Introduction

Desquamative gingivitis (DG) is a clinical term used to describe gingival tissues that demonstrate potentially painful gingival erythema, hemorrhage, sloughing, erosion, and ulceration (Figure 1 and Box 1). Lesions may be generalized or localized and may extend into the alveolar mucosa. Often similar lesions are found elsewhere in the oral cavity. DG is most frequently caused by mucocutaneous diseases with the most common being oral lichen planus mucous membrane pemphigoid and pemphigus vulgaris.30,49,56,65,72,77,90 Other potential causes include: lupus erythematosus, graft versus host disease, erythema multiforme, epidermolysis bullosa, epidermolysis bullosa acquisita, chronic ulcerative stomatitis, lichen planus pemphigoides, plasmacytosis, plasma cell gingivitis, orofacial granulomatosis, foreign body granulomas, and linear IgA disease.49,59,75,92,97 Hypersensitivity to dental materials, dental hygiene products or food flavorings and preservatives may mimic DG, while several systemic disorders including Crohn’s disease, psoriasis, sarcoidosis, and adverse drug reactions may possess some but usually not all of the clinical features of DG.30 Unpublished data from the Stomatology Center at Texas A&M University-Baylor College of Dentistry (TAMUBCD) indicates over 90% of DG treated at that center were the result of one of four conditions: oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris or hypersensitivity reactions to dental hygiene products, food flavorings or preservatives.26

Figure 1. Desquamative Gingivitis.
ce481-fig01-desquamative-gingivitis
Box 1. Desquamative Gingivitis.
  • A clinical manifestation of several diseases and disorders featuring gingival erythema, sloughing of the gingival epithelial tissues and potentially painful erosive gingival lesions.
  • Usually caused by mucocutaneous diseases with the most common being lichen planus, mucous membrane pemphigoid and pemphigus vulgaris. Other causes include hypersensitivity reactions to various oral hygiene products and dental materials.
  • Determination of etiology usually requires histopathological examination and direct immunofluorescence testing.

The clinical features of what is now consistent with DG were described in the dental literature as early as 1856, but it is believed to have been first discussed in the English dental literature by Tomes and Tomes in 1894. In 1932 Prinz coined the term desquamative gingivitis,66,94 and the consensus view at the time was that it represented a specific disease, possibly related to hormonal deficiencies in older women and occasionally men.108 This thinking may have been triggered by the observation that DG was far more common in females than males. However, in 1964 Glickman and Smulow suggested DG may have multiple causes.38 It was not until the advent of immunofluorescence diagnostic techniques that it became obvious DG was, in fact, a clinical manifestation of a variety of diseases and disorders capable of affecting either gender.13

Box 2. Characteristic Features of Desquamative Gingivitis.
  • Gingival erythema not resulting from plaque
  • Desquamation and erosion of gingival epithelium
  • Blister formation
  • Other intraoral and/or extraoral lesions
  • Possible positive Nikolsky’s sign (epithelial desquamation after application of a shearing force on normal-appearing gingival).

DG is often found to be closely associated with epithelial desquamation after application of a sliding or rubbing force on normal-appearing gingiva (Nikolsky’s sign – Figure 2). This phenomenon is very common in several mucocutaneous disorders.33,75,77,94,108

Figure 2. Nikolsky’s sign.
ce481-fig02a-nickolsky-sign
The epithelium is dislodged by gentle pressure.
ce481-fig02b-nickolsky-sign

The ability to readily determine the correct etiology of DG may sometimes be difficult due the extremely friable nature of the affected tissues. This can lead to separation or loss of the epithelial layer of biopsied tissue, making it virtually impossible to determine the correct histopathologic and/or immunofluorescence diagnosis.