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ORAL LICHEN PLANUS MANIFESTING

AS DESQUMATIVE GINGIVITIS- A CASE SERIES

Col (Dr) VB Mandlik

Lt Col (Dr) AK Jha
Surg Lt(Dr) Cdt Harjeet Singh
 Case 1
Name : ABC Age & Sex : 48 yrs/Female
Occupation Housewife
Chief complaint :
 Burning sensation of mouth on consumption of food
and since last six months

 Pain & bleeding from gums since 2 months

History of present illness :

 Pain and burning
 White patch
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Past medical history: Non Contributory

Family history : Non Contributory

Past dental history : visited a dentist about 1 yr

back with similar problem
Personal history :
Brushes twice daily
 Auxiliary aids – Nil
 No deleterious habits
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General examination
 Well nourished with normal built and gait
 No icterus, clubbing and cyanosis
 Vitals - WNL
 No enlargement of lymph nodes

Extraoral examination : No extraoral Skin

lesions were noted

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 Intra oral examination

 Oral Hygiene - Fair

 Halitosis - Absent
 No Periodontal pocket

 Erythematous erosive lesion on

maxillary anterior attached gingiva

 Erosive lesion bilaterally in buccal

mucosa with central area of erosion
with white radiating striae at
periphery of lesion (Wickham’s
striae)
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 Provisional Diagnosis: Erosive OLP
Investigations : Hemogram, Blood Sugar , Urine –RE,
Biopsy (HP & Direct Immunofluorescence )
Based on History, CF , HP examination : OLP

Initial Management : Oral Prophylaxis , OHI

Topical application of 0.05% Clobetasole x thrice/day for 2 wks
Marked improvement was noted at end of 2 Wks
Tapered over a period of 6 wks (0.1% Triamcinolone)
Patient is under follow-up & presently asymptomatic 7
 PRE TREATMENT

POST TREATMENT

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 Case 2
Name XYZ Age & Sex 51yrs/Female
Occupation Housewife
Chief Complaint Pain and Burning sensation in mouth for
last four months
Inability to tolerate spicy food since one
months
History of present illness Pain and burning in gingiva & cheek region
gradually increased over one year

Past Medical History Non contributory

Family History Non contributory
Past Dental History Non contributory

Personal History Use of tooth brush twice a day

Auxiliary aids – Nil
No deleterious habits
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 General examination
 Well built & normal gait
 No Pallor, cynosis, icterus & clubbing
 Vitals - WNL
 No enlargement of lymph nodes

Extra oral examination

No extraoral skin manifestations

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 Intra oral examination

 Oral Hygiene - Fair

 Gingiva – Bright red, erythematous

lesion in Maxillary & Mandibular
anterior region of gingiva

 White lacy strands, extending to 35-

37 & 45-48 region

 White radiating lines at periphery

of lesion (Wickham’s striae)
Provisional Diagnosis: Erosive OLP

 Initial Management : Oral Prophylaxis , OHI

 Investigations : Hemogram, Blood Sugar , Urine –RE,

Biopsy (HP & Direct Immunofluorescence)

 Based on Biopsy & DIF report : OLP

 0.05% Clobetasole x thrice/day for 2 wks

 Tapered over a period of 6 wks (0.1% Triamcinolone)

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 Post
Pre treatment
treatment

 Asymptomatic at end of therapy

 Reticular pattern persisted in posterior
region Pre treatment
 Resolution of erythematous lesion in
gingiva
 Follow-up: patient is asymptomatic

Post treatment 13
 Case 3
Name ABC Age & Sex 37yrs/Female
Occupation Housewife
Chief Complaint Burning sensation in gums and inability to eat
food since 3 months
Difficulty in brushing since 1 month

History of present illness Pain and burning in gingiva & bleeding from gingiva
gradually increased over last two months

Past Medical History Non contributory

Family History Non contributory
Past Dental History Was treated for the same problem 3 yrs back

Personal History Use of tooth brush twice a day

Auxiliary aids – Nil
No deleterious habits

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 Intra oral examination

 Oral Hygiene - Fair

 Halitosis : present

 Gingiva – Bright red , Margin to

MGJ (Appearance of erythematous
lesion )

 Rest of the oral mucosa appeared

normal
 Provisional Diagnosis: Erosive OLP
 Initial Management : Oral Prophylaxis , OHI, CHX

 Investigations : Hemogram, Blood Sugar , Urine –RE,

Biopsy, Direct Immunofluorescence

 Based on Biopsy & DIF : OLP

 0.05% Clobetasole x thrice/day for 2 wks

 Tapered over a period of 6 wks (0.1% Triamcinolone)

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Pre treatment Post treatment

Resolution of erythematous lesion in gingiva

Asymptomatic at end of therapy

Follow-up
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 Chronic Desquamative Gingivitis
 Tomes & Tomes – 1894

 Prinz 1932 – Chronic Diffused Desqumative Gingivitis

“Peculiar condition characterised by intense erythema,
desquamation & ulceration of free and attached gingiva”
Mc Carthy and colleagues (1960) : “Desquamative gingivitis is
not a specific disease entity, but a gingival response associated with
a variety of conditions”. (Manifestation of several mucous membrane
Diseases)
 Females: 4th to 6th decade (hormonal derangement)

 Studies have shown that DG is mostly related OLP & MMP

 In 70% of cases OLP is the primary disease associated with DG
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Disorders Associated with Desqumative Gingivitis

 85-90% of lesions – dermatological genesis

 MMP, OLP & PV

 Other Disorders associated with DG are:- EM, Graft
versus host disease, Plasma cell gingivitis, Lupus
erythematous, Lichenoid lesions

 MMP & OLP ( 95% of cases of DG)

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1. What should be the approach to a
confirmatory diagnosis?

2. What are the treatment options?

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 What should be the approach to a
confirmatory diagnosis?
Definitive diagnosis some time is complex when
limited to gingival tissue

Hence need for careful medical history, clinical

examination & HP examination with DIF/IIF

Accurate diagnosis is important

Serious complications can be avoided

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 DIAGNOSTIC PATHWAY FOR DESQUAMATIVE 3. Relevant data to should
GINGIVAL LESIONS be collected
ONSET ACUTE/ SUB ACUTE
4. Appropriate procedure
PROGRESSION
PATIENT COMPLAINT
SYMPTOM to be followed to gather
INFECTION VIRUS, BACTERIA,
FUNGI
information
CLINICAL HISTORY
TOPICAL SUBSTANCES TYPE SUSPICION AS A PRECAUTION
1. To establish
DRUG INTAKE RELATION OF LESION
correct diagnosis,
PREVIOUS DISEASE &
sequence of steps GENERAL HEALTH
TREATMENTS
has to be PRESENCE OF OTHER MORPHOLOGY NIKOLSKY’S SIGN
LESIONS LOCATION
performed INTRAORAL ASSESSMENT TOPOGRAPHIC
DENTAL MATERIALS RELATION OF LESIONS
APPROPRIATE REFERRAL
LOCATION
OTHER MUCOSA LESION MORPHOLOGY
LESION’S EXTENT
EXTRAORAL ASSESSMENT SKIN SYMPTOMS LABORATORY WORKUP
SYSTEMIC SIGNS AND
INTERNAL ORGANS SYMPTOMS
EPITHELIAL CELL THICKNESS
EPITHELIAL CELL- CELL DETACHMENT
MODIFICATIONS ACANTHOLYTIC CELLS
HISTOPATHOLOGICAL EXFOLIATIVE CYTOLOGY
ASSESSMENT BMZ ALTERATIONS BM INTEGRITY &THICKNESS ORAL AND / SKIN BIOPSY

INFLAMMATORY COMPOSITION
INFILTRATE LOCATION AND EXTENT
IMMUNORACTANTS TYPE DIRECT
INVOLVED TISSUE LOCATION & DISTRIBUTION IMMUNOFLOROSCENCE
IMMUNOPATHOLOGICAL
PATTERN
ASSESSMENT
AUTO ANTIBODIES SPECIFICITY INDIRECT
SERUM IMMUNO FLORESCENCE
AND TITTER
2. Parameters
should be DIAGNOSIS ESTABLISHMENT

evaluated
PERIODONTAL AND
GENERAL MANAGEMENT
Desqumative Gingivitis (HP & DIF)

Saw tooth retepegs ,

Tombstone
Lymphocytic infiltration

pattern
O Colloid bodies
L
P Intraepith clefting
above basal layer,
Acantholytic
keratinocytes (Tzanck
cells) PV
C3,IgG at BMZ

MMP

MMP

Subepith- clefting
C3,IgG at BMZ
Fibrin deposit
 Approach to Management
 Treatment should be directed to achieve specific goals after
considering the clinical involvement/clinical type & symptoms

 Asymptomatic – no treatment, base line biopsy and periodic

observation
 Eliminate mechanical trauma if any, Reinforcement of oral
hygiene procedures

 Erosive lesions: Treatment should be aimed to alleviate symptoms

and decrease the risk of malignant transformation/complications

 Initiate with potent topical preparation for rapid response &

switch to low strength topical applications (0.05%
Clobetasole & 0.1% Triamcinolone)
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 Intra lesional (Triamcinolone) 10-20mg/ml or Systemic
medication Prednisone 1mg/kg/day : 40-80 mg x 5
days
 Side effects : Infections, atrophy, adrenal suppression
 Obstacle to use of topical is lack of adherence for long
time, Elixir form used (Dexamethasone, triamcinolone
oral rinse)
 Use of anti fungal
 Immunosuppressant (Cyclosporine, Tracolimus,
Pimrecorolimus) may be beneficial 0.1%Tacrolimus
and 1%Pimecrolimus
 Topical Retinoids & Antihelmintic
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 Treatment of Lichen Planus

Asymptomatic Symptomatic

Erosive/ Large chronic ulcers/

Ulcerative Refractory
No therapy
Topical Intralesional steroids
Steroids
Periodic
Examination Resolution No Resolution

Wean off and monitor Refer to dermatologist

Retinoids Dapsone Cyclosporine Photopheresis Systemic Steroids

 Treatment of Cicatricial Pemphgoid

Refer to
Ophthalmologist

Asymptomatic Mild to moderate Severe

Prednisone

Plaque control Topical Refer to

steroids Dermatologist

Dapsone
No
resolution

Methotrexate Dapsone Cyclosporin Cyclophosphamide Azathioprine

 Treatment of Pemphigus vulgaris

Refer to Dermatologist

Primary treatment Secondary treatment

Prednisone

Azathioprine Cyclophosphamide Cyclosporin methyltrexate Photopheresis

Gold Plasmaphoresis
Systemic Implications of DG Associated Disorders
Disease Systemic Implications
MMP Ocular Scarring – Lead to blindness

Laryngeal scarring – Airway obstruction

which may be life threatening
OLP Risk of Malignant transformation

PV Potentially life threatening if untreated (Sepsis

or electrolyte loss)
EM Life threatening (Steven-Johnson syndrome,
ocular scarring)
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 Conclusion
 Periodontist may be called to diagnose & treat either
alone or as part of team

 Diagnosis at times difficult hence there is always a need

for HP examination

 Accurate diagnosis is important to prevent serious

complications

 Prevent further progression & help in improving quality

of life
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