desquamative gingivitis.ppt in periodontal dentistry

desquamative gingivitis.ppt in periodontal dentistry

1. DESQUAMATIVE DESQUAMATIVE
GINGIVITISGINGIVITIS

2. DESQUAMATIVE GINGIVITISDESQUAMATIVE GINGIVITIS
The term was coined by The term was coined by Prinz Prinz in 1932 to in 1932 to
describe a peculiar condition characterized describe a peculiar condition characterized
by intense erythema , desquamation and by intense erythema , desquamation and
ulceration of the free and attached gingiva.ulceration of the free and attached gingiva.

3. 
Desquamative gingivitis is a clinical Desquamative gingivitis is a clinical
term that describes a certain clinical term that describes a certain clinical
picture. picture.

It is notIt is not a diagnosis per se, but a a diagnosis per se, but a
gingival response associated with a gingival response associated with a
variety of condition variety of condition

4. The cause was unclear with a variety of The cause was unclear with a variety of
possibilities suggested :possibilities suggested :

Dermatologic genesisDermatologic genesis

Hormonal derangementHormonal derangement

Chronic bacterial , fungal and viral Chronic bacterial , fungal and viral
infectionsinfections

Reaction to medications , mouthwashes Reaction to medications , mouthwashes
and chewing gums.and chewing gums.

CrohnCrohn’’s disease , sarcoidosis some s disease , sarcoidosis some
leukamiasleukamias

5. DESQUAMATIVE GINGIVITISDESQUAMATIVE GINGIVITIS

Most cases were diagnosed in women Most cases were diagnosed in women
in the fourth to fifth decades of life and in the fourth to fifth decades of life and
hormonal derangement was suspectedhormonal derangement was suspected

6. Clinical features :Clinical features :
 Red, friable gingiva
Painful, desquamates easily
Buccal aspect of anterior attached
gingiva affected
Marginal gingiva spared
Not significantly improved by oral
hygiene measures alone

12. Diagnosis of desquamative Diagnosis of desquamative
gingivitisgingivitis: :

13. 
A systematic approach should be used A systematic approach should be used
to diagnose diseases that trigger to diagnose diseases that trigger
desquamative gingivitis.desquamative gingivitis.

14. Thorough clinical historyThorough clinical history

15. (1)Clinical history :(1)Clinical history :

History of present illnessHistory of present illness

Previous therapy Previous therapy

16. (2)Clinical examination :(2)Clinical examination :

Distribution of the lesion.Distribution of the lesion.

NikolskyNikolsky’’s sign(stripping of the s sign(stripping of the
epithelium when sliding pressure epithelium when sliding pressure
applied)applied)

18. 3/Biopsy3/Biopsy

An incisional biopsy for microscopic An incisional biopsy for microscopic
and immunologic evaluation should and immunologic evaluation should
be performed.be performed.
1.1.Light microscopic examination.Light microscopic examination.
2.2.Immunofluorescence techniques:Immunofluorescence techniques:
a)a)Direct.Direct.
b)b)Indirect.Indirect.

19. Biopsy :Biopsy :
(i)(i)A perilesional incisional biopsy.A perilesional incisional biopsy.
(ii) Uninvolved incisional biopsy .(ii) Uninvolved incisional biopsy .
An incisional biopsy of uninvolved lesion will An incisional biopsy of uninvolved lesion will
show the same immunofluorescence show the same immunofluorescence
findings as the biopsy from the perilesional findings as the biopsy from the perilesional
tissue except :tissue except :
1.1.Lichen planusLichen planus
2.2.Subacute lupus erythematosusSubacute lupus erythematosus
The specimen should be bisected and fixed by The specimen should be bisected and fixed by
buffered formalin for conventional (H&E) buffered formalin for conventional (H&E)
evaluation. Or transport by Michellevaluation. Or transport by Michell’’s s
buffer(ammonium sulfate buffer pH 7.0)buffer(ammonium sulfate buffer pH 7.0)

20. Immunofuorescence tests are positive Immunofuorescence tests are positive
if a fluorescent signal is observed either if a fluorescent signal is observed either
in the :in the :

EpitheliumEpithelium

Its associated basementmembraneIts associated basementmembrane

Underlying C.T Underlying C.T

21. (4) Management :(4) Management :
Depend on 3 factors :Depend on 3 factors :
1.1.PractitionerPractitioner’’s experience .s experience .
2.2.Systemic impact of the disease .Systemic impact of the disease .
3.3.Systemic complications of the Systemic complications of the
medications medications
Putting these factors into consideration one Putting these factors into consideration one
of three different scenarios should occur: of three different scenarios should occur:

22. 1.1.The dentist takes direct and exclusive The dentist takes direct and exclusive
responsibility for the treatment of the responsibility for the treatment of the
patient e.g. erosive lichen planus. patient e.g. erosive lichen planus.
2.2.The dentist collaborates with a The dentist collaborates with a
medical doctor to evaluate and treat medical doctor to evaluate and treat
the patient e.g. mucous membrane the patient e.g. mucous membrane
pemphigoid.pemphigoid.

23. 
The patient is immediately referred to a The patient is immediately referred to a
dermatologist for evaluation and dermatologist for evaluation and
treatment e.g. pemphigus vulgaris or treatment e.g. pemphigus vulgaris or
non responsive mucous membrane non responsive mucous membrane
pemphigoid.pemphigoid.

24. Diseases clinically presenting as Diseases clinically presenting as
desquamative gingivitis :desquamative gingivitis :
1.1.Lichen Planus .Lichen Planus .
2.2.Pemphigoid .Pemphigoid .
3.3.Pemphigus Vulgaris .Pemphigus Vulgaris .
4.4.Chronic Ulcerative Stomatitis .Chronic Ulcerative Stomatitis .
5.5.Linear IgA disease ( Linear IgA Linear IgA disease ( Linear IgA
Dermatosis ).Dermatosis ).
6.6.Dermatitis Herpetiformis .Dermatitis Herpetiformis .
7.7.Lupus Erythematosus . Lupus Erythematosus .
8.8.Erythema Multiforme . Erythema Multiforme .

25. Immune-mediated blistering
diseases
Intra-epithelial
Pemphigus
Subepithelial
Pemphigoid
Linear IgA disease
Dermatitis herpetiformis
Epidermolysis bullosa
Erythema multiforme

26. Vesicles And BullaeVesicles And Bullae

28. Lichen PlanusLichen Planus

30. 
It is a common chronic inflammatory It is a common chronic inflammatory
disease of the skin and mucous disease of the skin and mucous
membranes including the oral cavity membranes including the oral cavity
and of unknown etiology.and of unknown etiology.

It is suggested that lichen planus is a T- It is suggested that lichen planus is a T-
cell mediated auto immune disease in cell mediated auto immune disease in
which autocytotoxic CD8 T- which autocytotoxic CD8 T-
lymphocytes trigger apoptosis of oral lymphocytes trigger apoptosis of oral
epithelial cells.epithelial cells.

31. Lichen PlanusLichen Planus
Gingival / oral Lichen Planus :Gingival / oral Lichen Planus :
Clinical features :Clinical features :
It is more common in middle-aged to elderly
females.
Several forms of OLP are described
intraorally;
reticular,
papular,
plaque-like,
atrophic,
bullous and erosive forms.
( reticular and erosive forms are the most
common forms ) .

33. Nail involvementNail involvement

34. Atrophic Lichen PlanusAtrophic Lichen Planus

35. Bullous Erosive Lichen PlanusBullous Erosive Lichen Planus

36. Reticular LPReticular LP

39. DiagnosisDiagnosis

40. 
Can be performed clinically with presentation Can be performed clinically with presentation
of bilateral white patches with or without of bilateral white patches with or without
erosions and skin or nail involvement.erosions and skin or nail involvement.

It is confirmed with a biopsy and use of It is confirmed with a biopsy and use of
immunofluorescent techniques.immunofluorescent techniques.

41. 
In DIF a linear or shaggy deposit of In DIF a linear or shaggy deposit of
fibrin or fibrinogen is observed at the fibrin or fibrinogen is observed at the
basement membrane.basement membrane.

IIF is –ve in lichen planus but DNA test IIF is –ve in lichen planus but DNA test
may show titer
↑
may show titer
↑

42. Treatment of OLP :Treatment of OLP :
 high-potency topical steriods ( for example high-potency topical steriods ( for example
0.05 % fluocinonide ointment applied to the 0.05 % fluocinonide ointment applied to the
lesion 3 times daily ). lesion 3 times daily ). Vacuum formed custom
trays or gingival veneers can be constructed
to achieve this
 alternatively systemic steroids like alternatively systemic steroids like
prednisolone 40 mg daily for 5 days followed prednisolone 40 mg daily for 5 days followed
by 10-20 mg daily for 2 weeks .by 10-20 mg daily for 2 weeks .
 antifungal ( bc candiasis is associated with antifungal ( bc candiasis is associated with
symptomatic LP ) .symptomatic LP ) .

47. pemphigoidpemphigoid
the term is applied to a number of the term is applied to a number of
cutaneous , immune mediated , cutaneous , immune mediated ,
subepithelial bullous diseases that are subepithelial bullous diseases that are
characterized by a seperation of the characterized by a seperation of the
basement membrane zone :basement membrane zone :

bullous pemphigoid .bullous pemphigoid .

mucous membrane pemphigoid .mucous membrane pemphigoid .

pemphigoid herpes gestations .pemphigoid herpes gestations .

48. Mucous Membrane Pemphigoid Mucous Membrane Pemphigoid
( Cicatricial Pemphigoid ) ( Cicatricial Pemphigoid )

Unknown cause.Unknown cause.

Predominantly affect women in the fifth Predominantly affect women in the fifth
decade .decade .

Involve the oral cavity , conjunctiva and Involve the oral cavity , conjunctiva and
the mucosa of the nose , vagina , the mucosa of the nose , vagina ,
rectum and urethra .rectum and urethra .

51. ComplicationsComplications
1.1.Blindness.Blindness.
2.2.Hoarseness.Hoarseness.
3.3.Esophageal stenosis.Esophageal stenosis.
4.4.Upper airway obstructionUpper airway obstruction

52. PemphigusPemphigus
Pemphigus is one of the very few
potentially fatal mucocutaneous
diseases characterized by intraepithelial
bullous formation.

54. Erythema MultiformeErythema Multiforme

55. 
It is an acute bullous or macular It is an acute bullous or macular
mucocutaneous self limiting disease mucocutaneous self limiting disease
which has a wide range of clinical which has a wide range of clinical
manifestations.manifestations.

56. 
Pathogenesis is unknown, but it is Pathogenesis is unknown, but it is
suggested that the disease is a suggested that the disease is a
hypersensitivity reaction hypersensitivity reaction and the and the
manifestations are related to the manifestations are related to the
deposition of deposition of immune complexes immune complexes in in
which antigens may be of drug*, which antigens may be of drug*,
bacterial or viral origin. Other causes can bacterial or viral origin. Other causes can
be mechanical* or physical*. be mechanical* or physical*.

57. ClinicalClinical FeaturesFeatures

58. 
It occurs in teenagers and young adults It occurs in teenagers and young adults
and it is more common in males and and it is more common in males and
20% of cases in children.20% of cases in children.

It can be mild (erythema multiform It can be mild (erythema multiform
minor) or severe (erythema multiform minor) or severe (erythema multiform
major and or Stevens-Johnson major and or Stevens-Johnson
Syndrome*).Syndrome*).

59. 
Mild form involves skin lesions and Mild form involves skin lesions and
minor or no mucosal lesions. It may minor or no mucosal lesions. It may
present as a mild non specific upper present as a mild non specific upper
respiratory tract infection. Rash may respiratory tract infection. Rash may
appear within 3 days on the extremities, appear within 3 days on the extremities,
and it tends to subside in 10 - 14 days. and it tends to subside in 10 - 14 days.

62. Treatment :Treatment :

systemic corticosteroids (tapering of systemic corticosteroids (tapering of
the medication is done as soon as the medication is done as soon as
possible to minimize its side effects ).possible to minimize its side effects ).
.

63. Other Conditions Resembling Other Conditions Resembling
Desquamative gingivitisDesquamative gingivitis
1.1.Candidiasis.Candidiasis.
2.2.Wegner’s Granulomatosis.Wegner’s Granulomatosis.
3.3.Foreign body gingivitis.Foreign body gingivitis.
4.4.Squamous cell carcinoma.Squamous cell carcinoma.
5.5.Graft versus host disease.Graft versus host disease.

64. Thanks for your attentionThanks for your attention