Chronic Desquamative Gingivitis

✓^Although first recognized and reported in 1894,118 \I the term chronic <lestpiainutivc giitgivitis was coined > \/ -» in l<M2 by Prinz'" to describe a peculiar condition characterized by intense erythema, desquamation, and ulceration of I he free and attached gingiva dig. 21-1). Patients may be asymptomatic, however, when symptomatic, their complaints range from a mild burning sensation to an intense pain. Approximately 50% of desquamative gingivitis cases are localized to the gingiva, although involvement of the gingiva plus other intraoral and even extraoral sites is not uncommon.*' Initially, the cause of this condition was unclear with a variety of possibilities suggested. because most cases were diagnosed in women in the fourth to fifth decades of life (although desquamative gingivitis may occur as early as puberty or as late as the seventh or eighth decades), a hormonal derangement was suspected/ However, in I960 McCarthy and colleagues ' suggested

* See references 37, 42, /5, 92, 1 14. 124, and 125.

that desipiuntiitivc gingivitis was not a specific disease entity, hut a gingival response associated with o variety of condl-tians. This concept lias been further supported by numerous immunopathologic studies. s"" m

Use of clinical and laboratory parameters have revealed that approximately 75% of desquamative gingivitis cases have a dermatologic genesis. Cicatricial pemphigoid and lichen planus account for over 95% of the dermatologic cases.H> However, many other mucocutaneous autoimmune conditions such as bullous pemphigoid, pemphigus vulgaris, linear immunoglobulin A < IgA), dermatitis herpetiformis, lupus erythematosus, and chronic ulcerative stomatitis can clinically manifest as desquamative gingivitis.MM

Other conditions that must be considered in the differential diagnosis of desquamative gingivitis include chronic bacterial, fungal, and viral infections, as well as reactions to medications, mouthwashes, and chewing gum. Although less common, ( rohn's disease, sarcoidosis. some leukemics, and even factitious lesions have also been reported to clinicallv present as desquamative gingivitis.1,1 '

th'siiiuiiihitiVi (¡¡ngivitis ■ (IIAPTIK 21

Gingivitis

Fig. 21-1 Chronic desquamative gingivitis ot varied severity A, Moderate, with generalized edema and erythema associated with inflammation and exposure of underlying connective tissue B, Lingual view of patient shown in A. Aside Irom slight marginal erythema, there is little evidence of change in the gingiva and adjacent mucosa C, Severe, with scattered, irregularly shaped, denuded areas producing a mosaic appearance Note the ulceration between tfie right maxillary lateral and canine teeth D, Severe, with complete denudation ot the epithelium and exposure of underlying erythematous inflamed connective tissue (Courtesy Dr Gerald Shklar, Boston, Mass.)

Fig. 21-1 Chronic desquamative gingivitis ot varied severity A, Moderate, with generalized edema and erythema associated with inflammation and exposure of underlying connective tissue B, Lingual view of patient shown in A. Aside Irom slight marginal erythema, there is little evidence of change in the gingiva and adjacent mucosa C, Severe, with scattered, irregularly shaped, denuded areas producing a mosaic appearance Note the ulceration between tfie right maxillary lateral and canine teeth D, Severe, with complete denudation ot the epithelium and exposure of underlying erythematous inflamed connective tissue (Courtesy Dr Gerald Shklar, Boston, Mass.)

Therefore it is ot paramount importance to ascertain the identity of the disease responsible for desquamative gingivitis to establish the appropriate therapeutic approach and management, lb achieve this goal, the clinical examination has to be coupled with a thorough history, and routine histologic and immunofluorescenl studies.1" It should be mentioned, however, that despite this diagnostic approach, the cause of desquamative gingivitis cannot be elucidated in up to one third of the cases.

DIAGNOSIS OF DESQUAMATIVE GINGIVITIS: ASYSTEMATIC APPROACH

The previous sections have made clear that ih'siitmnnitivc gingivitis is only a clinical term that describes a peculiar clinical picture. I bis term is not a diagnosis per se and once it is rendered, a series of laboratory procedures should be used to arrive to a Final diagnosis, thus the success of any given therapeutic approach resides on the establishment of an accurate final diagnosis. I'he following represents a systematic approach to elucidate the dis ease triggering desquamative gingivitis. I his approach is also illustrated in Fig 21 -2.

Clinical History. \ thorough clinical history is mandatory to begin the assessment ol desquamative gingivitis. Data regarding the symptomatology associated with this condition, as well as its historical aspects (i.e., when did the lesion start, has it gotten worse, is there a habit that exacerbates the condition, etc.), provide the foundation fora thorough examination. Information regarding previous therapy that has been directed to alleviate the condition should also be documented.

Clinical Examination. Recognition of the pattern of distribution of the lesions (i.e., local or multifocal, with or without confinement to the gingival tissues) provides leading information to begin the formulation of .i differential diagnosis. In addition, a simple clinical maneuver such as Nikolsky's sign offers insight into the plausibility ol the presence ot a vesitulobullous disorder.

Other

Granulomatous Inflammation

Clinical history

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