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Referral and warning signs
When to refer
Refer to Dental personnel (HC4+/RR) to address sharp teeth/restorations. Refer if diagnosis uncertain, lesion persists >2 weeks, or secondary infection suspected needing antibiotics.
Red flags
- Ulcer persisting > 2-3 weeks (consider biopsy).
- Signs of significant secondary infection (spreading cellulitis, fever).
Signs and symptoms
- Thermal/Chemical Burns: Redness, blistering, or white/grey necrotic slough on mucosa. Painful. Location related to cause (e.g., palate/tongue for hot food; adjacent to tooth for chemical burn like aspirin placement).
- Trauma from Sharp Teeth/Restorations: Ulceration or irritation corresponding directly to location of sharp edge.
- Local Anaesthetic (LA) Ulceration: Painless biting of numb lip, cheek, or tongue during anaesthesia leads to large, often irregular ulceration appearing after anaesthesia wears off. Usually significant swelling.
- Common feature: Pain/discomfort, difficulty eating.
Risk factors
- Burns: Consuming very hot food/liquids. Improper use of chemicals in mouth (e.g., holding aspirin against tooth, caustic substances).
- Sharp Teeth: Fractured teeth, broken fillings, ill-fitting dentures.
- LA Ulceration: Dental procedures involving local anaesthesia (especially children, patients with intellectual disability).
Diagnosis
Clinical assessment
Diagnosis based primarily on history relating the lesion to a specific traumatic event (burn, sharp edge, recent LA) and the clinical appearance and location of the lesion.
Differential diagnosis
- Aphthous ulcer.
- Herpetic stomatitis.
- Infectious ulcers.
- Erosive lichen planus.
- Malignancy (persistent ulcer).
Investigations
- Clinical examination.
- Dental examination to identify sharp edges.
Diagnostic criteria
Clinical lesion consistent with history of specific trauma.
Management
Non-pharmacological management
- Burns: Reassurance (usually heals without scarring). Avoid further irritation. Soft diet.
- Sharp Teeth: Smooth the sharp edge of tooth/restoration or repair/replace faulty restoration. (LOC: HC4+/RR - Dental)
- LA Ulceration: Reassurance (will heal). Soft diet. Maintain hygiene.
Pharmacological treatment
- Symptomatic Relief:
- - Topical Anaesthetic: Lidocaine 2% gel/viscous solution applied before meals may help with eating. (LOC: RR - as per UCG, but may be available HC4)
- - Antiseptic Mouthwashes: Chlorhexidine or Warm Salt Water rinses to prevent secondary infection.
- Antibiotics: Generally NOT needed unless clear signs of secondary bacterial infection develop (increasing pain, swelling, pus, fever).
- - If secondary infection suspected (e.g., for LA ulcer): Amoxicillin 500mg PO Q8H for 5-7 days. (LOC: RR - as per UCG, likely applicable HC4 if infection)
Monitoring
Monitor healing of lesion (typically 7-14 days). Ensure source of trauma (sharp tooth) is addressed.
Complications
- Secondary infection.
- Pain impacting nutrition/hydration.
- Delayed healing.
- Scarring (rare, severe burns).
Prevention
- Caution with hot foods/liquids.
- Avoid holding medications against oral tissues.
- Regular dental care to address sharp teeth/restorations.
- Warning patients (especially parents of children) about risk of biting numb tissues after LA; advise soft diet until sensation returns.
Patient education
- Explanation of the cause of the lesion (burn, bite, irritation).
- Reassurance about healing.
- Symptomatic relief measures.
- How to prevent recurrence (avoid cause, smooth teeth, care after LA).
- Signs of infection requiring review.
Uganda-specific notes
Traumatic ulcers common. Need to differentiate from infectious causes. Addressing sharp teeth requires dental referral. Educating patients post-LA is important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.4.2