What to do about a 3mm x 3mm white raised bump on the side of the tongue that has been present for 3 months?

Management of a 3mm White Raised Bump on the Lateral Tongue Present for 3 Months

This lesion requires biopsy given its 3-month duration, as any oral lesion persisting beyond 2 weeks without response to treatment warrants tissue diagnosis to exclude malignancy or other serious pathology. 1, 2

Immediate Next Steps

Clinical Evaluation Before Biopsy

Before proceeding to biopsy, obtain the following blood tests to exclude contraindications and provide diagnostic clues 1:

• Full blood count - to rule out blood system diseases (anemia, leukemia) 1
• Coagulation studies - to exclude surgical contraindications 1
• Fasting blood glucose - hyperglycemia is a predisposing factor for invasive fungal infection 1
• HIV antibody and syphilis serology - to rule out infection-associated oral lesions 1

Physical Examination Specifics

Document the following characteristics 2, 3:

• Exact size, shape, and location on the lateral tongue 2
• Surface characteristics - note if the lesion has a well-demarcated border, yellow/white base, or erythematous border 2
• Palpation - assess for induration, fixation to underlying structures, or tenderness 1
• Neck examination - palpate for cervical lymphadenopathy, as nontender neck masses are more suspicious for malignancy 1
• Complete oral cavity inspection - examine all mucosal surfaces, floor of mouth, and oropharynx for additional lesions 1

Differential Diagnosis Considerations

For a 3mm white raised lesion persisting 3 months, consider 2, 3:

• Traumatic ulceration/fibroma - though typically resolves within 2 weeks if trauma eliminated 2
• Leukoplakia - potentially malignant disorder with 2-3% annual malignant transformation rate 4
• Epidermoid cyst - benign cystic lesion with yellowish-white surface, though rare on tongue body 5
• Early squamous cell carcinoma - must be excluded given 3-month duration 1, 3

Why Biopsy is Mandatory

Any oral lesion persisting beyond 2 weeks, especially without response to 1-2 weeks of treatment, requires biopsy. 1, 2 The 3-month duration in this case far exceeds the threshold for observation alone.

Biopsy Technique Considerations

• Excisional biopsy is preferred for a 3mm lesion, as complete removal allows full histopathologic assessment 3
• Include adequate margins to ensure representative tissue 1
• If pathology returns as "inflammatory" with nonspecific findings, consider sending paraffin-embedded specimens for expert pathology consultation 1

Critical Pitfalls to Avoid

• Do not assume this is benign based on small size alone - squamous cell carcinoma can present as small white lesions 1, 4
• Do not delay biopsy for further observation - the 3-month duration already represents excessive delay 1, 2
• Do not miss synchronous lesions - examine the entire oral cavity and oropharynx, as multiple lesions may indicate field cancerization 1
• Do not overlook risk factors - document tobacco use, alcohol consumption, and HPV risk factors in the history 1

If Biopsy is Delayed or Contraindicated

Only if the patient has absolute contraindications to biopsy, consider 1:

• Detailed medical history focusing on tuberculosis, diabetes, intestinal diseases, and medication history 1
• Chest CT if tuberculosis or invasive fungal infection suspected 1
• Multidisciplinary consultation with oral surgery or otolaryngology 1

However, these are secondary measures - tissue diagnosis remains the definitive next step for any persistent oral lesion. 1, 2, 3