Answers to Case Study Questions

Discussion

White Lesions

Case 1

Candidiasis—wrong. The lesion does not have a roughened, ragged appearance and the entire white component is removable (i.e., the Candida albicans hyphae/spores).
Leukoedema—wrong. The lesion disappears when stretched; it is not partially removable; it is bilateral.
White sponge nevus—wrong. The lesion has been present from an early age and is bilateral; it is not partially removable.
Morsicatio buccarum—correct. The ragged white clinical appearance is typical; tissue tags are “peelable” but frictional-induced white keratin component is not; patients are often not aware of their nibbling habit and/or deny it.

Case 2

Candidiasis—correct. The age, history, and clinical information are diagnostic for a typical case of pseudomembranous candidiasis.
Diphtheria—wrong. Similar-appearing lesions of necrotic debris may be seen but are in the oropharynx with diphtheria.
White sponge nevus—wrong. The patient's age is correct but white sponge nevus lesions do not wipe away.
Hairy leukoplakia—wrong. The patient's age and immune status and the lesion's wipeability and site are not correct.

Case 3

Chemical trauma—wrong. This is an aspirin burn and the white areas represent necrotic tissue. This should be part of your differential diagnosis.
Leukoedema—correct. Leukoedema lesions should be bilateral and disappear with stretching.
Morsicatio buccarum—wrong. Morsicatio may appear this way and be unilateral. This should be part of your differential diagnosis.
Tobacco pouch keratosis—wrong. The history would provide more details. Tobacco pouch keratosis is a type of keratotic reaction to the irritant chemicals in tobacco. This should be part of your differential diagnosis.

Case 4

Leukoedema—wrong. The lesion should be bilateral and disappear when stretched; leukoedema does not peel.
Lichen planus—wrong. The lesion should be bilateral and more linear; lichen planus does not peel.
Chemical reaction to mouthwash—correct. This is especially seen with mouthwash having a high alcohol content; coagulative necrosis portion peels off.
Uremic stomatitis—wrong. It has similar lesions but more widespread and there is a history of kidney failure; uremic stomatitis does not peel.

Case 5

Morsicatio—wrong. This diagnosis needs clinical corroboration or biopsy results.
Leukoplakia—correct. This is purely a clinical diagnosis; there is not enough information to diagnose it further.
Squamous cell carcinoma—wrong. Biopsy is necessary for diagnosis.
Hairy leukoplakia—wrong. The lesion is at an atypical site and there is no history of HIV. Biopsy is necessary for diagnosis.

Case 6

Desquamated epithelial cells and bacteria—correct. The bacteria likely cause the burning sensation.
Cells from white sponge nevus—wrong. The patient's age is too great, and there is no family history.
Necrosis from a chemical burn—wrong. The pattern is too generalized, and there is no history of caustic chemical use.
Hyperkeratosis—wrong. The pattern is distinct enough to allow a clinical diagnosis of coated tongue, and hyperkeratosis is not the cause of the coloring.

Case 7

Leukoedema—wrong. Leukoedema would have a different histology and is usually seen on the buccal mucosa.
Hyperplastic candidiasis—wrong. Histopathology would show fungal hyphae.
Tobacco pouch keratosis—correct. This is a hyperkeratosis from the irritation of chemicals in snuff.
Lichen planus—wrong. This is an unusual site and the histopathology is not consistent with lichen planus.

Case 8

Tobacco pouch keratosis—wrong. Lesion would not disappear upon stretching.
Pseudomembranous candidiasis—wrong. Lesion would wipe off, leaving a red base, and would not disappear if stretched.
Nicotine stomatitis—wrong. The location is incorrect, and the lesion would not disappear with stretching.
Leukoedema—correct. Leukoedema is clinically diagnosable from history, appearance, and behavior.

Case 9

Wickham's striae—correct. These are typical for lichen planus but similar lesions are seen with hypersensitivity reactions and lupus erythematosus.
Lines of Zahn—wrong. They are fibrin and platelet lines separating coagulated blood in a thrombus.
Lines of Retzius—wrong. They are the incremental deposition of enamel.
Koebner's striae—wrong. Koebnerization leads to Wickham's striae.

Case 10

Leukoplakia—wrong. There is enough information given along with the clinical presentation to make a diagnosis.
Hyperkeratosis with dysplasia—wrong. Diagnosis requires microscopic analysis.
Nicotine stomatitis—correct. Heat-induced changes cause inflammation of the salivary ducts.
Lichen planus—wrong. The red papules seen are not typical for lichen planus.

Case 11

Age of 60—correct. People of all ages get candidiasis.
History of chronic obstructive pulmonary disease (COPD)—wrong. People with COPD often take steroids, which may predispose to candidiasis.
Denture wear—wrong. Wearing dentures day and night, improper cleaning, and so on enhance the development of candidiasis.
Antibiotic use—wrong. Antibiotic may kill other organisms, resulting in an imbalance where yeast may overgrow.

Case 12

HIV testing—wrong. People without HIV can have hairy leukoplakia.
Biopsy with stains for Epstein–Barr virus—correct. The only way to confirm a diagnosis of hairy leukoplakia is to show the presence of Epstein–Barr virus.
The lesions should wipe away with gauze—wrong. That is true for some types of candidiasis.
Historical information about other family members with a similar condition—wrong. Hairy leukoplakia is not an inheritable disease such as white sponge nevus.

Red, Red-and-White, and Purpuric Lesions

Case 13-1

Erythema migrans—wrong. The lesion has the wrong morphology; there is usually a white raised rim and the lesion changes size.
Erythematous candidiasis—wrong. The lesion has the wrong color (blue) component; the history is not supportive.
Erythroplakia—wrong. The lesion has the wrong color (blue) component and wrong morphology.
Hemangioma—correct. The lesions may be blue besides red; they are compressible and blanchable.

Case 13-2

Neoplastic—wrong. Hemangiomas are not neoplastic but rather developmental hamartomas.
Developmental—correct. Hemangiomas are hamartomatous.
Inflammatory—wrong. Hemangiomas are not inflammatory but rather developmental hamartomas.
Reactive—wrong. Hemangiomas are not reactive lesions but rather developmental hamartomas.

Case 14-1

Cinnamon allergic reaction—wrong. Topical mucosal allergic reaction can be a mixture of red and white, and lesions do not wipe off.
Acute candidiasis—correct. The acute form is the pseudomembranous type and the white mixture of fungal hyphae, epithelial cells, keratin, and bacterial colonies can be wiped off.
Lupus erythematosus—wrong. The age, gender, and lack of wipeability fit, although the lesions are often painful since the red component is erosive in nature.
Cheek nibbling—wrong. The site is good for this and sometimes there is a lack of wipeable tissue shreds so that none of the white portion can be wiped off; the reddened area could be secondary inflammation and the habit can be unilateral.

Case 14-2

Lichen planus—wrong. Although the age and gender are good, the red component of the lesions would be painful erosions.
Cinnamon allergic reaction—correct. Although the history does not mention the use of cinnamon-flavored gum or candy, the color, site, morphology, and lack of wipeability all fit.
Thermal burn—wrong. The white component is wipeable.
White sponge nevus—wrong. The site is good but onset is in childhood for this autosomal dominant inherited condition, which is more extensive, bilaterally on the buccal mucosa.

Case 15-1

Lichen planus—wrong. There is no evidence of papules or striae; the red component is not erosive.
Verruciform xanthoma—wrong. This is not a typical site and verruciform xanthoma does not account for the diffuse, mottled reddened vermilion.
Actinic cheilosis—correct. The mottled red-and-white changes are typical of a sun-damaged lip; furthermore, the lesion has a rough, sandpaper surface texture.
Candidiasis—wrong. Candidiasis lesions are wipeable and more extensive.

Case 15-2

Lesion often oozes a mucous secretion—wrong. That condition is cheilitis glandularis.
Actinic cheilitis is more common on the upper lip—wrong. It is much more common on the lower lip.
Precancerous changes are reversible—wrong. The elastic and collagen fibers are permanently damaged as well as the surface epithelium.
A significant percentage of lesions are premalignant—correct. Approximately 20% will develop squamous cell carcinoma.

Case 16-1

Traumatic erythema—wrong. The lesion is not an ulcer and there is no mention of pain.
Erythema migrans—correct. The lesion is a flat reddened area encircled by a raised border; this condition comes and goes and the lesion frequently changes shape as different areas of the tongue undergo depapillation and then repappilation.
Erythroleukoplakia—wrong. This potentially malignant lesion is seen in middle-aged to elderly adults and does not have a cyclical appearance.
Nicotine stomatitis—wrong. This smoking-tobacco-related condition is not premalignant despite its leukoplakic component; the red component comprises inflamed minor salivary glands.

Case 16-2

Candidiasis—wrong. Neither the chronic erythematous nor the acute pseudomembranous form of this superficial fungal condition is associated with geographic tongue.
Erosive lichen planus—wrong. This condition is an immune-mediated condition in which there is a blistering process of the epithelium resulting in ulceration and erosion.
Psoriasis—wrong. Even though geographic tongue has histopathology similar to psoriasis, there is no evidence that it is related to psoriasis.
Fissured tongue—correct. This harmless developmental disorder is associated with geographic tongue in a relationship that is not understood.

Case 17-1

Anterior facial involvement—wrong. That is the most common site of involvement.
Erythema—wrong. Although the tissue may be firm and pink it is often secondarily inflamed.
Excess attached gingiva—wrong. In dentate areas the attached gingival hyperplasia creates areas of anatomical crown coverage.
Spontaneous gingival hemorrhage—correct. For this condition to be occurring, some inherited or disease-associated blood diathesis must be present.

Case 17-2

Leukemia—correct. The constitutional symptoms are seen along with an elevated white blood cell count; anemia and infections, in addition to decreased platelets with resultant spontaneous hemorrhage, are seen due to a bone marrow myelophthesic anemia (all three major blood cell lines are affected).
Infectious mononucleosis—wrong. Mononucleosis lesions are petechiae on the soft palate, 1–2 mm of extravasated blood due to capillary fragility; there usually is an associated pharyngitis/tonsillitis.
Scarlet fever—wrong. The oral site involved is the tongue (i.e., strawberry or raspberry tongue).
Hereditary hemorrhagic telangiectasia—wrong. The vascular lesions are pinpoint areas of extravasated blood due to a developmental defect in the blood vessel wall; no gingival hyperplasia is seen, nor are constitutional symptoms.

Case 18-1

Hemangioma—wrong. They are flat or raised, are compressible, and do not bleed or cause soreness.
Lichen planus—wrong. It is a chronic mucosal or cutaneous disorder that can be found in this age group and in men nearly as often as in women, but there should be a blister (vesicle); additionally, this would be a rare site of involvement.
Actinic cheilitis (cheilosis)—wrong. This lesion is related to sun damage and would not be sore, and it involves other areas of the lower lip more than the commissure.
Angular cheilitis—correct. The site, morphology, and color are correct as is the painful chronic nature.

Case 18-2

Vitamin deficiency—correct. Nutritional deficiencies such as vitamin B complex and iron can cause this condition, also known as perleche, besides certain infectious bacterial organisms.
Developmental defect—wrong. Developmental blind-ended epithelial lined pouches called commissural lip pits can be seen at this site but they are depressed areas that are asymptomatic and normal color.
Viral infection—wrong. Viral infections cause vesicle (blister) formation such as recurrent herpes labialis, which secondarily breaks down into clusters of small ulcers that then scab. Unless the patient is severely immunocompromised the lesions should be acutely painful for 7–10 days and then resolve; furthermore, there should not be bleeding.
Protozoan infection—wrong. Angular cheilitis is typically caused by the fungal organism Candida albicans and rarely by the bacterium Staphylococcus aureus.

Case 19

Topical steroid application—wrong. Although the lesion is likely lichen planus, which often positively responds to topical or systemic steroid treatment, the provisional diagnosis should be confirmed by biopsy.
Biopsy of left and right lesions—correct. The only way to know the diagnosis with absolute certainty is to perform incisional, perilesional biopsies of both sites of involvement; never assume that the diagnosis is the same for each side.
Cytology to rule out malignancy—wrong. Cytology is a screening procedure not a diagnostic procedure.
Antifungal medication—wrong. The provisional diagnosis is lichen planus with areas of erosion beginning; steroid medication is usually most effective.

Case 20

Treat both the denture and oral mucosa with antifungal agents—correct. The denture should be soaked nightly for 2 weeks in a nystatin rinse mixed with water; the oral mucosa should be treated with either clotrimazole troches (10 mg, five times daily; dissolved) or clotrimazole cream applied to the inner aspect of the denture.
Leave the denture out at night, clean it, and rinse it in an antifungal solution—wrong.
Use laser ablation followed by new denture construction—wrong. The diagnosis is chronic erythematous candidiasis, and laser ablation will not address the organisms that are within the denture's acrylic resin.
Apply antifungal cream to the affected oral soft tissues—wrong. In addition to managing the oral mucosa, the denture should be soaked in an antifungal solution (e.g., nystatin 100,000 I.U.; use several drops in a small container of water).

Acute Oral Ulcerations

Case 21

Patient's age—wrong. People of all ages get aphthae.
Asymptomatic lesion—correct. Aphthae are painful.
Healed spontaneously in 2 weeks—wrong. Aphthae usually resolve in 2 weeks.
Site—wrong. Although aphthae usually do not begin on the dry lip (i.e., vermilion), they start on the labial mucosa and can expand to the dry lip.

Case 22

Erythema multiforme—correct. Erosions of explosive onset are the typical finding.
Aphthous ulcers—wrong. Aphthae are a chronic recurrent problem with a recognizable prodrome.
Herpes simplex—wrong. Primary herpes would have a gingivostomatitis. Secondary lesions would begin as ulcers on nonmovable mucosa bound to bone.
Varicella—wrong. Oral lesions of chicken pox are usually nonpainful.

Case 23

Arthritis, dermatitis, facial paralysis—wrong.
Skin lesions, fissured tongue, oral ulcers—wrong.
Oral ulceration, genital ulceration, ocular inflammation—correct.
Blistering skin, nonpainful oral ulceration, hairy tongue—wrong.

Case 24

Herpangina—correct. Site, age, morphology, and mild symptoms are all correct.
Herpes simplex—wrong. Site is wrong and symptoms are too mild.
Recurrent aphthae—wrong. Aphthae do not begin with blisters.
Syphilis—wrong. Recurrent oral lesions are mucous patches and not ulcerative.

Case 25

Herpangina—wrong. The lesions are not vesicular.
Recurrent aphthous ulcers—correct. The only way to tell the difference is to search for systemic signs and symptoms.
Erythema multiforme—wrong. Chronicity and recurrence are different than the signs of erythema multiforme.
Pemphigus vulgaris—wrong. Pemphigus lesions begin as blisters and spread until the disease is controlled.

Case 26

Painful ocular inflammation—wrong. This occurs in Behcet's disease.
Gingivostomatitis—wrong. This occurs in primary herpes simplex.
Necrosis of the interdental papillae—wrong. This occurs in ANUG.
Vesicular skin lesions—correct. These lesions are typical for chicken pox.

Case 27

Herpetiform aphthae—correct.
Herpes simplex—wrong. This is an incorrect site for recurrent lesions.
Herpes zoster—wrong. Zoster does not cross the midline.
Chicken pox—wrong. Age, recurrence, and pain are not typical for chicken pox.

Case 28

Recurrent aphthous ulcer—correct. Aphthae occur on movable mucosa.
Necrotizing sialometaplasia—wrong. This is a likely diagnosis. Extranodal non-Hodgkin's lymphoma and salivary gland tumors should also be considered.
Superficial mucocele—wrong. This is a good site and they often have periodic rupture with painful ulceration.
Wegener's granulomatosis—wrong. This is a good site and presentation for this disease; however, lung and kidney involvement should also be present.

Chronic Vesiculoerosive and Ulcerative Lesions

Case 29

Wegener's granulomatosis—wrong. Lesions usually occur on palate with lung and kidney involvement.
Noma—wrong. Necrotic ulcerations are seen in immunocompromised patients.
Erosive lichen planus—wrong. Usually Wickham's striae are seen along with erythema and ulceration.
Pyostomatitis vegetans—correct. The peculiar lesions in conjunction with the history are indicative of inflammatory bowel disease (Crohn's, ulcerative colitis, etc.).

Case 30

Mucous membrane pemphigoid—correct. About 30% of cases have ocular involvement that can lead to scarring and blindness.
Erosive lichen planus—wrong. The oral lesions are similar but eye lesions are not present.
Erythema multiforme (Stevens–Johnson syndrome)—wrong. This disease can have oral and eye lesions but it is an acute rather than a chronic process.
Herpes zoster—wrong. Zoster stops at the midline; this patient's distribution is wrong.

Case 31

Squamous cell carcinoma—wrong. This should be the first choice in the differential diagnosis.
Deep fungal infection—wrong. This is a lesion of histoplasmosis. Deep fungal infections closely resemble carcinoma.
Mucous membrane pemphigoid—correct. Lesions of pemphigoid are usually multiple and shallow, and they heal.
Traumatic granuloma—wrong. These nonhealing ulcers are very similar to carcinomas in appearance.

Case 32

Behcet's syndrome—wrong. The ulcers seen in Behcet's are mucosal and there should also be cutaneous and ocular signs.
Midline lethal granuloma—correct. This is a T-cell lymphoma that occurs on the palate.
Tertiary syphilis—wrong. A gumma presents with a similar lesion but does not cause death by malignant spread.
Wegener's granulomatosis—wrong. A very similar presentation may be seen and it may prove fatal, but death is usually from kidney failure. It is not a malignancy.

Case 33

Lesions are bilateral—wrong. This is a typical sign of lichen planus.
Lesions come and go—correct. Lichen planus is a chronic disease with exacerbation and remission. Hypersensitivity reactions will remain as long as the allergen is in contact with the area.
White striae—wrong. White striations (striae) can be seen in lichenoid hypersensitivity reactions as well as lupus erythematosus.
Ulceration—wrong. Ulceration can be seen in erosive lichen planus as well as in a hypersensitivity reaction.

Case 34

Presence of rheumatoid factor—wrong. Rheumatoid factor is common in the serum of people with many autoimmune diseases.
Presence of antinuclear antibodies—wrong. This is seen in lupus erythematosus.
Positive Nikolsky sign—wrong. A Nikolsky sign will be present but it is seen in many blistering diseases.
Direct and indirect immunofluorescence studies—correct. Direct (tissue) and indirect (serum) immunofluorescence should be positive in pemphigus.

Case 35

Traumatic ulcerative granuloma—correct. These lesions are typically long-standing and are suspicious for carcinoma or deep fungal infection. They often spontaneously resolve after biopsy.
Deep fungal infection—wrong. Healing does not occur without treatment.
Squamous cell carcinoma—wrong. Lesion would not resolve without treatment.
Erythema multiforme—wrong. This is an acute disease and would not present as a long-standing single ulcer.

Case 36

Recurrent herpes—wrong. Herpes lesions will be on intraoral mucosa bound to bone and will be painful.
Traumatic ulcer—wrong. The ulcer is usually painful and has a history of injury.
Noma—wrong. Necrotic ulcerations occur in severely immunocompromised children, especially those who are malnourished.
Squamous cell carcinoma—correct. The leading site for intraoral carcinoma is the lateral ventral tongue and floor of mouth. The lesions are often asymptomatic.

Papillary Lesions

Case 37-1

Verruca vulgaris—wrong. The site, morphology, and color of the lesion all fit and so a reasonable clinical provisional diagnosis would include this lesion; however, the history of HIV-positivity does not make this choice the most likely diagnosis.
Hairy tongue—wrong. The site, but not the morphology or color, of the lesion does not fit and so this is not a reasonable clinical provisional diagnosis. The “hairs” of the dorsal tongue are elongated filiform papillae with excess keratin that is extrinsically stained, usually brown or black.
Squamous papilloma—wrong. The site, morphology, and color of the lesion all fit and so a reasonable clinical provisional diagnosis would include this lesion; however, the history of HIV-positivity does not make this choice the most likely diagnosis.
Hairy leukoplakia—correct. The site, morphology, and color of the lesion all fit and so a reasonable clinical provisional diagnosis would include this lesion; furthermore, the history of HIV-positivity makes this choice the most likely provisional diagnosis.

Case 37-2

Human papillomavirus—wrong. This family of DNA viruses, of which there are more than 130 types, cause some oral squamous papillomas and warts (verruca vulgaris) besides genital ones; 15 or so types are oncogenic, including cervical carcinoma.
Epstein–Barr virus—correct. When the immune system in an HIV-positive patient becomes increasingly inefficient (i.e., full-blown AIDS onset is imminent), then the Epstein–Barr virus for unknown reasons congregates especially on the lateral border of the tongue, invades the epithelial cells, and creates this benign neoplastic growth.
Human immunodeficiency virus—wrong. Although hairy leukoplakia is associated with the transformation of HIV-positivity to AIDS by severe immunodeficiency onset, it is another virus that then is able to infect and cause hairy leukoplakia.
Herpes simplex virus—wrong. Herpes simplex type 1 causes recurrent herpes labialis and intraoral lesions involving nonmovable mucosa in immunocompetent persons; the epithelial cells are invaded by the virus, the destroyed cells resulting in clusters of vesicles that then de-roof into coalescing shallow, irregular ulcers.

Case 38-1

Verruca vulgaris—wrong. Site, color, and morphology are all as expected for this lesion.
Squamous papilloma—wrong. Site, color, and morphology are all as expected for this lesion.
Verrucous carcinoma—correct. Although the surface texture, lack of pain, and color (some are red or a mixture of white and red) are acceptable, the size is much too small and the location is not particularly common; also the age of occurrence is generally patients in their 50s and older.
Verruciform xanthoma—wrong. Site, color, and morphology are all as expected for this lesion.

Case 38-2

Rapid onset—wrong. Verrucous carcinoma has a very slow, chronic onset.
Pain—wrong. Verrucous carcinoma is not a painful condition.
Smokeless tobacco habit—correct. Many elderly patients use this type of tobacco (snuff, chewing) and in 1–9% of users it forms where the tobacco is held against the mucosa.
Compressible—wrong. Verrucous carcinoma is not fluid-filled (vesicle–bulla).

Case 39-1

Verrucous carcinoma—correct. Typically seen in the vestibule, particularly with smokeless tobacco users; white intermixed with red and hemorrhage; slowly enlarges with a marked verrucous surface and advancing sessile borders.
Condyloma acuminatum—wrong. Usually multiple lesions with blunt projections; no bleeding.
Inflammatory papillary hyperplasia—wrong. Typically seen beneath a denture base, particularly in the palatal vault; multiple small pink papules often with erythema (red) but no hemorrhage.
Giant cell fibroma—wrong. Typically a smooth or papillated surface papule/nodule with no bleeding.

Case 39-2

Cessation of tobacco habit followed by chemical cauterization—wrong. Even those cases caused by smokeless tobacco use will not reverse the diagnosis once this well-differentiated form of squamous cell carcinoma has arisen; chemical cauterization can be helpful for painful conditions in which nerves are exposed to the oral cavity.
Complete surgical removal—correct. Once a diagnosis is established by a small biopsy of a representative area of the lesion, then its complete removal is necessary to ensure no recurrence.
Biopsy; antiviral treatment; then surgical removal—wrong. The intermediate step of antiviral treatment is not helpful and only delays completion of treatment.
Surgical removal followed by radiation therapy—wrong. Surgical removal is appropriate after an incisional biopsy diagnosis; however, controversy exists if radiation treatment can be used as primary or adjuvant treatment. Prior studies have shown radiation causes increased grade of tumor but more recent reports point to success with radiation as a primary therapy.

Case 40

Sessile macule—wrong. A macule is a flat lesion of abnormal color; sessile indicates a broad base with the base's size exceeding the length of any portion of the lesion superior to it.
Pedunculated vesicle—wrong. A vesicle is an elevated lesion filled with fluid so it is not firm but rather soft and compressible.
Sessile plaque—wrong. A plaque is a very slightly elevated lesion unlike the more marked elevated lesion seen.
Pedunculated papule—correct. The elevated lesion is firm and less than 5 mm in diameter and thus by definition is a papule and upon palpation will be firm; the base involves growth over unattached tooth surface and thus is pedunculated, with the base possessing less length in greatest dimension than the superior aspect of the lesion.

Case 41

Increased spongiosis of the stratum spinosum layer—wrong. Increased intracellular edema (i.e., spongiosis) results in leukoedema or white sponge nevus, which are whitish areas and in the case of white sponge nevus exhibit a thickened folded tissue.
Elongated hyperkeratotic filiform papillae—correct. The excess surface keratin in conjunction with the increased length of the dorsal papillae increase secondary extrinsic staining (often tea, coffee, cigarettes), resulting in a brown or black discoloration.
Excess melanin deposition in the basal cell layer—wrong. Focal melanosis results in a brown discoloration but the morphology is a macule; also, the pigmentation on the tongue generally only involves the tip of the papillae.
Interruption in the normal maturation sequence of the epithelium—wrong. By definition, this is dysplasia, which is a potentially malignant change; the morphology would be white or red plaques (i.e., leukoplakia, erythroplakia).

Case 42-1

Denture stomatitis—wrong. Erythematous form of candidiasis that can be asymptomatic or have a burning sensation, and it has a macular morphology.
Inflammatory papillary hyperplasia—correct. The reddish coloration is from chronic inflammation mixed with numerous individual papules that are coalescing; it is typically seen under a denture base.
Squamous cell carcinoma—wrong. Rare site for this type of cancer; the lesion is typically a white or red plaque that then breaks down into ulceration; verrucous carcinoma would be white and not necessarily associated with a denture.
Papilloma—wrong. Papilloma is usually more discreet and pink to white; it is not associated with a denture.

Case 42-2

Giant cell fibroma—wrong. Lesion is a solitary pink papule/nodule with smooth or rough surface; site is typically gingiva.
Verruca vulgaris—wrong. Lesion is a solitary white papule/nodule with a very rough, spiky surface.
Condyloma acuminatum—wrong. Lesions are usually multiple pink to white-pink papules/nodules lacking any erythematous (inflammatory) component.
Candidiasis—correct. Investigators are not sure if chronic erythematous candidiasis is always secondary to the onset of IPH.

Case 43

Acute pseudomembranous candidiasis—wrong. This type of fungal infection is wipeable; with the information provided, a provisional diagnosis can be made but a diagnosis would require microscopic information.
Geographic tongue—wrong. Although the site is appropriate, the color is incorrect (irregular, red flat area surrounded by a thin, elevated white rim); with the information provided a provisional diagnosis can be made but a diagnosis would require microscopic information.
Leukoplakia—correct. This is purely a clinical term for unwipeable white plaques that do not resolve in 2 weeks. When biopsied this lesion possessed premalignant changes; the tobacco habit is likely the chief etiologic factor.
White sponge nevus—wrong. Although this lesion is white and unwipeable, white sponge nevus is most often seen bilaterally on the buccal mucosa beginning early in life, unlike this patient's history; it is autosomal dominant inherited; it would not slowly enlarge as this lesion has.

Case 44

Condyloma acuminatum—correct. The lesion's site, color, morphology, and multifocal, multicentric distribution are all indicative of this venereal wart condition.
Squamous papilloma—wrong. Lesion is white to pink white and is not multifocal.
Verruciform xanthoma—wrong. Lesion is not multifocal and not common on ventral tongue.
Verrucous carcinoma—wrong. Lesion is red and/or white and is not multifocal.

Pigmented Lesions

Case 45

AZT treatment—wrong. AZT can cause pigmentation but it does not cause the other symptoms listed.
Opportunistic infection that has destroyed the adrenal cortex—correct. Adrenocortical insufficiency (Addison's disease) due to uncontrolled tuberculosis infection is a likely cause in AIDS patients.
Low lymphocyte counts—wrong. This may lead to infection but not pigmentation.
Increased melanocytic nevi in HIV-positive populations—wrong. No reported incidence.

Case 46

Incisive canal—correct. Incisive canal cysts may have a soft tissue component.
Mucocele—wrong. Salivary glands in the rugae area as well as mucoceles not seen.
Dentigerous cyst—wrong. All teeth are erupted; however, this may be an eruption cyst associated with a supernumerary tooth.
Cyst from a nonvital tooth—wrong. An intrabony lesion would not be seen clinically.

Case 47

Observation—wrong. Observation will not give a diagnosis.
Wide excision—wrong. Definitive treatment is not appropriate without a diagnosis.
Brush cytology for diagnosis—wrong. Cytology only looks at superficial cells confined to the epithelium; it is not appropriate for pigmented lesions.
Biopsy—correct. This is a melanoma; real pigmented lesions can rarely be diagnosed by clinical signs and need tissue for microscopic analysis.

Case 48

Melanoma—wrong. Wrong site, wrong age; rapid growth of a new lesion of melanoma is not typical.
Melanoacanthoma—correct. Trauma, buccal mucosa, and rapid growth are the usual findings.
Peutz–Jeghers syndrome—wrong. Pigmentation should be present from early childhood.
Blue nevus—wrong. Lesion usually occurs on palate and is not rapidly spreading.

Case 49

Pigmented nevus—wrong. Nevi are composed of a proliferation of benign melanocytes.
Melanoma—wrong. Melanomas are composed of a proliferation of malignant melanocytes.
Amalgam tattoo—wrong. Amalgam tattoo should have deposits of foreign material in the lamina propria.
Melanotic macule—correct. Lesion is most commonly seen on the lower lip.

Case 50

Mucous membrane pemphigoid—wrong. It is usually treated with topical steroids.
Lupus erythematosus—correct. Chloroquine acts as a steroid sparing anti-inflammatory.
Cat scratch disease—wrong. Disease is usually self-limited.
Diabetes mellitus—wrong. Antimalarials are not indicated for this use.

Case 51

Peutz–Jeghers syndrome—wrong. The pigmentation is similar but Peutz–Jeghers has colon polyposis, not bone lesions.
Addison's disease—wrong. Adrenal insufficiency will show bronzing of the skin but no bone lesions.
Melanotic neuroectodermal tumor of infancy—wrong. Pigmented intrabony lesions are in the anterior maxilla and are solitary; skin pigmentation is absent.
McCune–Albright syndrome—correct. Endocrine disorders, polyostotic fibrous dysplasia, and skin pigmentation are typical of Albright's syndrome.

Case 52

Mucocele—wrong. Good location and age but the lesion should have a history of size increase with fluctuance.
Foreign body—correct. This is a traumatic implantation of pencil “lead.”
Peutz–Jeghers syndrome—wrong. Age is correct but there should be multiple lesions and the patient should have other signs of the disease (colon polyps).
Albright's disease—wrong. There should be multiple lesions.

Soft Tissue Masses

Case 53

Mucocele—wrong. These occur almost exclusively on the lower lip rather than the upper lip.
Fibroma—wrong. Almost always there is a history of trauma, and fibromas rapidly enlarge in a few weeks to months and then remain the same size thereafter.
Nasolabial cyst—wrong. The site is incorrect and this cyst would have fluid in it and be fluctuant, not firm.
Monomorphic adenoma—correct. Over the age of 40 this benign salivary gland is more likely than a pleomorphic adenoma; both are common on the upper lip.

Case 54

Gingival fibromatosis—correct. The age, site, and eruption-pattern disruption are classic for this inherited overgrowth of gingiva caused by excess fibroblastic collagen production; the entire clinical crown can be covered.
Amyloidosis—wrong. The tongue is the most common intraoral site for this peculiar type of protein product that is most often seen at multiple sites in the elderly, associated with multiple myeloma.
Gingival cyst of the adult—wrong. Although it occurs at this site, it is a solitary lesion, often with a translucent bluish appearance; it would not delay the eruption of any tooth.
Neurofibromatosis type 1—wrong. Although the neurofibromas can be on the skin and in the mouth at multiple sites, the patient should also have brown, flat skin pigmentation (café au lait spot) and several other stigmata of the autosomal dominant inherited disorder. The tongue is overwhelmingly the most common oral site.

Case 55-1

Fat—wrong. If this lesion were firm and thus the morphology were a papule/nodule, then it could be a lipoma due to the proliferation of adipose tissue.
Lymphoid tissue—wrong. Although lymphoid tissue can cause soft tissue lesions to appear yellow, the site (not in Waldeyer's ring of lymphoid tissue) is not logical.
Pus—correct. The lesion's morphology is a vesicle and the contents a sea of neutrophils resulting in a focal abscess (i.e., pus).
Sebum—wrong. Sebum can appear yellow as, for example, in the small papules and coalesced plaque areas of Fordyce granules seen most often on the labial and buccal mucosa; Fordyce granules are not typically seen on the gingiva and the morphology is an elevated blisterform (i.e., vesicle and bulla).

Case 55-2

Mucocele—wrong. Mucoceles can occur on the gingiva very rarely but they will appear pink to blue depending on the depth of the pool of inspissated mucin; the history does not agree with this as a provisional diagnosis.
Parulis—correct. The periapical abscess has spread via a fistula to the surface, where a “gum boil” appears (the collection of pus).
Fistula—wrong. A fistula is the epithelial-lined tract extending from an intrabony abscess to the mucosal site.
Pyogenic granuloma—wrong. These are bright red due to the collection of granulation tissue and are more typically found in the interdental papilla area where an inciting etiologic factor is present (e.g., restorative overhang, calculus, retained cement or impression material, hormonal changes as in pregnancy).

Case 56-1

Regress and regrow—correct. The lesion is a mucocele that typically changes sizes due to macrophage involvement with the spilled (extravasated) mucin due to the injured duct of the minor salivary gland lobule.
Spontaneously involute—wrong. The lesion is a mucocele.
Continue to enlarge indefinitely—wrong. The lesion is a mucocele.
Remain the same size—wrong. The lesion is a mucocele.

Case 56-2

Inject sclerosing agent and then completely remove—wrong. Sclerosing agents are only used at times for vascular lesions such as hemangiomas.
Incisional biopsy—wrong. The lesion does not have a worrisome (i.e., malignant) diagnosis and is small enough for complete removal.
Excisional biopsy—wrong. If the damaged gland is not also removed, then the lesion will recur.
Excisional biopsy of the mucin and involved minor salivary gland—correct. If the damaged gland is not also removed, then the lesion will recur.

Case 57

Peripheral ossifying fibroma—wrong. This is a classic site and morphology for this lesion.
Peripheral giant cell granuloma—wrong. This is a classic site and morphology for this lesion.
Granular cell tumor—correct. This lesion is very common on the dorsum of the tongue but very rare at this site.
Pyogenic granuloma—wrong. This is a classic site and morphology for this lesion.

Case 58

Infection—wrong. Fat is not a source of infection and no other signs or symptoms of infection are mentioned or observed.
Physical trauma—wrong. This is a lipoma, which is a true neoplasm (no initiating traumatic event as seen in reactive lesions such as pyogenic granuloma and fibroma or fibrous nodule).
Herniation of the buccal fat pad—correct. At times rather than a neoplastic event (e.g., lipoma) there is an outpouching of normal fat at this site.
Excessive fat metabolism—wrong. There is no relationship between a lipoma and fat metabolism or weight.

Case 59

Mucocele—wrong. Although the site and color fit, the morphology does not; the lesion is stated to be firm whereas a mucocele is a vesicle filled with mucin and thus is soft and compressible.
Fibroma—correct. This is a classic site for accidental biting (as are the tongue and buccal mucosa); firmness indicates an elevated, nonblisterform papule rather than a vesicle.
Congenital epulis—wrong. It occurs in infants (>females) on the alveolar ridge (>anterior maxilla).
Pleomorphic adenoma—wrong. It is much more common on the upper lip than lower lip.

Case 60

Traumatic neuroma—wrong. This is a histological diagnosis; lesion is most often seen as a solitary mass in the mental nerve foramen area of mandibular denture wearers following ridge resorption; it is often painful.
Fibromas—wrong. This is a histological diagnosis of a reactive lesion (typically solitary) subsequent to acute trauma. The history is wrong although site and color fit.
Epulis fissuratum—correct. Low-grade chronic trauma of ill-fitting dentures (due to gradual ridge resorption) often creates a reactive exuberant growth of excess tissue in the denture flange area that is clinically referred to as epulis fissuratum.
Peripheral odontogenic tumor—wrong. This is a histological diagnosis even though the gingiva is the correct site.

Case 61-1

Plunging ranula—correct. This lesion occurs in the lateral or midline of the neck as a soft compressible and fluctuant swelling in which floor-of-mouth extravasated mucin spreads inferiorly.
Dermoid cyst—wrong. It is a soft and fluctuant swelling of the midline (not lateral) neck.
Cat scratch disease—wrong. Although the lateral neck is a typical site, there must be a history of a cat scratch that then subsequently leads to significant infection in a draining lymph node.
Infectious mononucleosis—wrong. Although there is a lateral neck swelling, the patient should be experiencing a sore throat, swollen and tender lymph nodes, and fatigue.

Case 61-2

Genioglossus—wrong.
Geniohyoid—wrong.
Omohyoid—wrong.
Mylohyoid—correct.

Case 62

Cervical lymphoepithelial cyst—wrong. The cyst would be soft and fluctuant; it is typically seen in somewhat older patients (young adults).
Abscess—wrong. The swelling would be painful with or without drainage, and there would not be night sweats.
Lipoma—wrong. The mass would be soft and there would not be a fever or night sweats.
Hodgkin's disease—correct. Classic location, signs, and symptoms; malignant nodes are not painful. Also, age is good since there is a bimodal age distribution with two mean peaks: young people and the elderly.

Case 63-1

Sarcoidosis—wrong. Although multiple lesions of the head and neck occur with this condition, they are usually associated with the eyes, ears, and mouth; the lesions are flat and violaceous; they do not involve the axilla.
Neurofibromatosis type 1—correct. The sites of involvement as well as the color and morphology are classic for this condition, which is autosomally inherited; each lesion is a neurofibroma.
Multiple endocrine neoplasia syndrome type 2b—wrong.
Amyloidosis—wrong. Pale areas are seen and most commonly on the skin near the eyes.

Case 63-2

Café au lait spots—correct.
Snail track lesions—wrong. These are seen in Crohn's disease
Ash leaf spots—wrong. These areas of hypopigmentation are seen in tuberous sclerosis.
Purpura—wrong. These are areas of extravasated blood seen in bleeding disorders and sites of trauma.

Case 64

Dermoid cyst—wrong. This is a microscopic diagnosis of a developmental disorder.
Ranula—correct. This term is a clinical descriptor that means the area appears like a frog's swollen belly.
Mucoepidermoid carcinoma—wrong. This malignant salivary gland tumor can occur in the floor of mouth and have a bluish hue; however, the name is a microscopic diagnosis, not a clinical term.
Nevus—wrong. The term nevus means a “spot” and is typically reserved for cutaneous lesions such as congenital and acquired melanocytic nevi.

Case 65

Connective tissue—correct. This patient's lesion is likely a reactive fibroma due to the trauma, with fibroblasts stimulated to produce extra collagen.
Neurofibroma—wrong. This nerve sheath tumor consists of proliferating neuritis and axonal tissue and is a true, nonreactive neoplasm.
Granular cell tumor—wrong. Although this is the most likely morphology, color, and site for this lesion, a granular cell tumor is not caused by trauma but rather is a true proliferation of Schwann cell origin.
Hemangioma—wrong. Hemangiomas are compressible and blanchable and usually more red and/or blue; they are not caused by trauma but rather are developmental hamartomas.

Case 66

Kaposi's sarcoma—wrong. This vascular neoplasm is frequently found in the palate of HIV-positive males and, although this patient's HIV status is not reported, the site, morphology, and color fit well.
Mucoepidermoid carcinoma—wrong. The palate is the most common intraoral site for this malignant salivary gland tumor; often it has a bluish hue as seen here.
Non-Hodgkin's lymphoma—wrong. The palate is the most common extranodal oral site for this kind of lymphoma, especially B-cell type; it often has a boggy consistency.
Mucocele—correct. Although superficial mucoceles are often seen associated with palatal minor salivary glands, they are small vesicles filled with mucin that are compressible instead of boggy and would not attain the size or color of this lesion.

Case 67

Cervical lymphoepithelial cyst—wrong. Although lateral in position, the cyst would be soft, fluctuant, and nontender.
Thyroglossal duct cyst—wrong. The cyst would be in a midline position, not lateral, and would be fluctuant and nontender.
Reactive lymphadenopathy—correct. This cyst is in a lateral position with tender reactive nodes subsequent to an infection.
Pleomorphic adenoma—wrong. Although the tail of the parotid may involve this benign salivary gland tumor, it would be nonpainful and unrelated to the constitutional symptoms mentioned.

Case 68

Prostate—wrong. Although distant metastasis from the prostate can spread to bone, brain, and soft tissues, including the oral cavity, it does not spread to cervical lymph nodes.
Hard palate—wrong. The hard palate is an infrequent site of primary squamous cell carcinoma and does not typically drain to the anterior triangle lymph nodes.
Floor of mouth—wrong. Although the floor of mouth is second in frequency to the posterior lateral tongue as a primary site of squamous cell carcinoma, it typically drains to the submental nodes rather than to the cervical lymph node chain seen in this patient.
Posterior lateral tongue—correct. This is the most common site of typical squamous cell carcinoma that arises due to the etiologic factor of long-term cigarette use.