Case #1 Discussion

Summary: This is a white surface lesion.  It is white due to epithelial thickening because it is rough, asymptomatic, and will not rub off. Lesions to Exclude from Differential Diagnosis: Leukoedema   ~Location – Bilateral buccal mucosa Lichen Planus   ~Bilateral and multifocal Nicotinic Stomatitis   ~Location – Hard Palate Familial Epithelial Hyperplasia (White sponge nevus)   ~Diffuse and multifocal   ~Present from early childhood   ~May have a familial history Hairy Tongue, Geographic Tongue, and Hairy Leukoplakia   ~Location - Tongue Lesions to Include in Differential Diagnosis: Hyperkeratosis   ~Most likely from the use of the stiff toothbrush Epithelial Dysplasia   ~Less likely due to location on keratinized attached gingiva Carcinoma in Situ   ~Less likely due to location on keratinized attached gingiva Superficial Squamous Cell Carcinoma   ~Less likely due to location on keratinized attached gingiva Initial Clinical Diagnosis: Hyperkeratosis Management Options: 1)  Explain to the patient the cause and nature of the lesion.  Provide the patient with a soft toothbrush and review tooth brushing techniques.  Re-evaluate in a month.  If it persists, an incisional biopsy is recommended.  Document history and clinical findings, differential diagnosis, and patient recommendations. 2) Perform an incisional biopsy to exclude epithelial dysplasia right away if the patient prefers or if you don’t believe the patient will return for a follow up.   Final Diagnosis: Hyperkeratosis – Resolved after the patient modified toothbrushing habits