Indian Journal of Multidisciplinary Dentistry

: 2018  |  Volume : 8  |  Issue : 1  |  Page : 52--54

Aphthous ulcer following forceps extraction: A complication or coincidental event

Clement C Azodo1, Paul Erhabor2,  
1 Department of Periodontics, School of Dentistry, University of Benin, Benin City, Edo State, Nigeria
2 Department of Periodontics, Dental Centre, Stella Obasanjo Hospital, Benin City, Edo State, Nigeria

Correspondence Address:
Dr. Clement C Azodo
Room 21, 2nd Floor, Department of Periodontics, Prof Ejide Dental Complex, University of Benin Teaching Hospital, P.M.B. 1111 Ugbowo, Benin City, Edo State


Trauma has been reported to contribute to the development of aphthous ulcer, but uncomplicated forceps extraction as a form of trauma has not been reported. This article reports a case of aphthous ulcer in an otherwise healthy 30-year-old female 2 days after forceps extraction of the upper right 3rd molar. The ulcer was painful and disturbed patient mastication. There was associated dysphagia and hypersalivation. Warm saline mouthwash, topical application of Bonjela cream (choline salicylate and cetalkonium chloride), and tablets of prednisolone (5 mg) were prescribed for the patient for 1 week while the patient continued the other postoperative medications. One-week review of the patient showed significant improvement in the clinical presentation. In conclusion, aphthous ulcer may be considered a potential complication of forceps extraction after excluding other contributing factors. The authors hereby recommend (1) ensuring adequate precaution geared toward minimizing trauma to the oral mucosa during forceps extraction and (2) inclusion of aphthous ulcer as a complication of forceps extraction to reduce chances of possible litigation.

How to cite this article:
Azodo CC, Erhabor P. Aphthous ulcer following forceps extraction: A complication or coincidental event.Indian J Multidiscip Dent 2018;8:52-54

How to cite this URL:
Azodo CC, Erhabor P. Aphthous ulcer following forceps extraction: A complication or coincidental event. Indian J Multidiscip Dent [serial online] 2018 [cited 2020 Jul 10 ];8:52-54
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Aphthous ulcer, also known as a canker sore, is of unknown etiology that usually affects the keratinized or nonkeratinized oral mucosa. It is one of the most common clinically obvious oral ulcerations and is among the oral mucosal conditions that dentists and physicians see most commonly in their patients.[1] Aphthous ulcer in all its forms (minor, major, and herpetiform) presents as painful lesions which appear without reason, last for several days or weeks, heal, and then after a variable interval recur.[2] The cause of aphthous ulcer is unknown,[3] but it is thought to be due to manifestation of autoimmunity to a component of the oral mucosa, local trauma, hormonal changes, stress, iron deficiency anemia, or nutritional deficiency such as folic acid and Vitamin B12.[3],[4],[5] Aphthous ulcer has been reported to be a common cause of dysphagia,[2],[6] daily activity disturbances, and emotional distress with resultant impairment in the quality of life.[7]

The prevalence of aphthous ulcer worldwide and the United States of America is about 25% and 40%, respectively.[8] In India, the prevalence of aphthous ulcer is about 21.7%[7] while the reported prevalence in Iran is 25.2%.[9] Arotiba et al. reported a prevalence rate of 15% for aphthous ulcer in HIV-infected Nigerian patients.[10] Aphthous ulcer could occur in apparently healthy individuals, or it could be present in individuals with an underlying recognizable clinical condition as in Behcet's disease and celiac disease.[4] It has been reported that minor variant is the more common type of aphthous ulcer.[2] Minor aphthous ulcer occurs on nonkeratinized oral mucosa whereas the major aphthous ulcer and herpetiform aphthous ulcer may be found anywhere on the oral mucosa: keratinized or nonkeratinized.[2],[4] Studies have reported a significant difference in distribution of aphthous ulcer between sexes, the females being more significantly affected than males.[7],[11],[12] Onset of aphthous ulcer is between the 2nd and 3rd decades of life.[2],[7],[12] Aphthous ulcer constitutes 47.3% of all oral ulcerative lesions in patients visiting dental center in the University of Teaching Hospital, Benin City, Nigeria.[13] The clinical diagnosis of aphthous ulcer is based on the characteristic clinical appearance.[3] Laboratory investigations to rule out predisposing factors such as iron deficiency anemia, deficiencies in folic acid and Vitamin B12, hormonal changes, as well as genetic analysis may be necessary to confirm the diagnosis.[4],[5]

Treatment for all aphthous ulceration is symptomatic and usually depends on the ulcer frequency and severity.[2] In some cases, treatment may be unnecessary, but where painful topical anesthetics such as Bonjela, antimicrobial, or corticosteroid preparation such as 0. 1% triamcinolone may be beneficial.[2],[14] Systemic corticosteroids may be necessary in severe cases, especially in cases where there are no underlying nutritional or endocrine disorders. 0.2% chlorhexidine mouthwash may be useful in patients who may have difficulty in keeping the mouth clean.[2],[4],[13] Literature review did not reveal any report of aphthous ulcer following uncomplicated forceps extraction of a single tooth in patients. This article hereby reports a case of aphthous ulcer as a possible complication or coincidental event after forceps extraction of a single tooth.

 Case Report

A 30-year-old businesswoman presented with a 6-day history of a throbbing pain from the upper right 3rd molar which disturbs the patient sleep and mastication. The pain was spontaneous in onset and associated with headache. There was a history of relief of pain by the drug aspirin. She is married with 2 children in a monogamous setting. A history of surgery (appendectomy) was uneventful.

Clinical examination revealed carious upper right 3rd molar which was tender to percussion. Periapical radiography revealed disto-occlusal radiolucency communicating with the pulp of the tooth. Forceps extraction of the tooth was carried out by an intern under the supervision of the consultant. 400 mg of metronidazole, 500 mg of amoxicillin, 1000 mg paracetamol, as well as warm saline mouthwash were prescribed. The patient was given a 1-week appointment for review.

The patient reported to the clinic, 2 days after extraction, with a complaint of severe pain which disturbed his chewing of foods. The patient also complained of difficulty in swallowing (dysphagia) and hypersalivation. The patient said that she was experiencing her menstrual flow at that point in time. Clinical examination revealed that a small, round ulcer measuring 12 mm with yellowish floor was found on the palate close to the extraction site. The ulcer was well circumscribed and the margins of the ulcer were reddish (erythematous). The features of the ulcer were consistent with the diagnosis of major aphthous ulcer [Figure 1]. Warm saline mouthwash, topical application of Bonjela cream (choline salicylate and cetalkonium chloride), and tablets of prednisolone (5 mg) for 1 week were prescribed for the patient while the patient continued with her other postoperative medication. She was given another 1-week appointment for review. On recall appointment, the aphthous ulcer has resolved.{Figure 1}


Aphthous ulcer is thought to occur due to a manifestation of autoimmunity to a component of the oral mucosa unknown. Several factors have also been shown to predispose an individual to the occurrence of aphthous ulcer.[3] The authors have reported aphthous ulcer following physical trauma.[14] Extraction using forceps and elevators, along with the digital manipulation of the oral tissues, puts pressure on the palatal mucosa while extracting the upper third molars. This pressure can cause microtrauma that may or may not be predisposing factor for aphthous ulcer. We hypothesize that during the procedure, the pressure exerted on the palate by the operator's digits and instruments may have caused injury unknown to the dentist and imperceptible to the patient, thus triggering the manifestation of the ulcer. Iatrogenic trauma, which is more common in treatment rendered by young practitioners, has been implicated as a predisposing factor for aphthous ulcer.[15],[16] In this reported case, the operator was a house officer.

The inadequate access to the upper 3rd molar in this case may have resulted in more chairside time to achieve extraction of the tooth. This may have been stressful and traumatic for the patient. The fact that the patient was experiencing her menstrual flow at the time of forceps extraction may have contributed to the stress experienced by the patient, thereby possibly serving as a form of predisposing factor. Local trauma, hormonal changes, and stress are among cited predisposing factors for aphthous ulcer in the literature.[3],[4],[5]

Although investigators have not fully elucidated the predisposing factors for aphthous ulcer, several factors have been identified: microtrauma, hormonal changes as seen in menstrual cycle, immunosuppression, dental procedures, local trauma, physical and emotional stress, iron deficiency anemia, and nutritional deficiencies such as folic acid and Vitamin B12. The patient in this reported case was in her menstrual flow and menstruation is commonly associated with hormonal changes and could also be a cause of great physical and emotional stress for the patient. Hormonal changes and stress are established predisposing factors for aphthous ulcer.[3],[4],[5] When considering aphthous ulcer after dental procedure in a female patient, it is therefore important to exclude hormonal changes during history taking. The diagnosis in this report was based strictly on the history and clinical finding of the oral ulcer and no further investigation was done, which may be an obvious limitation.

It has been stated that aphthous ulcer is most prevalent between the 2nd and 3rd decades of life.[2],[7],[12] In this case report, the patient was 30 years old, which was within the most prevalent age group. Studies have indicated that the females are more significantly affected than males by aphthous ulcer,[7],[11],[12] and in this report, our patient was a female. It appears that aphthous ulcer last for several days or weeks and the observation in this report is therefore consistent with the findings in documented literature.[2],[4]


Aphthous ulcer may be considered as a potential postoperative complication of forceps extraction after exclusion of other trigger factors. The authors therefore recommend the following:

Ensuring adequate precaution geared toward minimizing trauma to the oral mucosa during forceps extractionInclusion of aphthous ulcer as a complication of forceps extraction to reduce the chances of possible litigation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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