A patient presents with a blue-gray intraoral lesion distal to the last molar that does not show amalgam on X-ray. This is most likely:

Correct answer: A. Hemangioma/vascular lesion

• A. Correct. A purplish/blue-gray soft tissue lesion without corresponding radiopacity on X-ray is most consistent with a vascular lesion (hemangioma or varix). Blanching with pressure would confirm vascular origin.
• B. Kaposi sarcoma is an important differential in HIV patients but is not the first-line diagnosis without other clinical context.
• C. Amalgam tattoo requires radiographic evidence of metal particles. Without radiopacity on X-ray, this diagnosis cannot be made.
• D. Melanotic macule is flat (macule) and typically occurs on the lip or gingiva — it would not be the first choice for a lesion distal to the terminal molar.