Definitive and Differential Diagnosis of Desquamative Gingivitis Through Direct Immunofluorescence Studies

Direct Immunofluorescence of Skin and Oral Mucosa: Guidelines for Selecting the Optimum Biopsy Site

Direct immunofluorescence is a vital diagnostic test for assessing vesiculobullous disorders, vasculitides, and connective tissue diseases. It is a robust and valuable technique that offers essential diagnostic information for many critical dermatoses. Dermatopathologists depend heavily on the data obtained from direct immunofluorescence evaluation to confirm final diagnoses. Selecting the most appropriate biopsy site is necessary for maximizing diagnostic accuracy, and the best site may vary depending on the clinical differential diagnosis. Inaccurate biopsy site selection can significantly impact the accuracy of the results. To optimize the use of direct immunofluorescence studies, this review provides helpful guidelines and some practical tips for selecting the best biopsy site.

Prevalence of immune mediated vesiculobullous lesions among patients visiting a private dental hospital with special emphasis on gingival manifestation

Background and Aim

Vesiculobullous lesions are a group of mucocutaneous lesions that are predominantly immune-mediated but may also have a genetic or viral origin. The most common site of occurrence is buccal mucosa, whereas the number of cases involving gingiva is comparatively low. Based on the literature, although numerous studies have reported the prevalence of vesiculobullous lesions in the nonkeratinized epithelium, there is a dearth of knowledge about its occurrence in keratinized oral mucosa, especially gingiva. The objective of the study was to assess the prevalence of immune-mediated oral vesiculobullous lesions emphasizing the occurrence in keratinized mucosa, especially the gingiva, among patients visiting a private dental hospital.

Materials and Methods

The study was conducted in a private teaching dental institute and hospital setting. Out of 615 incisional biopsies received in the department of oral pathology, between June 2019 and April 2021, n = 22 samples were immune-mediated vesiculobullous lesions confirmed by clinical and histopathological diagnosis after eliminating lesions of viral origin. Patient details including age, gender, site, duration, and systemic illness were collected from the digital information archiving software and analyzed by appropriate statistics using SPSS software.

Results

Based on the results, 95.5% of the patients had histopathological features of intraepithelial clefting and only 4.5% of them showed subepithelial clefting. Female predilection was 6.3:1. The most common site of involvement was nonkeratinized mucosa (36.36%) and 59.09% of the patients presented with systemic illness.

Conclusion

The study shows most of the features of pemphigus is consistent in gingiva and other parts of oral mucosa. The dental practitioners should be aware of the various oral manifestations of such lesions to ensure accurate diagnosis and adequate treatment.

Desquamative Gingivitis in the Context of Autoimmune Bullous Dermatoses and Lichen Planus-Challenges in the Diagnosis and Treatment

Desquamative gingivitis (DG) is a clinical term that describes erythema, desquamation and erosions of the gingiva, of various etiologies. Although the clinical aspect is not specific for a certain disease, an accurate diagnosis of the underlying disorder is necessary because the disease course, prognosis and treatment vary according to the cause. DG may inflict significant oral discomfort, which is why patients typically present to the dentist for a first consultation, rendering it important for these specialists to be informed about this condition. Our paper aims to review the ethiopatogenesis and diagnostic approach of DG, focusing on the most common underlying disorders (autoimmune bullous dermatoses and lichen planus) and on the management of these patients. Potential etiological agents leading to an inflammatory immune response in the oral mucosa and DG appearance include genetic predisposition, metabolic, neuropsychiatric, infectious factors, medication, dental materials, graft-versus-host reaction and autoimmunity. A thorough anamnesis, a careful clinical examination, paraclinical explorations including histopathological exam and direct immunofluorescence are necessary to formulate an appropriate diagnosis. Proper and prompt management of these patients lead to a better prognosis and improved quality of life, and must include management in the dental office with sanitizing the oral cavity, instructing the patient for rigorous oral hygiene, periodic follow-up for bacterial plaque detection and removal, as well as topical and systemic therapy depending on the underlying disorder, based on treatment algorithms. A multidisciplinary approach for the diagnosis and follow-up of DG in the context of pemphigus vulgaris, bullous pemphigoid, cicatricial pemhigoid or lichen planus is necessary, including consultations with dermatologists, oral medicine specialists and dentists.

Direct immunofluorescence and immune function in patients with oral lichen planus

Background/Purpose

Direct immunofluorescence and immune function and patients with oral lichen planusThe etiology of oral lichen planus (OLP) is unknown, our purpose was to evaluate the diagnostic value of direct immunofluorescence (DIF) and to investigate the immune functions in OLP.

Materials and methods

We enrolled 65 patients with suspected lesions of OLP and 47 controls. In all participants, clinical and serologic testing were conducted. The histopathologic and DIF tests were conducted in 65 patients. The severity of OLP was evaluated by reticular/hyperkeratotic, erosive/erythematous, ulcerative (REU) scoring system.

Results

By hematoxylin and eosin (H&E) staining and DIF examination, 71.2% (42/59) were diagnosed as OLP, 28.8% (17/59) were diagnosed as non-OLP. DIF demonstrated 64.3% positive reactivity with 2 distinct distribution patterns and 8 staining patterns. Compared to the controls, serum IgA in OLP was higher (P < 0.01), and serum CD3+ cells, IgM, IgE, C3 and C4 were lower (P < 0.05). Pearson correlation analysis in OLP revealed correlations between REU score and IgM, IgA of DIF (r = 0.54, P = 0.026; and r = 0.56, P = 0.020, respectively), between serum IgG and IgG of DIF (r = 0.51, P = 0.038), between serum CD4+ and the ratio of CD4+/CD8+, IgM in DIF (r = −0.50, P = 0.048; and r = −0.54, P = 0.031, respectively), between serum CD8+ and IgM, IgA in DIF (r = 0.52, P = 0.038; and r = −0.50, P = 0.047, respectively).

Conclusion

A combination of H&E test and DIF is useful for the diagnosis of OLP. Compared to controls, immune changes happen to patients with OLP. There are significant associations between the OLP lesions and general cellular and humoral immune status, localized humoral immune response.

Idiopathic Desquamative Gingivitis

Desquamative gingivitis is described as an erythematous, desquamated gingival lesion. There are many etiologic factors for the appearance of such lesions. The aim of this case report is to diagnose the cause of the lesion by analyzing the complete medical, dental, and personal histories. An elaborated differential diagnosis is done, and the lesion is successfully treated accordingly. The gold standard treatment is usually provided by systemic or topical corticosteroids. Another treatment option is antioxidant therapy which provides rapid healing of the tissue

Practical Direct Immunofluorescence

Direct immunofluorescence (DIF) remains a valuable tool that may be underused because of perceived challenges in the interpretation, limitations, and processing of DIF specimens. The aim of this review is to provide a practical guide for appropriately incorporating DIF in a variety of clinical diseases, such as autoimmune blistering disorders. In vasculitis, the role of DIF continues to evolve, particularly in the setting of IgA vasculitis. Although typically not indicated for the workup of connective tissue disease, DIF may be helpful in cases with negative serologies, nondiagnostic histologic findings, or scarring alopecia. Practical pearls for biopsy technique, specimen handling, and storage are also discussed.

Desquamative gingivitis: a challenging diagnosis for clinicians

Introduction Diagnosis of underlying causes for desquamative gingivitis (DG) is often delayed in clinical settings, but little is known about factors influencing its delayed diagnosis. We investigated the diagnostic patterns and associated factors in a cohort of patients presenting primarily with DG.Materials and methods A total of 41 patients presenting primarily with DG were interviewed to evaluate professional and patient diagnostic delays. Severity of DG was evaluated using the desquamative gingivitis clinical score (DGCS) proposed by Arduino <i>et al.</i> (2017).Results The study sample was composed of 29 females and 12 males. On average, patients waited 10.8 ± 10 months (range 4-20 months) before seeking their first professional consultation (that is, patient delay). Less severe disease and female gender were significantly associated with longer patient delay. Patients consulted an average of 4.1 ± 2 healthcare professionals (range two to six) before a definitive diagnosis was reached, with an average professional delay of 7.3 ± 5 months (range 2-11 months). Professional delay was positively correlated with the number of professional consultations (r = 0.69) and absence of other oral mucosal lesions or extraoral involvement.Conclusions Considerable diagnostic delay is a feature of the natural history of DG. Increased patient knowledge and professional awareness regarding DG symptoms and diagnostic measures is needed to reduce diagnostic delay and improve patients' experience with this disease.

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.

Erythematous and Vascular Oral Mucosal Lesions: A Clinicopathologic Review of Red Entities

Erythematous lesions of the oral mucosa are common and can reflect a variety of conditions, ranging from benign reactive or immunologically-mediated disorders to malignant disease. Together with vascular abnormalities, which can vary from reddish to bluish-purple in color, the differential diagnosis for erythematous oral mucosal change is quite diverse. This review focuses on salient clinical features and histopathologic findings of selected conditions which clinically present as red or vascular-like oral mucosal alterations, including oral vascular malformations and neoplasms, pyogenic granuloma, localized juvenile spongiotic gingival hyperplasia, denture stomatitis, benign migratory glossitis (geographic tongue), orofacial granulomatosis, granulomatosis with polyangiitis (Wegener granulomatosis), megaloblastic anemia, and erythroplakia. Recognition of the characteristic clinical features of these conditions, in conjunction with thorough patient history, will allow clinicians to narrow the differential diagnosis and guide appropriate clinical decision making, including the need for tissue biopsy, in order to complete the diagnostic process and initiate optimal patient care.

Oral lichenoid lesions: distinguishing the benign from the deadly

Oral lichen planus is a chronic inflammatory disease of unknown etiology or pathogenesis with varied disease severity that waxes and wanes over a long period of time. Although a common oral mucosal disease, accurate diagnosis is often challenging due to the overlapping clinical and histopathological features of oral lichen planus and other mucosal diseases. Other immune-mediated mucocutaneous diseases can exhibit lichenoid features including mucous membrane pemphigoid, chronic graft-versus-host disease, and discoid lupus erythematosus. Reactive changes to dental materials or to systemic medications can mimic oral lichen planus both clinically and histologically. In these situations the clinical presentation can be useful, as oral lichen planus presents as a multifocal process and is usually symmetrical and bilateral. Dysplasia of the oral cavity can exhibit a lichenoid histology, which may mask the potentially premalignant features. Proliferative verrucous leukoplakia, an unusual clinical disease, can often mimic oral lichen planus clinically, requiring careful correlation of the clinical and pathologic features.

Diagnosis of oral lichen planus: a position paper of the American Academy of Oral and Maxillofacial Pathology

Despite being one of the most common oral mucosal diseases and recognized as early as 1866, oral lichen planus (OLP) is still a disease without a clear etiology or pathogenesis, and with uncertain premalignant potential. More research is urgently needed; however, the research material must be based on an accurate diagnosis. Accurate identification of OLP is often challenging, mandating inclusion of clinico-pathological correlation in the diagnostic process. This article summarizes current knowledge regarding OLP, discusses the challenges of making an accurate diagnosis, and proposes a new set of diagnostic criteria upon which to base future research studies. A checklist is also recommended for clinicians to provide specific information to pathologists when submitting biopsy material. The diagnostic process of OLP requires continued clinical follow-up after initial biopsy, because OLP mimics can manifest, necessitating an additional biopsy for direct immunofluorescence study and/or histopathological evaluation in order to reach a final diagnosis.

Comparison the efficacy of herbal mouthwash with chlorhexidine on gingival index of intubated patients in Intensive Care Unit

Background:

Intubated patients in Intensive Care Unit (ICU) are not able to take care of their mouth health, so they are at risk of bacterial colonization and dental plaques formation that can lead to systemic diseases such as pneumonia and gingivitis.

Aims:

In randomized, double-blind clinical study, the efficacy of natural herbal mouthwash containing Salvadora persica ethanol extract and Aloe vera gel was compared with chlorhexidine on gingival index (GI) of intubated patients in ICU.

Materials and Methods:

Seventy-six intubated patients (18–64 years old with mean age 40.35 ± 13.2) in ICU were admitted to this study. The patients were randomly divided into two groups: (1) Herbal mouthwash and (2) chlorhexidine solution. Before the intervention, the GIs was measured by modified GI device into two groups. The mouth was rinsed by mouthwashes every 2–3 h for 4 days. 2 h after the last intervention, GIs were determined.

Results:

Along with mechanical methods, herbal mouthwash in reducing GI was statistically significant than that of chlorhexidine (P < 0.05).

Conclusion:

The results of this study introduce a new botanical extract mouthwash with dominant healing effects on GI (1.5 ± 0.6) higher than that of synthetic mouthwash, chlorhexidine (2.31 ± 0.73).

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.

Use of Fusidic Acid for Desquamative Gingivitis Treatment: 1-Year Follow-Up

<p>This study evaluated retrospectively the effect of fusidic acid on the management of desquamative gingivitis (DG). The study population consisted of 15 patients with DG. Patients were requested to make topical application of 2% fusidic acid ointment 4 times a day for 6 weeks. Clinical assessments were recorded at baseline, at 6 weeks and 12 months after beginning the therapy. Patients' examination involved lesion size area, pain score and impact on daily activities. All patients presented lesions in maxilla; in 9 patients (60.0%) lesions were predominately at the anterior region and 6 (40.0%) at the posterior region of maxilla. Treatment significantly (p<0.05) reduced the pain intensity (from 5.4±1.12 to 1.16±0.97) and its periodicity (from 53.33% with pain>3 x/week to 13.33%), and the lesion size in 72.47% (±4.12) immediately after 6 weeks of treatment. Improvements were sustained for 12 months compared to baseline (p<0.001). It also reduced the impact of disease in daily activities (eating and oral hygiene performance), and improved the emotional condition of patients, who reported better social relationships and habits. Topical application of fusidic acid may be a possible alternative local palliative therapy for desquamative gingivitis treatment.</p>

Direct Immunofluorescence in Oral Lichen Planus

INTRODUCTION

Oral lichen planus (OLP) is a common immune-mediated oral mucosal disease. Diagnosis of OLP depends mainly on both clinical and histopathological features. Direct immunofluorescence (DIF) is a useful investigation method to distinguish between similar lesions and to confirm diagnosis in cases of uncharacterized features.

AIM

The purpose of this study was to evaluate the prevalence and pattern of DIF in a group of Thai patients with OLP.

MATERIALS AND METHODS

Records of clinically and histologically diagnosed OLP patients attending the Oral Medicine Clinic, Faculty of Dentistry, Mahidol University, Bangkok, Thailand were consecutively reviewed for DIF results. The DIF patterns in these patients were analysed.

RESULTS

There were 82 atrophic and/or erosive OLP patients with a mean age of 51.6 years. Male to female ratio was 1:5. Of these, 82.9% showed positive DIF. Buccal mucosa was superior to the gingiva and palate in terms of sensitivity for DIF. All specimens except one (98.5%) demonstrated deposition of fibrinogen at the basement membrane zone (BMZ) in a shaggy pattern. The most common DIF pattern was shaggy fibrinogen at BMZ with IgM deposition on the colloid bodies (CB) (35.3%) followed by shaggy fibrinogen along BMZ (27.9%).

CONCLUSION

The prevalence of positive DIF in Thai OLP patients was 82.9%. The most common finding was shaggy fibrinogen at BMZ. The typical pattern was shaggy fibrinogen along BMZ with or without positive IgM at CB. DIF pattern could be evaluated for the diagnosis of OLP lacking clinical and/or histopathological characteristic features.

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.