Volume 75 • Number 5
Case Series
Traumatic Lesions of the Gingiva: A Case Series
Swati Y. Rawal,* Lewis J. Claman,* John R. Kalmar,† and Dimitris N. Tatakis*
Background: The most recent classification of peri-
odontal diseases includes a new section on traumatic
gingival lesions. Traumatic lesions of the gingiva are
thought to be highly prevalent, yet the periodontal lit-
erature contains few references on the topic. The pur-
pose of this article is to present a broad spectrum of
traumatic gingival lesions of iatrogenic, accidental, and
factitious origin.
Methods: Twelve clinical cases were selected to doc-
ument chemical (due to aspirin, snuff, and peroxide),
physical (due to malocclusion, flossing, removable par-
tial denture, oral piercing, and self-inflicted trauma),
and thermal (due to overheated ultrasonic scaler, hot
food, and ice) injury to the gingiva.
Results: Chemical, physical, and thermal gingival
injuries of iatrogenic, accidental, or factitious origin can
have a variety of presentations with overlapping clin-
ical features. Although the appearance and associated
symptoms of a gingival lesion may be suggestive of a
particular traumatic etiology, useful or confirmatory
diagnostic information is often discovered through care-
ful history-taking. The management of gingival injuries
typically requires elimination of the insult and symp-
tomatic therapy. If permanent gingival defects resulted
from the injury, periodontal plastic surgery may be
necessary.
Conclusions: A variety of chemical, physical, and
thermal injuries may involve the gingiva. Accidental
and iatrogenic injuries are often acute and self-limiting,
while factitious injuries tend to be more chronic in
nature. J Periodontol 2004;75:762-769.
KEY WORDS
Frostbite; gingiva/injuries; gingival diseases/
diagnosis; gingival diseases/etiology; gingival
diseases/pathology; gingival recession; self-injurious
behavior; self-mutilation.
* Section of Periodontology, College of Dentistry, The Ohio State University
Health Sciences Center, Columbus, OH.
† Section of Oral Pathology, College of Dentistry, The Ohio State University
Health Sciences Center.
762
The most recent classification of periodontal diseases
introduced a new section on gingival diseases.1 Besides
the highly prevalent dental plaque-induced gingival con-
ditions,2 the system includes a wide range of non-plaque
induced gingival lesions.3 Among this latter group, trau-
matic lesions are a specific subcategory. Despite the
probable high prevalence of traumatic gingival lesions,
the periodontal literature contains few references on the
topic (and the various subtopics), as determined from
the published reviews3 and our online literature search
of MEDLINE. The purpose of this article is to present a
series of cases that encompasses and illustrates the
broad spectrum of traumatic gingival lesions (i.e., chem-
ical, physical, and thermal injury) stemming from iatro-
genic, accidental, or factitious origin.
CLINICAL REPORTS
Chemical Injury
Case 1: Aspirin burn. A 74-year-old male patient pre-
sented with pain arising from the area of a recent den-
tal extraction (tooth #18). A loosely adherent yellow white
plaque-like lesion was noted on the buccal attached gin-
giva of the mandibular left second premolar (Fig. 1). The
lesion extended apically to the alveolar mucosa and
vestibule. Erythema was present on the margins of the
lesion. Upon questioning, the patient complained of dis-
comfort in the area and reported that he had been apply-
ing a paste of crushed aspirin and water to the mandibular
left side for a few days prior to presentation. The patient
was advised to discontinue use of the paste. The area was
gently cleansed and chlorhexidine (0.12%) was applied.
Systemic analgesic medication (acetaminophen 1g, every
6 hours) was prescribed for 3 days.
Case 2: Gingival lesion due to snuff holding. A
38-year-old male patient presented with an asympto-
matic gingival recession localized on the labial aspect of
tooth #25 (Fig. 2). The attached gingiva near the apical
aspect of the recession was slightly white in appearance.
The alveolar and labial mucosa appeared thickened,
wrinkled, and white in color. The patient communicated
a history of placing snuff in the anterior mandibular
vestibule. The proposed treatment plan included dis-
continuation of the habit, scaling and root planing, oral
hygiene instructions, and gingival grafting.
Case 3: Hydrogen peroxide burn. A 25-year-old male
presented with a chief complaint of pain and ulceration
J Periodontol • May 2004
Figure 1.
Case 1: Aspirin burn. Note the extent of the lesion from the buccal
attached gingiva to the alveolar mucosa and vestibule.
Figure 2.
Case 2: Snuff lesion. Gingiva and alveolar mucosa are slightly white in
appearance, while the alveolar and labial mucosa are also wrinkled
and appear thickened.
in the right maxillary region. He reported gingival dis-
comfort for several days that prompted him to repeat-
edly apply hydrogen peroxide (3%) to the region with
a cotton swab. Examination revealed an extensive area
of ulceration and erythema, from canine to first molar,
involving primarily the marginal and attached gingiva
with minimal alveolar mucosal involvement (Fig. 3).
The patient was advised to discontinue use of undiluted
hydrogen peroxide and the area was gently rinsed with
saline to remove necrotic tissue. A topical anesthetic
gel was applied and a prescription was given for the
same. A bland diet was recommended and a 1-week fol-
low-up scheduled for periodontal examination to ascer-
tain the cause for the gingival discomfort that had led
to the application of hydrogen peroxide.
Rawal, Claman, Kalmar, Tatakis
Figure 3.
Case 3: Hydrogen peroxide burn. Ulceration and erythema are readily
apparent. (Photograph courtesy of Dr. Carl Allen, Columbus, Ohio.)
Physical Injury
Case 4: Gingival injury (facial) due to malocclusion.
A middle-aged female patient presented with gingival
recession on the labial aspect of the mandibular ante-
rior teeth (Fig. 4A). Cervical abrasions were also evi-
dent. Periodontal probing depths in the area were less
than 3 mm and the gingiva exhibited no clinical evi-
dence of inflammation. There was little to no attach-
ment loss in the interproximal areas of the affected
teeth. Occlusal examination revealed a deep overbite
with the incisal edge and palatal aspect of the maxil-
lary central incisors contacting the labial aspect and
gingival margin of the mandibular anterior teeth (Fig.
4B). The proposed treatment plan included ortho-
dontic treatment to correct the overbite followed by
gingival grafting to correct the mucogingival defor-
mity.
Case 5: Gingival injury (palatal) due to malocclusion.
A 36-year-old male patient presented with gingival
recession on the palatal aspect of the maxillary central
incisors (Fig. 5). Gingival erythema was present, along
with signs of injury corresponding to the incisal edges
of the mandibular incisors. The palatal aspects of teeth
#8 and #9 revealed attrition lesions near the cingulum,
coinciding with the incisal edge of tooth #25, which was
labially positioned. After initial periodontal therapy, the
patient was referred to the orthodontic department for
consultation.
Case 6: Flossing injury. A 42-year-old female patient
presented with gingival recession and clefting on the
mesial aspect of the maxillary left first molar (Fig. 6A).
There was no bleeding on probing and the gingiva had
normal color and consistency. The dental history
revealed that the patient was very meticulous about her
oral hygiene and flossed overzealously. She habitually
forced the dental floss deep into the gingival sulcus and
763
Traumatic Lesions of the Gingiva
Figure 4.
Case 4: Gingival injury due to malocclusion. A) The lesion is localized
on the labial aspect of the mandibular anterior teeth. B) The position
of the maxillary anterior teeth in occlusion.
Figure 5.
Case 5: Gingival injury due to malocclusion. The lesion is localized
on the palatal aspect of the maxillary incisor teeth. Note the
imprint of the incisal edge of tooth #26 on the palatal gingiva
of tooth #8.
764
Volume 75 • Number 5
Figure 6.
Case 6: Flossing injury. A) Buccal view of the lesion (mirror image). B) The
patient demonstrating the manner in which she used the floss in the area.
used it in a sawing motion. She also demonstrated this
by placing the floss in the defect (Fig. 6B). She was in-
structed on the correct method of flossing to prevent fur-
ther injury to the gingiva and placed on a maintenance
program.
Case 7: Gingival trauma due to removable partial
denture. An elderly male patient presented with gin-
gival recession on the lingual surfaces of the mandibu-
lar anterior teeth. The recession defects were much
more pronounced on the canines. In addition, a linear
soft tissue depression was present in the gingiva, from
canine to canine, approximately at the apical level of
the canine recession defects (Fig. 7A). Except for the
depicted teeth, the patient was edentulous and wore a
removable partial denture. The canine recession defects
and the soft tissue depression present were associated
with the position of the major connector of the partial
denture. Insertion of the partial denture resulted in evi-
dent localized ischemia (Fig. 7B). The treatment plan
included construction of an interim removable partial
denture, gingival grafting for the lingual aspect of the
J Periodontol • May 2004
Figure 7.
Case 7: Gingival trauma from removable partial denture. A) The lesions
(recession, linear depression) on the lingual aspect of the mandibular
anterior teeth. B) The removable partial denture in place. Note the
blanching of the gingiva associated with the denture (arrow).
canines, and fabrication of a permanent removable
partial denture.
Case 8: Factitious gingival injury. A 28-year-old
male patient presented with an unusual form of gingi-
val recession of the maxillary central incisors, involving
the labial and interproximal areas. There was complete
destruction of the interdental papilla between teeth #8
and #9 with reverse gingival architecture (Fig. 8). The
gingiva was of normal color and consistency. The inci-
sive papilla on the palatal aspect was reduced. Plaque
control by the patient was adequate and probing depths
were within normal limits. There was significant wear
of the incisal edges of teeth #8 and #9. The patient
related a history of fingernail biting and forcing his
thumbnail between the central incisors. The patient was
counseled regarding the destructive habit and advised
to make every effort to discontinue it. The periodontal
treatment plan included the placement of a connective
tissue graft to minimize the gingival recession.
Rawal, Claman, Kalmar, Tatakis
Figure 8.
Case 8: Factitious gingival injury.The gingival color is normal
and the extent of tissue loss on the labial surface of the central
incisors is significant.
Case 9: Gingival trauma caused by oral piercing.
A young female patient presented with asymptomatic
gingival recessions affecting the lingual surface of the
mandibular central incisors (Fig. 9A). Her tongue had
previously been pierced and she was wearing a tongue
barbell. Her oral hygiene was adequate and probing
depths were within normal limits. The gingiva in the
recession areas was generally erythematous with
slightly white appearance at the gingival margin, which
was more pronounced on tooth #24. The erythema-
tous appearance extended into the alveolar mucosa,
also more pronounced lingual to tooth #24. Exami-
nation revealed mucogingival deformities where the
tongue barbell was in repeated contact with the gingi-
val margin of the mandibular central incisors, more
readily seen on tooth #24 (Fig. 9B). The patient was
informed of the gingival condition and advised to have
the tongue barbell removed, followed by a connective
tissue graft.
Thermal Injury
Case 10: Burn injury caused by overheated ultrasonic
scaler tip. A 21-year-old male patient diagnosed with
generalized aggressive periodontitis presented for the
disease control phase of therapy. After administration
of local anesthesia, an ultrasonic scaler was used as the
first means to perform scaling and root planing. Dur-
ing the course of the procedure, the instrument tip
became overheated and caused burns to the patient’s
lower lip (vermilion border), labial mucosa, and gingiva.
The lesions on the labial mucosa and vermilion border
presented as a white slough. The gingival lesion con-
sisted of an erosion involving the papillary, marginal,
and attached gingiva, where sloughing of the surface
epithelium had occurred (Fig. 10). The erosion ex-
765
Traumatic Lesions of the Gingiva
Figure 9.
Case 9: Gingival trauma from oral piercing. A) Note the greater
involvement of the gingiva and alveolar mucosa on the lingual of tooth
#24. B) The tongue barbell as routinely placed by the patient against
the same area (Photographs courtesy of Dr. James Chou, Columbus,
Ohio).
tended slightly apical to the mucogingival junction. The
lesions were treated by application of an anesthetic
topical gel (benzocaine 20%) and chlorhexidine (0.12%)
mouthrinse.
Case 11: Burn injury caused by hot baked potato.
A middle-aged male patient presented with mild pain
in the right palatal region. Examination revealed
erythema of the marginal gingiva and palatal mucosa
around the maxillary right premolars and first molar.
Focal areas of ulceration and sloughing were also noted
(Fig. 11). The history revealed that the patient had
previously bitten into a hot baked potato, resulting in
the burn injury. The treatment plan included recom-
mendation for a bland diet and application of topical
anesthetic gel (benzocaine 20%) for pain relief.
Case 12: Frostbite injury. A young male patient
presented to the emergency dental clinic with a tooth-
ache related to the maxillary right first molar. Exam-
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Volume 75 • Number 5
Figure 10.
Case 10: Burn injury from overheated ultrasonic scaler. Note the extent
of the erosion present.
Figure 11.
Case 11: Hot baked potato injury. Erythema and focal areas
of ulceration are evident.
ination revealed a creamy white slough extending
from the marginal gingiva of the first molar apically
to the alveolar mucosa and buccal vestibule (Fig.
12). The lesion was more extensive in the vestibular
area and clearly demarcated from the surrounding
unaffected area by a thin erythematous margin. The
patient reported that he had a severe toothache the
night before and called the emergency room. The
emergency room personnel advised him to apply ice
to the area. The patient stated that he then began
applying ice cubes to the area, continuously, one after
another, for about 7 hours. A diagnosis of cold injury
(mucosal frostbite) and necrosis was made. Man-
agement included analgesic prescription (ibuprofen
600 mg, every 6 hours) and definitive dental treat-
ment.
J Periodontol • May 2004
Figure 12.
Case 12: Frostbite injury.White slough clearly demarcated from
the surrounding unaffected area by a thin erythematous margin.
(Photograph courtesy of Dr. Douglas Damm, Lexington, Kentucky).
DISCUSSION
One of the unique features of the most recent classifi-
cation of periodontal diseases is the recognition of non-
plaque induced traumatic gingival lesions as distinct
periodontal conditions.1 Traumatic lesions, whether
chemical, physical, or thermal in nature, are among the
most common in the mouth.4,5 Although the preval-
ence of traumatic lesions on the gingiva is not known,
it has been suggested that gingival presentations are
rare for traumatic oral lesions.6
Chemical injuries of the gingiva and oral mucosa
may readily occur due to the large number of chemical
substances, such as drugs and various agents, which
come in contact with the oral cavity. Among the com-
monly implicated substances are aspirin; hydrogen per-
oxide; silver nitrate; phenol; and endodontic materials
such as paraformaldehyde, sodium hypochlorite, and
calcium hydroxide.6-9 Burns of the oral mucosa induced
by salicylic acid and its derivatives have been reported
in several cases.10-12 Injury due to peroxide prepara-
tions has been reported by several authors, and in some
reports appears associated with use of vital bleaching
agents.13,14 Smokeless tobacco use has been associ-
ated with gingival recession in some patients, among
other oral changes.15,16 A characteristic painless loss
of gingival and periodontal tissues has been reported
in the area of repeated placement of the tobacco pro-
duct. Topical application of cocaine has been associated
with chemical injury of the gingiva.17,18 Even topical
use of alcohol has been reported to cause mucosal and
gingival injury.7,19
The majority of traumatic lesions seen by dental
practitioners probably stem from accidental physical
injuries. Emergency room personnel frequently are the
first to see severe physical injury cases related to acci-
Rawal, Claman, Kalmar, Tatakis
dents.20-22 Besides accidents, causes of physical injury
include malocclusion, poorly fitting removable partial
dentures, overly aggressive or improper oral hygiene
practices, oral piercing, and self-inflicted trauma.
Deep overbite has been associated with gingival
inflammation and recession. Excessive incisor overlap
may result in injury to both soft tissues and teeth. Gin-
gival abrasion, recession, and attrition of root surfaces
are common findings. These are found either palatally
in the maxillary anterior segment or labially in the
mandibular anterior segment.23
Pressure from a poorly designed or fitting denture
clasp or partial denture can cause gingival trauma
and recession. Studies have confirmed the relation-
ship between removable partial dentures and gingival
recession.24,25
Iatrogenic gingival injuries, most predominantly phys-
ical in nature, are quite common. Iatrogenic gingival
injuries have been attributed to rotary or other instru-
ments accidentally slipping during tooth preparation or
other dental procedures,26 to rubber dam clamp imping-
ing during placement,27 to retraction procedures,26,28,29
to cotton roll removal without prior moistening,9 to caus-
tic endodontic treatment agents,6,9,30 and other more
rare causes.31,32
Self-inflicted gingival injuries are reportedly more
common in children than in adults.33,34 Although fingers/
fingernails are the usually reported instruments of dam-
age, more unusual objects, such as pencils35 and strands
of hair36 have also been used.
Standard oral hygiene procedures, whether tooth-
brushing37-39 or flossing,40,41 may lead to frequent tran-
sient and minimal gingival injury. The injury may
become significant if oral hygiene is performed improp-
erly or in an overly aggressive manner.38,41-43 This type
of injury may present as lacerations, abrasions, kera-
tosis, and recession, with the facial marginal gingiva
most frequently affected. Use of hard toothbrushes44
and chewing sticks45,46 and excessive brushing fre-
quency38,44,47 have also been associated with signifi-
cant gingival injury.
Oral piercing as a form of body art has become
more widespread and, as a result, deleterious effects
of these practices are becoming prevalent.48 Localized
gingival recession is a common complication of oral
piercing, increasing in severity and prevalence with
years of wear.48 Lip piercing is often associated with
labial gingival recession and tongue piercing with lin-
gual gingival recession.48,49
In the era of microwave cooking, drive-through cof-
fee shops, and hurried lifestyles, thermal injuries of the
gingiva are probably more prevalent than ever before
in industrialized countries. However, many patients may
not seek care for them. Most reported cases of ther-
mal mucosal injury are caused by heat (i.e., hot pizza,
hot potato, etc.).7,50 Other unusual causes include hot
767
Traumatic Lesions of the Gingiva
eating utensils,7 heated extraction forceps,32 and injury
from a metal gag overheated during laser surgery.31
Although far less common than heat injury, thermal
injury due to cold has also been reported.51
From this series of cases, it is evident that these
lesions share clinical characteristics. In acute cases, the
appearance of slough (necrotized epithelium), erosion,
or ulcer and the accompanying erythema are common
features. In chronic cases, permanent gingival defects
are usually present, mostly in the form of recession.
Many of the lesions are asymptomatic. Typically, the
localized nature of the lesions, the lack of extraoral or
systemic involvement, and the lack of symptoms
readily eliminate from the differential diagnosis sys-
temic conditions that may present with erosive or ulcer-
ative oral lesions.
Because of the similarity in clinical appearance
among traumatic lesions, a detailed and accurate his-
tory is often critical to the practitioner in the diagnosis
of possible or probable traumatic injury. Occasionally,
the challenge is to elicit relevant information from the
patient. Patients may be unaware of the significance
of potentially injurious habits, practices, or agents. In
other cases, history taking and diagnosis may be com-
plicated by patient reluctance to disclose information.
The management of gingival injuries requires removal
of the offending agent and symptomatic therapy. Per-
manent removal of the agent is usually easy to accom-
plish in iatrogenic or accidental injury cases. In cases
of self-inflicted injury it might be difficult to compel
the patient to stop the noxious habit, as has been
reported for oral piercing.48,49 Symptomatic therapy is
typically limited to topical or systemic analgesics. In
asymptomatic cases, patient reassurance may be all
that is needed beyond removal of the causative factor.
Periodontal plastic surgery, including gingival grafting,
may be necessary when the injury results in permanent
gingival defects.
ACKNOWLEDGMENTS
The authors express our gratitude to Dr. Carl Allen, Sec-
tion of Oral Pathology, and Dr. James Chou, Section of
Periodontology, College of Dentistry, The Ohio State Uni-
versity, Columbus, Ohio and Dr. Douglas Damm, Depart-
ment of Oral Health Sciences, Division of Oral Pathology,
College of Dentistry, University of Kentucky, Lexington,
Kentucky, for generously allowing us to publish photos
of their cases. This work was supported by the Section
of Periodontology, College of Dentistry, The Ohio State
University.
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Correspondence: Dr. Dimitris N. Tatakis, Section of Periodon-
tology, College of Dentistry, The Ohio State University, 305 W.
12th Ave., P.O. Box 182357, Columbus, OH 43218-2357. Fax:
614/292-4612; e-mail: tatakis.1@osu.edu.
Accepted for publication October 10, 2003.
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