Sir, I read with interest the letter from Gogna et al. (BDJ 2015; 219: 560) regarding palatal mucosal necrosis after administration of a local anaesthetic palatal infiltration, and would like to highlight a similar case.

In August 2015 a 43-year-old Caucasian female with an unremarkable medical history was urgently referred to our oral and maxillofacial department by her dentist with suspected oral cancer. The patient reported an eight-day history of a painful ulcer on the hard palate, and on examination there was a 1.0 × 1.5 cm diameter 'punched out' ulcer on the left posterior hard palate which extended down to bone. The defect contained loose, yellow sloughing tissue and the adjacent tissues were erythematous with raised, rolled margins (Fig. 1). An urgent incisional biopsy was performed which confirmed a diagnosis of acute necrotising sialometaplasia and excluded dysplasia. The patient was reassured of the diagnosis, advised to maintain good oral hygiene, and subsequently reviewed to assess for healing. The patient was discharged eight weeks later following complete resolution of the lesion.

Figure 1
figure 1

The 'punched out' ulcer on the left posterior hard palate which extended down to bone

Full size image

Acute necrotising sialometaplasia is a rare, benign and self-limiting inflammatory condition of salivary gland tissue which occurs as a result of trauma causing the tissues to become ischaemic and necrotic.1 It typically presents as a unilateral necrotic ulcer on the hard palate but is often preceded by a firm, fluctuant and often painful swelling which can mimic a dental abscess.1 This condition has been associated with trauma, heavy smoking, excessive alcohol consumption and violent vomiting, such as in patients with bulimia, but can also occur following palatal infiltrations.2 As Dr Gogna's patient did not receive a biopsy to confirm a diagnosis, I wonder if acute necrotising sialometaplasia could have been a differential diagnosis to consider? The most significant issue to highlight is that it can mimic malignancy, both clinically and histologically, which could result in an incorrect diagnosis and unnecessary intervention. The condition is self-limiting and does not require treatment besides supportive measures, often healing spontaneously within 4-10 weeks without complication.1

Should this condition present in general dental practice, then an urgent referral to the oral and maxillofacial or oral medicine team for a second opinion is advisable, as an incisional biopsy will often be undertaken to confirm a diagnosis and exclude malignancy.