Chief complaint & History of present illness

Case report
 32 years-old female patient from mangalore
 Complains of burning sensation of
her gums
 Duration : 4 months
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Chief complaint & History of present illness
 Small boil like formation on the gums
 Boils appears whenever she bites on hard food
 Bleeding while brushing
 No difficulty in swallowing & speaking
 No history of itching
 No such lesions on other parts of the body
 No history of systemic symptoms
Past medical/dental/family history
 General physical examination- NAD

Local examination of the lesion
 Extra oral examination
 Inspection
 Palpation

Intra oral examination
Local examination of gingiva
 Inspection
 Palpation

 Intra oral examination
 Inspection
 Palpation

Chair side investigation
 Nikolsk’y sign = -ve
Differential diagnosis
 Mucous membrane pemphigoid
 Pemphigus vulgaris
Investigations
 Cytological
 Incisional biopsy

Histological results
 Cytological smears
 H/F

Final diagnosis
 Mucous membrane pemphigoid
 Chronic generalized gingivitis
 Dental caries- 16, 26
 Partially edentulous area in relation to - 15, 25
Treatment plan
Treatment for Mucous membrane pemphigoid
Oral prophylaxis
Restoration of 16, 26
Prosthetic rehabilitation i.r.t 15, 25

Discussion
Mucous membrane pemphigoid
 Rare chronic blistering autoimmune diseases
Etiology & pathogenesis
 The autoantibodies directed against protiens in the BMZ
 autoantibodies activate complement that attracts neutrophils. The
release of proteolytic enzymes from neutrophils
causes lysis of cells, detachment of the basal cells from the BMZ
resulting in the subepithelial clefting at the lower lamina lucida and
lamina densa levels.

C/F
 Age
 sex
 Oral manifestations
 Eye
 Skin lesions
 Laryngeal involvement, esophagus

Histopathology & Direct Immunofluorescence

D/D
 Pemphigus vulgaris
 Erosive lichen planus
 Erythema multiforme

Treatment
 severity of symptoms, site & progression
low-risk patients ( oral mucosa and/or skin only)
 Topical corticosteroids and intralesional steroid injections
 Tetracycline 1-2g/day and Nicotinamide 2-2.5g/day.
 Therapy with dapsone (25-200mg/day) may be initiated if poor response is
seen to topical steroids
 low doses of prednisone (0.5 mg/kg per day), with or without azathioprine
(100 mg/day)
 If severe oral disease, high doses of prednisone are required, with or
without immunosuppressor
(lópez-jornet p, bermejo-fenoll A. Treatment of pemphigus and pemphigoids -
med oral patol oral cir bucal 2005;10:410-411)

High risk patients. ocular, genital, esophageal and
nasopharyngeal location. rapid progression.
 Prednisone 1-1.5mg/kg/day and cyclophosphamide (1-2mg/kg/day),
also intravenously.
 If cyclophosphamide is not tolerated, azathioprine is used (1-
2mg/kg/day).
 Immunoglobulin: intravenous (therapy resistant, ocular disease).
 Plasmapheresis has also been effective in some patients.
 For serious ocular disease - subconjunctival mitomycin.
First International Consensus on Mucous Membrane Pemphigoid, Arch
Dermatol 2002;138:370-9

The treatment follow up sequel of our case
 Application of Triamcinolone acetonide 0.1% (kenacort) 1-1-1-1 for
7 days
 2nd week - Prednisone (Wysolone)50mg (OD) was prescribed for
2 weeks along with the local application of kenacort. B.P=
120/80mmhg. FBS = 92mg/dl

Follow up
4th week
 Eroded areas were seen in the labial aspect of the upper right
gingival area in close proximity to 15,14,13 & one fresh vesicle was
seen on the gingiva in the anterior lingual area of the lower arch

6th weeks -
 Erythematous areas reduced, 1 new ruptured vesicle on forehead
region. Same medications continued
 Review of blood sugar & blood pressure
 B.P= 110/70mmhg. FBS = 173mg/dl

7th week
 Erythematous areas had reduced in size.
 Dosage was tapered to 30mg (OD)

9th week
 B.P was 100/60mmhg & blood sugar was 98mg/dl. Small
generalized eroded areas were seen on the lingual aspect of the
gingiva

 12th week - Oral lesions had reduced. The patient complained of
severe giddiness & body ache. She had developed edema in her face
& in her body . B.P= 100/60, FBS = 96/dl.
 Prednisone dosage is reduced to 20mg/day

 14th week - On examinations oral lesions had healed. Drug dosage
was again reduced to 10mg/day

17th week –
 Few eroded areas were seen on the lingual gingival area of the
lower arch near 44 & 45 region & also fresh vesicle had erupted on
the right side of the cheek.
 Prednisone 10mg , Tetracycline (Restaclin)250mg as a mouth rinse,
Triamcinolone acetonide (Tess cream) & clobetasol propionate
(Tenovate cream) twice daily for the skin lesion for 15 days

 19th week

 21st week - Patient reported with new lesions, drug dosage was
increased to 20mg/day for 15 days

23rd week - Lesions had not healed
 Cyclophosphamide (Endoxan50mg) (BID) for 1 month along with
20mg Wysolone (OD)& rantac150mg (BID).

27th week - lesions got healed & side effects of corticosteroides had
subsided.

Conclusion

Its not enough that we do our best;
some times we have to do what’s required.
Sir Winston Churchill

Chief complaint & History of present illness

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