Copy - Case Presentation

Oral Medicine Case Presentation

Prepared and presented by Karim, Muhaned, Hassan Ali, Ehdaa, Hassan Badr, Abdulrahman

Personal Data

Our patient is a 28 year old male who lives in Omdurman.He works as a police officer. He presented to the clinic with a chief complain of pain in the lower posterior teeth and a painful sore area in the lateral border of the tongue.

History of the Chief Complain

The lesion appeared two months ago after a motorcycle accident. The pain is constant and numbing. The lesion didn't increase in size in the past two months.

Oral Hygiene Habits

He brushes his teeth two times a day with a flouridated toothpaste in a horizontal technique. He does not floss his teeth nor uses mouthwash. The patient doesn't smoke, snuff dips or uses any drugs.

Patient's History

The patient is medically fit. He was hospitalized after an motorcycle accident and was given analgesics after treatment. He is not on medication currently. There is no family history of significance and this is the patient's first dental visit.

Discription of the Lesion and Clinical Findings:

It is a 2cm in diameter ulceration found on the the left lateral surface of the tongue; it has an erythematous center with a white and raised border. The lesion is painful and has been present for over 2 months.

Abstract

Traumatic ulcerative granuloma is an uncommon lesion of the oral mucosa affecting the tongue mainly and is considered a reactive lesion. The aetiopathology is unclear but trauma have been found the contributing factor in most cases. We report a case of a 28-years-old man who presented with a chronic ulcer on the lateral border of the tongue. The patient reported that the ulcer appeared right after the trauma and didn't change in size for 2 months, so a biopsy was done to confirm the diagnosis and rule out other conditions.

Introduction

Traumatic ulcerative granuloma has been known by different names sublingual granuloma, traumatic granuloma, eosinophilic granuloma, eosinophilic ulcer, and ulcerative eosinophilic granuloma. The tongue is the most common site but can occur in other areas of the mouth such as inside of the lips, inner cheeks, or floor of the mouth. The lesion is characterized by ulceration, and it may sometimes grow rapidly or create a mass which in some cases can resemble an oral cancer. TUG is more common in the 3rd to 7th decade of life but can occur at any age and can be of any size.

Lesion Photo

Differential Diagnosis:

1. Traumatic Ulcerative Granuloma: results from injury and mostly found on the tongue. Could remain for extended periods of time. It is a well-circumscribed ulceration with white border that surrounds erythema. These lesions are also male predominant and are painful. 2. Major Apthous Ulcer: these lesions are the most common ulcers. They are painful and persist for months. They have well-circumscribed border and are round or ovoid in shape. They are not commonly seen in keratinized mucosa like the dorsum of the tongue. 3. Squamous cell carcinoma: commonly found on the tongue. It could be an erythematous ulceration with irregular borders and is usually 2cm in diameter and male predominant.

Diagnosis

*Diagnosis: The patient reported an ulceration that resulted from trauma. It has been present for over 2 months and not exhibiting any changes. The histopathological examination of the biopsy showed an ulcerated stratified squamous epithelium overlying mixed inflammatory cell infiltrate, predominantly consisting of eosinophils followed by lymphocytes and histiocytes extending deep into the sub mucosa. Based on the history, clinical and histopathological findings a final diagnosis of Traumatic Ulcerative Granuloma was given.

Treatment

The biopsy made was excisional so the whole lesion was removed and NSAIDS (Diclofinac) was prescribed for the pain.

Discussion

Traumatic Ulcerative Granuloma can easily be mistaken for SCC or infectious diseases, such as primary syphilis or EBV-associated mucocutaneous ulcer. With clinical inspection alone, a malignant process cannot be excluded, therefore a biopsy is always mandatory. Screening for the aforementioned infectious diseases is recommended. The typical histological findings are vaguely granulomatous tissue changes, sometimes jigsaw-like appearance. The lesion presents a diffuse polymorphic inflammatory infiltrate, predominately consisting of histiocytes, activated and predominantly T-lymphocytes, and of eosinophils and histiocytes. The ulceration is often extending into the submucosa, deeper muscle fibers, and salivary glands. The pathogenesis of this lesion is still under debate, although a local traumatic event has been suggested to be a major contributing factor, as it also became apparent in our case.

Conclusion

As Traumatic Ulcerative Granuloma may mimic malignancy or infectious diseases, biopsy is mandatory and should be combined with thorough clinical examination. A screening for infectious diseases (mainly syphilis, Epstein-Barr virus, and HIV infections) must be performed routinely. In most cases, the lesions resolve spontaneously, obviating the need of further actions other than clinical follow-up. The pathogenesis of these lesions is still under debate, although local traumatic events and an immune response have been suggested to be major contributing factors.

Thanks!