Incidence of Traumatic Ulcer among the Patients Visiting Private Dental Hospital- Retrospective Study

Introduction: Oral mucosal ulcers are one of the most common types of ulcer of which Traumatic ulcers are common and acute in nature, caused by some form of trauma to the mucous membrane in the oral cavity. It is most commonly seen in the Buccal Mucosa, Lips, and occasionally in the Palate and Lateral border of tongue. It is caused by physical, chemical or thermal trauma resulting in damage and ulcer formation. Materials and Methods: The data for the present study n = 345 patients was collected by analysing case sheets of patients who visited Saveetha Dental College from June 2019February 2021. The collected data was subjected to statistical analysis using the SPSS software by IBM of version 23. Results: From the results of the study, Traumatic Ulcer has Male predilection with incidence rate of 62.2% compared to females with incidence of 37.7%. Most of them were in the age group of 21-30 years age group (34.5%) and least in the 71-85 years age group (2.9%). Traumatic ulcer was most common in the Alveolar mucosa (32.2% ) Conclusion: From the present study it can be concluded that Traumatic ulcer is more common in Males. However, Gender, Age, Oral Hygiene, Usage of Tobacco products were not significantly influencing the rate of incidence of Traumatic Ulcer. Original Research Article Selvi and Ramani; JPRI, 33(64A): 444-454, 2021; Article no.JPRI.81874 445


INTRODUCTION
Oral health is important to maintain the quality of life of all individuals. The oral mucosa serves as a protective barrier against trauma, pathogens, and carcinogenic agents [1,2]. Oral lesions can interfere with daily social activities in involved patients through impact on mastication, swallowing, and speech, and symptoms such as xerostomia, halitosis, or dysesthesia [3]. Diagnosis of the wide variety of lesions that occur in the oral cavity is an essential part of dental practice. Proper clinical management of a patient with an oral lesion starts with an accurate diagnosis. Hence, oral soft tissue examination is crucial and should be done systematically to include all parts of the oral cavity [4].
An Ulcer can be defined as a break or discontinuity in the integrity of the skin or mucous membrane with loss of surface tissue and disintegration of the epithelium [5][6][7]. Oral mucosal ulcers are one of the most common types of ulcers, which may or may not be associated with systemic diseases. Oral ulcers may present as a single ulcerative lesion or as multiple ulcerative lesions. Aphthous ulcer and Traumatic ulcer are the most common types of oral mucosal ulcers. Aphthous ulcer is painful and inflammatory ulceration of the oral mucosa. It usually appears as multiple pinpoint ulcers in the mucous membrane [8]. The aetiology of Aphthous ulcer is usually Idiopathic in nature but also associated with various systemic diseases like Malabsorption syndrome, inflammatory bowel disease, vitamin deficiencies, etc. The management of Aphthous Ulcer is the usage of Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Corticosteroids, Mouthwash for maintaining proper oral hygiene [9,10].
Traumatic ulcers are common and acute in nature, caused by some form of trauma to the mucous membrane in the oral cavity. The ulcer is most commonly seen in the Buccal Mucosa, Lips, and occasionally in the Palate and Lateral border of the tongue [11,12]. A traumatic ulcer can be caused by physical, chemical, or thermal trauma resulting in damage and ulcer formation in the mucous membrane [13]. Physical trauma includes harsh tooth brushing, flossing, the sharp cusp of the tooth, ill-fitting dentures, orthodontic appliances, cheek biting, lip biting [14,15]. Consumption of very hot food, accidental injury with a heated dental instrument are some Thermal causes of traumatic ulcer. thermal ulceration is most commonly seen in the palate and posterior part of the buccal mucosa. Some of the dental materials like eugenol, Sodium Hypochlorite, Formocresol, Monomer can cause chemical ulceration, other causes include holding Aspirin tablets next to a painful tooth, Silver nitrate [16].
Traumatic ulcers can be Acute or Chronic in nature. Acute ulcers are usually self-resolving in nature within 5-7 days, whereas Chronic Traumatic ulcers are commonly found in Buccal mucosa, lateral border of Tongue, or Lips . It usually presents as a solitary ulcer with shallow or sometimes deep epithelial discontinuity and also showing peripheral keratosis of varying degrees. The ulcer heals with or without scar formation depending on the extent of the ulceration, on eliminating the causative factor for the trauma.
Epidemiologic studies provide information important to understanding the prevalence, incidence, and severity of oral disease in a specific population, but the results of such studies (including those on the established variety of changes that can occur in the oral mucosa) have rarely been published worldwide.

MATERIALS AND METHODS
The data for the present study were collected by analysing case sheets of 5,35,951 out-patients who had visited Saveetha Dental College from June 2019-February 2021, the case sheets were reviewed and analysed individually. The advantages of the present study are available data and similar ethnicity and geographical locations and the isolated populations could be the limitations of our study.
The inclusion criteria for the study were mainly the patients having oral ulceration due to Trauma, age group of 5-80 years, and complete available data were considered. The exclusion criteria for this study were patients below the age group of 20 and patients with medical complications, incomplete and censored data. Based on the inclusion and exclusion criteria the sample size was n= 345 including the Age, Gender, Site of the Traumatic Ulcer, treatment given, and presence of any systemic problems. The case sheet verification was done using the photographic method. To minimise sampling bias simple random sampling was done. The collected data were subjected to statistical analysis using the SPSS software by IBM of version 23 in which both the descriptive and the inferential test has been done, which was the Chi-square test. The dependent variables were Traumatic Ulcer and the Independent variables were Age and Gender.

RESULTS
Out of the n=345 patients who had Traumatic ulcer, 0.29% were in age group of 7-10 years, 6.69% in 11-20 years, 34.59% in 21-30 years, 20.35% in 31-40 years, 16.28% in 41-50 years, 10.47% in 51-60 years, 8.43% in 61-70 years, 2.9% in 71-85 years of age (Fig 1), among which 62.2% were males and 37.8% were Females (Fig  2). According to the present study, 14% had an ulcer in the upper arch buccal mucosa, 31.7% had an ulcer in the lower arch buccal mucosa, 22.1% had an ulcer in both upper and lower arch buccal mucosa and 32.2% had ulcers in the Alveolar mucosa near the specific tooth (Fig 3). Association of age and gender of traumatic ulcer revealed that there was a significant association between them, males in the age group of 21 -30 years had increased incidence of traumatic ulcer (p-value = 0.02) ( Fig  4). Association of gender with the site of traumatic ulcer revealed that there is no significant association between them, (p-value = 0.2) ( Fig 5).

DISCUSSION
Traumatic Ulcers are usually solitary lesions with an erythematous margin. Despite Traumatic ulcer being the most common ulcer the rate of incidence of Traumatic Ulcer in the present study was only 0.06%. The rate of incidence is lesser which might be attributed to misjudgment of the ulcer as Aphthous ulcer or ignorance of the ulcer . In a study by Aishwarya et al., [36] The rate of incidence of the traumatic ulcer was higher, imparting 17.5% among the other oral mucosal lesions. This increased rate is due to rough brushing, Sharp cusps of teeth in old age people.
There is no specific age group or category of persons for Traumatic Ulcer incidence. It can occur in any age group due to any kind of trauma to the oral mucosa like accidental cheek biting. Lip biting, sharp cusps, hard food substances, consumption of hot food. In the present study, it was found in early adulthood 34.5% were in 21-30 years of age followed by 20.3% in 31-40 years of age (Fig 1). It is more common in this age group of increased Orthodontic Treatment during a Young age. In concordance with the present study, Amadori et al., [37] also demonstrated that Traumatic ulcer was more common in Teenagers, which was most likely associated with the health status and behavioural changes during the adolescence period [38]. In contrast to it Gambhir et al., reported a high incidence of mucosal lesion in the old age group of more than 50 years of age, which is due to prolonged usage of Tobacco products, usage of dental prosthesis caused traumatic lesions in the old age group compared young age [39].
Oral Traumatic Ulcers are more common in males compared to that of Females, the prevalence rate in the present study was 62.2% in males and 37.7% in females (Fig 2). It is more common in Males as comparatively, they have increased biting forces than the Females. Also, males have an increased risk because of the usage of Tobacco products [40]. Traumatic ulceration is more commonly seen in the Alveolar mucosa in 32.2% of the patients and 31.6% of them had an ulcer in the lower arch buccal mucosa (Fig 3). Ulcers in the alveolar mucosa were most likely to be contributed by the sharp cusps of the teeth . Accidental biting of the mucosa. In a study by Prithivraj et al., the most common site of the mucosal lesion was the Buccal mucosa and the least affected site was the lip and the hard palate [35]. In a study by Ghannaei et al., [42] the lateral border of the tongue was the most common site of traumatic ulcers in Iran [43].
In both Male and Females who presented with Traumatic ulcers, the majority of them were in the age group of 21-30 years, Of which 20.9% of them were Males and 13.7% were females (Fig  4). Males usually have more biting forces comparatively which is more likely to injure the mucosa and cause an ulceration. Also at a young age, patients prefer Orthodontic treatment for Cosmetic reasons. Also, 21.2% of Males had ulceration in the Alveolar mucosa and 13.4% of females had ulceration in the Lower arch Buccal mucosa (Fig 5). Several studies had reported that Buccal mucosa is the common site for traumatic ulcers as it is more prone to accidental cheek biting, irritation of braces or appliance wires during orthodontic treatment [44].
Most often, traumatic ulcers can heal spontaneously and uneventfully without complications in a brief period [45,46]. But, in case of persistent traumatic factors, such as the presence of sharp tooth morphology, cutting edges of restorations, and puncturing appliance contours, especially inadequate surfaces of removable prosthesis, continuous trauma arising from the above-mentioned causes can lead to the formation of chronic ulcers which has high risk of transforming into an Oral Squamous Cell Carcinoma [47].
With the limitations of the small sample size and restricted region is taken into consideration, has attempted to categorise and demographic profile patients who had an incidence of Traumatic ulcer. In the future, further research can be conducted over a large sample size and wide inclusion of geographic location which helps to intervene and create awareness on the importance of maintaining oral hygiene and any ulcers had to be intervened as early as possible to prevent any malignant transformation.

CONCLUSION
Oral cavity ulcerations are caused by any of a spectrum of etiologic factors including infection, immune dysregulation, trauma, and neoplasms. Through careful clinical and medical history and clinical evaluation may lead to a strong presumptive clinical diagnosis, a biopsy may be necessary to confirm the diagnosis or rule out neoplastic sources. From the present study, it can be concluded that Traumatic ulcer is more common in Males. However, Gender, Age, Oral Hygiene, Usage of Tobacco products were not significantly influencing the rate of incidence of Traumatic ulcers. Larger community-based studies should be conducted to estimate more representative percentages of Traumatic ulcers.

DISCLAIMER
The products used for this research are commonly and predominantly used in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
Ethical approval was obtained from the institutional ethical committee (Ethical approval number: SDC/SIHEC/2020DIASDATA/0619-0320