Clinical features of gingival pemphigus vulgaris

Gingival Manifestations in Oral Chronic Autoimmune Bullous Diseases: A Retrospective Study

Background and Objectives: Desquamative gingivitis (DG) is a clinical term indicating "peeling gums" and is associated with different oral manifestations. In this study, we aimed to assess the association between DG and autoimmune blistering mucocutaneous diseases (ABMD) with oral manifestations. Materials and Methods: A retrospective study including 88 patients diagnosed between 1998 and 2019 with ABMD (intraepithelial and subepithelial autoimmune blistering diseases) was performed at the Oral Medicine Department, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy in Bucharest. For each patient, the sociodemographic and anamnestic data, as well as clinical features of oral lesions (location), histological evaluation, and direct immunofluorescence data were collected. Results: Most of the patients involved in the study were female (78.4%). In total, 34 patients (38.63%) were diagnosed with subepithelial autoimmune diseases (SAD) and 54 (61.36%) had intraepithelial autoimmune diseases (IAD). Differences in the anatomic distribution of oral involvement were found between SAD and IAD. The presence of DG was significantly more common in patients with SAD compared to those with a diagnosis of IAD. Conclusions: Specific anatomical locations of the oral lesions are significantly associated with different subtypes of ABMD, with gingiva and hard palate mucosa being more involved in SAD and the soft palate and buccal mucosa in IAD. Desquamative gingivitis is a clinical sign that raises diagnostic challenges for several conditions in oral medicine.

Erythema multiforme-like lip presentation in pemphigus vulgaris patients: a multicenter case series

Pemphigus vulgaris (PV) is a chronic autoimmune mucocutaneous blistering disease. Autoantibodies are directed against desmogleins, leading to the formation of intraepithelial bullae. PV, as with other autoimmune mucocutaneous disorders of the oral cavity, presents diagnostic and therapeutic challenges. Approximately 50-70% of cases present first with oral lesions. The lesions commonly start as vesicles or bullae that rapidly rupture, leading to erosions and ulcerations. The palatal, gingival, buccal, and labial mucosa are the most commonly affected sites. Oral PV can mimic several other diseases that cause mucosal erosions and/or ulcerations, including erythema multiforme (EM). EM is an acute, immune-mediated, self-limited hypersensitivity condition primarily associated with herpes simplex infection. Oral lesions can be variable, but a very characteristic presentation with labial hemorrhagic erosions, ulcerations and crusting is commonly seen. In this case series, we present six cases of PV: one male patient and five female patients whose ages ranged from 34 to 65 years old. All patients presented with hemorrhage and crusting of the lips in addition to multiple intraoral erosions and ulcerations. Three patients presented with oral and skin lesions. All patients underwent biopsies, and a diagnosis of PV was confirmed. All patients were treated with steroids (topical and systemic) and variable steroid-sparing agents. This case series emphasizes that oral PV may be misdiagnosed as EM in a subgroup of patients who present with persistent lip hemorrhage and crusting. Therefore, a comprehensive history, clinical examination and incisional biopsies should be considered in such patients.

Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge

BACKGROUND

Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges.

METHODS AND RESULTS

A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft.

CONCLUSIONS

To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients.

KEY POINTS

Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Clinical presentation and diagnostic delay in pemphigus vulgaris: A prospective study from Turkey

BACKGROUND

To evaluate the diagnostic patterns and factors that may influence delays in the diagnosis of pemphigus vulgaris (PV) with oral involvement.

MATERIALS AND METHODS

In this prospective cohort study, 36 newly diagnosed PV patients with oral involvement were clinically examined and interviewed about the natural history of the oral lesions, number of medical consultations (Med consultation), medical treatment history, and diagnostic delay time (DD time).

RESULTS

Thirty (83%) PV patients presented initially with oral mucosal involvement (OMI) and 6 (17%) presented initially with skin involvement (SI). The mean DD time was 6.19 ± 3.82 months, and the mean number of Med consultation was 5.8 (n = 36). The means of all the parameters were significantly higher for the OMI patients than for the SI patients (P < .05). All of the patients with OMI had been misdiagnosed. The DD time was significantly longer in patients who presented initially with desquamative gingivitis (8.25 ± 3.81) than patients who presented with ulcers and erosions (4.78 ± 1.11) (P < .05). There was a statistically significant positive correlation between DD time and Med consultation (r = 0.91).

CONCLUSION

Even with the high frequency of oral involvement and easy access to the oral cavity, diagnostic delays are still common for patients with oral PV. This underlines the need for education to improve healthcare providers' awareness and knowledge of the clinical oral presentation of PV.

Mucocutaneous Diseases

Mucocutaneous diseases affecting the oral cavity are predominantly immune mediated or inflammatory. Three of the most common and clinically significant conditions are reviewed in this article: lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid. Because oral manifestations may be the first or only manifestation of mucocutaneous diseases, oral health professionals play a critical role in the early diagnosis and multidisciplinary management of these conditions.

[Oral care recommendations for patients with oral autoimmune bullous diseases]

BACKGROUND

Autoimmune bullous diseases (AIBD) may cause chronic oral lesions that progress insidiously.

AIMS

To provide recommendations for optimal oral-dental management of patients presenting AIBD with oral involvement.

PATIENTS AND METHODS

In the absence of scientific studies with high levels of proof, these recommendations have been drawn up at two meetings by a committee of experts on AIBD comprising 7 dermatologists, 1 stomatologist, 1 maxillofacial surgeon, 2 odontologists and 4 parodontologists.

RESULTS

The oral lesions associated with AIBD may be classified into three grades of severity: severe (generalised erosive gingivitis affecting at least 30% of dental sites), moderate (localised erosive gingivitis affecting less than 30% of dental sites) and controlled (no erosive oral lesions). Good oral-dental hygiene suited to the severity of the oral lesions, must be practised continually by these patients so as to avoid the formation of dental plaque, which aggravates symptoms. Dental and parodontal care must be considered in accordance with the severity grade of the oral lesions: in severe cases, the dental plaque must be eliminated manually with a curette, but several types of care (descaling, treatment for tooth decay, non-urgent extractions, etc.) must be suspended until the grade of severity is moderate or until the disease is stabilised.

Oral Lesions: The Clue to Diagnosis of Pemphigus Vulgaris

Pemphigus is a group of potentially fatal dermatoses with both cutaneous and oral manifestations. Characterized by the appearance of vesicle or bullae, their manifestations in the oral cavity often precede those on the skin by many months or may remain as the only symptoms of the disease. It is therefore important that the oral manifestations of the disease are recognized on time, to make a proper diagnosis and initiate timely treatment. Here we present a case of Pemphigus Vulgaris (PV) that presented with oral lesions at multiple sites including tongue, to highlight the importance of timely recognition of the oral lesions during routine dental practice for the diagnosis and management of this disease.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Oral mucosal manifestations of autoimmune skin diseases

A group of autoimmune diseases is characterised by autoantibodies against epithelial adhesion structures and/or tissue-tropic lymphocytes driving inflammatory processes resulting in specific pathology at the mucosal surfaces and the skin. The most frequent site of mucosal involvement in autoimmune diseases is the oral cavity. Broadly, these diseases include conditions affecting the cell-cell adhesion causing intra-epithelial blistering and those where autoantibodies or infiltration lymphocytes cause a loss of cell-matrix adhesion or interface inflammation. Clinically, patients present with blistering, erosions and ulcers that may affect the skin as well as further mucosal surfaces of the eyes, nose and genitalia. While the autoimmune disease may be suspected based on clinical manifestations, demonstration of tissue-bound and circulating autoantibodies, or lymphocytic infiltrates, by various methods including histological examination, direct and indirect immunofluorescence microscopy, immunoblotting and quantitative immunoassay is a prerequisite for definitive diagnosis. Given the frequency of oral involvement and the fact that oral mucosa is the initially affected site in many cases, the informed practitioner should be well acquainted with diagnostic and therapeutic aspects of autoimmune dermatosis with oral involvement. This paper reviews the pathogenesis and clinical presentation of these conditions in the oral cavity with a specific emphasis on their differential diagnosis and current management approaches.

Conservative approach in patients with pemphigus gingival vulgaris: a pilot study of five cases

Objectives. The aim of this pilot study was to describe the clinical efficacy of a conservative oral hygiene protocol in patients affected by gingival pemphigus vulgaris (PV) applied in a case series. Methods. Subjects suffering from PV with gingival localisation and slightly responsive to conventional treatment with systemic corticosteroids and immunosuppressive drugs were selected among individuals treated in the Unit of Oral Medicine Section of the University of Turin. Five subjects received nonsurgical periodontal therapy, over a 7-day period, including oral hygiene instructions; patients were instructed about domiciliary oral hygiene maintenance and instructions were reinforced at each visit and personalised if necessary. Clinical outcome variables were recorded at baseline (before starting) and 16 weeks after intervention, including full mouth plaque score (FMPS), bleeding scores (FMBS), probing pocket depth (PPD), oral pemphigus clinical score (OPCS), and patient related outcomes (visual analogue score of pain). Results. Five patients were treated and, after finishing the proposed therapy protocol, a statistical significant reduction was observed for FMBS (P = 0.043) and OPCS (P = 0.038). Conclusions. Professional oral hygiene procedures with nonsurgical therapy are related to an improvement of gingival status and a decrease of gingival bleeding in patients affected by PV with specific gingival localization.

Clinical and histological characterization of oral pemphigus lesions in patients with skin diseases: a cross sectional study from Sudan

Background

Pemphigus is a rare group of life-threatening mucocutaneous autoimmune blistering diseases. Frequently, oral lesions precede the cutaneous ones. This study aimed to describe clinical and histological features of oral pemphigus lesions in patients with skin disease has been canceled aged 18 years and above, attending outpatient’s facility of Khartoum Teaching Hospital - Dermatology Clinic, Sudan. In addition, the study aimed to assess the diagnostic significance of routine histolopathology along with immunohistochemical (IHC) examination of formalin-fixed, paraffin-embedded biopsy specimens in patients with oral pemphigus.

Methods

A cross-sectional hospital-based study was conducted from October 2008 to January 2009. A total of 588 patients with confirmed skin has been canceled disease diagnosis completed an oral examination and a personal interview. Clinical evaluations supported with histopathology were the methods of diagnosis. IHC was used to confirm the diagnosis. Location, size, and pain of oral lesions were used to measure the oral disease activity.

Results

Twenty-one patients were diagnosed with pemphigus vulgaris (PV), 19 of them (mean age: 43.0; range: 20–72 yrs) presented with oral manifestations. Pemphigus foliaceus was diagnosed in one patient. In PV, female: male ratio was 1.1:1.0. Buccal mucosa was the most commonly affected site. Exclusive oral lesions were detected in 14.2% (3/21). In patients who experienced both skin and oral lesion during their life time, 50.0% (9/18) had oral mucosa as the initial site of involvement, 33.3% (6/18) had skin as the primary site, and simultaneous involvement of both skin and oral mucosa was reported by 5.5% (1/18). Two patients did not provide information regarding the initial site of involvement. Oral lesion activity score was higher in those who reported to live outside Khartoum state, were outdoor workers, had lower education and belonged to Central and Western tribes compared with their counterparts. Histologically, all tissues except one had suprabasal cleft and acantholytic cells. IHC revealed IgG and C3 intercellularly in the epithelium.

Conclusions

PV was the predominating subtype of pemphigus in this study. The majority of patients with PV presented with oral lesions. Clinical and histological pictures of oral PV are in good agreement with the literature. IHC confirmed all diagnoses of PV.

Gingival pemphigus vulgaris preceding cutaneous lesion: A rare case report

Pemphigus is a group of autoimmune diseases characterized by formation of intraepithelial bullae in skin and the mucous membrane. Pemphigus vulgaris affects the oral mucosa in nearly all cases. Pemphigus vulgaris is characterized by auto antibodies directed against desmosome-associated protein antigens (desmoglein-3) found in epithelial and epidermal intercellular substance. We report here a case of pemphigus vulgaris of gingiva in an adult female patient at an early stage followed by dermatologic involvement. Perilesional incision was taken and histopathological and direct immunofluorescence was done for identification of specific antibodies. The oral lesions were treated with 0.1% Triamcinolone acetonide ointment and Prednisolone 20 mg twice daily with multivitamins was administered systemically for skin lesion.

Severe manifestation of oral pemphigus

This article describes a case of pemphigus vulgaris in a relatively young patient with exacerbated characteristics, widespread lesions, and rapid evolution. A 40-year-old woman sought treatment, complaining about severe oral pain and dysphagia. Intraoral inspection revealed ulcerated lesions on the lips, buccal mucosa, and floor of the mouth. The number of lesions quickly increased and resembled erythema multiforme. She also presented blistering lesions on the back, abdomen, neck, and eyes. Incisional oral biopsy revealed pemphigus vulgaris. This report emphasizes the importance of early diagnosis of an oral biopsy in systemic diseases and the management of the lesions.

Desquamative gingivitis as a manifestation of chronic mucocutaneous disease

Desquamative gingivitis (DG) is a clinical descriptive term indicating "peeling gums". DG is usually the result of a disease process that causes separation of the epithelium from the underlying connective tissue in the oral masticatory mucosa. DG may be a manifestation of several mucocutaneous diseases, most commonly cicatricial pemphigoid, pemphigus vulgaris and lichen planus. Correct diagnosis of the underlying disease in DG patients requires careful clinical observation, detailed examination of medical history, biopsy and histopathological examination of the lesions as well as more specialized tests such as direct and indirect immunofluorescence. Treatment of DG consists of treating the underlying disease and often requires the use of immunosuppressive agents, such as corticosteroids. Elimination of local gingival irritants, such as dental plaque and calculus, can significantly improve the treatment outcome.

Nikolsky's sign on the gingival mucosa: a clinical tool for oral health practitioners

BACKGROUND

Nikolsky's sign is a clinical sign which is elicited by a horizontal, tangential pressure to the mucosa and/or skin resulting in blisters extending and separating or peeling away. Few data are currently available in the literature about its usefulness, specificity, and sensitivity in the diagnosis of either oropharyngeal or cutaneous bullous diseases. The purpose of this study was to determine the sensitivity and specificity of the gingival Nikolsky's sign in the identification of an autoimmune blistering disease.

METHODS

Over a period of 13 years, we recruited 566 patients with autoimmune oral bullous and non-bullous diseases who possessed either maxillary or mandibular gingival mucosal lesions. All patients were subjected to a test causing a gingival Nikolsky's sign at their first visit during the diagnostic algorithm and in the active disease phase before commencing treatment.

RESULTS

A total of 566 patients (184 with and 382 without bullous lesions) had at least gingival involvement. A positive gingival Nikolsky's sign resulted in 100 (17.7%) of 566 patients: 86 patients with bullous lesions (53 with pemphigus vulgaris, eight with mucous membrane pemphigoid, 22 with bullous/mixed lichenoid lesions, and three with erythema multiforme) and 14 with non-bullous lesions (12 with non-bullous lichenoid lesions and two with systemic lupus erythematous/mixed connective tissue disease). Thus, the specificity of Nikolsky's sign was higher (96.3%) than the sensitivity (46.7%).

CONCLUSION

The results of this study support the use of Nikolsky's sign of the gingival mucosa as a viable test to establish the presence of oral bullous diseases.

Desquamative gingivitis: A sign of mucocutaneous disorders-a review

Desquamative gingivitis is a clinical term to describe red, painful, glazed and friable gingivae which may be a manifestation of some mucocutaneous conditions such as lichen planus or the vesiculobullous disorders. It is important to be aware of this rare clinical entity so as to distinguish desquamative gingivitis from plaque induced gingivitis which is an extremely common condition, easily recognized and treated daily by the dental practitioner. This article gives an overview of desquamative gingivitis, its presentation, the possible causes, diagnosis and treatment. Early recognition of these lesions may prevent delayed diagnosis and inappropriate treatment of potentially serious dermatological diseases.

Corticosteróide tópico oclusivo no tratamento de manifestações gengivais de doenças vesicobolhosas auto-imunes

O tratamento das lesões gengivais de doenças vesicobolhosas auto-imunes constitui grande desafio na estomatologia, principalmente pela natureza crônica das lesões. O tratamento sistêmico é necessário no controle das apresentações mais graves; entretanto, quando possível, o tratamento tópico é preferível. Este artigo descreve uma técnica oclusiva para aplicação de corticosteróide tópico que tem demonstrado ser eficaz no controle dessas lesões, sobretudo em pacientes com manifestações exclusivamente gengivais.

Oral challenge test for the diagnosis of gingival hypersensitivity to apple: A case report

Food intolerance is the term used to describe a hypersensitivity reaction to a food component. These reactions refer to the drug-like side effects caused by a range of chemicals that may be present in food as natural or added components. The range of symptoms which can be induced by food intolerance are very similar to those caused by food allergy, oral allergy syndrome, acute infectious diseases and vesiculobullous disorders; so that on initial presentation, it can be difficult to differentiate between these conditions. A 48-year-old woman with complaints of allergic symptoms was examined with skin prick test (SPT), specific IgE analysis, and oral challenge test for definitive allergen determination. The patient was negative in both specific IgE detection and SPT with commercial extracts of apple, whereas the oral challenge test revealed positive objective symptoms with blister and ulcer formation. Apple has been reported to be the cause of food allergy. To our knowledge, there is no report of apple intolerance in which the lesions are only confined to gingival tissues.

Gingival lesions as a first symptom of pemphigus vulgaris in pregnancy

The erosive gingival lesions associated with vesiculobullous diseases can be an important early clinical manifestation of serious diseases such as pemphigus vulgaris (PV). PV is a vesiculobullous disease of the skin and mucosa which tends to be chronic and which normally affects people of 40-60 years of age. Its incidence varies from 0.5 to 3.2 cases per 100,000 per year. Mucosal lesions are located mainly in the oral and pharyngeal mucosa, although conjunctiva, larynx, nasal mucosa, vulva, vagina, cervix, and ano-rectal mucosa may also be involved. It is a serious mucocutaneous disease of an autoimmune nature, whose appearance during pregnancy is extremely rare.

Position Paper: Oral Features of Mucocutaneous Disorders

Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.