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DESQUAMATIVE GINGIVITIS PDF

ABSTRACT. Desquamative gingivitis is a descriptive term of nonspecific clinical expression in the gingiva (redness, burning, erosion, pain) of several. Desquamative gingivitis (DG) is a clinical term used to describe gingival tissues that demonstrate potentially painful gingival erythema, hemorrhage, sloughing. Lichen planus is an idiopathic t-cell mediated inflammatory condition. Although its etiology is unknown OLP is sometimes associated with other medical.

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Gingival desquamation is a clinical sign in which the gingiva appears reddish, glazed and friable with destruction of the epithelium. Gingival desquamation may be the result of various disease processes in gingiva.

Mucous membrane pemphigoid Deesquamativeoral lichen planus and pemphigus vulgaris accounts for the major causes of gingival desquamation. MMP is a rare, chronic autoimmune blistering disorder characterized by subepithelial bullae. The condition frequently involves mucous membranes, with rare skin involvement.

Oral cavity is mostly affected and desquamative gingivitis is the most common manifestation. Hereby, we present an interesting case of MMP manifesting as desquamative gingivitis, along with a brief review of the literature.

Chronic desquamative gingivitis was first described by Tomes and Tomes in A classification was proposed based on etiologic considerations, together with histologic and immunologic findings.

The exclusive gingival involvement in this multi mucosal disorder entails careful history taking and diagnosis by dental professional, thus signifying the role of dentists in such mucocutaneous disorders. This was a case report of a year-old female patient who reported to the out-patient Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai with a complaint of burning sensation and tenderness in the gums, which worsened on intake of spicy food since 9 months.

The patient also noticed the appearance of blisters on her gums on and off which would heal subsequently without any medical intervention. Her medical history was non-contributory. There were no associated ocular, cutaneous or genital lesions. Intraoral examination revealed an erythematous and inflamed labial gingiva with interspersed areas of normal gingiva in relation to 11, 12, 21, The marginal gingiva was scalloped in outline and had rolled borders with absence of melanin pigmentation [ Figure 1 ].

There was a diffuse area of desquamation and erythema involving the buccal aspect of free, marginal and attached gingiva in relation to 24, 25, 26 and Faint white striae were visible bordering the areas showing desquamation.

The desquamated area showed loss of stippling. Single, isolated discrete hemorrhagic bullae, oval in shape, 1. The bulla was relatively resilient to puncture [ Figure 2 ]. Gentle manipulation of the normal mucosa induced a positive Nikolsky’s sign. The patient’s oral hygiene was poor and gingiva showed bleeding on probing with no attachment loss. After obtaining an informed consent from the patient, an incisional biopsy was taken from the buccal aspect of left maxillary gingival region adjacent to the bullae region for histopathologic and immunofluorescent studies.

Histopathology showed variable thickness parakeratinized stratified squamous epithelium, subepithelial cleft and basal cell degeneration in few areas. Linear deposition of IgG and C3 at the dermo-epidermal junction was evident in direct immmunofluorescence [ Figure 5 ]. Differential diagnosis was made solely on the basis of clinical features. Dermatological pathologies like bullous pemphigoid, MMP, pemphigus vulgaris and bullous lichen planus were considered as the most probable differential diagnosis.

Absence of skin lesions excluded the possibility of bullous pemphigoid. Presence of intact bullae and absence of erosions clinically and subepithelial cleft histopathologically ruled out pemphigus vulgaris. The striking presence of desquamative gingivitis in a year-old female patient with an intact hemorrhagic bullae without coexisting skin lesionsin association with characteristic histopathological and immunofluorescent features confirmed the diagnosis of MMP.

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Thorough oral prophylaxis was done and the patient was counseled to maintain good oral hygiene. Thereafter, the patient was prescribed topical application of high potency steroids Clobetasole propionate thrice daily for 1 month and vitamin supplements cap zincovit once daily for 1 month. The patient was reviewed every 2 weeks for the first 1 month. The patient was asked to stop the topical steroid application and reinforcement of oral hygiene instructions were given. Since the lesions may recur, the patient was under observation for 1 year and there was no recurrence.

Blood tinged intact bulla with desquamative gingivitis seen in respect to left maxillary posterior teeth. Histopatholgy showing sub-epithelial cleft and basal cell degeneration, along with chronic inflammatory cells and hemorrhagic areas. Photomicrograph showing sub-epithelial cleft and basal cell degeneration, with haemmorhagic areas. Direct immunofluorescence showing a linear deposition of IgG and C3 at the dermo-epidermal junction.

MMP is a heterogeneous group of autoimmune, chronic inflammatory, subepithelial blistering disease of mucous membranes, oral, ocular, genital, nasopharyngeal, esophageal, and laryngeal mucosa are frequently affected, with rare skin involvement. The condition belongs to a group of mucocutaneous autoimmune blistering disorders often collectively referred to as subepithelial bullous dermatoses. Wichmanns was the first to describe a case of MMP as early as late 18 th century. The exact etiology of MMP is not known.

However, no direct relationship between MMP and smoking or menopausal status has been cited in the literature. MMP antigens are usually present in lamina lucida of basement membrane, but lamina densa may also be the primary site of involvement in some cases. The epidemiological characteristics of MMP were unclear, with a reported incidence of 1. In patients with ocular MMP who were not treated or are inappropriately treated, scarring may lead to blindness.

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Laryngeal stenosis can lead to fatal asphyxia. Esophageal strictures may lead to dysphagia and may rarely rupture to result in mediastinitis. The most frequent first site involved in MMP is the oral cavity.

The commonest intraoral site affected is the gingiva[ 2021 ], and the lesions tend to heal with insignificant scarring. Desquamative gingivitis is the main oral feature of MMP[ 22 ] and may be the sole presenting feature. Desquamative gingivitis is a fairly common disorder in which the gingivae are desquamated. Chronic soreness is commonly seen and intake of spicy foods may further worsen the condition. Erythematous gingiva with loss of stippling, extending apically from the gingival margins to the alveolar mucosa is a frequent observation.

Desquamative gingivitis – Wikipedia

Severity may range from mild, almost insignificant small patches to widespread erythema[ 23 ] with glazed appearance. Occassionally, gingival inflammation may occur in the absence desauamative bacterial plaque, in the form of chronic desquamative gingivitis.

Gallagher and Shklar[ 22 ] compiled desuamative data of patients and observed gingival involvement in almost all cases. Vesicles or bullae may also occur elsewhere on the oral mucosa in MMP, and positive Nikolsky sign[ 22 ] elicited by palpation with a finger, mouth mirror or periodontal probe is a fairly common observation.

Pseudomembrane covered, irregularly shaped erosions constitute the second most common manifestation in MMP. Erosions have a yellowish slough and are surrounded by an inflammatory halo. However, the oral lesions usually heal desqkamative scarring.

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In the present case, the affected patient was a year-old female who presented with exclusive oral involvement without any other mucosal or cutaneous involvement. There was widespread erythema gingiviits inflammation of maxillary anterior labial gingiva. However, the palatal gingiva was unaffected. Desquamative gingivitis affecting the marginal and attached gingiva was appreciated with respect to left maxillary gingival region, along with the presence of blood filled bullae.

Gentle manipulation induced a positive Nikolsky’s sign. The features reported in the present case were consistent with the previous literature reviews. The definitive diagnosis can only be established based on the histopathological data and immunofluorescence studies. Gingival biopsy is best avoided, as gingival chronic inflammation may lead to confusion. Histologically, MMP is characterized by junctional separation at the level of the basement membrane ginhivitis resultant sub-basilar split.

Chronic inflammatory infiltrate in the lamina propria contains eosinophils, lymphocytes, and neutrophils. Circulating antibodies can be detected by indirect immunofluorescence and immunoblot assays. Indirect immunofluorescence using salt-split mucosa provides more sensitive assay.

Histopathological features in the present case, showed subepithelial cleft and basal cell degeneration, along with band of intense chronic inflammatory cell infiltrate consisting predominantly of plasma cells and areas of hemorrhage.

There is no standard treatment protocol for the management of patients with MMP. The treatment strategies vary according to the preference of the physician, the age of the patient, the severity of the disease and the deequamative involved. Patient’s education and motivation should be done, as plaque induced gingivitis may worsen or aggravate the course of the disease. Good oral hygiene and use of a soft bristle toothbrush may partly alleviate the patient’s discomfort.

Desquamative gingivitis: A review

An anti-plaque agent such as 0. Systemic drugs or agents are reserved for skin or mucosal locations other than oral sites, such as the conjunctiva. Oral MMP may be more difficult to manage than other subgroups of the disease. Secondary infections, constant trauma from chewing and the use of a tooth brush, may delay the healing process. This in turn may lead gingjvitis malnutrition.

Other treatment regimen includes intravenous immunoglobulins, plasmapheresis, and Low level laser therapy LLLT. LLLT has anti-inflammatory effects, causes pain relief dfsquamative accelerates regeneration of damaged tissues. The patient in the present case underwent thorough oral prophylaxis and was treated with topical steroids and vitamin supplements for 1 month.

The lesions showed considerable improvement after steroid application. Regular follow up was done and the desqumative showed no signs of recurrence. Dentists could be the first health professionals to recognize this multi-mucosal involvement disorder. Correct diagnosis of the condition entails taking a detailed history, vesquamative with a thorough intraoral and extraoral examination, along with histopathology and Immunofluoroscence studies.

The gingival lesions are usually treated by improved oral hygiene measures and topical corticosteroid therapy. National Center for Biotechnology InformationU. Gingivitiis Pharm Bioallied Sci. Author information Article notes Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Gingival desquamation is a clinical sign in which the gingiva appears reddish, glazed and friable with destruction of the epithelium.

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