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Desquamative Gingivitis: Early Presenting Symptom of Mucocutaneous Disease

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Desquamative Gingivitis: Early Presenting Symptom of Mucocutaneous Disease University of Pennsylvania ScholarlyCommons Departmental Papers (Dental) Penn Dental Medicine 2003 Desquamative Gingivitis: Early Presenting Symptom of Mucocutaneous Disease Eric T. Stoopler University of Pennsylvania, [email protected] Thomas P. Sollecito University of Pennsylvania, [email protected] Scott S. DeRossi University of Pennsylvania Follow this and additional works at: https://repository.upenn.edu/dental_papers Part of the Dental Public Health and Education Commons, Oral Biology and Oral Pathology Commons, and the Pathological Conditions, Signs and Symptoms Commons Recommended Citation Stoopler, E. T., Sollecito, T. P., & DeRossi, S. S. (2003). Desquamative Gingivitis: Early Presenting Symptom of Mucocutaneous Disease. Quintessence International, 34 (8), 582-586. Retrieved from https://repository.upenn.edu/dental_papers/40 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/dental_papers/40 For more information, please contact [email protected]. Desquamative Gingivitis: Early Presenting Symptom of Mucocutaneous Disease Abstract Desquamation of the gingiva is a sign that may be encountered in clinical practice. Various diseases can affect the gingival tissues. Mild desquamation that is localized may be associated with mechanical irritation or induced by trauma. Moderate to severe generalized desquamation associated with ulceration and erythema may be indicative of a more serious systemic condition. Although often overlooked, mucocutaneous diseases frequently present with gingival desquamation as an early presenting symptom. The most common mucocutaneous diseases that affect the oral cavity are lichen planus, pemphigus, and mucous membrane pemphigoid. This article reviews the etiology, signs and symptoms, and therapies for these disorders. Increased knowledge of mucocutaneous diseases can help the clinician recognize these disorders and enable the patient to receive appropriate therapy. Keywords desquamative gingivitis, erosive lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, reticular lichen planus Disciplines Dental Public Health and Education | Dentistry | Oral Biology and Oral Pathology | Pathological Conditions, Signs and Symptoms This journal article is available at ScholarlyCommons: https://repository.upenn.edu/dental_papers/40 Desquamative gingivitis: Early presenting symptom of mucocutaneous disease Eric T. Stoopler, DMD'fThomas P. Soll ecito, DMD2/Scott S. DeRossi, DMD' Desquamation of the gingiva is a sign that may be encountered in clinical practice. Various diseases can affect the gingival tissues. Mild desquamation th at is localized may be associated with mechanical irritation or induced by trauma. Moderate to severe generalized desquamation associated with ulceration and ery­ thema may be indicative of a more serious systemic condition. Although chen overlooked, mucocutaneous diseases frequently present with gingival desquamation as an early presenting symptom. The most com­ mon mucocutaneous diseases that affect the oral cavity are lichen planus, pemphigus, and mucous mem­ brane pemphigoid. This article reviews the etiology, signs and symptoms, and therapies for these disor­ ders. Increased knowledge of mucocutaneous diseases can help the clin ician recognize these disorders and enable the patient to receive appropriate therapy. (Quintessence lnt 2003;34:582-586) Key words: desquamative gingivitis, erosive lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, reticular lichen planus ingival tissue can be differentiated based on its may be attributed to mechanical abrasion or irritation. Ganatomic position. The free gingiva comprises the Aggressive toothbrushing or parafunctional habits may gingival tissue at the vestibular and lingual/palatal as­ cause these localized forms of gingival desquamation. pects of the teeth and in health, is coral pink and has Various oral hygiene products may also cause a mild a dull surface and firm consistency.' The attached gin­ superficial peeling of the gingiva. Toothpaste hyper­ giva extends apically from the free gingiva to the sensitivity, especially to tartar-control products, has mucogingival junction, where it becomes contiguous been reported as an etiology of desquamative gingivi­ with the darker red alveolar mucosa. The alveolar mu­ tis.2 The patient should be educated on proper tooth­ cosa is loosely bound to the underlying bone and is brushing techniques and encouraged to discontinue relatively mobile. The attached gi ngiva is firm ly adher­ parafunctional habits if these are the suspected etiolo­ ent to the underlying alveolar bone and in health, is gies. More severe desquamation may be generalized coral pink and often shows a fine, surface stippling, and accompanied by intense erythema and ulcerations giving it the appearance of an orange peel. ' on the free and attached gingiva, as well as the alveo­ Desquamation or peeling of the epithelial tissue lar mucosa. When local factors cannot be attributed to usually occurs mainly on the free and attached gin­ the etiology of the desquamation, systemic conditions giva. Mild cases that are localized and display minimal must be considered. Three common mucocutaneous loss of tissue with mild erythema and no ulceration diseases that can present with initial symptoms of desquamative gingivitis (peeling of the gi ngival tissue usually accompanied by erythema, ulceration, and pain) are lichen planus, pemphigus, and mucous mem­ 1Assistant Professor, Department of Oral Medtcme, University of brane pemphigoid. These conditions are immune me­ Pennsytvama School of Dental Medic ine, Phtladelphta, Pennsylvania. diated and are managed via topical and/or systemic ZAssociate Professor, Department of Oral Medtcine, University of medications. Knowledge of the etiology, signs and Pennsytvanta School of Dental Med!Ctne, Phtladelptua, Pennsytvama. symptoms, and therapies for these diseases will enable Reprint requests: Dr Enc T. Stoopler. Department of Oral Medicme. umverstty ol Pennsylvanta School of Dental Medte•ne. 240 South 401h the clinician to more effectively recognize and diag­ Slreet. Philadelphia, PA 19104. E· mail: etsOpobox.upenn.edu nose these conditions. 582 Volume 34. Number 8, 2003 ------------------------- - ----------- Stoopleret al - - LICHEN PLANUS Lichen planu s (LP) is a relatively common dermato­ logic disorder that occurs on the skin and oral mucous membranes. There are several forms of this disease, in­ cluding reticular, papular, atrophic, bullous, and ero­ sive patterns. This discussion will focus on the reticu­ lar and erosive forms of LP. The reticular form of LP is the most common and most readily recognized form of the disease. It consists of slightly elevated. fine, whitish lines (Wickham's striae) that produce a lacelike lesion.' Reticular LP is most commonly seen bilaterally on the cheeks and is usually asymptomatic requiring no treatment. Fig 1 Generalized desquamation and erythema in the maxillary Erosive LP presents as chronic multiple oral mu­ and mandibular ging1vae of a pat1ent d1agnosed with erosive cosal ulcers. A significant number of cases of erosive lichen planus LP presents with an initial sign of erythema and/ or desquamative gingivitis' Figure 1 demonstrates gener­ alized desquamative gingivitis in a patient diagnosed with erosive LP. In some cases, the lesions start as vesicles or bullae (bullous LP), and in others, the dis­ Treatment of LP/ lichenoid reactions can be wide ease is characterized solely by erythema or ulcers (ero­ ranging. If the patient has been using navori ng agents, sive LP). The etiology of LP is idiopathic, which distin­ they should be advised to discontinue the use of such guishes itself from lichenoid reactions. Li chenoid products. If the patient has started a new medication reactions have a similar clinical presentation to LP but that correlates to the onset of LP, they should discuss are differentiated on the basis of the association of the changing classes of medication with their physician. reactions \vith administration of a drug, systemic dis­ The erosive type of LP should be managed more ag­ ease, or contact allergy, and they may slowly resolve gressively with the use of high potency (fluocinonide) when the allergen is discontinued or the disease is and ultra high potency (clobetasol) topical steroid treated. Drugs that have been reported to induce gels. These agents may be placed in an occlusive den­ lichenoid reactions are penicillamine, ACE inhibitors, tal splint that covers the affected area of the gi ngiva to and nonsteroidal anti-inflammatory drugs (NSA!Ds), increase healing time and decrease pain. Topical although, less commonly, numerous other drugs have steroid rinses and topical steroids applied to gauze been implicated.' Contact allergens such as cinnamon pads are other methods of administering medication. and peppermint, as well as mercury and gold in select Intralesional steroid injections may be necessary to d ental ma te rials have been reported to cause a treat lesions that are recalcitrant to conventional ther­ lichenoid reaction due to contact allergy.' Hepatitis C apy; however, this may be difficult for gingival lesions. is a systemic condition that has been implicated with A short course of systemic steroids may be considered induction of LP-Iike lesions• for extremely indolent lesions• Recently, several re­ The diagnosis of LP and lichenoid reactions is ports have been published regarding the use of topical made by biopsy. Three characteristic features of LP are tacrolimus
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