aetiology: Smoking history Leading to increased melanin production by melanocytes as a protective response Clinical features: Commonly seen on anterior facial gingiva in cigarette smokers Buccal mucosa in pipe smokers Areas of hyperpigmentation significantly increase in the first year of smoking 29 SMOKER’S MELANOSIS Hyperpigmentation of the oral mucosa (emedicine.medscape.com) 30 AMALGAM TATTOO Incorporation of dental amalgam within the oral mucosa Aetiology: Amalgam that deposits in soft tissues during dental treatment Clinical features: Black, blue or gray macules Well defined or irregular borders Usually, one site affected Common sites: gingiva, alveolar mucosa and buccal mucosa 31 Amalgam tattoos associated with amalgam restorations (pocketdentistry.com) 32 OSTEORADIONECROSIS Serious complication of head and neck radiation Risk of development is increased by surgical therapy within 21 days of radiation initiation or within 12 of radiation therapy Mostly arises secondary to local trauma, but may develop spontaneously Mostly develop in the mandible, may be found in the maxilla 33 OSTEORADIONECROSIS Serious complication of head and neck radiation The following may be present: Risk of development is increased by surgical therapy Intractable pain within 21 days of radiation initiation or within 12 of radiation therapy Mostly arises secondary to local trauma, but may develop spontaneously Fistula formation Surface ulceration Pathological fracture Mostly develop in the mandible, may be found in the maxilla 34 OSTEORADIONECROSIS cont. Clinical features: Bone necrosis, associated with radiation dose Other factors: Tumour proximity to bone Remaining dentition Type of treatment Age Male Poor health and nutritional status Tobacco and alcohol use 35 clinicalradiologyonline.net Radiographically: • Ill defined areas of radiolucency that eventually develop into radiopacities. • Cortical perforation and pathological fractures may be present Osteoradionecrosis of the mandible (pocketdentistry.com) 36 PREVENTION OF OSTEORADIONECROSIS Before radiation therapy: Extract or restore questionable teeth Eliminate foci of infection Improve oral hygiene At least 3 weeks of healing time *During radiation therapy is an absolute contraindication of extractions and bone trauma 37 TREATMENT AND PROGNOSIS OF OSTEORADIONECROSIS PREVENTION!!! Antibiotics Debridement Irrigation Removal of necrotic bone until bright bleeding edges are visible Hyperbaric oxygen use: controversial Low level laser therapy 38 BISPHOSPHONATE RELATED NECROSIS OF THE JAW BRONJ Bisphosphonates inhibit osteoclasts, may interfere with angiogenesis, and inhibit osteogenesis during bone healing Used to slow down osseous involvement of some cancers (multiple myeloma, metastatic breast and prostate cancer), Paget’s disease and treatment of osteoporosis 2 types: First generation Aminobisphosphonates (nitrogen containing) e.g. Zameta, Fosamax 39 BISPHOSPHONATE RELATED NECROSIS OF THE JAW Clinical and radiographic features: Majority of osteonecrosis found in jaws: medication incorporated in areas of active remodeling Intravenous formulations mostly affected >90% Factors affecting patients on oral bisphosphonates: Patients older than 45 years Corticosteroids Diabetes Smoking/ alcohol use Poor OH Prolonged use of bisphosphonates 40 BISPHOSPHONATE RELATED NECROSIS OF THE JAW Radiographically: bone may demonstrate increased radiopacity before clinical necrosis is seen May show periosteal hyperplasia Moth-eaten and ill-defined radiolucency, may have central sequestrate Treatment and prognosis: PREVENTION!! Avoid surgical therapy Eliminate dental bacterial biofilm Eliminate pain, minimise progression Systemic antibiotics and chlorhexidine in symptomatic. 41 Bisphosphonate-associated necrosis of the mandible (aafp.org) The clinical picture of bisphosphonate-associated osteonecrosis of the jaw is rather similar to the lesions seen in patients with infected osteoradionecrosis. Clinical pictures of a stage 2 bisphosphonateassociated osteonecrosis of the jaw (A) and infected 42 osteoradionecrosis (B) REFERENCES Bowe, D C et al. “The management of dry socket/alveolar osteitis.” Journal of the Irish Dental Association 57 6 (2011): 305-10 . Neville, B.W., Damm, D.D. and Allen, C.M., Chi, A.C., 2016. Oral and Maxillofacial Pathology. Elsevier Health Sciences. Scully, C., 2012. Oral and maxillofacial medicine: the basis of diagnosis and treatment. Elsevier Health Sciences. 43
