DESQUAMATIVE GINGIVITIS

IntroductionChronic disease characterized by erythematous, erosive, vesiculobullous or desquamative lesions of the free and attached gingiva.

HistoryFirst recognized & reported in 1894 Prinz(1932)-chronic diffuse desquamative gingivitis Merritt(1984)-milder cases of this condition. McCarthy et al(1960)- Desquamative gingivitis was not aspecific disease entity, but a gingival response associated with a variety of conditions.

Clinical Features-

Fairy red color gingiva with smooth and shiny surfaces.

Peeling away of epithelium can occur.

Ulceration may occur after chewing of food.

May involve whole gingiva uniformly or single or multiple, discrete or irregular patches.

Most frequent in young and middle aged women.

Other intraoral and extra oral sites can be involved.

Patients may be free of symptoms or complain of a burning sensation with or without intense pain.

Etiologic considearionsI. Dermatoses (75.4%)*Cicatricial pemphigoid Lichen planus Pemphigus Psoriasis Bullous pemphigoid Epidermolysis bullosa acquisita Contact Stomatitis

II. Endocrine imbalanceEstrogen deficiencies following oophorectomy and in postmenopausal women Testosterone imbalance Hypothyroidism

III. Aging IV. Abnormal response to bacterial plaque V .Idiopathic VI. Chronic infectionsTuberculosis Chronic candiadiasis Histoplasmosis

Glickman and Smulow(1953)

DIAGNOSIS OF DESQUAMATIVE GINGIVITISCLINICAL 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)

BIOPSY MICROSCOPIC EXAMINATION IMMUNOFLORESENCE -Direct immunofluoresence -Indirect immunofluoresence:

DESCRIPTION OF STAINING REACTION WITH PERIODIC ACID-LEIUCOFUCHSIN METHOD OF CERTAIN TISSUE COMPONENTS IN NORMAL GINGIVA AND IN DESQUAMATIVE GINGIVITIS

Normal gingivaBasement membrane Sharply defined undulating lines

DESQUAMATIVE GINGIVITIS Absent or discontinuous, some time swollen

Ground substance of sub epithelial connective tissue Cement substance of epithelial

Intense red

Diffuse pink

Well-defined light pink lines

Absent or swollen and disorganized cells

ENGEL, RAY, AND ORBAN(1950)

DISEASES CLINICALLY PRESENTING AS DESQUAMATIVE GINGIVITISLichen Planus Pemphigoid : Bullous & Cicatricial Pemphigoid Pemphigus Vulgaris Chronic Ulcerative Stomatitis Linear IgA Disease Dermatitis Herpetiformis Lupus Erythematosus Erythema Multiforme

Lichen planusInflammatory mucocutaneous disorder that may involve mucosal surfaces (oral cavity, genital tract) & skin (scalp & nails) first described by Wilson(1869)

CLINICAL FEATURESORAL LESIONS Reticular- asymptomatic, bilateral, interlacing White lines on posterior region of buccal mucosa.

Erosive Fine white radiating striations bordering ulcerated zone.

Gingival lesions Keratotic- raised, white lesions are present. Erosive-extensive, erythematous area Vesicular-raised ,fluid filled area Atrophy-epithelial thinning take place.

HISTOPATHOLOGY Hyperkeratosis Hydropic degeneration of basal layer Dense infiltrate of lymphocytes. Civatte bodies are seen. Max-joseph spaces are seen

IMMUNOPATHOLOGY Fluorescence along the basement membrane zone with numerous extension into lamina propia.Daniel and Quadra-White(1980)

Direct immunofluorescence of cluster of cytoid bodies.

Bullous pemphigoidBullous pemphigoid is a chronic, autoimmune, subepidermal bullous disease with tense bullae that rupture and become flaccid in the skin.

Oral lesions

Oral lesions are smaller and form more slowly. Gingival lesions consist of generalized edema, Inflammation, desquamation and localized area of vesicle formation.

Histopathology Sub epithelial clefting with epithelial separation from underlying lamina propria, leaving intact basal layer

Immunofluorescence IgG deposits along epithelial basement membrane. Basement membrane antibodies in 40-70% cases with indirect immunofluorescence

Cicatricial Pemphigoidchronic, vesiculo-bullous autoimmune disorder of unknown cause that predominantly affects women in the fifth decade of life.

Oral lesions

areas of erythema, desquamation, ulceration, and vesiculation, of the attached gingiva The bullae tend to have a relatively thick roof and rupture in 2 to 3 days, leaving irregularly shaped areas of ulceration

Pemphigus VulgarisAutoimmune blistering disease of the skin and mucous membrane Characterized by vesicles and bullae in which fluid filled blisters are formed.

Oral lesions

Bullae rupture easily and tender on palpitation. Show Nikolsky phenomenon Difffuse erythematous involvement of gingiva.