Blok STS

7/6/2013 drg. Nur Hidayati NP 1

Jumat, 07 Juni 2013
Definisi
Gambaran klinis khas dr gingiva: merah,
desquamasi, ulkus pada gingiva bebas maupun
cekat, bisa asimptomatik maupun
simptomatic.
Kehilangan stippling & gingiva mudah
mengalami deskuamasi dg trauma minimal.

Bukan ciri khas suatu penyakit, merupakan
manifestasi dr bbrp kondisi mukokutan


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Gambar 1. Desquamative gingivitis. Note that the patient has
relatively good oral hygiene but the attached gingiva have lost
their keratinization making them more susceptible to
desquamation with trauma.
Sumber: Australian Dental Journal (2003)
Chronic Desquamative Gingivitis
Erythema berat
Deskuamasi
Ulcerasi
Asimptomatik / simptomatik
Simptomatik: keluhan mulai sensasi
terbakar ringan nyeri berat
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Chronic Desquamative Gingivitis
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Gambar 2. Chronic Desquamative Gingivitis. Irregular,
conspicious erythema involves the free and attached gingiva
Sumber: Aguirre, et.al. (2006)
Karakteristik
usia pertengahan-tua
nyeri
Sebagian besar mempengaruhi gingiva buccal/
labial
Penampilan klinis scr signifikan dg tindakan
oral hygiene tradisional atau terapi
periodontal konvensional
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Gambaran Klinis
Tabel 1. Gambaran Klinis Desquamative
Gingivitis
- Gingiva merah, menyala, mudah rapuh
- Nyeri, mudah mengalami deskuamasi
- Aspek bukal dr gingiva cekat anterior terpengaruh
- Marginal gingiva tetap bertahan
- Tidak secara signifikan meningkat dg tindakan OH
sendiri
Sumber: Australian Dental Journal (2003)

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Gambaran Klinis
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Gambar 3. Fiery, red gingiva of desquamative gingivitis. The
clinical features are non-specific. This patient has mucous
membrane pemphigoid.
Sumber: Australian Dental Journal (2003)
Etiologi
Pada awalnya tidak jelas
Suspect: kekacauan Hormonal
Mc Carthy (1960): DG penyakit spesifik,
respon gingiva terkait kondisi yg bervariasi
Konsep tsb didukung sejumlah studi
Immunopatologi

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Etiologi
75% kasus DG : dermatologi (Cicatricial
pemphigoid & LP)
Kondisi autoimun mukokutan (bullous
pemphigoid, Pemphigus vulgaris, Linear IgA
disease, Dermatitis herpetiformis, LE, chronic
ulcerative stomatitis)
Infeksi virus, jamur, & bakteri kronis
Reaksi medikasi, mouthwashes & chewing
gum
Chrons disease, sarcoidosis, leukimia,
factitious lesions jarang


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Diagnosis DG: Pendekatan Sistemik
Riwayat Klinis
Pemeriksaan Klinis
Biopsi
Pemeriksaan Mikroskopik
Immunofluorosence *)
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Riwayat Klinis
Harus teliti
Data mengenai simptom/aspek riwayat :
Kapan mulai terjadi lesi?
Apakah memburuk?
Adakah kebiasaan yg memperburuk kondisi
tsb?
Info terapi sebelumnya hrs dicatat
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Pemeriksaan Klinis
Pola distribusi lesi:
Fokal/multifokal
Dengan/tanpa batasan menuju jar.gingiva
DD
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Biopsi
Penting pertimbangkan pemilihan lokasi
biopsi
Incisi perilesi menjauhi area ulserasi krn
nekrosis & pengambilan area ulser sangat
menghambat proses diagnosis
Jaringan difiksasi dg formalin 10% HE
mikroskopis
Immunofluoresence Michells buffer
(Ammoniun sulfat,pH 7)

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Pemeriksaan
1. Mikroskopis
Pondasi untuk diagnosis lesi DG
Pewarnaan: HE (mikroskop cahaya)

2. Immunofluoresence
direct immunofluorescence:unfixed frozen
sections are incubated with a variety of
fluorescein-labeled, anti-human serum (anti-
IgG,anti-IgA, anti-IgM, anti-fibrin and anti-
C3).
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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 allow
attachment of any serum antibodies to the
mucosal tissue.


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- Jaringan kemudian diinkubasi dg fluorescein-
labeled antihuman serum (anti-IgG, anti-IgA,
anti-IgM, anti-fibrin, and anti-C3).

- Immunofluorescence (+) fluorescent signal
is observed either in the epithelium, its
associated basement membrane or in the
underlying connective tissue.
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Manajemen
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Pengalaman praktisi
Pengaruh sistemik dr penyakit
Komplikasi sistemik dr medikasi
Diagnosis Approach
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Kondisi dengan DG
Penyakit
Reaksi obat
Beragam kondisi menyerupai DG

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Penyakit dengan Gambaran Klinis DG


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Lichen Planus
Pemphigoid
Pemphigus vulgaris
Chronic Ulcerative Stomatitis
Linear IgA Disease/Dermatosis
Lupus Erythematous
Erythema Multiforme
Lichen Planus
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Lichen Planus
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LP is a relatively common immunologically
mediated mucocutaneous disease disorder where
host T lymphocytes play a central role

Kerusakan pd permukaan mukosa (cav. Oris,
tract. Genital) & kulit (kulit kepala & kuku)
ORAL LESION

Bentuk klinis: retikular, atrophic, erosive,
bullous
Mukosa bukal, lidah, gingiva (10 % kasus)

*Retikular : asimptomatik, bilateral, posterior
mukosa bukal, eritema (background),
berhubungan dg candidiasis
*Erosive : nyeri, ulserasi, eritema,dikelilingi oleh
white striation, sensitif thd panas, makanan
yang asin dan spicy
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Gingival Lesion

1. Keratotic lesions. Lesi putih, menonjol,
papula or papules, linear or reticulate lesions,
or plaquelike configurations

2. Erosive or ulcerative lesions. These extensive
erythematous areas with a patchy
distribution may present as focal or diffuse
hemorrhagic areas. These lesions are
exacerbated by slight trauma (e.g.,
toothbrushing)
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3. Vesicular or bullous lesions. These raised,
fluid-filled lesions are uncommon and short
lived on the gingiva, quickly rupturing and
leaving an ulceration.

4. Atrophic lesions. Atrophy of the gingival
tissues with ensuing epithelial thinning
results in erythema confined to the gingiva.
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Lichen Planus
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Gambar 4. Gingival lichen planus. The whole thickness of the
attached gingiva up to the mucogingival junction may be affected
Sumber: Australian Dental Journal (2003)
Lichen Planus
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Gambar 5. Erosive lichen planus. The bucal tissue are erythematous,
ulcerated, and painful.
Sumber: Aguirre, et.al. (2006)
Lichen Planus
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Histopatologi
Epithel Hyperkeratosis
Basal cell liquefaction / hydropic degeneration
Subepithelial: padat, infiltrat limfosit T
seperti pita pd lamina propia


Lichen Planus
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Gambar 6. Gambaran mikroskopis Lichen Planus
Sumber: Carranza, et.al. (2006)
Lichen Planus
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DD:
Klasik: Lichenoid mucositis
Erosive: LE & Chronic ulcerative stomatitis
stria putih: Cicatricial pemphigoid &
Pemphigus vulgaris
Linear IgA disease


Pemphigoid
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Pemphigoid
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Number of cutaneous, immune-mediated,
subepithelial-bullous diseases membrana
basalis terpisah

Bullous pemphigoid
Kronis, autoimun, bula supepidermal
Lesi Oral: DG (erosive) & bula
Deposit IgG dan C3 pada membrana basalis
dan Antibodi IgG bersirkulasi pada membrana
basalis



MMP (Cicatricial Pemphigoid)
- Kronis, autoimun, lesi vesikobulosa
- Lesi Oral: DG, erythema, deskuamasi,
ulserasi, vesikel pd gingiva cekat, ruptur 2-
3hari ulkus
- Mukosa bukal, palatum, alveolar ridge, lidah
- 2 antigen determinan : Bullous Pemphigoid 1
dan 2 (BP1 dan BP2)
- Most case : BP2, epiligrin, beta-4-integrins

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Pemphigoid
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Gambar 7. Desquamative gingivitis in a patient with pemphigoid
bulla formation.
Sumber: Australian Dental Journal (2003)
Pemphigoid
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Gambar 8. Gingival MMP
Sumber: Aguirre, et.al. (2006)
Pemphigoid
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Gambar 9. Gambaran mikroskopis MMP
Sumber: Aguirre, et.al. (2006)
Pemphigoid
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DD:
Bullous LP
Dermatitis herpetiformis
Linear IgA disease
Erythema multiforme
Herpes gestationis
Epidermolysis bullosa acquisita : MMP



Pemphigus Vulgaris
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Pemphigus Vulgaris
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Vesikobulllosa, autoimun, kulit dan membran
mukosa melepuh
- Lesi Oral:
Vesikel-bulla
Bula ruptur area ulcer yg luas
Palatum lunak, mukosa bukal, lidah, mukosa
bibir bawah, gingiva
Diagnosis klinis: DG tampak sbg satu-satunya
manifesatasi oral pemphigus (consistent with
DG)



Pemphigus Vulgaris
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Gambar 10. Gingiva pd Pemphigus vulgaris
Sumber: Aguirre, et.al. (2006)
Pemphigus Vulgaris
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Histopatologi:
Intraepithelial separation di atas lap. sel basal
Lap.superfisial epithel hilang, sel basal utuh
melekat pd lamina propria/lamina basal
Tombstone pd sel basal
Acantholysis (pemisahan sel epithel dg stratum
spinosum)
Tzanck cells pd intraepithelial cleft
Setelah vesikel/bulla ruptur infiltrsi PMNs
Pemphigus Vulgaris
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Gambar 11. Gambaran mikroskopis Pemphigus vulgaris
Sumber: Aguirre, et.al. (2006)
Pemphigus Vulgaris
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DD:
Erythema multiforme
Pemphigoid
LP
Linear IgA disease
Chronic ulcerative stomatitis






Chronic Ulcerative
Stomatitis
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Chronic Ulcerative Stomatitis
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Lesi Oral:
Painful
Solitary small blister
Erosions with surrounding erythema on the
gingiva and lateral border of the tongue

Chronic Ulcerative Stomatitis
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Gambar 12. Chronic ulcerative stomatitis
Sumber: Aguirre, et.al. (2006)
Chronic Ulcerative Stomatitis
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Histopatologi = Erosive LP
Immunofluorescence:stratified epitheliumspesific
antinuclear antibodies(SES-ANA) Dx
DD:
Erosive LP
Pemphigus vulgaris
Pemphigoid (Bullous Pemphigoid & MMP)
LE
Linear IgA disease

Linear IgA Disease
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Linear IgA Disease (LAD)
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Jarang, a.k.a Linear IgA dermatosis
Pruritic vesicullobullous rash
Biasa pd usia pertengahan-tua
Plak dikelilingi lingkaran spt gelang pd kulit:
tubuh atas & bawah, bahu, paha, tungkai
bawah, wajah
Mukosa oral : 50% kasus

Linear IgA Disease (LAD)
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Lesi Oral:
Vesikel
Nyeri ulkus & erosi
Erosive gingivitis/cheilitis
Sering pada palatum, pilar tonsila, mukosa
bukal, lidah, gingiva
Histopatologi:
= Erosive LP

Linear IgA Disease (LAD)
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Gambar 13. Linear IgA disease. Intense erythema and ulceration of
the gingiva consistent with DG
Sumber: Aguirre, et.al. (2006)
Linear IgA Disease (LAD)
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DD:
Erosive LP
Chronic ulcerative stomatitis
Pemphigus vulgaris
Bullous Pemphigoid
LE


Dermatitis
Herpetiformis
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Dermatitis Herpetiformis
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Papula/vesikel simetris bilateral pd
ektremitas, sacrum, pantat, kadang pd
wajah, cav. Oris
Lesi Oral: ulserasi yg nyeri krn pecahnya
vesikel/bula
Histopatologi:
Lesi awal tampak sekumpulan fokal neutrophil
& eosinophil di antara tumpukan fibrin
Immunofluorescence : IgA dan C3 perilesi
Lupus Erythematosus
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Lupus Erythematosus
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Penyakit autoimun
Dibagi 3: SLE, CCLE, SCLE
SLE: Rash spt butterfly, oral ulceration =
LP, plak hiperkeratotik pd mukosa bukal &
palatum
CCLE: plak spt LP pd palatum & mukosa
bukal
SCLE = CCLE, tp scar & atropi

Lupus Erythematosus
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Gambar 14. LE. Intense erythema with ulceration is bordered by
whitw radial lines
Sumber: Aguirre, et.al. (2006)
Lupus Erythematosus
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DD:
Erosive LP
Erythema multiforme
Pemphigus vulgaris

Erythema Multiforme
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Erythema Multiforme
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Multipel
Besar
Dangkal
Ulkus dg tepi merah, nyeri
Nyeri pd saat mengunyah & menelan
Mukosa bukal & lidah, mukosa labial, dasar
mulut, palatum, gingiva

Erythema Multiforme
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Gambar 15. Erythema Multiforme
Sumber: Aguirre, et.al. (2006)
Erythema Multiforme
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Histopatologi:
Liquefaction degeneration pd epitel atas
Pseudoepitheliiomatous hyperplasia &
Necrotic keratinocytes pd epithel
degeneratif pd basement membrane
Drug Eruptions
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Sulfonamide, Barbiturate, Antibiotik
Lesi Multiform , tersering vesikel atau bula
Obat parenteral : stomatitis medicamentosa
Obat local : stomatitis venenata / contact
stomatitis
DG: tartar control toothpaste
(pyrophosphates & flavoring agent)

Beragam kondisi menyerupai DG
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Candidiasis
Graft-versus-host disease : pd resipien
transplantasi sumsumtulang allogenic
Wegeners granulomatosis : stawberry gum
Foreign body gingivitis : dental material
Kindler syndrome : cutaneous neonatal bulla

Beragam kondisi menyerupai DG
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Beragam kondisi menyerupai DG
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