ANAHTAR KELİMELERKimyasal yanık, Nodyum bikarbonat, Eritematöz makül.

ÖZET

KEYWORDSChemical burn, Nodium bicarbonate, Erythematous

macule.

ABSTRACT

Elektrik, sıcak, soğuk, radyasyon ve kimyasal veya meka-nik stimulus oral mukozada hasara neden olabilir. Eritematöz bir makül şeklinde ortaya çıkan kimyasal veya termal yanığın nedeni, genellikle kostik (yakıcı) ilaç veya sıcak yiyecek veya içeceklerdir. Vakaların çoğunda kimyasal yanıkların klinik görünümleri doku hasarı-nın şiddetine bağlıdır. Bu yanıklar lokalize mukozitis, keratotik beyaz lezyonlar şeklinde olabileceği gibi doku yüzeyindeki koagülasyon nedeniyle; irrite, kanamalı, ağrılı doku yüzeyleri şeklinde de ortaya çıkabilirler. Bu makalede sodyum bikarbonat nedeniyle sağ bukkal mukozasında kimyasal yanık oluşmuş olan bir vaka sunulmakta ve ayırıcı tanıda hasta hikayesinin önemi vurgulanmaktadır.

Electricity, heat, cold, radiation, and chemical or mec-hanical stimuli can be cause injury of the oral mucosa. The cause of a chemical or thermal burn which presents as an erythematous macule is usually a caustic drug or hot foods or beverages. The clinical appearance of the chemical burns in most cases depends on the severity of the tissue damage. These burns may produce localized mucositis, keratotic white lesions or as well as raw, ble-eding, painful tissue surface due to the coagulation of the tissue. In this report, a case of an unusual chemical burn localized in the right buccal mucosa, produced by sodium bicarbonate, is reported and the importance of the history in differential diagnosis is emphasized.

Hacettepe Dişhekimliği Fakültesi DergisiCilt: 30, Sayı: 1, Sayfa: 63-66, 2006

A Chemical Erythematous Macule of the Buccal Mucosa

Bukkal Mukozada Kimyasal Eritematöz Makül

*Dilek Aynur UĞAR DDS, PhD, *Süleyman BOZKAYA DDS, PhD, *Bülent GÜNER DDS, PhD, *İnci KARACA DDS, PhD

*Gazi University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery

OLGU RAPORU (Case Report)

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INTRODUCTION

Injury of the oral mucosa can be caused by electricity, heat, cold, radiation, and chemical or mechanical stimuli1,2. The cause of a chemical or thermal burn which presents as an erythematous macule is usually a caustic drug or hot foods or beverages3. The severity of the lesion depends on the type of chemical agent utilized and the con-centration and duration of contact of the noxious agent with the tissues4. Phenol, eugenol, trichloro-acetic acid, aspirin, iodine, alcohol, acrylic resin, sodium perborate, silver nitrate, sodium hypochlo-rite, paraformaldehyde, chlorine compounds and agriculture chemical agents are but a few examples. The signs and symptoms of burns of the oral mu-cosa vary considerably, depending on the nature of the causative agent. When the burn is reasonably severe, the coagulated mucosa can usually, though painfully, be seperated from the underlying tis-sues3.

In this paper an exceptional case of a chemical burn produced by misuse of sodium bicarbonate for oral hygiene practice which is believed to be caused for the first time to such a lesion reported in the dental literature is presented and the importance of the history in differential diagnosis is emphasized.

CASE REPORT

A 51-year- old female was referred to the Oral and Maxillofacial Surgery Department with a com-plaint of a red and painful lesion on her right buc-cal mucosa by her general dental practitioner. Her history revealed that her gingiva was red, swollen and she observed bleeding both during the brush-ing and sometimes spontaneously. She had decided on her own to get antibiotic orally and use sodium bicarbonate as an adjunct to brushing for improv-ing her oral hygiene. For this purpose she used sodium bicarbonate/water mouthwash with each tooth-cleaning episode. Because she didn’t satis-fied from the outcome, she decided to use sodium bicarbonate powder on her gingiva directly. She continued both to get antibiotic and use sodium bicarbonate approximately for three weeks. When

she saw a red, painful area in her right buccal mu-cosal region, she admitted to a dental practitioner. She was called that the cause of this erythematous lesion may be an atrophic candidiasis due to long lasting antibiotic use and antifungal treatment was recommended. Although such a treatment, there was no improvement.

The patient’s past medical history was non-con-tributory and there were no extraoral findings. The intraoral examination showed a red, 2 x 1,5 cm, tender, superficial lesion extending from the corner of the mouth to the posterior buccal mucosa in the right side (Fig 1). Visual examination of the remain-ing intraoral soft tissues disclosed unhealthy peri-odontal condition.

An incisional biopsy was performed with local anesthesia. Histologic examination showed marked intracellular and extracellular edema in the surface of the epithelium. The superficial part of the lamina propria contained dense inflammatory cell infil-trate (Fig 2). PAS-staine sections demonstrated the absence of fungal organisms in the epithelium.

Treatment consisted of triamcinolone in Ora-base as a protective coating, an analgesic and a bland diet. The burn healed in 2 weeks (Fig 3).

DISCUSSION

The clinical appearance of the chemical burns in most cases depends on the severity of the tissue damage. These burns may produce localized muco-sitis, keratotic white lesions or as well as raw, bleed-ing, painful tissue surface due to the coagulation of the tissue3,5. In the case presented the clinical ap-pearance of the lesion was red and painful.

Chemical burns most often result from the pa-tient applying analgesics such as aspirin or acet-aminophen near to the mucosa adjacent to an ach-ing tooth1,6. It is also reported that caustic inges-tion, accidental ingestion of hot foods or beverages, excessive consumption of fresh fruit and fresh fruit juice, and wrong oral hygiene practice may cause burns of the oral tissues7. In the present case, the gingiva was hyperemic and swollen due to the poor oral hygiene.

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Sodium bicarbonate that the patient used for improving her oral hygiene is a white, crystalline powder chiefly used a gastric antacid. In aqueous solution, it is used locally for washing the nose, mouth, and vagina, and as a cleansing enema7. Al-though it is known that in saturated solution so-dium bicarbonate is used as a dressing for minor burns, in this case according to the patient’s his-tory we have thought that the use of sodium bi-carbonate, especially the application of its powder caused an erythematous macule. Some products as toombak and snuff that are known to contain so-dium bicarbonate have strong alkalinity. Idris et al8 detected the clinical and histopathological char-acteristics of toombak-associated oral mucosal le-sions. They reported that this property of toombak may contribute to the epithelial surface changes which are similar to those seen in lesions induced by snuff. It is concluded that chronic exposure of these products may result in an alkaline burn on the oral mucosa.

The Keyes technique that is used for the treat-ment of periodontal disease involves local mechan-ical therapy, local chemical therapy and systemic antibiotics. For the local chemical therapy baking soda and peroxide are used as an adjunct to home plaque control. However it is emphasized that abuse of the practices may lead to gingival injury9. Herrin et al10,11 investigated whether the oral application of a baking soda - % 3 hydrogen peroxide dentifrice and a nearly saturated sodium chloride mouthwash, as a home care method for treating periodontal dis-ease, creates a sodium burden for human subjects. They concluded that raw, erosive desquamative gingival lesions were seen in all treated subjects. In this case, it is thought that because of the high con-centration of baking soda that the patient applied caused a red, tender, superficial lesion just after the application. This clinical appearance is consistent with the observation of Herrin et al.

Until a careful history is taken, the patient is usually unaware of the cause of the lesion6. The identification of the chemical burn lesion is best accomplished by determining, through the patient history6,12.

FIGURE 1

Patient shown on day of admission

FIGURE 2

Surface of the epithelium showing marked intracellular and extracellular edema. The lamina propria contained dense

inflammatory cell infiltrate (H&E x 40).

FIGURE 3

The right buccal mucosa after 2 weeks of treatment.

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In chemical burns, a white, white-brownish or red surface can be seen12. In the chemical burn le-sions which appear as a red surface, as in this pa-tient, erythema from mechanical trauma, purpiric macule, cellulitis, allergic manifestations, erythro-plakia, atrophic candidiasis, herald spot of dissemi-nated red conditions, and fungal infections should be taken into account in differential diagnosis6. This patient had been previously treated under an incorrect diagnosis of atrophic candidiasis due to long lasting antibiotic use and inappropriate anti-fungal treatment was recommended. In our clinic the chemical burn lesion was differentiated from the atrophic candidiasis via a detailed patient his-tory and histologic examination confirmed the di-agnosis.

The treatment for chemical burns is the applica-tion of a protective coating such as Orabase with or without steroids and initiation of a bland diet1,6. In most cases, treatment is mainly symptomatic. If the agent is completely eliminated and there are no further exposures, prompt recovery is the rule1,3. If pain is a problem, systemic analgesic may be ad-ministered. The analgesic tablets are to be swal-lowed and not be used topically6. In the current case besides triamcinolone in Orabase and a bland diet, a systemic analgesic was recommended.

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6. Wood NK, Goaz PW. Chemical Burns. In: DifferentialDiagnosisofOralLesions.4thed.St.Louis:MosbyYearBook;1991;68-70,144-145

7. Dorlan’s Illustrated Medical Dictionary. 26th ed.Philadelphia,1981,W.B.SaundersCompany.

8. IdrisAM,WarnakulasuriyaKA,IbrahimYE,NielsenR,CooperD,JohnsonNW.Toombak-associatedoralmucosallesions in Sudanese show a low prevalence of epithelialdysplasia.JOralPatholMed.1996;25(5):239-44

9. Currentunderstandingoftheroleofmicroscopicmonitoring,baking soda, and hydrogen peroxide in the treatment ofperiodontaldisease.CommitteeonResearch,ScienceandTherapy. The American Academy of Periodontology. JPeriodontol.1998;69(8):951-4

10. Herrin JR, Rubright WC, Squier CA, et al. Local andsystemiceffectsoforallyappliedsodiumsalts.JAmDentAssoc.1986;113(4):607-11

11. Herrin JR, Squier CA, Rubright WC. Development oferosivegingivallesionsafteruseofahomecaretechnique.JPeriodontol1987;58(11):785-8

12. StrassburgM,KnolleG.Diseases of the oralmucosa.AColorAtlas.2nded.Chicago:QuinteisencePublishingCoInc;1994.

CORRESPONDING ADDRESS

Süleyman BOZKAYA DDS, PhDGaziUniversity,FacultyofDentistry,DepartmentofOralandMaxillofacialSurgery

Tel:+903122126220extention350,Fax:+903122239226,E-mail:sbozkaya@gazi.edu.tr