oprm-web-case-op-st-35

Patient: Adult, either sex.

Chief Complaint:
The patient reports a nontender, soft tissue enlargement of at least two months duration that doesn't bleed except when the patient bites it.

Medical History:
No abnormalities identified.

Dental History:
Last dental visit was six months ago. The patient has good oral hygiene.

Clinical Findings:
A well circumscribed, nonbleeding, soft tissue enlargement, 2 cm in diameter, is present on the left buccal mucosa at the level of the occlusal plane. The lesion is nontender, mildly compressible, smooth surfaced, and fixed to surface mucosa but not deep structures. The lesion does not blanch upon pressure.

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:
The patient complains of a nontender, soft tissue enlargement of at least 2 months duration.  The lesion is well-circumscribed, mildly compressible, smooth surfaced, 2 cm in diameter, and is fixed to surface mucosa but not deep structures.  The lesion is located on the left buccal mucosa at the level of the occlusal plane.  The lesion does not blanch upon pressure and doesn’t bleed except when the patient bites it.

Lesions to Exclude from the Differential Diagnosis:
This lesion is described as a soft tissue enlargement.  Reactive soft tissue enlargements can be excluded from the differential diagnosis because the lesion is persistent and asymptomatic except when the patient bites it.

Within the category of tumors, malignant tumors can be excluded because the lesion is well-circumscribed and is not fixed to deep structures.  Soft tissue cysts may also be eliminated because these are significantly compressible since they are filled with fluid or semi-solid debris.

Benign tumors is the only category remaining, and they are often defined by their slow growth rate (months to years), usually asymptomatic and usually are not attached to deep or surrounding structures—all of which describe the present case.  Within the category of benign tumors, epithelial lesions can be eliminated because these have a tan or white surface which is rough to palpation. 

For benign mesenchymal tumors, epulis fissuratum (inflammatory fibrous hyperplasia) can be excluded based on location and its association with the flange of a denture.  Peripheral ossifying fibroma and peripheral giant cell granuloma can be excluded because these occur only on gingiva and attached alveolar ridge mucosa.  Rhabdomyoma, neurofibroma, and granular cell tumor can be excluded because these are fixed to underlying tissue.  Hemangioma can be excluded because these are present from childhood and blanch upon pressure.  Lymphangioma can be excluded because these are more compressible and are present from childhood.  Pyogenic granuloma can be excluded because these are compressible, have a reddish-blue color and blanch upon pressure, have a rapid initial growth rate, and are frequently ulcerated   Neuroma can be excluded because these are generally painful to palpation.  Congenital epulis can be excluded because these are present from infancy and are located on the attached alveolar mucosa.

For benign salivary gland tumors, papillary cystadenoma lymphmatosum can be excluded because these tumors occur in the parotid gland.  Low-grade mucoepidermoid carcinoma can be excluded because these lesions are significantly compressible because they are filled with mucus.

Lesions to Include in the Differential Diagnosis:
The differential diagnosis thus includes irritation fibroma, leiomyoma, polymorphous low-grade adenocarcinoma, acinic cell adenocarcinoma, and adenoid cystic carcinoma.  Schwannoma, lipoma, pleomorphic adenoma and monomorphic adenoma are typically encapsulated and freely-movable, but trauma may have ruptured the superficial portion of the capsule causing the lesion to be attached to surface mucosa.

Management:
Treatment is excisional biopsy. 

Final Diagnosis:
Irritation fibroma. 
The prognosis of irritation fibroma is good with recurrence rare.