Chief complaint & History of present illness

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1. Case report 32 years-old female patient from mangalore Complains of burning sensation of her gums Duration : 4 months www.indiandentalacademy.com INDIAN DENTAL ACADEMY Leader in continuing Dental Education

2. Chief complaint & History of present illness Small boil like formation on the gums Boils appears whenever she bites on hard food Bleeding while brushing No difficulty in swallowing & speaking No history of itching No such lesions on other parts of the body No history of systemic symptoms Past medical/dental/family history General physical examination- NAD www.indiandentalacademy.com

3. Local examination of the lesion Extra oral examination Inspection Palpation www.indiandentalacademy.com

4. Local examination of gingiva Intra oral examination Local examination of gingiva Inspection Palpation www.indiandentalacademy.com

5. Local examination of gingiva Intra oral examination Inspection Palpation www.indiandentalacademy.com

6. Chair side investigation Nikolsk’y sign = - ve Differential diagnosis Mucous membrane pemphigoid Pemphigus vulgaris Investigations Cytological Incisional biopsy www.indiandentalacademy.com

7. Histological results Cytological smears H/F www.indiandentalacademy.com

8. Final diagnosis Mucous membrane pemphigoid Chronic generalized gingivitis Dental caries- 16, 26 Partially edentulous area in relation to - 15, 25 Treatment plan Treatment for Mucous membrane pemphigoid Oral prophylaxis Restoration of 16, 26 Prosthetic rehabilitation i.r.t 15, 25 www.indiandentalacademy.com

9. Discussion Mucous membrane pemphigoid Rare chronic blistering autoimmune diseases Etiology & pathogenesis The autoantibodies directed against protiens in the BMZ autoantibodies activate complement that attracts neutrophils. The release of proteolytic enzymes from neutrophils causes lysis of cells, detachment of the basal cells from the BMZ resulting in the subepithelial clefting at the lower lamina lucida and lamina densa levels. www.indiandentalacademy.com

10. C/F Age sex Oral manifestations Eye Skin lesions Laryngeal involvement, esophagus www.indiandentalacademy.com

11. Histopathology & Direct Immunofluorescence www.indiandentalacademy.com

12. D/D Pemphigus vulgaris Erosive lichen planus Erythema multiforme www.indiandentalacademy.com

13. Treatment severity of symptoms , site & progression low-risk patients ( oral mucosa and/or skin only) Topical corticosteroids and intralesional steroid injections Tetracycline 1-2g/day and Nicotinamide 2-2.5g/day. Therapy with dapsone (25-200mg/day) may be initiated if poor response is seen to topical steroids low doses of prednisone (0.5 mg/kg per day), with or without azathioprine (100 mg/day) If severe oral disease, high doses of prednisone are required, with or without immunosuppressor (lópez-jornet p, bermejo-fenoll A. Treatment of pemphigus and pemphigoids -med oral patol oral cir bucal 2005;10:410-411) www.indiandentalacademy.com

14. High risk patients. ocular, genital, esophageal and nasopharyngeal location. rapid progression. Prednisone 1-1.5mg/kg/day and cyclophosphamide (1-2mg/kg/day), also intravenously. If cyclophosphamide is not tolerated, azathioprine is used (1-2mg/kg/day). Immunoglobulin: intravenous (therapy resistant, ocular disease). Plasmapheresis has also been effective in some patients. For serious ocular disease - subconjunctival mitomycin. First International Consensus on Mucous Membrane Pemphigoid, Arch Dermatol 2002;138:370-9 www.indiandentalacademy.com

15. The treatment follow up sequel of our case Application of Triamcinolone acetonide 0.1% ( kenacort) 1-1-1-1 for 7 days 2nd week - Prednisone (Wysolone)50mg (OD) was prescribed for 2 weeks along with the local application of kenacort. B.P= 120/80mmhg. FBS = 92mg/dl www.indiandentalacademy.com

16. Follow up 4 th week Eroded areas were seen in the labial aspect of the upper right gingival area in close proximity to 15,14,13 & one fresh vesicle was seen on the gingiva in the anterior lingual area of the lower arch www.indiandentalacademy.com

17. 6 th weeks - Erythematous areas reduced, 1 new ruptured vesicle on forehead region. Same medications continued Review of blood sugar & blood pressure B.P= 110/70mmhg. FBS = 173mg/dl www.indiandentalacademy.com

18. 7 th week Erythematous areas had reduced in size. Dosage was tapered to 30mg (OD) www.indiandentalacademy.com

19. 9 th week B.P was 100/60mmhg & blood sugar was 98mg/dl. Small generalized eroded areas were seen on the lingual aspect of the gingiva www.indiandentalacademy.com

20. 12 th week - Oral lesions had reduced. The patient complained of severe giddiness & body ache. She had developed edema in her face & in her body . B.P= 100/60, FBS = 96/dl. Prednisone dosage is reduced to 20mg/day www.indiandentalacademy.com

21. 14th week - On examinations oral lesions had healed. Drug dosage was again reduced to 10mg/day www.indiandentalacademy.com

22. 17 th week – Few eroded areas were seen on the lingual gingival area of the lower arch near 44 & 45 region & also fresh vesicle had erupted on the right side of the cheek. Prednisone 10mg , Tetracycline (Restaclin)250mg as a mouth rinse, Triamcinolone acetonide ( Tess cream) & clobetasol propionate ( Tenovate cream) twice daily for the skin lesion for 15 days www.indiandentalacademy.com

23. 19 th week www.indiandentalacademy.com

24. 21 st week - Patient reported with new lesions, drug dosage was increased to 20mg/day for 15 days www.indiandentalacademy.com

25. 23 rd week - Lesions had not healed Cyclophosphamide (Endoxan50mg) (BID) for 1 month along with 20mg Wysolone (OD)& rantac150mg (BID). www.indiandentalacademy.com

26. 27 th week - lesions got healed & side effects of corticosteroides had subsided. www.indiandentalacademy.com

27. Conclusion www.indiandentalacademy.com

28. Its not enough that we do our best; some times we have to do what’s required . Sir Winston Churchill Thank you www.indiandentalacademy.com