An unusual case of linear IgA disease affecting only the oral gingiva: a case report

BACKGROUND

We present a case report on desquamative gingivitis diagnosed as linear IgA disease (LAD), which is a rare autoimmune bullous disease exclusively affecting the oral gingiva. The oral mucosa can be impacted by various autoimmune bullous diseases, and our report focuses on this particular manifestation of LAD.

CASE PRESENTATION

This patient presented with atypical symptoms, as frequent blister formation on the gingiva was the primary clinical manifestation. A combination of systemic and local treatment was administered to the patient. Following the treatment, there was a significant improvement observed in both the erythema and the bullous lesions on the gingiva.

CONCLUSIONS

A more suitable local treatment strategy should be formulated for patients presenting with oral topical lesions, which clinicians can employ effectively.

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.

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

Diagnostic Concordance between Optical Coherence Tomography and Histological Investigations for Immune-Mediated Desquamative Gingivitis: Observational Study

Desquamative gingivitis (DG) denotes a heterogeneous immune-mediated disease for which early diagnosis represents a great challenge. The main aim of this study is to validate diagnostic concordance between specific Optical Coherence Tomography (OTC) patterns for DG related to oral Lichen Planus (OLP), Pemphigus Vulgaris (PV), and Mucous Membrane Pemphigoid (MMP) and definitive histological diagnosis. Forty-three patients with suspected immune-mediated DGs, were progressively recruited. Before biopsy, an OCT preliminary evaluation was performed using specific pre-determined OCT diagnostic patterns (i.e., morphology and localization of blisters, status of the basal membrane, epithelial thickness, presence/absence of acantholytic cells into blister and/or inflammatory infiltrate) related to OLP, PV and MMP. After histological confirmation, OCT and histological diagnoses were compared. Using pre-determined patterns, OCT diagnoses of DGs were: 22 (51%) OLP, of which 11 (26%) were with the bullous variant, 4 (9%) PV and 6 (14%) MMP. The same diagnoses were found by histological investigations (with the main OCT discriminatory potential for the bullous variant of OLP). The concordance between the two diagnostic methods was confirmed by the Fisher exact test (p-value < 0.01). These specific OCT patterns show a diagnostic reliability in 100% of the cases investigated, suggesting their accuracy to support the complex diagnosis and management of immune-mediated DGs.

Immune-Mediated Desquamative Gingivitis and Optical Coherence Tomography Diagnostic Patterns: Clinical Implication from a Systematic Review

Desquamative Gingivitis (DG) comprises heterogeneous clinical manifestations of numerous immune-mediated muco-cutaneous diseases. Optical Coherence Tomography (OCT) has been proposed as a valuable diagnostic support even if, to date, there are no standardized OCT-diagnostic patterns applicable to DGs. A systematic review was performed to detect existing data on in vivo OCT diagnostic patterns of the most common immune-mediated DGs (i.e., pemphigus vulgaris, mucous membrane pemphigoid and oral lichen planus). It has been found that OCT exhibits specific patterns that address the diagnosis of DG by pemphigus vulgaris (i.e., intraepithelial unilocular blister, reduced epithelial thickness, presence of acantholytic cells in the blister) and by mucous membrane pemphigoid (i.e., subepithelial multilocular blister, presence of inflammatory infiltrate), but not by oral lichen planus. These patterns could offer an attractive diagnostic OCT framework to support the clinical preliminary assessment and monitoring of these complex pathological conditions.

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.

Oral mucous membrane pemphigoid - Two case reports with varied clinical presentation

Mucous membrane pemphigoid (MMP) is a heterogeneous group of autoimmune chronic inflammatory, subepithelial blistering disorder, predominantly involving the mucous membranes. It has a female predilection and commonly occurring after the fifth decade of life. The oral mucosa is affected in more than 90% of cases. Dentists could be the first health personnel to identify and diagnose this rare mucocutaneous lesion. Two unique cases of oral MMP with varied clinical presentation, the diagnostic modality, treatment and follow-up are presented.

Desquamative gingivitis as only presenting sign of mucous membrane pemphigoid

Desquamative gingivitis (DG) is a clinical condition in which the gingiva appears reddish, glazed, and friable with loss of superficial epithelium. DG is considered a clinical manifestation of many gingival diseases and hence not identified as a diagnosis itself. Mucous membrane pemphigoid (MMP) is an autoimmune vesiculobullous disorder of mucous membrane characterized by subepithelial bullae formation. MMP can affect the mucous membranes of oral cavity, conjunctiva, nasopharynx, larynx, esophagus, genitourinary tract, and anus and vary in its severity. The most commonly affected sites are oral cavity and conjunctiva. Since DG may be the early sign or only presenting sign of these conditions, most of the times, dental surgeon plays a key role in the diagnosis and prevention of the systemic complications of these diseases. We report a case of a 41-year-old male patient presented with DG. Histopathological examination revealed subepithelial clefting suggestive of MMP. The patient was treated with topical application of triamcinolone acetonide 0.1% 3-4 times a day for 1 month.

Chronic desquamative gingivitis in siblings: A report of two cases

Desquamative gingivitis is a gingival response associated with a variety of clinical conditions and characterized by intense erythema, desquamation and ulceration of free and attached gingiva. A variety of diseases such as lichen planus, pemphigus, pemphigoid, dermatitis herpetiformis, linear IgA disease, lupus erythematosus, erythema multiformae manifest clinically as desquamative gingivitis. Of all the disease entities, Lichen Planus is a relatively common disorder affecting the skin and mucous membrane. Very often it has oral manifestations. These lesions of oral lichen planus (OLP) have myriad but distinct morphology. As they mimic other mucocutaneous disorders with regard to clinical appearance, many lesions of oral lichen planus go undiagnosed or are wrongly diagnosed. Reported here are two cases of desquamative gingivitis. One of these was diagnosed as erosive lichen planus based on the symptoms, clinical findings, histologic, and immunofluorescent examination. Further management was done in consultation with a dermatologist.

Desquamative gingivitis: what's behind it? A case report

Desquamative gingivitis (DG) is a clinical term used to describe red, painful, glazed, friable gingiva. It may be a manifestation of a mucocutaneous condition, such as lichen planus or other vesiculobulous disorders. Dentists must be aware of this rare clinical entity in order to distinguish DG from the far more common plaque-induced gingivitis. This case is unique in that it involves oral lichen planus and chronic DG, which may be secondary to plaque or a manifestation of the oral lichen planus. Intraoral examination and biopsy reports revealed features of chronic DG and oral reticular lichen planus.

Desquamative gingivitis - A clinical sign in mucous membrane pemphigoid: Report of a case and review of literature

Gingival desquamation is a clinical sign in which the gingiva appears reddish, glazed and friable with destruction of the epithelium. Gingival desquamation may be the result of various disease processes in gingiva. Mucous membrane pemphigoid (MMP), oral lichen planus and pemphigus vulgaris accounts for the major causes of gingival desquamation. MMP is a rare, chronic autoimmune blistering disorder characterized by subepithelial bullae. The condition frequently involves mucous membranes, with rare skin involvement. Oral cavity is mostly affected and desquamative gingivitis is the most common manifestation. Hereby, we present an interesting case of MMP manifesting as desquamative gingivitis, along with a brief review of the literature.

Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: a randomized controlled study

AIM

To undertake cost-effectiveness and cost-benefit analyses of an intervention to improve oral health in patients presenting with the gingival manifestations of oral lichen planus (OLP).

MATERIALS & METHODS

Eighty-two patients were recruited to a 20-week randomized controlled trial. The intervention was personalized plaque control comprising powered tooth brushing and inter-dental cleaning advice. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. Private cost data and stated willingness-to-pay (WTP) values for treatment were obtained from intervention patients at 20 weeks.

RESULTS

Overall, 81% of intervention patients showed improvement in both plaque index and mucosal disease score at 20 weeks compared to 30% of controls that continued with their usual plaque control regimen. All intervention group patients stated a positive WTP value. The mean net value of the treatment was £172 compared to the incremental cost of the treatment estimated at £122.75. The cost-effectiveness analysis resulted in an incremental cost-effectiveness ratio of £13 per OHIP point.

CONCLUSIONS

The tailored plaque control programme was more effective than control in treating the gingival manifestations of oral lichen planus. The programme is cost effective for modest values placed on a point on the OHIP scale and patients generally valued the treatment in excess of the cost.

Discoid lupus erythematosus involving gingiva

Desquamative gingival lesions are non-plaque induced inflammatory gingival lesions. It is a clinical description and not a diagnosis. These desquamative lesions represent oral manifestations of various dermatoses. Discoid lupus erythematosus is one of the rare dermatoses which show desquamative lesions as oral manifestations. This article presents a rare case report of discoid lupus erythematosus with oral lesions involving gingiva of a 66-year-old female patient.