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Desquamative Gingivitis: a Clinical, Histopathoiogic, and Immunologie Study

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Desquamative Gingivitis: a Clinical, Histopathoiogic, and Immunologie Study Periodontics Desquamative gingivitis: A clinical, histopathoiogic, and immunologie study A- K.. Markopoulos*/D. Antoniades*/P. Papanayotou*/G. Trigonidis* Abstract Desquamative gingivitis is believed to be a clinical sign of certain mucocutaneous diseases rather than a distinct pathologic entity. The prevalence of desquamative gingivitis was studied in a group of patients with the most common mucocutaneous diseases. Of 414 patients with pemphigus vulgaris. mucous membrane pemphigoid, or oral lichen planus. 49 (¡1.8%) exhibited gingival lesions in the form of desquamative gingivitis. Desquamative gingivitis was most prevalent in the patients with mucous membrane pemphigoid (41.6%) followed by those with pemphigus vulgaris (9.1%). Other elinieal characteristics, as well as histo- pathoiogic and imtnunohistochemical findings, that aid in early diagnosis are presented. (Quintessence Int ¡996:27:763-767.') Clinical relevance and is edematous. Tbe epithelium is quite friable and can be removed easily from the underlying connective Desquamative gingivitis, in most cases, represents a tissue, leaving a red surface that bleeds readily after manifestation of systemic diseases. Because it has no minimal trauma. Other gingival sites, such as palatal specific clinical pathognomonic features, laboratory and lingual surfaces, are rarely involved,"* aids, such as histopathoiogic and immunohistochem- The etiology of DG remains obscure. Early investi- ical examination, should be used to unmask the gators believed that there was a single cause. McCarthy underlying disease so that the appropriate treatment et al^ were among the first who proposed that DG is a can be provided. nonspecific reaction pattern that can be associated with any one of several diseases or conditions. This group suggested that dermatologie diseases, hormonal factors, aging, metabolic disturbances, irdtational factors, and chronic infections could cause DG, Introduction However, in recent years, it has been shown that the great majority (approximateiy 75%) of cases of DG are Desquamative gingivitis (DG) is characterized by manifestations of mucocutaneous diseases, primarily erythematous and desquamative lesions of the free and mucous membrane pemphigoid (MMP), oral lichen attached gingiva. The condition was first described by planus (OLP), and pemphigus vulgaris (PV).'''^"''' Tomes and Tomes' in 1894 and was further defined In the present investigation, the prevalence of DG several years later by Prinz^ and Merrit,^ who pro- was retrospectively studied in a large group of patients posed the term chronic diffuse desquamative gingivitis. with these mucocutaneous diseases. Furthermore the UsuaUy the changes are confined to the labial clinical, histopathoiogic, and immunologie features in gingival mueosa, which varies from bright to dark red each disease group were analyzed. ' Department of Oral Medicine and Pathology, Aristotle University of Thessaloniki, School of Dentistry, Thessaloniki, Greece. Method and materials Reprint requests: Dr A. K. Markopoulos, Department of Oral Medicine The records of all patients with PV, MMP, and OLP and Pathology, Aristotle University ofThessaloniki, School of Dentistry, Thessaloniki 54006, Greece. who were seen during the period from Januari' 1983 to Quintessence Intemalional Volume 27, Number 11/1996 763 Markopoulos et al Fig 1 Desquamalive gingivitis in a palien! with pemphigus. Fig 2 Desquamalive gingivitis in a patient with mucous Areas oí erosion are seen. membrane pemphigoid. were acantholysis and intraepithelial ciefting forma- tion for PV; subepithelial bulla formation for MMP; and hydropic degeneration of the basal layer of the epithelium with bandiike lymphocytic infiltration of the upper lamina propria for OLP. The immunohistochemical slides had been stained with a streptavidin-biotin immunoperoxidase tech- nique using polycional antibodies for the demonstra- tion of immunoglobulin G (IgG), immunoglobulin A (IgA), immunoglobulin M (IgM). and complement (C3) on paraffin-embedded tissues (Immunostain Diagnostic Products, Lianbaris), Direct immuno- fluorescence had also been performed on fresh tissues Fig 3 Desquamalive gingivitis in a patient wiih oral lichen for the demonstration of fibrin-fibrinogen. The major planus. immunologie criteria that we used were the following; intercellular deposition of IgG and IgA at the epithe- lial surface for PV; deposition of IgG and IgA in the linear basement membrane for MMP; nonspecific January 1993 in the Oral Medicine Clinic were immunohistochemical staining of IgG and IgA for retrieved from the files ofthe Oral Pathology Depart- OLP; and deposition of IgM and fibrin-fibrinogen for ment. A total of 414 cases were studied. Each file was OLP. examined carefully for documentation of DG, The final diagnosis was established on the basis of clinical, histopathologic, and immunohistochemical criteria. Results From the clinical point of view, only t>pical patients with severe lesions were included in the study. Typical An interim clinical diagnosis ofthe underlying disease patients were considered to be those presenting with in DG patients was based on the presence of erythema- bright to dark red, edematous, and friable gingival tous and friable gingival mucosa or on the occasional mucosa, Tlie patients were subjected to careflii phy- presence of accompanying clinical matufestations of sical examination, including slit-lamp examination, each disease in other sites of the oral mucosa; the laryngoscopy, and examination of the ear canal, presence of vesiculoerosive lesions and Nikolsky's anogenital area, and skin. sign, which are indicative of PV and MMP, or the The histologie slides were stained with hematoxylin presence of laceiike white lesions combined with and eosin. The major criteria for the histopathologic erosions or atrophie mucosa, which are suggestive of diagnosis of each mucocutaneous disease category erosive or atrophie OLP. 764 Quintessence International Volume 27, Number 11/1996 Markopoulos et al Table ! Prevalence of desquamative gingivitis (DG) in 414 patients with mucosal disease No. of patients Patients Mean age of with mucosal Underlying No. of witb DG Male Female patients with lesions in other disease patients No. (%) No, (%) No. (%) DG oral sites Pemphigus vulgaris 33 3 ( 9.1) 1 (33.3) 2 (66.7) 37.7 y 1 Mucous membrane pemphigoid 53 22 ( 41.6) 4 (18.2) 18 (81,8) 55,1 y 8 Oral lichen plan us 326 22 { 6.8) 6 (27.3) 16 (72,7) 50,0 y 12 Idiopathic 2 2 (100,0) 1 (50,0) 1 (50.0) 45.4 y 0 Total 414 49 ( 11.8) 11 (23.4) 36 (76.6) 47.1 y 21 Tabie 2 Immunohistochemical findings in biopsy specimens taken from patients with desquamative gingivitis Streptavidin-biotin immunoperoxidase staining Direct immunoñuorescence Positive Neinative for fibrinogen Und e dying No. of disease patients IgG IgA IgM C3 IgG IgA IgM C3 Positive Negative Pemphigus vulgaris 3 3 3 1 3 2 Mucous membrane pemphigoid 22 17 16 4 16 5 6 18 6 Oral lichen planus 22 10 22 22 12 22 19 3 Idiopathic 2 2 2 2 2 'Nol performed. The DG lesions were confined to the labial gingiva, MMP were found positive for IgG and IgA to a lesser which appeared bright to dark red and edematous extent (17 of 22 patients). In contrast all patients with (Figs 1 to 3). Accompanying lesions were found OLP were negative for IgG and IgA. and some were mainly in patients with OLP (12 of 22) (Table 1). posirive for IgM and fibrin-fibrinogen. The idiopathic Thorough physical examination ofthe patients did not cases were negative in all the immunohistochemical reveal any extraora! manifestations. Pain was a pre- stainings that were performed. The immunohistochem- dominant symptom in many patients, while the pre- ical findings are illustrated in Figs 4 to 6. sence of local factors, such as plaque or dental Table 1 reveals that the majority of parients with DG calculus, was evident in the majority of patients in each have MMP (41.6%). while 9.1% and 6,8% have PVand group. OLP, respectively. The great majority ofthe patients in On the basis of histopathologic and immunohisto- all disease groups were female. chemical examination the 49 DG patients were divided into four categories; Py MMP. OLP, and Discussion idiopathic cases. Histopathologicaily. 47 patients ful- filled the classic criteria for PV, MMP, or OLP (Table The clinical appearance of DG is not pathognomonic. 2). Two parients did not manifest specific microscopi- Therefore, supplementary procedures, such as histo- cally pathognomonic features, and therefore their pathologic examination and immunohistochemical cases were considered idiopathic. All the patients with tests of gingival biopsy specimens, are necessary for a PV were positive for IgG and IgA. while parients with definitive diagnosis. In the present study, one of the Quintessence Intemational Volume 27, Number 11/1996 765 Markopouios et ai Fig 4 Desquamative gingivitis m pemphigus. Intercellular Fig 5 Desquamative gingivifis in mucous membrane pem- deposition ol igG is apparent (Streptavidin-biotin staining, phigoid. The linear basemenf membrane exhibifs deposits originai magnification x480.1 of IgG (Sfreptavidin-biotin sfaining; originai magnificafion epithelium after mild rubbing with a cotton tip) was positive in these lesions. The lowest prevalence of DG( 6.8%) was counted in the OLP group. Erosive or atrophie lesions accom- panied the gingivai desquamation in 12 of 22 patients, suggesting that erosive and atrophie forms are the most common forms of OLP to be the underlying disease in DG, Similar findings have been repotied by Daniels
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