A Note on Diseases Clinically Presenting as Desquamative Gingivitis

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.
http://4.bp.blogspot.com/-nUlRv1qBL1E/TqS0KbpG0MI/AAAAAAAABBI/2sthAaIedeU/s1600/Gingivitis+clinical+features.jpghttp://4.bp.blogspot.com/-nUlRv1qBL1E/TqS0KbpG0MI/AAAAAAAABBI/2sthAaIedeU/s1600/Gingivitis+clinical+features.jpg


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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.
http://1.bp.blogspot.com/-u2vgJisCcnI/TqSz508LwnI/AAAAAAAAA_o/f0Tzw1SdGn4/s1600/Chronic+ulcerative+stomatitis.jpghttp://3.bp.blogspot.com/-DUedOX2ao60/TqS0GsoKbNI/AAAAAAAABAw/BHrJlMb8h2w/s1600/Pemphigus+vulgaris+of+the+oral+cavity.jpghttp://1.bp.blogspot.com/-u2vgJisCcnI/TqSz508LwnI/AAAAAAAAA_o/f0Tzw1SdGn4/s1600/Chronic+ulcerative+stomatitis.jpghttp://3.bp.blogspot.com/-DUedOX2ao60/TqS0GsoKbNI/AAAAAAAABAw/BHrJlMb8h2w/s1600/Pemphigus+vulgaris+of+the+oral+cavity.jpg


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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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A Note on Diseases Clinically Presenting as Desquamative Gingivitis

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