desquamative gingivitis

1. Dr Jaffar Raza Syed Page 1
Desquamative gingivitis

2. 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 features
mild, 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 pittingon pressure.
•Nicolsky’s sign +ve
•Remainder of the mucosa
is also extremely smooth
and shiny.
Age: 30 – 40 years.
C/o of burningsensation
and sensitivity to thermal
changes.
C. Severe form
•Scattered, irregularly
shaped areas -strikingred
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’s
sign)
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

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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 arrangement
forming 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
malnutrition
infection
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.

18. 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

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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
bullae
Rupture of bullae leads to extensive
areas of ulceration
Any area of oral cavity involved-
Oral lesions confine less often to
gingival tissues

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Histopathology
Sub epithelial clefting with epithelial separation f
basal 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.

29. 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.

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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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