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The oral cavity may exhibit a vast number of pathologic conditions, often dealt with by different medical disciplines. Combined with a substantial variation in clinical appearance, an accurate diagnosis may provide difficult to establish in selected cases. Histopathological investigations are therefore mandatory for correct diagnosis and adequate treatment. We describe a common, truly benign condition in the oral cavity, which due to histopathological misinterpretation was planned for major surgery and subsequent chemotherapy. This was avoided by spontaneous regression of the lesion. The case illustrates that uncritical trust in laboratory diagnostic tests may lead to severe mistreatment.

patient safety in surgery

Misinterpretation of histopathological results as an important risk factor for unneeded surgery – case report of a "near miss" event in a pregnant woman