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General and Oral Pathology for the Dental Hygienist, 2nd Edition
Leslie DeLong and Nancy W. Burkhart
Instructor Case Studies, Chapter 11, Lesions That Have a Vesicular Appearance
Case study 11.1
Image: Courtesy of Dr. Doron Aframian.
The above image may be described in clinical terms, but because of the widespread area
that encompasses the width of the tongue, a digital image would be more reliable. If a
written description were used, because digital images are not available, we suggest the
following:
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
The tongue appears somewhat edematous with markings that extend from lateral
border to lateral border with a raised appearance and a clear indentation. The
raised areas do not appear to be ulcerated. The indented area is a patterned
indentation with no notation of ulceration. Measurements may include the tongue
width or they may be from the central area to the lateral border on each half of the
tongue.

The patient reports no pain anywhere in the oral region.

The student may be asked to provide an educated guess to the etiology of the
indentation.

What would you expect to find in the palate region?

Would the tongue be problematic when brushed?

Is there any treatment that should be administered?
The above image is, of course, the direct indentation caused by an orthodontic spacer.
The patient is also causing a suction process making the indentation more pronounced.
Often just calling attention to this fact makes the patients aware that they are causing the
suction themselves and they may be able to stop the process.
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I
mage: Courtesy of Dr. Doron Aframian.
Case Study 11.2
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A 47-year-old male, Mr. L, arrives at your office for an appointment. His chief complaint
is that “after taking an antibiotic, a sore has appeared in my mouth.” The patient reports
having had smallpox and chickenpox as a child. He has a history of hypertension and is
taking Cozaar 50 mg and Nadolol 160 mg. The history of the lesions is approximately 8
to 12 months, with the lesions on the axilla more recent. The lesions are described as
painful, with large desquamative ulcerative lesions across the soft palate and the
mandibular buccal gingiva. Bullous lesions are also noted on the scalp and axilla.
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Figure 11.23A shows a clinical view of erythematous lesions around teeth 26, 27, and 28.
(Courtesy of Dr. Terry Rees.)
Figure 11.23B shows ulcerative lesions in the posterior area of the right side of the
mouth. (Courtesy of Dr. Terry Rees.)
Figure 11.23C shows the left external region anterior to the left ear. (Courtesy of Dr.
Terry Rees.)
Figure 11.23D depicts a separation above the basal cell layer, with the basal cell layer
adhering to the connective tissue. Free-floating cells are noted with inflammatory cells
throughout the tissue. (Courtesy of Dr. Terry Rees.)
1.
2
Which of the following would you not consider in your differential diagnosis?
a.
Epidermolysis bullosa
b.
Epidermolysis bullosa acquisita
c.
Benign mucous pemphigoid
d.
Pemphigus vulgaris
e.
Shingles
If you suspect that Mr. L may have shingles, which of the following would you
evaluate first?
a.
Whether the lesions are extremely painful
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3.
b.
Whether the eyes are involved
c.
Whether there is raw, erosive lesion involvement
d.
Whether there is asymmetry
e.
Whether the lesions are small and vesicle-like
Which of the above-mentioned diseases would most likely involve the external
skin surfaces?
a.
A, B, and C
b.
A, B, D, and E
c.
A, C, and B
d.
A, C, and E
e.
They may all involve the external surfaces
Case Continued:
Laboratory tests are performed using incisional biopsy specimens, and they are examined
with H&E stains and immunofluorescence. The biopsy results indicate that the basal cell
layers are adhering to the underlying connective tissue, with artifactual separation within
the epithelium. There are free-floating epithelial cells.
Figure 11-23D shows the histology of the case report.
4.
Given the above histology slide, which of the above diseases would you suspect?
a.
Epidermolysis bullosa
b.
Epidermolysis bullosa acquisita
c.
Benign mucous pemphigoid
d.
Pemphigus vulgaris
Copyright © 2013 Lippincott Williams & Wilkins / Wolters Kluwer Health. All rights reserved.
e.
Shingles
Copyright © 2013 Lippincott Williams & Wilkins / Wolters Kluwer Health. All rights reserved.