Oral Mucosal & Soft Tissue Lesions MCQ

Most of what shows up on the oral mucosa is benign or reactive, and the clinical skill is pattern recognition: sort lesions by color (white, red, pigmented), by whether they wipe off or stretch away, and by how long an ulcer has lasted. That sorting tells you what to reassure, what to remove, and what to biopsy. This module covers the benign, reactive, and immune-mediated soft tissue lesions; the premalignant and cancerous lesions have their own module.

White Lesions

• Frictional keratosis is a white thickening from chronic rubbing (a sharp tooth, cheek biting, denture); it resolves when the irritant is removed, which both confirms the diagnosis and treats it.
• Leukoedema is a benign, filmy grey-white change of the buccal mucosa that disappears (or fades) when the mucosa is stretched, distinguishing it from a true white lesion.
• Lichen planus is a chronic T-cell-mediated condition; the reticular form shows lacy white lines (Wickham striae), usually bilateral on the buccal mucosa, while the erosive form is painful and red.
• White sponge nevus is a harmless hereditary white, spongy, bilateral lesion. Candidiasis, by contrast, wipes off to leave a red base, and a white patch that cannot be wiped or stretched away (leukoplakia) is treated as premalignant until biopsy proves otherwise.

Reactive and Hyperplastic Growths

• The irritation (traumatic) fibroma is the most common reactive oral growth: a firm, smooth, painless nodule at a site of chronic trauma such as the bite line.
• Pyogenic granuloma is a soft, red, vascular mass that bleeds easily; it is common on the gingiva and in pregnancy (the 'pregnancy tumor', or pregnancy epulis), driven by hormones plus local irritants.
• Peripheral giant cell granuloma is a red-purple gingival mass that arises only on the gingiva or alveolar ridge and shows multinucleated giant cells; the peripheral ossifying fibroma is a related gingival reactive lesion.
• Epulis fissuratum is folds of fibrous tissue along an ill-fitting denture flange, and inflammatory papillary hyperplasia is the cobblestone palate under a denture; drug-influenced gingival enlargement is caused by phenytoin, cyclosporine, and calcium channel blockers (such as nifedipine).

Ulcerative and Vesiculobullous (Immune-Mediated) Disease

• Recurrent aphthous stomatitis (canker sores) appears on movable, non-keratinized mucosa, is not caused by a virus, and recurs; minor aphthae are small and heal in about two weeks, while major aphthae are larger and scar.
• Pemphigus vulgaris is an autoimmune disease against desmogleins (the cell-to-cell adhesion proteins), causing an intraepithelial split, flaccid bullae, a positive Nikolsky sign, and potentially serious disease.
• Mucous membrane (cicatricial) pemphigoid targets the basement membrane, causing a subepithelial split with tense bullae and desquamative gingivitis; the split level distinguishes it from pemphigus.
• Erythema multiforme is an acute hypersensitivity reaction (often to drugs or herpes simplex) with target skin lesions and hemorrhagic, crusted lips; biopsy with direct immunofluorescence is how the autoimmune blistering diseases are diagnosed.

Pigmented Lesions

• The amalgam tattoo is the most common oral pigmentation: a grey-black macule near a restored tooth from embedded restorative debris, and the metal fragments may be visible on a radiograph, which confirms it.
• The oral melanotic macule is a benign, flat, well-defined brown spot, and physiologic (racial) pigmentation is symmetric, diffuse, and benign; smoker's melanosis follows tobacco use.
• Oral melanoma is rare but dangerous: a new, enlarging, irregular, or color-varied pigmented lesion (especially on the palate or gingiva) must be biopsied to exclude it.
• The reassuring features are stability over time, a clear cause (an adjacent amalgam restoration), and symmetry; the worrying features are change, irregular borders, and variegated color.

Tongue and Developmental Variants

• Geographic tongue (benign migratory glossitis) shows red depapillated patches with white serpentine borders that migrate over days; it is benign and often only needs reassurance.
• Fissured tongue is a benign pattern of deep grooves on the dorsum, frequently seen together with geographic tongue.
• Fordyce granules are ectopic sebaceous glands appearing as harmless small yellow papules on the buccal mucosa or lips, a normal variant.
• Hairy tongue is elongation and staining of the filiform papillae (managed by tongue cleaning and addressing predisposing factors), and median rhomboid glossitis is a central, depapillated rhomboid patch associated with Candida.