Persistent Painful Ulcer of the Posterior Lingual Mandibular Mucosa

Clinical Findings

A well-defined raised ulcer with a gray-white base, measuring about 7 mm by 3 mm, was evident on the left posterior lingual mandibular mucosa above the mylohyoid ridge. (Figure 1)  Gentle manipulation of the ulcer base with a periodontal probe revealed the floor of the ulcer was hard, insensitive, and slightly mobile.
left pos mandible
Figure 1. Ulcer with gray-white base involving posterior left lingual mandibular mucosa.
Figure 2. Buccal exostoses involving left maxilla.
The teeth tested vital, and there was no evidence of periodontal involvement. The left second mandibular molar showed mild buccal inclination when compared to the first molar; the second molar also showed a prominent wear facet on the distal aspect of the occlusal surface. Other findings included buccal exostoses that were evident on the left maxillary alveolar bone (Figure 2) and to a lesser extent on the right maxilla (not shown). There was a mild left submandibular lymphadenopathy when compared to the right side.

Radiographic Findings

A periapical film of the left mandibular molars adjacent to the ulcer was not contributory. (Figure 3)  An occlusal film showed a localized opacity contiguous to the lingual mandible in the area of the ulcer. (Figure 4)
distinct lingual opacity
Figure 3. Periapical film of left posterior mandible; no bone anomalies are evident.
distinct lingual opacity
Figure 4. Occlusal film of the same region shown in Figure 3 shows a distinct lingual opacity (arrow).
Pathological Findings

The edge of the ulcer base was gently explored with a spoon curette. It was possible to find an edge under the hard base that could be engaged with the curette. Using minimal pressure, a hard irregular fragment (Figure 5) was lifted through the ulcer.
ulcer fragment
Figure 5. Irregular fragment removed through ulcer floor.
fragment cross-section
Figure 6. Microscopic view of a cross-section of the fragment after decalcification. There is a non-vital piece of bone showing irregular resorption, granulation tissue (arrows), and acute inflammatory cells.
Figure 7. Medial view of the mandible showing prominence of the mylohyoid ridges (arrows).
low power
Figure 7. Medial view of the mandible showing prominence of the mylohyoid ridges (arrows).
low power
  Figure 8. An occlusal view of the same mandible in Figure 7 showing the lingual inclination of the posterior molars (arrows) over the mylohyoid ridges.
buccal exostoses
Figure 9. High power photomicrograph showing uniform nuclei within the myxoid stroma. These nuclei are spindle-shaped to stellate and evenly distributed across the field. (Hematoxylin and eosin, original magnification 400x).