Edentulous patient with reddened palatal mucosa

Correct answer: A. Inflammatory papillary hyperplasia

• A. CORRECT. INFLAMMATORY PAPILLARY HYPERPLASIA is the pebbly, granular, erythematous overgrowth of the hard palate that develops beneath an ill-fitting denture worn continuously by a patient with poor hygiene. The surface is made of multiple small papillary projections, giving the characteristic cobblestone appearance. It is a reactive hyperplasia and is not premalignant.
• B. Squamous cell carcinoma of the palate is typically an indurated ulcer or a fixed exophytic mass in a smoker or drinker, not a symmetric pebbly erythema confined to the denture-bearing area.
• C. Nicotinic stomatitis produces a diffusely white, keratotic palate studded with red inflamed minor salivary duct openings, and is caused by heat from pipe or cigar smoking, not by a denture.
• D. Epulis fissuratum is the folded, fibrous hyperplastic tissue that forms along an overextended denture FLANGE in the vestibule — which is exactly the SECOND lesion described in this patient, at the depth of the groove. It does not occur on the hard palate.

Note: This case contains TWO separate denture-induced lesions — papillary hyperplasia on the palate and epulis fissuratum in the vestibule. The recall noted the exam did not specify which lesion the questions referred to, so read the stem carefully and match the answer to the anatomical site being named.

Correct answer: C. A fungus

• A. Bacterial plaque accumulates on the fitting surface and contributes to the inflammatory load, but it is not the principal organism. Antibacterial therapy alone does not resolve the lesion.
• B. Protozoa have no role in denture-associated palatal disease.
• C. CORRECT. CANDIDA ALBICANS. Continuous denture wear creates a warm, moist, low-oxygen environment beneath an acrylic surface that Candida colonises readily, particularly when the denture is never removed and hygiene is poor. The resulting chronic atrophic candidiasis (denture stomatitis) is the substrate on which papillary hyperplasia develops.
• D. Viruses do not produce this pattern. Viral lesions of the palate are vesicular or ulcerative and acute, not chronic and papillary.

Note: Management is a package, not a single drug: remove the denture at night, clean it and soak it in an antifungal or a disinfectant (the prosthesis is the reservoir — treating the mouth alone guarantees reinfection), treat the mucosa with a topical antifungal such as nystatin, and correct the ill-fitting prosthesis.

Correct answer: C. Excise the lesion and submit it for histopathologic examination

• A. Delivering a new prosthesis without addressing the persistent lesion repeats the original error, and postponing evaluation for six months leaves an undiagnosed lesion in place.
• B. Additional antifungal therapy is futile against established fibrous hyperplasia. The papillary tissue itself no longer resolves with medical management once it has organised.
• C. CORRECT. Once the CAUSE has been removed and the lesion still does not resolve, the tissue has become fibrotic and irreversible — and any lesion that persists after the etiology is eliminated must be BIOPSIED. Surgical removal (excision, laser or electrosurgery) both establishes the diagnosis histologically and creates the sound, level tissue bed a new denture needs.
• D. Impressing over a hyperplastic, inflamed and mobile tissue bed records a distorted, unstable form. The new denture would fit tissue that is about to change, and the fit would be lost.

Note: The governing principle is general: ANY oral lesion that fails to resolve within roughly two weeks of removing its suspected cause requires biopsy. Tissue conditioning with a soft liner for one to two weeks before surgery is a useful intermediate step, since it lets reversible inflammation settle so the surgeon removes only what is genuinely irreversible.