What is the cause of a small pimple-like lesion on the ventral side of the tongue with a punctum-like dark mark?

Small Pimple-Like Lesion on Ventral Tongue with Dark Punctum

This lesion most likely represents a blocked or inflamed minor salivary gland (mucocele or mucous retention cyst) or an irritation fibroma, both of which are benign and self-limiting conditions that typically resolve without intervention.

Clinical Assessment

The ventral (underside) surface of the tongue is a common location for benign oral lesions. The key diagnostic features to evaluate include:

• Size and consistency: Small pimple-like lesions (<5mm) are typically benign 1
• The dark punctum: This suggests a blocked duct opening or small area of hemorrhage/pigmentation 1
• Tenderness: Painful lesions suggest inflammation or infection, while painless lesions may indicate cystic or neoplastic processes 1
• Duration: Lesions present for weeks without change are more likely benign 1

Most Likely Diagnoses

Mucocele or Mucous Retention Cyst

• These are the most common benign oral lesions, occurring when minor salivary gland ducts become blocked 1
• The dark punctum likely represents the blocked duct opening
• These typically appear as small, fluid-filled bumps and may spontaneously rupture and recur 1

Irritation Fibroma

• Results from chronic low-grade trauma or irritation 1
• Appears as a firm, pink to white papule
• The dark mark could represent a small area of surface trauma or pigmentation 1

Red Flags Requiring Biopsy

A biopsy must be considered if any of the following are present 1:

• Persistent lesion that fails to resolve after 2-3 weeks of observation
• Progressive growth or change in appearance 1
• Ulceration or erosion that doesn't heal 1
• Marked asymmetry or unusual features 1
• Associated symptoms such as numbness, bleeding, or difficulty with tongue movement 1
• White, red, or mixed white-red patches (leukoplakia, erythroplakia) which may indicate dysplasia 1, 2

Management Approach

Initial Conservative Management

• Observation for 2-3 weeks is appropriate for small, asymptomatic lesions 1
• Avoid trauma to the area (check for sharp teeth, dental appliances) 1
• Maintain good oral hygiene 1

When to Refer

Refer to an oral surgeon or dermatologist if 1:

• The lesion persists beyond 2-3 weeks without improvement
• Any red flag features develop
• The lesion causes functional impairment
• Diagnostic uncertainty exists

If Biopsy is Performed

• The biopsy should be taken from the most representative area of the lesion 1
• Good clinicopathological correlation with discussion between clinician and pathologist is vital 1

What This is NOT

This presentation is not consistent with:

• HPV-related lesions (verruca vulgaris, condyloma, squamous papilloma): These typically appear as exophytic, papillary growths with a pebbly or cauliflower-like surface, not as simple pimples with puncta 1, 3
• Malignancy: Small, stable pimple-like lesions without ulceration, induration, or progressive growth are unlikely to be malignant 1, 2
• Pemphigus or other bullous diseases: These present with fragile blisters and erosions, not discrete papules 1

Common Pitfalls to Avoid

• Over-treatment: Most small oral lesions are benign and self-limiting; avoid unnecessary interventions 1
• Delayed biopsy: Don't observe suspicious lesions indefinitely—if there's any doubt after 2-3 weeks, biopsy 1
• Missing malignancy: While rare in young patients, oral squamous cell carcinoma can present as non-healing ulcers or persistent masses, particularly in patients with risk factors (tobacco, alcohol, HPV) 1, 2