Slide 1: CHAPTER 21 DESQUAMATIVE GINGIVITIS Chronic desquamative gingivitis was first recognized and reported in 1894. In 1932, Prinz described it as a peculiar condition characterized by intense erythema, desquamation and ulceration of the free and attached gingiva. Patients may be asymptomatic,however when symptomatic, their complaints range from a mild sensation to an intense pain. Etiology is unknown. 50% of desquamative gingivitis cases are localized to gingiva, although involvement of intraoral and extra oral sites is not uncommon. Diagnosed in women in the fourth to fifth decades of life (may occur as early as puberty or as late as seventh or eighth decades). In 1960 McCarthy and colleagues suggested that desquamative gingivitis was not a specific disease entity, but a gingival response associated with a variety of conditions. Slide 2: There may be threads or loose necrotic epithelium. It involves not only marginal gingiva, but also peels the attached gingiva often in a band- like fashion. The differential diagnosis of desquamative gingivitis include a variety of diseases such as lichen planus, cicatrical pemphigoid, bullous pemphigoid, pemphigus vulgaris,linear IgA disease, dermatitis herpetiformis and drug reaction or eruptions. DIAGNOSIS : The success of any given therapeutic approach resides on the establishment of an accurate final diagnosis. CLINICAL FEATURES : Mild form. Moderate form. Severe form. Slide 3: MILD FORM : There is diffuse erythema of the marginal, interdental and attached gingiva. It is usually painless and occurs most frequently in females between 17 & 23yrs. of age. MODERATE FORM : Patchy distribution of bright- red and gray areas involving marginal and attached gingiva. The surface is smooth and shiny, normal resilient gingiva becomes soft, edematous and massaging of gingiva results in peeling off the epithelium. Usually seen in the age group of 30 to 40 yrs. Patient complains of burning sensation. The labial surface is more frequently involved. Slide 4: SEVERE FORMS : This form is characterized by scattered irregularly- shaped areas in which the gingiva is denuded and strikingly red in appearance. The gingiva is speckled and the surface epithelium seem shredded, friable and can be peeled off in small patches. The mucous membrane other than gingiva is smooth and shiny and may present fissuring in the cheek adjacent to the line of occlusion. The condition is painful. There is a constant, dry, burning sensation throughout the oral cavity. HISTOPATHOLOGY : Microscopically, desquamative gingivitis often appears as bullous lesions or lichenoid lesions. Occasionally there will be thin , atrophic epithelium with little or no keratin at the surface and a dense, diffuse infiltration of chronic inflammatory cells in the underlying connective tissue. Slide 5: Histochemical and ultastructural studies revealed separation of collagen fibrils and a decrease in the number of anchoring fibrils. THERAPY : It can be of two phases : Local Treatment. Systemic Treatment. LOCAL TREATMENT : Oral hygiene instructions (soft toothbrush). Oxidizing mouthwashes (Hydrogen peroxide 3% diluted). Topical corticosteroid ointments or cream- like triamcinolone 0.1%, flucocinamide 0.05%, desonide 0.05 %. Slide 6: SYSTEMIC TREATMENT : Systemic corticosteroids in moderate doses. Prednisolone can be used in a daily or every- other- day dose of 30 - 40 mg and gradually- reduced to a daily maintenance dose of 5 – 10 mg. Slide 7: PEMPHIS VULGARIS OF THE GINGIVA. ORAL LESIONS CONFINED TO THE GINGIVA CONSISTENT WITH DESQUAMATIVE GINGIVITIS Slide 8: CHRONIC ULCERATIVE STOMATITIS. ERYTHEMA AND ULCERATION OF THE GINGIVA CONSISTENT WITH A CLINICAL DIAGNOSIS OF DESQUAMATIVE GINGIVITIS Slide 9: LINEAR IgA. INTENSE ERYTHEMA AND ULCERATION OF THE GINGIVA CONSISTENT WITH DESQUAMATIVE GINGIVITIS Slide 10: LUPUS ERYTHEMATOSUS OF THE ORAL CAVITY PRESENTING AS DESQUAMATIVE GINGIVITIS. INTENSE ERYTHEMA WITH ULCERATION BORDERED BY WHITE RADIAL LINES. Slide 11: PLASMA CELL GINGIVITIS . THE GINGIVA PRESENTS A BAND OF MODERATE TO SEVERE INFLAMMATION REMINISCENT OF DESQUAMATIVE GINGIVITIS Slide 12: WEGNER’S GRANULOMATOSIS AFFECTING TISSUES. THE CLASSIC “ STRAWBERRY GUMS “ APPEARANCE OF THE MANDIBULAR GINGIVA. A SLIGHT RESEMBLANCE WITH DESQUAMATIVE GINGIVITIS IS EVIDENT.