Compiled from clinical pathology references. Medically reviewed by Dr Cristian Dunker , Principal Dentist, ArtSmiles Cosmetic Dentistry.
Quick summary
Also called | Traumatic ulcer formation, denture sore, factitious ulcer, eosinophilic ulcer / traumatic granuloma (TUGSE), Riga-Fede disease (in infants) |
How urgent? | 🟡 Worth a check-up, most heal within 7,10 days once the cause is removed, but any ulcer that has not healed after two weeks needs a dental assessment to rule out something more serious. |
Common or rare? | Very common, the most frequent cause of a single ulcer in the mouth |
Who it affects | Anyone, at any age, from infants with newly erupted teeth to denture wearers in later life |
Who treats it | General dentist, with specialist referral if the ulcer does not heal as expected |
Based on | Regezi, Neville, Cawson, Laskaris |
What is it?
A traumatic ulcer is a break in the lining of the mouth caused by a physical, chemical or thermal injury. The protective surface layer is lost, leaving a tender, shallow crater with a yellow-grey base and a red border.
These are the most common ulcers seen in dental practice. The cause is usually obvious, a sharp tooth, an ill-fitting denture, an accidental cheek bite, or a sip of coffee that was hotter than expected. Once the source of irritation is removed, the area normally heals on its own within a week to ten days.
Who tends to get it?
Traumatic ulcers can affect anyone with teeth or dentures, which is to say almost everyone at some point in life. They turn up in several recognisable groups:
Adults with sharp or broken teeth, rough fillings or fractured restorations that rub against the tongue or cheek.
Denture wearers, particularly in the first few weeks after a new prosthesis is fitted, where an over-extended flange (the part of the denture that sits against the gum) digs into the sulcus (the fold between cheek or lip and gum).
Children and adults who accidentally bite the lip, cheek or tongue after a dental local anaesthetic, while the area is still numb.
Infants with natal (present at birth) or newly erupted lower front teeth, who can develop an ulcer on the underside of the tongue from breastfeeding (a presentation known as Riga-Fede disease).
People with learning difficulties or certain neurological conditions who may chew or injure the lips and cheeks repeatedly.
Older adults with extensive dental work, where chemical irritants, sharp restorations or denture pressure are more likely.
A particular variant called the eosinophilic ulcer (also known as TUGSE, short for traumatic ulcerative granuloma with stromal eosinophilia) is more common in adults over 40 and slightly more common in men. It earns its name from a particular pattern of immune cells (eosinophils, a type of immune cell) seen on biopsy (a small tissue sample sent to the lab for testing).
What causes it?
The sources of injury fall into three broad groups:
Mechanical (physical) trauma
Sharp or broken-down teeth, fractured fillings or worn cusps
Accidental biting of the cheek, lip or tongue, especially while eating or after a numbing dental injection
Over-extended or poorly fitting dentures, particularly along the flanges and posterior borders
Orthodontic brackets, wires or sharp clasps on partial dentures
Hard or sharp foodstuffs, such as a piece of crusty bread or a fish bone
Aggressive tooth-brushing with a hard-bristled brush
Iatrogenic (treatment-caused) injuries during dental treatment, for example, suction from a saliva ejector, an inadvertent slip of a rotary instrument, or pressure from cotton rolls
Chemical irritation
An aspirin tablet held against the gum to relieve toothache, which can cause a chemical burn
Strong oxidising agents used in some dental procedures, such as hydrogen peroxide for bleaching
Acidic etching agents, phenol-containing cavity medications, and certain over-the-counter mouth ulcer remedies if used too frequently or held in one place
Thermal injury
Hot food and drinks, the classic example being a "pizza burn" on the palate from molten cheese
Microwaved foods, where the inside is far hotter than the outside
Burns from hot dental impression materials
A much smaller group are factitious, self-inflicted ulcers, often associated with anxiety, habit or an underlying psychological issue. These can be difficult to recognise because the patient may not volunteer the cause.
How does it develop?
The lining of the mouth is a thin, moist surface designed to handle the everyday wear of eating and speaking. When something rubs, presses or burns against that lining for long enough, the surface cells are stripped away and the underlying connective tissue is exposed. This is what produces the typical "crater" appearance.
The body responds the same way it would to a graze on the skin. Inflammation brings extra blood flow (the red halo), fluid leaks from the small vessels (the swelling), and a protective layer of fibrin, a yellowish-grey protein meshwork, forms over the raw surface. Once the irritant is gone, new cells from the edges of the ulcer slide inward across the granulation tissue (new healing tissue) base, and the surface knits back together.
If the trauma keeps happening, a denture flange that has not been adjusted, a sharp tooth that has not been smoothed, a habit of cheek-biting, the wound is never given the chance to close. Repeated injury at the same spot can lead to a chronic ulcer with raised, scarred margins, which is why these long-standing ulcers can begin to look concerning on examination.
What might you notice?
What it looks like
A typical traumatic ulcer is a single, well-defined, shallow lesion with a yellow-grey or yellow-white floor and a thin red border. It tends to be oval and may range from a few millimetres to a centimetre or more across. The base is usually soft when gently pressed.
The most common locations are the lateral border of the tongue, the inner cheek along the bite line, the lips, and the gum or sulcus next to a denture. Chronic ulcers may develop a slightly raised, white, hyperkeratotic (thickened) rim around the edge.
The eosinophilic ulcer variant tends to appear as a deeper, crater-like ulcer on the tongue, sometimes with a raised mass that can look unsettling. In infants with Riga-Fede disease, the ulcer is typically on the underside of the tongue, where it contacts the new lower front teeth during breastfeeding.
What it feels like
Mild to moderate soreness, particularly when eating spicy, salty, acidic or crunchy foods
A sharp catching sensation against a particular tooth, denture edge or filling
Discomfort when speaking or moving the tongue, depending on the site
Sometimes very little pain, chronic traumatic ulcers, especially on the tongue, can be surprisingly asymptomatic
In infants, ulcers from Riga-Fede disease may interfere with feeding, causing fussiness or refusal to suckle.
What happens at the dentist?
The diagnosis is usually made on the history and the clinical examination. At ArtSmiles, your dentist will:
Ask about the duration of the ulcer, any obvious cause such as a recent bite or dental procedure, and whether it has changed over time
Examine the area carefully, paying attention to nearby teeth, fillings, dentures and orthodontic appliances that could be the source of irritation
Gently feel the ulcer to check whether the base is soft (typical of trauma) or firm and indurated (which would warrant further investigation)
Look for any associated swelling of nearby lymph nodes
If an obvious cause is found, the dentist will remove or smooth it, adjusting a denture, polishing a sharp tooth edge, or replacing a fractured filling, and ask you to return for review.
The two-week rule. If the ulcer has not healed within two weeks of the cause being removed, a biopsy is recommended. This is the single most important safety rule in oral medicine. Several serious conditions, including oral squamous cell carcinoma, can mimic a traumatic ulcer in their early stages, and a small tissue sample is the only reliable way to be certain.
A biopsy involves taking a small piece of the ulcer under local anaesthetic and sending it to an oral pathologist for examination. Curiously, in the eosinophilic ulcer variant, healing often occurs rapidly after the biopsy itself.
Is this serious?
🟢 Most traumatic ulcers are not serious. They are uncomfortable but heal completely within 7,10 days once the cause is taken away.
🟡 A non-healing ulcer is a different matter. Any oral ulcer that persists beyond two weeks after the suspected cause has been addressed should be assessed promptly. Early oral cancer can be painless and may look very similar to a benign traumatic ulcer in its first stages, which is why dentists are taught to be cautious with anything that does not heal on schedule.
🔴 Particular concern is warranted if an ulcer is firm or hard to the touch, has rolled or raised borders, is fixed to deeper tissues, or is associated with an unexplained lump in the neck. Persistent denture-related ulceration in older adults that does not settle once the denture is adjusted should always be biopsied.
If you have noticed an ulcer in your mouth for more than two weeks, it is worth booking an assessment.
Could it be something else?
Many conditions can produce an ulcer that resembles a simple traumatic one, which is why the two-week rule matters. Differentials documented in the source textbooks include:
Squamous cell carcinoma (oral cancer), the most important condition to exclude. Can look identical to a chronic traumatic ulcer in its early stages. A dentist distinguishes it by feeling for a firm, indurated base, looking for raised or rolled borders, and arranging a biopsy if the ulcer does not heal as expected.
Recurrent aphthous ulcers (canker sores), also painful and yellow-floored, but usually multiple, recurrent in pattern, and located on non-keratinised mouth lining (mucosa). They are not linked to a clear physical cause.
Eosinophilic ulcer / traumatic ulcerative granuloma with stromal eosinophilia (TUGSE), a recognised variant of traumatic ulceration that is deeper and slower to heal. Diagnosed on biopsy by its distinctive pattern of inflammatory cells.
Necrotising sialometaplasia, a deep, crater-like ulcer of the hard palate caused by injury to a small salivary gland. Heals on its own over several weeks but is often biopsied because it can mimic cancer.
Primary syphilis (chancre), a painless ulcer with a hard, raised border. Distinguished by serology (blood tests for antibodies) and the patient's history.
Tuberculosis, produces a chronic, ragged ulcer, usually on the tongue, in patients with active pulmonary disease. Ruled out by chest imaging and biopsy.
Deep fungal infections, uncommon, but can cause chronic ulcers in people who are immunosuppressed.
Oral lymphoma, a rare cause of a non-healing oral mass or ulcer. Diagnosed on biopsy.
Drug-induced ulceration and chemotherapy-related mucositis, distinguished by the medication history and the typically widespread, multiple appearance.
Behçet's disease and other systemic ulcerative conditions, distinguished by ulcers occurring elsewhere on the body and a recurrent pattern.
Factitious (self-inflicted) ulceration, often has a bizarre shape, sharp outlines, sits in an area the patient can easily reach, and does not match any typical disease pattern.
Ruptured blood blister (localised oral purpura), leaves a tender ulcer after the blister breaks, but the recent history of a blood-filled bullae (large blisters) usually makes this clear.
How is it treated?
Treatment has two parts: removing the cause, and helping the area to settle. For a broader look at managing sore spots and ulcers in the mouth, our guide to mouth ulcers and how to treat them covers the day-to-day measures that help most lesions heal.
At the dentist
Smoothing or restoring a sharp tooth, broken filling, fractured cusp or rough crown
Adjusting an over-extended or pressing denture flange, most denture-related ulcers heal within 24,48 hours of relief
Replacing or recontouring an orthodontic component that is rubbing
For Riga-Fede disease in infants, smoothing the incisal edges (biting edges) of the lower teeth or applying a protective covering rather than removing the teeth, which are usually retained
A topical corticosteroid (an anti-inflammatory gel) or protective film may be prescribed for symptomatic relief if the ulcer is uncomfortable
A biopsy is recommended if the ulcer does not heal within two weeks of the cause being addressed
At home
Rinsing gently with warm salty water or a sodium bicarbonate mouth rinse to keep the area clean
Avoiding spicy, salty, acidic and very hot foods until the ulcer has healed
Using a soft-bristled toothbrush, particularly near the affected area
Avoiding the temptation to place an aspirin or other tablet directly against a sore spot, which often causes a chemical burn on top of the original injury
For habitual cheek or lip biting, becoming aware of the habit is the first step; in some cases a custom mouth shield made by a dentist can help break the cycle
What's the long-term outlook?
The outlook for a simple traumatic ulcer is excellent. Once the source of irritation is removed, healing is usually complete within 7,10 days and the area returns to normal without scarring.
Chronic traumatic ulcers, those caused by ongoing irritation that has not been identified, can take longer to settle but will generally heal once the cause is found and addressed. The eosinophilic ulcer variant may take a few weeks to a few months to resolve, but it tends to heal completely after biopsy.
The only situation where the outlook becomes more serious is when a persistent ulcer turns out, on biopsy, to be something other than simple trauma. That is precisely why the two-week rule exists: it is not designed to alarm patients, but to make sure that the small number of ulcers that are not what they appear are picked up early, when they are most treatable.
If you wear dentures, regular reviews allow your dentist to spot pressure points before they become painful ulcers. If you notice a tooth becoming sharp, a filling beginning to break down or a denture starting to rub, an early adjustment is far easier than waiting until an ulcer develops.
A note on this article
This article is for educational purposes only and does not constitute a clinical diagnosis. Please consult a registered dental practitioner for assessment and treatment advice.
References
Regezi, J. A., Sciubba, J. J., & Jordan, R. C. K. (2017). Oral pathology: Clinical pathologic correlations (7th ed.). Elsevier. Chapter 2, Ulcerative Conditions: Reactive Lesions / Traumatic Ulcerations, pp. 23,28.
Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2023). Oral and maxillofacial pathology (5th ed.). Elsevier. Chapter 8, Physical and Chemical Injuries: Traumatic Ulcerations, pp. 273,276.
Cawson, R. A., & Odell, E. W. (2017). Cawson's essentials of oral pathology and oral medicine (8th ed.). Elsevier. Chapter 13, Diseases of the Oral Mucosa: Non-infective Stomatitis (Traumatic Ulcers), p. 220; and Miscellaneous Mucosal Ulcers (Eosinophilic Ulcer), p. 238.
Laskaris, G. (2003). Color atlas of oral diseases (3rd ed.). Thieme. Section 4, Mechanical Injuries: Traumatic Ulcer, pp. 44,45.