Control Phase Alternatives

The clinician has several alternatives to choose from in managing DG. Aggressive therapy with very high potency topical or short-term systemic corticosteroids may bring about improvement of lesions more rapidly but are more likely to initiate adverse side effects, therefore requiring more frequent recall intervals. Moderate therapy with high or very high potency topical steroids (Box 9) and/or intralesional steroid injections is often a suitable alternative in severe lesions of the tongue, soft palate and buccal or labial mucosa. Mild therapy with medium or low potency topical corticosteroids such as triamcinolone mixed into a denture adhesive, another adherent paste or under an adhesive patch, may cause fewer side effects but also may prolong therapy and may not be effective for advanced DG. Topical cream, ointment or gel medicaments may be used with a carrier tray to achieve more prolonged soft tissue contact.34,51

Box 9. Control Phase Alternatives.
  • Aggressive therapy with very high potency topical or systemic corticosteroids
  • Moderate therapy with high potency topical corticosteroids combined with intralesional injections when indicated
  • Mild therapy with medium or low potency topical corticosteroids and carrier trays (triamcinonlone in a paste, denture adhesives, adhesive patches etc.)

Although immunosuppressants applied in carrier trays are often very effective in controlling DG, the clinician should take care to avoid potential adverse effects if trays are used (Box 10).

Box 10. Disadvantages to Carrier Trays.
  • Insertion and removal may initiate gingival desquamation – relieve sites as necessary
  • Increased risk for secondary candidiasis – monitor
  • Risk of increased systemic uptake – discontinue as soon as possible
  • Risk of gingival epithelial thinning – discontinue as soon as possible

The authors prefer moderate to aggressive therapy depending on the nature of the desquamative condition. Topical corticosteroids are often available as a cream, ointment or gel. Some evidence suggests the gel form is more retentive in the oral cavity. Typically, a very high or high potency topical steroid such as clobetasol proprionate 0.05% gel is prescribed initially to be used 2-3 times daily until significant clinical improvement has taken place. Concerns are sometimes raised over the possibility of creating immune suppression with the use of intraoral corticosteroids or other immunosuppressant topical agents (Box 11). However, to date no studies have confirmed this possibly because the quantity of medicament used in the oral cavity is quite small compared to skin applications. However, it is probably wise to closely monitor steroid use. Empirically, we advise patients they should use no more than 15 mg of corticosteroid in a two-week period.

Box 11. Immune Suppression.
  • Oral application of fluocinonide resulted in no detectable systemic uptake.106
  • Application of large quantity of topical clobetasol to skin resulted in significant systemic uptake. Effect was dose related.108
  • Oral use of topical clobetasol 1.5 gm daily for 2 weeks resulted in a small but detectable systemic uptake.107,109
  • To date, no study has confirmed an adverse systemic immunosuppression related to judicious use of oral topical corticosteroids.

After achieving satisfactory DG improvement or resolution, the patient transitions into the consolidation phase of therapy. However, if the patient is only minimally responsive to topical therapy, one might consider the use of an alternative therapeutic approach or referral to a physician for more potent immunosuppressant therapy. Insufficient response may also alert the clinician to the possibility the DG may represent a lichenoid drug reaction that may require close medical/dental coordination to address.