Desquamative Gingivitis

Desquamative gingivitis is a clinical pattern of diffuse erythema, desquamation, erosion or blistering of the attached gingiva, and it is a sign of several mucocutaneous diseases rather than a diagnosis.

Oral lichen planus and mucous membrane pemphigoid account for most cases, with pemphigus vulgaris, linear IgA disease, chronic ulcerative stomatitis, lupus erythematosus, contact allergy and drug reactions making up the rest. It occurs mainly in women over 40.

Pathophysiology. Loss of epithelial integrity at the gingiva occurs by different mechanisms. In lichen planus the lesion is T-cell mediated basal cell damage. In pemphigoid autoantibodies target basement membrane proteins (BP180, laminin 332) with subepithelial separation. In pemphigus autoantibodies against desmogleins cause intra-epithelial acantholysis.

Gingival tissue is exposed to friction and plaque, so lesions are easily triggered and persist.

Burning, soreness and bleeding on brushing or eating, with red, shiny or peeling gingiva, sometimes with blisters and erosions on the buccal gingiva and a positive Nikolsky sign. Plaque control is difficult because of pain, so secondary plaque gingivitis is common.

Check eyes (conjunctival scarring or symblepharon), nose, pharynx, larynx, oesophagus, genitals and skin for coexisting disease. Hoarseness, dysphagia, red eye or visual symptoms need urgent assessment because of scarring in pemphigoid.

• Biopsy from perilesional tissue at the edge of an erosion or an intact area. Take two samples, one in formalin for histology and one in Michel medium or fresh and chilled for direct immunofluorescence.
• Direct immunofluorescence: linear IgG and C3 at the basement membrane in pemphigoid, intercellular IgG and C3 in pemphigus, shaggy fibrinogen at the basement membrane in lichen planus, granular IgG, IgM and C3 in lupus, and linear IgA in linear IgA disease.
• Indirect immunofluorescence and ELISA for anti-BP180 and anti-desmoglein 1 and 3 antibodies.
• Patch testing and drug review when contact reaction or lichenoid drug reaction is likely.
• Full blood count, ferritin, vitamin B12, folate, glucose, antinuclear antibody and hepatitis C serology, selected to match the suspected cause.
• Ophthalmology and ENT review when eye, nose or laryngeal symptoms are present.

Differential diagnosis.

• Oral lichen planus
• Mucous membrane pemphigoid
• Pemphigus vulgaris
• Plasma cell gingivitis and contact allergy
• Linear IgA disease and chronic ulcerative stomatitis
• Lupus erythematosus
• Plaque induced gingivitis and candidiasis
• Gingival squamous cell carcinoma

• Plaque control with a soft brush, professional scaling and chlorhexidine 0.2% 10 mL twice daily for up to 2 weeks, then a non-alcohol mouthwash, because plaque worsens the lesions. Avoid cinnamon and strongly flavoured toothpaste.
• Topical corticosteroid delivered by a thin custom soft tray for 10 to 15 minutes: clobetasol propionate 0.05% gel 1 to 2 times daily for 2 to 4 weeks, then reduced. Review for candidiasis, with miconazole oral gel 20 mg/g, 2.5 mL four times daily for 7 days when needed, avoiding it with warfarin.
• Lichen planus resistant to steroid: tacrolimus 0.1% ointment twice daily (boxed warning on malignancy with prolonged use), hydroxychloroquine 200 mg once or twice daily, or systemic prednisolone for a short course.
• Mucous membrane pemphigoid:
  • Mild: topical steroid in the tray plus dapsone 25 mg daily, increased by 25 mg each week to a usual 50 to 100 mg daily (maximum 150 mg), after testing for G6PD deficiency. Monitor haemoglobin, reticulocytes and methaemoglobin, with full blood count weekly for the first month, then monthly for 3 months and 3-monthly. Stop for haemolysis or agranulocytosis.
  • Moderate to severe or ocular disease: prednisolone 0.5 to 1 mg/kg daily with cyclophosphamide, mycophenolate mofetil 1 to 1.5 g twice daily or rituximab 1000 mg intravenously on day 1 and day 15, directed by the specialist team. Ocular, laryngeal and oesophageal disease needs urgent immunosuppression to prevent scarring.
• Pemphigus vulgaris: prednisolone 0.5 to 1 mg/kg daily with rituximab 1000 mg intravenously on days 1 and 15, and a repeat 500 mg at month 12 and then every 6 months, with methylprednisolone 100 mg intravenously before each infusion. Screen for hepatitis B and tuberculosis first.
• Patients on long term steroid treatment need bone protection, glucose monitoring and Pneumocystis prophylaxis when combined with other immunosuppressants.

Monitoring. Review every 4 to 6 weeks until controlled, then every 3 to 6 months. Photograph and score gingival disease at each visit. Eye review at least annually in pemphigoid.

Referral and escalation. Refer all new cases to oral medicine. Refer urgently to ophthalmology for any eye symptoms, to ENT for laryngeal symptoms, and to dermatology or immunology for pemphigus, pemphigoid or multisite disease.