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on Jan 13, 2012 Says :
I found it very useful since it is common problem.
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DESQUAMATIVE GINGIVITIS PRESENTED BY- SHAHIN UGHRADAR B.D.S. FINAL YEAR
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INTRODUCTION Earlier it was described as a peculiar condition characterized by intense erythema, desquamation, and ulceration of free and attached gingiva. Desquamative gingivitis involves not only the marginal gingiva as in most cases of gingivitis, but it also peels off the attached gingival in a band like fashion. Use of clinical and laboratory parameter have revealed that approximately 75% of desquamative gingivitis cases have a dermatologic genesis.
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Cicatricial pemphigoid and lichen planus accounts for more than 95% of cases. Many other mucocutaneous auto immune condition can clinically manifest as desquamative gingivitis such as: Bullous pemphigoid. Phemphigous vulgaris Linear IgA disease Dermatitis herpetiformis Lupus erythematous Chronic ulcerative stomatitis
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Chronic bacterial, viral and fungal infections, reactions to medication, mouthwashes and chewing gums and less commonly crohn’s disease, sarcoidosis and leukemias have also been reported to present clinically as DESQUAMATIVE GINGIVITIS. Thus the identity of the disease responsible for desquamative gingivitis is necessary for appropriate therapeutic approach and management.
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DIAGNOSIS OF DESQUAMATIVE GINGIVITIS: Following parameters are necessary for establishing the diagnosis of the disease. CLINICAL HISTORY: A thorough clinical history is mandatory to begin assessment of the disease. Data regarding symptomatology associated with the condition as well as historical aspect; i.e when did the lesion start? Has it worsened? Is there any habit that worsened the condition? Information regarding previous therapy should also be collected.
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CLINICAL FEATURES: Clinical features vary in severity as mild, moderate and severe form: MILD FORM: Manifested as diffuse erythema of the free, attached and interdental gingiva. Usually painless and occurs most frequently in females of age between 17-23 yrs of age.
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MODERATE FORM: Patchy distribution of bright red and grey areas involving marginal and attached gingiva. Surface is smooth, shiny. Gingiva becomes soft, edematous and massaging of gingiva leads to peeling off the epithelium. Seen in age groups of 30-40 yrs. Patient complains of burning sensation.
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SEVERE FORM: Characterized by scattered irregularly shaped areas in which the gingiva is denuded and strikingly red in appearance. Gingival seems to be speckled and surface epithelium seems to be shredded, friable and can be peeled off in small patches. Condition is painful. There is constant dry burning sensation throughout the oral cavity.
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Diseases clinically presenting as Desquamative Gingivitis. LICHEN PLANUS: bilateral white striae purple pruritic papule seen in middle age buccal mucosa most commonly affected
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HISTOPATHOLOGY: hyperkeratosis. hydropic degeneration of basal cell layer. saw toothed rete pegs. colloid bodies present. lamina propria exhibit band like infiltration of T- lymphocytes.
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CICATRICIAL PEMPHIGOID: multiple painful ulcers preceded by bullae. positive nikolsky’s sign middle aged or elderly women most commonly affected. may affect mucous membrane of oral cavity and eyes . HISTOPATHOLOGY: Sub epithelial clefting with epithelial separation from lamina propria leaving an intact basal layer.
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BULLOUS PEMPHIGOID: skin disease with infrequent oral lesion. ulcers preceded by bullae. no scarring. seen in elderly persons. HISTOPATHOLOGY: Sub epithelial clefting with epithelial sepration from lamina propria leaving an intact basal layer.
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PEMPHIGUS VULGARIS: multiple painful ulcers preceded by bullae. middle aged patients commonly effected. positive Nikolsky’s sign. it is a progressive disease. HISTOPATHOLOGY: intra epithelial clefting above the basal layer. “Tombstone” appearance of basal cell layer. acantholysis present.
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DERMATITIS HERPETIFORMIS: Skin diseases with rare oral involvement. vesicles and pustules. exacerbation and remission seen. young and middle aged patients are commonly effected. HISTOPATHOLOGY: Collection of esoniophils, neutrophils and fibrin in connective tissue papillae.
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LINEAR IgA DISEASE: manifested as vesicles. painful ulcers are seen. erosive gingivitis. HISTOPATHOLOGY: Separation of the basement membrane.
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BIOPSY: Incisional biopsy is the best alternative to begin the microscopic and immunological examination. Selection of the biopsy site is very important. Perilesional/ incisional biopsy should avoid areas of ulceration as necrosis and epithelial denudation severely hampers the diagnostic approach.
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MICROSCOPIC EXAMINATION: Approximately 5 micron sections of formalin fixed, paraffin embedded tissue stained with H & E are obtained for light microscopic examination. IMMUNOFLUORESENCE: It is of two types. Direct immunofluoresence. Indirect immunofluoresence.
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Direct immunofluoresence: For this unfixed frozen sections are incubated with a variety of fluorescein labeled anti human serum(anti IgA, anti IgM, anti IgG, antifebrin & anti c-3) Indirect immunofluoresence: In this technique frozen sections of oral and esophageal mucosa from an animal such as monkey are first incubated with the patient’s serum to allow attachment of any serum antibodies to the mucosal tissue. The tissue is the then labeled with fluorescein labeled anti human serum.
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Summary of diagnostic procedure: CLINICAL HISTORY (data regarding the symptoms & historical aspect is collected & information about previous therapy is also collected ) (recognition of the pattern of distribution of lesion & performing Nikolsky’s sign) CLINICAL EXAMINATION BIOPSY [ Either incisional or perilesional] MICROSCOPIC EXAMINATION IMMUNOFLORESENCE
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Management: Once the diagnosis is established the dentist must choose the optimum management for the patient. This is accomplished according to three factors: practitioner’s experience. systemic impact of the disease. systemic complication of the medication.
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In the first scenario the dental practitioner takes direct and exclusive responsibility for the treatment of the patient. In the second scenario the dentist collaborates with another health care provider to evaluate or treat the patient concurrently. In the third scenario the patient is immediately referred to the dermatologist for further evaluation and treatment.
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The therapy must be based on the understanding of the basic disease process causing the gingival reaction. It can be of two phases: Local treatment. Systemic treatment.
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Local treatment: Give proper instructions to the patient regarding the maintenance of proper oral hygiene. Use of soft brush is advised. Advice use of oxidizing mouthwashes (hydrogen per oxide 3% diluted) Topical corticosteroid ( triamcinolone 0.1%, flucocinonide 0.5%, desonide 0.5, tacrolimus .1%, clobetasol propionate 0.5%)
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Systemic treatment: Systemic corticosteroid in moderate cases. Prednisolone can be used a daily or every other day dose of 30 to 40 mg and reduced gradually to daily dose of 5 to 10 mg.
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CONCLUSION: Desquamative gingivitis is not a specific disease entity but a gingival response associated with variety of conditions. Proper diagnosis of the underlying disease should be well established by the dentist and best possible treatment must be provided to the patient.
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Failure to evaluate properly and systematically a patient with a clinical condition that is consistent with desquamative gingivitis can lead to unpleasant outcomes. The clinician should also be alert to the possibility of squamous cell carcinoma of the gingival tissue presenting initially as desquamative gingivitis.
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Carranza’s-Textbook of clinical periodontology Newman Takei Kilokkevold Carranza reference
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