Delayed Diagnosis of Desquamative Gingivitis
Figure 1. Oral MMP prior to treatment
a. The maxillary right, buccal gingiva,
exhibits well-defined ulcerations with
flat, erythematous borders.
b. The maxillary left, buccal gingiva,
exhibits moderate erosion along with
a 3×3 mm vesicle.
The intraoral examination revealed generalized, moderate
desquamative gingivitis. The maxillary right, buccal gingiva
exhibited two well-defined ulcerations with flat, erythematous
borders. Both were 2×1 cm and bled easily on slight palpation.
The maxillary left, buccal gingiva exhibited moderate erosion
along with a 3×3 mm vesicle. On the lower right buccal gingiva,
there was a 2×2 mm erosion (Figure 1).
Two incisional biopsies were ordered. One specimen was
transferred to 10% buffered formalin solution and the other
to Michel’s solution. The biopsy was taken from lesional tissue
adjacent to the vesicle on the maxillary left, buccal gingiva.
The specimens were sent to a dermatopathologist, and the
definitive diagnosis was MMP (Figure 2).
Topical management with a corticosteroid, dexamethasone
elixir 0.5 mg/5 mL, was initiated. She was instructed to rinse with
1 tablespoon 4 times daily for 2 minutes and then expectorate.
In 2 weeks, the oral ulcerations had completely healed, and the
desquamative gingivitis had resolved by 90%. She was referred
to her ophthalmologist and dermatologist to rule out ocular
and skin involvement. No evidence of disease was found in
these areas. Her dermatologist started her on dapsone 25 mg,
2 tablets per day, which allowed her to reduce the frequency
of the topical steroid rinse to twice a day. She was also referred
back to her dentist for regular professional dental prophylaxis
procedures. At her three-month follow-up, her symptoms were
maintained with no new oral lesions. She did not report any
other mucosal involvement.
22
MAY/JU NE 2017 | P EN N S YLVA N IA D EN TA L J O UR N A L
c. Generalized, desquamative gingivitis
can be noted both in maxillary and
mandibular gingivae.
DISCUSSION
Early diagnosis of MMP is vital because of the potentially
devastating consequences of ocular manifestations. Unfortunately,
as in this case, patients may experience a considerable delay
in diagnosis. Such factors as clinician skill level and knowledge
regarding mucosal disorders, timing of the biopsy, proper
biopsy technique, number of providers consulted, number
of treatments prior to a definitive diagnosis, the patient’s
awareness and concern for the oral lesion, and the recognition
for referral to specialists, all can result in delay of diagnosis. 10, 12
While MMP is rare, with an estimated prevalence of 1.3 to 2.0 per
million per year, careful history and examination can aid the
clinician in considering this diagnosis. 6, 7, 13 Diagnosis is confirmed
by clinical presentation, histopathological examination, and on
occasion, blood tests. 7 In this case, the history of oral blisters was
a key descriptor. Age and gender were other risk factors. Definitive
diagnosis was established by histopathological examination.
The biopsy should be obtained from the lesional area and adjacent
normal tissue for comparison. Ideally, both would be seen in
each specimen submitted in formalin and Michel’s solution.
Specimens placed in 10% buffered formalin solution are evaluated
under routine histopathology, and findings will show a subepithelial
split and inflammatory infiltrate comprised of eosinophils,
neutrophils, and lymphocytes. 5
Biopsies of chronic ulcerative diseases involving the oral mucosa
should also involve immunofluorescence analysis. For this, the
specimen must be placed in Michel’s solution or snap-frozen in
liquid nitrogen. Direct immunofluorescence, which detects
autoantibodies bound to the patient’s tissue, 1, 5, 14 and indirect
immunofluorescence, which detects antibodies circulating in
the blood, can be used for analysis. A section of tissue similar to
human oral mucosa is incubated with the patient’s serum.