Presentation on desquamative gingivitis.

1. DESQUAMATIVE
GINGIVITS
-AISHWARYA PANDEY
-P.G. FIRST YEAR
-DEPARTMENT OF PERIODONTOLOGY

2. DEFINITION
A peculiar condition characterized by intense erythema, desquamation,
and ulceration of the free and attached gingiva
- Prinz (1932)

3. ETIOLOGY
• Certain dermatoses
• Hormonal influences
• Abnormal responses to irritation
• Chronic infections
• Idiopathic

4. CLINICAL FEATURES
Clinical features vary in severity ( Glickman and Smulow):
• Mild
• Moderate
• Severe

5.  MILD FORM
- Diffuse, mild erythema
- Painless condition
- Prevalence- more in females
- 17-23 years of age

6.  MODERATE FORM
- Patchy distribution of bright red and gray areas
- Surface is smooth, shiny and soft in consistency
- Slight pitting on pressure
- Prevalence- 30-4- years of age
- Patient presents with C/O of burning sensation and sensitivity to
thermal changes.

7.  SEVERE FORM –
- Striking fiery red appearance
- Scattered irregularly shaped areas
- Most of the area is greyish blue giving an overall speckled
appearance
- Surface epithelium is shredded and friable and can be peeled off in
small patches
- Patient presents with C/O of constant dry and burning sensation
throughout the oral cavity, inability to tolerance coarse food or
temperature changes

8. DIAGNOSIS
 Clinical History
 Clinical Examination
 Biopsy
 Microscopic Examination
 Immunofluorescence

9. The diagnostic approach for desquamative gingivitis includes hematoxylin and eosin (H&E)
and direct immunofluorescence evaluation of biopsy specimens.

10.  CLINICAL HISTORY
 A thorough clinical history is mandatory to begin the assessment of
desquamative gingivitis.
 Data regarding the symptoms associated with this condition and its
historical aspects (e.g., lesion onset, whether it has worsened, habits
that exacerbate it) provide the foundation for a thorough
examination.
 Information about previous therapy to alleviate the condition
should be documented.

11.  CLINICAL EXAMINATION
 The distribution pattern of the lesions (e.g., focal or multifocal,
with or without confinement to gingival tissues) provides
information that can begin to narrow the differential diagnosis.
 A simple clinical maneuver such as the Nikolsky sign offers insight
into the plausibility of a vesiculobullous disorder.

12.  BIOPSY
 An incisional biopsy is the best strategy for beginning the
microscopic and immunologic evaluation.
 An important consideration is the selection of the biopsy site.
 A perilesional incisional biopsy should avoid areas of ulceration
because necrosis and epithelial denudation severely hamper the
diagnostic process.
 After the tissue is excised from the oral cavity, the specimen can be
bisected and then submitted for microscopic examination

13.  Buffered formalin (10%) should be used to fix the tissue for
conventional hematoxylin and eosin (H&E) evaluation.
 Michel’s buffer (i.e., ammonium sulfate buffer, pH 7.0) is used as
the transport solution for immunofluorescence assessment.
 MICROSCOPIC EXAMINATION
 Sections of approximately 5 µm of formalin-fixed, paraffin-
embedded tissue stained with conventional H&E are obtained for
light microscopy examination.

14.  IMMUNOFLUORESCENCE
 For direct immunofluorescence, unfixed frozen sections are incubated
with a variety of fluorescein-labeled, antihuman serum (i.e., anti-IgG,
anti-IgA, anti-IgM, antifibrin, and anti-C3).
 For indirect immunofluorescence, unfixed frozen sections of oral or
esophageal mucosa from an animal such as a monkey are first
incubated with the patient’s serum to enable attachment of serum
antibodies to the mucosal tissue. The tissue is then incubated with
fluorescein-labeled antihuman serum.
 Immunofluorescence tests are positive if a fluorescent signal is
observed in the epithelium, its associated basement membrane, or the
underlying connective tissue .

15. MANAGEMENT AND TREATMENT
 After the diagnosis is established, the dentist must choose the
optimal management strategy.
 The choice depends on the practitioner’s experience, the systemic
impact of the disease, and the systemic complications of the
medications.

16.  Oral Hygiene Evaluation
 All patients with DG should have a thorough inspection of the oral
cavity.
 The clinician should carefully inspect the gingiva and teeth for
accumulation of dental plaque, signs of gingival retraction,
evidence of dental root exposure, and tooth loss.
 All mucosal surfaces should be inspected for the presence of
microbial colonization, including evaluation for the white plaques
of oral candidiasis, punched-out erosions of herpes simplex virus,
or honey-colored crust of impetigo.

17.  Plaque control
 An effective oral hygiene regimen is critical to the care of patients
with DG, and should be performed in addition to disease-targeting
therapies.
 Institution of a plaque control program improved not only plaque
and gingival bleeding indices, but also pain of lesions and overall
disease activity.
 Though different protocols have been used for plaque control in
studies, some general principles should be applied for all patients
with DG.

18.  First, all patients should undergo a baseline tooth cleaning with a dental professional comfortable
in the management of patients with DG.
 Second, patients should perform at-home dental cleaning with tooth brushing twice daily.
 A soft toothbrush is recommended (either manual or electric) while active erosions are present,
using a modified Bass technique, where the bristles are placed at a 45▫ angle to the tooth surface at
the edge of the gum, and strokes are performed to the tooth edge. Rough maneuvers should be
avoided.
 Plaque control should be performed either via gentle flossing or the use of a Waterpik, which is as
efficacious but gentler than flossing.
 Antiseptic mouth rinse should be performed twice daily, with avoidance of alcohol-based rinses.
 Periodic teeth cleaning procedures should be performed, and avoidance of local irritants, such as
ill-fitting prostheses or unsatisfactory restorations, is critical.

19.  Decolonization
 Reduced oral hygiene and treatment with local immunosuppressant medications can lead to
increased microbial colonization in patients with DG.
 Institution of an antiseptic protocol with regular antifungal prophylaxis is recommended.
 This can be performed with the twice-daily use of an antiseptic mouth rinse containing
hydrogen peroxide and daily use of antifungal troches.
 An empiric treatment with a short course of an oral antifungal at the time of diagnosis, then as
needed for evidence of candidal disease can also be performed.

20.  Medical therapies
 Topical therapies
 Topical therapies are an important component to the therapy of DG.
 For some diseases, topical therapies alone can be sufficient to control disease when mild to
moderate.
 For immunobullous diseases, systemic therapies are generally required, but topical modalities
represent an important adjunctive treatment.
 The most commonly used first-line topical therapy is a topical corticosteroid.
• Triamcinolone acetonide 0.1%
• Fluocinonide 0.05 %
• Desonide Cream, 0.05%

21.  Systemic therapies
 Topical therapy alone is sometimes insufficient to control disease activity.
 When patients continue to have erosions and pain despite compliance with topical
therapy, treatment with systemic therapy is indicated.
 Systemic corticosteroids : Prednisolone 30-40 mg/day up to 7 days followed by 10 mg
every second day.
 When steroid therapy is not successful, Tetracycline 250 mg/day for 7 days can be
helpful.
 Nutritional supplements
 Maintenance of proper hydration

22. DIFFERENTIAL DIAGNOSES

23. THANK YOU !