Pathology · patient case with 4 questions
Case: something under the denture
Scenario: A denture wearer reports feeling something beneath the prosthesis and is worried it may be malignant. On examination the palate is diffusely red beneath the denture, and there is a folded, fibrous overgrowth of tissue at the denture border. Four linked questions followed.
Question 1
What is the tissue lesion at the denture border?
Show answer and explanation
Correct answer: B. Epulis fissuratum
- A. Carcinoma would be indurated and ulcerated with rolled borders, and would not conform so neatly to the flange outline. The patient's fear is reasonable but the clinical picture is reassuring.
- B. Correct. Epulis fissuratum is a reactive hyperplasia of fibrous connective tissue produced by a chronically overextended or ill-fitting denture flange. The classic sign is folds of tissue with the flange sitting in the fissure between them.
- C. A peripheral giant cell granuloma is a purple-red gingival mass arising from the periodontal ligament or periosteum, typically in dentate areas, and can resorb underlying bone.
- D. A fibroma is a discrete, smooth, dome-shaped nodule from focal trauma — not a folded overgrowth along a denture border.
Question 2
Which fungal species is responsible for the redness of the palate?
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Correct answer: B. Candida albicans
- A. Aspergillus is the second most common oral fungus but causes invasive sinus and pulmonary disease, chiefly in the immunocompromised.
- B. Correct. Candida albicans is the commonest fungal organism of the oral cavity and the cause of denture stomatitis, in which the erythema mirrors the denture outline exactly.
- C. Cryptococcus causes meningitis in immunosuppressed patients and rarely involves the mouth.
- D. Histoplasmosis produces a chronic oral ulcer that can mimic malignancy — a very different presentation.
Note: The erythematous form is far more common than the white pseudomembranous one in denture wearers, and it is easy to overlook because it does not wipe off.
Question 3
What is the treatment for the palatal infection?
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Correct answer: D. Nystatin
- A. Amoxicillin is antibacterial. It would not help and could worsen candidal overgrowth.
- B. Acyclovir is an antiviral for herpes group infections and has no antifungal activity.
- C. Chlorhexidine has some antifungal activity and is useful for disinfecting the denture, but it is not the definitive treatment.
- D. Correct. Nystatin is a topical polyene that binds ergosterol in the fungal membrane. It is not absorbed from the gut, so it acts locally with minimal systemic effect.
Note: The denture itself must be treated or the infection will simply recur — soak it nightly, and instruct the patient to stop wearing it overnight.
Question 4
After the denture has been adjusted, the tissue lesion persists. What now?
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Correct answer: C. Surgical excision of the lesion
- A. Leaving it interferes with the fit of the new denture and forfeits the histologic confirmation that this patient, who feared malignancy, deserves.
- B. Further adjustment has already been tried. Continuing it delays definitive care without addressing established fibrous tissue.
- C. Correct. Once the cause is removed, an epulis fissuratum will regress only partly. Mature fibrous tissue that persists is excised — and the specimen is sent for histopathology — before the new prosthesis is constructed.
- D. Corticosteroids reduce inflammation but do not remove fibrous hyperplasia.