Dr Jaffar Raza Syed Page 1

Desquamative gingivitis

Dr Jaffar Raza Syed

Desquamative Gingivitis describe a peculiar condition characterized by intense erythema, desquamation and ulceration of the free and attached gingiva

desquamative gingivitis is not a specific disease entity, but a gingival response associated with a variety of conditions

Desquamative Gingivitis

describe a peculiar condition characterized by intense erythema, desquamation and ulceration of the free and attached gingiva

desquamative gingivitis is not a specific disease entity, but a gingival response associated with a variety of conditions

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desquamative gingivitis is not a specific disease entity, but a gingival

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CLASSIFICATION

A. Dermatoses

• Oral lichen planus

• Mucous membrane pemphigoid

• Pemphigus vulgaris

• Bullous pemphigoid

• Erythema multiforme

• Linear IgA disease

• Lupus erythematosus

• Epidermolysis bullosa aquisita

• Dermatitis herpetiformis

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B. Local hypersensitivity reactions to

Toothpastes,

mouthwashes,

dental materials,

drugs,

cosmetics,

chewing gum

cinnamon, etc C. Miscellaneous

Chronic ulcerative stomatitis

Orofacial granulomatosis

Plasma cell gingivitis

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Clinical Features • Females are more frequently affected. • Buccal aspect of anterior gingiva most commonly affected. • The gingiva is fiery red, friable and desquamates easily • Patients complain of soreness, especially when eating spicy or acidic food, and of bleeding and discomfort with toothbrushing. • Lesions get aggravated by local plaque accumulation. • A positive Nikolsky’s sign where the surface epithelium “floats away” when lateral pressure is applied to the mucosa, may indicate vesiculobullous disorders • The presence of white plaques or white striae indicate lichen planus

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Etiology • The etiology is unclear • Mainly affects women at middle and advanced age

Etiology

•Certain dermatoses•Hormonal influences.•Abnormal responses to irritation •Chronic infections•Idiopathic

Clinical featuresmild, moderate and severe forms

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A. Mild form Diffuse erythema.Condition is painless Age: 17 – 23 years common in females.

B. Moderate form •Patchy distribution of bright red and gray areas.

•Surface is smooth and shiny and soft in consistency.

•Slight pitting on pressure.

•Nicolsky’s sign +ve

•Remainder of the mucosa is also extremely smooth and shiny. Age: 30 – 40 years.

C/o of burning sensation and sensitivity to thermal changes.

C. Severe form •Scattered, irregularly shaped areas -striking red appearance. •areas is grayish blue giving an overall speckled appearance. •Surface epithelium -shredded and friable and can be peeled off in small patches. •Areas of involvement seem to shift to different locations on the gingiva.•Patient cannot tolerate coarse food, condiments or temperature changes.•Constant dry and burning sensation throughout the oral cavity,

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The gingiva presents erythema and edema! And ulcerous areas in the anterior vestibular sectors of the mouth.

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Symptoms • Warmth, tenseness, tingling, itchiness, burning, and pain. • Erythema and edema of the marginal and attached gingiva are clinically Observed predominantly in the frontal areas. Signs • Desquamation of the epitelium with painfull erosive lesions and sometimes formation of hemorrhagic bullae by pressing. Diagnosis • Detailed clinical examination of the oral and perioral lesions • Biopsy (perilesional)

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• Biopsy for direct immunofluorescence and with indirect immunofluorescence of the serum

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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 Nikolsky’ssign)

BIOPSY

[ Either incisional or perilesional]

MICROSCOPIC EXAMINATION IMMUNOFLORESENCE

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Management • Plaque control: Oral Hygiene, education • Avoid stimulants, e.g spicy foods… • Identify and manage the cause • Topical corticosteroids are the mainstay of treatment for lichen planus and MMP And should be applied directly onto the affected gingiva. • Systemic corticosteroids are needed for pemphigus • Treat • Collaborate with other clinicians • Refer

Dr Jaffar Raza Syed

Diseases Clinically Presenting As Desquamative Gingivitis Lichen Planus

Lichen planus is an inflmmatory mucocutaneous disorder mucosal surfaces (e.g., oral cavity, genital tract, and skin (including the scalp and the nails)

occurs as a bilateral disease

presence of cutaneous violaceous

appears as radiating white or gray

‘Wickham’s striae’ or ‘Honiton Lace’ Gingival types

Keratotic lesions:

Erosive lesions:

Vesicular or bullous lesions:

Atropic lesions:

Diseases Clinically Presenting As Desquamative Gingivitis

inflmmatory mucocutaneous disorder that may involve mucosal surfaces (e.g., oral cavity, genital tract, and other mucosae) and the

scalp and the nails)

presence of cutaneous violaceous papules that may coalesce to form plaques

appears as radiating white or gray-velvety thread like lesion, which consists of papules

Honiton Lace’

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may involve other mucosae) and the

that may coalesce to form plaques

velvety thread like lesion, which consists of papules

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ORAL MANIFESTATIONS:-

•Radiating white or gray, velvety, thread-like papules in a linear, annular or retiform arrangementforming typical lacy, reticular patches, rings and streaks over the buccal mucosa, lips, tongue and palate.

•Vesicle and bulla formation.

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•ETIOLOGY

• Unknown•Seen mostly in nervous, high strung persons•Course of disease is long•Other causes- traumatism

malnutritioninfection

A triad of lichen planus, diabetes mellitus and vascular hypertension-GRINSPAN SYNDROME

•Hereditary etiology also suggested

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Erosive lichen planus18

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HISTOPATHOLOGY

hyperkeratosis.

hydropic degeneration of basal cell layer.

saw toothed rete pegs.

colloid bodies present.

lamina propria exhibit band like infiltration of T- lymphocytes.

Dr Jaffar Raza Syed

Treatment

Corticosteroids Topical application and local injection of steroids

topical steroid such as 0.05 percent Fluocinolone acetonide

triamcinolone acetonide (10 to 20 Other treatment modalities are

retinoids,

hydroxychloroquine,

cyclosporine and

free gingival grafts.

Addition of antifungal therapy

Topical application and local injection of steroids

topical steroid such as 0.05 percent Fluocinolone acetonide

triamcinolone acetonide (10 to 20 mg)

Addition of antifungal therapy additional benefits>>>

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Topical application and local injection of steroids

Dr Jaffar Raza Syed

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Cicatricial Pemphigoid (Mucous Membrane Pemphigoid MMP)

chronic autoimmune subepithelial disease primarily affecting the mucous membranes of patients over the age of 50

multiple painful ulcers preceded by bullae.

characterized by mucosal blister formation with subsequent scarring affect women more than men

oral mucosal presentation

erosion or desquamation of attached gingival tissues or large areas of vesiculobullous eruptions

healing with scarring

+ve Nikolsky’s sign

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•Vesicles and areas of erosion and ulceration

•Gingival lesions similar to cicatricial pemphigoid-generally involves most of gingival mucosa-exceedingly painful.

•Gingival tissues erythematous and desquamate even on minor friction.

•Vesicles and ultimately erosions appear on gingiva and even on buccal mucosa, palate, floor of mouth and tongue

Oral Manifestations

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Erythema of gingiva

Bullae on gingiva

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ORAL MANIFESTATIONS

• Desquamative gingivitis with areas of erythema, desquamation, ulceration, and vesiculation of the attached gingiva

• Lesions may also occur in other areas of the mouth

• Bullae- thick roof- rupture in 2-3 days leaving irregular shaped areas of ulceration; healing- 3 weeks or longer

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ORAL LESIONS:-

60% of the patients oral lesion is the 1st sign and may herald dermatological lesion by a yr or more.Range from small vesicles to large bullaeRupture of bullae leads to extensive areas of ulcerationAny area of oral cavity involved-Oral lesions confine less often to gingival tissues

Dr Jaffar Raza Syed

Histopathology Sub epithelial clefting with epithelial separation fbasal layer

Sub epithelial clefting with epithelial separation from lamina propria leaving an intact

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rom lamina propria leaving an intact

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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.

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Pemphigus Vulgaris

multiple painful ulcers preceded by bullae.

middle aged patients commonly effected.

positive Nikolsky’s sign.

it is a progressive disease. Histopathology

intra epithelial clefting above the basal layer.

“Tombstone” appearance of basal cell layer.

acantholysis present.

Dr Jaffar Raza Syed

pemphis vulgaris of the gingiva. oral lesions confined to the gingiva consistent with desquamative gingivitis

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pemphis vulgaris of the gingiva. oral lesions confined to the gingiva consistent with

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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.

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Linear IgA disease:

manifested as vesicles.

painful ulcers are seen.

erosive gingivitis. Histopathology:

Separation of the basement membrane.

Dr Jaffar Raza Syed

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An acute bullous and/or macular inflammatory mucocutaneous disease where a series of immunopathologic mechanisms occur.

ERYTHEMA MULTIFORME

3 factors

1. Herpes simplex infections

2. Mycoplasma infection

3. Drug reactions- sulfonamides, penicillin's,

phenylbutazone, and phenytoin

•Hemorrhagic crusting of the vermillion border of lips common; • Presence of crusting important in arriving at diagnosis

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•Target or iris lesions with central clearing •Multiple, large, shallow painful ulcers with an erythematous borders•Lesions –so painful that chewing and swallowing is impaired

•EM minor- lasts approx 4weeks-•moderate cutaneous and mucosal involvement

•Stevens –Johnson syndrome- lasts month or longer –•involves skin, conjunctiva, oral mucosa and genitalia

requiring more aggressive therapy.

•Toxic epidermal necrolyisis – most severe form of EM

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Toxic epidermal necrolysis

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Treatment

•No specific Rx, some cases resolve spontaneously•bullous or ulcerative lesions require intervention-

Mild symptoms- systemic and local antihistamines topical anesthetics and debridement of lesions with an oxygenating agent.

•Intravenous human Ig (high dose)

Severe symptoms- corticosteroids- but its use is not completely accepted

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