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DESQUAMATIVE GINGIVITIS

Introduction
Earlier it was described as a peculiar condition characterized by intense erythema, desquamation, and ulceration of free and attached gingiva. Desquamative gingivitis involves not only the marginal gingiva as in most cases of gingivitis, but it also peels off the attached gingival in a band like fashion. Use of clinical and laboratory parameter have revealed that approximately 75% of desquamative gingivitis cases have a dermatologic genesis.

Cicatricial pemphigoid and lichen planus accounts for more than 95% of cases. Many other mucocutaneous auto immune condition can clinically manifest as desquamative gingivitis such as:
1. 2. 3. 4. 5. 6. Bullous pemphigoid Phemphigous vulgaris Linear IgA disease Dermatitis herpetiformis Lupus erythematous Chronic ulcerative stomatitis

Chronic bacterial, viral and fungal infections, reactions to medication, mouthwashes and chewing gums and less commonly crohns disease, sarcoidosis and leukemias have also been reported to present clinically as DESQUAMATIVE GINGIVITIS.
Thus the identity of the disease responsible for desquamative gingivitis is necessary for appropriate therapeutic approach and management.

DIAGNOSIS OF DESQUAMATIVE GINGIVITIS


Following parameters are necessary for establishing the diagnosis of the disease.

CLINICAL HISTORY A thorough clinical history is mandatory to begin


assessment of the disease. Data regarding symptomatology associated with the condition as well as historical aspect; i.e when did the lesion start? Has it worsened? Is there any habit that worsened the condition? Information regarding previous therapy should also be collected.

CLINICAL FEATURES
Clinical features vary in severity as mild, moderate and severe form MILD FORM Manifested as diffuse erythema of the free, attached and interdental gingiva. Usually painless and occurs most frequently in females of age between 17-23 yrs of age.

MODERATE FORM Patchy distribution of bright red and grey areas


involving marginal and attached gingiva. Surface is smooth, shiny Gingiva becomes soft, edematous and massaging of gingiva leads to peeling off the epithelium Seen in age groups of 30-40 yrs. Patient complains of burning sensation

SEVERE FORM
Characterized by scattered irregularly shaped areas in which the gingiva is denuded and strikingly red in appearance. Gingival seems to be speckled and surface epithelium seems to be shredded, friable and can be peeled off in small patches. Condition is painful. There is constant dry burning sensation throughout the oral cavity.

Diseases clinically presenting as Desquamative Gingivitis LICHEN PLANUS bilateral white striae purple pruritic papule seen in middle age buccal mucosa most commonly affected

HISTOPATHOLOGY hyperkeratosis.
hydropic degeneration of basal cell layer. saw toothed rete pegs. colloid bodies present. lamina propria exhibit band like infiltration of Tlymphocytes.

CICATRICIAL PEMPHIGOID
multiple painful ulcers preceded by bullae. positive nikolskys sign middle aged or elderly women most commonly affected. may affect mucous membrane of oral cavity and eyes HISTOPATHOLOGY. Sub epithelial clefting with epithelial separation from lamina propria leaving an intact basal layer

BULLOUS PEMPHIGOID:
skin disease with infrequent oral lesion. ulcers preceded by bullae. no scarring. seen in elderly persons.

HISTOPATHOLOGY:
Sub epithelial clefting with epithelial sepration from lamina propria leaving an intact basal layer.

PEMPHIGUS VULGARIS:
multiple painful ulcers preceded by bullae. middle aged patients commonly effected. positive Nikolskys sign. it is a progressive disease. HISTOPATHOLOGY: intra epithelial clefting above the basal layer. Tombstone appearance of basal cell layer. acantholysis present.

DERMATITIS HERPETIFORMIS: Skin diseases with rare oral involvement.


vesicles and pustules. exacerbation and remission seen. young and middle aged patients are commonly effected.

HISTOPATHOLOGY:
Collection of esoniophils, neutrophils and fibrin in connective tissue papillae.

LINEAR IgA DISEASE:


manifested as vesicles. painful ulcers are seen.
erosive gingivitis.

HISTOPATHOLOGY:
Separation of the basement membrane.

BIOPSY
Incisional biopsy is the best alternative to begin the microscopic and immunological examination. Selection of the biopsy site is very important. Perilesional/ incisional biopsy should avoid areas of ulceration as necrosis and epithelial denudation severely hampers the diagnostic approach.

MICROSCOPIC EXAMINATION:
Approximately 5 micron sections of formalin fixed, paraffin embedded tissue stained with H & E are obtained for light microscopic examination.

IMMUNOFLUORESENCE:
It is of two types. Direct immunofluoresence. Indirect immunofluoresence.

Direct immunofluoresence:
For this unfixed frozen sections are incubated with a variety of fluorescein labeled anti human serum(anti IgA, anti IgM, anti IgG, antifebrin & anti c-3)

Indirect immunofluoresence:
In this technique frozen sections of oral and esophageal mucosa from an animal such as monkey are first incubated with the patients serum to allow attachment of any serum antibodies to the mucosal tissue. The tissue is the then labeled with fluorescein labeled anti human serum.

Summary of diagnostic procedure


CLINICAL HISTORY
(data regarding the symptoms & historical aspect is collected & information about previous therapy is also collected )

CLINICAL EXAMINATION
(recognition of the pattern of distribution of lesion & performing Nikolskys sign)

BIOPSY
[ Either incisional or perilesional]

MICROSCOPIC EXAMINATION

IMMUNOFLORESENCE

Management:
Once the diagnosis is established the dentist must choose the optimum management for the patient. This is accomplished according to three factors: 1. practitioners experience. 2. systemic impact of the disease. 3. systemic complication of the medication.

In the first scenario the dental practitioner takes direct and exclusive responsibility for the treatment of the patient. In the second scenario the dentist collaborates with another health care provider to evaluate or treat the patient concurrently. In the third scenario the patient is immediately referred to the dermatologist for further evaluation and treatment.

The therapy must be based on the understanding of the basic disease process causing the gingival reaction. It can be of two phases: 1. Local treatment. 2. Systemic treatment.

Local treatment:
Give proper instructions to the patient regarding the maintenance of proper oral hygiene. Use of soft brush is advised. Advice use of oxidizing mouthwashes (hydrogen per oxide 3% diluted) Topical corticosteroid ( triamcinolone 0.1%, flucocinonide 0.5%, desonide 0.5, tacrolimus .1%, clobetasol propionate 0.5%)

Systemic treatment:
Systemic corticosteroid in moderate cases. Prednisolone can be used a daily or every other day dose of 30 to 40 mg and reduced gradually to daily dose of 5 to 10 mg.

CONCLUSION:
Desquamative gingivitis is not a specific disease entity but a gingival response associated with variety of conditions. Proper diagnosis of the underlying disease should be well established by the dentist and best possible treatment must be provided to the patient.

Failure to evaluate properly and systematically a patient with a clinical condition that is consistent with desquamative gingivitis can lead to unpleasant outcomes. The clinician should also be alert to the possibility of squamous cell carcinoma of the gingival tissue presenting initially as desquamative gingivitis.

Reference
Carranzas-Textbook of clinical periodontology Newman Takei Kilokkevold Carranza

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CHAPTER 21 DESQUAMATIVE GINGIVITIS


1. 2. Chronic desquamative gingivitis was first recognized and reported in 1894. In 1932, Prinz described it as a peculiar condition characterized by intense erythema, desquamation and ulceration of the free and attached gingiva. Patients may be asymptomatic,however when symptomatic, their complaints range from a mild sensation to an intense pain.

3.

4.
5.

Etiology is unknown.
50% of desquamative gingivitis cases are localized to gingiva, although involvement of intraoral and extra oral sites is not uncommon.

6.

Diagnosed in women in the fourth to fifth decades of life (may occur as early as puberty or as late as seventh or eighth decades).
In 1960 McCarthy and colleagues suggested that desquamative gingivitis was not a specific disease entity, but a gingival response associated with a variety of conditions.

7.

8. 9. 10.

There may be threads or loose necrotic epithelium. It involves not only marginal gingiva, but also peels the attached gingiva often in a band- like fashion. The differential diagnosis of desquamative gingivitis include a variety of diseases such as lichen planus, cicatrical pemphigoid, bullous pemphigoid, pemphigus vulgaris,linear IgA disease, dermatitis herpetiformis and drug reaction or eruptions. DIAGNOSIS :

The success of any given therapeutic approach resides on the establishment of an accurate final diagnosis. CLINICAL FEATURES :

1. 2. 3.

Mild form. Moderate form. Severe form.

1.
a) b)

MILD FORM :
There is diffuse erythema of the marginal, interdental and attached gingiva. It is usually painless and occurs most frequently in females between 17 & 23yrs. of age.

2. a) b)

MODERATE FORM : Patchy distribution of bright- red and gray areas involving marginal and attached gingiva. The surface is smooth and shiny, normal resilient gingiva becomes soft, edematous and massaging of gingiva results in peeling off the epithelium. Usually seen in the age group of 30 to 40 yrs. Patient complains of burning sensation. The labial surface is more frequently involved.

c) d) e)

3. a)

SEVERE FORMS : This form is characterized by scattered irregularly- shaped areas in which the gingiva is denuded and strikingly red in appearance. The gingiva is speckled and the surface epithelium seem shredded, friable and can be peeled off in small patches. The mucous membrane other than gingiva is smooth and shiny and may present fissuring in the cheek adjacent to the line of occlusion. The condition is painful. There is a constant, dry, burning sensation throughout the oral cavity. HISTOPATHOLOGY :

b)

c)

d) e)

1. 2.

Microscopically, desquamative gingivitis often appears as bullous lesions or lichenoid lesions. Occasionally there will be thin , atrophic epithelium with little or no keratin at the surface and a dense, diffuse infiltration of chronic inflammatory cells in the underlying connective tissue.

3.

Histochemical and ultastructural studies revealed separation of collagen fibrils and a decrease in the number of anchoring fibrils.
THERAPY :

1. 2.

It can be of two phases :


Local Treatment. Systemic Treatment.

LOCAL TREATMENT : 1. Oral hygiene instructions (soft toothbrush).

2.
3.

Oxidizing mouthwashes (Hydrogen peroxide 3% diluted).


Topical corticosteroid ointments or cream- like triamcinolone 0.1%, flucocinamide 0.05%, desonide 0.05 %.

SYSTEMIC TREATMENT : 1. Systemic corticosteroids in moderate doses.

2.

Prednisolone can be used in a daily or every- other- day dose of 30 - 40 mg and gradually- reduced to a daily maintenance dose of 5 10 mg.

PEMPHIS VULGARIS OF THE GINGIVA. ORAL LESIONS CONFINED TO THE GINGIVA CONSISTENT WITH DESQUAMATIVE GINGIVITIS

CHRONIC ULCERATIVE STOMATITIS. ERYTHEMA AND ULCERATION OF THE GINGIVA CONSISTENT WITH A CLINICAL DIAGNOSIS OF DESQUAMATIVE GINGIVITIS

LINEAR IgA. INTENSE ERYTHEMA AND ULCERATION OF THE GINGIVA CONSISTENT WITH DESQUAMATIVE GINGIVITIS

LUPUS ERYTHEMATOSUS OF THE ORAL CAVITY PRESENTING AS DESQUAMATIVE GINGIVITIS. INTENSE ERYTHEMA WITH ULCERATION BORDERED BY WHITE RADIAL LINES.

PLASMA CELL GINGIVITIS . THE GINGIVA PRESENTS A BAND OF MODERATE TO SEVERE INFLAMMATION REMINISCENT OF DESQUAMATIVE GINGIVITIS

WEGNERS GRANULOMATOSIS AFFECTING TISSUES. THE CLASSIC STRAWBERRY GUMS APPEARANCE OF THE MANDIBULAR GINGIVA. A SLIGHT RESEMBLANCE WITH DESQUAMATIVE GINGIVITIS IS EVIDENT.