Post on 07-Apr-2018
8/3/2019 A Note on Diseases Clinically Presenting as Desquamative Gingivitis
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DISEASES CLINICALLY PRESENTING AS
DESQUAMATIVE GINGIVITIS
Lichen PlanusLichen planus is a relatively common, chronic,
dermatosis characterized by the presence of
cutaneous violaceous papules that may
coalesce to form plaques. The current evidence
suggests that lichen planus is an immunologically
mediated mucocutaneous disorder where host T
lymphocytes play a central role . Although the oral
cavity may present lichen planus lesions with a
distinct clinical configuration and distribution, the
clinical presentation sometimes may simulate
other mucocutaneous disorders. Therefore aclinical diagnosis of oral lichen planus should be
accompanied by a broad differential diagnosis.
Numerous epidemiologic studies have shown that
oral lichen planus presents in 0.1% to 4% of the
population." The majority of patients with orallichen planus are middle-aged and older females
with a 2:1 ratio of females to males. Although
possible, children are rarely affected. In a dental
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setting, cutaneous lichen planus is observed in
about one third of the patients diagnosed with oral
lichen planus. In contrast, two thirds of patientsseen in dermatologic clinics exhibit oral lichen
planus.
Oral Lesions
Although there are several clinical forms of oral
lichen planus (reticular, patch, atrophic, erosive
and bullous), the most common are the reticular
and erosive subtypes. The typical reticular lesions
are asymptomatic, bilateral, and consist of
interlacing white lines on the posterior region of
the buccal mucosa. The lateral border and
dorsum of the tongue, hard palate, alveolar ridge,and gingiva may also be affected. In addition, it is
not unusual for the reticular lesions to have an
erythematous background, a feature that is
associated with the coexistence of candidiasis.
Oral lichen planus lesions follow a chronic courseand have alternating, unpredictable periods of
quiescence and flares.
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The erosive subtype of lichen planus is often
associated with pain and clinically manifests as
atrophic, erythematous areas. Fine white radiatingstriations are observed bordering the atrophic
zones. These areas may be sensitive to heat,
acid, and spicy foods.
Gingival Lesions
Up to 10% of patients with oral lichen planus have
lesions restricted to the gingival tissue that may
occur as one or more types of four distinctive
patterns:
1. Keratotic lesions. These raised white lesions
may present as groups of individual papules,
linear or reticulate lesions, or plaquelikeconfigurations.
2. Erosive or ulcerative lesions. These extensive
erythematous areas with a patchy distribution may
present as focal or diffuse hemorrhagic areas.
These lesions are exacerbated by slight trauma(e.g., toothbrushing).
3. Vesicular or bullous lesions. These raised,
fluid-filled lesions are uncommon and short lived
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on the gingiva, quickly rupturing and leaving an
ulceration.
4. Atrophic lesions. Atrophy of the gingival tissueswith ensuing epithelial thinning results in
erythema confined to the gingiva.
Histopathologic, Direct, and Indirect Immunofluorescence Findings in Selected Condition
Disease Histopathology
Direct Immun
Biopsy Perilesional
Mucosa
Pemphigus Intraepithelial clefting
above the basal celllayer. The basal cells
have a characteristic
"tombstone" appear-
ance. Acantholysis ispresent.
Intercellular deposits
in all cases, C3 in mo
Cicatricial
pemphigoid
Subepithelial clefting
with epithelial separation from theunderlying lamina propria, leaving an intact
basal layer.
Linear deposits of
C3, with or withoutIgG at the basement
membrane zone in
almost all cases.
Bullous
pemphigoid
Subepithelial cleftingwith epithelial separa-
tion from the under-
lying lamina propria,leaving an intact basal
layer.
Linear deposits ofC3, with or without
IgG at the basement
membrane zone inalmost all cases.
Epidermolysis
bullosa
acquisita
Similar to bullous and
cicatricial pemphigoid.
Linear deposits of
IgG and C3 at theBasement membrane
cases.
Lichen planus Hyperkeratosis, hydropic degeneration of the
basal layer, "saw-toothed" rete pegs.The lamina propria
exhibits a dense, band-
like infiltrate primarilyof T lymphocytes. Colloid bodies are present.
Fibrilar depositsof fibrin at the
dermal-epiderma
junction.
Chronic Similar to erosive lichen planus
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ulcerative
stomatitis
(hype rkeratosis,
acanthosis, basal celllayer liquefaction, sub-
epithelial clefting, and
lympho-histiocytic
chronic infiltrate in abandlike configuration.
IgG deposits in nucle
epithelial cells.
Linear IgA
disease
Similar to erosive lichen planus. Linear deposits of Ig
membrane zone.
Dermatitis
herpetiformis
Collection of neutro-
phils, eosinophils, and
fibrin in connectivetissue papillae.
IgA deposits in
dermal papillae
in 85% of cases.
Systemic lupus
erythematosus
Hyperkeratosis, basal
cell degeneration,
epithelial atrophy,
and perivascularinflammation.
I g (G or M), with or
at dermal-epidermal
junction.
Chronic cutaneous lupus
erythematosus
Hyperkeratosis, basal
cell degeneration,epithelial atrophy,
and perivascular
inflammation.
Ig (G or M), with or
at dermal-epidermaljunction.
Subacute lupus
erythematosus
Less inflammatory cell
infiltrate than systemic
and chronic cutaneous
lupus erythematosus
but with similarmicroscopic features.
Ig (G or M), with or
at dermal-epidermal
junction in 60% of c
deposits in basal cell
of cases.
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Gingivitis: clinical features. A, Localized, diffuse, intensely red area facial of tooth #7 and
dark pink marginal changes in the remaining anterior teeth. B, Generalized papillary
gingivitis. C, Generalized marginal inflammatory lesion. D, Generalized diffuse inflammatorylesion. E, Papillary gingival enlargement. F, Different degrees of recession. Recession is slight
in teeth #26 and 29 and marked in #27 and 28.Note the irregular contours of the gingiva in #28 and the lack of attached gingiva in #27. G,Insertion of a probe into the gingival sulcus.Note the lack of stippling, the slightly rolled margins, and the dark red color. H, Bleeding
appears about 30 seconds after probing.
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A, Necrotizing ulcerative gingivitis: typical punched out interdental papilla between mandibularcanine and lateral incisor.B,Necrotizing ulcerative gingivitis: typical lesions with progressive
tissue destruction. C, Necrotizing ulcerative gingivitis: typical lesions with spontaneous
hemorrhage.D, Necrotizing ulcerative gingivitis: typical lesions producing irregular gingival
contour.E, Primary herpetic gingivostomatitis: typical diffuse erythema.F, Primary herpetic
gingivostomatitis: vesicles on the gingiva.
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Erosive lichen planus presenting as desquamative gingivitis. The gingival tissues are
erythematous, ulcerated, and painful.
Gingival mucous membrane pemphigoid. Lesions of cicatricial pemphigoid confined to the
gingival tissues, producing a typical desquamative gingivitis appearance.
Pemphigus vulgaris of the gingiva. Clinical appearance of a patient with pemphigus vulgaris
presenting oral lesions confined to the gingiva. The clinical diagnosis was consistent with
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desquamative gingivitis.
Pemphigus vulgaris of the oral cavity. Multiple and coalescent areas of ulceration covered by
necrotic epithelium. This patient presented with large ulcers in the labial mucosa, tongue, andsoft palate.
Chronic ulcerative stomatitis. Erythema and ulceration of the gingiva consistent with a
clinical diagnosis of desquamative gingivitis.
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Linear IgA. Intense erythema and ulceration of the gingiva consistent with desquamative
gingivitis.
Lupus erythematosus of the oral cavity presenting as desquamative gingivitis. Intense
erythema with ulceration bordered by white radial lines.
Plasma cell gingivitis. The gingiva presents a band of moderate to severe inflammation
reminiscent of desquamative gingivitis.
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Graft versus host disease in a recipient of an allogenic bone marrow transplant. The maxillarygingiva exhibits features consistent with desquamative gingivitis.
Wegener's granulomatosis affecting the gingi-val tissues. The classic "strawberry gums"appearance of the mandibular gingiva is seen in this patient. A slight resemblance with
desquamative gingivitis is evident.
Erythema multiforme. Large, shallow, and painful ulcers involving the labial and buccal
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