chief complaint & history of present illness

Case report

32 years-old female patient from mangalore Complains of burning sensation of her gums Duration : 4 months

INDIAN DENTAL ACADEMYLeader in continuing Dental Education

www.indiandentalacademy.com

Chief complaint & History of present illness

Small boil like formation on the gums Boils appears whenever she bites on hard food Bleeding while brushing No difficulty in swallowing & speaking No history of itching No such lesions on other parts of the body No history of systemic symptoms Past medical/dental/family history

General physical examination- NAD

Local examination of the lesion

Extra oral examination Inspection Palpation


Intra oral examination Local examination of gingiva Inspection Palpation

Intra oral examination Inspection Palpation

Chair side investigation Nikolsk’y sign = -ve

Differential diagnosis Mucous membrane pemphigoid Pemphigus vulgaris

Investigations Cytological Incisional biopsy


Histological results Cytological smears H/F

Final diagnosis Mucous membrane pemphigoid Chronic generalized gingivitis Dental caries- 16, 26 Partially edentulous area in relation to - 15, 25

Treatment plan Treatment for Mucous membrane pemphigoidOral prophylaxis Restoration of 16, 26Prosthetic rehabilitation i.r.t 15, 25


Discussion Mucous membrane pemphigoid Rare chronic blistering autoimmune diseases Etiology & pathogenesis The autoantibodies directed against protiens in the BMZ autoantibodies activate complement that attracts

neutrophils. The release of proteolytic enzymes from neutrophils

causes lysis of cells, detachment of the basal cells from the BMZ resulting in the subepithelial clefting at the lower lamina lucida and lamina densa levels.


C/F Age sex Oral manifestations Eye Skin lesions Laryngeal involvement, esophagus


Histopathology & Direct Immunofluorescence


D/D Pemphigus vulgaris Erosive lichen planus Erythema multiforme


Treatment severity of symptoms, site & progression low-risk patients ( oral mucosa and/or skin only) Topical corticosteroids and intralesional steroid injections Tetracycline 1-2g/day and Nicotinamide 2-2.5g/day. Therapy with dapsone (25-200mg/day) may be initiated if poor

response is seen to topical steroids low doses of prednisone (0.5 mg/kg per day), with or without

azathioprine (100 mg/day) If severe oral disease, high doses of prednisone are

required, with or without immunosuppressor

(lópez-jornet p, bermejo-fenoll A. Treatment of pemphigus and pemphigoids -med oral patol oral cir bucal 2005;10:410-411)


High risk patients. ocular, genital, esophageal and nasopharyngeal location. rapid progression.

Prednisone 1-1.5mg/kg/day and cyclophosphamide (1-2mg/kg/day),

also intravenously. If cyclophosphamide is not tolerated, azathioprine is used

(1-2mg/kg/day). Immunoglobulin: intravenous (therapy resistant, ocular

disease). Plasmapheresis has also been effective in some patients. For serious ocular disease - subconjunctival mitomycin. First International Consensus on Mucous Membrane Pemphigoid,

Arch Dermatol 2002;138:370-9

The treatment follow up sequel of our case

Application of Triamcinolone acetonide 0.1% (kenacort) 1-1-1-1 for 7 days

2nd week - Prednisone (Wysolone)50mg (OD) was prescribed for 2 weeks along with the local application of kenacort. B.P= 120/80mmhg. FBS = 92mg/dl

Follow up 4th week Eroded areas were seen in the labial aspect of the upper

right gingival area in close proximity to 15,14,13 & one fresh vesicle was seen on the gingiva in the anterior lingual area of the lower arch

6th weeks - Erythematous areas reduced, 1 new ruptured vesicle on

forehead region. Same medications continued Review of blood sugar & blood pressure B.P= 110/70mmhg. FBS = 173mg/dl

7th week Erythematous areas had reduced in size. Dosage was tapered to 30mg (OD)

9th week B.P was 100/60mmhg & blood sugar was 98mg/dl. Small

generalized eroded areas were seen on the lingual aspect of the gingiva

12th week - Oral lesions had reduced. The patient complained of severe giddiness & body ache. She had developed edema in her face & in her body . B.P= 100/60, FBS = 96/dl.

Prednisone dosage is reduced to 20mg/day

14th week - On examinations oral lesions had healed. Drug dosage was again reduced to 10mg/day

17th week – Few eroded areas were seen on the lingual gingival area of

the lower arch near 44 & 45 region & also fresh vesicle had erupted on the right side of the cheek.

Prednisone 10mg , Tetracycline (Restaclin)250mg as a mouth rinse, Triamcinolone acetonide (Tess cream) & clobetasol propionate (Tenovate cream) twice daily for the skin lesion for 15 days

19th week

21st week - Patient reported with new lesions, drug dosage was increased to 20mg/day for 15 days


23rd week - Lesions had not healed Cyclophosphamide (Endoxan50mg) (BID) for 1 month along

with 20mg Wysolone (OD)& rantac150mg (BID).

27th week - lesions got healed & side effects of corticosteroides had subsided.


Conclusion


Its not enough that we do our best; some times we have to do what’s required. Sir Winston Churchill