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Oral Pathology:  Soft Tissue Case #1

 

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Patient: Young adult, either sex

Chief Complaint:
Patient requests a routine examination.

Medical History:
No abnormalities are identified.

Dental History:
Patient had a congenitally missing permanent tooth and a retained deciduous tooth. The patient's last dental visit was two years ago. The patient has good oral hygiene. S/he uses a stiff toothbrush and brushes with the left hand.

Clinical Findings:
A localized white plaque is present on the attached gingiva buccal to the mandibular right second premolar. The lesion is nontender, slightly thickened, firm, rough and fixed to the surface mucosa and underlying structures. The lesion does not rub off. The patient was unaware of the lesion.

Teeth and Gingiva, Right Side
teeth and gingiva, right side

 

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
This is a white surface lesion.  It is white due to epithelial thickening because it is rough, asymptomatic, and will not rub off.

Lesions to Exclude from Differential Diagnosis:
Leukoedema
  ~Location – Bilateral buccal mucosa

Lichen Planus
  ~Bilateral and multifocal

Nicotinic Stomatitis
  ~Location – Hard Palate

Familial Epithelial Hyperplasia (White sponge nevus)
  ~Diffuse and multifocal
  ~Present from early childhood
  ~May have a familial history

Hairy Tongue, Geographic Tongue, and Hairy Leukoplakia
  ~Location - Tongue

Lesions to Include in Differential Diagnosis:
Hyperkeratosis
  ~Most likely from the use of the stiff toothbrush

Epithelial Dysplasia
  ~Less likely due to location on keratinized attached gingiva

Carcinoma in Situ
  ~Less likely due to location on keratinized attached gingiva

Superficial Squamous Cell Carcinoma
  ~Less likely due to location on keratinized attached gingiva

Initial Clinical Diagnosis:
Hyperkeratosis

Management Options:
1)  Explain to the patient the cause and nature of the lesion.  Provide the patient with a soft toothbrush and review tooth brushing techniques.  Re-evaluate in a month.  If it persists, an incisional biopsy is recommended.  Document history and clinical findings, differential diagnosis, and patient recommendations.

2) Perform an incisional biopsy to exclude epithelial dysplasia right away if the patient prefers or if you don’t believe the patient will return for a follow up.

Final Diagnosis:
Hyperkeratosis – Resolved after the patient modified toothbrushing habits