A 64-year-old female presented with a small whitish-pink lesion on her pterygomandibular fold. She was unaware of the lesion and experienced no symptoms. Based on the clinical appearance and location near a recent dental restoration, the supervising dentist believed it was likely an irritation fibroma. However, a definitive diagnosis would require an excisional biopsy for microscopic examination. The lesion was small at 3x3x1mm with a sessile base, characteristics consistent with an irritation fibroma. It was determined to be non-concerning and would be monitored without biopsy due to the patient's good health and lack of symptoms.
2. MEDICAL
HISTORY
64 year-old female
Patient is in good health
Medications:
•10mg Atrevastatin
•May cause xerostomia
•Takes for high cholesterol
•40mg Fluoxetine
•May cause xerostomia
•Takes for depression
Vitals:
•Blood Pressure: 130/82
•Pulse: 64 bpm
•Respiration: 14 rpm
•Temperature: 98.1℉
3. DENTAL HISTORY
• Patient receives routine dental cleanings
• This was her first appointment at SFCC
• Recently had a restoration placed on #18
• Brushes teeth 2x daily
• Flosses or uses Waterpik 1x daily
• Uses fluoridated toothpaste and mouth rinse
6. LESION CHARACTERISTICS
• Location: Pterygomandibular fold, distal to #18
• Size: 3x3x1mm
• Shape: Circular
• Base: Sessile
• Color: Whitish pink
• The patient was completely unaware of the lesion and has experienced
no symptoms, such as pain, swelling, or discomfort.
9. LYMPH TISSUE
• The supervising dentist at SFCC believed that the lesion could possibly
be lymph tissue that had come to the surface.
• He was not certain this was the true diagnosis
• Lymph tissue may surface in the mouth as a sign of illness (Ibsen &
Phelan, 2014).
• A referral was written to the patient’s general dentist for closer
inspection and a biopsy if needed.
10. IRRITATION FIBROMA
• An irritation fibroma is a “broad-
based, persistent exophytic lesion
composed of dense, scar like
connective tissue containing few
blood cells” (Ibsen & Phelan, 2014).
• Benign
• Occurs as result of trauma
• Usually a small lesion (less than 1cm)
• Frequently found on buccal mucosa
• Light pink to white in color
• May have sessile or pedunculated base
11. DIAGNOSIS
• Based on the clinical findings, this lesion
is likely an irritation fibroma.
• To confirm this diagnosis, excision and
microscopic examination of the tissue
must be performed (Ibsen & Phelan,
2014).
• Reasons why this is likely an irritation fibroma:
• Caused by trauma
• Patient recently had restoration placed on #18
that could have rubbed/irritated the area
• Small in size/sessile base
• Lesion was 3x3x1mm
• Found on buccal mucosa
• Pterygomandibular fold
• Reasons it is likely not lymph tissue:
• The patient is in good health
RATIONALE
DIAGNOSIS
12. PROGNOSIS
• Both the supervising dentist at SFCC and the patient’s general dentist
believe that this lesion is nothing to worry about.
• A biopsy was not performed due to lack of concern about the lesion and
no patient discomfort.
• The lesion will be monitored and remeasured at each continuing care
appointment.
13. REFERENCE
Ibsen, O. A., & Phelan, J. A. (2014). Oral Pathology for the Dental Hygienist. St. Louis,
MO: Elsevier.
