Management of Unhealing Ulcers on Bilateral Borders of the Tongue

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On intraoral examination, an ulcer measuring 10x8 mm with red base and white margins was found on the right lateral border of her tongue (Figure 1). A similar lesion was present on the left lower border with much smaller dimension (Figure 2). Caries history was very significant leading to many restored teeth with amalgam and composite. Some of the restorations appeared deteriorated requiring repair or replacement. She also had dental bridges, one on each side of mandible and one on right side of maxilla. The abutments of the bridge were fabricated with porcelain fused to metal (PFM) and the pontics with porcelain.

Figure 2. Unhealed lesion on left lower border of tongue

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2. Treatment

As patient was very anxious and complaining of insomnia due to cancer-phobia, psychotherapy was done for her reassurance and Tablet Alprazolam 0.25 mg was prescribed to be taken before going to bed.

Many restorations were showing leaky margins or were partially damaged and deteriorated. Keeping in mind the psychological status of the patient, it was anticipated that rubbing of tongue against the damaged restorations may be the persistent source of frictional trauma to the tongue, not allowing the ulcers to heal ^[1]. All such restorations were either repaired or replaced. To see the effect of correcting the restorations patient was recalled after 3 weeks. The patient did not find any relief. On visual inspection, the lesion did not show any shrinkage or sign of healing. One more clinical inspection was done after two weeks but dimensions of the lesion were unchanged since first inspection.

Thinking that the bridges may be the cause of these ulcers as some patients show allergy to metals used in dental appliances or restorations ^[2], it was decided to remove them. The core of the bridges was fabricated using some base metal alloy, which normally contains Nickle as one of its major constituent. The bridges were functional to the extent that she was not ready to sacrifice them. With great difficulty, she was convinced to have her one of the bridges removed. As the lesion on the right side was bigger and more painful, the bridge was removed from the same side first. On next appointment after 3 weeks, the lesion looked better with reduced redness and pain. But during this period, the lesion on the left border of the tongue became active and annoying for the patient. It was therefore decided to remove all bridges from her mouth.

Though after 6 weeks of removal of the bridges, the lesion stopped progressing and became less painful but remained unhealed. It was therefore decided to have a biopsy from both ulcers. The biopsy report showed Pseudoepitthliomatous Hyperplasia with chronic inflammation. Like other inflammatory hyperplasia, excision was the only option left to treat it. The patient was referred to an oral surgeon with the request for local excision of the lesion along with removal of chronic inflammatory infiltrate. The surgeon performed the procedure under general anesthesia and the lesions took two weeks to heal (Figure 3 & Figure 4). After 2 more weeks when patient was much comfortable, new all zirconia bridges ( 3M ESPE US) were inserted in place.

For last one year patient is happily using these bridges without any complaint of difficulty in eating or chewing spicy food.

Figure 3. healed lesion on right lateral border of tongue

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Figure 4. Healed lesion on left side of tongue

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