Abstract
<title>Abstract</title> <p>Background Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an uncommon benign reactive lesion of the oral mucosa that can mimic malignancy. Its bimodal age distribution is recognized, but the clinical implications of this distribution remain underexplored. We report four biopsy-proven cases spanning a wide age range across childhood–adolescence and older adulthood to examine age-specific malignancy mimicry, trauma source, and the dissociation between tissue and peripheral eosinophilia. Case presentation: Four consecutive patients diagnosed at a single tertiary oral and maxillofacial surgery center between December 2025 and May 2026 were reviewed: three pediatric or adolescent males (7, 8, and 17 years) and one 68-year-old woman. The suspected malignancy differed by age — lymphoma in the pediatric cases, and recurrent or second primary oral squamous cell carcinoma in the older patient, who had a remote palatal carcinoma treated with radiotherapy and a long-standing history of removable partial denture wear, a combination not previously reported. The likely trauma source varied similarly, from cheek biting and suspected self-injurious behavior to prosthetic trauma on previously irradiated mucosa. Despite eosinophil-rich histology, calculated peripheral eosinophil counts (60–217/µL) remained well below the diagnostic threshold, with normal lymphocyte proportions and inflammatory markers. All lesions healed without recurrence. Conclusions TUGSE mimicked different malignancies at different ages, each with a different likely trauma source. Neither the clinical pattern of the lesion nor the peripheral blood differential reliably excludes the diagnosis; biopsy must remain the decisive diagnostic step, particularly in pediatric patients with lymphoma-like ulceration and in head and neck cancer survivors with new ulcers within a previously irradiated field.</p>