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

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

Post extraction lingual mucosal ulceration

with bone necrosis
a,*
Juma Alkhabuli , Vladimir Kokovic b, Abdullah Emad c

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

Received 20 February 2015; revised 29 March 2015; accepted 6 April 2015

Available online 27 April 2015

KEYWORDS 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
Cortical necrosis;
patient had extraction a few days before development of the ulcer. The patient’s medical history
Post-extraction;
was clear and not on any drugs. Clinically, he presented with moderate pain and discomfort.
Oral ulceration;
Mucositis; Intraoral examination revealed a discrete ulcer of about 1 cm in diameter and exposure of the
Bone diseases 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 CC BY-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-
* Corresponding author at: RAK College of Dental Sciences, P.O. oid region. Injury to this region may lead to full thickness
Box: 12973, RAK, United Arab Emirates. Tel.: +971 72222593. ulceration and subsequent exposure of the cortical bone.
E-mail address: juma@rakmhsu.ac.ae (J. Alkhabuli). Furthermore, prominent mylohyoid ridge or mandibular tori
Peer review under responsibility of King Saud University. place this area at a high risk of traumatic ulceration.1,2 The
exposed lingual bone invariably endures ischemic necrosis
and possibly sequestration. In addition, poor vascularization
of this anatomical site prolongs the healing process from a
Production and hosting by Elsevier
week to several months.3,4
http://dx.doi.org/10.1016/j.sjdr.2015.04.002
2352-0035 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/).
Post extraction lingual mucosal ulceration with bone necrosis 35

Oral ulceration with potential osteitis or sequestration has

been associated with numerous factors, such as aphthous
stomatitis, systemic diseases, oral bisphosphonate, syphilis
and radiotherapy.5–8 Onset of bone necrosis can be provoked
by a number of conditions related to poor host immune
response, including immunosuppression, diabetes mellitus,
malnutrition and extreme age.9
Although lingual mucosal ulceration (LMU) with
osteonecrosis 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 of
LMU, two involving a history of recent extraction. In one of
the cases, ulceration developed a week after extraction with
no associated trauma. In the second case ulceration developed
a month after extraction and the exposed necrotic bone further
caused traumatic ulceration to the lateral surface of the ton- Figure 1 Initial presentation of the ulcer and cortical bone
gue. Several cases of spontaneous LMU with osteonecrosis necrosis.
‘‘Idiopathic benign sequestration of the mandible’’ have been
reported in various forms and sizes and were neither associated
with history of trauma nor extraction. Interestingly, one of the
reported cases had simultaneous bilateral lingual ulceration
with bone exposure.11–13
Obviously, trauma is the most common cause of oral ulcer-
ation. There is an array of diverse etiological factors including
iatrogenic damage during dental treatment that may clinically
manifest 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 familiar
with these lesions. The affected patients usually presented with
mild to moderate pain and discomfort. The clinical presenta-
tion reveals an avascular yellowish necrotic bone at the base
of the ulcer. There might be necrotic bone spicules projecting
out, which may cause trauma to the adjacent soft tissues.
The ulcer margins may show redness and irregularities.
Figure 2 A radiograph revealing extraction socket (before
Usually, there are no or subtle bone changes, therefore radio-
surgical intervention).
graphic examination has little or no value to add in the
examination.
to be healing normally. Ulcer margins and tissues in the vicin-
2. Case report ity were edematous, sensitive and erythematous. The yellowish
exposed bone (osteonecrotic bone) was insensitive with no sign
A 49-year-old male patient attended the oral diagnosis depart- of vascularity; however, not separated from the lingual plate
ment, College of Dentistry, Medical and Health Sciences (no sequestrum formation). Extra-oral examination revealed
University, Ras Al-Khaimah, UAE complaining of moderate no swelling, tenderness or regional lymphadenopathy. A radio-
pain on the lower right lingual mucosa of 3 days duration. graph was taken but showed no evidence of any pathology
Pain developed a few days after the extraction of his lower (Fig. 2). No other findings of significance were noticed. A diag-
right third molar. The extraction was performed by a senior nosis of idiopathic lingual ulcer with ostietis was made.
dental surgeon in the college dental clinic. Review of the The treatment was initiated by filing the exposed bone
patient’s medical and dental history, revealed neither he was under inferior alveolar nerve block to avoid any injury to the
suffering from systemic illnesses nor taking any medicine. He tongue. Oral antibiotics in the form of Amoxicillin 500 mg
reported pain in relation to a badly decayed 48 tooth, which three times daily for 5 days and Brufen 400 mg tablets twice
was removed without any difficulty or complication. daily were prescribed to control the acute phase of the condi-
However, one interrupted suture was placed on the mesial tion. In the second visit (4 days later), clinically, most of the
aspect of the socket to approximate the soft tissues, which were acute signs and symptoms had been resolved. Under mandibu-
elevated to take a deep grip of the broken crown. lar nerve block anesthesia, the margins of the ulcer were
Intraoral examination revealed a round ulcer with an ery- slightly elevated by periosteal elevator and the lingual necrotic
thematous halo of 1cm in diameter associated with exposure bone at the base of the ulcer was removed by surgical bur
of the underlying bone. The ulcer was located on the right lin- down to the vascularized bone layer (Fig. 3). The freshly
gual aspect of the extraction socket, just above the mylohyoid exposed bone was covered by iodoform gauze and sutured in
ridge line (Fig. 1). The socket was filled with clot and appeared place to promote healing (Fig. 4). Post-surgical instructions
36
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.
including maintenance of good oral health with the aid of
antiseptic 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 healed
completely within 3 weeks (Fig. 6).
J. Alkhabuli et al.
Figure 6 Complete healing of the lesion by the fourth week of
surgery.
3. Discussion
LMU with osteonecrosis is not commonly seen in daily dental
practices, thus understating of the potential causes, differential
diagnosis and clinical presentations is paramount, particularly
to general dental practitioners.
Normally, the lower posterior teeth are lingually inclined
and 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 vulnerable
to masticatory forces or occlusal trauma, which may lead to
ulceration and bone denudation.
Wounds associated with the surgical removal of third
molars 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, the
lingual cortex is distant from the main vascular bed of the
mandible 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 been
reported 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 the
lingual cortical bone necrosis is far from the diagnosis of minor
aphthous ulcer.
Patients are usually unaware of bone exostosis or enlarged
mylohyoid ridge until trauma causes ulceration. A careful
examination 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. This
is probably due to the early diagnosis and management of
the case.
Post extraction lingual mucosal ulceration with bone necrosis
A variety of treatment modalities including prescription of
antibacterial mouth rinses and anti-inflammatory creams as
non-invasive and supportive treatment to aid the healing pro-
cess have been advocated.2 Potential injury to tongue from the
exposed 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 any
surgical intervention. However, some authors are reluctant
to active surgical intervention asserting compromised cortical
bone vascularity.2 In the absence of clear sequestration,
removal of the necrotic surface layer provides better and
quicker healing environment. The presented case showed com-
plete healing in approximately 3 weeks after surgery. A radio-
graphic examination 6 weeks post-surgical intervention
revealed no adverse bone changes.
4. Conclusion
Lingual mucosal ulceration and associated osteonecrosis are
presented clinically with mild to moderate symptoms. There
might be an iatrogenic cause, nevertheless, in many cases there
is no obvious attributable factor making the diagnosis quite
challenging. Although oral and maxillofacial surgeons are
encountering such cases in their practices, it is imperative for
general dental practitioners to be familiar with the potential
etiological factors and clinical presentation to exclude any sin-
ister pathology and properly treat the patients.
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