Sheep in Wolf’s Clothing – Enigma Unravelled

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A 65-year-old female reported to our dental clinic at Airoli, Navi Mumbai, India with complain of an ulcer on the left lateral border of tongue for the past 5 months. The ulcer had been growing in size since then. The patient did not complain of any pain or burning sensation and did not complain of any discomfort during mastication. She had received some medication from a general practitioner, but was not relieved. Her medical history was non-contributory.

Figure 2. Photomicrograph showing stratified squamous epithelium with underlying connective tissue stroma containing inflammatory cell infiltrate and blood vessels (H & E stain, 10X). (case 1)

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On intraoral examination, an ill defined ulcerative lesion, 1.5 × 1 cm in size was present on the posterior left lateral border of the tongue (Figure 1). Patient gave a history of using mishri (form of tobacco used for cleaning teeth by women in rural India) twice a day for 30 years. The molar teeth in the maxillary left quadrant were carious and had sharp margins. It was non tender on palpation. The clinical appearance raised the suspicion of a malignant ulcer and a biopsy was advised. Hematological investigations were within normal limits. At the time of biopsy, the carious teeth i.e. maxillary left molar teeth with ragged margins seemingly associated with the lesion were also extracted. Histopathological examination showed the presence of parakeratinized stratified squamous epithelium showing proliferation at places. Underlying connective tissue stroma showed chronic inflammatory infiltrate and blood vessels. There was no evidence of malignancy. A diagnosis of fibro-epithelial hyperplasia was arrived (Figure 2). The patient was recalled after one week for suture removal. Healing was uneventful (Figure 3).

Figure 3. Intraoral photograph of the healing ulcer. (case 1)

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2.2. Case 2

Figure 4. Intraoral photograph of the ulcer on the left lateral border of the tongue. (case 2)

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A 58-year-old female patient reported to our dental clinic with a complaint of an ulcer on the left lateral border of the tongue for the past two months. The patient had a history of bruxism. On intraoral examination an ulcer of 3×3 cm in size was observed on the left lateral border of the tongue (Figure 4). The ulcer had everted margins and the base was covered with slough. Mandibular left posterior teeth were attrited with sharp margins. Patient had a history of applying mishri and chewing tobacco for the last 25 years. There was generalised attrition of teeth. In view of the present condition a biopsy was advised. At the time of biopsy the sharp margins of the mandibular posterior teeth were rounded off. Histopathological examination showed the presence of parakeratinized stratified squamous epithelium showing ulceration at places. Underlying connective tissue stroma showed chronic inflammatory infiltrate and blood vessels. There was no evidence of malignancy. A diagnosis of traumatic ulcer was arrived (Figure 5). The patient was recalled after one week for suture removal. However the patient was lost to follow-up.

Figure 5. Photomicrograph showing ulcerated stratified squamous epithelium with underlying connective tissue stroma containing inflammatory cell infiltrate and blood vessels (H & E stain, 10X). (case 2)

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3. Discussion

Dentist and medical practitioners often encounter a wide spectrum of oral mucosal lesions. These include mild mucosal alterations needing simple therapeutic remedies to life threatening lesions such as carcinomas. Traumatic ulcers can be recognized if the clinician can establish the cause of physical injury. Sometimes, the nature of trauma is obscure; and hence the diagnosis may be difficult to establish. Traumatic lesions especially those that occur on the tongue, may persist for weeks; and may be included in the differential diagnosis of persistent ulcers (Table 1).

Table 1. Clinical feature to assign a high index of suspicion of malignant oral ulcer

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