The Saudi Journal for Dental Research (2016) 7, 34–37

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sawww.sciencedirect.com

CASE REPORT

Post extraction lingual mucosal ulceration

with bone necrosis

* Corresponding author at: RAK College of Dental Sciences, P.O.

Box: 12973, RAK, United Arab Emirates. Tel.: +971 72222593.

E-mail address: juma@rakmhsu.ac.ae (J. Alkhabuli).

Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

http://dx.doi.org/10.1016/j.sjdr.2015.04.0022352-0035 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Juma Alkhabuli a,*, Vladimir Kokovic b, Abdullah Emad c

a Basic and Medical Sciences Department, RAK College of Dental Sciences, United Arab Emiratesb Oral Surgery, RAK College of Dental Sciences, United Arab Emiratesc RAK College of Dental Sciences, United Arab Emirates

Received 20 February 2015; revised 29 March 2015; accepted 6 April 2015Available online 27 April 2015

KEYWORDS

Cortical necrosis;

Post-extraction;

Oral ulceration;

Mucositis;

Bone diseases

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 pro-

cess. 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.ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is

an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Mucosa covering the lingual cortex of mandible is thin and

vulnerable to trauma, particularly the posterior supra mylohy-oid region. Injury to this region may lead to full thicknessulceration and subsequent exposure of the cortical bone.Furthermore, prominent mylohyoid ridge or mandibular tori

place this area at a high risk of traumatic ulceration.1,2 Theexposed lingual bone invariably endures ischemic necrosisand possibly sequestration. In addition, poor vascularization

of this anatomical site prolongs the healing process from aweek to several months.3,4

Figure 1 Initial presentation of the ulcer and cortical bone

necrosis.

Figure 2 A radiograph revealing extraction socket (before

surgical intervention).

Post extraction lingual mucosal ulceration with bone necrosis 35

Oral ulceration with potential osteitis or sequestration hasbeen associated with numerous factors, such as aphthousstomatitis, systemic diseases, oral bisphosphonate, syphilis

and radiotherapy.5–8 Onset of bone necrosis can be provokedby a number of conditions related to poor host immuneresponse, including immunosuppression, diabetes mellitus,

malnutrition and extreme age.9

Although lingual mucosal ulceration (LMU) withosteonecrosis following extraction of lower molars is uncom-

mon, it remains a known condition among oral and maxillofa-cial surgeons. Jackson and Malden10 reported three cases ofLMU, two involving a history of recent extraction. In one ofthe cases, ulceration developed a week after extraction with

no associated trauma. In the second case ulceration developeda month after extraction and the exposed necrotic bone furthercaused traumatic ulceration to the lateral surface of the ton-

gue. Several cases of spontaneous LMU with osteonecrosis‘‘Idiopathic benign sequestration of the mandible’’ have beenreported in various forms and sizes and were neither associated

with history of trauma nor extraction. Interestingly, one of thereported cases had simultaneous bilateral lingual ulcerationwith bone exposure.11–13

Obviously, trauma is the most common cause of oral ulcer-ation. There is an array of diverse etiological factors includingiatrogenic damage during dental treatment that may clinicallymanifest as ulcers or bone necrosis with sequestration.14

Nevertheless, in the majority of these cases the cause is identi-fiable and a differential diagnosis can be made.

Oral and maxillofacial surgeons are aware of these condi-

tions; nevertheless, general dental practitioners are less familiarwith these lesions. The affected patients usually presented withmild to moderate pain and discomfort. The clinical presenta-

tion reveals an avascular yellowish necrotic bone at the baseof the ulcer. There might be necrotic bone spicules projectingout, 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 radio-graphic examination has little or no value to add in theexamination.

2. Case report

A 49-year-old male patient attended the oral diagnosis depart-

ment, College of Dentistry, Medical and Health SciencesUniversity, Ras Al-Khaimah, UAE complaining of moderatepain on the lower right lingual mucosa of 3 days duration.

Pain developed a few days after the extraction of his lowerright third molar. The extraction was performed by a seniordental surgeon in the college dental clinic. Review of the

patient’s medical and dental history, revealed neither he wassuffering from systemic illnesses nor taking any medicine. Hereported pain in relation to a badly decayed 48 tooth, whichwas removed without any difficulty or complication.

However, one interrupted suture was placed on the mesialaspect of the socket to approximate the soft tissues, which wereelevated to take a deep grip of the broken crown.

Intraoral examination revealed a round ulcer with an ery-thematous halo of 1cm in diameter associated with exposureof the underlying bone. The ulcer was located on the right lin-

gual aspect of the extraction socket, just above the mylohyoidridge line (Fig. 1). The socket was filled with clot and appeared

to be healing normally. Ulcer margins and tissues in the vicin-ity were edematous, sensitive and erythematous. The yellowishexposed bone (osteonecrotic bone) was insensitive with no signof vascularity; however, not separated from the lingual plate

(no sequestrum formation). Extra-oral examination revealedno swelling, tenderness or regional lymphadenopathy. A radio-graph was taken but showed no evidence of any pathology

(Fig. 2). No other findings of significance were noticed. A diag-nosis 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 thetongue. Oral antibiotics in the form of Amoxicillin 500 mgthree times daily for 5 days and Brufen 400 mg tablets twice

daily were prescribed to control the acute phase of the condi-tion. In the second visit (4 days later), clinically, most of theacute signs and symptoms had been resolved. Under mandibu-lar nerve block anesthesia, the margins of the ulcer were

slightly elevated by periosteal elevator and the lingual necroticbone at the base of the ulcer was removed by surgical burdown to the vascularized bone layer (Fig. 3). The freshly

exposed bone was covered by iodoform gauze and sutured inplace to promote healing (Fig. 4). Post-surgical instructions

Figure 3 Surgical removal of the necrotic bone and exposure of

the vial bone.

Figure 4 Idoform gauze sutured in place to promote the healing

process.

Figure 5 48 h postsurgical intervention depicting the initial

epithelialization process.

Figure 6 Complete healing of the lesion by the fourth week of

surgery.

36 J. Alkhabuli et al.

including maintenance of good oral health with the aid ofantiseptic mouth rinse were given to the patient. The patient

was reviewed 48 h after surgery and good initial epithelializa-tion of the ulcer was evident (Fig. 5). The condition was healedcompletely within 3 weeks (Fig. 6).

3. Discussion

LMU with osteonecrosis is not commonly seen in daily dental

practices, thus understating of the potential causes, differentialdiagnosis and clinical presentations is paramount, particularlyto general dental practitioners.

Normally, the lower posterior teeth are lingually inclinedand 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 vulnerableto masticatory forces or occlusal trauma, which may lead toulceration and bone denudation.

Wounds associated with the surgical removal of thirdmolars are invariably closed with multiple sutures.Theoretically, tongue and associated tissues may exert a mus-cular 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, thelingual cortex is distant from the main vascular bed of themandible 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 beenreported that minor trauma, such as those arising from scaling

or even thermoplastic impression materials may initiate ulcer-ation with subsequent bone necrosis.5,16 Trauma is a well-known precipitating factor in minor aphthous stomatitis, how-

ever, the clinical picture of the present case, particularly thelingual cortical bone necrosis is far from the diagnosis of minoraphthous ulcer.

Patients are usually unaware of bone exostosis or enlargedmylohyoid ridge until trauma causes ulceration. A carefulexamination of our case confirmed that none of such abnor-

malities 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 radio-

graphically could see evidence of sequestrum formation. Thisis probably due to the early diagnosis and management ofthe case.

Post extraction lingual mucosal ulceration with bone necrosis 37

A variety of treatment modalities including prescription ofantibacterial mouth rinses and anti-inflammatory creams asnon-invasive and supportive treatment to aid the healing pro-

cess have been advocated.2 Potential injury to tongue from theexposed necrotic bone has been reported.10 Therefore, control-ling of the acute symptoms and prevention of potential compli-

cation, as described earlier are mandatory and prior to anysurgical intervention. However, some authors are reluctantto active surgical intervention asserting compromised cortical

bone vascularity.2 In the absence of clear sequestration,removal of the necrotic surface layer provides better andquicker healing environment. The presented case showed com-plete healing in approximately 3 weeks after surgery. A radio-

graphic examination 6 weeks post-surgical interventionrevealed no adverse bone changes.

4. Conclusion

Lingual mucosal ulceration and associated osteonecrosis arepresented clinically with mild to moderate symptoms. There

might be an iatrogenic cause, nevertheless, in many cases thereis no obvious attributable factor making the diagnosis quitechallenging. Although oral and maxillofacial surgeons are

encountering such cases in their practices, it is imperative forgeneral dental practitioners to be familiar with the potentialetiological factors and clinical presentation to exclude any sin-

ister pathology and properly treat the patients.

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