5.1 Physical factors

  1. mechanical – in the sense of injuries to the mucosa (sharp edges of carious teeth, dental tartar, defective prosthesis) that can be acute or chronic.

  2. thermal – the effect of heat (burns – caused by hot food or dental treatment) or cold, caused by the patient himself or the attending physician.

  3. irradiation – ultraviolet rays (only concerns lip red), X-ray radiation overdose (or even therapeutic doses), penetrating radiation during accidents of atomic emitters.

  4. electric current – it can damage tissue in the oral cavity either during an accident (giving rise to extensive necroses that heal with difficulty) or due to the galvanic irritation.

5.1.1 Traumatic changes of the oral mucosa

There are various mechanisms of injury of the oral mucosa causing acute or chronic changes. Long-term inflammatory changes causing a permanent chronic trauma can become precancerous.

Traumatic ulcer


It is the most common ulcer on the oral mucosa resulting from mechanical irritation. If resulting from pressure irritation caused by a denture, we speak of decubitus or pressure ulcers. It usually presents as a flat or dish-shaped ulceration with distinct margins. Defects can occur anywhere in the oral cavity – the respective location depends on the traumatizing factor. The most common sites are the lateral side of the tongue, the buccal mucosa, lips or gingiva. It is painful, the surrounding area is erythematous and can be covered by a greyish pseudomembrane. Patients report severe pain; regional lymph nodes can be swollen. The ulcer develops due to the traumatization of the oral mucosa – most commonly caused by unsuitable dental prosthesis (decubitus ulcer), carious or destructed teeth with sharp edges or hygienic dental tools; the causes may however include orthodontic apparatus, surgical splints, tools used in dental treatment or externally applied drugs. In most cases, the causes of such defects can be easily recognized and proved both clinically and based on personal history of the patient; in some patients, however, it can only be established indirectly or with difficulties.

Neurodystrophic ulcer of the oral mucosa

The neurodystrophic ulcer develops in patients who were given local anaesthetics (usually mandibular) who injure the (at the time insensitive) oral mucosa by their own teeth. Typical sites include the mucosa of the lower lip and vestibule. Lesions have ulcerative character and are very painful; informing the patient after administering the anaesthetic is helpful in preventing this problem.

Traumatic gingivitis/stomatitis


This problem results from long-term deliberate or unintentional damage (including self-injury) of the oral mucosa and gingiva. Typically, such injuries are caused by hygienic dental tools but other objects may be also at fault. Clinically, we observe an erythematous mucosa with erosions. Petechiae can be also present, ulcerations can develop at a later stage.

Epulis fissuratum (denture hyperplasia)


It appears in the vestibular region in patients with a poorly fitting dental prosthesis. It manifests as a hyperplastic fold of various extents with erythematous mucosa and possibly a pressure ulcer. It forms in the vestibulum of the edentulous alveolar process in places of long-term mechanical irritation of the tissue by a flange of an ill-fitting denture. It is usually not associated with any subjective problems.

Th.: Traumatic defects of the oral mucosa cannot be successfully (i.e., completely and permanently) cured without removing the provoking cause. Once the cause is removed, spontaneous healing of the mucosal defect should occur within 1-2 weeks, depending on the size, severity and location of the defect. In the keratinized areas of the mucosa (dorsum and sides of the tongue, hard palate), healing takes longer. Sometimes, it is necessary to change the patient’s hygienic habits, eliminate unsuitable dental care tools and/or teeth cleaning technique. Healing can be augmented with mouthwashes, gels or mucoadhesive preparations with wound healing and antiseptic effects. Most frequently, herbal infusions (chamomile, agrimony, yarrow, sage, etc.) are used for this purpose. Of other antiseptics, CHX can be used. The treatment can be augmented with application of surface anaesthetics (especially before eating). Denture hyperplasia must be surgically removed. .

Cheek and lip bite stomatitis (morsicatio buccarum et labiorum)


The reason for this problem is the bad habit of biting the buccal or lip mucosa with teeth. The clinical picture is characterized by epithelial damage in the respective area. The epithelium is „torn“, locally hyperplastic or desquamating. The finding is not always clear – when in doubt, histological examination is recommended (with this diagnosis, a chronic inflammation will be revealed). The prognosis is often problematic as it depends to a large degree on the patient’s cooperation.

Frictional keratosis

Increased production of keratin causes a whitish discoloration of the oral mucosa, i.e., keratosis. Microscopically, ortho-, para- or hyperkeratosis can be distinguished. Frictional keratosis is caused by mechanical irritation (e.g. of gingiva when using a toothbrush incorrectly – hard bristles, horizontal method of cleaning).

Histology: No dysplastic changes can be found histopathologically, only a simple hyperkeratosis is present (i.e., this is not a premalignant lesion).

Th.: A biopsy is not necessary, long-term observation is however recommended. Keratosis can disappear after removing the provoking cause.

Dif. dg.: Leukoplakia.

Cotton roll stomatitis

This problem appears after an oral procedure when a cotton roll or swab used during the procedure sticks to the vestibular mucosa and when removed without appropriate care, it can tear away the surface layer of the epithelium.

Oral haematoma

A random one-time bite on one’s cheek or side of the tongue that injures a blood vessel and the blood gets into the submucosal connective tissue is the most common cause of oral haematoma. The appearance is that of a (usually) small round dark red spot, often slightly elevated.

Suction trauma of the palatal mucosa

This problem arises as a result of repeated application of positive and negative pressure on the mucosa. Those mechanisms probably lead to rupturing of small vessels in the submucosal connective tissue of the traumatized mucosa and to bleeding into the mucosa. Clinically, an enanthema is observed, i.e., red spots on the palatal mucosa, which are well circumscribed with small petechiae. Remaining parts of the mucosa remain normal. While taking the patient’s history, the etiology can be found if the patient is willing to disclose it. Healing usually does not last for longer than two weeks, no therapy is needed.

Common cheilitis (chapped lips, cheilitis simplex)

This term describes changes on the vermilion zone and border manifesting as drying and chapping of lips, the development of which is affected by multiple factors. Besides mechanical (usually unconscious) irritation such as biting or constant licking of lips, adverse effects of weather can play a role (sunshine, frost, wind). The lip red is too dry, epithelial desquamation occurs; sometimes, even small crevices are formed. It is recommended to moisturize the lips regularly and to prevent their traumatization and chronic irritation.

Exfoliative cheilitis (cheilitis exfoliativa)


Compared to the simple cheilitis, the exfoliative cheilitis is characterized by a greater (pathological) degree of keratinization of the vermilion zone; the changes may also spread periorally. In addition to the above mentioned causes, some chronic dermatoses (atopic or seborrhoeic eczema, ichthyosis). It occurs more frequently in persons breathing through their mouths, a contribution of mental stress is also expected. When the keratinized scales are torn away, crevices and fissures appear, even secondary infections (mostly in the corners if the mouth) or slight oedema can develop. The disease recurs frequently and its treatment is more difficult than in common cheilitis. It is necessary to prevent the chronic irritation and to support the healing with local preparations with antiseptic, keratolytic and wound healing effects. Sometimes, even a short-term application of corticoids is necessary.

5.1.2 Stomatitis caused by thermal factors


Burns can occur by accident due to random drinking hot beverages or eating hot meals, or due to carelessness during manipulation with some medical tools. Low temperatures (frost, snow) can represent the etiology, e.g. of frozen lips in skiers, etc. Depending on the temperature and duration of the exposure, the clinical picture can show various changes ranging from simple erythema with oedema to tissue necrosis with a subsequent development of an ulcer. A chronic exposure to heat may lead to hyperkeratotic changes. Damage due to low temperatures again depends on the intensity and duration of the exposure. Initially, it presents as a pale to livid discolouration, later as an oedema with ulcerative mucosal defects. Diagnosis is usually clear from the patient’s description of the etiology.

Th.: The therapy is local, preparations with wound-healing and antiseptic effects are recommended.

5.1.3 Electrogalvanic stomatitis


The presence of various metals in metallic tooth fillings or prosthetic devices may initiate the development of electrogalvanic irritation with the metals acting as electrodes and saliva as an electrolyte. All substances that can be used as electrodes in a galvanic cell are ranked according to their potential. The function of the galvanic cell depends on a difference between potentials of both metals. When two metals with similar potential (e.g. silver, platinum, gold) are both present in the oral cavity, the risk of developing a dangerous potential difference is much lower than where metals from further apart in the table are concerned (e.g. gold versus zinc or tin). This leads to development of various electric currents depending on the potential difference (voltage) and resistance of individual tissues (Ohm’s Law). The manifestations of galvanism result either from the direct effects of the electric current (the tolerated, i.e., „no damage“ intensity is 10 microamperes, tolerable voltage is approximately 80-100 mV) or from electrolysis which leads (via ionization of tissue liquids) to decomposition of organic substances and irritation of the oral mucosa. This results in electrogalvanic stomatitis, which may produce both general (GIT symptoms, headache, joint pain) and local symptoms in the oral cavity. Patients usually report subjective problems such as tingling, burning or metallic taste. Objective findings reveal various changes ranging from erythema, erosion or ulcer to hyperplastic changes. Symptoms usually occur at the site of contact between each of the metal and the edge of the tongue or the buccal mucosa.

5.1.4 Actinic cheilitis (solar cheilitis, ch. actinica, solaris, abrasiva)


This type of cheilitis is a chronic damage to the vermilion zone occurring as a result of a long-term exposure to the sunlight (its UV-component). It mostly occurs in older people and especially affects the lower lip.

Clinical picture: First, a small oedema or erythema develops, the lip is dry; later, small scales begin to desquamate from the vermilion zone and erosions appear. Leukoplakia patches may appear in the vicinity. The condition is not constant, it improves and gets worse again over time.

Th: The treatment is difficult; in the initial stages, local preparations with wound-healing and antiseptic effects may improve the condition. A surgical removal of the lesion including histopathological examination is often necessary. Carcinoma develops in approx. 10 % of cases of solar cheilitis.