Desquamative gingivitis - A clinical sign in mucous membrane pemphigoid: Report of a case and review of literature
This was a case report of a 57-year-old female patient who reported to the out-patient Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai with a complaint of burning sensation and tenderness in the gums, which worsened on intake of spicy food since 9 months. The patient also noticed the appearance of blisters on her gums on and off which would heal subsequently without any medical intervention. Her medical history was non-contributory. There were no associated ocular, cutaneous or genital lesions. Intraoral examination revealed an erythematous and inflamed labial gingiva with interspersed areas of normal gingiva in relation to 11, 12, 21, 22. The marginal gingiva was scalloped in outline and had rolled borders with absence of melanin pigmentation []. There was a diffuse area of desquamation and erythema involving the buccal aspect of free, marginal and attached gingiva in relation to 24, 25, 26 and 27. Faint white striae were visible bordering the areas showing desquamation. The desquamated area showed loss of stippling. Single, isolated discrete hemorrhagic bullae, oval in shape, 1.5 × 1 mm in diameter was also appreciated on the buccal attached gingiva in region of 25. The bulla was relatively resilient to puncture []. Gentle manipulation of the normal mucosa induced a positive Nikolsky's sign. The patient's oral hygiene was poor and gingiva showed bleeding on probing with no attachment loss. After obtaining an informed consent from the patient, an incisional biopsy was taken from the buccal aspect of left maxillary gingival region (adjacent to the bullae region) for histopathologic and immunofluorescent studies. Histopathology showed variable thickness parakeratinized stratified squamous epithelium, subepithelial cleft and basal cell degeneration in few areas. Underlying connective tissue stroma revealed chronic inflammatory cell infiltrate, mainly plasma cells along with areas of hemorrhage [Figures and ]. Linear deposition of IgG and C3 at the dermo-epidermal junction was evident in direct immmunofluorescence []. Differential diagnosis was made solely on the basis of clinical features. Dermatological pathologies like bullous pemphigoid, MMP, pemphigus vulgaris and bullous lichen planus were considered as the most probable differential diagnosis. Absence of skin lesions excluded the possibility of bullous pemphigoid. Presence of intact bullae and absence of erosions clinically and subepithelial cleft histopathologically ruled out pemphigus vulgaris. The striking presence of desquamative gingivitis in a 57-year-old female patient with an intact hemorrhagic bullae (without coexisting skin lesions), in association with characteristic histopathological and immunofluorescent features confirmed the diagnosis of MMP. Thorough oral prophylaxis was done and the patient was counseled to maintain good oral hygiene. Thereafter, the patient was prescribed topical application of high potency steroids (Clobetasole propionate) thrice daily for 1 month and vitamin supplements (cap zincovit) once daily for 1 month. The patient was reviewed every 2 weeks for the first 1 month. The lesions improved considerably with topical steroids within 4 weeks of starting the treatment [Figures and ]. The patient was asked to stop the topical steroid application and reinforcement of oral hygiene instructions were given. Since the lesions may recur, the patient was under observation for 1 year and there was no recurrence.