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.

1. LESION CASE STUDY
Kalvin Smith
Oral Pathology
State Fair Community College

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

4. CLINICAL APPEARANCE OF
LESION

5. VELESCOPE

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.

7. DIFFERENTIAL DIAGNOSIS

8. POSSIBLE
DIAGNOSES
Lymph tissue
Irritation fibroma

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.