Mucous membrane pemphigoid with exclusive gingival involveme
The present case has been reported in the Journal of Orofacial Sciences.

A 45 year old female patient reported to the department of Oral medicine and Radiology with a complaint of burning sensation and tenderness in the gums on intake of spicy food for the past 9 months. The patient had also noticed the formation of blisters on the gums on and off which would break off on their own.

The medical history was not significant and she was otherwise in good health. There were no associated ocular, cutaneous or genital lesions. Intraoral examination revealed generalized erythematous and inflammed labial and buccal gingiva. There was an area of desquamation involving the buccal aspect of free, marginal and attached gingiva in relation to 23, 24, 25, 26, 27, 33, 34, 35, 36 and 37. Gentle manipulation of the normal mucosa induced a positive Nikolsky's sign. Erosions were noticed involving the marginal and attached gingiva in relation to 13, 46.

The patient's oral hygiene was fair and gingiva showed bleeding on probing with no attachment loss. Faint grey-white striae could be seen bordering the desquamated area in some part. Considering a history of burning sensation with formation of on and off blisters, and oral examination revealing generalized erythematous gingiva, with desquamative gingivitis, positive nikolsky's sign and areas of erosions, provisional diagnosis of Desquamative gingivitis due to vesiculo-bullous disorder was given.

Differential diagnosis included mucous membrane pemphigoid, bullous pemphigoid, pemphigus vulgaris and bullous lichen planus. After an informed consent from the patient, an incisional biopsy was taken from the perilesional gingival tissue for histopathologic and immunofluorescent studies. Histopathological picture showed parakeratinised stratified squamous epithelium of variable thickness along with presence of subepithelial cleft and basal cell degeneration in few areas.

Connective tissue stroma showed band of intense chronic inflammatory cells (plasma cells) along with areas of vascularity and hemorrhage. Direct immunofluorescence showed a linear deposition of IgG and C3 at the dermo-epidermal junction. Final diagnosis of Mucous membrane pemphigoid was made based on the clinical, histopathological and immunofluorescent interpretations. The patient was subjected to thorough oral prophylaxis and oral hygiene instructions.

Thereafter, the patient was prescribed topical application of medium potency steroids (flucinonide 0.01% Lidex) 3-4 times daily for one month and vitamin B complex supplements. The patient was reviewed every 2 weeks for the first one month. The lesions improved considerably with topical steroids within 4 weeks of starting the treatment.

The frequency of topical steroid application was tapered to once daily application for the next 15 days. The patient was asked to stop the topical application and reinforcement of oral hygiene instructions was given. Since the lesions can recur, the patient was under observation for one year and there was no recurrence.

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