Forum for Clinical and Surgical Oral Pathology

Case BBOPF 06-2

The following case was contributed by Dr. Dennis Lynch (Marquette University, USA). Dr. Lynch invites your comments on the following case. This case will be posted from January 26 to February 3, 2006. A summary of the responses will be posted in BBOP.

Clinical History

This 40-ish, otherwise healthy female was seen in April 2005 with a presenting diagnosis of "desquamative gingivitis" for 12 years. A gingival biopsy done several years ago was signed out as "non-specific gingivitis" and she was prescribed topical Protopic by her dermatologist. When she was seen in April 2005, the gingiva was somewhat erythematous, but not dramatically so. The gingiva could be lifted up with a probe to reveal some more erythematous granulation tissue in the depth of the sulcus. There was no evidence of Wickham's striae, Nikolsky's sign, erosions, ulcerations, etc. The radiographs showed some bone loss, consistent with chronic inflammatory periodontal disease, but nothing dramatic. She was rebiopsied for H&E and direct IF at that time. The H&E was signed out, again, as non-specific gingivitis and the direct IF was signed out as "consistent with either lichen planus or lupus erythematosus". To me, it's not clinically really like either LP or LE--or anything else, for that matter.

SEVERAL QUESTIONS:

1. Any thoughts on other potential diagnoses?
2. If you accept the fact that it's an immunologically-mediated mucosal condition, what do you do?

A) Gingivectomy (which would have protean esthetic ramifications)? B) Topical anti-inflammatory medications, e.g., Protopic, Lidex, Temovate, etc.? C) Systemic immunosuppressive therapy of some sort? Some sort of periodontal procedure?

Any comments or insights would be most welcome.

Dr. Dennis Lynch

Images

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).