Introduction

Normal oral mucosa is a soft tissue membrane that stretches posteriorly from the palatopharyngeal folds to vermilion edge of the lips anteriorly. Dentists are typically the first to notice any variation in the oral cavity's natural features. A wide range of factors, including infections (bacteria, fungus, viruses, parasites, and others), physical and environmental factors, immune system changes, systemic disorders, neoplasia, trauma, and others, can induce changes in the oral mucosa [1].

Oral lesions commonly encountered in the dental practice either reflect disease or trauma which could result from any physical, chemical or thermal insults. Trauma associated with road traffic accidents is primarily seen on hard tissues like jaw fractures while trauma associated with soft tissue lesions is encountered in routine daily activities while brushing and chewing. Another side of this spectrum lies the self-inflicted injuries like lip/ cheek biting, thermal or chemical burns and even from iatrogenic causes like defective dentures, orthodontic brackets or other treatments involving oral cavity such as intubation under general anesthesia [2]. So, trauma can have multifaceted presentation in oral cavity ranging from a minor oral ulcer to a malignant lesion and no age group and gender is exempted from these traumatic lesions. They can hamper basic processes like feeding, swallowing, speech and are also typically accompanied with pain and suffering. Oral traumatic lesions differ from other oral lesions in clinical presentation and progression. Some of them could be acute lesions while majority are chronic in nature. A thorough history and clinical examination is mandatory to trace the traumatic cause of such pathologies. Although trauma associated injuries are usually not subjected to histopathological examination, but soft tissue trauma should be kept as differential diagnosis while dealing with the soft tissue pathologies.

Extensive search on scientific data in English literature, revealed relatively rare studies on trauma-associated lesions in oral and maxillofacial region in developing Asian countries and those that do exist are typically restricted to studies of fractures of the jawbone or traumatic injuries to teeth with no emphasis on soft tissue trauma [3]. This has resulted in neglect of a wide category of traumatic pathologies occurring in oral mucosa leading to diverse array of histopathological diagnosis.

In order to better understand the demographics of such soft tissue traumatic lesions a histopathological study was planned that included data spanning over past 12 years. The study findings made us realize that traumatic oral pathologies are actually a huge spectrum that include diverse histopathological diagnosis and sometimes early intervention is anticipated.

Materials and Methods

A retrospective cross-sectional study was conducted in Department of Oral and Maxillofacial Pathology, PGIDS, Rohtak, Haryana by retrieving demographic data and recording chief complaints from the requisition forms mentioning anywhere in the form the term “trauma” of any nature, “accident”, “history of fight” or any other type of “physical abuse”. This data was obtained from January 2010- December 2022. Ethical approval was taken from institutional ethical committee vide letter no. PGIDS/BHRC/24/29.

Study sample

All patient biopsy requisition records in the department for the specified time period were analyzed and all cases with a mentioned history of trauma were included in the study and those without were excluded from study. Of the 5,468 patient’s data analyzed, 307 cases favoring the inclusion criteria were selected for final evaluation.

Sample type

The biopsy requisition record of patient with documentation on previous medical and dental history were noted. The data collected included demographic data mentioned in medical records, data on trauma history, type of injury, duration and site of injury and the histopathological diagnosis was confirmed by two experienced oral and maxillofacial pathologists. The data was then entered in Microsoft excel and analyzed.

Results

From the total 307 cases analyzed, the male (201) to female (106) ratio was 1.8:1. The patients’ age ranged from five to eighty years with the mean age being 33.24. The traumatic oral lesions and demographic data are presented in Table 1. The oral lesions associated with trauma included soft tissue lesions like mucocele, traumatic fibroma, fibroepithelial hyperplasia (FEH) and periapical lesions. The youngest patient was diagnosed with traumatic fibroma while oldest had well-differentiated oral squamous cell carcinoma (WD-OSCC).

Mucocele was the most common oral lesion with history of trauma (40.7%) followed by traumatic fibroma (27.6%) and fibroepithelial hyperplasia (FEH) (11.4%). The presenting complaint of patients varied from swelling, growth, pain, ulcer and restricted mouth opening from which the most common presentation was swelling (71.8%). Considering the site of lesion, the lower lip was the most commonly involved site (42.7%) followed by buccal mucosa (29.7%). The time duration between the time of trauma and symptom of the lesion was found different with different cases. The time period between trauma to initial presentation of lesion was found with a range of 14 days to >6 months (Table 1).

Discussion

Oral cavity is susceptible to many forms of physical, chemical and thermal insults which can result in traumatic injuries to jaw bones as well as soft tissue of oral mucosa. The trauma associated with jaw fractures does not warrant any biopsy and usually heals uneventfully. However traumatic lesions in oral mucosa may require attention and further histopathological investigations. These lesions appear as acute or chronic ulcers, mucositis, reactive hyperplasia, or even as white or red lesions which mimic other potentially malignant disorders raising a concern for prompt diagnosis.

To the best of our knowledge, this is the first study in this region which attempted to find the prevalence of trauma associated oral pathologies and proposed a working classification for such entities based on the frequency of its occurrence with trauma.

In the present study a male preponderance with 65.4% was observed which was similar to previous studies on oral lesions which may indicate a higher incidence of trauma in males who are involved more in physical activities and parafunctional habits [3-5].Out of the lesions analyzed, the most commonly encountered were mucocele, traumatic fibroma and fibroepithelial hyperplasia which contributed to 79.8% (245) of the total traumatic oral lesions. Similar higher incidence for mucocele as a traumatic lesion is reported frequently in literature. [6, 7]. For mucoceles, some studies have reported female gender prevalence [8,11] while some [9,10] showed a male gender predominance similar to that seen in our study. Lower lip was the most common affected site in our study as well as in literature [6,7,8,9] (Figure 1 A and B). Given that the lower lip moves dynamically during mastication and speech, this can be primarily explained by the fact that it is one of the oral locations most susceptible to trauma during parafunctional or functional activities. Patients with mucocele were more common in age group of 19-44 years, with mean age of 33.3 years and were generally younger than those exhibiting traumatic fibroma which was found more in age group of 45-64 years. The main etiological reason for the mucus extravasation phenomena is thought to be mechanical trauma, mostly due to parafunctional habits, which is thought to be more likely to occur in younger age group [6,7].

Fig 1: A. Clinical presentation of mucocele on lower lip B. Histologic presentation of mucocele (4x) C. Clinical picture of fibroepithelial hyperplasia on buccal mucosa D. Histologic presentation of fibroepithelial hyperplasia (10x).

Traumatic fibroma (85, 27.6%) and fibroepithelial hyperplasia (35, 11.4%) were the second and third most common lesions encountered. A similar prevalence for these reactive lesions has been reported [12, 13], however authors also report a much higher prevalence i.e., 48% [14]. This can be due to geographical and lifestyle differences and the fact that many such lesions are clinically diagnosed but not biopsied. The most common location observed was buccal mucosa in our study whereas previous studies indicated towards a predilection for gingiva for these lesions [12, 13] (Figure 1 C and D). The increased incidence in younger age group and involvement of buccal mucosa can be attributed to increased parafunctional habits and irritation of mucosa from orthodontic devices in these age groups.

Periapical lesions secondary to trauma which included periapical cysts and granulomas together accounted for 9.4% of total cases in present study. This increased prevalence was seen in 0-18 age group, most commonly associated with non – carious, non-vital anterior teeth and presented mostly as a swelling and was associated with pus discharge. The increased prevalence associated with this age group can be associated with increased incidence of trauma due to fall in patients visiting our institute.

Development of malignancies due to trauma is rare but not uncommon as continuous irritation from a sharp tooth or prosthesis can lead to transformation of a traumatic ulcer to oral squamous cell carcinoma. In our study, a considerable number of traumatic lesions (22, 7.1%) were found to be OSCC, especially in older age group, with buccal mucosa and tongue being most commonly involved. All the patients reported the history of a faulty denture use or a sharp tooth. Other lesions found in this study included pyogenic granuloma and hemangioma which although accounted less in number but are usually associated with a traumatic history.

Maximum number of soft tissue traumatic lesions in the present study were in the age range of 19-44 years (156), followed by 0-18 years (67) 45-64 years (64) and least in 65-84 years (21). This was in contrast to findings by other studies [4,5] which reported an older age group prevalence. The difference can be attributed to the fact that these studies included all oral mucosal lesions, which may be habit associated also, and habit prevalence increased with age. On the other hand, our study focused mainly on trauma associated lesions which were reported more in younger age groups due to increased awareness even for acute lesions in this group. Another observation recorded was that a traumatic ulcer of longer duration of more than 3 months could make the lesion suspicious for malignancy as in our study traumatic ulcers showed malignant transformation within time period of 3 months. However, few oral traumatic lesions like mucocele, fibroma, periapical and pyogenic granuloma showed small duration of presentation of 14 days from the time of trauma reflecting reactionary response.

It was also observed that 24.3% of these lesions recurred with traumatic fibroma, mucocele and ulcers as the most common recurring pathologies. These findings point towards the significance of identification of the etiology in traumatic pathologies as removal of causes like sharp tooth and faulty denture prevents the recurrence of these lesions.

Literature lacks a proper classification for trauma associated oral soft tissue pathologies and this study motivated us to propose a working classification of this common and widespread but frequently neglected. Hence, we are proposing a classification system based on the relationship between frequency of occurrence of a lesion and traumatic etiology seen in our institutional experience. We included the findings of our study as well as those from the literature in this classification (Figure 2).

Fig 2: Proposed working classification of traumatic oral pathologies

Conclusion

Data from this study will be helpful for epidemiological documentation of the type of traumatic oral lesions as well as educating about the significance of this group of oral cavity lesions. Also, the proposed classification will help in easy categorization of traumatic oral pathologies. Knowledge about the demographics of traumatic oral lesions can help us in providing an insight into such common but frequently neglected pathologies and sensitize the practitioner for the cautionary follow up. Similar attempts to identify and classify oral soft tissue traumatic lesions from multiple centers will help us to put weightage to our pioneer attempt.

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